Skip to main content

The contribution of changes in diet, exercise, and stress management to changes in coronary risk in women and men in the Multisite Cardiac Lifestyle Intervention Program


Background: The relative contribution of health behaviors to coronary risk factors in multicomponent secondary coronary heart disease (CHD) prevention programs is largely unknown.Purpose: Our purpose is to evaluate the additive and interactive effects of 3-month changes in health behaviors (dietary fat intake, exercise, and stress management) on 3-month changes in coronary risk and psychosocial factors among 869 nonsmoking CHD patients (34% female) enrolled in the health insurance-based Multisite Cardiac Lifestyle Intervention Program.Methods: Analyses of variance for repeated measures were used to analyze health behaviors, coronary risk factors, and psychosocial factors at baseline and 3 months. Multiple regression analyses evaluated changes in dietary fat intake and hours per week of exercise and stress management as predictors of changes in coronary risk and psychosocial factors.Results: Significant overall improvement in coronary risk was observed. Reductions in dietary fat intake predicted reductions in weight, total cholesterol, low-density lipoprotein cholesterol, and interacted with increased exercise to predict reductions in perceived stress. Increases in exercise predicted improvements in total cholesterol and exercise capacity (for women). Increased stress management was related to reductions in weight, total cholesterol/high-density lipoprotein cholesterol (for men), triglycerides, hemoglobin A1c (in patients with diabetes), and hostility.Conclusions: Improvements in dietary fat intake, exercise, and stress management were individually, additively and interactively related to coronary risk and psychosocial factors, suggesting that multicomponent programs focusing on diet, exercise, and stress management may benefit patients with CHD.

This is a preview of subscription content, access via your institution.


  1. (1)

    American Heart Association:Heart Disease and Stroke Statistics—2005 Update. Dallas, TX: Author, 2005.

    Google Scholar 

  2. (2)

    Yusuf S, Hawken S, Ounpuu S, et al.: Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART Study): Case-control study.Lancet. 2004,364:937–952.

    PubMed  Article  Google Scholar 

  3. (3)

    Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L: The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: The emerging field of behavioral cardiology.Journal of the American College of Cardiology. 2005,45:637–651.

    PubMed  Article  Google Scholar 

  4. (4)

    Ades PA: Cardiac rehabilitation and secondary prevention of coronary heart disease.New England Journal of Medicine. 2001,345:892–902.

    PubMed  Article  CAS  Google Scholar 

  5. (5)

    van Dixhoorn J, White A: Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: A systematic review and meta-analysis.European Journal of Cardiovascular and Preventive Rehabilitation. 2005,12:193–202.

    Article  Google Scholar 

  6. (6)

    Koertge J, Weidner G, Elliott-Eller M, et al.: Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project.American Journal of Cardiology. 2003,91:1316–1322.

    PubMed  Article  Google Scholar 

  7. (7)

    Haskell WL, Alderman EL, Fair JM, et al.: Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP).Circulation. 1994,89:975–990.

    PubMed  CAS  Google Scholar 

  8. (8)

    Linden W: Psychological treatments in cardiac rehabilitation: review of rationales and outcomes.Journal of Psychosomatic Research. 2000,48:443–454.

    PubMed  Article  CAS  Google Scholar 

  9. (9)

    Lisspers J, Sundin O, Ohman A, et al.: Long-term effects of lifestyle behavior change in coronary artery disease: Effects on recurrent coronary events after percutaneous coronary intervention.Health Psychology. 2005,24:41–48.

    PubMed  Article  Google Scholar 

  10. (10)

    Ornish D, Scherwitz LW, Billings JH, et al.: Intensive lifestyle changes for reversal of coronary heart disease: Five-year follow-up of the Lifestyle Heart Trial.Journal of the American Medical Association. 1998,280:2001–2007.

    PubMed  Article  CAS  Google Scholar 

  11. (11)

    Ornish D: Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project.American Journal of Cardiology. 1998,82:72T-76T.

    PubMed  Article  CAS  Google Scholar 

  12. (12)

    Gould KL, Ornish D, Scherwitz L, et al.: Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification.Journal of the American Medical Association. 1995,274:894–901.

    PubMed  Article  CAS  Google Scholar 

  13. (13)

    Denke MA: Cholesterol-lowering diets. A review of the evidence.Archives of Internal Medicine. 1995,155:17–26.

    PubMed  Article  CAS  Google Scholar 

  14. (14)

    Blumenthal JA, Sherwood A, Babyak MA, et al.: Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: A randomized controlled trial.Journal of the American Medical Association. 2005,293:1626–1634.

    PubMed  Article  CAS  Google Scholar 

  15. (15)

    Taylor RS, Brown A, Ebrahim S, et al.: Exercise-based rehabilitation for patients with coronary heart disease: Systematic review and meta-analysis of randomized controlled trials.American Journal of Medicine. 2004,116:682–692.

    PubMed  Article  Google Scholar 

  16. (16)

    Frasure-Smith N, Prince R: The ischemic heart disease life stress monitoring program: Impact on mortality.Psychosomatic Medicine. 1985,47:431–445.

    PubMed  CAS  Google Scholar 

  17. (17)

    Friedman M, Thoresen CE, Gill JJ, et al.: Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: Summary results of the recurrent coronary prevention project.American Heart Journal. 1986,112:653–665.

    PubMed  Article  CAS  Google Scholar 

  18. (18)

    Pickering TG: Lifestyle modification and blood pressure control: Is the glass half full or half empty?Journal of the American Medical Association. 2003,289:2131–2132.

    PubMed  Article  Google Scholar 

  19. (19)

    Gordon NF, Scott CB, Levine BD: Comparison of single versus multiple lifestyle interventions: Are the antihypertensive effects of exercise training and diet-induced weight loss additive?American Journal of Cardiology. 1997,79:763–767.

    PubMed  Article  CAS  Google Scholar 

  20. (20)

    Jakicic JM, Wing RR, Winters-Hart C: Relationship of physical activity to eating behaviors and weight loss in women.Medicine and Science in Sports and Exercise. 2002,34:1653–1659.

    PubMed  Article  CAS  Google Scholar 

  21. (21)

    Billings JH: Maintenance of behavior changes in cardiorespiratory risk reduction: A clinical perspective from the Ornish Program for reversing coronary heart disease.Health Psychology. 2000,19:70–75.

    PubMed  Article  CAS  Google Scholar 

  22. (22)

    Franklin B, Whaley M, Howley E (eds):ACSM’s Guidelines for Exercise Testing and Prescription (4th Ed.). Philadelphia: Lippincott, 1991.

    Google Scholar 

  23. (23)

    Karvonen MJ, Kentala E, Mustala O: The effects of training on heart rate: A longitudinal study.Annales Medicinae Experimentalis et Biologiae Fenniae. 1957,35:307–15.

    PubMed  CAS  Google Scholar 

  24. (24)

    Perloff D, Grim C, Flack J, et al.: Human blood pressure determination by sphygmomanometry.Circulation. 1993,88:2460–70.

    PubMed  CAS  Google Scholar 

  25. (25)

    Medicare, Medicaid and CLIA programs: Regulations implementing Clinical Laboratory Improvement Amendments of 1988 (CLIA).Federal Register. 1992,57:7002

    Google Scholar 

  26. (26)

    Radloff LS: The CES-D Scale: A self-report depression scale for research in the general population.Applied Psychological Measurements. 1977,1:385–401.

    Article  Google Scholar 

  27. (27)

    Barefoot JC, Dodge KA, Peterson BL, Dahlstrom WG, Williams RB Jr: The Cook-Medley hostility scale: Item content and ability to predict survival.Psychosomatic Medicine. 1989,51:46–57.

    PubMed  CAS  Google Scholar 

  28. (28)

    Cohen S, Kamarck T, Mermelstein R: A global measure of perceived stress.Journal of Health and Social Behavior. 198324:385–396.

    PubMed  Article  CAS  Google Scholar 

  29. (29)

    Allison PD: Change scores as dependent variables in regression analysis.Sociological Methodology. 1990,20:93–114.

    Article  Google Scholar 

  30. (30)

    Cronbach LJ, Furby L: How should we measure change—or should we?Psychological Bulletin. 1970,74:68–80.

    Article  Google Scholar 

  31. (31)

    Glymour MM, Weuve J, Berkman LF, Kawachi I, Robins JM: When is baseline adjustment useful in analyses of change? An example with education and cognitive change.American Journal of Epidemiology. 2005,162:267–278.

    PubMed  Article  Google Scholar 

  32. (32)

    Brinton EA, Eisenberg S, Breslo JL: A low fat diet decreases high density lipoprotein (HDL) cholesterol concentrations by decreasing HDL apolipoprotein transport rates.Journal of Clinical Investigation. 1990,85:144–151.

    PubMed  Article  CAS  Google Scholar 

  33. (33)

    Ornish D, Brown SE, Scherwitz LW, et al.: Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial.Lancet. 1990,336:129–133.

    PubMed  Article  CAS  Google Scholar 

  34. (34)

    Ornish D, Scherwitz LW, Doody RS, et al.: Effects of stress management training and dietary changes in treating ischemic heart disease.Journal of the American Medical Association. 1983,249:54–59.

    PubMed  Article  CAS  Google Scholar 

  35. (35)

    Hu FB, Willett WC: Optimal diets for prevention of coronary heart disease.Journal of the American Medical Association. 2002,288:2569–2578.

    PubMed  Article  CAS  Google Scholar 

  36. (36)

    Weidner G, Connor SL, Hollis JF, Connor WE: Improvements in hostility and depression in relation to dietary change and cholesterol lowering. The Family Heart Study.Annals of Internal Medicine. 1992,117:820–823.

    PubMed  CAS  Google Scholar 

  37. (37)

    Griffin KW, Weidner G: Cholesterol-lowering and psychological well-being.Comprehensive Therapy. 1994,20:518–522.

    PubMed  CAS  Google Scholar 

  38. (38)

    Brochu M, Poehlman ET, Savage P, et al.: Modest effects of exercise training alone on coronary risk factors and body composition in coronary patients.Journal of Cardiopulmonary Rehabilitation. 2000,20:180–188.

    PubMed  Article  CAS  Google Scholar 

  39. (39)

    Berlin JA, Colditz GA: A meta-analysis of physical activity in the prevention of coronary heart disease.American Journal of Epidemiology. 1990,132:612–628.

    PubMed  CAS  Google Scholar 

  40. (40)

    Lawlor DA, Hopker SW: The effectiveness of exercise as an intervention in the management of depression: Systematic review and meta-regression analysis of randomised controlled trials.British Medical Journal. 2001,322:763–767.

    PubMed  Article  CAS  Google Scholar 

  41. (41)

    Blumenthal JA, Babyak MA, Moore KA, et al.: Effects of exercise training on older patients with major depression.Archives of Internal Medicine. 1999,159:2349–2356.

    PubMed  Article  CAS  Google Scholar 

  42. (42)

    Matthews KA, Gump BB, Harris KF, Haney TL, Barefoot JC: Hostile behaviors predict cardiovascular mortality among men enrolled in the Multiple Risk Factor Intervention Trial.Circulation. 2004,109:66–70.

    PubMed  Article  Google Scholar 

  43. (43)

    Barefoot JC, Larsen S, von der Lieth L, Schroll M: Hostility, incidence of acute myocardial infarction, and mortality in a sample of older Danish men and women.American Journal of Epidemiology. 1995,142:477–484.

    PubMed  CAS  Google Scholar 

  44. (44)

    Kristal AR, Littman AJ, Benitez D, White E: Yoga practice is associated with attenuated weight gain in healthy, middle-aged men and women.Alternative Therapies in Health and Medicine. 2005,11:28–33.

    PubMed  Google Scholar 

  45. (45)

    Daubenmier JJ: The relationship of yoga, body awareness, and body responsiveness to self-objectification and disordered eating.Psychology of Women Quarterly. 2005,29:207–219.

    Article  Google Scholar 

  46. (46)

    Epel E, Lapidus R, McEwen B, Brownell K: Stress may add bite to appetite in women: A laboratory study of stress-induced cortisol and eating behavior.Psychoneuroendocrinology. 2001,26:37–49.

    PubMed  Article  CAS  Google Scholar 

  47. (47)

    Black PH, Garbutt LD: Stress, inflammation and cardiovascular disease.Journal of Psychosomatic Research. 2002,52:1–23.

    PubMed  Article  Google Scholar 

  48. (48)

    Stoney CM, Bausserman L, Niaura R, Marcus B, Flynn M: Lipid reactivity to stress: II. Biological and behavioral influences.Health Psychology. 1999,18:251–261.

    PubMed  Article  CAS  Google Scholar 

  49. (49)

    Linden W, Stossel C, Maurice J: Psychosocial interventions for patients with coronary artery disease: A meta-analysis.Archives of Internal Medicine. 1996,156: 745–752.

    PubMed  Article  CAS  Google Scholar 

  50. (50)

    Ismail K, Winkley K, Rabe-Hesketh S: Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes.Lancet. 2004,363:1589–1597.

    PubMed  Article  Google Scholar 

  51. (51)

    Surwit RS, Schneider MS: Role of stress in the etiology and treatment of diabetes mellitus.Psychosomatic Medicine. 1993,55:380–393.

    PubMed  CAS  Google Scholar 

  52. (52)

    Rosmond R: Role of stress in the pathogenesis of the metabolic syndrome.Psychoneuroendocrinology. 2005,30:1–10.

    PubMed  Article  CAS  Google Scholar 

  53. (53)

    Hammerfald K, Eberle C, Grau M, et al.: Persistent effects of cognitive-behavioral stress management on cortisol responses to acute stress in healthy subjects: A randomized controlled trial.Psychoneuroendocrinology. 2005,31:333–339.

    PubMed  Article  Google Scholar 

  54. (54)

    Chandalia M, Garg A, Lutjohann D, et al.: Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus.New England Journal of Medicine. 2000,342:1392–1398.

    PubMed  Article  CAS  Google Scholar 

  55. (55)

    Atkins RC, Ornish D, Wadden T: Low-carb, low-fat diet gurus face off.Journal of the American Medical Association. 2003,289:1767–1773.

    PubMed  Article  Google Scholar 

  56. (56)

    Caulin-Glaser T, Blum M, Schmeizl R, et al.: Gender differences in referral to cardiac rehabilitation programs after revascularization.Journal of Cardiopulmonary Rehabilitation. 2001,21:24–30.

    PubMed  Article  CAS  Google Scholar 

  57. (57)

    Scott LA, Ben-Or K, Allen JK: Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion.Journal of Women’s Health. 2002,11:773–791.

    PubMed  Article  Google Scholar 

  58. (58)

    Mosca L, Manson JE, Sutherland SE, et al.: Cardiovascular disease in women: A statement for healthcare professionals from the American Heart Association.Circulation. 1997,96:2468–2482.

    PubMed  CAS  Google Scholar 

  59. (59)

    Evenson, KR, Rosamond, WD, Luepker, RV: Predictors of outpatient cardiac rehabilitation utilization: The Minnesota Heart Survey Registry.Journal of Cardiopulmonary Rehabilitation. 1998,18:192–198.

    PubMed  Article  CAS  Google Scholar 

  60. (60)

    Moore SM, Kramer FM: Women’s and men’s preferences for cardiac rehabilitation program features.Journal of Cardiopulmonary Rehabilitation. 1996,16:163–168.

    PubMed  Article  CAS  Google Scholar 

  61. (61)

    Centers for Medicare and Medicaid Services:Decision Memo for Cardiac Rehabilitation Programs (CAG-00089R). Retrieved January 3, 2007 from viewdecisionmemo.asp?id=164.

Download references

Author information



Corresponding author

Correspondence to Gerdi Weidner Ph.D..

Additional information

This study was supported in part by a grant from the Department of the Army (U.S. Army Medical Research Acquisition Activity W81XWH-06-2-0565) and the Department of Health and Human Services (Health Resources and Services Administration #4C76HF00803-01-01) and does not reflect the position or the policy of the government; Highmark, Inc.; Safeway, Inc.; and the PepsiCo Foundation.

About this article

Cite this article

Daubenmier, J.J., Weidner, G., Sumner, M.D. et al. The contribution of changes in diet, exercise, and stress management to changes in coronary risk in women and men in the Multisite Cardiac Lifestyle Intervention Program. ann. behav. med. 33, 57–68 (2007).

Download citation


  • Health Behavior
  • Psychosocial Factor
  • Cardiac Rehabilitation
  • Behavioral Medicine
  • Stress Management