Having worked in cardiac rehabilitation for over twenty years I learned early on that many patients are in the best shape of their lives the day they complete the program. That makes sense, to some extent, because they’ve just spent the last four months in a supervised exercise program. They also feel better for it. In addition, some have lost weight, many (nearly all) have increased their exercise capacity and strength, the few that smoke have quit or cut back, and they have also improved their diet.

These patients are obviously responding, in a positive way, to a health (or should I say disease) event. Even though many of us know what it takes to live a healthy life and many of my posts talk about it, why does it take some threat to one’s health to make that change? Why weren’t these patients in better shape before?

First off, change is difficult. No question about that. And sustained change is even more of a challenge. Over time, many of the patients I’ve followed after cardiac rehab have drifted back into being more sedentary, not eating as well and some even re-starting smoking. Given that, the average patient is still better off for having done the rehab program.

I would also include myself in this group as I’ve made changes since my heart disease diagnosis last year (eating less sugar, not snacking at night). Even though I’ve been eating healthy all along, there was still room for improvement and it took this diagnosis to improve it that much better. This followed an increase in exercise in my mid-20s when my blood pressure was around 160/95 mmHg. Incredibly high for anyone, let alone a 26 year old. Shortly after, it went down to 130s/80s.

I’ve also seen similar changes in friends and family. People care about health, but in the long run, health isn’t a key motivator for many to make lifelong change. This might be because the benefits (longer life, preventing that heart attack from happening or delaying a cancer diagnosis) are so far in the future, abstract and not certain (apart from death, that is).

Most often, people have other, more immediate reasons for doing a behaviour (imagine how your motivation for work would change if you got paid once every two years instead of every two weeks). I commute by bicycle to work, which obviously helps keep me healthy, but I’m not sure I would do it if it wasn’t more efficient than driving (during rush hour cycling takes no longer than driving) and saved me money (unlike driving, I don’t have to pay for gas or parking).

For a lot of us, it’s that seemingly sudden diagnosis or first symptoms, or unfortunately, a heart attack, stroke or other major event, that makes us aware that we have a chronic disease. As a result, many of us will attempt to change our lives for the better. However, those first signs or symptoms are not the beginning of the disease, it is only a new step in it. For many chronic diseases, the biological process of the disease has been going on for decades. It is only when the disease has progressed to the point it becomes noticeable (or measurable) that we learn about it.

When it comes to heart disease, the first time someone finds out about it is when they feel chest pain or have a heart attack. And for many people, death due to a heart attack is their first (and only) symptom. Similar things happen with stroke, cancer and other diseases, it’s not until we feel something wrong, that we seek care and take preventive steps.

In fact, the process that leads to that heart attack or cancer has been developing for years. An eye-opening study in the 70s identified atherosclerosis in autopsies of soldiers who died in the Vietnam war; many of them had atherosclerosis as young as 19 years old. This study was key in giving us insight into how early atherosclerosis can begin.

Likewise with diabetes, by the time a person is diagnosed, problems with sugar metabolism have been going on for years. In most countries physicians will conduct routine blood sugar tests starting at middle-age to identify diabetes before any long-term damage like blindness, foot amputation and a possible heart attack occur. However, an elevated blood sugar is only a sign of poor sugar metabolism and not the initiating incident.

While elevated blood sugar levels do increase a person’s risk for heart disease and early death, levels of insulin, which controls blood sugar, have likely been abnormal for years causing havoc on the body’s metabolism. It’s only when insulin can no longer control blood sugar levels that we see blood sugar rise. In the meantime, the elevated insulin can also result in creeping increases in blood pressure, inflammation and triglycerides.

Another example is osteoporosis, which is coined a pediatric disease with geriatric consequences because the primary time for strengthening bones is during adolescents but the problems don’t appear until the fifth or sixth decade. But try telling a teenager to care about how healthy he/she will be in later life.

The whole point of this is the realization that many chronic diseases have their foundation at much younger ages than we think and that it’s never too early to start preventing chronic disease. And as the saying goes; an ounce of prevention is worth a pound of cure.

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