The case for targeted mid-life interventions to prevent cardiovascular disease

To the editor:

Mid-life (the life stage spanning ages 45 to 64) is a critical period for cardiovascular health and are a rapidly growing age group across the U.S. and Western Europe.^1,2 During mid-life, the onset of cardiac-risk conditions, including hypertension³ and type 2 diabetes,⁴ is very common and likely contributes to subsequent emergence of major cardiac events such as myocardial infarction (mean age of onset in Americans between 65–72⁵) in the years immediately following mid-life.

A substantial contributor to the development cardiac disease in mid-life is poor adherence to health behaviors. Most mid-life adults do not meet recommended levels of physical activity,⁶ despite evidence that physical activity in mid-life is linked to lower rates of cardiac illness and greater survival over the following decade.^7,8 Likewise, many mid-life persons have an unhealthy diet,⁹ smoke,¹⁰ or engage in binge drinking,¹¹ all of which are also linked to heart disease.

Why is mid-life adherence to cardiac health behaviors poor? Multiple competing demands in mid-life can conspire to impede cardiac health behavior participation.¹² Many mid-life persons are at the pinnacle of their career, leading to more occupational demands and responsibilities.¹³ Furthermore, they often have greater financial pressures related to mortgages, child care, tuition, and medical expenses,¹⁴ and in many cases they must provide care to children, adolescents, aging parents, or other family.¹⁵

Indeed, in qualitative interviews in cardiac-related populations, mid-life persons report rates of occupational, financial, and caregiving stressors that were vastly higher than in other adults with the same conditions, and these stressors led to substantial time pressure.¹⁶ These convergent factors may also contribute to greater psychological distress observed in mid-life persons at cardiac risk compared to older adults,¹⁶ and to the observation in the U.S., Europe, Asia, and Latin America that there is a U-shaped curve of psychological well-being that reaches its nadir during mid-life.¹⁷ Such a combination of stress, time pressure, and low overall well-being can serve as a major barrier for mid-life adults to maintain healthy lifestyles.¹⁸

What can be done? Existing programs to promote health behaviors (e.g., programs based on the Diabetes Prevention Program¹⁹) have been effective in specific settings and populations but may be suboptimal for many mid-life adults. First, many of these programs require substantial time commitments, with repeated in-person sessions and requirements for travel and transportation; these factors may be suboptimal for busy, stressed mid-life adults. Indeed, participation in such programs appears to be lower in mid-life, even among those with existing illness (e.g., cardiac rehabilitation).²⁰ Second, such programs are not tailored to the above-mentioned common mid-life circumstances and barriers to health behaviors that can impede the maintenance of any changes made during the program.

To be effective, mid-life health promotion programs should target the needs of this population. For example, such programs could utilize content that is focused on challenges common in mid-life, such as difficulties with time management or coping with parental or caregiver stress, that serve as barriers to completing physical activity and other health self-management tasks in mid-life adults. Specific modular content on these areas, such as caregiving-focused interventions,^21,22 could facilitate lasting changes in health behaviors.

In addition, such programs might utilize evidence-based interventions that specifically promote stress reduction, such as mindfulness meditation²³ or mindfulness based-stress reduction,²⁴ or programs that cultivate well-being, such as positive psychology interventions.²⁵ These programs have been used in patients at elevated cardiac risk, appear to be effective and well-accepted,^26–29 and could target the high stress and low overall well-being associated with mid-life that can sap energy, optimism, and motivation. Finally, given the time pressure and multiple competing demands experienced by mid-life persons, interventions that can be delivered remotely by phone, video, text, or mobile application may be substantially more likely to lead to broad engagement.³⁰

Societal factors are also important and can explain differences in well-being and health in midlife (and all) adults in different locations. Countries that have extensive social support networks with universal health coverage, broad parental leave, culture of greater time away from work, and greater income equality—all of which address midlife stressors common in the U.S.—appear to have greater well-being³¹ and longer life expectancy.³² Finally, it is important to consider other life stages. Developing healthy lifestyles early in life for primordial prevention is critical to mid-life health³³, while addressing the issues of older adults, who have the highest rates of cardiac events,³⁴ is critical to prevent initial or recurrent events.

In sum, mid-life adults are at high risk for the development and progression of cardiac risk factors and heart disease. The life circumstances of mid-life adults make adherence to key cardiac health behaviors challenging, and existing interventions may not optimally address these circumstances. However, with specifically targeted interventions, there may be a great opportunity to improve the health trajectory of individuals during this critical phase of life.