Initiating CV preventive medication can have both positive and negative effects on lifestyle
Lifestyle Changes in Relation to Initiation of Antihypertensive and Lipid‐Lowering Medication: A Cohort StudyLiterature - Korhonen MJ, Pentti J, Hartikainen J et al., - J Am Heart Assoc. 2020;9:e014168
Introduction and methods
Antihypertensive medications and statins are increasingly used for primary CV prevention. Lifestyle modification remains central to CVD prevention, both before and during the use of pharmacotherapeutic options.
Little is known whether and how initiation of preventive medication affects lifestyle. The perceived effectiveness of pharmacotherapy may motivate people to adopt a lifestyle that also prevents disease. Alternatively, it may be postulated that individuals make less healthy lifestyle choices when they use medication. Evidence is available that persons with a new diagnosis of CVD or diabetes improved some lifestyle factors, as did persons with hypertension or hyperlipidemia who initiated medical therapy. Other studies have also reported that people who initiated  or used [2,3] statins or antihypertensive medication  showed lower physical activity than people not taking these drugs.
The US NHANES data has also demonstrated that in the early 2000s, statin users had lower caloric and fat intake than non-statin users, while in the mid-2000s this difference faded, and was reversed by 2010 . It has also been described that the prevalence of obesity increased faster among users [3,5].
This study set out to assess the extent to which initiation of antihypertensive or statin therapy predicts changes in lifestyle factors, such as BMI, leisure-time physical activity, alcohol consumption and smoking. Repeat observational data of a large cohort of Finnish adults were used, to answer the question whether initiation of preventive medication is more likely to complement a healthy lifestyle change or to substitute for it. Data were obtained with questionnaires administered in 4-year intervals from 2000 to 2013 (average response rate 70%). Participants who responded to 2 consecutive surveys (‘waves’), who were >40 years and free of CVD at the first questionnaire were included (n=41,225). The data were organized into three pre-post data sets with separate baselines and corresponding follow-ups (eg 2000-2002 with 2004-2005 as follow-up). Data on medication use was ascertained with records of pharmacy claims.
- Of the total cohort, 8,837 (10.8%) were considered initiators of preventive medication, 26,914 (32.9%) as prevalent users and 46,021 (56.3%) as non-initiators.
- In a fully adjusted model, the mean increase in BMI was larger in initiators of medication (difference in change: 0.19, 95%CI: 0.16-0.22). Among participants who were obese or non-obese at wave 1, in both groups, initiators showed a higher odds of obesity at wave 2 than non-initiators (obese: HR: 1.37, 95%CI: 1.15-1.65, nonobese: HR: 1.82, 95%CI: 1.63-2.03).
- Average MET h/day declined among initiators compared with non-initiators (-0.09, 95%CI: -0.16 to -0.02). Irrespective of baseline activity, initiators were more likely to be physically inactive at wave 2.
- Initiators showed a decline in average weekly alcohol consumption compared with non-initiators (-1.85 g/week, 95%CI: -3.67 to -0.14).
- Baseline smokers who initiated medication were more likely to quit smoking compared to smokers who remained untreated (adjOR: 0.74, 95%CI: 0.64-0.85). And, initiators who smoked during both waves reduced their cigarette use/day more than their non-initiator counterparts (adj difference in change in number: -0.34, 95%CI: -0.60 to -0.08).
- In participants with 0-2 unhealthy lifestyles at baseline, the adjOR of having 3-4 unhealthy lifestyles at wave 2 was 1.66 (95%CI: 1.40-1.98) for initiators vs. non-initiators.
In this large Finnish cohort of adults free of CVD, persons who started preventive therapy more often showed higher BMI, higher chance to become obese or physical inactivity after about four years than persons not initiating preventive medication. These observations support the substitution hypothesis. Results on smoking and alcohol consumption were in line with the complementation hypothesis, namely that those starting preventive therapy reduced these behaviors.