Revamping weight loss for heart health

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Revamping weight loss for heart health

• Lucy Aphramor RD
• Senior Health Promotion Specialist
• Diet and Cardiovascular Health
• Atrium Health Ltd.

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Therapeutic Relationship

• Respect
• Evidence based
• First do no harm

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Energy Balance Metaphor
health
energy expenditure
Kcal
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Why encourage weight loss?

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BHF Reducing your blood cholesterol
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BHF Eating for Your Heart
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
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British Dietetic Association
Size Matters 2004, BDA
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BBC Wales, Welsh Assembly Government.
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• Its about making you feel bad about
• yourself. That cannot be about anything
• else than saying at the moment you
• are not acceptable can it?

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The beneficial effects of modest weight loss on
cardiovascular risk factors Van Gaal et al 1997

• n9
• 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

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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

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Beneficial effects of modest weight
lossGoldstein, D. (1992) Int J Obesity 16,
397-415.

• obese patients with serious medical
  complications
• Eg. NIDDM lt1000 patients, n 7 to 118
• drug treatment, 330kcal/day, relaxation, CBT
• 4 weeks 18 months

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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

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Dattilo Kris-Etherton, 1992

• 6 of studies had over 50 people
• 82 of studies had no control
• 35 studies lasted only 210 weeks
• not on cholesterol-lowering medication
• Impossible to identify effect of fat modification

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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.

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Why arent there more studies?
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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 Years resolution. NEJM 1998338.

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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)

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• Medicares Search for Effective Obesity
  Treatments Diets are not the answer
• American Psychologist, 2007, 62,3, 220233.

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Why promote healthy eating and exercise

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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.
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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,
37380.

• n22,000 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 (lt87
  cm) had greater risk of all-cause mortality than
  did fit men with high waist girths ( 99 cm)

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JAMA (2005) 293 (15) 1861-1867

• Excess deaths associated with underweight,
  overweight and obesity
• Overweight (25 BMI lt30) was not associated with
  excess mortality.

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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.

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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

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• 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

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Is it ethical to promote weight loss for
overweight adults?
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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

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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

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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
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BMI and Prognosis in Patients with Chronic Heart
FailureKenchaiah et al (2007) Circulation
116627-636.

• 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.

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Therapeutic Implications

• Consent
• Advantages and risks of treatment
• Likelihood of getting desired results
• Are there any alternatives?

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Prevalence of obesity by sex and ethnic group,
1999, England
Health Survey for England (2001)
www.heartstats.org
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Percentage of adults perceiving severe lack of
social support by sex and ethnic group, 1999,
England
www.heartstats.org
Health Survey for England (2001)
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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

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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 Oct28(10)2480-5

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McDonaldizing Mens 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

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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 200014(3)25-26.

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Implications for Practice

• Ensure evidence based practice
• Promote health not thinness
• Consistent and systematic

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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.

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Health For All

• Good health is not defined by body size it is
  a state of physical, mental and social wellbeing

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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

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FAQ

• Does trying to making fat people thin improve
  their health?
• Wouldnt 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?

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INDD 2007
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Atrium Health Ltd.
Lucy.aphramor_at_uhcw.nhs.uk 024 76965688