Re: Focus on health, not weight

Obesity and weight loss diets have long been frustrating issues in lifestyle counseling. In the BCMJ April issue I was glad to see the Council on Health Promotion encourage physicians to focus on health rather than weight [Shifting the focus to health, not weight: First, do no harm, BCMJ [2012;54:144]. 

Weight loss is incredibly difficult for most people to achieve and maintain. Many patients become stressed at their failed efforts to lose weight and despite all exhortations, have given up trying because it ends in failure, makes them depressed, and adds to the negative image they may al­ready have of themselves. Despite occasional successes, recurring poor results fuel the cynicism felt by many physicians about the value of time spent on weight loss counseling.

While preparing for a debate on the relative merits of diet and exercise at the World Diabetes Congress in Montreal in 2009 I came across a paper by Ross and Janiszewsky raising the question, “Is obesity the wrong target?”[1] I firmly believe that it is.

The obesity epidemic has spawned a multibillion dollar diet industry. Diets (often championed by celebrities) come and go, with little solid evidence of long-term benefit. Conversely, the benefits of exercise are powerfully evidence based. Low fitness is one of the strongest predictors of all-cause mortality, may now ex­ceed the risks of smoking, and, for most individuals, far exceeds the risks associated with modest obesity.[2,3] 

High-quality studies show many of the benefits of increased physical activity are independent of weight loss. These include reductions in risk for cardiovascular disease, diabetes, and various types of cancer, along with improved lung function, stronger muscles and bones, and an enhanced immune system.

Perhaps even more important than the multiple physical benefits are those less tangible, such as benefits on quality of life, mood, and coping skills—all those “intangibles” especially im­portant to individuals living with a chronic disease such as CVD, type 2 diabetes, cancer, and depression.

It is no exaggeration to say that regular exercise may be the cheapest, safest, and most effective means to long-term health. Some experts now identify inactivity and sedentary lifestyles as the major public health challenge of the 21st century.

There is probably no organ system in the body that does not benefit from regular exercise. Until very recently the hard evidence for the benefits of exercise was vague. That has changed, and the evidence is now unequivocal. The benefits of an active lifestyle cannot be overstated.

We should all put far more emphasis on encouraging patients to be more active.[4] A commitment of 30 minutes in 24 hours is not huge and even if (as is likely for many) there is no weight loss, the multitude of other benefits must be stressed. The goal is not weight loss!

I encourage patients to make that 30 minutes in their day a priority, telling them to see it as an investment in their arteries—more vital to them than an investment in their bank ac­count. A pedometer is an inexpensive and powerful motivator for many people. The goal is 10000 steps a day.

A preprinted prescription using the “FITT” concept can convince the pa­tient that this is a serious issue:
    Frequency: Five days per week.
    I ntensity: Moderate to vigorous (i.e., can converse without being overly short of breath).
    Time: Thirty minutes per day.
    Type: Aerobic 5/7, resistance 3/7.

It helps if you are seen as someone who practises what they preach—a good role model—and certainly you must convince with conviction!
—Andrew Farquhar, MD
Kelowna

References

1.    Ross R, Janiszewski PM. Is weight loss the optimal target for obesity-related cardiovascular disease risk reduction? Can J Cardiol 2008;24:25D-31D.
2.    Lee DC, Sui X, Church TS, et al. Changes in fitness and fatness on the development of cardiovascular disease risk factors hypertension, metabolic syndrome, and hypercholesterolemia. J Am Coll Cardiol 2012;59:665-672.
3.    Church TS, Cheng YJ, Earnest CP, et al. Exercise capacity and body composition as predictors of mortality among men with diabetes. Diabetes Care 2004;27:83-88.
4.    Evans M. 23 and 1/2 hours [video]. My Favourite Medicine. Accessed 2 May 2012. www.myfavouritemedicine.com/23-12-hours/.