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Attitude of people towards the preventive methods of CHD Regarding the attitude of people today towards healthy and

balanced diet, dietitian, Dr Rosemary Stanton has something to say. Dr.Stanton : "We are eating more snack foods, fast food, takeaway foods and soft drinks. Foods children used to eat at parties, they now eat for snacks. Studies show 80 per cent of children take a packaged snack to school every day and this takes the place of fruit." Dr Stanton says both children and adults are presented with a distorted menu of foods that are available. Her statements tell a lot about the attitude of people today towards healthy and balanced diet. Issue about physical inactivity or sedentary lifestyle among people in this era is no longer a stranger to all of us. The Australian Bureau of Statistics recently reported that, of a sample of 13,000 Australians over the age of 18, only 55 per cent say they regularly take part in a sport or physical activity. That's barely one in two Australians and down from the 59 per cent who said they did so in 1999. The International Journal of Sports Medicine recently also estimated that we would need to walk an extra 19km a day to match the activity levels of our ancestors. All of these tell the attitude of people today towards physical activity. Dr Colin Kratzing who is a member of Australia's Healthy Weight Task Force and a Brisbane GP also commented on the attitude of people today towards physical activity. He mentioned that most people nowadays are very busy doing sedentary things, like watching television or going to the movies, so they don't have time to pursue active hobbies and activities. To make the matter worse, human has found ways to engineer all the effort out of our lives. Remote controls for televisions and garage doors, electric can openers, escalators instead of stairs, even shopping on the internet are all modern "advances" that are robbing us of movement. Regarding the attitude of people today towards smoking, its quite a controversy as some researches showed that there is a decresing trend in smoking habit, while other researches showed that the smoking habit is in an increasing trend. The decresing smoking trend is evidenced by Blendon (1998) who reported that American attitudes have changed remarkably since the mid- 1980s. His research indicated that the majority of Americans now favor increased regulation and taxation on tobacco products. These attitudes propelled the 106th United States Congress to introduce 50 bills concerning the topic of smoking (Thomas Legislative Information on the Internet, 2000). In fact, in Florida, there is an effort underway through a public initiative to place on the ballot a proposed amendment to prohibit smoking in all public places including restaurants (Norman, 2001). However, the research by DeBernardo, Aldinger, Dawood, Hanson, Lee, and Rinaldi (1999) indicated that although 98% of college students were aware of the consequences of smoking, only 39% of smokers desired to quit smoking while 11% of non-smokers wanted to start smoking. Also, Wechsler et al. (1998) reported cigarette smoking by college students rose 28% from 1993 to 1997. They also discovered over one quarter of students began smoking after beginning college. In addition, 85% (95 of 116) of the colleges used in the sample reported an increase in smoking. These data supported a study by Sax (1997) that found that the annual survey of college freshmen, which have been administered for thirty consecutive years at

colleges and universities nationwide, reported an increase in cigarette smoking. Research by Wechsler et al. (1998) discovered the increase in college smoking began with a rise in high school smoking in the early 1990s.

Regarding the attitude of people today towards compliace of hypertensive treatment, a research on the Impact of Patients Knowledge, Attitude and Practices on Hypertension on Compliance with Antihypertensive Drugs in a Resource-poor Setting published by TAF Preventive Medicine Bulletin, 2010: 9(2) mentioned that the compliance with antihypertensive drugs was poor. Although the study was done on outpatients in a clinical setting, and the method of assessment of compliance might be subjective, findings are not largely different from reports of previous studies (24-27). Reasons for poor compliance included poor knowledge of disease and ignorance of need for long-term treatment, high cost of medications, adverse drug reactions, religious practices and cultural beliefs, lack of access to medical care and facilities and use of complimentary medications and practices. Among out-patients, compliance with antihypertensive drugs range from 20% to 56% (28,29). Poor compliance with drugs is an inherent problem in the treatment of chronic asymptomatic conditions and is one major reason why HT may not be treated effectively with drugs.(29) Poor compliance to antihypertensive drugs may also account for apparent resistant to treatment in more than one third of patients with HT (30,31). In this study, poor knowledge of HT and of antihypertensive drugs had a significant negative impact on compliance. Patients level of education, skilled occupations and being health conscious have been previously shown to be associated with improved compliance among patients with HT (24,32). Although the issue of compliance with antihypertensive drugs requires a holistic approach that takes into consideration all the identified factors, there is need to invent and adopt new means of educating the public in general and the patients in particular (33). 24. Bovet P, Burnier M, Madeleine G, Waeber B, Paccaud F. Monitoring One-Year Compliance to Antihypertension Medication in the Seychelles. Bulletin of the World Health Organization. 2002; 80 (1): 33-39. 25. Moname M, Bohn RL, Gurwitz JH, et al. The Effects of Initial Drug Choice and Comorbidity on Antihypertensive Therapy. International Journal of Clinical Practice. 1999; 53: 37-38. 26. Lee JY, Kusek JW, Greene PG, Bernhad S, Norris K, Smith D et al. Assessing Medication Adherence By Pill Count and Electronic Monitoring in the African American Study of Kidney Disease and Hypertension (AASK) Pilot Study. American Journal of Hypertension. 1996; 9: 719-725. 27. Mengden T, Un S, Dusing R, Weisse B, Vetter H. Drug Compliance Decreases Between Clinic Visits: the Effect of White Coat Compliance on 24-hour Ambulatory Blood Pressure Monitoring. J Hypertens. 2000; 18 (Suppl 4): S169. 28. Schwartz GL, Sheps SG. A review of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Current Opinion in Cardiology. 1999; 14: 161-165. 29. Luscher TF, Vetter H, Siegenthaler W, Vetter W. Compliance in Hypertension: Facts and Concepts. J Hypertens 1985; 3: 53-59. 30. Bertholet N, Favrat B, Fallab-Stubi CL, Brunner HR, Burnier M. Why Objective Monitoring of Compliance is mportant in the Management of Hypertension. J Clin Hypertens. 2002; 2: 258- 262.

31. Rudd P. Clinicians and Patients With Hypertension: Unsettled ssues about Compliance. American Heart Journal. 1995; 130: 572-587. 32. Hungerbuhler P, Bovet P, Shamlaye C, Burnand B, Waeber B. Compliance With Medication Among Outpatients With Uncontrolled Hypertension in the Seychelles. Bulletin of the World Health Organization. 1995; 73: 437-442. 33. Gruninger UJ, Duffy FD, Goldstein MG. Patient Education in the Medical Encounter: How to Facilitate Learning, Behaviour Change and Coping. In: Lipkins M, Lazare A, Putnam S (eds). The Medical Interview. New York. Springer, 1994. 34. Beaglehole R. Global cardiovascular disease prevention: time to get serious. Lancet. 2001;161: 1501-1508. Regarding the attitude of people today towards compliance to treatment of diabetes, it has been generally acknowledged for years that nonadherence rates for chronic illness regimens and for lifestyle changes are 50%.1 As a group, patients with diabetes are especially prone to substantial regimen adherence problems.2 In general, research has shown that the diabetes regimen is multidimensional, and adherence to one regimen component may be unrelated to adherence in other regimen areas.2-4 For example, research has shown better adherence for medication use than for lifestyle change.5 In other studies, adherence rates of 65% were reported for diet3 but only 19% for exercise.4 Two studies showed that adherence to oral medications in patients with type 2 diabetes was 53 and 67% when measured by electronic monitoring.6,7 In a more recent study of older type 2 diabetic patients' adherence to sulfonylureas, adherence, when measured by pill counts, was 104% to a one-per-day regimen and 87% to twice- or thrice-daily regimens. However, electronic monitoring revealed reduced adherence rates of 94 and 57% for once-daily and twice- or thrice-daily regimens, respectively.8 Haynes RB, Taylor DW, Sackett DL: Compliance in health care. Baltimore, Md., Johns Hopkins University Press, 1979 Kurtz SMS: Adherence to diabetes regimens: empirical status and clinical applications. Diabetes Educ 16:50 -56, 1990 Glasgow RE, McCaul KD, Schafer LC: Self-care behaviors and glycemic control in type 1 diabetes. J Chron Dis 40:399 -412, 1987 CrossRefMedline Kravitz RL, Hays, RD, Sherbourne CD, DiMatteo MR, Rogers WH, Ordway L, Green-field S: Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med153 : 1869-1878,1993 Abstract/FREE Full Text Anderson RM, Fitzgerald JT, Oh MS: The relationship of diabetes-related attitudes and patients' self-reported adherence. Diabetes Educ19 : 287-292,1993 Mason BJ, Matsuyama JR, Jue SG: Assessment of sulfonylurea adherence and metabolic control. Diabetes Educ 21:52 -57, 1995

Paes AHP, Bakker A, Soe-Agnie CJ: Impact of dosage frequency on patient compliance. Diabetes Care 20:1512 -1517, 1997 CrossRefMedline Winkler A, Teuscher AU, Mueller B, Diem P: Monitoring adherence to prescribed medication in type 2 diabetic patients treated with sulfonylureas. Swiss Med Wkly 132:379 -385, 2002 Medline

Regarding the attitude of people today towards losing weight, it is also quite a controversy as some references show that people are not intending to lose weight, but some other references show that people are trying hard to lose weight. The saying of people are not trying to lose weight is based on the latest statistics published by the World Health Organization (WHO) that globally there are more than 1 billion overweight adults, and the number is growing. However, there is also a saying that people are trying hard to lose weight (either for health or cosmetic purpose) as evidenced by the U. S. Food and Drug Administration (FDA) that Americans spent an estimated $30 billion a year in 1992 on all types of diet programs and products, including diet foods and drinks. Marketdata, a market research firm that has tracked diet products and programs since 1989 releases its findings in its biennial study: "The U.S. Weight Loss & Diet Control Market." which in its 2007 study estimates the size of the U.S. weight loss market at $55 billion. It is now estimated to have reached over $60 Billion.

Regarding the attitude of people today towards taking statins prescribed as preventive of CHD, the majority of patients for whom statins are prescribed in clinical practice either stop taking the drug altogether or take less than the prescribed dose within a year. Cohort studies of patients prescribed statins show variable but disappointingly high rates of discontinuation of therapy and poor adherence to drug regimens [1, 2, 3, 4, 5], and failure to reach targets for cholesterol reduction in those who continue with therapy [6]. Discontinuation rates at five years in clinical trials range from 6-30%, but in clinical practice the rates are much higher. Studies show that the number of patients continuing therapy falls sharply in the first few months of treatment, followed by a more gradual decline. In the USA it is estimated that only about 50% of patients continue at six months, and 30-40% at one year [7]. Similar rates have been found in Australia [4], and the same problem exists in the UK [8]. There is no single cause of failure to comply with prescribed medication, and the problem is not restricted to statins. The causes of non-compliance include: multiple daily dosing, multiple drug regimens, asymptomatic, feeling in good health, lack of knowledge about disease, need for treatment and side effects, some comorbidity e.g. dementia, depression, MI after statin started.

J Avorn et al. Persistence of use of lipid-lowering medications. A cross-sectional study. JAMA 1998 279: 1458-1462. JS Benner et al. Long-term persistence in use of statin therapy in elderly patients. JAMA 2002 288: 455-461. CA Jackevicius et al. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002 288: 462-467. LA Simons et al. Apparent discontinuation rates in patients prescribed lipid-lowering drugs. Med J Aust 1996 164: 208-211. J Larsen et al. High persistence of statin use in a Danish population: compliance study 19931998. Br J Clin Pharmacol 2002 53: 375-378. JP Frolkis et al. Statins do not meet expectations for lowering low-density lipoprotein cholesterol levels when used in clinical practice. Am J Med 2002 113: 625-629. Third report on National Cholesterol Education Program expert panel on detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. IX Adherence. Circulation 2002 106: 3359-3366. S Carter D Taylor. A Question of Choice: Compliance in Medicine Taking. Medicines Partnership 2003, Regarding the attitude of people today towards taking aspirin prescribed as preventive of CHD, according to a research on low-dose aspirin therapy for cardiovascular prevention published on Medscape website, poor compliance and treatment discontinuation are common among patients prescribed low-dose ASA therapy for primary or secondary cardioprotection, placing these patients at substantially increased risk of CV events including MI, ischemic stroke, and death. As many as one-quarter of patients chose to discontinue taking low-dose ASA therapy following prescription, without physician direction. In the studies included in this review, a number of patient-related characteristics were identified as possible risk factors for poor compliance with and withdrawal of low-dose ASA therapy, primarily including depression, a history of diabetes, obesity, lack of exercise, cigarette smoking, lower education level, and female sex. As many patients who are prescribed low-dose ASA for CV protection tend to be older, there is the possibility that co-morbid disease with associated polypharmacy and age-related memory impairment may contribute towards poor compliance and continuation rates. Unfortunately, in the studies included in this review, such patient characteristics were either not captured or inconsistently reported. With regard to drug -related factors that influence compliance, it is important to note that upper GI symptoms were reported by 18% of patients receiving low-dose ASA in the CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events) study, and by more than 60% of low-dose ASA users in a study by Laheij et al. In this study, patients using low-dose ASA were 1.79 times (95% CI 1.1, 2.9) more likely to experience GI symptoms than those not using low-dose ASA. Continuous low-dose

ASA treatment is associated with a risk of GI problems, including peptic ulcers and their complications such as bleeding and perforation.