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Happy Heart —

August 8, 2014

Halfway-There

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Weight LossFat HealthFat ScienceExerciseDiet Talk

Trigger warning: Discussion of diet, exercise, health and weight loss.

I know, I know, I promised you all a kickass interview this week, which I’ve been working on in all my spare time, but work has been merciless the last two weeks and I’m not quite done with it. I had alreadyWord Map planned to post this after the interview, so I’m just swapping it out because it’s all ready to go and some may find it informative.

Basically, someone on reddit asked for Health at Every Size® (HAES) resources on heart disease. I had never specifically researched this subject, despite my own struggle with a family history of heart disease. The problem is, HAES has only recently been run through the peer-review ringer, so there isn’t a lot of HAES-specific material on this subject. But there’s plenty of research backing up HAES principles as they apply to heart disease. What follows is my response and the research I unearthed in my search for data on this subject.

First and foremost, the idea of fighting cardiovascular disease (CVD) is a big part of my own personal concern because of my family history. I had an uncle who died in his mid-40s, and he was big into weight lifting. But he was also highly stressed, like your mother. But in general, to prevent or slow the progression of CVD (as genetics still play a significant role as well), there are a quite a few things a person can do, like manage stress (as you mentioned), get enough sleep, don’t smoke, eat a healthy diet and exercise. Those last two are what society tends to zero in on. While they are certainly important, when it comes to being fat, the emphasis is entirely on weight loss as the solution through diet and exercise.

But as I will share in the upcoming interview, essentially all research on all intensive weight loss approaches results in an average weight loss of 5-10% of starting weight, which researchers refer to as “clinically significant weight loss.” So even if you follow a strict regimen, you may only lose 15, 20, 30 pounds, when you’re hoping to lose much more thanks to pop science which says you can. Yes, some people do lose more, but they are the outliers. The vast majority of people pursuing weight loss don’t lose as much as they hope to or else they do and they find the lifestyle unsustainable. Either way, those people ultimately give up the healthy lifestyle changes and regain that weight and more.

So it’s best to focus solely on lifestyle changes for the metabolic benefits they bring alone. So, what lifestyle improves health the most? First, exercise is necessary. Getting your heart rate up for a sustained period is the goal, but there are many options for how to do that. As a guideline, I always recommend the ACSM guidelines: 150 minutes moderate or 75 minutes vigorous exercise per week, plus strength training. Building muscle is important (that doesn’t mean getting bulky, btw) because it helps regulate the sugar in your diet. But doing something is always better for your health than doing nothing. The most important thing is that your exercise is sustainable.

For diet, there’s a lot of good evidence that the Mediterranean Diet yields the best results, which means more fruits, vegetables, fish and whole grains, and fewer unhealthy fats. If you use the HAES approach to eating with the goal of leaning Mediterranean, you should see some great results in your bloodwork even if you don’t lose weight.

Since you’ve got perfect cholesterol, BP and blood sugar levels, then keep doing whatever you’re doing. You’re fine. Even people with perfect lifestyles get heart disease. I mean, you can’t get a much more natural diet or physically active than a caveman, and yet they found thickened arteries in an iceman recently.

As far as the research on how lifestyle change improves CVD risk, even if you don’t lose weight, I’ve got quite a few resources:

“Exercise in Cardiovascular Disease”

Despite relatively modest weight reductions associated with structured programs of physical activity, findings from large epidemiological studies support the concept that a reduced risk of cardiovascular disease and all-cause mortality occurs among more active individuals regardless of weight loss. In a large follow-up from the ACLS (n=25 714), higher fitness levels were associated with lower risk of mortality in normal-weight, overweight, and obese men.88 Compared with other risk factors (total cholesterol, hypertension, and smoking), having a low fitness level carried similarly heightened risks in each weight category for both cardiovascular and all-cause mortality. In a subsequent study from the ACLS among older subjects (>60 years), higher waist circumference was associated with higher mortality, but this association was not significant after adjustment for fitness. Fitness strongly predicted mortality independent of measures of body dimensions. These investigators suggested that it is as important for clinicians to assess the fitness status of an overweight or obese patient as it is to evaluate BP, inquire about smoking habits, and measure fasting plasma glucose and lipid levels.

Similarly, in the Nurses’ Health Study (n=116,564), higher levels of physical activity in women were associated with reduced mortality risk across all categories of body weight. After adjustment for age, smoking status, parental history of CHD, menopause, hormonal use, and alcohol consumption, higher levels of physical activity reduced mortality risk but did not eliminate the high risk associated with obesity. Regardless of weight category, the relative risk for cardiovascular and all-cause mortality was significantly higher in women whose physical activity level was <1 h/wk. In a subsequent study from the Nurses’ Health Study, being physically active moderately attenuated but did not eliminate the adverse effects of obesity on coronary risk, and being lean did not counteract the increased risk associated with being physically inactive.91 Other prospective studies performed over the last decade have assessed the independent and joint associations between fitness, physical activity patterns, and outcomes. In each of these studies, the highest mortality risks were observed in subjects who were obese, unfit, or comparatively sedentary. When stratified within a given category of body dimensions (body mass index, waist circumference, or weight), subjects who are more physically active or fit consistently have a lower risk for adverse outcomes compared with those who are inactive or unfit. Higher levels of physical activity attenuate the mortality risk in all categories of adiposity, and both physical inactivity and excess weight are independently associated with the risk of cardiovascular disease.

“The role of exercise for weight loss and maintenance”

Resistance training has recently been shown to have positive effects on body composition but does not typically show significant decreases in weight. Regardless of weight loss, both aerobic exercise and resistance training have been shown to diminish risk factors for cardiovascular disease and diabetes.

“Primary Prevention of Cardiovascular Disease with a Mediterranean Diet”

In this trial, an energy-unrestricted Mediterranean diet supplemented with either extra-virgin olive oil or nuts resulted in an absolute risk reduction of approximately 3 major cardiovascular events per 1000 person-years, for a relative risk reduction of approximately 30%, among high-risk persons who were initially free of cardiovascular disease. These results support the benefits of the Mediterranean diet for cardiovascular risk reduction. They are particularly relevant given the challenges of achieving and maintaining weight loss.

Note: You’ll notice in this study that they don’t actually mention how much weight the subjects loss, but this supplemental (PDF) for another study on the PREDIMED diet does say:

Weight changes among the 418 participants at the end of follow-up were −0.2 ± 4.6 kg for the olive oil diet group, −0.6 ± 4.2 kg for the nut diet group, and −0.6 ± 4.3 kg for the low-fat diet group (P = 0.74 for the comparison between groups). Likewise, physical activity changes were similar in the three groups: −17.4 ± 336, −58.8 ± 297, and −35.8 ± 257 kcal/day, respectively (P = 0.50). As shown in supplementary Table 1, at the end of the study, participants sustained weight loss >5% to a similar extent in the three groups, and a lower proportion of those in the control group were in the top tertile of physical activity.

Likewise, just 10% of people on the olive oil group lost more than 5% of their starting weight. So keep that in mind when you read this study on the Mediterranean Diet.

“The Role of Exercise and Physical Activity in Weight Loss and Maintenance” (PDF)

High physical activity (PA) levels or exercise training (ET) should be an integral part of any treatment plan for obese individuals regardless of weight loss goals, and is associated with numerous CV benefits. High levels of PA and cardiorespiratory fitness (CRF) are inversely associated with CV disease, T2DM and all-cause mortality. Several epidemiological studies even suggest that high levels of PA or CRF attenuate the health risk of obesity. Moreover, CRF levels have been shown to alter the relationship of the obesity paradox, where high CRF level is associated with greater survival in all body mass index (BMI) categories. So above all, clinicians should always encourage their patients to adhere to ET programs or engage in regular PA regardless of the weight loss achieved.

“Three-month exercise and weight loss program improves heart rate recovery in obese persons along with cardiopulmonary function”

The important finding of this study was that the strong predictors of an improvement in [Heart rate recovery (HRR)] were all markers of cardiopulmonary function (resting heart rate, peak exercise heart rate, and PWC75%HRmax/weight). On the other hand, a number of metabolic parameters (weight, BMI, Fat%, waist circumference, hip circumference, visceral fat area, LDL-chol, and leptin) were found to be weak predictors that only showed a significant association in univariate analysis… Furthermore, Kim et al. reported improvement in HRR after a weight loss program that only involved exercise without any change in calorie intake [29]. They investigated 20 middle-aged obese men with metabolic syndrome and 20 men without this syndrome. They showed improvement in HRR after 12 weeks of exercise training in both groups of men. Their hypothesis was the same as ours, i.e. the change in HRR appears to be related to a change in resting HR, regardless of weight loss and improvement in cardiovascular fitness.

So there’s quite a bit of research on how a healthy lifestyle, regardless of whether you lose a bunch weight, mitigates the risk of CVD. I hope this puts you at ease and helps you figure out what you’re trying to figure out. 🙂

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