Svansdottir et al. BMC Public Health 2012, 12:42 http://www.biomedcentral.com/1471-2458/12/42 population attributable risk [47]. Thus, a predisposition towards unhealthy diet choices is a plausible mediating mechanism in the relationship between Type D person- ality and clinical CVD events, and as such, should be inspected more thoroughly. Although no differences in exercise and rehabilitation were found, a trend towards a higher prevalence of weight gain was noticed in Type D patients, which was significant in a post hoc analysis in overweight patients. Hence, overweight Type D patients may be more prone to gain weight after a coronary angiography, although how much weight these participants gained is unknown. Weight loss is of significant importance in obese indivi- duals, and cardiac patients in particular, as it can improve or prevent many of the obesity-related risk fac- tors for coronary heart diseases [49]. Type D patients were more likely to smoke at follow- up than non-Type D patients, although this difference was not significant at baseline. Other studies have also found an association between Type D personality and smoking [33,50,51]. Difficulties with maintaining smok- ing abstinence have been related to neuroticism [52,53] and psychological distress [52]. Type D individuals may experience the prospect of smoke-cessation as a more threatening and stressful event, due to their tendency to experience things in a more negative way, and might therefore need more support with altering their smoking habits. Taken together, Type D individuals may need more assistance with smoking cessation and other health-related behaviors, such as changing dietary habits. Behavioral interventions to reduce psychological distress might facilitate more successful modifications of unhealthy lifestyles [54]. Assessment of Type D personality could be useful to identify patients who have an increased risk of adverse clinical events [17]. Type D personality has also been associated with inadequate consultation behavior [25,55], poor medication adherence [41] and negative ill- ness perception [56] in cardiac patients. Rozanski [57] has argued that cardiologists should consider including a brief screening of psychological factors that might influence patient behavior and adherence into their standard care. The DS14 is a short, reliable measure of Type D that is easy to administer (2-3 minutes) and score [19], and that could be used by health profes- sionals to identify Type D patients that may benefit from more tailored intervention in clinical care. Little is known about the population attributable risk Type D poses for CVD incidence in the community, as the main emphasizes in Type D research has not been to assert causal connection with CVD incidence, but rather to examine the association between general dis- tress and prognosis in cardiovascular populations [17]. As a consequence, most studies on Type D personality Page 8 of 10 and coronary heart disease have been conducted in car- diovascular samples. Yet, a number of general popula- tion studies on Type D personality have exposed Type D personality as a vulnerability factor for worse self- reported health status, more somatic health complaints and disease-promoting mechanism [58] and unhealthier lifestyle behaviors [22]. Finally, the current findings support the cross-cultural validity for the association of Type D personality with psychological distress, and are consistent with recent finding from Denmark [59], Germany [60] and the Uni- ted States [61]. Thus, the effect of Type D personality is not limited to Dutch and Belgian populations [9]. The results of the current study should be interpreted with some caution due to the following limitations. The participant sample consisted of a heterogeneous group of cardiac patients undergoing coronary angiography, and thus measurements of disease severity employed in this study may not portray effectively worse disease status for a small proportion of the sample (for instance in arrhythmia patients). In addition, the current findings regarding Type D and psychological status might be susceptible for reverse causation, due to the cross-sectional origin, but previous longitudinal reports demonstrating that Type D predicts onset, prevalence and severity of psychological distress after adjustments for baseline depression [17] diminish such a risk. Furthermore, health-related behaviors were assessed with self-report and not by extensive and psycho- metrically examined measurement devices. Yet, the cur- rent sample represented a broad group of cardiac patients undergoing a coronary angiography in the only hospital in Iceland that performs angiographies, and thus the sample portrays effectively the population of cardiac patients of a whole nation as non-selectively as possible. Conclusions In summary, the results of the present study indicate that Type D personality is associated with more psycho- logical distress and unhealthy lifestyle behaviors in Ice- landic cardiac patients, and support the cross-cultural validity of the Type D personality construct. Further stu- dies should be implemented to investigate, in more detail, the association between Type D personality and health-related behavior, for such investigations could generate intervention strategies to improve the prognos- tic outlook for cardiac patients with Type D personality. Acknowledgements The present research was supported by Rannís, The Icelandic Centre for Research (Reykjavík, Iceland) with a grant to Dr. Hróbjartur Darri Karlsson, a grant from the Landspitali-Hospital Research Found (Reykjavík, Iceland) to the project, and by the Netherlands Organisation for Scientific Research (The Hague, The Netherlands) with a VICI grant (453-04-004) to Dr. Johan Denollet. Our thanks to Axel F. Sigurdsson and Kristján Eyjólfsson for assistance with acquisition of funding. Special thanks to Unnur