Weight Loss Versus Behavioral Change as the Primary Goal in Clinical Practice

Abstract

Physical activity is a well-established lifestyle target that has shown considerable benefit in older adults. Findings from a subset population in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study revealed that changes in behavior (i.e., nonsmoking, physical activity) were superior to achieving numerical goals (i.e., waist circumference) to reduce the risk of recurrent coronary heart disease and all-cause mortality. This study provides strong evidence that health care providers should emphasize behavioral change and not set weight loss as the primary goal in clinical practice.

PA [physical activity] in older adults has been shown to improve quality of life, high-density lipoprotein levels, bone mineral density (BMD) mass, and fall reductions.

Optimal exercise capacity in older adults has undoubtedly been shown to be advantageous. In a 20-year study of 5314 patients ages 65 to 92 (mean 71.4 years, SD ±5.0), exercise capacity was an independent predictor of reduced all-cause mortality. The patients who died during the study had a lower baseline exercise capacity while those who survived had a higher baseline capacity. ¹ In addition, for each 1-metabolic equivalent (MET) increase, the adjusted hazard for death decreased by 12% (confidence interval = 0.86-0.90) and those with the highest METs (>9) had a 61% decrease in mortality risk compared with those with the lowest. ¹ There are numerous other studies discussing the benefits of exercise capacity or as a broader term, physical activity (PA). ² PA in older adults has been shown to improve quality of life, ³ high-density lipoprotein levels, ⁴ bone mineral density (BMD) mass, ⁵ and fall reductions. ⁶

Controversy of PA

In spite of the benefits of PA, there has been substantial controversy in older adults whether or not weight loss should be the primary goal of increased exercise. Considerable controversy exists regarding the impact PA has on weight loss regardless of age, ⁷ but for older adults specifically, weight loss may be associated with decreased BMD,^8,9 and a loss of lean body mass, accelerating sarcopenia. ¹⁰ Weight loss may also be related to increased mortality risks.^11,12 Though it may be speculated that the type of exercise (i.e., aerobic) leading to weight loss may contribute to the negative outcome, this has not been confirmed.^13,14 Furthermore, with an exponential growth of the geriatric population and increased life expectancy, ¹⁵ clinical trials have not had the longevity needed to produce accurate guidelines for older adults.^14,16,17 Thus, it is difficult to place appropriate goals in terms of weight loss for older adults.

This ambiguity of guidelines and recommendations raises 2 questions: Should the primary clinical targets be numerical, or should the primary clinical targets be behavioral, which are accompanied by a secondary numerical target? Though most health care providers would likely favor the latter, the former is more likely to occur in clinical practice due to the ease of assessing progress. For example, a 69-year-old male (body mass index [BMI] 24) who does not exercise regularly sees his provider for a physical. Due to his BMI being in a healthy weight range, the provider often views the patient as healthy and may not recommend lifestyle change. In a different example, a 69-year-old male (BMI 31) who exercises 4 to 5 times weekly sees his provider for a physical. Due to his BMI being in an unhealthy weight range, the provider views the patient as unhealthy and is more likely to recommend behavioral modifications in order to achieve a healthier BMI.

Numerical targets are important, particularly in a culture driven by data and objective outcomes. Numbers provide patients with tangible objectives to meet a given goal. Numbers are also vital to the practice of medicine to provide guidance for safe guidelines and warnings when practices may become harmful. In addition, behavioral changes are important. Behavioral changes allow patients to have a means to reach a goal. Behavioral changes also have multiple secondary effects such as improved psychological well-being and reduced depressive symptoms.^18,19 However, lifestyle change is inherently more complicated than a single numerical target. Lifestyle change introduces subjectivity such as self-reporting. It also adds complexities such as will power, motivation, and individual desires. Due to this complexity and subjective nature, providers may choose to focus on a numerical objective target that is measurable, established, and familiar.

From a goal setting perspective, it is ideal to establish the behaviors that lead to the goal as targets and determine the best ways to make these behavioral changes. For example, it is best to establish dietary and PA changes that will take place in the next week rather than the amount of weight loss that will occur. However, patients typically have a goal for weight loss in mind even if the goals established are behavioral. Health care providers are encouraged to reinforce the benefits of lifestyle changes even if a patient’s overall goal is not being achieved.

REasons for Geographic and Racial Differences in Stroke: The REGARDS Study

The importance of lifestyle behaviors was recently demonstrated in a subset of a sample (n = 4174) from the REGARDS study (N = 30 239) who had a history of coronary heart disease (CHD).^13,20 Even though lifestyle factors are recommended for patients with CHD, less than 20% of CHD patients complete a PA program.^21,22 This study evaluated which lifestyle modifications were associated with reduced risk of recurrent CHD and all-cause mortality.

In this large study of older adults (mean age 68.8 years), investigators evaluated the association between 4 lifestyle factors (i.e., diet, PA, smoking, and waist circumference) and recurrent CHD and all-cause mortality. Definitions for the 4 lifestyle factors included a Mediterranean diet score in the highest quartile, PA greater than or equal to 4 times per week, nonsmoker verses smoker or nonsmoker with a significant smoking history, and a waist circumference less than 102 cm for men and less than 88 cm for women.

During a median of 4.3 years, a total of 447 patients had recurrent CHD events and a total of 745 patients died. After multivariable adjustment, patients who did not smoke had the lowest hazard ratio for recurrent CHD and death (p<0.001) followed by patients who exercised greater than or equal to 4 times per week (p<0.001). Patients who achieved a recommended target for waist circumference did not have a significant hazard risk reduction (p<0.320).

Summary

Though the benefits of PA in older adults are well established, there are controversies. Some of these controversies relate to the weight loss associated with exercise. Possibilities for this controversy include potentially negative clinical outcomes from the weight loss as well as generalized numerical guidelines for older adults with limited clinical trials to support those guidelines. In the REGARDS study, investigators found that patients with a history of CHD were more likely to benefit from behaviors than a numerical goal. Specifically, patients who were physically active had a statistically significant decrease in hazard ratio compared with those who achieved a recommended numerical target for waist circumference.

Conclusions

In a society that highly values numerical targets, it is easy to forget the need to keep the focus on and encourage behavioral changes. Findings such as those in the REGARDS study do not decrease the importance of striving for numerical goals. Rather, they emphasize the importance of the behaviors needed to reach those numerical targets.