Healthy Lifestyle and the Risk of Stroke in Women Reducing Recurrent Stroke: Methodology of the Motivational Interviewing in Stroke (MIST) Randomized Clinical Trial Preventive effects of multiple domain interventions on lifestyle and risk factor changes in stroke survivors: Evidence from a two-year randomized trial A telehealth intervention to promote healthy lifestyles after stroke: The Stroke Coach protocol Primary Prevention of Stroke by Healthy Lifestyle Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial Utility of electronic patient records in primary care for stroke secondary prevention trials [The lifestyle modification coaching program for secondary stroke prevention]. Alcohol and Risk for Ischemic Stroke in Men: The Role of Drinking Patterns and Usual Beverage
BACKGROUND Healthy lifestyle has been associated with decreased risk of coronary heart disease . In contrast , little is known about its association with stroke risk . METHODS This is a prospect i ve cohort study among 37 636 women 45 years or older participating in the Women 's Health Study . Stroke was self-reported and confirmed by means of medical record review . We considered the following self-reported lifestyle factors : smoking , alcohol consumption , exercise , body mass index , and diet . The health index was calculated from these variables by assigning scores from 0 to 4 to the respective variable categories , with a higher score indicating healthier behavior . Healthy behavior was defined as never smoking , alcohol consumption between 4 and 10.5 drinks per week , exercise 4 or more times per week , body mass index ( calculated as weight in kilograms divided by the square of height in meters ) less than 22 , and a diet high in cereal fiber , folate , and omega-3 fatty acids , with a high ratio of polyunsaturated to saturated fat , and low in trans fat and glycemic load . RESULTS During 10 years of follow-up , 450 strokes ( 356 ischemic , 90 hemorrhagic , and 4 undefined ) were confirmed . Compared with participants with 0 to 4 health index points ( 4.3 % ) , women with 17 to 20 health index points ( 4.7 % ) had multivariable-adjusted hazard ratios ( 95 % confidence interval ) of 0.45 ( 0.24 - 0.83 ; P<.001 for trend ) for total stroke , 0.29 ( 0.14 - 0.63 ; P<.001 for trend ) for ischemic stroke , and 1.27 ( 0.37 - 4.29 ; P = .62 for trend ) for hemorrhagic stroke . CONCLUSIONS In this large prospect i ve cohort of apparently healthy women , a healthy lifestyle consisting of abstinence from smoking , low body mass index , moderate alcohol consumption , regular exercise , and healthy diet was associated with a significantly reduced risk of total and ischemic stroke but not of hemorrhagic stroke . Our findings underscore the importance of healthy behaviors in the prevention of stroke Rationale Recurrent stroke is prevalent in both developed and developing countries , contributing significantly to disability and death . Recurrent stroke rates can be reduced by adequate risk factor management . However , adherence to prescribed medications and lifestyle changes recommended by physicians at discharge after stroke is poor , leading to a large number of preventable recurrent strokes . Using behavior change methods such as Motivational Interviewing early after stroke occurrence has the potential to prevent recurrent stroke . Aims and /or hypothesis The overall aim of the study is to determine the effectiveness of motivational interviewing in improving adherence to medication and lifestyle changes recommended by treating physicians at and after hospital discharge in stroke patients 12 months poststroke to reduce risk factors for recurrent stroke . Design Recruitment of 430 first-ever stroke participants will occur in the Auckl and and Waikato regions . R and omization will be to intervention or usual care groups . Participants r and omized to intervention will receive four motivational interviews and five follow-up assessment s over 12 months . Nonintervention participants will be assessed at the same time points . Study outcomes Primary outcome measures are changes in systolic blood pressure and low-density lipoprotein levels 12 months poststroke . Secondary outcomes include self-reported adherence and barriers to prescribed medications , new cardiovascular events ( including stroke ) , changes in quality of life , and mood . Discussion The results of the motivational interviewing in stroke trial will add to our underst and ing of whether motivational interviewing may be potentially beneficial in the management of stroke and other diseases where similar lifestyle factors or medication adherence are relevant Background and aim Behavioral and lifestyle interventions in stroke patients need to be intense enough to result in sustainable treatment differences among groups of a r and omized trial . Therefore , we report the effects of multidomain interventions on lifestyle and laboratory parameters after 12 and 24 months from a trial that examined whether intensive risk factor management can prevent cognitive decline in ischemic stroke patients . Methods This prospect i ve r and omized , open-label , blinded endpoint trial recruited patients within three months after acute stroke in five Austrian neurological clinics during June 2010 and November 2012 . One hundred and one patients were r and omized into multidomain intervention and 101 into st and ard care . Lifestyle interventions were individualized to match predefined targets of regular physical activity , healthy diet , and adequate physiological risk factor control . Results A total of 167 participants ( 80 intervention , 87 control ) completed the 12-month visit and 155 ( 76 intervention , 79 control ) the 24-month visit . During the first 12 months , adherence to healthy lifestyle and adequately controlled physiological parameters ( measured by summary scores ) improved significantly in the intervention group compared to controls ( p < 0.01 ) . The consumption of reduced-fat milk ( p = 0.031 ) , reduced-fat spreads ( p = 0.007 ) , and fish ( p = 0.021 ) increased in the intervention group from baseline to 12 months but not in controls . After 24 months , the group difference was significant for the lifestyle summary score but no longer for the combined laboratory lifestyle score . Conclusions These results demonstrate that intensified individualized multidomain lifestyle interventions in stroke patients are effective in promoting healthy lifestyle in stroke care Rationale Recurrent stroke is prevalent and associated with high mortality rates , disability , and social and economic costs . Adequate management of risk factors may reduce recurrent stroke ; however , many stroke survivors have poor control of risk factors . We have developed a theoretically sound and evidence -based lifestyle modification program called the Stroke Coach , a telephone-based self-management program to improve control of risk factors . Hypothesis Individuals who participate in Stroke Coach will achieve more lifestyle improvements than individuals in an attention controlled Memory Training Program . Design In this single blind r and omized controlled trial , 126 community-living stroke survivors will be r and omized to Stroke Coach or the attention control group . Participants r and omized to the six-month Stroke Coach will receive seven telephone lifestyle coaching sessions , self-management education and practice , and a self-monitoring kit , comprised of a health report card , with blood pressure and activity monitors . Study Outcomes The primary outcome will be measured using the Health Promoting Lifestyle Profile II . Secondary outcomes include behavioral and physiological risk factors , quality of life , cognitive status , health and social service use . Measurements will be taken at baseline , immediately after the intervention and six-month post-intervention . Summary The results of this trial will add to our underst and ing of the use of self-management to improve control of risk factors , and may facilitate the development of a larger trial evaluating the effect of Stroke Coach on endpoints such as recurrent stroke or cardiac events as the primary outcome Background — The combination of healthy lifestyle factors is associated with lower risk of coronary heart disease , diabetes , and total cardiovascular disease . Little is known about the impact of multiple lifestyle factors on the risk of stroke . Methods and Results — We conducted a prospect i ve cohort study among 43 685 men from the Health Professionals Follow-up Study and 71 243 women from the Nurses ’ Health Study .  Diet and other lifestyle factors  were up date d from self-reported question naires . We defined a low-risk lifestyle as not smoking , a body mass index < 25 kg/m2 , ≥30 min/d of moderate activity , modest alcohol consumption ( men , 5 to 30 g/d ; women , 5 to 15 g/d ) , and scoring within the top 40 % of a healthy diet score . We documented 1559 strokes ( 853 ischemic , 278 hemorrhagic ) among women and 994 strokes ( 600 ischemic , 161 hemorrhagic ) among men during follow-up . Women with all 5 low-risk factors had a relative risk of 0.21 ( 95 % confidence interval [ CI ] , 0.12 , 0.36 ) for total and 0.19 ( 95 % CI , 0.09 , 0.40 ) for ischemic stroke compared with women who had none of these factors . Among men , the relative risks were 0.31 ( 95 % CI , 0.19 , 0.53 ) for total and 0.20 ( 95 % CI , 0.10 , 0.42 ) for ischemic stroke for the same comparison . Among the women , 47 % ( 95 % CI , 18 to 69 ) of total and 54 % ( 95 % CI , 15 to 78 % ) of ischemic stroke cases were attributable to lack of adherence to a low-risk lifestyle ; among the men , 35 % ( 95 % CI , 7 to 58 ) of total and 52 % ( 95 % CI , 19 to 75 ) of ischemic stroke may have been prevented . Conclusion — A low-risk lifestyle that is associated with a reduced risk of multiple chronic diseases also may be beneficial in the prevention of stroke , especially ischemic stroke Background Coronary Heart Disease and Cerebrovascular Disease share many predisposing , modifiable risk factors ( hypertension , abnormal blood lipids and lipoproteins , cigarette smoking , physical inactivity , obesity and diabetes mellitus ) . Lifestyle interventions and pharmacological therapy are recognised as the cornerstones of secondary prevention . Cochrane review has proven the benefits of programmes incorporating exercise and lifestyle counselling in the cardiac disease population . A Cochrane review highlighted as priority , the need to establish feasibility and efficacy of exercise based interventions for Cerebrovascular Disease . Methods A single blind r and omised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack ( TIA ) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure , lipid profile , smoking and diabetic status and lifestyle factors of habitual smoking , exercise and healthy eating participation . Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale , the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test .  A total of 144 patients , over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA , will be recruited from Dublin community stroke services and two tertiary T.I.A clinics . Exclusion criteria will include oxygen dependence , unstable cardiac conditions , uncontrolled diabetes , major medical conditions , claudication , febrile illness , pregnancy or cognitive impairment . Participants will be block-statified , r and omly allocated to one of two groups using a pre-prepared computer generated r and omisation schedule . Both groups will receive a two hour education class on  risk reduction  post stroke  .  The intervention group will receive a 10 week programme of supervised aerobic exercises ( twice weekly ) and individually tailored brief intervention lifestyle counselling . Both groups will be tested on week one and week ten of the programme . Follow-up at 1 year will assess longer term benefits . Analysis will test for significant changes in the key variables indicated . Discussion Application of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology . It is hoped the anticipated improvement in vascular risk factors and fitness result ing from such a programme will enhance health and social gain in this population .Trial Registration Current Controlled Trials ISCTRN90272638 Background This study aim ed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records ( EPRs ) as potential outcome measures . The study also evaluated achievement of recommended st and ards of care ; variation between family practice s ; and changes in risk factor values from before to after stroke . Methods Data from the UK General Practice Research Data base ( GPRD ) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practice s. For each subject , the EPR was evaluated for the 12 months before and after stroke . Measures relevant to stroke secondary prevention were analysed including blood pressure ( BP ) , cholesterol , smoking , alcohol use , body mass index ( BMI ) , atrial fibrillation , utilisation of antihypertensive , antiplatelet and cholesterol lowering drugs . Intraclass correlation coefficients ( ICC ) were estimated by family practice . R and om effects models were fitted to evaluate changes in risk factor values over time . Results In the 12 months following stroke , BP was recorded for 90 % , cholesterol for 70 % and body mass index ( BMI ) for 47 % . ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol . For subjects with records available both before and after stroke , the mean reductions from before to after stroke were : mean systolic BP , 6.02 mm Hg ; diastolic BP , 2.78 mm Hg ; total cholesterol , 0.60 mmol/l ; BMI , 0.34 Kg/m2 . There was an absolute reduction in smokers of 5 % and heavy drinkers of 4 % . The proportion of stroke patients within the recommended guidelines varied from less than a third ( 29 % ) for systolic BP , just over half for BMI ( 54 % ) , and over 90 % ( 92 % ) on alcohol consumption . Conclusions Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention . Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke . Better recording of lifestyle factors in the GPRD has the potential to exp and the scope of the GPRD for health care research and practice PURPOSE The purpose of this study was to investigate the effects of the lifestyle modification coaching program on self efficacy , lifestyle and physiologic indexes related to the recurrence of stroke in patients with stroke . METHODS Sixty-one patients with stroke registered with a stroke center participated in this study . Of the participants , 32 were assigned to the experimental group and 29 to the control group .  Self efficacy , alcohol drinking , smoking , physical activity , BMI ( body mass index ) , WHR ( waist-hip ratio ) , blood lipid level , and blood pressure were measured both for the baseline , as well as after intervention . The lifestyle modification coaching program consisted of an 8-week telecoaching session following face-to-face education . The control group received only the face-to-face education . RESULTS There were significant differences in physical activities , WHR , blood pressure within and between groups after intervention . The lifestyle modification coaching program had significant influences on blood pressure even after gender , age , and physical activity had been adjusted . CONCLUSION The results of the study indicate that lifestyle modification coaching program is effective for physical activity , abdominal obesity and blood pressure . Therefore it can be used by nurses in hospitals and communities as one of the secondary stroke prevention programs for patients with stroke Context Past studies do n't clearly show that alcohol consumption affects the risk for ischemic stroke . Contribution This prospect i ve cohort study involving 38156 male health professionals followed for 14 years found that consuming more than 2 drinks daily was associated with an increased risk for ischemic stroke . Two drinks or fewer were not associated with increased risk .  Consuming red wine , but not other beverage types , was associated with a lower risk . Caution s The study had limited power to determine the precise drinking patterns that were associated with stroke risk . Implication s These findings support public health recommendations to avoid consuming more than 2 drinks daily . The Editors Although epidemiologic studies consistently link moderate alcohol consumption with a lower risk for myocardial infa rct ion ( 1 ) , the relationship between alcohol consumption and ischemic stroke is less clear . However , previous studies of alcohol consumption and ischemic stroke have often had important limitations , including failure to assess drinking pattern , assessment s of alcohol intake that have not been vali date d , failure to distinguish stroke subtypes , insufficient follow-up to incorporate changes in alcohol use over time , and lack of control for various healthy lifestyle features associated with moderate drinking ( 2 , 3 ) . Another area of controversy is the role of beverage type . Red wine contains specific phenolic compounds that may prevent oxidation of low-density lipoprotein cholesterol and inhibit smooth-muscle cell proliferation ( 4 , 5 ) . In keeping with these experimental findings , the Copenhagen City Heart Study reported that consumption of wine , but not of beer or liquor , was associated with a lower risk for stroke ( mostly ischemic ) ( 6 ) . However , a healthier lifestyle among wine drinkers , rather than the nonalcoholic components of wine , may explain the apparent benefits attributable to wine ( 7 ) . Most previous studies of alcohol and ischemic stroke did not account for dietary and other lifestyle differences among wine drinkers , drinkers of other alcoholic beverages , and abstainers . To address these questions , we studied the relationship between alcohol consumption and incident ischemic stroke over a 14-year period among 38156 participants of the Health Professionals Follow-up Study ( 8) , a prospect i ve cohort of male health professionals in the United States . In these analyses , we assessed how drinking pattern , baseline and up date d measures of alcohol consumption , and individual beverage types influence the association of alcohol consumption with risk for ischemic stroke . Methods The Health Professionals Follow-up Study enrolled 51529 U.S. male dentists , veterinarians , optometrists , pharmacists , osteopathic physicians , and podiatrists 40 to 75 years of age who returned a mailed question naire regarding diet and medical history in 1986 . Follow-up question naires were sent biennially to up date information on exposures and newly diagnosed illnesses . For this analysis , we excluded 5544 men who reported a baseline history of cardiovascular disease or cancer ( other than nonmelanoma skin cancer ) , 1706 who had missing or implausible nutritional information at baseline ( including missing alcohol consumption , 70 missing food items , or estimated daily energy intake 800 or 4200 kcal ) , and 89 whose initial question naires had other technical problems . To minimize the inclusion of sick quitters , we also excluded 6034 men who consumed no alcohol at baseline but who reported that they had consumed alcohol in the previous 10 years , leaving 38156 men eligible for analysis . We assessed alcohol consumption within a 131-item semi-quantitative food-frequency question naire . The question naire included separate items about beer , white wine , red wine , and liquor . We specified st and ard portions as a glass , bottle , or can of beer ; a 4-ounce glass of wine ; and a shot of liquor . For each beverage , participants were asked how often , on average over the past year , they consumed that amount . We calculated ethanol intake by multiplying the frequency of consumption of each beverage by the alcohol content of the specified portion size ( 12.8 g for beer , 11.0 g for wine , and 14.0 g for liquor ) and summing across beverages ( 9 ) . This process was repeated in 1990 , 1994 , and 1998 , with an added item about light beer in 1994 . In 1986 , men also reported the number of days per week that they typically drank any form of alcohol . We previously assessed the validity of alcohol consumption estimated with the food-frequency question naire by comparing it with intake from two 1-week dietary records collected approximately 6 months apart among 136 participants residing in eastern Massachusetts ( 10 , 11 ) ; the Spearman correlation coefficient between these 2 measures was 0.86 . Estimated mean alcohol intake was 12.8 g/d using dietary records and 12.5 g/d with the food-frequency question naire , with no evidence of apparent systematic bias . The correlation coefficient for drinking frequency between our question naire and diet records was 0.79 . Alcohol consumption estimated from the question naires also correlated well with serum high-density lipoprotein cholesterol concentrations , with a Spearman correlation coefficient of 0.31 to 0.35 . We wrote to participants who reported an incident stroke on the follow-up question naires to confirm the report and request permission to review medical records . We defined a stroke as confirmed if it produced a typical neurologic deficit of rapid or sudden onset lasting 24 hours or more and was attributable to a cerebrovascular event . Physicians blinded to risk factor status conducted the medical record review . We defined a stroke as probable if we could not obtain medical records but the participant required hospitalization and the diagnosis was corroborated by supplementary correspondence ; only 1.2 % of included cases were considered probable rather than confirmed , and their exclusion did not affect our results . We categorized stroke types according to National Survey of Stroke criteria ( 12 ) , with categories of ischemic ( embolic or thrombotic ) , hemorrhagic ( subarachnoid or intracerebral ) , and unknown . We confirmed fatal strokes by using medical records ( 84 % ) , autopsy reports ( 2 % ) , or death certificates supplemented by confirmatory evidence from family members or previously collected medical history when medical records and autopsy reports were unavailable ( 14 % ) . There were too few cases of hemorrhagic stroke to study it separately in these analyses . Deaths were reported by families and postal officials and through the National Death Index . Follow-up for deaths was over 98 % complete when these sources were combined in a similar study among women ( 13 ) . Covariate information was generally derived from biennial question naires . Nutritional information ( energy , saturated fat , trans fatty acids , folate , vitamin E , magnesium , potassium , -3 fatty acids , dietary fiber , and caffeine ) was derived from food-frequency question naires administered every 4 years . Participants reported the presence of cardiovascular risk factors ( physician-diagnosed hypertension , diabetes , and hypercholesterolemia ; cigarette smoking ; and parental history of myocardial infa rct ion ) . Aspirin use included use of aspirin and aspirin-containing products at least twice weekly . Nutritional variables , anthropomorphic measures , aspirin use , and self-reported cardiovascular risk factors have been vali date d ( 14 - 19 ) . We calculated person-years for each participant from the date of return of the 1986 question naire to the date of the first stroke , the date of death , or January 2000 . We calculated incidence rates by dividing the number of ischemic strokes in each category by person-years of follow-up in that category . The relative risk was computed as the rate in a specific category of alcohol consumption divided by the rate in abstainers , with direct adjustment for age in 5-year categories and smoking in 6 categories ( never , former , 1 to 14 cigarettes/d , 15 to 24 cigarettes/d , 25 cigarettes/d , and missing ) . As in previous multivariate analyses ( 20 ) , we used pooled logistic regression and up date d covariates ( 21 ) . We simultaneously controlled for age ; smoking ; body mass index ( in quintiles ) ; aspirin use ; diabetes ; hypercholesterolemia ; average daily exertion ( in 5 categories ) ; energy intake ( in quintiles ) ; parental history of myocardial infa rct ion at or before age 60 years ; and energy-adjusted intake of saturated fat , trans fatty acids , folate , vitamin E , and dietary fiber ( each in quintiles ) , along with geographic region ( in 4 categories ) ( 22 ) and energy-adjusted intake of magnesium and potassium ( 23 ) and -3 fatty acids ( 24 ) . We did not include hypertension as a covariate in primary analyses but included it in sensitivity analyses to assess the degree to which it may mediate a positive association between alcohol use and risk for stroke . Dietary variables  were up date d every 4 years ; other potential confounding variables were up date d every 2 years . We assigned indicator variables where smoking or exercise information was missing , accounting for 12 % and 15 % of cumulative person-time , respectively . We stopped updating alcohol use at development of cancer ( other than nonmelanoma skin cancer ) , cardiovascular disease ( other than stroke ) , or hypertension ; analyses that censored participants at diagnosis of cancer or cardiovascular disease yielded similar results ( Appendix Table 1 ) . We conducted tests of linear trend across increasing categories of alcohol consumption by treating the midpoints of consumption in categories as a continuous variable . In most analyses , we categorized participants as abstainers , light drinkers ( 0.1 to 9.9 g/d ) , moderate drinkers ( 10 to 29.9 g/d ) , and heavier drinkers ( 30.0 g/d ) . These categories approximately correspond to average intake of no alcohol , less than 1 st and ard drink per day , 1 to 2 drinks per day , and more than 2 drinks per day . We performed primary analyses by
Conclusion Stroke secondary prevention lifestyle interventions are effective in terms of effecting positive change in lifestyle behaviors and secondary outcomes , and appear promising in relation to physiological outcomes .
There was insufficient evidence to determine the effect of intervention on incidence of stroke recurrence
Background A feature of stroke is that it recurs ( 25 % within five-years ) .
Risk factors for stroke and recurrent stroke include smoking , alcohol consumption , poor diet , and physical inactivity .
Aim To evaluate the effectiveness of secondary prevention lifestyle interventions design ed to change lifestyle behavior following stroke .
This short paper presents a summary of the systematic review process and findings .