Lora E. Burke

Clinical Implications of Obesity With Specific Focus on Cardiovascular Disease A Statement for Professionals From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation

Obesity adversely affects cardiac function, increases the risk factors for coronary heart disease, and is an independent risk factor for cardiovascular disease. The risk of developing coronary heart disease is directly related to the concomitant burden of obesity-related risk factors. Modest weight loss can improve diastolic function and affect the entire cluster of coronary heart disease risk factors simultaneously. This statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism reviews the relationship between obesity and the cardiovascular system, evaluates the effect of weight loss on coronary heart disease risk factors and coronary heart disease, and provides practical weight management treatment guidelines for cardiovascular healthcare professionals. The data demonstrate that weight loss and physical activity can prevent and treat obesity-related coronary heart disease risk factors and should be considered a primary therapy for obese patients with cardiovascular disease.

Self-Monitoring in Weight Loss: A Systematic Review of the Literature

Self-monitoring is the centerpiece of behavioral weight loss intervention programs. This article presents a systematic review of the literature on three components of self-monitoring in behavioral weight loss studies: diet, exercise, and self-weighing. This review included articles that were published between 1993 and 2009 that reported on the relationship between weight loss and these self-monitoring strategies. Of the 22 studies identified, 15 focused on dietary self-monitoring, one on self-monitoring exercise, and six on self-weighing. A wide array of methods was used to perform self-monitoring; the paper diary was used most often. Adherence to self-monitoring was reported most frequently as the number of diaries completed or the frequency of log-ins or reported weights. The use of technology, which included the Internet, personal digital assistants, and electronic digital scales were reported in five studies. Descriptive designs were used in the earlier studies whereas more recent reports involved prospective studies and randomized trials that examined the effect of self-monitoring on weight loss. A significant association between self-monitoring and weight loss was consistently found; however, the level of evidence was weak because of methodologic limitations. The most significant limitations of the reviewed studies were the homogenous samples and reliance on self-report. In all but two studies, the samples were predominantly white and women. This review highlights the need for studies in more diverse populations, for objective measures of adherence to self-monitoring, and for studies that establish the required dose of self-monitoring for successful outcomes.

Value of primordial and primary prevention for cardiovascular disease: a policy statement from the American Heart Association.

The process of atherosclerosis may begin in youth and continue for decades, leading to both nonfatal and fatal cardiovascular events, including myocardial infarction, stroke, and sudden death. With primordial and primary prevention, cardiovascular disease is largely preventable. Clinical trial evidence has shown convincingly that pharmacological treatment of risk factors can prevent events. The data are less definitive but also highly suggestive that appropriate public policy and lifestyle interventions aimed at eliminating tobacco use, limiting salt consumption, encouraging physical exercise, and improving diet can prevent events. There has been concern about whether efforts aimed at primordial and primary prevention provide value (ie, whether such interventions are worth what we pay for them). Although questions about the value of therapeutics for acute disease may be addressed by cost-effectiveness analysis, the long time frames involved in evaluating preventive interventions make cost-effectiveness analysis difficult and necessarily flawed. Nonetheless, cost-effectiveness analyses reviewed in this policy statement largely suggest that public policy, community efforts, and pharmacological intervention are all likely to be cost-effective and often cost saving compared with common benchmarks. The high direct medical care and indirect costs of cardiovascular disease-approaching

Compliance with cardiovascular disease prevention strategies: A review of the research,

450 billion a year in 2010 and projected to rise to over

Translating the Diabetes Prevention Program: A Comprehensive Model for Prevention Training and Program Delivery

1 trillion a year by 2030-make this a critical medical and societal issue. Prevention of cardiovascular disease will also provide great value in developing a healthier, more productive society.

Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: A scientific statement from the American Heart Association and the American Diabetes Association

The efficacy of cardiovascular risk-reduction programs has been established. However, the extent to which risk-reduction interventions are effective may depend on adherence. Non-compliance, or non-adherence, may occur with any of the recommended or prescribed regimens and may vary across the treatment course. Compliance problems, whether occurring early or late in the treatment course, are clinically significant, as adherence is one mediator of the clinical outcome. This article, which is based on a review of the empirical literature of the past 20 years, addresses compliance across four regimens of cardiovascular risk reduction: pharmacological therapy, exercise, nutrition, and smoking cessation. The criteria for inclusion of a study in this review were: (a) focus on cardiovascular disease risk reduction; (b) report of a quantitative measure of compliance behavior; and (c) use of a randomized controlled design. Forty-six studies meeting these criteria were identified. A variety of self-report, objective, and electronic measurement methods were used across these studies. The interventions employed diverse combinations of cognitive, educational, and behavioral strategies to improve compliance in an array of settings. The strategies demonstrated to be successful in improving compliance included behavioral skill training, self-monitoring, telephone/mail contact, self-efficacy enhancement, and external cognitive aids. A series of tables summarize the intervention strategies, compliance measures, and findings, as well as the interventions demonstrated to be successful. This review reflects the progress made over two decades in compliance measurement and research and further, advances made in the application of behavioral strategies to the promotion of cardiovascular risk reduction.

Randomized clinical trials of weight loss maintenance: a review.

BACKGROUND The Diabetes Prevention Program (DPP) demonstrated that lifestyle intervention reduces risk for type 2 diabetes and the metabolic syndrome. A universal framework for translation of multiple aspects of the DPP intervention, including training, support, and evaluation is needed to enhance treatment fidelity in a variety of settings. PURPOSE This study aims to develop a comprehensive model for diabetes prevention translation using a modified DPP lifestyle intervention. METHODS The DPP lifestyle intervention was adapted to a 12-session group-based program called Group Lifestyle Balance for implementation in the community setting. A model for training and support mirroring that of the DPP was developed for prevention professionals administering the program. The process of training/support and program implementation was evaluated for feasibility and effectiveness using a nonrandomized prospective design in two phases (N=51, Phase 1: 2005-2006; N=42, Phase 2: 2007-2009; data analysis completed 2008-2009). A total of 93 nondiabetic individuals with BMI >or=25 kg/m(2) and the metabolic syndrome or prediabetes participated. Measures were collected at baseline and post-intervention for all and 6 and 12 months post-intervention for Phase 2. RESULTS Significant decreases in weight, waist circumference, and BMI were noted in both phases from baseline. Participants in Phase 2 also demonstrated decreases in total cholesterol, non-HDL cholesterol, and systolic and diastolic blood pressure that were maintained at 12 months. Average combined weight loss for both groups over the course of the 3-month intervention was 7.4 pounds (3.5% relative loss, p<0.001); 23.8% and 52.2% of those who completed the program reached 7% and 5% weight loss, respectively. More than 80% of those achieving 7% weight loss in the Phase-2 group maintained their weight loss at 6 months. CONCLUSIONS A comprehensive diabetes prevention model for training, intervention delivery, and support was shown to be successful and was effective in reducing diabetes and cardiovascular disease risk factors in this group of high-risk individuals.

Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association.

Cardiovascular disease risk factor control as primary prevention in patients with type 2 diabetes mellitus has changed substantially in the past few years. The purpose of this scientific statement is to review the current literature and key clinical trials pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the recent literature, new guidelines, and clinical targets, including screening for kidney and subclinical cardiovascular disease for the contemporary management of patients with type 2 diabetes mellitus.

Using mHealth Technology to Enhance Self-Monitoring for Weight Loss A Randomized Trial

The problem of overweight and obesity has reached epidemic proportions in the United States and globally, and the high prevalence is due in part to the recidivism associated with weight loss treatment. Approximately one-third of lost weight is often regained in the first year after treatment and, at times, continues. Because a plethora of comorbid diseases are associated with obesity, in particular, cardiovascular disease, hypertension, and hyperlipidemia, clinicians and researchers have attempted to find useful strategies for maintaining weight loss. This review presents the findings from 42 randomized clinical trials of weight loss maintenance from 1984 through 2007 using interventions that include (1) the Internet, (2) strategies after a very low calorie diet, (3) pharmacotherapy, (4) behavioral strategies, (5) physical activity, and (6) alternative strategies. The results of the reviewed trials revealed that treatment with orlistat or sibutramine combined with dietary modification, caffeine or protein supplementation, consuming a diet lower in fat, adherence to physical activity routines, prolonged contact with participants, problem-solving therapy, and the alternative treatment of acupressure were efficacious in reducing weight regain after weight loss treatment. The limitations of some studies may reduce the robustness of their findings, and future studies are necessary to replicate and support these results so that individuals are able to maintain weight loss and retain the health benefits associated with a lower weight.

The Effect of Electronic Self-Monitoring on Weight Loss and Dietary Intake: A Randomized Behavioral Weight Loss Trial

Obesity is associated with comorbidities that may lead to disability and death. During the past 20 years, the number of individuals with a body mass index >30, 40, and 50 kg/m2, respectively, has doubled, quadrupled, and quintupled in the United States. The risk of developing comorbid conditions rises with increasing body mass index. Possible cardiac symptoms such as exertional dyspnea and lower-extremity edema occur commonly and are nonspecific in obesity. The physical examination and electrocardiogram often underestimate cardiac dysfunction in obese patients. The risk of an adverse perioperative cardiac event in obese patients is related to the nature and severity of their underlying heart disease, associated comorbidities, and the type of surgery. Severe obesity has not been associated with increased mortality in patients undergoing cardiac surgery but has been associated with an increased length of hospital stay and with a greater likelihood of renal failure and prolonged assisted ventilation. Comorbidities that influence the preoperative cardiac risk assessment of severely obese patients include the presence of atherosclerotic cardiovascular disease, heart failure, systemic hypertension, pulmonary hypertension related to sleep apnea and hypoventilation, cardiac arrhythmias (primarily atrial fibrillation), and deep vein thrombosis. When preoperatively evaluating risk for surgery, the clinician should consider age, gender, cardiorespiratory fitness, electrolyte disorders, and heart failure as independent predictors for surgical morbidity and mortality. An obesity surgery mortality score for gastric bypass has also been proposed. Given the high prevalence of severely obese patients, this scientific advisory was developed to provide cardiologists, surgeons, anesthesiologists, and other healthcare professionals with recommendations for the preoperative cardiovascular evaluation, intraoperative and perioperative management, and postoperative cardiovascular care of this increasingly prevalent patient population.