Revamping weight loss for heart health
Lucy Aphramor RDSenior Health Promotion Specialist –
Diet and Cardiovascular Health Atrium Health Ltd.
SIGN references one study that provides data showing that intentional weight loss
decreases risk of chronic disease.
Williamson DF et al, Am J Epidemiology, 1995
BHF Eating for Your Heart
“It’s about making you feel bad about yourself. That cannot be about anything else than saying ‘at the moment you are not acceptable’ can it?”
The beneficial effects of modest weight loss on cardiovascular risk factors Van Gaal et al 1997
• n=9 • “data on the effects of weight loss on Lp(a)
are scarce and contradictory”• “possible effects of exercise were difficult
to determine”• “it cannot be proven that weight loss per
se is the most important trigger of the reduced mortality”
“Studies have investigated whether modest weight reduction results in improved cardiovascular morbidity and mortality.”
One week residential course Low-fat near vegan diet – no kcal
restriction No caffeine/ smoking Exercise recommendations Group support Stress management
Beneficial effects of modest weight lossGoldstein, D. (1992) Int J Obesity 16, 397-415.
‘obese patients with serious medical complications’
Eg. NIDDM <1000 patients, n = 7 to 118
drug treatment, 330kcal/day, relaxation, CBT
4 weeks – 18 months
Standards and Core Components for Cardiac Rehabilitation (2007)
Diet and weight management: CR should include:
Assessment of body mass index (BMI) and waist circumference
Use of best practice standards and guidelines for dietary prescription and weight management
Ref: DH guidelines , SIGN No. 97
Dattilo & Kris-Etherton, 1992
6% of studies had over 50 people
82% of studies had no control
35% studies lasted only 2–10 weeks
not on cholesterol-lowering medication
Impossible to identify effect of fat modification
Obesity & Disease Management: Effects of Weight Loss on Comorbid ConditionsAnderson & Konz 2001 Ob Res 9(4) 326S-334S
“Promoting weight loss and maintenance of weight loss should have the highest priority in prevention and a very high priority in treatment of CHD risk factors.”
“increased physical activity expends energy and, perhaps more importantly, reminds individuals
of weight management task at hand.”
NEJM Editorial
The data linking overweight and death, as well as the data showing the beneficial effects of weight loss, are limited, fragmentary and often ambiguous.
Kassirer, et al. Losing weight – an ill-fated New Year’s resolution. NEJM 1998;338.
Synthesis of systematic reviews of obesity treatment and prevention
“Although these were the best studies available according to the principles of evidence based medicine, many did not fulfil its requirements…. These flaws bias the results and can exaggerate the effects…..Rather than showing what does work for preventing and treating obesity, research to date shows us clearly what does not.” (Jain BMJ 2006)
Medicare’s Search for Effective Obesity Treatments: Diets are not the answer
American Psychologist, 2007, 62,3, 220–233.
Improving Health
National Institute of Health guidelines reveal strong evidence that physical activity alone, without weight loss, reduces the risk for cardiovascular disease and other disease factors.
Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: NIH, 1998.
The Relation of Body Mass Index, Cardiorespiratory Fitness and All
Cause Mortality in WomenFarrell et al, Obesity Research, June 2002
Method9925 women followed for 26 years
– 7801 “normal” BMI 18.5 to 24.99– 1527 “overweight” BMI 25 to 29.99– 597 “obese” BMI 30 or >
The Relation of Body Mass Index, Cardiorespiratory Fitness and All
Cause Mortality in WomenFarrell et al, Obesity Research, June 2002
Results• Assumption that all overweight and obese
individuals are sedentary and unfit is not valid. • A low level of CRF fitness as measured by
maximal treadmill exercise test was a more important predictor of all cause mortality than was baseline BMI.
Lee, C. D., Blair, S. N., & Jackson, A. S. (1999). Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men. Am J Clin Nutr 69, 373–80.
n=22,000 men Unfit, lean men had a higher risk of
all-cause and CVD mortality than did men who were fit and obese
Unfit men had a higher risk of all-cause and CVD mortality than did fit men in all fat and fat-free mass categories
Similarly, unfit men with low waist girths (<87 cm) had greater risk of all-cause mortality than did fit men with high waist girths ( 99 cm)
JAMA (2005) 293 (15) 1861-1867
Excess deaths associated with underweight, overweight and obesity
“Overweight (25≥ BMI <30) was not associated with excess mortality.”
PLoS Medicine (2005) 2 (6) e171
Intention to lose weight, weight changes, and 18-y mortality in overweight individuals without
co-morbidities.
“Deliberate weight loss in overweight individuals without known co-morbidities may be hazardous in the long term.”
Why recommend dieting? Weight gain Enhance nutritionally inadequate diets Jeopardise metabolic fitness Decrease bone mass Increase eating distress Keep tobacco industry afloat Exacerbate weight cycling Increase discrimination and bullying
Increase depression Discourage healthy behaviour Completely waste resources Increase exercise
addiction/resistance Reinforce sense of hopelessness Promote body hatred in children Poorer prognosis in heart patients Demonstrate professional
ineffectiveness Obscure useful research directions Mislead the public
Weight Cycling and Heart Health
Increase risk of hypertension among women at high risk for heart disease.
“Positive association between body weight fluctuation and all-cause mortality, and usually … with coronary mortality in particular.” BNF Task Force Obesity
CAD and CV Events in Women
906 women followed for 3.9 years
‘Overweight’ women more likely to have CV risk factors but BMI/abdominal obesity not associated with adverse CV events
Being fat poses less risk for heart disease than being unfit
Wessel R et al (2004) Relationship of Physical Fitness vs. Body Mass Index with Coronary Artery Disease and Cardiovascular Events in Women.JAMA 292: 1179-1187
European recommendations
“ …. state that overweight people after MI should be recommended to lose weight. But the recommendations are not based on any studies because our study is in fact the first in the field… medical science may have shortened the lives of a number of overweight patients with myocardial infarction by persuading them to diet.”
Willenheimer, 2006
BMI and Prognosis in Patients with Chronic Heart FailureKenchaiah et al (2007) Circulation; 116:627-636.
Double-blind, placebo controlled; 7599 patients; mean FU 37+ months
Baseline BMI no influence on risk of hospitalisation
BMI 30 -35 improved prognosis Increased risk death BMI ≥35 not sig.
Therapeutic Implications
Consent:
Advantages and risks of treatment
Likelihood of getting desired results
Are there any alternatives?
Health Survey for England (2001) www.heartstats.org
0
5
10
15
20
25
30
35
40
General population Black Caribbean Indian Pakistani Bangladeshi Chinese
Men
Women
Prevalence of obesity by sex and ethnic group, 1999, England
05
1015202530354045
Generalpopulation
Black Caribbean Indian Pakistani Bangladeshi Chinese Irish
%
Men
Women
Percentage of adults perceiving severe lack of social support by sex and ethnic group, 1999, England
Health Survey for England (2001) www.heartstats.org
Health Survey for England 2004 –Health of ethnic minorities
Study of 8,000 adults and 4,000 children in England from Bangladeshi, Black Caribbean, Black African, Irish, Pakistani, Indian, Chinese and groups
obesity does not seem to have a clear association with diabetes, CHD and stroke
Metabolic Syndrome
Analysis of 10,300 civil servants showed a clear link between the amount of stress experienced at work and symptoms of metabolic syndrome. Chandola, Brunner, Marmot. (2006). BMJ
The prevalence of the metabolic syndrome did not increase in Mexico City between 1990-1992 and 1997-1999 despite more central obesity.
Diabetes Care. 2005 Oct;28(10):2480-5
McDonaldizing Men’s Bodies?
“Dom thought his hypertension was related to the stresses of moving to his current place of residence where his young children were bullied on account of his weight, and where teenage boys smeared excrement on his car door handles.”
Monaghan, 2006
Ethics of Promoting Weight Loss
Promoting weight loss essentially suggests that thinness is the desired goal irrespective of health. Inherent in that message is the underlying assumption that fatness is undesirable which in turn perpetuates size discrimination.
Hawks SR, Gast JA. The ethics of promoting weight loss. Healthy Weight Journal 2000;14(3):25-26.
Implications for Practice
Ensure evidence based practice
Promote health – not thinness
Consistent and systematic
Tenets of Size Acceptance
Self-esteem and body image are strongly linked. Helping people feel good about their bodies can help motivate and maintain healthy behaviours.
Health For All
Good health is not defined
by body size; it is a state of physical, mental and social wellbeing
Assessment Heavy with intuitive eating pattern Overeating in response to food
deprivation Preoccupied with food due to past dieting Weight gain after reduced activity levels Emotionally troubled intuitive eater Emotionally troubled with eating distress Weight gain after starting medication
Melcher 1998
FAQ Does trying to making fat people thin
improve their health?
Wouldn’t a no-diet approach to CR give people permission to eat what they like?
What if someone wants to lose weight for their own confidence?
2027Wow. Same old useless results. Look how ‘Hearts R Us’ have got
on promoting the wellness-approach after Cardiff.