Chapter Two Conceptual framework

2.1 Introduction

In this chapter key concepts, as identified in Chapter One, namely the patient

(who suffers from CAD and underwent CABG surgery, PTCA or insertion of a

coronary stent), lifestyle adaptations, CAD and risk factors for CAD are

discussed.

2.2 The patient The patient in this study suffers from CAD. CAD is an insidious, progressive

disease that results in coronary arterial narrowing or complete occlusion. There

are numerous causes of CAD but atherosclerosis is the most prevalent.

Fatty streaks occur within the arteries during childhood, but symptoms, such as

angina, only occur when the atherosclerotic plaque occludes 75% of the vessel

lumen, usually in late middle age. Epidemiologic data collected during the past 50

years have demonstrated an association between the presence of specific risk

factors and the development of CAD. One of the most important epidemiologic

studies is the Framingham Heart Study, which began in 1948 and continues

today with third and fourth generations of participants. Blood cholesterol,

smoking, activity levels, blood pressure and electrocardiographic results are

checked on a regular basis for participants in this study. As a result, specific risk

factors and lifestyle habits have been identified as being associated with an

increased probability for the development of atherosclerosis. These are referred

to as CAD risk factors (Urden, Stacey & Lough, 2002:395; Clochesy et

al.,1996:336-337). Risk factors for CAD are discussed in 2.3.

A patient, suffering from CAD, who underwent CABG surgery, PTCA or insertion

of a coronary stent, is regarded as a holistic being and not just the physical but

13

also spiritual concept is taken in consideration. The patient functions in an

integrated, interactive manner with the environment, and the environment in turn

influence the way patients regard their illness, and the meaning to their lives of

having these procedures done. Human health behaviour is influenced by the

internal and external environment. To ensure commitment and maintenance in

the type of lifestyle adaptations and health behaviour essential for cardiac

rehabilitation this holistic nature of the patient, integrated in the external and

internal world, should be kept in mind. The process of rehabilitation and lifestyle

adaptations is such an extensive step that it involves all dimensions of the patient

as a holistic being. An important part of the external environment is the family. It

is therefore crucial to involve them in the rehabilitation process to improve the

patient’s willingness to adapt their lifestyle and maintenance of this lifestyle

(Rand Afrikaans University, 2002:2-8).

The patient’s body includes several anatomic structures and physiological

processes. In this case the body suffers from CAD and is thus not a normal

healthy body. In order to ensure a long and healthy life the patient should

maintain a healthy lifestyle to ensure optimum health. Patients’ motivation to

maintain a healthy lifestyle is influenced by their instinct to survive. If patients feel

or understand that to behave in certain ways can or will be potentially dangerous

to their bodies they might not act in such a manner. They might rather behave in

a way that will be beneficial to their health and will ensure a long and healthy life.

Patients with CAD should for instance stop smoking, eat a healthy diet, exercise

and take their medication as prescribed, among other things (Bridgeman,

1988:95-129; Friedman, 1990:57-90).

Human behaviour is complex and difficult to predict. Decisions are frequently a

response to chance events and apparently random thought processes. The

Health Belief Model (Kozier, Erb, Blais & Wilkinson,1995:27). is one of the

numerous models of behavioural decision-making developed to try and provide a

basic understanding of at least some of the processes underlying human

14

behaviour. This model suggests that the likelihood of individuals engaging in a

particular type of health-related behaviour is a function of their perceptions of the

relationship between that behaviour and an illness, their perceived susceptibility

to that illness, its seriousness and the particular costs and benefits involved in

engaging in any type of behaviour. The costs may be social, financial and/or

physical. Factors influencing adherence to anti-hypertension medication, for

example, may include the perceived health benefits (often not immediately

obvious), the hassle of remembering to take medication and concerns about

side-effects and consequences of long-term use of medication. A final influence

on behaving in a specific manner is the presence of cues to action. These may

take the form of a reminder to engage in some form of action, including such

things as health checks, reminders from doctors on routine visits, and so on

(Kozier et al. 1995:250-251).

The psyche which refers to all experiences and also behaviour in the individual,

includes intellectual, emotional and will processes. Intellect refers to the capacity

and quality of psychological processes of association, analysis, judgement and

comprehension to which an individual is capable. Emotion refers to the

instrument of the patient’s dislikes and preferences. Will is the instrument of the

individual’s decision-making and is indicative of the individual’s capacity to make

choices. It expresses the “want to” or “not want to” and is a decision made

without external pressure. To undergo the necessary lifestyle adaptations,

patients with CAD, who underwent CABG surgery, PTCA or insertion of a

coronary stent, have to understand and comprehend the changes that are to be

made and need to have the will, intellect and emotional readiness to continue

with these changes for the rest of their lives (Rand Afrikaans University, 2002:2-

5).

According to Friedman (1991:21-29) personality, which is part of a person’s

psyche, is influenced by the effects of stress on the body in view of the fact that

the body is from childhood to adulthood exposed to different physical reactions

15

on stress. Stress is influenced by the individual’s perception and interpretation of

a situation, how harmful it is and his ability/willingness to handle the situation.

Stress has different physiological reactions on the body, such as tiredness,

hypertension and suppression of the immune system. It also causes some

people to smoke more, use more alcohol, exercise less, eat unhealthily etc. Most

of the above-mentioned reactions will have a negative effect on someone who

was just diagnosed with CAD and underwent CABG surgery, PTCA or insertion

of a coronary stent. It is therefore important to understand how stress influences

the body and know how to cope with it in a more productive way (Argyle,

1992:231-236; Kagan in Levi, 1981:8-11; Sutherland & Cooper, 1990:1-224).

Douglas (1992:54-64) emphasizes the inclusion of stress management and

behaviour modifications for type A personalities. The type of lifestyle that these

individuals live, make them more susceptible to CAD. Krantz and Blumenthal

(1987:8) state type A individuals as hard-driving, competitive, aggressive and

impatient. In retrospective and prospective studies type A behaviour patterns are

associated with over twice the rate of new coronary events, compared to the type

B behaviour patterns. If a person is genetically inclined to be more aggressive

and has a dominant temperament his energy should rather be redirected so that

these characteristics influence his illness in a positive rather than negative way.

He can for example learn how to use his anger to motivate him to exercise

(Friedman, 1990:38-58; Friedman, 1991:22).

People are brought up with certain values and important influence of these

values on their attitude has over the years been accepted by different

researchers (Botha, 1972:15-23; Hattingh, 1991:93-95; Kirchenbaum, 1977:8-9;

Smith, 1977:240-243; Straughan, 1993:49). Values contribute strongly to the

internal environment of a patient. According to Smith (1977:241) values are

determinants of virtually all kinds of behaviour that could be called social

behaviour. Values will influence the way patients adapt their lifestyle. Hattingh

(1991:39) describes values as the preference attitude, moral convictions,

16

principles and standards of a group or individual. The values that a patient have

and the principles and standards that are regarded important in the group that

they find themselves in will have a great influence on how they perceive CAD and

undergoing CABG surgery, PTCA or insertion of a coronary stent, and how they

will adapt their lifestyle to it. It will determine whether they feel it is important to

change their lifestyle or not.

Taking responsibility for, and adopting the right attitude towards illness and the

adaptations that have to be undertaken in his life, is essential for the patient with

CAD who underwent CABG surgery, PTCA or insertion of a coronary stent.

Patients who do not take responsibility for their condition and who do not adhere

to the necessary changes put their own health at risk, and are in danger of going

through the whole ordeal again. Douglas (1992:75) states that it might seem

reasonable to presume that if people actively seek help from a physician, they

will follow the instructions or advice given to them. However, this would be a rash

presumption and one that is not supported by the available evidence. The

commonly reported statistic is that around fifty percent of individuals drop out of

such programmes, or do not fulfil anything close to their requirements (Douglas

1992:75).

It seems to be in our nature as human beings to want to break the rules. It is

jokingly said that the first recorded incidence of non-compliance occurred when

Eve defied God’s prescription in the Garden of Eden and ate an apple from the

forbidden tree.

The external environment points at situations outside the individual which have

an influence on his life. This influences the way patients behave, respond and

maintain their lifestyle. All meaningful stimuli or objects, in the individual’s

external environment, are referred to as the physical environment. Stimuli refer to

any aspect which leads to direct or indirect adaptation in behaviour. Object is any

part of the environment of which the individual is aware and to which he reacts

17

with a certain attitude. Aspects of the physical environment which have an effect

on health behaviour include location, climate, geography and income. How

convenient or inconvenient it is for patients to comply with adaptations, for

example exercise, in terms of climate, geography and location will influence their

adaptability and compliance towards these changes. It may not be worthwhile for

a farmer to travel 200 km to be able to participate in exercises in a gym, but to

walk 20 minutes on his farmland can be much more convenient. Aspects such as

these should be kept in mind when discussing lifestyle adaptations with a patient

(Rand Afrikaans University, 2002:2).

The most important part of the external environment is the social aspect. This

refers to all persons or meaningful others (family, next of kin, partners) in the

individual’s external environment. Because patients are social beings it is

impossible for them to function in isolation. Therefore the whole family, as part of

the external environment, should be involved in the rehabilitation program. The

social support of family, friends, colleagues and partners can make an individual

feel accepted and may encourage behaviour that improves his health. It may also

improve compliance. If patients’ families “join in” the new healthy lifestyle they will

encourage the patients in their effort to adapt their lifestyle. As Wright and

Leahey (2000:13) explains: “Nursing has a commitment and obligation to involve

families in healthcare” Cohen, Mock and Rinqvist (1981:233) support this by

stating that some determinants of successful long-term outcome, as reflected by

return to functional levels and lifestyle seen prior to infarction, include the family

structure and personal relationships, attitudes of personal physicians and

employers, and social support within the community. (Argyle, 1992:237-240;

Friedman, 1990:97-115; Friedman, 1991:25-27).

The spiritual environment, which is also part of the external environment,

includes meaningful spiritual elements or events in the individual’s external

environment including values, convictions, norms, ethical principles, meaning of

life as well as relationships with others (Rand Afrikaans University, 2002:2).

18

“What people believe about health matters has an important effect on what they

do about their health; namely their health behaviour” (Argyle, 1992:243) If people

are misinformed they might interpret symptoms incorrectly or believe that illness

is some kind of punishment. Several philosophers claim that contemplation about

the seriousness of disease, with the belief that the possibility exists to contract

the disease, as well as the fact that some types of health behaviour will be

successful in preventing the disease will motivate people to adopt a certain type

of health behaviour. Some people see illness as a challenge and this motivates

them even more to reveal a certain type of health behaviour (Bandura,

1977:1977; Janz & Becker, 1984:1-47; Fishbein & Ajzen, 1975:223).

It is for this reason important that patients’ background, values and beliefs should

be kept in mind when approaching them to adapt their lifestyle. This will ensure

better compliance and understanding of what is expected of them. Patients who

are at risk to develop CAD are discussed next.

2.3 Risk factors for coronary artery disease It is encouraging to know that public awareness of risk factors contributing to the

development of CAD is increasing. However, as people are living longer than

before and cardiovascular disease is most prevalent in elderly persons, CAD

continues to be a worldwide public health problem (Urden et al. 2002:395).

Factors that increase the risk of developing CAD include age, gender, genetic

factors (family history), hyperlipidaemia, diet high in saturated

fat/cholesterol/calories, obesity, impaired glucose tolerance, physical inactivity,

homocystein, cigarette smoking, oral contraceptives and hypertension (Urden et

al. 2002:395-397; Lindsay & Gaw, 2004:33; Connaughton, 2001:87).

Urden et al. (2002:395-397) further divide risk factors into modifiable and non-

modifiable factors. Risk factors for CAD are discussed under these headings next

19

2.3.1 Non-modifiable risk factors Non-modifiable risk factors include factors that cannot be changed such as age,

gender and family history.

2.3.1.1 Age

CAD increases with age in both men and women. This is due to the fact that the

arteries also become older and more rigid, making them more susceptible for

atherosclerosis and increasing the risk of CAD. It is rare in the first two decades

of life, becoming more prevalent after the age of 30 (Lindsay & Gaw, 2004:33;

Urden et al. 2002: 395).

2.3.1.2 Gender CAD symptoms occur approximately 10 years later in women than in men.

Before the age of 60 years CAD is much more marked in males than females.

Beyond 60 years of age, CAD in females increases at an accelerated rate and

after the seventh decade the rate approaches that in males. Epidemiological

studies reveal that women are relatively protected against CAD while pre-

menopausal and that this protection is less evident in the postmenopausal years

(Urden et al. 2002:395; Lindsay & Gaw, 2004:33-34).

2.3.1.3 Family history A significant family history of CAD is considered to be present if the disease is

diagnosed in first-degree relatives before the age of 60 years. The clustering of

factors such as hypertension, diabetes and obesity is also common. This fact

suggests a genetic predisposition to the development of CAD (Urden et al.

2002:395-396; Lindsay & Gaw, 2004:34).

2.3.2 Modifiable risk factors Modifiable risk factors are factors that can be changed by means of adopting a

healthier lifestyle.

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2.3.2.1 Elevated serum lipids Hyperlipidaemia or hypercholesterolaemia (raised levels of blood lipids) is a

leading factor responsible for severe atherosclerosis, which in its part leads to

CAD. This can be caused by both genetic and environmental factors and, most

importantly, through interactions between genetic make-up and lifestyle factors

such as diet.

Cholesterol is subdivided into the following specific proteins:

1. High-density lipoprotein cholesterol (HDL-C) which is associated with

‘good’ cholesterol

2. Low-density lipoprotein cholesterol (LDL-C) which is associated with

‘bad’ cholesterol

3. Very-low density lipoprotein cholesterol (VLDL-C) which is associated

with ‘very bad ‘ cholesterol

(Urden et al. 2002:398; Premitt & Kramer, 2005:113)

High levels of LDL cholesterol have been associated with atherosclerosis and

CAD. In contrast, high levels of HDL cholesterol have been shown to reduce

some of the harmful effects of LDL and VLDL cholesterol.

HDL cholesterol moves easily through the blood and is actually beneficial to the

body. It is stable and does not adhere to artery walls. It helps to prevent heart

disease by carrying cholesterol away from the arteries back to the liver, where

the process of its removal from the body begins. LDL and VLDL cholesterol

contains more fat and less protein than HDL. LDL and VLDL cholesterol is

‘unstable’ and tends to disintegrate. Rather then being removed from the body by

the liver, it adheres to and can damage the cells lining the inside of artery walls,

causing atherosclerosis and CAD (Premitt and Kramer. 2005).

21

Table 2.1 Levels for HDL and LDL cholesterol considered as normal by doctors and hospitals in Gauteng

Pathologist Ampath Lancet

Cholesterol 3.0 - 5.2 mmol/L 3.21 – 5.2 mmol/L

HDL cholesterol 0.9 – 1.6 mmol/L > 1.0 mmol/L

LDL Cholesterol 2.0 – 3.4 mmol/L < 3.4 mmol/L

(Lancet & Ampath Pathologists, 2005)

2.3.2.2 High fat diet There are three major types of fat – saturated, polyunsaturated and mono-

unsaturated that can be taken in through diet:

• Saturated fats are mainly found in foods of animal origin e.g. red meat,

poultry (skin), eggs, full cream milk and full cream dairy products, take-

away foods and processed meats. Vegetable sources of saturated fat are

palm and coconut oils and fats, often used in commercial snacks and

baked goods.

• Polyunsaturated fats are found in vegetable oils such as sunflower oil,

fish and polyunsaturated margarines.

• Mono-unsaturated fats are found mainly in plant foods e.g. olive oil,

canola oil, nuts and avocado. It is also found in mono-unsaturated

margarines.

Polyunsaturated fats and mono-unsaturated fats are less likely to promote

heart disease and should therefore be used in preference to saturated fats. They

all, however, have the same energy content. It is emphasised that a patient

should know to cut out the “bad” fats (saturated fats) or at least cut down to

smaller amounts. They are encouraged to rather use “good” fats

(polyunsaturated and mono-unsaturated fats). Fats are however very

important to the body and should not be cut out of the diet completely.

(Niewenhuyzen & Muller, 2005:1).

22

Diets that are high in saturated fats and oils greatly increase the risk of the

following:

• Atherosclerosis, as early as childhood

• Hypertension

• Obesity (defined as a body mass index of higher than 30), which can

place tremendous strain and additional workload on the heart. (The

formula to calculate BMI to discussed under 2.3.2.3. Obesity.)

(Sacher 2005)

2.3.2.3 Obesity Obesity is a condition in which a person has a body mass index of 30 or higher. It

is the second largest leading cause of preventable death, contributing to serious

health problems such as cancer, heart disease (CAD) and stroke. About 40% of

South Africans are obese. Obesity is often associated with sedentary lifestyle. It

also increases susceptibility to the development of other risk factors, such as

hypertension, diabetes type two and hyperlipidaemia. Research has shown that

the distribution pattern of fat on the body is now considered an indicator of CAD

risk factors. The more weight carried in the abdominal area, producing a large

waist, the greater the risk of developing CAD. Excess abdominal adiposity

indicates additional fat around the abdominal organs, including the heart, as

compared to individuals who have a smaller waist and larger hips (Urden et al.

2002:397; Roitman, La Fonteine & Drimmer, 1998:118; Lindsay & Gaw,

2004:35).

There are two basic ways in which obesity increases the risk of heart disease.

Firstly, it can indirectly contribute to heart disease by causing changes in the

body that increase the risk of heart disease. These changes include the following:

• Hypercholesterolemia

• Elevated triglycerides

• Lowered levels of LDL cholesterol

• Hypertension

23

• Increased risk of type two diabetes

The second way is by causing unhealthy changes in the heart itself. As the heart

struggles to compensate for extra body mass through which it must circulate

blood, the left ventricle can become hypertrophic. This can eventually lead to

heart failure.

Body mass index is a tool by which one uses weight and height to determine if

one is underweight, overweight or obese.

BMI is calculated as follows:

[ weight (kilograms)] / [height (metres)2].

Table 2.2 Body mass index

Body mass index

Classification Risk of developing CAD, type two diabetes and hypertension

< 18.5 Underweight Low

18.5 – 24.9 Normal Low

25.0 – 29.9 Overweight Increased

30.0 – 34.9 Obese High

35.0 – 39.9 Very obese Very high

> 40 Extremely

obese

Extremely high

(D’Agostino 2005).

2.3.2.4 Diabetes mellitus Diabetes mellitus is a major public health problem reaching epidemic proportions.

Type two diabetes mellitus increases the risk of all manifestations of vascular

disease, including CAD. CAD accounts for the majority of type two diabetes

mellitus-related morbidity and mortality. As much as 75% of deaths in people with

24

type two diabetes mellitus will be from cardiovascular disease (Urden et al.

2002:851-853; Clochesy et al. 1996:1101; Lindsay & Gaw, 2004:313-314).

Insulin resistance is now known to be the major culprit in the conglomeration of

cardiovascular risk factors collectively termed the ‘metabolic syndrome’. It

includes hyperinsulinaemia, insulin resistance, obesity, hypertension,

hyperglyceridaemia and reduced HDL cholesterol concentration. In addition to

the above-mentioned risk factors, other thrombotic risk factors correlating with

insulin resistance include elevated levels of plasminogen activator inhibitor I (PAI-

I), factor VII and fibrinogen. Hyperinsulinaemia and insulin resistance thus help

promote the development of atheromatous plaque. In association with a

prothrombin antifibrinolytic state it promotes cardiovascular disease (Clochesy et

al. 1996:1141; Urden et al. 2002:852; Lindsay & Gaw, 2004:313-314;

www.Health24.co.za, 2005).

2.3.2.5 Physical inactivity Research shows that people who get regular exercise are less likely to have

heart attacks or die from heart disease. Exercise has dramatic benefits for the

heart and blood vessels, which include the following:

• Decreases oxygen demand on the heart

• Strengthens the myocardium

• Reduces levels of triglycerides, LDL cholesterol and homocystein

• Increases HDL cholesterol

• Lowers blood pressure

• Stimulates the process of angiogenesis, by which the body creates

collateral veins to bypass clogged or diseased blood vessels

• Helps to keep blood vessels clear of clots and build-up of plaque

• Prevents obesity

• Prevents the process of atherosclerosis. (Research done among identical

female twins provided results that proved a direct link between

accumulation of fat in the abdominal region and arterial stiffness. The

conclusion was drawn that even women with a genetic predisposition to

25

arterial stiffness can reduce this risk, if they engage in regular physical

activity.)

• Decreases the risk of type two diabetes mellitus

(www.Health24.co.za, 2005; Urden et al. 2002:397; Lindsay & Gaw, 2004:34-

35).

2.3.2.6 Homocystein Homocystein is an amino acid produced as a normal by-product in the

breakdown of methionine. Methionine is an essential amino acid acquired mostly

from eating red meat. Moderate levels of homocystein are helpful for growth and

maintenance of healthy tissue. However, excessive homocystein levels have

been shown to correlate closely with various types of vascular damage and heart

disease. With a proper nutritional balance (more fruit, vegetables and poultry and

less red meat), homocystein is either converted back into methionine (an

essential amino-acid) or into simple amino-acids (cystein and cystathionine)

which are easily flushed from the body via urine. This conversion of homocystein

cannot occur unless the body has enough of three B-Vitamins: vitamin B6,

vitamin B12 and folic acid. Research seems clear that high levels of

homocystein can be prevented or treated by increasing the intake of Vitamin B

(www.Health24.co.za).

Many studies have found a link between high homocystein levels and heart

disease. Research on this topic began in 1968, when Kilmer McCully of Harvard

Medical School investigated the early deaths of children with a rare genetic

disorder, homocystinuria, involving high levels of homocystein. He was surprised

to discover that these children had severe atherosclerosis and often died from

heart attacks or strokes, which is extremely rare among children. Thereafter

numerous studies have been done and have found links between high

homocystein levels and atherosclerosis. (www.Health24.co.za).

26

Table 2.3 Levels of homocystein considered normal by doctors and hospitals in Gauteng

Pathologists Ampath Lancet

Homocystein levels

5.0 – 15.0

umol/L

4.5 – 12.4 umol/L

(Lancet & Ampath Pathologists, 2005)

2.3.2.7 Smoking Smoking is the chief avoidable cause of premature death and ill health in the

world. The main diseases caused by smoking are CAD and lung cancer. The

greater the number of cigarettes smoked per day, the greater the risk of CAD.

Cigarette smoking alters serum lipid levels unfavourably, decreasing HDL

cholesterol levels and increasing LDL cholesterol levels. Smoking rapidly

increases the heart rate and constricts blood vessels, while simultaneously

reducing the blood’s capacity to carry oxygen. Smoking is associated with both

aspects of atherosclerosis. It promotes the development of artherosclerotic

lesions, thus creating sites susceptible to blockage, and promotes the occurrence

of triggering events, such as adhesion of platelets to these lesions, which lead to

blockage (Lindsay & Gaw, 2004:135; Urden et al. 2002:397). A multinational

study done in New York on 5000 patients indicated that smokers who have had a

heart attack at a relatively young age run the same risk of having a stroke,

another heart attack or dying as do their older counterparts who do not smoke

(Douglas, 2004:4).

2.3.2.8 Oral contraceptives The risk of CAD in women is increased by oral contraceptives. These drugs alter

blood coagulation, platelet function and fibrinolytic activity. It may adversely affect

the integrity of vascular endothelium, resulting in atherosclerosis and CAD. The

risk is further increased by cigarette smoking or the presence of other risk

factors. Women already at risk of developing CAD are encouraged to use other

forms of contraception (Urden et al. 2002:397).

27

Oral contraceptives containing estrogens are the most common cause of

hypertension in women. Though initially mild, hypertension usually increases with

oral contraceptive use over time. Concomitant use of cigarettes and alcohol

increases the risk of cardiovascular morbidity in women (Clochesy et al.

1996:525).

2.3.2.9 Hypertension

Hypertension is the elevation of systolic or diastolic blood pressure in the

vascular system. The higher the pressure, the higher the risk of damage to the

arteries, which lead to atherosclerosis and a greater risk of CAD. In

epidemiological studies, there is a close relationship between blood pressure

(systolic and diastolic) and the risk of stroke, CAD and other cardiovascular

events. Hypertension has many predisposing factors that overlap with CAD risk

factors including older age, high dietary sodium intake, obesity, sedentary

lifestyle, excessive alcohol consumption etc. (Urden et al. 2002:397; Lindsay &

Gaw, 2004:77; Clochesy et al. 1996:367).

Table 2.4 Blood pressure classification

Category Systolic (mmHg)

Diastolic (mmHg)

Normal BP

Normal < 130 < 85

High-Normal 130 – 139 85 – 89

Hypertension

Stage 1 140 – 149 90 – 99

Stage 2 160 – 179 100 – 109

Stage 3 >180 > 110

(Urden et al. 2002:433)

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2.3.2.10 Stress and anger Type A behaviour patterns, including time-urgency, hostility, anger and anxiety

have also been associated with the development of CAD. The type of lifestyle

that these individuals live make them more susceptible to CAD. Krantz &

Blumenthal (1987:8) defines type A individuals as hard-driving, competitive,

aggressive and impatient. In retrospective and prospective studies type A

behaviour patterns are associated with over twice the rate of new coronary

events, compared to type B behaviour patterns. Anger causes tachycardia,

hypertension and narrowing of the arteries. This results in blood being more

viscous and increases the risk of blood clots (Urden et al. 2002:397;

www.health24.co.za, 2005).

How stress and behaviour influence the development of CAD is not understood

well. The possible mechanisms by which stress exerts its negative effects on the

risk of CAD have been cited as an increase in blood pressure and heart rate,

increased plasma cholesterol levels and adverse effects on coagulation and

fibrinolysis (Lindsay & Gaw, 2004:35-36; Urden et al. 2002:397).

2.3.2.11 Alcohol A strong inverse relationship exists between the moderate consumption of

alcohol (30g alcohol/day: 1-2 drinks for women, 2-3 drinks for men) and the

incidence of CAD . This apparent protective effect of alcoholic beverages on CAD

has been ascribed to properties of alcohol itself and not other components of

specific drinks. As much as 50% of this benefit is thought to be due to the

capacity of alcohol to increase HDL and reduce thrombotic tendency, effects

which may be mediated through an increase in the ratio of oestrogen to

testosterone. In addition, red wine contains natural antioxidant compounds

(polyphenols) that may also contribute to cardio protection. In sharp contrast to

these favourable effects of alcohol, it is well known that intake above a moderate

level is associated with an increased level of CAD, a variety of cancers and other

socially deleterious effects (Lindsay & Gaw, 2004:163-164).

29

Various studies have shown that moderate intake of alcohol (one drink per day)

significantly improves the elasticity of arteries, which is an important indicator of

cardiovascular health. This positive effect seems to be true of not only red wine,

but even beer and hard liquor. In contrast, studies have proved that heavy

drinking is detrimental to cardiovascular health (www.Heartcentreonline.com,

2005).

Patients who are at risk of CAD should undergo lifestyle adaptations (defined in

1.5.2). The focus of the study is on the adaptations that these patients undergo

and the rehabilitative road they walk in adapting their lifestyle and maintaining

this new lifestyle. The researcher is aware that lifestyle adaptation is part of the

cardiac rehabilitation process that the patient with CAD should undergo after

having CABG surgery, PTCA or insertion of a coronary stent. The cardiac

rehabilitation process is therefore discussed next.

2.4 Cardiac rehabilitation Berra et al. (1991:41) describe cardiac rehabilitation as the process by which a

person with cardiovascular disease, including but not limited to patients with

coronary heart disease, is restored to or maintained at his or her optimal

physiological, social, vocational and emotional status. The World Health

Organization defines cardiac rehabilitation as follows: “The sum of activities

required to ensure the best possible physical, mental and social conditions so

that the cardiac patient may resume as normal a place as possible in the life of

the community” (www.medicinet.com, 2005).

Guidelines compiled by the Agency for Health Care Policy and Research

(AHCPR) in the United States of America describe cardiac rehabilitation as a

comprehensive long-term program which includes medical evaluation, prescribed

exercise, risk monitoring, education and counselling (www.medicinet.com, 2005).

30

It is a continuous process that includes patient education, psychosocial

counselling, risk factor modification, an exercise program and re-education.

Cardiac rehabilitation is subdivided into four phases (discussed in 2.4.1). These

four phases make provision for the patients’ specific needs in the different stages

of illness and the recovery period. Patients will move from one stage to the next

according to their individual needs and disease (Coats, Mc Gee, Stokes and

Thompson, 1995:12-13; Hatchett & Thompson, 2002:840; Hoeman, 2002:730;

Woods, Sivarajan Froelicher & (Underhill) Motzer, 2000:840).

The aims of cardiac rehabilitation are to return patients to optimum health within

the confines of their disease, to highlight individual risk factors and encourage

patients to make long-term adaptations where indicated. It also provides the

opportunity to educate relatives. Educating relatives does not only serve as

opportunity to teach them but also enables them to better understand what the

patient is going through and to support them better. The importance of the family

as part of the patient’s external environment is once more emphasized. Family

and friends should be encouraged to participate in the education process.

Cardiac rehabilitation also provides an environment where patients and family

acknowledge their role in accepting responsibility for their health and emphasizes

the necessity of dealing with a progressive disease (Hatchett & Thompson,

2002:840; Lindsay & Gaw, 2004:274).

Cardiac rehabilitation strives for the achievement and maintenance of optimal

cardiac condition and includes the control of cardiac risk factors. A better

conditioned cardiovascular system improves the quality of life and may decrease

morbidity in the patient with cardiac disease (Hojnacki as quoted by King,

1975:231).

Cardiac rehabilitation can be divided into four different phases, which are

discussed next.

31

2.4.1 Phases of cardiac rehabilitation Phase one occurs during inpatient stay or after a stepwise change in the patient’s

condition, e.g. acute myocardial infarction, admission for revascularization,

admission with unstable angina, CABG surgery, PTCA or insertion of a coronary

stent (Hoeman, 2002:730; Lindsay & Gaw, 2004:274). This phase usually

includes light supervised exercise such as walking the halls and stair climbing.

Most rehabilitation teams are multidisciplinary and advice and education may be

given by the most relevant health-care professional. Issues such as risk factors,

diet, medication, sexual activity, exercise, returning to work and normal life at

home are addressed. This phase usually lasts from five days to two weeks.

During this time a patient is normally hospitalized in a cardiac intensive care unit.

Hatchett & Thomson (2002:231) emphasizes that the opportunity should be used

during this phase to discuss the symptoms and prognosis of CAD. In this way a

positive approach towards recovery, early mobilization and discharge can be

established (http://www.sts.org/doc/3563 ,2004; Coats et al. 1995:13; Hoeman

2002:730).

Risk factors are also assessed during this phase. Risk factors are divided into

modifiable and non-modifiable risk factors, (as discussed earlier in 2.3) It is an

integral part of the rehabilitation process and is carried out throughout the four

phases of rehabilitation. Advice at this stage should be tailored to patients’ needs

and willingness to make adaptations to their life. Discussions should be initiated

about preventive strategies and necessary lifestyle adaptations. Information

should be collected about risk factors such as family history of CAD, personal

history of CAD, smoking history, dietary habits and blood lipid profile, body mass

index, blood pressure and history of hypertension, diabetes, physical activity

levels and functional capacity, stress, anxiety, socio-economic status, vocational

status and leisure activities (Lindsay & Gaw, 2004: 275-276; Van Zyl, 2003: 21).

32

Patients should be reassured about their medical status, financial issues and the

influence on their professional life. Sometimes these aspects are at the forefront

of patients’ minds and the quicker they are reassured that the event need not

have a negative effect on their life, the better. All misconceptions the patient may

possibly have about CAD must be dealt with in a realistic way, because it may

influence his potential for recovery after having CABG surgery, PTCA or insertion

of a coronary stent. Here the support of family and colleagues is once again very

important. The patient shouldn’t unnecessarily be stressed by financial worries or

work-related issues (Coats et al. 1995:14; Woods et al. 2000:853; Lindsay &

Gaw, 2004:275).

According to Coats et al. (1995: 17-18) it is important to plan patients’ discharge

properly. The patient should be urged from the beginning to think about small

lifestyle adaptations (discussed in 2.4) Issues such as returning to work, driving a

car, sexual relations and drug therapy should be addressed. Confusion about

these issues or unanswered questions can result in unnecessary stress.

Phase two begins right after discharge from hospital. It usually lasts from two to

twelve weeks, depending on the patient’s progress. Patients often feel anxious

and isolated during this stage. As cardiac mortality rate is very high during this

time, due to the fact that patients are participating in physical activity for the first

time again after the event and also because the patients are home and alone

again for the first time, it is very important that patients should know and

understand which signs and symptoms are dangerous and which are not.

Extensive education should be given to the patient with regards to starting

exercise and initiating activities. Patients are usually very motivated during this

time and the opportunity should be used to the fullest by all rehabilitation

personnel (Coats et al. 1995: 20; Hoeman, 2002:737; Lindsay & Gaw, 2004:278-

279).

33

According to the American Society of Thoracic Surgeons (STS) the goals of

phase two are to:

• Improve functional capacity and endurance

• Provide education of lifestyle adaptations

• Reduce fear and anxiety about increased activity or exercise

• Assist in making optimal social and psychological adjustments

The importance of education in the following areas are also emphasized:

• Medication review

• Lifestyle adaptations and goal setting

• Nutrition counselling

• Stress management

• Safe performance of activities including sexual activity, vocational and

recreational pursuits

(http://www.sts.org/doc/3563, 2005).

Woods (2000:841) adds that education and counselling should be aimed to uplift

patients’ psychological status and prevent depression and anxiety which is

prevalent in this phase.

Phase three takes the form of a structured exercise and health education

program that lasts from four to twelve weeks, starting about two to four weeks

after discharge. The exercise and activities are more intense and are structured

to suit patients’ individual needs and fitness levels (Coats et al. 1995:25-26;

Hatchett & Thompson, 2002:32).

The American STS sets out the following goals for phase three:

• Provide an ongoing exercise program

• Offer support necessary to make and maintain lifestyle adaptations

• Achieve the desired goal, such as, independent lifestyle or return to work

• Prevent progression of heart disease

(http://www.sts.org/doc/3563, 2005).

34

During this phase patients generally return to work and support is aimed at

assisting them in this step. Where returning to previous employment is not

possible appropriate suggestions may be made (Coats et al. 1995:26). Lindsay &

Gaw (2004:279-281) also emphasize that this is the time when patients’

motivation starts to drop due to the fact that they are now on their own and less

supervision is present. It is important to encourage patients to become

independent as soon as possible and to strengthen their confidence to make

adaptations on their own. It is during this phase that the patient’s values should

be strengthened and emphasized. As mentioned before by Smith (1977:241)

values are determinants of virtually all kinds of behaviour that could be called

social behaviour. Values will influence the way patients adapt their lifestyle.

Hattingh (1991:39) also emphasises that values influence the preference attitude,

moral convictions, principles and standards of a group or individual.

Phase four is a wellness program, consisting of two stages. Coats et al.

(1995:27-28) explain it as follows: Firstly the maintaining of long-term, individual

goals and secondly the professional monitoring of patients’ clinical status and

general progress (doctors’ follow-up visits). Issues that are monitored include

medication, risk factors, lifestyle adaptations, weight control, psychosocial status

and vocational support. During phase four patients are handed over from

rehabilitation staff to primary health care staff. Relevant patient records,

especially on progress and medication, are given to the patient’s general

practitioner who will continue the treatment (Coats et al. 1995:28-29; Lindsay &

Gaw, 2004:28).

It is again important to strengthen and emphasise the patients’ values during this

phase, in order to ensure that they adapt their lifestyle and are motivated to

continue this new life. Throughout the phases of cardiac rehabilitation the patient

is motivated to adapt his lifestyle. Like cardiac rehabilitation this is a continuous

process. The lifestyle adaptations patients with CAD, who underwent CABG

surgery, PTCA or insertion of a stent are discussed next.

35

2.5 Lifestyle adaptations

In the lifestyle heart trial conducted by Ornish (1998:387), the objective was to

determine if lifestyle adaptations in diet, exercise, smoking and stress could

affect coronary atherosclerosis. Patients with angiographically documented CAD

were assigned to an experimental group or to a usual care control group. The

experimental group patients were prescribed a regimen that included a low-fat

vegetarian diet, smoking cessation, stress management training, moderate

aerobic exercise and group support. After only one year, patients in the

experimental group showed significant overall regression of coronary

atherosclerosis. After five years, these findings were confirmed with reduced

severity of coronary artery stenoses and reduced numbers of myocardial

infarctions, cardiac related hospital admissions and cardiovascular related deaths

in the experimental group (Ornish et al. 2005:387).

Connaughton (2001: 87) also emphasizes that patients with CAD should address

lifestyle adaptations such as stopping smoking, dietary modifications, following a

structured exercise program and management of stress and alcohol

consumption. The different lifestyle adaptations will be discussed next.

2.5.1 Eating a healthy diet and maintaining a healthy weight Hyperlipidaemia, obesity, diabetes, and hypertension are recognized as major

risk factors for CAD (as described in 2.4.2). Dietary modifications have an

important role to play in the management of these risk factors. It is not

uncommon for individuals to present with one or more of these conditions

(www.medicinet.com, 2005; Lindsay & Gaw, 2004:159).

Every individual has certain food preferences and it is not easy to set out rules of

what to eat and what to avoid. Aspects such as allergies and religious restrictions

should also be taken into consideration. Dietary modifications should therefore be

planned on an individual basis and will vary from person to person.

36

However to achieve and maintain a heart-healthy eating pattern, the following

guidelines are recommended:

Eat a variety of fruit and vegetables. Choose five or more servings of

whole fruits and vegetables - especially dark green, orange or yellow -

each day.

Eat a variety of grain products, especially whole grains, choosing six or

more servings per day.

Include low-fat or fat-free dairy products, fish (at least two servings per

week), legumes (beans), poultry (skin removed) and lean meats.

Limit cholesterol-raising fats such as saturated fats. Limit full-fat dairy

products, high-fat meats, fried foods, products made with partially

hydrogenated vegetable oils, tropical oils (e.g. palm kernel oil, coconut oil)

and egg yolks. Instead choose fats and oils with two grams or less

saturated fat per tablespoon, low-fat or non-fat dairy products, and lean

meats. In addition, limit dietary cholesterol to less than 300 mg per day.

Balance the total number of calories (energy) you eat with the total energy

used each day to maintain a healthy body weight.

Maintain a level of physical activity that keeps you fit and matches your

energy (calorie) intake to maintain a healthy body weight. Participate in at

least 30 minutes of physical activity on most days. For weight loss,

maintain an activity level that exceeds the amount of calories that you eat

every day.

Limit intake of foods that are high in calorie content and low in nutrition,

including foods with a high sugar content such as soft drinks or candy.

Consume less than 2400 mg (approximately one teaspoon) of sodium per

day. People with hypertension should strive for an even lower intake.

Avoid salty foods and avoid adding salt to food during and after cooking.

Check food labels for salt content of packaged foods.

Limit alcohol intake to no more than one alcoholic drink per day for women

and no more than two drinks per day for men.

(www.medicinet.com, 2005)

37

These guidelines encourage eating a wide variety of foods high in complex

carbohydrates from whole grains, fibre, vitamins and minerals. This diet is also

low in fat, cholesterol and salt. Eating excessive amounts of foods (especially

foods high in saturated fat, sugar and salt) should be avoided. Every meal or

dinner party may not meet all these guidelines. Instead of concentrating on each

meal, these guidelines should be applied to achieve an overall heart-healthy

eating pattern (www.medicinet.com, 2005).

Compliance appears to be improved if factors such as dietary advice are aimed

at the whole family so that the patient’s adapted diet style is readily incorporated

into the family’s eating pattern. Individualizing the diet to the patients’ specific

needs and preferences also has a positive effect on compliance

(www.medicinet.com, 2005; Urden et al. 2002:396, Lindsay & Gaw, 2004:172).

2.5.2 Stop smoking CAD is one of the main diseases caused by smoking. However, the benefits of

quitting are experienced within the first day.

As soon as a smoker stops smoking the body starts to eliminate tobacco

constituents. Within eight hours nicotine levels will be reduced by half and within

24-48 hours of stopping, the smoker’s carbon monoxide level will be comparable

with that of a non-smoker. The oxygen level gradually returns to normal and the

heart beat slows. The lungs start to clear the tar, the cilia recover and the ex-

smoker feels less wheezy and breathless. Within a week the senses of smell and

taste improve, teeth are whiter and breath fresher (Urden et al. 2002:397,

Lindsay & Gaw, 2004:134).

The long-term benefits to cardiovascular risk are considerable and these benefits

occur at all age groups and all stages of cardiovascular disease. The excess risk

of CAD from smoking reduces by half within 1 year of stopping smoking. After 15

years, the risk reverts to about the same level as that of someone who has never

38

smoked. As would be expected, the level to which the risk drops varies between

individuals and depends on how long the patient smoked, how heavily they

smoked and other risk factors present. For an individual who already has heart

disease or who has had a heart attack, giving up smoking reduces the risk of

premature death of another heart attack by up to 50% or more (Lindsay & Gaw,

2004:134-135).

In order to successfully stop smoking one should understand smoking, determine

why someone started in the first place and why they continue or decide to stop.

Some of the factors why people start smoking are peer pressure or curiosity. Due

to reasons such as dependence patients on nicotine cannot or do not want to

give it up. Nicotine is very addictive and a smoker gets used to a certain level of

nicotine in their blood. They then have to smoke to maintain the nicotine levels in

their blood. Many smokers enjoy the taste and ritual handling of their cigarettes.

They may reward themselves with a cigarette after completing a difficult task.

Cigarettes also have a social function and can act as ice breakers, be used as

time fillers and to deal with boredom (www.heartcenteronline.com).

Smokers learn to use cigarettes as a means of relieving stress and believe that

cigarettes “calm the nerves”. In fact nicotine is a powerful stimulant and what

actually happens is that withdrawal symptoms emerge when a smoker has not

smoked for a while. The next cigarette alleviates these symptoms and the

smoker feels better and relaxed. Some smokers smoke to aid their concentration

but again, this is more a result of habit and association. The smoker deliberately

chooses to use a cigarette to help him concentrate (and to ward off withdrawal

restlessness) and therefore feels more concentrated – a self-fulfilling prophecy.

Smokers are very good at denial or adopting a fatalistic approach to the

consequences of smoking. They tell themselves: “I’m going to die any way” or

“My uncle is 92 and he still smokes 40 a day”. Research proved that out of 1000

young male smokers, one will be murdered, six will be killed on the roads and

250 will be killed by tobacco. Forty percent of smokers do not collect their

39

pension as they die before retirement, compared with only 15% of non-smokers

(www.medicinet.com, 2005 ; Lindsay & Gaw , 2004:156).

Another powerful obstacle is fear of gaining weight, particularly in young women

who are under constant social pressure to be thin. Even though cigarettes

contribute to elevated metabolism that promotes weight loss, people tend to gain

weight after stopping mostly due to the habit of smoking being replaced by eating

(Urden et al. 2002:397, Lindsay & Gaw, 2004:134).

.

The three main components of smoking are pharmacological addiction, habit and

psychological dependence. All three need to be addressed in an attempt to stop.

Health professionals have a high credibility with smokers and can be effective in

helping them to stop for good. Most patient contacts can provide an opportunity

to intervene on smoking. The most effective intervention strategy for health

professionals is minimal intervention, backed up with referral to specialist

services. Minimal intervention aims to equip patients with the knowledge and

motivation they need to adopt different behaviour, one stage at a time.

Motivational interviewing techniques should be used in discussing smoking with

patients, involving open questions and active listening, with the patient doing the

decision-making. Advice and information offered should be relevant to what the

patient says. The whole practice can be involved in creating the climate for

cessation. Non-smoking should be promoted as the norm throughout the practice

(www.medicinet.com, 2005 ; Lindsay & Gaw , 2004:156).

2.5.3 Exercise Physical activity has a key part to play in improving health and well-being. One of

its benefits is that it helps prevent CAD (Lindsay & Gaw 2004 :189). It has been

calculated by the British Heart Foundation that 37% of deaths due to CAD under

the age of 75 are attributable to physical inactivity. Exercise is an everyday part

of life for many people. Previously people with heart disease were advised to

“take it easy” and certainly never to take part of any form of exercise. Now,

however, not only is exercise recommended as a way to prevent heart disease,

40

but it is used as part of the rehabilitation process in those who suffer from CAD

after having CABG surgery, PTCA or insertion of a coronary stent (British Heart

Foundation, 2002:www.health24.com:2005).

The idea behind exercise to either prevent, or treat heart disease is that a regular

training program will improve general cardiovascular fitness. In simple terms, this

will improve your ability not only to exercise, but to carry out normal everyday

activities (www.health24.com:2005).

Exercise does not only have physical but also emotional benefits. Exercise is an

excellent component of stress management. Taking a walk after dinner can be as

helpful to the mind as the digestive system. Walking as a family can improve

communication and teach healthy habits that will last a lifetime. Exercise is also

well known for its ability to reduce depression. It can increase the confidence and

independence of a patient suffering from CAD, especially after a frightening

episode such as a myocardial infarction or coronary artery bypass surgery.

Exercise is a good tool for feeling both physically and emotionally stronger after

going through a period of fear and vulnerability.

Connaughton (2001:86) identified various non-pharmacological interventions

proven to reduce the risk of recurrent cardiac events. For example, the negative

effects of alcohol consumption and smoking are eliminated or reduced, this risk

reduces accordingly. Dietary modifications regarding cholesterol reduction and

control, weight reduction and regular physical activity and exercise all reduce the

risk of cardiac events recurring ( www.heartcenteronline.com ).

Exercise prescriptions should be individualised. It is important that the exercise

fits in with the patient’s lifestyle and daily activities so that they don’t experience

exercise as a burden and compliance to the program is poor. Parameters such

as type, intensity, duration, and frequency should be specified and realistic

exercise gaols should be set. It is also important that the patient enjoys the

41

exercise to ensure better compliance (Lindsay & Gaw, 2004:313-314; Clochesy

et al. 1996:367).

2.5.4 Behavioural adaptation

CAD is dependent, to a large extent, on our behaviour and our psychological

circumstances. Cigarette smoking, dietary behaviour, exercise levels and the

prevalence and impact of psychological stress are considered key behavioural

risks.

Although patients may ultimately wish to optimise their health, whether or not

they engage in health-promoting behaviours are governed more by short-term

costs and benefits than by long-term possible health outcomes. Patients may

consider adopting a low-fat diet to reduce their risk of CAD, but be beset by more

immediate problems. Their families may not wish to adapt their diet, they may

have to learn new cooking methods, eat less favoured foods, perhaps even

increase the cost of their shopping. These short-term costs may override the

benefit of potential long-term health gains and prevent adoption of appropriate

behavioural change (Lindsay & Gaw, 2004: 217-234).

At any one time patients may be more or less motivated to adapt their behaviour.

A key aspect of counselling is to identify what stage of adaptation the individual is

at and to tailor any intervention accordingly (Lindsay & Gaw, 2004: 217-234).

Taking responsibility and the right attitude towards illness and the lifestyle

adaptations to be undertaken is essential for the health of the patient with CAD

who underwent CABG surgery, PTCA or insertion of a coronary stent. Patients

who do not take responsibility for their condition and who do not adopt the

needed changes put their own health at risk, and are in danger of going through

the whole ordeal again. It should be stressed that the patient is suffering from

CAD and if he does not adapt his lifestyle cardiac events will recur. Statistics

have shown that second time CABG surgery, PTCA and coronary stents are less

42

successful and the mortality rates are higher (According to Statistics South

Africa). Patients with coronary artery reduction are forced, due to physiological

changes, to make lifestyle adaptations (Gotto as quoted by Palm, 1990:1).

It is also important that patients comply with medicine regimes and follow-up

visits to their doctor. A recent study has shown that in patients who suffer from

CAD, who underwent CABG surgery, PTCA or insertion of a coronary stent, and

who also have elevated cholesterol levels, the use of cholesterol-lowering

medication can lower cholesterol levels and prolong vein graft function. Patients

are also advised about the importance of lifestyle adaptation to lower their

chance of developing further atherosclerosis in their coronary arteries. These

include stopping smoking, exercise, reducing weight and dietary fat, as well as

controlling blood pressure and diabetes (http://www.medicinenet.com, 2004).

The discussion in 2.5 makes it clear that it is important to identify and address

risk factors present in the lifestyle of patients with CAD who underwent CABG

surgery PTCA or insertion of a coronary stent. These patients should be informed

on how they can adapt their lifestyle and motivated to maintain this new lifestyle.

2.6 Conclusion In this chapter (chapter two) various aspects of the conceptual framework were

discussed. It was shown that when lifestyle adaptations are considered for

patients with CAD who underwent CABG surgery, PTCA or insertion of a

coronary stent, all aspects of their environment should be taken note of. Various

risk factors for CAD and the different phases of cardiac rehabilitation were looked

into, as part of the lifestyle adaptations needed to be done. These factors were all

taken into account when the questionnaires for the study were compiled (see

table 2.5 and 2.6).

43

Table 2.5 Relevant topics covered in questionnaire one (Annexure one)

Topic Question number

Age 2.3.1.1 5

Gender 2.3.1.2 4

Obesity 2.3.2.3 10 + 11

Physical activity 2.3.2.5 + 2.5.1 + 2.5.3 19 + 20

Diet 2.3.2.1 + 2.3.2.2 + 2.3.2.6 + 2.5.1 23 – 27

Smoking 2.3.2.7+ 2.5.2 28 – 30

Stress and anger 2.3.2.10 13 + 33 – 34

Alcohol 2.3.2.11 21 + 22

Behavioural adaptation 2.5.4 14 – 18 + 37

Family and social support 2.2 5 + 35 + 36

History of previous cardiac event 8

Medication 2.2. 31

Table 2.6 Relevant topics covered in questionnaire two (Annexure two)

Topic Question number

Obesity 2.3.2.3. + 2.5.1 1

Physical activity 2.3.2.5 + 2.5.1 + 2.5.3 7 + 8

Diet 2.3.2.1 + 2.3.2.2 + 2.3.2.6 + 2.5.1 11 – 14

Smoking 2.3.2.7 + 2.5.2 15 - 18

Stress and anger 2.3.2.10 20

Alcohol 2.3.2.11 9 + 10

Behavioural adaptation 2.5.4 2 – 6 + 23 + 24

Family and social support 2.2 21 - 22

Medication 2.2 19

44