Obesity is a complex medical condition impacted by genetic, metabolic, and behavioral factors. It is associated with varied chronic diseases and medical conditions, including systemic inflammation, diabetes, insulin resistance, high blood pressure, obstructive sleep apnea, and cardiovascular disease (CVD). Obesity is acknowledged widely as a common U.S. societal trait, with nearly 35% of U.S. adults now classified as obese, using body mass index (BMI) criteria (Table) (12). To help frame what constitutes healthy and unhealthy BMIs, consider a 5′10″ individual with a BMI of 30 kg/m2. In this example, a reduction of 35 lbs equates to a decrease of approximately 5 BMI units, yielding the upper limits of normal for both body weight and BMI (i.e., 25 kg/m2).
This review builds on the above-referenced themes, with specific reference to the classification and causes of obesity, the controversy regarding metabolically healthy obesity, using physical activity and improved cardiorespiratory fitness to help counter the adverse impact of obesity on cardiovascular health, exercise programming for overweight/obese clients, and research-based counseling interventions to improve clients’ lifestyle behaviors. We also review the obesity paradox noted in patients with CVD, highlighting the puzzling survival advantage that overweight and mildly obese patients have over their leaner counterparts.
CAUSES OF THE OBESITY EPIDEMIC
Although unhealthy eating habits are generally considered the primary factor underlying our national weight problem, recent studies suggest that technologic advances and the associated reduction in physical activity are the major culprits. In fact, one recent report showed that, during the last 50 years, work-related energy expenditure has decreased by more than 100 calories per day, largely accounting for the increased prevalence of obesity among women and men (7). Comparable declines in energy expenditure have been reported in household management activities during this period.
According to the Bureau of Labor Statistics, the most common shared contemporary occupational health risk is sedentary behavior. Increasingly, we are paid to think, to provide specific sedentary skills, or to communicate or process information. Smartphones and computers have become part of our vocational garb. Automobiles, elevators, escalators, moving walkways, Segways, video games, television remote controls, and energy-saving devices such as washing machines, dishwashers, microwave ovens, self-propelled lawn mowers, automatic garage door openers, and online ordering/bill paying have largely engineered physical activity out of daily life.
CAN OBESE PEOPLE BE HEALTHY?
In recent years, scientists have identified an obese population cohort that is characterized by the absence of “metabolic risk factors.” These risk factors may include elevated blood pressure, increased triglyceride levels, decreased high-density lipoprotein cholesterol (the “protective” cholesterol subfraction), elevated blood glucose, insulin resistance, and systemic inflammation. Individuals without these risk factors are classified typically as “metabolically healthy” or, in this case, metabolically healthy obese, which seems somewhat paradoxical. Interestingly, among U.S. adults, there is a high prevalence of normal-weight adults who have these metabolic risk factors as well as overweight/obese individuals who are metabolically healthy (33). A critical question, however, is whether metabolically healthy obese adults maintain this profile during the long-term or whether they naturally transition into unhealthy obesity.
According to a study of British government workers, approximately half of initially healthy obese adults developed metabolic risk factors during the next 20 years (2). In other words, they gravitated to the unhealthy obese category. Moreover, only 10% of the initial group transitioned to the healthy nonobese category, meaning they remained largely free of risk factors and simultaneously lost weight. People who started out obese but healthy were eight times more likely than their healthy nonobese counterparts to progress to an unhealthy obese state after two decades. Other studies have now shown that, compared with metabolically healthy normal-weight persons, metabolically healthy obese individuals are at an increased risk for type 2 diabetes, cardiovascular events, congestive heart failure, and all-cause mortality during the long-term (20). These findings and other recent reports suggest that long-term stability of healthy obesity may be the exception, rather than the norm. Because the natural history of body weight is an increase across time, obese but healthy is likely to evolve to heavier and unhealthy at some point. The implication is that, relative to the prevention of chronic disease, all types of obesity warrant treatment, even those that seem to be transiently healthy.
ARE THE CONSEQUENCES OF OBESITY INEVITABLE?
Despite the higher risk of disease and death, the vast majority of Americans are unable to lose weight and keep it off during the long-term. Moreover, healthy obesity is likely to transition to unhealthy obesity across time. Consequently, the question arises: “Do excess body weight and fatness, per se, invariably result in adverse health outcomes?”
Fortunately, there are other variables that can have a significant impact on the relationship between body fatness and mortality. For example, consider the “fat real estate” axiom: location matters. Fat location plays an important role in determining the coronary risk factor profile as well as the prevalence of chronic diseases, such as metabolic syndrome, type 2 diabetes, and coronary heart disease. Individuals with a substantial amount of abdominal fat will have a much higher risk for chronic disease than those whose fat tissue is distributed more in the hips and thighs (9). Similarly, it’s better to be overweight or mildly obese and fit than thin and unfit (23).
FITNESS, FATNESS, AND MORTALITY
During the past 20 years, numerous studies have examined the relationship between cardiorespiratory fitness and/or habitual physical activity and mortality. Results consistently demonstrate that, when matched for age and body habitus (normal-weight, overweight, obese), unfit men and women generally have a twofold to threefold higher mortality rate than their fit counterparts. Because of the “obesity paradox,” described below, underweight/normal-weight unfit patients with CVD have a reduced life expectancy as compared with those who are overweight or obese and unfit. On the other hand, the prognosis in fit patients with CVD is generally excellent, at least among those who are normal weight, overweight, or mildly obese (class I) (23). Collectively, these studies suggest that, although structured exercise, increased lifestyle physical activity, or both may not make all people achieve normal BMIs, it seems that an active way of life confers significant health-fitness and survival benefits, even for those who remain overweight or mildly obese.
To clarify whether higher levels of physical activity can ameliorate the health hazards associated with obesity, researchers examined 116,564 women (aged 30 to 55 years) who were initially free of known CVD and cancer (16). During a 24-year follow-up period, the relative risk of death of lean-active (BMI <25 kg/m2), lean-inactive, obese-active (BMI ≥30 kg/m2), and obese-inactive increased incrementally (Figure 1). It was concluded that both increased BMI and reduced physical activity are strong and independent predictors of death.
THE OBESITY PARADOX: HIGHER WEIGHT = LOWER RISK?
Clearly, obesity and its complications increase the risk for developing many diseases, including metabolic syndrome, diabetes, heart disease, and heart failure. However, during the past decade, researchers have uncovered a startling and perplexing revelation: being overweight or mildly obese may not be as bad as once thought and actually may be protective, especially in patients with established CVD. This finding is referred to commonly as the “obesity paradox” (23).
Why do overweight and mildly obese patients generally have a lower mortality risk? Some have suggested that such individuals may receive earlier and more aggressive medical treatment because of their “unhealthy” weight. Others suggest that such individuals may fare better than underweight/normal-weight persons because of their genetic makeup or because the latter may be more likely to be smokers or have underlying illnesses. Still others contend that modest amounts of body fat actually may be protective. Differences in muscle mass, muscular strength, and cardiorespiratory fitness also may help explain the obesity paradox partially (23).
A recent analysis of numerous studies involving nearly 2.9 million people, with and without CVD, confirmed the obesity paradox (13). In fact, people who were overweight or mildly obese (class I) were at lower risk of dying than those in the normal BMI category. Moreover, numerous studies now indicate that being at the ends of the BMI continuum, more severe obesity (class II or III or BMI >35 kg/m2) or very thin (BMI <18.5 kg/m2) have unfavorable health implications. It is what clinicians refer to as a classic U-shaped curve, where it is safer to be in the middle of the distribution. In other words, especially in patients with CVD, being overweight or mildly obese actually may be protective. However, purposeful weight loss for long-term health remains important, particularly for individuals with BMIs approaching or exceeding 35 kg/m2 (23).
PRESCRIBING EXERCISE AND PHYSICAL ACTIVITY FOR OVERWEIGHT AND OBESE CLIENTS
Successful weight management programs commonly incorporate caloric restriction with increased physical activity and/or structured exercise, with the goal of achieving a 500- to 1,000-kcal per day energy deficit (or 1 to 2 lbs per week) to attain a clinically significant and sustainable weight loss (26). This approach especially is effective in overweight and mildly obese individuals, whereas more severely obese patients may require additional interventions (e.g., pharmacologic treatment, bariatric surgery) (32). However, for most overweight and obese individuals, exercise alone is not sufficient to evoke weight loss (17,18).
EXERCISE PROGRAMMING — GETTING THE PRESCRIPTION RIGHT
Interventions that combine caloric restriction with regular exercise, as opposed to caloric restriction alone, provide added cardiometabolic benefits in overweight/obese clients, including significant improvements in insulin sensitivity and aerobic fitness; greater reductions in diastolic blood pressure, abdominal fat, low-density lipoprotein cholesterol, and comorbidity risk; and preservation of lean body mass (22,32). After screening for signs and symptoms of heart disease, uncontrolled hypertension, and metabolic disease, a safe and comprehensive exercise program can be developed and should include aerobic exercise, resistance training, flexibility exercise, and neuromuscular training (26). Although each of these components provide independent and additive benefits, aerobic exercise ascends as a focal point because it more prominently impacts caloric expenditure to achieve a negative energy balance. Figure 2 highlights current American College of Sports Medicine (ACSM) recommendations for prescribing aerobic exercise to overweight and obese individuals, with an emphasis on overall duration of exercise (which significantly impacts caloric expenditure) over intensity (26,32). In addition, resistance training should be used to complement the exercise regimen because it more favorably impacts bone mineral density, muscle mass, strength, insulin sensitivity, and basal metabolism as compared with aerobic activities (34). The use of resistance bands, free weights, or cable pulley exercises that involve pushing, pulling, and overhead press movements for upper body muscle groups, along with leg press exercises, is recommended (32).
Approximately 60 to 90 minutes per day of moderate-intensity physical activity may be necessary to achieve long-term weight control, especially in formerly obese clients (18). However, for the novice exerciser, in particular, this goal should be balanced with an initial exercise prescription that is attainable, sustainable, and enjoyable and minimizes discomfort and injury risk. Continuous or multiple shorter (≥10 minutes each) daily activity bouts may be used preferentially to achieve the recommended total exercise duration because both approaches promote comparable improvements in fitness and weight loss (19).
SPECIAL EXERCISE CONSIDERATIONS AND BARRIERS TO PHYSICAL ACTIVITY
After screening for signs/symptoms of heart disease, uncontrolled hypertension, and metabolic disease, the exercise professional can design a safe and effective exercise program for the overweight or obese client. An evaluation of physical limitations, such as lower-extremity orthopedic problems, should be conducted to avoid activities that may increase the incidence of injury or aggravate existing musculoskeletal conditions. Activities such as lumbar strengthening and joint specific exercises that are designed to strengthen muscles around the knees and hips also may be helpful in reducing musculoskeletal discomfort and the incidence of injury.
Many obese individuals, especially women, have low ratings of self-esteem (14). Almost all have low perceived body attractiveness, high social physique anxiety, and reduced confidence in their ability to perform unaccustomed physical activity. The overweight or obese woman may be highly self-conscious in a conventional gym setting, making it an uncomfortable environment. Recommending an all-women program such as “Curves” may be helpful in this regard. For the client with low self-esteem, positive initial exercise experiences are crucial. Critical factors affecting the setting include the sensitivity of the supervising exercise professional, providing a nonthreatening activity environment, exercising with individuals of similar body habitus, and offering a social atmosphere that focuses more on the psychological needs of the novice exerciser, rather than the weight loss objective per se (14).
Finally, it should be emphasized that obese individuals may differ from their normal-weight counterparts in how they perceive the relative intensity/difficulty of their exercise (11). In other words, their self-rated “moderate” or “vigorous” intensity may not align well with the relative heart rate – oxygen consumption relations suggested by ACSM. Consequently, the personal trainer needs to be mindful of the client’s perception of effort and allow them additional freedom in choosing their exercise intensity.
PHYSICAL ACTIVITY — A CONTRIBUTING FACTOR IN SUCCESSFUL WEIGHT MANAGEMENT
Structured exercise is essential in achieving the desired energy balance for weight loss, simultaneously improving indices of cardiorespiratory, muscular, and joint health (26). Moderate-intensity walking regimens not only expend calories and contribute to successful weight loss but also reduce the subsequent incidence of coronary heart disease and all-cause mortality (24). However, the added benefits of complementary daily physical activity — that is, any bodily movement that increases calorie requirements over resting energy expenditure — should not be underestimated (26). Lifestyle physical activity such as gardening, carrying groceries, folding laundry, climbing stairs, vacuuming, conventional or pole walking, and mowing the grass can bolster the impact of structured exercise in weight loss interventions (32).
To promote public health, the recent Physical Activity Guidelines for Americans recommended 30 minutes or more of moderate-intensity physical activity on 5 or more days per week or 20 minutes of vigorous-intensity physical activity 3 days per week (31). Although this recommendation should serve to reduce the risk for developing chronic diseases, it is likely ineffective in countering the current obesity epidemic. Accordingly, previously sedentary habits (e.g., watching television, prolonged computer interactions) should be replaced with leisure time physical activity as a complement to structured exercise that aligns with current ACSM recommendations for this population.
The concept of tracking daily physical activity is viewed increasingly as a motivational tool, and current technology ranges from simple pedometers to more advanced accelerometers and smartphone-based free or low-cost wellness applications (or “apps”) (3). Social media-based physical activity interventions also have the potential to serve as adjunctive motivational tools to combat our increasingly hypokinetic lifestyle (4). These options not only assist individuals and their health care providers with assessing progress toward activity goals but also provide immediate feedback that can moderate behavior effectively toward increasing physical activity to enhance weight loss. In one recent report, obese women assigned pedometers during a 3-month weight loss intervention lost an average of 8.7 kg as compared with a 1.4-kg reduction in the control group using the same dietary modifications without pedometer tracking (5). Indeed, this striking example highlights the usefulness of activity-tracking tools for maximizing outcomes in weight loss interventions.
GUIDING BEHAVIOR CHANGE IN OVERWEIGHT AND OBESE CLIENTS
Although the benefits of regular exercise are well documented, only 22% of adults in the United States are moderately active for at least 30 minutes per day on most days of the week. Moreover, 24% are completely sedentary and 53% could benefit from additional physical activity (6). Dropout rates among those who voluntarily enter structured exercise programs are highest in the first 3 months, increasing to approximately 50% by 12 months. In overweight and obese populations, enrollment in exercise programs is low and rates of early dropout are high. To improve exercise compliance, the health-fitness professional should embrace a client-centered approach to assess readiness to change and, using nonjudgmental positive communication and coaching skills, implement an action plan to achieve lasting lifestyle changes. Furthermore, counseling skills are skills; as such, considerable training and practice are needed to achieve competence. Additional education/coaching certification also may be helpful in this regard.
FACILITATING BEHAVIOR CHANGE
The Transtheoretical Model of behavior change is a blueprint for effecting self-change in health behaviors, including eating habits and exercise (27). This model recognizes that, at any given time, people can be classified across a continuum of readiness (to change), which covers a span of five stages.
- 1. Precontemplation: Client is not thinking about making lifestyle changes.
- 2. Contemplation: Client is considering but is not yet ready to change.
- 3. Preparation: Client has taken some behavioral steps and intends to take action in the next 30 days.
- 4. Action: Client begins to demonstrate the new behavior consistently for less than 6 months.
- 5. Maintenance: Client has been in action for 6 months or longer.
Movement through the stages is not necessarily linear but more likely cyclical, as many individuals do not succeed in their initial attempts at behavior change (relapse; client returns to former [unhealthy] lifestyle habits). Specific examples when using this approach (i.e., case studies) have been described previously (21).
The five As approach has been reported to elicit significant improvements in a variety of health behaviors, including smoking cessation, dietary choices, and physical activity (Figure 3) (30). Fortunately, more providers now perform the first two As, that is, assess the risk behavior and advise behavior change. In contrast, it is the less frequently performed As (shaded; agree, assist, arrange), which require more time to implement and specific counseling skill sets to facilitate, that have the greatest impact on healthful behavior change. Effective behavior change strategies include motivational interviewing, along with rewards or incentives, asking clients to self-monitor behaviors, enhancing clients’ self-efficacy (confidence), accessing social support from family and friends, developing the client’s own wellness vision, and scheduling regular follow-up communications/meetings to assess progress.
COMMUNICATING WITH CLIENTS: MOTIVATIONAL INTERVIEWING AND COACHING
Motivational interviewing is a collaborative patient-centered counseling method to help individuals explore and resolve their ambivalence about health behavior change. According to one review that evaluated 72 randomized clinical trials using motivational interviewing to modify varied health outcomes, including BMI, hemoglobin A1c, total cholesterol, systolic blood pressure, and cigarette smoking, beneficial results were noted in 74% of the reported studies. Moreover, motivational interviewing outperformed traditional advice giving in 75% of the studies reviewed (28).
Motivational interviewing consists of two phases. During the initial phase, intrinsic motivation is enhanced and, in phase 2, commitment to change is strengthened (25). The four general principles of motivational interviewing include expressing empathy; developing an awareness of where individuals’ health habits are and where they would like them to be; rolling with resistance (i.e., acknowledging and exploring client arguments against changing); and supporting self-efficacy (i.e., helping the client find resources to implement new behaviors and overcome barriers) (25).
Exercise professionals can use coaching skills with their clients to help them progress in achieving their goals. To ensure that clients set goals that they have confidence in their ability to accomplish, three foundational tasks should be completed before attempting behavior change:
- 1) helping clients identify strong, personal, positive motivators (benefits)
- 2) helping clients recognize their major barriers (obstacles)
- 3) helping clients delineate possible solutions (strategies) for each of the barriers
MOTIVATION TO BEHAVIOR CHANGE
By using motivational interviewing and coaching effectively, the client can enhance intrinsic motivation and increase self-confidence in achieving behavior change, leading to the establishment of additional goals and objectives. Besides weight loss, progress records can be reviewed including distance walked, frequency or duration of exercise sessions, and improvement in selected physiologic parameters. For some people, clinical improvements may serve as a motivator. For many others, however, it revolves around increased positivity, improved body/self-image, increased self-confidence, and the ability to once again perform enjoyable activities.
In addition, educating the client on relevant topics such as the benefits of exercise, appropriate warm-up and cooldown, correct body mechanics, warning signs and symptoms, potential metabolic complications (e.g., hypoglycemia), proper exercise clothing and footwear, and the influence of environmental extremes on the exercise response should serve to reduce the incidence of injury/complications and enhance compliance. As the overweight/obese client’s fitness improves across time, exercise professionals can refresh the physical conditioning regimen by introducing enjoyable variations such as Zumba, step aerobics, water aerobics, and modified recreational games (e.g., one-bounce volleyball). Exercise programming also may include aerobic interval training with brief higher-intensity bouts alternated with longer periods of lower-/moderate-intensity exercise during the endurance phase. Strong social support systems including family, friends, exercise partners, coworkers, and health-fitness professionals can influence exercise motivation positively (15).
The achievement of realistic goals and maintenance of healthy behaviors across time should serve to bolster self-confidence in overweight and obese clients. Moreover, improved self-confidence may enhance self-efficacy, a prerequisite for lasting behavior change (1). Thus, a primary objective of effective coaching is to assist clients in visualizing future success (i.e., you become what you think about).
Increasing evidence suggests that technologic advances and the associated reduction in daily energy expenditure are major contributors to the current obesity epidemic. Unfortunately, the natural history of body weight is an increase across time. Moreover, obese clients who are metabolically healthy often gravitate to an unhealthy state, suggesting that all types of obesity warrant treatment. Increased physical activity and improved cardiorespiratory fitness confer significant health and survival benefits in clients with and without heart disease, even for those who remain overweight or mildly obese. Purposeful weight reduction for long-term health remains important, especially for metabolically healthy obese and more severely obese clients. Improvements in cardiovascular structure and function, as well as notable reductions in the incidence of cardiovascular events, also have been reported after intentional weight loss in patients with CVD (8,10,29). Using principles of exercise prescription that align with contemporary ACSM guidelines, motivational activity-tracking tools, and research-based behavior modification strategies can be helpful in achieving these objectives.
BRIDGING THE GAP
Because obesity is associated with varied chronic diseases and medical conditions and the natural history of body weight is an increase across time, all types of obesity warrant some form of treatment. Perhaps greater emphasis should be placed on increasing physical activity and fitness rather than weight loss per se, especially in overweight and mildly obese clients. Purposeful weight reduction remains important for long-term health, especially for metabolically healthy obese and more severely obese clients. Using activitytracking tools and research-based counseling strategies can be helpful in this regard.
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