Pam Stewart Fahs knows how good biscuits and sausage gravy can taste. She grew up in rural Harlan County, Ky. (pop. 33,202), where traditional Southern foods rule.
"You think of food as part of life and celebration," says Fahs, a professor at the Decker School of Nursing at Binghamton (N.Y.) University who directs a program to improve heart-healthy behavior, particularly among rural women. "You don't think about long-term consequences."
But Fahs began thinking about such consequences early, when her mother had a heart attack at age 50. "She had horrible cholesterol levels," says Fahs, 58. Her mother's illness became part of Fahs' decision to focus her professional research on cardiovascular disease, and she designed a three-year program, funded by the National Institute of Nursing Research, to improve heart health among rural women.
Fahs focused on the heart because cardiovascular disease is the No. 1 killer of women in the nation. She chose rural women because of her own background and also because of their particular circumstances.
"Many have to drive too far for care, and rural people may have less health care coverage," she says. Many women in rural America also smoke, a major risk factor for heart disease.
In 2006, Fahs set out with colleagues to try to reduce the heart disease risk of 167 women, ages 35 to 65, in two rural areas of New York and Virginia. In each state, half of the study participants were in a "community intervention group" and half in a "nurse" group.
At the study's start, researchers recorded the women's cholesterol levels, blood pressure, EKGs, weight and height. Fahs met with the two community groups and asked the women to suggest ways to reduce their heart disease risk. The Virginia community group expanded an annual health fair at a church to include blood pressure readings, EKGs and other risk assessments for cardiovascular disease. The New York community group wanted more public information about the best places to exercise.
"In rural areas, many times there aren't sidewalks, so it may be unsafe," Fahs says. And in some rural areas, people worry about bears, she adds.
Peg Pribulick, clinical instructor of nursing at Binghamton University and a partner in the study, worked with the local health department, finding free outdoor exercise places and posting the locations and hours on the health department's website.
The women in the nurse groups met with a nurse four times in 14 months and spoke by phone twice a month. They filled out lengthy questionnaires indicating their readiness to make changes in three areas: smoking, diet and physical activity. Each woman chose an area to focus on.
"If they were ready [to lower] their cholesterol levels, we talked about limiting fat intake and reading package labels, making sure that the fat was no more than 30 percent of the total calories," says Pribulick, who also spoke to women about heart-endangering fats such as trans fat and saturated fat.
"I would tell them there's a balance: A little butter once in a while is not a bad thing," she adds. "But there need to be limits."
In the nurse groups, Pribulick and Fahs also stressed eating more fruit and vegetables and increasing fiber intake by eating more whole grains and cereal. "In lowering cholesterol, you particularly focus on reducing fat and increasing fiber," Fahs says. "Fiber can bind with fat in the gut so that you can excrete it. And fiber makes you full so you don't eat so many high-fat foods."
For exercise—also a cholesterol reducer—the focus for the nurse groups was incorporating simple lifestyle changes, such as parking farther from the office door or playing outside with their children.
Fahs gave pedometers to participants in all four groups and asked them to aim for 10,000 steps a day. "Some women began to miss the exercise if they couldn't do it," she says.
The women in all four groups also kept journals recording what they ate and how they exercised. "Many commented that just by journaling, they saw what they needed to change and what to focus on," Pribulick says.
Fahs and Pribulick were surprised by their findings. The community intervention groups lowered cholesterol levels by an average of 11 points, the nurse group by only half a point. "We had expected the nurse group to do much better than the community group because of the additional support from nurse visits," Fahs says.
They attribute the dramatic change in total cholesterol in the community intervention groups to the use of cholesterol-lowering medication by more participants who did not have nurse visits. After seeing their initial cholesterol readings, some women in those groups started taking lipid-lowering medication. "And we know that works," Fahs says.
Progress occurred in the nurse's groups as well. By study's end, the women were eating more fruits and vegetables, and as participants made changes in one area, their awareness rose in another. "If they were exercising, at some point they felt a cigarette was counterproductive," Fahs says. "And if you're doing well with a diet, you might feel better and more interested in exercising."
"What was striking was that the information women received at the [initial] screening was enough for them to make a change," Pribulick says. "As soon as women found out their [cholesterol] numbers, many in the control group went to the doctor."
The assumption behind the study bore out too: You have to be ready to change before you can make changes. And the changes can be small ones, like reaching for blackberries instead of blackberry ice cream.
"I still love green beans with fatback," Fahs says. "But now I cook them with a lean pork chop to reduce the saturated fat. It's making small changes every day that makes a difference in heart health."