The treatment of obesity in cardiac rehabilitation

Abstract

Obesity is an independent risk factor for the development of coronary heart disease (CHD). At entry into cardiac rehabilitation (CR), more than 80% of patients are overweight and more than 50% have the metabolic syndrome. Yet, CR programs do not generally include weight loss programs as a programmatic component and weight loss outcomes in CR have been abysmal. A recently published study outlines a template for weight reduction based on a combination of behavioral weight loss counseling and an approach to exercise that maximized exercise-related caloric expenditure. This approach to exercise optimally includes walking as the primary exercise modality and eventually requires almost daily longer-distance exercise to maximize caloric expenditure. In addition, lifestyle activities such as stair climbing and avoidance of energy-saving devices should be incorporated into the daily routine. Risk factor benefits of weight loss and exercise training in overweight CHD patients are broad and compelling. Improvements in insulin resistance, lipid profiles, blood pressure, clotting abnormalities, endothelial-dependent vasodilatory capacity, and measures of inflammation such as C-reactive protein have all been demonstrated. Cardiac rehabilitation/secondary prevention programs can no longer ignore the challenge of obesity management in CHD patients. Individual programs need to develop clinically effective and culturally sensitive approaches to weight control. Finally, multicenter randomized clinical trials of weight loss in CHD patients with assessment of long-term clinical outcomes need to be performed.

Figure 1

The Energy Balance Equation. In a steady state situation, energy intake would equal energy expenditure.

Figure 2

Quintiles of Physical Activity by Accelerometer (Kcal/day) vs. Weight Loss (r = 0.64, P<.0001).

Figure 3

Components of total daily energy expenditure by group, before and after weight loss and exercise. ^aP<.05 within group for physical activity energy expenditure. ^bP<.05 change pre-post between groups for physical activity energy expenditure.

Figure 4

Weight loss by group at 5 and 12 months (with permission, American Heart Association). *P<.05 vs. baseline. †P<.05 vs. change in standard cardiac rehabilitation group.