Heart Disease Introduction
Lifestyle Changes and Psychosocial Treatments
Even modest weight loss can reduce the risk factors for heart disease and diabetes. The simplest (but still difficult) approach to weight loss is reducing calories and exercising at least 150 minutes a week. Behavioral and mental changes in eating habits, physical activity, and attitudes about food and weight are also essential to weight management. Studies show that people who lost at least 10% of their body weight and kept the weight off for more than 1 year share several characteristics, including:
- Exercising for at least 1 hour each day
- Eating a low-fat, low-calorie diet
- Eating breakfast each day
- Weighing themselves regularly and often
- Eating the same diet on weekends as they do on weekdays
Some Tips for Losing Weight. The following are some general suggestions for dieters:
- Start with realistic goals. Diet failure is extremely common, and the odds of significant weight loss are low, particularly in people with the highest weights. People who are able to restrict calories, engage in an exercise program, and get help in making behavioral changes can expect to lose 5 - 10% of their current body weight. That is generally all that is needed to achieve meaningful health changes. Certainly, the distorted image of a super-thin female shape should not be anyone's goal.
- Maintain a regular exercise program, assuming you have no health problems that will stop you. Choose a program that you enjoy. Check with your doctor about any health considerations. [For more information, see In-Depth Report #29: Exercise.]
- Do not use hunger pangs as cues to eat. A stomach that has been stretched by large meals will continue to signal hunger for large amounts of food until its size reduces over time with smaller meals.
- Be honest about how much you eat and start by recording all calories in writing. Many people significantly underestimate their consumption of high-calorie foods and overestimate intake of low-calorie foods. People who do not carefully note everything they eat tend to take in too many calories when they believe they are dieting.
- Observe weekend eating. People tend to eat more on the weekends. If it is difficult to monitor all meals during the week, it be may be useful to at least track eating habits during the weekends.
- Once the pounds are lost, do your best to keep the healthier weight. Make daily, even hourly, conscious decisions about eating and exercising activities. Such thinking, in many cases, can become automatic and not painful.
- Don't give up, even after repeated weight loss failures. Most studies indicate that yo-yo dieting or weight cycling have no bad psychological or physical effects. Repeated dieting also does not harm the body's ability to burn calories efficiently.
- Weight loss, in any case, should not be the only or even the primary goal for people concerned about their health. The success of weight loss efforts should be evaluated according to improvements in disease risk factors or symptoms, and by the adoption of healthy lifestyle habits, not just by the number of pounds lost.
Key Components of a Lifestyle Change Program
Reduce rate of eating.
Keep food records.
Eliminate environmental triggers to eating.
Identify high-risk situations for overeating.
Separate eating from other activities.
Face up to emotional barriers to exercise.
Understand the link between exercise and weight control.
Establish reasonable exercise goals.
Develop a plan for regular activity.
Add increased activity into daily lifestyle.
Develop reasonable weight-loss goals.
Avoid "all or none" thinking.
Focus attention away from the scale and toward behavior.
Uncouple weight from self-esteem.
If you "fall off the wagon," take steps to ensure you do not repeat the situation (recover from lapses with constructive action).
Understand the key role of social support to health.
Identify supportive others.
Match personal style to support-seeking activities.
Be specific in making support requests.
Be assertive but reinforcing in drawing help from others.
Resist the temptation of popular fad diets.
Eat with your health in mind; do not concentrate on what should be "off-limits."
Eat with moderation in mind.
Develop a tailored plan.
From Brownell KD. The LEARN Program for Weight Control. 7th ed. Dallas, Tex: American Health Publishing Company; 1998.
Managing Overweight Children
Childhood obesity is best treated by a non-drug, multidisciplinary approach, including diet, behavior modification, and exercise. Children should be screened for obesity at age 6, and referred to weight management programs if needed at that time. Moderate-to-intense programs have the highest rate of success with children and adolescents. These programs include counseling and behavior modifications.
Evidence suggests that reducing calories by only 200 - 260 per day would prevent weight gain in most overweight children. Here are some tips for children who are overweight:
- Limit (or avoid, if possible) take out, fast foods, high-sugar snacks, commercial packaged snacks, soda, and sugar-sweetened beverages (including too much juice).
- Let children snack but make sure the snacks are healthy. Eating small frequent healthy meals (instead of two or three large ones) has been associated with being thinner and having a better cholesterol profile.
- Let children choose their own food portions. One study indicated that children naturally ate 25% less when they chose their own portion size. When they were given larger portions their bite sizes were larger and they ate more.
- Do not criticize a child for being overweight. It does not help, and such attitudes could put children at risk for eating disorders, which are equal or even greater dangers to their health.
- Limit television, video games, and computer use to a few hours a week. This can contribute significantly to weight control, regardless of diet and physical activity.
- For young children, try the traffic-light diet. Food is designated with stoplight colors depending on their high caloric content: Green for go (low calories), yellow for "eat with caution" (medium calories), and red for "stop" (high calories).
- Try a low glycemic index diet. This may be as beneficial, possibly more, than a standard reduced-fat diet in overweight children. Such a diet focuses on certain carbohydrates (for example, dried beans and soy), which raise blood sugar more slowly than other types of carbohydrates. This diet is sometimes used in diabetes, and as a dietary approach in overweight adults. [For more information, see In-Depth Report #42: Diabetes Diet.]
We Can! (Ways to Enhance Children's Activity & Nutrition) is a new national program designed to help children live healthier lives. This program "focuses on three important behaviors: improved food choices, increased physical activity and reduced screen time." We Can! Is a collaboration of the National Heart, Lung, and Blood Institute; the National Institute of Diabetes and Digestive and Kidney Diseases; the National Institute of Child Health and Human Development; and the National Cancer Institute.
Support Groups and Behavioral Approaches
Commercial and Nonprofit Support Programs for Weight Loss. There are many different types of weight-loss program. (This report cannot address all of the many commercial and nonprofit weight-loss programs currently available, nor can it assess their claims.)
Taking off Pounds Sensibly (TOPS), a nonprofit support organization with many local chapters, is one of the least expensive programs, costing $26 a year.
Most of the commercial programs, such as Weight Watchers, Jenny Craig, and NutriSystem, offer individual or group support, lifestyle changes, and packaged meals. These programs tend to be expensive. There are few well-conducted studies on these programs.
Many regard the inability to follow a diet and lose weight as reflecting a lack of willpower. Unfortunately, these feelings simply reinforce a sense of failure. Some suggest attempting to shift the approach to one of managing where one focuses their attention. Evidence exists that exercise and adequate sleep will enhance the ability to manage and self-regulate behavior.
Short-term specific goals regarding exercise and eating should be approached as something to be learned rather than performed. Also, planning ahead when invited to eat out or going to another home for food is recommended.
Cognitive Behavioral Approaches. Most support programs use some form of cognitive-behavioral methods to change the daily patterns associated with eating. They are very useful for preventing relapse after initial weight loss. The following is a typical approach:
- The patient first records in a diary all activity related to eating patterns, including the times of day, length of meal, emotional states, companions, and, of course, the kind and amounts of food eaten. Most people -- even professional dieticians, according to one study -- tend to underreport their daily calorie intake. However, writing it down is still a good method for increasing a person's awareness of eating patterns. (One patient said that recording circumstances surrounding relapses was a particularly valuable guide for understanding the stresses leading to her own eating behaviors.)
- The patient reviews the diary with a therapist or group to set realistic goals and identify patterns that the patient can change. For instance, if food is normally eaten while watching television, then the patient may be advised to eat in another room instead.
- Good eating habits are reinforced by rewards. These rewards are other pleasures that substitute the high calorie consumption and sedentary activities.
Behavioral modification has been shown to be helpful particularly for people who have an overly strong response to the taste, smell, and appearance of food. It also may be useful for binge eaters.
Stress-Reduction Techniques. Stress reduction and relaxation techniques may be helpful for some people with obesity, such as those whose weight is related to night-eating syndrome. [For more information, see In-Depth Report #31: Stress.]
Changing Sedentary Habits and Exercise
Changing Sedentary Habits. Making even small changes in physical activity can expend energy. For example, simply getting up to turn the TV on and off instead of using the remote, and standing (instead of sitting) while talking on the phone may help a person lose up to five pounds a year. Other suggestions include cooking one's own food (instead of eating take-out or fast food), walking to as many places as possible, using stairs instead of escalators or elevators, and gardening. Even fidgeting may be helpful in keeping pounds off, and, in one study, chewing gum increased energy expenditure.
No one should rely on such mild activities, however, for serious weight loss. Only high levels of physical activity -- not just using up energy -- help prevent obesity.
Interventions to help children and adolescents lose weight and maintain weight loss have yet to show consistent benefit
Approach to Exercise. Exercise, which replaces fat with muscle, is the critical companion for any weight control program. In a one-year study, women who regularly averaged 3.5 days (176 minutes) of exercise each week lost significantly more weight than women who did not exercise regularly. Women who exercised more than 195 minutes a week lost nearly 7% of their abdominal fat.
It should be noted that increasing activity level in daily work and home life helps a great deal. For example, walking down the hall to speak with a coworker, rather than spending the same time sending an e-mail, may result in a loss of 5 kg over a 10-year period.
People who exercise are more apt to stay on a diet plan. Exercise improves psychological well-being and replaces sedentary habits that usually lead to snacking. Exercise may even act as a mild appetite suppressant. Moreover, exercise improves overall health even with modest weight loss.
Be aware, however, that the pounds won't melt off magically. Losing significant weight requires both intensive exercise and calorie restriction. In addition, if a person exercises but doesn't diet, any actual pounds lost may be minimal, because denser and heavier muscle mass replaces fat. Nonetheless, regardless of weight loss, a fit body will look more toned and be healthier. In addition, exercise benefits the heart even with modest weight loss.
The following are some suggestions and observations on exercise and weight loss:
- The more strenuous the exercise, the better the chances for short-term and long-term success. With intense exercise, the metabolism continues to burn calories before returning to its resting level. This state of elevated metabolism can last for as little as a few minutes after light exercise to as long as several hours after prolonged or heavy exercise.
- Of the standard aerobic machines, the treadmill burns the most calories. It may be particularly effective when used in short multiple bouts during the day. In fact, frequent exercise sessions as short as 10 minutes in duration (about four times a day) may be the most successful exercise program for obese people.
- Resistance or strength training is excellent for replacing fat with muscles. It should be performed two or three times a week.
- As people slim down, their initial level of physical activity becomes easier and they burn fewer calories for the same amount of work. The rate of weight loss slows down, sometimes discouragingly so, after an initial dramatic head start using diet and exercise combinations. People should be aware of this phenomenon and keep adding to their daily exercise program.
- As people age, they also need to exercise more to keep off the same amount of weight.
- Changes in fat and muscle distribution may differ between men and women as they exercise. Men tend to lose abdominal fat (which lowers their risk for heart disease faster than reducing general body fat). Exercise, however, does not appear to have the same effect on weight distribution in women. In one interesting study, women in aerobic and strength training programs lost fat in their arms and trunk, but did not gain muscle tissue in these regions.
Spot Exercising. Anyone seeking to lose weight must expect that the results may not be as cosmetically satisfying as one would wish. Spot exercising (training particular areas of the body) is ineffective in reducing fat in specific locations because exercise draws on fat stores throughout the body. Gimmicky devices such as bust developers, vacuum pants, and exercise belts do absolutely nothing to reduce fat or add bulk in specific locations. Electrical pads wrapped around the waist, arms, or thighs were reported to cause burns and fires.
Warning Note. Because obesity is one of the risk factors for heart disease and diabetes, anyone who is overweight must discuss their exercise program with a doctor before starting. Sudden demanding exercise, in such cases, can be very dangerous. [For more information, see In-Depth Report #29: Exercise.]