Revamping weight loss for heart health

Lucy Aphramor RDSenior Health Promotion Specialist –

Diet and Cardiovascular Health Atrium Health Ltd.

Therapeutic Relationship

Respect

Evidence based

First do no harm

Kcal energy expenditure

Energy Balance Metaphor

health

Why encourage weight loss?

. . . . .

BHF Reducing your blood cholesterol

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

British Dietetic Association

“Size Matters” 2004, BDA

BBC Wales, Welsh Assembly Government.

“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.”

Why aren’t there more studies?

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.

Why promote healthy eating and exercise…

. . . . . . . .

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

Is it ethical to promote weight loss for ‘overweight’ adults?

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?

INDD 2007

2027Wow. Same old useless results. Look how ‘Hearts R Us’ have got

on promoting the wellness-approach after Cardiff.

Atrium Health Ltd.

Lucy.aphramor@uhcw.nhs.uk

024 76965688