Holistic lifestyle interventions outshine drugs in preventing cardiometabolic diseases

While lifestyle interventions show promise in tackling cardiometabolic diseases, their long-term success hinges on policy-driven environments that make healthy living accessible for all.

Study: Lifestyle interventions for cardiometabolic health. Image Credit: Shutterstock AI

A recent study published in the journal Nature Medicine reviewed the benefits of combined lifestyle interventions (CLIs) on cardiometabolic health.

Obesity and overweight are risk factors for cardiometabolic diseases (CMDs), and their global prevalence has tripled in recent decades. Societal changes have shifted from leisure activities or labor-intensive work to more sedentary and inactive lifestyles. Concurrently, dietary patterns have shifted from plant-based diets to Western diets that are characterized by high-energy, low-fiber, and high-sugar foods. The study highlights that these trends disproportionately affect socioeconomically disadvantaged populations, where CMD prevalence can be up to five times higher than in more affluent groups.

CLIs target multiple lifestyle behaviors and have the potential to prevent CMD in at-risk populations. However, in the long term, they are not always sustainable, and their effects attenuate in routine care. In the present study, researchers reviewed the short—and long-term benefits and cost-effectiveness of CLIs for obesity, overweight, and related CMDs in controlled studies and routine care.

Contributions of Lifestyle Behaviors to CMD Risk

Unhealthy diets high in saturated fat, sodium, and added sugar and low intake of fruits and vegetables are major contributors to premature mortality related to CMDs. Collectively, they account for up to 35% of cardiovascular disease (CVD)-related deaths. In addition, physical inactivity impacts CMD development and contributes an estimated 6% and 7% to CVD and type 2 diabetes (T2D) burden, respectively.

Moreover, sedentary behavior also increases the risk of CMDs. Although other lifestyle behaviors, such as chronic stress and sleep deprivation, are associated with a greater CMD risk, their contribution to the global CMD burden is unclear. The study highlights that unhealthy behaviors often cluster, particularly in disadvantaged communities, compounding the risk of premature death. Therefore, addressing multiple lifestyle behaviors concurrently is crucial to improving cardiometabolic health.

Effects of CLIs

CLIs are delivered by health professionals in structured and controlled programs and commonly target sedentary, physical activity, and dietary behaviors. Evidence indicates that CLIs have consistently reduced T2D incidence by about 40% over three to six years of intervention in high-risk individuals compared to usual care in controlled settings.

CLI effects are mainly driven by decreases in glycemic markers, body weight, blood pressure, and low-density lipoprotein cholesterol. Further, studies comparing CLIs to metformin, a glucose-lowering medicine, observed that the drug was about half as effective as CLIs. A network meta-analysis found that a CLI reduced T2D risk by 60% compared to pharmacotherapy, and this effect was partly persistent for many years post-intervention. For instance, the Finnish Diabetes Prevention Study reported a sustained 20% reduction in diabetes incidence 20 years after the intervention, highlighting the potential for long-term benefits.

Longitudinal evaluations of CLIs beyond the active intervention period have revealed T2D risk reduction, albeit to a lesser extent, over 3–20 years of follow-up. Despite these long-term benefits, meta-analyses have not observed long-term benefits of CLIs on CVD or all-cause mortality. However, the Da Qing Diabetes Prevention Study in China demonstrated a significant reduction in all-cause and CVD mortality after 23 years of follow-up, underlining the variability in outcomes across different settings.

CLI Implementation and Cost-Effectiveness

Studies have translated controlled CLIs to routine care settings, given their promising effects on T2D risk. A meta-analysis of 25 translational or before-after studies found about a third to half of the effectiveness noted in the original studies, with a clinically relevant weight loss after one year, leading to improvements in CMD risk factors.

Based on these analyses, diabetes prevention programs were implemented for high-risk individuals in Finland, the United States, Australia, and the United Kingdom. However, there is limited evidence on the effectiveness of these implementations, although the programs appear effective for people who completed them. Regarding the cost-effectiveness of CLIs, there is a paucity of evidence in routine practice. The study emphasizes the need for further economic evaluations, particularly in low- and middle-income countries where CMD prevalence is rising rapidly.

Population-Level Approaches for Healthy Lifestyles

Although CLIs have been effective at CMD prevention, targeting only high-risk individuals in routine care is insufficient to curb metabolic disease prevalence in the population. Therefore, measures targeting the entire population are needed. Population-based approaches have been successful in reducing smoking by 27% to 37%; this could be exemplary in informing policy decisions affecting other lifestyle behaviors.

Urban planning policies can also play a pivotal role in reducing CMD risk. For example, designing walkable neighborhoods and increasing access to green spaces have been associated with lower rates of T2D and CVD. Similarly, implementing sugar-sweetened beverage taxes and subsidizing fruits and vegetables can positively influence dietary habits, particularly in underserved populations.

Concluding Remarks

While CLIs yield CMD benefits in trials and clinically relevant improvements in translational studies, their long-term effects in routine practice require further evaluation. In addition, drivers and barriers to implementing CLIs in routine practice should be evaluated. Together, CLIs can yield clinically relevant metabolic health effects, especially when reinforced by policy measures and supportive environments targeting population-level lifestyle behaviors. As such, CLIs should remain an essential component of approaches to combat the CMD epidemic.