Intensive Lifestyle Intervention Outcome Data

Nearly 70% of US adults are overweight or obese; the prevalence of abdominal obesity stands at 53% and continues to rise. At any one time, 55% of the population is on a weight-loss diet, which do not provide long term benefits. Fewer than 15% of adults exercise sufficiently, and over 60% engage in no vigorous activity. Among adults, 11%-13% have Type 2 Diabetes Mellitus, 34% have Hypertension, 36% have pre-Hypertension, 36% have pre-Diabetes Mellitus, 12% have both pre-Diabetes and pre-Hypertension, and 15% of the population with either Diabetes Mellitus, Hypertension, or Dyslipidemia are undiagnosed. About one-third of the adult population, and 80% of the obese, have lifestyle induced Fatty Liver Disease. Half of adults have at least one cardiovascular risk factor, and less than 1% of the population attains ideal cardiovascular health. Despite falling coronary death rates for decades, Coronary Heart Disease (CHD) death rates in US women 35 to 54 years of age is now increasing because of the obesity epidemic. Up to 65% of adults do not have their conventional heart disease risk factors under control. Only 30% of high risk adults with CHD achieve aggressive cholesterol targets. Of those adults with multiple risk factors, fewer than 10% have all of them adequately controlled. Even when adults are titrated to evidence-based targets, about 70% of cardiac events remain unaddressed. Primordial prevention, resulting from healthful lifestyle habits that do not permit the appearance of risk factors, is the preferred method to lower cardiovascular risk. Lowering the prevalence of obesity is the most urgent matter, and is pleiotropic since it affects blood pressure, lipid profiles, glucose metabolism, inflammation, and atherosclerotic disease progression. Given the current obstacles, success of primordial prevention remains uncertain. At the same time, the consequences of delay and inaction will inevitably be disastrous, and the sense of urgency mounts. Since most CHD events arise in a large subpopulation of low- to moderate-risk individuals, identifying those who will go on to develop cardiovascular events with accuracy remains unlikely. The current model of targeting high-risk individuals for aggressive therapy may not succeed alone, especially given the rising burden of risk. Estimating lifetime cardiovascular risk using scoring systems such as the American Heart Association’s (AHA) and American College of Cardiology (ACC) Pooled risk model is the preferred method of identifying this subpopulation. The use of lifetime risk is an important conceptual advance, since ≥90% of young adults with a low 10-year risk have a lifetime risk of ≥39%; over half of all US adults have a low 10-year risk but a high lifetime risk. Pathological and epidemiological data confirm that atherosclerosis begins in early childhood, and advances seamlessly and inexorably throughout life. When indicated, aggressive treatment should begin at the earliest indication, and be continued for years. Several recent proposals and methods to lower cardiovascular risk exist with only a few demonstrating long term benefit. The United States Preventive Services Task Force (USPSTF) strongly recommends (SOR A – high level of evidence) the use of high intensity counseling combined with behavioral interventions, referred to as Intensive Lifestyle Intervention (ILI), to produce sustained weight loss and optimize health outcomes. Studies providing evidence for ILI rely on multidisciplinary team-based models utilizing allied health professionals in combination with physicians.

The National Weight Control Registry (NWCR) was established in 1994 as a prospective investigation of long-term successful weight loss maintenance. In 2014, a 10-year observation report of 2,886 participants revealed that the mean weight loss of participants was 14.2 pounds at 1 year, 10.8 pounds at 5 years and 10.5 pounds at 10 years. 87% of participants were still maintaining at least a 10% weight loss after 5 and 10 years. These impressive data show that long-term weight loss maintenance is possible in self-selected weight losers. The 1999–2006 National Health and Nutrition Examination Survey examined the prevalence and the correlates of long-term weight loss maintenance, defined as weight loss maintained for at least 1 year, in 14,306 US adults. The survey found that more than 17% of US adults who have ever been overweight or obese has accomplished long-term weight loss maintenance of at least 10% of their initial body weight. Although the period of weight maintenance was much shorter than in the case of the NWCR observational report, the National Health and Nutrition Examination Survey confirms that also in non-selected individuals in the community, long-term weight loss is possible.

A recent systematic review on the outcome of weight loss lifestyle modification programs found that at 1 year, about 30% of participants had a weight loss ≥10%, 25% between 5% and 9.9%, and 40% ≤4.9%. Weight loss reaches its peak within 6 months of the start of treatment, and in the absence of a weight maintenance program, the trend begins to reverse thereafter, with 50% of participants returning to their original weight after about 5 years. These data indicate that traditional lifestyle modification programs require a greater focus on long-term maintenance to be considered successful. The latest generation of weight loss lifestyle modification programs, including the most innovative and powerful cognitive behavioral procedures are producing even better long-term results. The most striking example is the Look AHEAD (Action for Health in Diabetes) study, which assessed the effects of intentional weight loss on cardiovascular morbidity and mortality in 5,145 overweight and obese adults with Type 2 Diabetes Mellitus, randomly assigned to ILI or usual care (i.e., Diabetes Support and Education [DSE]). At year 1, more ILI than DSE participants had lost ≥5% of their initial weight (68.0% vs 13.3%), with the ILI group showing an average weight loss of 8.5%, which was significantly greater than the 0.6% seen in DSE participants. At year 8, 88% of both groups completed an outcomes assessment, which revealed that ILI and DSE participants lost, on average, 4.7% and 2.1% of their initial weight, respectively. Among the ILI and DSE participants, 50.3% and 35.7%, respectively, lost ≥5%, and 26.9% and 17.2% lost ≥10%. These impressive figures show that well-conducted ILI programs can produce clinically meaningful long-term weight loss and reduce the risk of cardiovascular events in all adults regardless of risk.