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Effectiveness of Life Style Modification on Lipid Profile for Patients with

Hyperlipidemia

Article  in  American Journal of Nursing Science · January 2020

DOI: 10.11648/j.ajns.20200901.12

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American Journal of Nursing Science 2020; 9(1): 8-18

http://www.sciencepublishinggroup.com/j/ajns

doi: 10.11648/j.ajns.20200901.12

ISSN: 2328-5745 (Print); ISSN: 2328-5753 (Online)

Effectiveness of Life Style Modification on Lipid Profile for Patients with Hyperlipidemia

Magda Moawad Mohsen 1 , Neima Ali Riad

2 , Amina Ibrahim Badawy

2, * ,

Badria Mahrous Abd El-Hammed 2, 3

, Dalia Mahmoud Abd Elmonem Elsherbini 4, 5

1Community Health Nursing, Faculty of Nursing, Menoufia University, Al Minufya, Egypt 2Medical-Surgical Nursing, Faculty of Nursing Menoufia University, Al Minufya, Egypt 3Nursing Department, Faculty of Applied Medical Science, Al Baha University, Al Baha, Saudi Arabia 4Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka, Saudi Arabia 5Department of Human Anatomy and Embryology, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Email address:

*Corresponding author

To cite this article: Magda Moawad Mohsen, Neima Ali Riad, Amina Ibrahim Badawy, Badria Mahrous Abd El-Hammed, Dalia Mahmoud Abd Elmonem

Elsherbini. Effectiveness of Life Style Modification on Lipid Profile for Patients with Hyperlipidemia. American Journal of Nursing Science.

Vol. 9, No. 1, 2020, pp. 8-18. doi: 10.11648/j.ajns.20200901.12

Received: December 9, 2019; Accepted: December 23, 2019; Published: January 4, 2020

Abstract: Background: Major predisposing factors of Coronary artery diseases were urbanized lifestyles and growth of

ageing populations in developing country like Egypt. The modifiable risk factors for cardiovascular disease (CVD) such as

hyperlipidemia, diabetes mellitus, and obesity are likely to increase in the future, but they can be controlled through lifestyle

modification. Aim of the study: This study was carried out to examine the effect of life style modification for patients with

hyperlipidemia on their lipids profile. Design: Quasi experimental design was utilized. Setting This study was conducted

among the patients attending at cardiac outpatient department, Menoufia University Hospital, Menoufia Governorate, Egypt.

Subject: A purposive sample of 100 men and women attending cardiac outpatient clinic were selected. The subjects were

divided equally into study and control groups. Instrumentations: a. Structured interview questionnaire: it consists of

sociodemographic and medical data b. Bio-physiological measurement: Fasting venous blood samples for Glycosylated

hemoglobin level, Lipid profile were obtained from all participants, and sent to biochemistry laboratories. Blood pressure

assessment and BMI for all patients were compiled. Results: Statistical analysis showed that there were statistical differences

among study and control group regard to total cholesterol, triglyceride, high-density lipoprotein cholesterol and low-density

lipoprotein cholesterol and their arterial blood pressure level. Conclusion: The need for tailoring and following up of

intervention for coronary artery diseases is an essential maneuver to reduce their risk factors occurrence. Recommendations:

Implementation of lifestyle modification for at risk patient for coronary artery diseases by modifying their lifestyle. Routine

screening for all subjects above the age of forty to detect abnormal lipid profile early and to increase their awareness to prevent

and control of cardiovascular disease (CVD) is recommended.

Keywords: Life Style Modification, Lipid Profile, Hyperlipidemia

1. Introduction

Hyperlipidemia is an excess of lipids in the blood, largely

cholesterol and triglycerides. It can be manifested by excess

of the serum total cholesterol, low-density lipoprotein (LDL)

cholesterol and triglyceride concentrations, and a decrease in

the high-density lipoprotein (HDL) cholesterol concentration

[1, 2].

Hyperlipidemia is a common risk factor for the

development of cardiovascular disease, there are many risk

factors, and some can be controlled but not others. The risk

factors that can be controlled (modifiable) are: hypertention,

smoking; diabetes; overweight or obesity; sedentary life;

unhealthy diet and stress. biochemical risk factors were

American Journal of Nursing Science 2020; 9(1): 8-18 9

increased levels of TG, total cholesterol, LDL-cholesterol,

and low HDL-cholesterol level (El-Moselhy et al, 2018) [3,

4]. Those that cannot be controlled (conventional) are: Age

(simply getting older increases risk); sex (men are generally

at greater risk of coronary artery disease); family history; and

race [5, 6].

World Health Organization (WHO) estimates suggested

that 30% (17.3 million) of all deaths worldwide could be

attributed to cardiovascular disease (CVD) [7, 8].

By the year 2030, the Goals of United Nation are

reducing premature mortality from non-communicable

diseases by a third especially Cardiovascular diseases

which are the most common non-communicable diseases

globally and they are responsible for an estimated 17·8

million deaths in 2017, of which more than three quarters

were in developing countries [8]. By 2025, adults aged 40

years or older who are at high risk of cardiovascular disease

will be reduced for at least 50% by providing teaching and

drug treatments based on WHO recommendation to reduce

the global burden of cardiovascular disease [9].

Lifestyle modification involves changes for long-term habits

and maintaining the new behavior for months or years.

Lifestyle modification includes, apart from what we eat and

drink, physical activity, weight reduction, smoking, and stress.

Based on the recommendation of the WHO, stated that the all

health facilities should enhance health promotion activities by

creating an environment conducive to therapeutic lifestyle

change (TLC) regarding diet, weight management, increasing

physical activity and smoking cessation for the purpose of

reduction the morbidity and mortality of CAD. [10, 11]. Diet

teaching should be emphasized on minimizing intake of highly

saturated fat and cholesterol. Weight reduction and

encouraging physical activity should be promoted following

Body Mass Index (BMI) targets and WHO recommendations

for physical activity. A study conducted among elderly

Egyptian patients with CAD and concluded that modifiable

risk factors that can have an effective role in preventing and

better treatment of CVD, and promoting patients health. This

could be achieved through health education programs targeting

the modifiable risk factors; smoking, obesity, sedentary

lifestyle, bad dietary habits and soul and mind peace, and to

trained patients regarding these lifestyle changes [12]. As

indicated from figure 1. Lifestyle changes for preventing

cardiovascular disease include physical activity, weight

management, lipid modification therapy, diet management,

and stopping smoking and alcohol. [12].

Figure 1. Lifestyle changes for preventing cardiovascular disease [12].

The recently published recommendations by The American

College of Cardiology (ACC) and the American Heart

Association (AHA) which are concerning lifestyle to reduce

the risk of cardiovascular disease (CVD) addressed diet and

nutrition, exercise and physical activity, body weight,

tobacco use, as well, the guidelines concerning dietary

recommendations such as eating a diet high in vegetables,

fruit, legumes, nuts, whole grains, and fish, limiting sodium,

saturated fats, refined carbohydrates, sweetened beverages,

and processed meats, and omitting trans fats [12]. lifestyle

changes can reduce the risk of premature death and disability

due to heart disease, both of diabetes and elevated level of

cholesterol added as leading causes of increased incidence of

CAD which still remains as one of the most leading causes of

morbidity and mortality in Egypt where latest statistics in

2013, it is considered first killer [12-14].

Obesity frequently raises cholesterol levels in both very-

low-density lipoprotein (VLDL) and LDL fractions, elevates

triglyceride levels, lowers HDL cholesterol levels, raises

blood pressure and promotes glucose intolerance. Weight loss

lowers blood pressure and improves glycemic control, in

addition to lowering total cholesterol and its LDL and VLDL

fractions, triglycerides and raises HDL cholesterol [14-16].

Exercise programs are very important for patients to help

tilt the caloric balance toward a caloric deficit and thus elicit

weight loss. Aerobic exercise increases metabolic rate over

the 24 hours post-exercise. Physical activity has multiple

benefits that include increasing in bone density, support for

and creation of new vascular tissue, increases in fat

metabolism, insulin sensitivity, memory and brain function

and providing the greatest increases in cardiorespiratory

fitness and short-term weight loss. Up-dated studies have

documented that exercise stimulates local cardiomyocyte

stem cells and cardiomyocyte progenitor cells to increase

proliferation and specialization to a greater extent in the heart.

This finding is critical to patients who have experienced

some forms of ischemic heart failure which are manifested

by cardiac cell death. In regard to exercise impact on lipid

profile, claimed that exercise leads to increase in HDL

cholesterol and decrease in TGs level while dietary

approaches eventually lead to decrease in TGs levels, LDL

cholesterol, total serum cholesterol. Added the exercise that

benefit from aerobic exercise that targets large muscle groups,

performed for 30 minutes four or more times a week,

10 Magda Moawad Mohsen et al.: Effectiveness of Life Style Modification on Lipid Profile for Patients with Hyperlipidemia

overweight patients should engage in low-intensity exercise

more frequently and for longer durations [17-20].

Dietary modification to reduce cardiovascular disease

(CVD) risk remains the cornerstone of both the National

Cholesterol Education Program (NCEP) and American Heart

Association (AHA) recommendations for the treatment of

hyperlipidemic individuals [21-23].

The diet for healthy heart should focuses on fiber intake

from whole grains, vegetables, fruits, fish, poultry, and nuts,

while curbing sugary foods and beverages to lower

cholesterol levels by ten percent [24].

Other lifestyles of concern in managing CAD include

smoking, alcohol and consumption. As lifestyle pattern

influences the condition of CAD patients, it is important to

find dietary habits and other lifestyle patterns for a good lipid

profile [25] mentioned that combination of both of healthy diet

and physical activity are effective pathway for the reduction of

chronic disease and they have beneficial effects on the

cardiovascular system. [26] study concluded that, daily intake

of 1500 mg of vitamin C has positive lowering effect on

anthropometric measurements and lipid profile among obese

patients. Vitamin C administration may be helpful in

controlling obesity and related disorders by advising high

intake of vitamin C through the diet like guava, citrus fruits

etc., [26] added the intakes of vitamin D3, high protein,

omega-3 fatty acid, calcium, high fibre diet, -glucan, zinc and

multi-mineral/vitamin improved lipid profile. Seaweeds, nuts,

mate tea, soy and argon oil intakes also ameliorated lipid

profile. Concluded that prescription of exercise and nutrition

by primary care providers may elicit greater long term weight

loss than current medical weight management practices.

Finally diet and exercise can have a beneficial effect on

managing serum levels of lipid profile [26, 27].

1.1. Significance of the Study

It is suspected that lifestyle modification that can be

administered though cardiac outpatient department in

addition to usual care results in sustained lowering of

cardiovascular risk in terms lowering BMI, controlling BP,

controlling of HbA1 c values to an acceptable level of

glycemic control as well as sustains a desirable lipid profile.

In Egypt, a little nursing research had conducted to

investigate the effect of life style modification among those

patients. Therefore, there is a standing need to provide

information about lifestyle modification for this category of

patients, which might be useful to nursing as well as other

health care professionals. Such intervention is an essential

prerequisite for the alleviation of the disease risk factors. It is

also hoped that this effort will allow those patients to assume

an active, integral and participatory role in their health care,

which is considered the utmost goal of any nursing

intervention. Moreover, it might generate an attention and

motivation for further researches into this area.

1.2. Aim of the Study

This study was carried out to examine the effect of life

style modification for patients with hyperlipidemia on their

lipid profile.

1.3. Research Hypothesis

1. The BMI of the patients who undergo intervention will

show more improvement than who do not.

2. The blood pressure of the patients who undergo

intervention will show more improvement than who do

not.

3. The blood glucose level of the patients who undergo

intervention will show more improvement than who do

not.

4. The mean lipid profile score of the patients who

undergo intervention will show more improvement than

who do not.

1.4. Operational Definitions

Lifestyle: In sociology, a lifestyle is the way a person lives;

in public health, lifestyle generally means a pattern of an

individual’s behavioral choices and practices that lead to

elevated or reduced health risk [11].

Lifestyle modification is the adoption and practice of

attitudes and habits (healthy behaviors) that promote healthy

living and enhance wellness. Healthy living refers to regular

display of healthy behaviors leading to promotion of

optimum health of an individual [12].

2. Subjects and Method

2.1. Study Variables

The independent variable in the study was life style

modification provided for the hyperlipidemic patients, while

the dependent variable was lipid profile result and blood

pressure, blood glucose result and body mass index.

2.2. Design

Quasi experimental design was utilized.

2.3. Setting

This study was conducted among the patients attending at

cardiac out patients department Menoufia University

Hospital, Menoufia Governorates, Egypt.

2.4. Subject

A purposive sample of 100 men and women attending

cardiac outpatient department were selected. The subjects

were divided equally into study and control groups, 50

subjects for each with the following matching criteria:

a) Age above 20 years old.

b) Blood pressure above 130\90 mmHg and

c) High lipid profiles results.

2.5. Calculation of Sample Size and Power of the Study

In order to calculate the required sample size, the

American Journal of Nursing Science 2020; 9(1): 8-18 11

researcher used the Epi statistical program from the Open

Source Statistics for Public Health. The assumptions were:

a two sided confidence level of 95%=(1- α); a power (1- β)

or (% chance of detecting) of 80%; ratio of sample size,

unexposed (control)/ exposed (study group)=1% of

unexposed with outcome (awareness)=5%; Then the

researcher entered one of four parameters which was % of

exposed, s=25%, and the other three parameters would be

calculated by the Epi website program and results were

presented using methods of Kelsey and Fleiss (2010) [28]

with a continuity correction. The final sample consisted of

one hundred subjects.

2.6. Instrumentation

2.6.1. Structured Interview Questionnaire

It consists of sociodemographic and medical data. It

included patient age, sex, level of education, occupation and

medical history.

2.6.2. Bio-physiological Measurement

Fasting venous blood samples were obtained from all

participants, and sent to biochemistry laboratories.

Glucosylated hemoglobin (HbA1c) and Lipid profile

assessment: lipoprotein and glucose was assessed by Cobas C

311 analyzer operation's manual from the clinical chemistry

analyzer Cobas c311 5th generation. The lipid profile tests

including total cholesterol (TC), triglyceride (TG), high-

density lipoprotein cholesterol (HDL-C) and low-density

lipoprotein cholesterol (LDL-C).

2.7. Procedure for Data Collection

2.7.1. Period of the Study

The study was conducted starting from March 2019 to the

end of October at the same year.

2.7.2. Approval to Conduct the Study

An official permission was obtained from director of

Menoufia University Hospital and head nurses of the cardiac

outpatient clinic after explanation the aim of the study.

2.7.3. Protection of Human Rights

Each subject was informed about the purpose and the

nature of the study. The subject was informed that their

participation is totally voluntary and the confidentiality and

anonymity were assured.

2.7.4. Ethical Approval Was Obtained

Ethical approval was obtained written consent to

participate in the study was obtained from all participants.

2.7.5. Tool Validity

The tools were tested for content validity by two expert in

medical surgical nursing to ascertain relevance and

competence

2.7.6. Reliability

Reliability of the tools was done by test- retest for

measuring internal consistency with a period of two weeks

interval. The cronback's alpha for the structured

interviewing questionnaire tool was 0.89 indicating good

reliability. The test and retest reliability of the bio-

physiological measurement was 0.91 indicating good

reliability.

2.7.7. Pilot Study

Pilot study was done on a sample of ten hypertensive

patients who attended the medical outpatient clinic. The aim

was to test the feasibility of the study tools. According to the

results obtained, some questions were restructured and

rephrased to give the most accurate response.

1. A list of names of eligible subjects was obtained from

the registered nurse of cardiac outpatient clinic to obtain

base line data for the study subjects then subjects were

randomly assigned to the study and control group.

2. Initially, the base line data about demographic and

medical problems were collected. Also the base data of

the blood pressure, body mass index, glycosylated

hemoglobin (Hemoglobin1c) and lipid profile were

measured.

The subject was reminded about following life style

modification through phone once a week.

2.7.8. The Lifestyle Modification (LSM)

Teaching was given individually about the life style

modification (LSM) for 8 weeks. At the counseling, a

brochure containing information on exercise and diet were

distributed. The patients were asked to do brisk walking

exercises for at least 30 minutes four times per week. They

were asked to follow diet schedule during the period of the

study. The subject was reminded about following lifestyle

modification through phone once a week. The patients were

asked to come for measure blood pressure, BMI, lipid profile,

and glycosylated hemoglobin (Hemoglobin1c) checkup

(posttest) after 3 and 6 months period.

2.7.9. Evaluation

Evaluation was done at 3 and 6 months after the

intervention, the blood pressure, body mass index,

glycosylated hemoglobin (Hemoglobin1c) and lipid profile

were measured.

3. Statistical Analysis

The data was tabulated and analyzed by using SPSS

program (statistical package for social science software)

version 18.

Quantitative data was expressed as mean and standard

deviation (×±SD). A qualitative data was expressed in

numbers and percentage (No. & %). T test and the

relationships among quantitative variables, and one-way

ANOVA, Statistical significance was started at p-value

<0.05.

4. Results

Table 1 Participants in study and control group were on

12 Magda Moawad Mohsen et al.: Effectiveness of Life Style Modification on Lipid Profile for Patients with Hyperlipidemia

mean average 59.91±10.52 and 57.01±9.50 years old

respectively, with nearly 76% and 60% of participants

being female in both groups. Most participants (48% and

44%) were having a secondary school respectively. So, it

was apparent that there are similarity and no significant

difference between both in regard to all socio-demographic

variables.

Table 2 shows that most of the Menoufia university

cardiac outpatient department subjects had myocardial

infarction (62%), diabetes mellitus (56%), nearly equal

percentage had a history of hypertension (40%) and heart

failure (42%), about one third of the total subjects had angina

pectoris (30%) and only (20%) were smokers. Patients with

an abnormal triglycerides level were more liable to suffer

from coronary artery disease (CAD), where its percentage

was (71%) (70%) (90%) (82.1%) (85.7%) and it was

considered as a paramount risk factor, followed by HDL-C

then LDL-C among those patients

Table 3 reveals that BMI of the study group statistically

significantly (P=0.05) decreased when comparing baseline

assessment with the third assessment time. Only at third

assessment (at 6 months of intervention), there were

statistically significant differences both of intervention and

control groups (P=0.05) where there was a decrease in BMI

when compared intervention group with control group

(24.0+4.61 vs. 28.3+4.81 respectively). So, the first

hypothesis was supported.

Table 4 reveals a highly statistically significant differences

in systolic blood pressure in the study group (p=< 0.001) and

only a statistically significant differences in diastolic blood

pressure (p < 0.05) within the intervention group.

Additionally this table reveals that there is a highly

statistically significant difference (p=0.003) between both

groups at 6 months respectively after the intervention. It is

apparent that levels and scores of arterial blood pressure of

the intervention group were lower than those of the control

group after receiving risk reduction intervention combining

with the routine health education. So, the second hypothesis

was supported.

Table 5 summarized the mean HbA1c values for both

groups, first measurement of both study and control group

individuals’ mean HbA1c values showed a poor level of

glycemic control, and no significant difference was found

between the two groups. However, final measurement of the

intervention group individuals’ mean HbA1c values is

7.21+4.61 mg/dL, which is considered as an acceptable level

of glycemic control. The difference between the two groups

for the final measurement was statistically significant.

So, the third hypothesis was supported.

Table 6 shows that highly statistically significant

differences were found between intervention and control

groups at second and third measurement for all lipid profile

variables except for HDL-C (mg/dl) variable, where there is

no statistical significant differences between both groups

(p=0.61, p=0.35, p=0.31) respectively. likely, for the

intervention group, the table also shows that the means of all

lipid profile variables were improved all through study

phases except for HDL-C (mg/dl) variable, This

improvement was significantly associated with adherence to

suggested lifestyle pattern, whereas, concerning the control

group ones who only received a routine care, there were no

statistically significant differences found for all lipid profile

variables among the three measurements. So, the fourth

hypothesis was supported.

Figure 2 shows the effect of age on lipid profile in male

cardiac patients. Among male cardiac patients, the lipid

values of the different age groups differed significantly for all

TG, HDL-C, LDL-C and TC without increasing without

advancing of age.

Figure 3 revealed effect of age on lipid profile in female

cardiac patients. Among female cardiac patients, the lipid

values of the different age groups differed significantly for all,

TG, HDL-C, LDL-C and except TC level still stationary in

all age groups.

Figure 4 clarified effect of educational level on lipid

profile in cardiac patients.

In regard to the effect of educational level, it was

appearing that subjects with primary level suffer from

elevated level of TG, HDL-C, LDL-C while Cholesterol still

stationary while subjects with secondary and university level

had the same level in all lipid profile.

Table 1. Descriptive Characteristics of study and Control Groups pre-intervention.

Variables Intervention Group N=50 Control Group N=50

P value No % No %

Age

<40 years 12 24 10 20

0.34 ns 40-60 years 22 44 28 56

> 60 years 16 32 12 24

Mean±SD 59.91±10.52 57.01±9.50

Gender

0.71 ns Female 38 76 30 60

Male 12 24 20 40

Levels of education

0.42 ns Primary 16 32 10 20

Secondary 24 48 22 44

University 10 20 18 36

American Journal of Nursing Science 2020; 9(1): 8-18 13

Table 2. Relation between Abnormal Lipid Profile and Coronary Artery Disease and its Association with Risk Factors.

Coronary artery disease

parameter (total N.=100)

Lipid profile as a risk factor.

TC Reference range

0.00-200

TG Reference range

0.00-150

LDL-C Reference range

100-130

HDL-C Reference range

40-50

Normal Abnor. Normal Abnor. Normal Abno. Normal Abnor.

No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)

Myocardial infarction n=62 (62%) 34 (54.8%) 28 (45.2%) 18 (29%) 44 (71%) 30 (48.4%) 32 (51.6%) 26 (41.9%) 36 (58.1%)

Angina pectoris n=30 (30%) 18 (60%) 12 (40%) 12 (40%) 18 (60%) 16 (53.3%) 14 (46.7%) 4 (3.3%) 26 (86.7%)

Smoking n=20 (20%) 14 (70%) 6 (30%) 6 (30%) 14 (70%) 10 (50.0%) 10 (50.0%) 8 (40%) 12 (60%)

Hypertension n=40 (40%) 14 (35%) 26 (65%) 4 (10%) 36 (90%) 20 (50.0%) 20 (50.0%) 22 (55%) 18 (45%)

Diabetes mellitus n=56 (56%) 26 (46.4%) 30 (53.6%) 10 (17.9%) 46 (82.1%) 28 (50.0%) 28 (50.0%) 24 (50%) 28 (50%)

Heart failure n=42 (42%) 18 (42.9%) 24 (57.1%) 6 (14.3%) 36 (85.7%) 20 (47.6%) 22 (52.9%) 22 (52.4%) 20 (47.6%)

Table 3. Effect of lifestyle modification on BMI for study and Control Groups throughout Study period.

BMI at different points of assessment Study Group N=25 Control Group N=25

P value Mean±SD Mean±SD

Baseline assessment (before intervention) 31.1+6.98 29.90+4.94 0.31

Second assessment (at 3 months of intervention) 28.70+4.81 29.0+4.35 0.52

Third assessment (at 6 months of intervention) 24.0+4.61 28.3+4.81 0.05*

F -p value 0.05* 0.91 ns

ns=not significant *=significant>0.05.

Normal (18.5-24.99).

Overweight (25-29.99).

Obese (>30).

Table 4. Effect of lifestyle modification on Improving Systolic and Diastolic Pressure for cardiac patients throughout Study Period.

Systolic and Diastolic pressure Study Group N=50 Control Group N=50

P value Mean±SD Mean±SD

� Systolic blood pressure levels at different points of assessment

Baseline assessment (before intervention) 157.4±11.7 154.5±10.4 0.43

Second assessment (at 3 months of intervention) 143.5±9.9 151.2±10.0 0.02*

Third assessment (at 6 months of intervention) 130.2±8.2 151.3±10.0 0.003**

f-p value < 0.001*** 0.41 ns

� Diastolic blood pressure levels at different points of assessment

Baseline assessment (before intervention) 89.0±7.9 88.0±7.9 0.43

Second assessment (at 3 months of intervention) 86.7±7.7 88.4±7.7 0.31

Third assessment (at 6 months of intervention) 81.3±7.3 89.0±7.9 0.02*

f-p value < 0.05* 0.46 ns

Table 5. Effect of Lifestyle Modification on Improving HbA1c Levels in Diabetic Individuals for Study and Control Group throughout Study Period.

HbA1c Levels at different points of assessment Study Group N=50 Control Group N=50

P value Mean±SD Mean±SD

Baseline assessment (before intervention) 8.5+4.11 8.19+4.80 0.31

Second assessment (at 3 months of intervention) 7.60+4.7 7.92+4.31 0.52

Third assessment (at 6 months of intervention) 7.21+4.61 8.09+4.80 0.05*

F -p value 0.05* 0.91 ns

Table 6. Effect of lifestyle modification on Lipid Profile for study and Control Groups throughout Study period.

Lipid Profile Variables Intervention Group N=50 Control Group N=50

P value Mean±SD Mean±SD

Total cholesterol (mg/dl): Reference range (0.00-200)

Baseline measurement (before intervention) 233.3±48.8 229.3±47.8 0.51 ns

Second measurement (at 3 months of intervention) 195.4±43.2 224.3±46.8 0.01**

Third measurement (at 6 months of intervention) 163.3±33.2 227.3±46.9 0.001***

F -p value 0.000*** 0.89 ns

Triglycerides (mg/dl): Reference range (0.00-150)

Baseline measurement (before intervention) 226.0±45.9 228.0±46.9 0.71 ns

Second measurement (at 3 months post intervention) 185.3±40.2 223.3±45.1 0.001***

Third measurement (at 6 months post intervention) 121.1±33.0 220.3±45.0 0.001***

F -p value 0.001*** 0.79 ns

LDL-C (mg/dl): Reference range (100-130)

Baseline measurement (pre intervention) 151.0±44.4 148.0±44.0 0.61 ns

Second measurement (at 3 months of intervention) 139.1±34.2 146.0±43.2 0.001***

14 Magda Moawad Mohsen et al.: Effectiveness of Life Style Modification on Lipid Profile for Patients with Hyperlipidemia

Lipid Profile Variables Intervention Group N=50 Control Group N=50

P value Mean±SD Mean±SD

Third measurement (at 6 months of intervention) 128.0±33.0 142.0±43.0 0.001***

F -p value 0.001*** 0.59 ns

HDL-C (mg/dl): Reference range (40-50)

Baseline measurement (before intervention) 37.2±22.0 35.6±21.00 0.61 ns

Second measurement (at 3 months post intervention) 40.3±23.0 38.2±22.8 0.35 ns

Third measurement (at 6 months of intervention) 42.2±21.00 38.9±22.8 0.31 ns

F -p value 0.99 ns 0.19 ns

P value *<0.05 is significant.

P value **<0.001 is highly significant.

P value=ns (non-significant).

Figure 2. Effect of age on lipid profile in male cardiac patients

Figure 3. Effect of age on lipid profile in female cardiac patients.

Figure 4. Effect of educational level on lipid profile in cardiac patients.

5. Discussion

Hyperlipidemia is a serious emerging concern all over the

world and correlated to sudden cardiac deaths and CVD [29].

The current study aimed to examine the effect of lifestyle

modification among those patients on their BMI, BP, and

HbA1c level and lipid profile values. The findings of the

current study verifying the hypotheses and proved that using

reduction of risk factors has positive effects on BMI, BP,

HbA1c level and lipid profile values.

Effective correction of risk factors of cardiovascular

diseases is a key component of cardiac rehabilitation and

prevention programs, which has proven impact on both the

prognosis of patients with CAD [30].

Lifestyle changes and pharmacotherapy, can help lowering

the risk of atherosclerotic disease [31, 32].

Abnormal Lipid Profile

The current study findings reported that there were

elevated Triglyceride, Low Density Lipoprotein (LDL),

cholesterol and decrease High Density lipoprotein (HLD) in

patients of CHD, that was consistent with studies done in

Arab countries [3, 33]. That show the abnormal lipid profile

remains a strong risk factor of CHD. All of them concluded

that patients with CHD have altered lipid profile, with higher

levels of TGs, total cholesterol, and LDL and low level of

serum HDL; this difference may play a role in the

pathophysiology found in Patients with CHD.

Regarding blood glucose level

In current study there was no statistically significant

differences between the study and control group regarding

the HbA1c level at baseline assessment (before intervention),

while there was a statistically significant difference between

the both groups at 3 and 6 months of intervention. Results of

the current study were consistent with the results of [34] that

studied the impact of telemedicine Service for the Secondary

Prevention of CAD and concluded that life style modification

helped in improving the risk profile in ACS survivors,

especially for overweight patients. These also were in

accordance with the results of [35, 36] who indicated that

there was an obvious decreasing in the level of HbA1c after

following life style modification. These also were in

consistent with the results of [37] who evaluated risk factor

control for CAD secondary prevention on 5,034 CAD

patients suffering also from diabetes mellitus, they indicated

that individual risk factor control was improved compared

with baseline. Several studies have revealed that nursing

intervention in outpatient clinics is at least as beneficial in

achieving goals and actually result in marked improvement in

the outcomes, such as a randomized-controlled trial that

conducted by [38] who revealed that their designated

intervention program improved both SBP and DBP and

American Journal of Nursing Science 2020; 9(1): 8-18 15

glycemic control through patient self-management education,

establishment of an individualized care plan, behavioral goal

setting, and close surveillance of patients. A logical

explanation of this result is that risk reduction intervention

that introduced to those patients by cardiac outpatient nurse

and continuous enhancement during follow up sessions on

regular bases and they would be provided with some

information about their illness and their treatment method

among intervention group led to better adherence to diet, and

drug therapy prescribed by the doctor, more adaption to

physical activity, increased awareness and also changing their

bad health behaviors which in turn improve blood glucose

level. Therefore this nursing strategy could proceed as a part

of health plan for CAD patients. Indeed this preventative

nursing strategy provides patients with the opportunity to

maintain their education effectively without interruptions, as

well as this will empower them to recognize lifestyle changes

that need to be addressed while becoming self-efficient. This

empowerment will lead to better of glucose control which

will improve their clinical outcomes.

Regarding Lipid Profile

Findings of the current study revealed that mean of total

lipid profile scores of studied sample were similar in baseline

assessment in both groups. However, the results of this study

revealed that implementing risk reduction intervention

resulted in improving lipid profile values. It seems that

improvement in these results of CAD patients is dependent

on behavior change and also lifestyle modification. These

results came in accordance with [39].

The mean scores of total lipid profile were highly

significantly decreased at 3 months among study subjects

patients after implementing risk reduction intervention and

continued to be decreased in the 6 months assessment time,

with considerable significant difference with subjects in

control groups, this positive change in the study group

subjects reflected that risk reduction intervention could make

change in their lipid profile and showed a considerable

difference in its results after the implementing this

intervention. In other words, the reductions in the LDL-C

level and the TC, HDL-C were greater for intervention

patients. After adjustment for baseline differences in blood

lipid levels, the study group was also more likely to reach the

recommended lipid targets. This positive result was

supported the study hypothesis, the clinical impact of risk

reduction intervention feedback was high. This was due, in

part, to designated risk reduction intervention which mainly

based on encouraging patients to adherence to the suggested

lifestyle modification protocol including enhancing self-

monitoring and using the support of family and friends.

These results came in accordance with recommendation of

[40]. This means that that the lifestyle modification has an

association and positive impact upon lipid among patients

who suffering from hyperlipidemia.

Moreover, the present study results were consistent with

many previous studies as [34] who claimed that effective

correction of cardiovascular risk factors is a key component

of cardiac rehabilitation and secondary prevention programs,

which has proven impact on both the prognosis of patients

with CAD. Also, this supported by [29] who claimed that

both of lifestyle changes and pharmacotherapy, can help

reduce the risk of atherosclerotic. Life style modification

implies eat heart-healthy foods, exercise on most days of the

week and increase physical activity, smoking cessation,

weighting lose, and moderation of alcohol intake.

The current results supported by [41] who stated that

aerobic exercise decreases cardiovascular disease risk in

postmenopausal women and shows potential impact on lipid

profile and better quality of life. It also came in accordance

with study done by [42] which suggested that improving diet

and aerobic fitness will result in a better lipid profile. Also,

[40] added that hyperlipidemia can be controlled by weight

loss, decreasing dietary fat, regular exercise, and medications.

These modalities of treatment decrease TC, LDL, and TG as

well as increase the serum level of HDL cholesterol.

This study results were contradicted with [43] who found a

non-significant improvement in other lipid profile parameters

with exercise was confirmed.

In this study, it was observed that the elevated Triglyceride,

Low Density Lipoprotein (LDL), cholesterol and decrease

High Density lipoprotein (HLD) in patients of CAD that

correspond with [3, 33] that shows the abnormal lipid profile

remain strong risk factor of CHD. All of them concluded that

patients with CHD have altered lipid profile, with higher

levels of TGs, total cholesterol, and LDL and low level of

serum HDL; this difference may play a role in the

pathophysiology found in Patients with CHD.

It is apparent from study findings that, female more than

40 years of age and subjects with primary level of education

had significantly the highest mean total lipid profile scores,

the older the woman, the higher the elevated lipid profile

score with stationary level in cholesterol. Subjects who had

primary education had higher abnormal lipid profile score

than those who had secondary and university level.

Furthermore, the findings of the existing study reported that,

there is a strong positive correlation was found significant

variations by socio-demographic characteristics.

Regarding BMI and BP

The current risk reduction intervention stressed the

importance of weight reduction in order to reduce blood

pressure and the body weight and thus reduce the risk of

recurrent CVD. The current results revealed a statistically

significant difference with the intervention group with a

reduction of systolic, diastolic blood pressure as well as loss

of weight as manifested by reduction in their BMI. A logical

explanation may be pertained to changing diet and increasing

physical activity among those patients a step to lifestyle

modification where they received advice to do more general

daily physical activities. These results came in accordance

with [44] who conducted the Euroaction trial of a nurse-led,

multidisciplinary hospital programme for CAD patients; they

concluded that there were significant improvements in diet

and physical activity levels, with three times as many patients

achieving the physical activity target in comparison with

usual care.

16 Magda Moawad Mohsen et al.: Effectiveness of Life Style Modification on Lipid Profile for Patients with Hyperlipidemia

However, these results were contradicted with [45] study

who mentioned that despite the high use of blood pressure

lowering medications just over half of patients had achieved

the recommended blood pressure goal and lipid control was

unsatisfactory in a large proportion of patients. [46, 47]

Linked such results to the reasons for the poor lifestyle

adherence because of persuading patients to adapt to

healthier habits needs skills in behavioral science and time

enough to explain the importance. Moreover, and as shown

by [48] added that patients have anxiety and depression

symptoms after CHD events. Thus, the receptivity to lifestyle

advice may be less than optimal immediately after the

coronary event, repeating or reinforcing when the patient is

in a better condition to accept such counseling is essential.

6. Conclusions

Cardiac outpatient department nurses can be utilized

lifestyle modifications appropriately as a risk reduction

intervention for CAD patients who were suffering from

hyperlipidemia. This intervention had an impact upon the

clinical outcomes parameters among those patients which in

turn will positively impact their quality of life, which is a

paramount to the effective intervention for this chronic

disease. They should increase their familiarity with exercise

programming and dietary protocols to better provide

comprehensive preventive and curative lifestyle

modifications. In order to effectively combat CAD, they

should underscore the necessity of lifestyle modification as a

risk reduction intervention and prioritize its use in outpatient

department. Implementing such intervention is associated

with a measurable improvement in the efficacy of clinical

outcomes parameters.

7. Recommendation

In the light of the study findings, the following

recommendations are suggested:

1. Risk reduction intervention should be integrated to be a

part of health plan for CAD patients.

2. Further researches are required to study the factors

affecting implementation and utilization of risk

reduction intervention.

3. Health care providers must be better trained in risk

reduction intervention through their formal and clinical

education.

4. Hyperlipidemia among CAD patients may potentially

decrease if providers prescribe lifestyle modification

program more frequently.

Abbreviation

Lifestyle modification (LSM) total cholesterol (TC),

triglyceride (TG), high-density lipoprotein cholesterol (HDL-

C) and low-density lipoprotein cholesterol (LDL-C),

coronary heart disease (CHD).

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