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- Effective and positive communication helps motivate patients to make lifestyle changes to modify their cardiovascular
- Lifestyle modification is usually best approached by making small changes over time and setting realistic health
- Involve whanau in treatment decisions and lifestyle changes.
Modifying risk factors
Once a patient understands that they have a higher risk of a cardiovascular event occurring, the next step is to engage
them in participating in their healthcare and making lifestyle changes to reduce this risk.
Treatment needs to be tailored to the individual taking into account their beliefs and attitude towards modifying their
The guidelines recommend:
- Drug therapy and lifestyle modification initiated simultaneously for people whose CVD risk is greater than 20%
- Lifestyle modification initiated three to six months prior to initiating drug treatment for patients whose CVD risk
However for some patients with less than 20% risk it may be appropriate to initiate drug treatment simultaneously with
lifestyle interventions if you consider outcomes will be better, for example if they are unlikely to undertake lifestyle
measures or the addition of a prescription is likely to better engage them in addressing their cardiovascular risk.
Agree on realistic patient-centred health goals
It is unrealistic to expect patients to make all lifestyle changes at once. Changes are more likely to occur if each
patient prioritises lifestyle changes and sets realistic targets.
All health targets should be S.M.A.R.T:2
Specific - a specific target would be: “I’m going to go for a 30-minute walk
everyday in my lunch break”, rather than: “I’m going to exercise more”.
Measurable - targets must be able to be measured. The target above of a 30-minute walk
every lunch time is able to be measured, it is clear if it has been done or not.
Achievable - do not set unrealistic targets. For example setting a target weight loss
of 20 kg in two months is unrealistic and will most likely fail and reduce the patient’s confidence. Setting a lower
target such as 500 g a week is more achievable and if exceeded, will increase the patient’s confidence.
Rewarding - targets that are rewarding increase confidence in ability to achieve goals.
Time bound - goals are more likely to be carried out if a specific time to achieve them
has been agreed in advance.
All people who smoke should be advised and supported to stop
Smoking increases the risk of coronary, cerebral and peripheral arterial disease.3 This effect is dependent
on the lifetime exposure to tobacco smoke i.e. the amount of tobacco smoked daily and the duration of smoking.4
The risk of cardiovascular disease declines rapidly after smoking is stopped.
Assess current behaviour: How many cigarettes does the patient smoke? Do they want to stop?
Advise about the benefits of changing behaviour: The latest New Zealand guidelines for smoking cessation suggest advising
every patient who smokes, about the benefits of stopping smoking, at least once a year.
Advise that it is never too late to stop and tell patients that the benefits of smoking cessation include:
- Within two days of quitting your ability to smell and taste improves
- Within three months of quitting your circulation improves
- You will save money
- You will set a good example for your children
Agree on patient-centred goals to change behaviour: A first step to engaging patients in reducing or stopping smoking
may be to encourage a smoke-free house and car.
Arrange follow-up and support: Make a follow up appointment to ask about current smoking status. Support involves prescribing
medicines including nicotine replacement therapy which is now able to be prescribed by all GPs and practice nurses.
All Māori who smoke should be encouraged and supported to stop
Māori are equally as motivated and just as likely as non-Māori to have made a quit attempt in the past year.
Māori can be encouraged to quit smoking using nicotine replacement therapy (NRT) and programmes such as Aukati Kai
Paipa, a smoking cessation support programme delivered by Māori for Māori that takes a whanau based approach
to smoking cessation. The programme reports that quit rates for Māori are significantly better for Aukati Kai Paipa
than conventional programmes.
Aukati Kai Papa: www.auahikore.org.nz
Encourage weight loss for those who are overweight
Obesity, particularly abdominal obesity, increases cardiovascular risk.
Weight reduction results in lower blood pressure, lower LDL cholesterol and triglycerides, and higher HDL cholesterol.
An initial goal may be a small change in weight over a set time, achieved by introducing changes in diet and physical
A healthy diet is good for the heart and can modify other risk factors. A diet rich in fruit and vegetables and low
in saturated fat is beneficial for preventing and managing cardiovascular disease.
Key targets for dietary modification
- Limit dietary intake of fat, particularly saturated fat
- Replace saturated fats with unsaturated fats
- Increase the intake of fresh fruit and vegetables to at least five portions a day
- Regularly eat fish (at least two servings per week)
- Limit intake of salt
- Limit alcohol to less than 21 units per week for men or less than 14 units per week for women
Dietary changes, while recommended for an individual, often need to be adopted by a whole whanau in order for change
to take place, therefore expectations of this change need to be realistic and culturally acceptable.
Approach dietary modification in a step wise manner; a recommended approach is:
Assess current behaviour: what does the patient currently eat? For example, find out the components of a patients diet
that may be contributing the most fat.
Advise about the benefits of changing behaviour: Advise patients about the key targets for dietary modification listed
above but provide some suggestions. Encourage any healthy suggestions the patient makes for changing their diet.
Agree on patient centred goals to change behaviour. Initial goals may be to replace some foods with healthier alternatives.
- Replace white bread with grain bread
- Replace butter with margarine
- Replace fruit juices or soft drinks with water, or low fat milk
- Replace full fat milk (‘blue top milk’) with lower fat milk (‘light blue’ or ‘green’ top
Or provide some food cooking and preparation tips:
- Cut fat off meat
- Grill instead of frying
Arrange follow-up and support. Make a follow up appointment to assess changes in diet. Provide simple written material
to reinforce messages when a patient gets home. Material that is personalised can be shared with whanau.
Encourage an increase in physical activity
A sedentary lifestyle is associated with an increased risk of cardiovascular disease.3 Being physically active
can also modify other risk factors, for example, reduce weight, lower blood pressure and increase the level of protective
In general, Māori like other indigenous cultures, place great emphasis on the spoken word and
eloquence is traditionally valued. Be careful when using medical jargon (e.g. myocardial infarction for heart attack)
and ordinary words that have a specialised meaning in a medical context (e.g. ‘the patient is complaining of
a headache’ can be taken by the patient to mean the GP does not believe them).
Māori are less likely to question a GP so it is important to check on their understanding in different ways.
Open questions and the involvement of whanau can assist with this. Everyone, regardless of background has a preference
for receiving information in a particular way. Information may need to be delivered in a number of ways to check that
the patient has understood what is being communicated.
When discussing cardiovascular risk and the actions that can be taken to reduce the risk, it may be appropriate to
include other whanau members. Rather than just educating the patient there are benefits in investing time in educating
all members of the whanau. Any actions or changes will be most successful if they are understood and adopted by the
Although these education sessions may take a bit longer than the average consultation it can be an excellent investment
of time and energy. Not only may the patients CVD risk be lowered, but other whanau members can similarly benefit.
Best health outcomes for Māori: Practice
Implications. Available from:
www.mcnz.org.nz – look under "Publications"
Provide advice about physical activity that is patient centred, achievable and measurable; a recommended approach is:
Assess current behaviour: Ask about current levels of activity including activities that the patient may not associate
with exercise. For example, ask about method of getting to work or time each week spent gardening or gathering kaimoana
Advise about the benefits of changing behaviour: Advise patients that physical activity can be accumulated throughout
the day. Three ten minute bouts of exercise per day are equivalent to one 30 minute session. Activities that can be incorporated
into everyday life, such as brisk walking, using stairs and cycling, are recommended as people may be more likely to participate
in these activities.
Agree on patient-centred goals to change behaviour: An initial goal may be a small but agreed and measurable increase
in exercise, for example these activities may be done at least three times per week:
- Walk to school or shops
- Get off the bus one stop earlier than usual
- Use the stairs instead of the lift
- Park a block away from work and walk
Group activities may encourage some people to engage in physical activity because the social aspect can be enjoyable.
Arrange follow-up and support: Set measurable goals that can be evaluated at follow-up.
Consider issuing a Prescription or referring patients to a local sports trust.
Te Hotu Manawa Māori provides Māori specific resources for lifestyle intervention www.tehotumanawa.org.nz
- New Zealand Guidelines Group. The assessment and management of cardiovascular risk. December 2003. Available from www.nzgg.org.nz (accessed
- The New Zealand Heart Foundation. A practical guide to management of CVD risk 2007.
- JBS 2: Joint British Societies Guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91:1-52.
- SIGN (Scottish Intercollegiate Guidelines Network). 97: Risk estimation and the prevention of cardiovascular disease.
Available from www.sign.ac.uk/pdf/sign97.pdf (Accessed