There's no stronger scare tactic into leading a healthy lifestyle than suffering a heart attack or stroke, which is why it may be surprising that many survivors don't make changes needed to improve their health.
A study published in April in the Journal of the American Medical Association shows one in four men doesn't make any lifestyle changes after a heart attack, stroke or other major cardiac event. Women were more likely to change unhealthy behaviors, and urban residents were more likely to make at least two lifestyle changes than those who lived in rural areas.
Three behaviors were included for the study: smoking cessation, healthy eating and physical exercise. Out of 7,519 patients surveyed in 17 countries, just 4.3 percent of participants improved their habits in all three areas, more than 30 percent made two lifestyle changes and more than 47 percent changed at least one lifestyle behavior to better their health.
Dr. Mark Friedman, a cardiologist at the SSM Heart Institute, said changing one's lifestyle can be very difficult.
"Patients don't want to be talked down to," he said. "They don't want to be told they're bad."
But much of the problem is lack of education. While patients used to stay in the hospital for up to two weeks after a cardiac event, they now are discharged within a day or two. This leaves little time for the medical staff to educate patients on what happened to them and what it could mean for their future.
Friedman attempts to motivate patients by starting small. While the American Heart Association recommends walking for 30 minutes a day five times a week, the SSM cardiologist encourages his patients to begin with walking three days a week. He also recommends frozen fish and fruit for those on a low budget.
What really surprised Friedman about the study is that patients had the most success with smoking cessation - more than 52 percent. People in wealthier countries had more success than those in poorer countries, the study showed. Friedman said higher income individuals are likely to have more education and resources to quit smoking.
The numbers pleased him, though, as Friedman said smoking cessation is one of the best ways to avoid heart disease. Still, he said he believes it is one of the hardest habits for his patients to cut, and they have to really want to stop for it to work.
Other changes include diet, with 39 percent reporting eating more healthful food, and physical activity, with 35 percent saying they were more active.
Urban area residents were 22 percent more likely in the study than those in rural areas to make at least two lifestyle changes. Friedman said this could again be because of more education and resources in cities. More physical activity was reported by people at all income levels.
Women were more likely than men to make lifestyle changes after a major cardiac event.
More than 7 percent of women made all three recommended lifestyle changes, compared to less than 2.5 percent of men. They were also 66 percent more likely than men to make at least two lifestyle changes, and more than 26 percent of men changed nothing compared to about 7 percent of women.
Friedman and his team do their best to educate victims of major cardiac events by bringing in dietitians and models that show what's happening in the patient's body. Then they have a mandatory follow-up visit.
Deb Garbo, a nurse practitioner, sees patients shortly after their release from the hospital to prescribe medications and treatment. She said many people don't absorb what they're taught in the hospital because they're more focused on being released, so it's her duty to reteach the patients everything.
Garbo assesses patients' readiness to make changes. Sometimes they will tell her that they aren't confident they can handle breaking a habit, so she doesn't force it on them.
A scared straight method that Garbo uses sometimes is she will ask the patients to hang a photo of their heart stent in their homes so they can look at it when they're tempted to smoke a cigarette or eat unhealthily.
One way to succeed is to participate in a cardiopulmonary rehabilitation program, she said.
At the heart institute, patients are overseen by a medical director for an hour three times a week for exercise and education. Amy Puricelli, a nurse at the St. Mary's Health Center cardio rehab, said the patients she sees usually are genuinely trying to make changes.
However, only 10 percent to 20 percent of patients eligible for cardiac rehab actually sign up for the program.
Many people may not be able to fit it into their work schedule.
Rose Burns, 70, a St. Louis resident, had a heart stent procedure four years ago because of a clogged artery and had to receive another stent in April.
Burns believed she was not at risk because of her slender build, so she continued to eat unhealthily after her first event. Now that she's in the cardiac rehab program, she said she feels more motivated because nurses hold her accountable by asking about her daily habits.
"I'm running out of years," she said. "That makes a big difference in your life. It's very important to me to have a lifestyle of better eating habits."
Fred Piercefield, 73, of Kirkwood, Mo., had a heart attack in June 2012 and again in June of this year. He said he changed his diet after his first attack and did the cardiac rehab, but after his second attack he's more aggressively making lifestyle changes.
"A heart attack makes a believer out of you, and it shows you that you're not invincible and not immortal," he said.
Though the percentage of people making lifestyle changes after a major cardiac event is not as high as it could be, Friedman said he thinks there has been improvement, considering more than 50 percent quit smoking and 39 percent reported keeping a healthier diet.
"We're on the right track," he said. "But a lot more has to be done for sure."