Abstract
The prevalence of chronic diseases including dyslipidemia has increased as the prevalence of healthy lifestyles has decreased. Intensive interventions targeting lifestyle management of chronic diseases have proven effective in producing meaningful outcomes in research settings. However, it is not clear whether the comprehensive and intensive components of these interventions could be translated into real-world clinical and community settings. There are certain barriers that health care providers should consider when counseling patients.
‘Lifestyle behaviors such as a high caloric intake, . . . and smoking significantly increase one’s risk of developing multiple chronic diseases including heart disease, cancer, chronic respiratory disease, cerebrovascular disease, and diabetes.’
A multitude of chronic diseases is on the rise. Many of these are classified as lifestyle-related chronic health conditions. For example, as discussed in this issue by Bronas and Salisbury, dyslipidemia is a serious condition associated with lifestyle and environmental factors. 1 Lifestyle behaviors such as a high caloric intake, low levels of physical activity, excess body weight, and smoking significantly increase one’s risk of developing multiple chronic diseases including heart disease, cancer, chronic respiratory disease, cerebrovascular disease, and diabetes. 2 These lifestyle-related chronic health conditions are among the leading causes of disease and death in Americans,3,4 and the prevalence of having one or more of these chronic conditions has increased in recent years. 5 Although advances have been made in the treatment of these conditions, there is still a need for successfully addressing the underlying lifestyle behaviors associated with these diseases. For example, in the case of dyslipidemia, pharmacological therapies are successful in lowering lipids and improving related health issues,6,7 but less is known about how to effectively address the underlying problem of obesity in a primary care setting.
Practicing a healthy lifestyle (eg, not smoking and maintaining a healthy body mass index through diet and physical activity) has been shown to significantly decrease one’s risk for heart disease, stroke, diabetes, and cancer.8-11 However, the prevalence of Americans who can be classified as having a healthy lifestyle has dramatically decreased in the last decade. Currently, fewer than 10% of Americans report having a healthy lifestyle. 12 The percentage of Americans who smoke has decreased from 20.9% in 2005 to 18.1% in 2012. 13 While smoking is on the decline, the prevalence of obesity among adults is increasing, explaining the overall reduction in the percentage of Americans living a healthy lifestyle. 14 The increasing rates of obesity are particularly alarming because it is such an intractable disease.
Weight loss of as little as 3% has been shown to result in improvements in blood pressure, lipids, and the risk of developing type 2 diabetes. 15 Currently researchers have identified efficacious interventions to address lifestyle behaviors underlying obesity that have demonstrated efficacy to promote and maintain weight loss for up to 8 years.16-18 However, these interventions are typically labor intensive for both the health care provider (HCP) and recipient, involving the prescription of a low calorie diet and ≥175 minutes of physical activity per week, in addition to 3 to 4 face-to-face meetings per month for 1 year, followed by a slightly less intensive maintenance phase.
While time intensive for individuals, these interventions have been shown to promote a weight loss of 5% or more in the first year for slightly greater than two thirds of those enrolled and 65% of whom were able to maintain this weight loss at 8 years. 18 The long-term maintenance of weight loss has been attributed to the high levels of adherence exhibited by the participants even 8 years later.17,18 For example, participants who kept the weight off were more likely to exercise frequently, eat a reduced calorie diet, and weigh themselves frequently, underscoring the importance of adherence to the successful maintenance of weight loss. Currently, we know how to encourage adherence in order to promote weight loss maintenance in controlled research settings, but we lack evidence regarding practical ways to achieve long-term adherence in real-world settings. Specifically, it is of great importance to examine whether results from intensive research trials can be translated into clinical and community settings. 19
Barriers to Achieving Long-Term Weight Maintenance
While there is a clear need for the promotion of long-term adherence to weight control practices, there are several barriers that make this difficult for HCPs and patients.
Magic Bullet Phenomenon
One barrier to achieving long-term results is the desire for a quick fix or “magic bullet” solution to obesity. If supply is any indication of demand, this phenomenon may be best illustrated by the large number of commercially available weight loss products and fad diets that guarantee to provide a quick fix.20,21 However, the weight loss results purported by these products and fad diets often do not have a scientific basis and their long-term effectiveness have not been documented. 22 Achieving weight loss is a significant endeavor involving changes to diet and physical activity levels, daily routines, and social and educational support. These changes not only affect the patient but everyone in their support network. Patients seeking a magic bullet solution are often not willing to make these significant changes. As a HCP, it is important to identify when a patient appears to be seeking a magic bullet solution and counsel them that the treatment of obesity requires dedication on their part. 20 However, once lifestyle transformation is achieved, the rewards can be meaningful and long-term.
Prioritization
Most individuals are faced with competing priorities that make it difficult to adhere to a healthy lifestyle. For example, patients must deal with a variety of demands including work, family, and community obligations. Initiating and maintaining healthy eating and physical activity behaviors requires a great deal of time, planning, and organization, which may interfere with other demands in a patient’s life. As a result, it is important to help patients find ways to not only prioritize health but also identify which behaviors they will engage in less often in order to support adherence to a healthier lifestyle. For example, a patient that plans to wake up earlier to exercise may need to limit time spent watching television during the previous night in order to achieve adequate sleep and support adherence to a morning exercise routine. HCPs can play a meaningful role in helping patients to prioritize behavioral changes that will be beneficial to supporting long-term adherence to a healthy lifestyle.
The decreasing prevalence of healthy lifestyles among Americans is likely associated with the increasing rates of lifestyle-related chronic health conditions. 12 Several research interventions, based on behavioral principles and incorporating intensive nutritional, physical activity, and educational components, have been effective in improving these lifestyle-related health problems. However, it is not clear whether these components can effectively be delivered in real-world settings. 19 Overall, there is a need for effective methods of promoting long-term adherence to weight management practices. This will likely require individuals to reprioritize their current investment of time and resources in order to support adherence to meaningful changes.