taking statins and bp meds can undercut healthy lifestyle
Geoff A. Modest, M.D.
Wed 2/12/2020 8:08 AM
An article was just published finding that the initiation of antihypertensive and lipid-lowering medications may affect patients' lifestyle choices (see statin htn meds dec lifestyle JAHA2020 in dropbox or DOI: 10.1161/JAHA.119.014168)
Details:
-- 41,225 participants of the Finnish Public Sectors study, aged >40yo who were initially free of cardiovascular disease and responded to at least 2 consecutive surveys in 4-year intervals from 2000-2013. This study reflects a cohort of employees in 10 towns and 6 hospital districts
-- 84% female, mean age 52, 76% married/cohabitating, 32% upper grade non-manual workers/27% lower grade non-manual workers/34% manual workers, 89% employed, 50% normal BMI/36% overweight/15% obese, 41% physically active/34% moderately active/26% inactive, 72% moderate alcohol consumption/15% non-drinkers/13% high alcohol, 68% never smokers/18% former/13% current, 3% diabetic
-- number of unhealthy lifestyles (obesity, physical inactivity, alcohol consumption, current smoking): 52% had 0, 45% 1 to 2, 3% 3 to 4
--11% were new initiators of antihypertensives or statins, 33% were prevalent users, and 56% were non-initiators
-- medication use was assessed through pharmacy claims data
-- 44% of statin initiators and 24% of non-statin initiators were users of anti-antihypertensives at baseline; 8% of antihypertensive initiators and 5% of non-initiators used statins
-- changes in BMI, physical activity, alcohol consumption, and smoking was assessed for 8837 initiators of antihypertensive or statin medications, and 46,021 non-initiators
Results:
-- those who initiated medications vs non-initiators:
--BMI increased by 0.19 (0.16-0.22)
-- the likelihood of becoming obese increased 82%, OR 1.82 (1.63-2.03)
-- physical activity declined by 0.09 MET hrs/d (0.02-0.16)
-- the likelihood of becoming physically inactive increased 8%, OR 1.08 (1.01-1.17)
-- alcohol consumption decreased 1.85 g per week (0.14-3.67)
-- no difference in the odds of high alcohol consumption
-- smoking cessation increased: odds ratio of continuted smoking decreased 26%, OR 0.74 (0.64-0.85)
-- and, smoking consumption overall decreased more in initiators of these new medications
-- those with 0-2 unhealthy lifestyles at baseline: the adjusted OR of increasing to 3 to 4 unhealthy lifestyles was 66% higher, aOR 1.66 (1.40-1.98)
-- sensitivity analyses:
-- exclusion of patients with diabetes or new CVD did not materially change the results
-- the association for statin initiation was somewhat weaker than for antihypertensives
-- there was no modification in the above results by sex of the participant, or in terms of BMI, weekly alcohol consumption, or physical activity
Commentary:
-- studies have been mixed in the past on the relationship between starting medications, especially statins, and adherence to lifestyle changes. Some of found that those on medications actually improve their lifestyle as part of their overall approach to health. Others have found that medications are substitutes for lifestyle changes
-- more recent studies have found that meds are associated with less healthy lifestyles (the "substitution" hypothesis). for example the US NHANES study found in the early 2000s that those on statins had lower caloric and fat intake, this difference disappeared in the mid-2000s and reversed by 2010. Other recent studies have suggested that statin users consume more calories and fat than nonusers and that their prevalence of obesity increased faster than nonusers, including in the Framingham Heart Study Offspring Cohort
-- this study, the 1st large-scale prospective cohort study on this issue based on individual-level data with repeated measurements, found that those initiating statins or antihypertensives had increases in BMI, and decreases in physical activity, though alcohol consumption decreased and smoking cessation increased
-- a few issues that could confound the results:
-- statin use may be associated with increased muscle complaints, and that this could interfere with physical activity; this study found no differences in changes in physical activity between those who were new initiators of statins, or prevalent users.
-- see http://gmodestmedblogs.blogspot.com/2016/04/nonstatin-lipid-lowering-drugs-and.html , for a review of statin myopathy, finding that it was not much different from placebo, and http://gmodestmedblogs.blogspot.com/2017/05/statin-myopathy-and-vitamin-d-deficiency.html for a study finding that vitamin D helped myopathy
-- smoking cessation itself may be related to increases in BMI, but there was no difference between new initiators or prevalent users in the current study
-- women may gain weight around menopause, though looking at each age group there did not seem to be any differences in weight change, though the association of weight gain was stronger in those to age 40-49 than in older age groups (the average age of menopause is 51yo). Also, there was no difference between men and women in this finding
Limitations of the study:
-- a relatively homogeneous sample of white public-sector workers, low representation of men, and mean age being >50yo. these demographics limit the generalizability of the results
-- this was a pretty healthy and health-conscious population: more than half with 0 unhealthy lifestyles, only 3% with 3-4 unhealthy ones, and only 3% with diabetes (doesn't sound much like the US population.....)
-- during this time period there were intensive public health initiatives in Finland, different from other countries, and they may have affected lifestyle changes (e.g. smoking restrictions in workplaces and restaurants, national program for prevention and care of diabetics, ...)
-- there was no information on the specific interactions patients had with their clinicians about lifestyle issues, or how aggressively these clinicians continued to discuss them after starting an effective medication
-- there was no information on the quality of diets, or the patients' blood pressures or cholesterol levels
-- much of the information was self-reported, which may well underestimate obesity, smoking, and alcohol consumption
So, a few issues:
--this study does reinforce that prescribing statins or BP meds can be associated with decreases/reversals in healthy lifestyle changes (busy clinicians may well focus on other issues when the blood pressure or lipids are well-controlled; and patients may be relieved that all is good despite gaining some weight, or eating less healthy diets). ie, i think it is incumbent on us clinicians to both acknowledge how great it is that blood pressure/lipids are well-controlled but also consistently reinforce the importance of lifestyle changes:
--healthy lifestyles are associated with an array of benefits well beyond the blood pressure or lipid targets, including decreased cancer, dementia, and all-cause mortality (see blogs referenced below)
for some prior blogs on healthy lifestyle benefits:
-- for exercise, see http://gmodestmedblogs.blogspot.com/2019/03/5-10-min-of-exercise-may-improve-health.html
-- for diet, see http://gmodestmedblogs.blogspot.com/2017/08/changing-diet-changes-lifespan.html, or http://gmodestmedblogs.blogspot.com/2018/06/mediterranean-diet-with-olive-oil-or.html
geoff
If you would like to be on the regular email list for upcoming blogs, please contact me at gmodest@uphams.org
to get access to all of the blogs:
2. click on 3 parallel lines top left, if you want to see blogs by category, then click on "labels" and choose a category
3. or you can just click on the magnifying glass on top right, then type in a name in the search box and get all the blogs with that name in them
please feel free to circulate this to others. also, if you send me their emails, i can add them to the list
Comments
Post a Comment
if you would like to receive the near-daily emails regularly, please email me at gmodest@uphams.org