Heart disease remains the leading cause of death in the United States and worldwide, yet primary care physicians have more tools than they may realize to move the needle on prevention.
Better heart health can start with the conversations that physicians and patients have in the exam room, said two Mayo Clinic cardiologists.
Francisco Lopez-Jimenez, M.D., M.S., and Kyla M. Lara-Breitinger, M.D., M.S., co-edited the “Mayo Clinic Guide to a Happy, Healthy Heart” with the late Amir Lerman, M.D., whose research helped define how the endothelium — the inner lining of blood vessels — influences cardiovascular health.
The physicians spoke with Medical Economics to discuss how to redirect patients seeking quick fixes toward sustainable behavior change, why effective goal-setting focuses on actions rather than outcomes, and how asking a patient about their biggest source of stress can be one of the most powerful tools in a clinician's prevention arsenal.
This transcript has been edited for length and clarity.
Working alongside a leading heart health researcher
Medical Economics: I would be remiss if I didn't mention that your coauthor was the late Dr. Amir Lerman, and there are at least 30 other contributors to the book. Can you share your thoughts on Dr. Lerman's research and the work of those other contributors?
Francisco Lopez-Jimenez, M.D., M.S.: Dr. Lerman was really a pioneer in many things in cardiology, but perhaps one of the most relevant contributions was his discovery of how the inner layer of the arteries works and how that is relevant for what we know as cardiovascular health. That portion of the arteries was basically unknown or ignored before because a lot of those functions were not known. And he really pioneered that area, among many other things, but I will say that was his major contribution to science.
Medical Economics: This is a work that has had a lot of collaboration behind it. What was it like to manage everybody involved?
Kyla M. Lara-Breitinger, M.D., M.S.: It was wonderful. Mayo Clinic is really a collaborative environment, and so we feel 100% that the more, not only the merrier, but the wealth of expertise across all of our campuses has been truly wonderful, and we wouldn't have been able to produce a book without them. And so we have CVOB, we have stress experts, we have meditative experts, we have, even beyond cardiology, exercise physiologists, cardiologists across the board, Mayo, Arizona and here. We wanted to give a special shout out to them in terms of their recognition, and then really having interviews with them throughout the process, recording them and then having kind of digesting that into reader friendly information that's easily actionable, bitable for the common audience.
Francisco Lopez-Jimenez, M.D., M.S.: And I will just add that something unique about those contributors is that everybody sees patients in a regular basis. So at Mayo Clinic, our concept of being an expert in is not just being known outside for what we do scientifically or publications, et cetera, but the fundamental tenet of this is that we do see patients in a regular basis, because that's, at the end of the day, what gives us more and more experience.
Medical Economics: Patients go into the exam room they may want a quick fix, or, as the book puts it, just one thing they can do for their heart or for overall health to begin with. What's some good practical advice for primary care physicians for redirecting that conversation toward sustainable behavior change without losing patient engagement?
Francisco Lopez-Jimenez, M.D., M.S.: We do this in a regular basis, and we emphasize that small changes are, in many situations, big, big changes. It sounds contradictory, but what is a small in terms of a relatively modest goal actually represents a big thing for the body. For example, for somebody who is completely sedentary, just moving around a few minutes every day means a lot, and actually the greatest benefit people get is going from doing nothing to doing something in a regular basis. And when patients learn that, they recognize that health is not really so far in the horizon, or wellness shouldn't be something too difficult to achieve when they think about small goals, one at a time.
Kyla M. Lara-Breitinger, M.D., M.S.: I would just add that it could be overwhelming with social media and all of these longevity experts that are telling you 30 different things to do. And most people have to work, they have families, they have professional responsibilities, and it can really take and consume your whole day just to become healthier. And so I totally agree with Dr. Lopez-Jimenez. Decreasing the activation energy, or the threshold, to change one or two things per week and add and kind of co-synergetically improve over the course of time, and really sticking to little habits that you feel that you can accomplish and not feel like a failure, where then you just kind of go from 100 to zero, as opposed to doing 20% of something. Eating 20% less ultraprocessed foods in the week. Saying, instead of having ice cream every day of the week, and I love sweets, maybe having it three times a week. And over time, seeing results, making these small changes that take time. The problem is, with longevity and health, health span, it's delayed gratification. So, if you're not going to die from doing something tomorrow, you're less likely to do it unless you're a very disciplined person, which most of us, distracted in our world, it's very difficult to focus on that every day.
Medical Economics: Early on in the book you mentioned the importance of physicians asking patients to consider goals, and also that the goal, such as “I want to be healthier,” is too broad, it's too vague. What advice would you give to primary care physicians to guide that conversation about goal-setting with patients?
Francisco Lopez-Jimenez, M.D., M.S.: We talk about goals because we recognize that it gets more difficult to improve something that we don't measure or don't set a specific goal. So goal-setting is key for behavioral change. But again, one of the basic principles is to set realistic goals and not something that would be so difficult. When we talk about goals, we need to be careful and set up goals that are easy to track, easy to measure, goals that patients can evaluate in a regular basis and not always depending on complex machines or wearables, et cetera. Some of those things will require something to measure, like steps, for example, which is a very common goal we set. But you know, these days, just having a smartphone in your pocket will be enough to measure that.
Now, as we know, technology is advancing and more and more things are coming up to measure pretty much everything we want, from the sugar level in the blood every single minute to measuring your stress or measuring your sleep, et cetera. But all in all, we recommend primary care clinicians to focus on simple goals.
Kyla M. Lara-Breitinger, M.D., M.S.: I would just add that number one, I commend primary care physicians, health care professionals across the country, they have the most difficult job of trying to encompass the whole person in a single visit and having to see so many patients. And so in addition to what Dr. Lopez-Jimenez mentioned is, just asking that patient in front of you how they're doing and what's their biggest cause of stress right now. And then understanding that, reading our book, having the toolkit in the back of your head, you can identify something individual to that person in front of you and treat them like a human based on their individual circumstances, and then apply one of these small goals for them. It can over time, if you follow them on a continuous basis, improve that relationship and that trust to, hey, this physician, this NP, this PA, listen to me about the stress I have but they're giving me a goal that seems very pragmatic and it can fit my schedule without deterring too far, that makes it insurmountable for me.
Francisco Lopez-Jimenez, M.D., M.S.: The other thing is, when we talk about goals, is we focus on goals that are really under the power and control of people. This is important to clarify to patients, because we can set up a goal of weight loss. Well, that is one type of goal, but truly as a clinician, my primary goal for my patients will be, let's start eating differently and eating smaller portions, for example. That is more under the control of the person than the actual amount of weight loss. The same goes with blood pressure. We as clinicians focus on blood pressure numbers as goals. I mean, we are doctors, that's what we do every day, right? But for a patient, is going to be a more realistic goal to consume less salt, less sodium, and to eat more fruits and vegetables that, yes, ultimately, will improve blood pressure. But the blood pressure itself is not necessarily under the total control of the patient, but the behavior is.
The book is available through Mayo Clinic Press. Proceeds of book sales support the Mayo Clinic Cardiovascular Research Department.
