1. How can we reduce central obesity during a cardiac rehabilitation program? Noeleen Fallon CNM 2 Cardiac Rehabilitation Department, AMNCH MSc Cardiac Rehabilitation Trinity College Dublin

2. Noeleen Fallon MSc TCD 2 Definition of Obesity Unhealthy excess accumulation of body fat with multiple organ- specific pathological consequences (Haslam, 2006). Obesity is: a major public health problem with associated morbidity and mortality classified as an independent risk factor for cardiovascular disease and diabetes

3. Noeleen Fallon MSc TCD 3 Obesity is an escalating problem that is expected to become the most common health problem of the 21st century Obesity is highly prevalent within cardiac rehabilitation populations (Brochu 2000, Ades 2001, Shubair 2004, Savage 2006).

4. Noeleen Fallon MSc TCD 4 Prevalence of Obesity Estimated that 1.6 billion adults are overweight and 400 million are obese (WHO, 2006) In the USA recent estimates reveal that 61% of the adult population are overweight or obese (Lee, 2007) In European adults, levels of overweight and obesity range from 10-27% in men and up to 38% in women (International Obesity Taskforce, 2005). EuroASPIRE III results revealed that 82.7% of the population were overweight and obesity levels were 38% The recent SLAN survey in Ireland demonstrated that 36% of the population were overweight and 14% were obese (Morgan, 2008).

5. Noeleen Fallon MSc TCD 5 Aim of the study To examine if additional dietary education and exercise would reduce central obesity in a cardiac rehabilitation population.

6. Study Participants 80 participants over a 6 month period 8 dropped out 49 study participants 22 in the intervention group 29 in the control group 60 patients eligible (CAD and overweight) 57 agreed

7. Baseline parameters for both groups InterventionControl Gender Male / Female 68% (15) 32% ( 7)74% (20) 26% ( 7) Age 59.86 ± 6.94 SD59.85 ± 9.57 SD Diagnosis STEMI NSTEMI CABG PCI ANGINA 1 8 9 5 2 1 8 13 3 Smoking Yes No Ex 2 16 4 3 15 9 Alcohol > 21 units < 21 units Nil 1 14 7 2 20 5 SBP (mmHg)135 ± 17.89 SD132 ± 19.96 SD Weight85.0 ± 12.48 SD83.4 ± 14.01 SD BMI30.23 ± 3.38 SD29.32 ± 3.50 SD WC100.14 ± 9.33 SD99.41 ± 10.66 SD

8. Base line parameters for both groups (cont.) WHR0.95 ± 0.06 SD0.95 ± 0.05 SD Fat Mass (kg)26.85 ± 6.15 SD25.30 ± 6.22 SD Fat % body weight31.77 ± 6.56 SD30.50 ± 6.16 SD Lipid Profile TC LDL HDL Trigs 4.05 ± 1.10 SD 2.29 ± 0.98 SD 1.08 ± 0.29 SD 1.50 ± 0.61 SD 4.29 ± 1.02 SD 2.35 ± 0.99 SD 1.09 ± 0.20 SD 1.77 ± 1.13 SD BSL5.81 ± 1.18 SD5.55 ± 0.80 SD Shuttle walk Distance VO 2 METS 403.64 ± 139.54 SD 14.06 ± 4.12 SD 3.64 ± 0.93 SD 403.33 ± 174.82 SD 14.23 ± 4.36 SD 3.69 ± 1.14 SD HADS Anxiety Depression 6.41 +/- 4.84 SD 3.59 +/- 2.77 SD 6.22 ± 3.60 3.85 ± 2.52 IPAQ METS min/week PA low / mod / high 1352.25 ± 1297.63 SD 8 / 13 / 1 1081.19 ± 1071.16 SD 10 / 17 / 0

9. Noeleen Fallon MSc TCD 9 Methodology Intervention group: Walk for one hour in addition to the routine phase III exercise program Completed exercise diarys and wore polar watches Individual dietary advice following analysis of 3 day food diary Additional educational talk and discussion focusing on exercise, diet and motivation Daily contact with researcher Control group Attended phase III routine CR program.

10. Noeleen Fallon MSc TCD 10 Results from the study Results from the study Data was analysed using SPSS version 14 Analyses using descriptive statistics gave parameters of mean median SD minimum and maximum of all variables Analyses of variance (ANOVA) parametric test was performed to examine the mean differences at baseline between the intervention and control group and analyse the response to intervention to see if there was a statistically significant difference between the two groups. A p value of <0.05 was utilised as a level of significance

11. Noeleen Fallon MSc TCD 11 Results from study There was no significant difference in any of the anthropometric measurements or fitness level parameters between the two groups

12. Weight Weight Amongst Groups 75 80 85 90 95 100 InterventionControl Mass (Kg) Pre Post

13. Waist Circumference

14. Shuttle Walk Test Distance

15. METS calculated from Shuttle Walk Test

16. Noeleen Fallon MSc TCD 16 Results from study Parameters of both control and intervention groups (N = 49) were examined using paired t tests pre and post program to evaluate the effect of the program

17. Noeleen Fallon MSc TCD 17 Results of study Analyses of data from both groups combined demonstrated significance in Body weight (p = 0.021) BMI (p = 0.029) WC (p = 0.003) TC (p = 0.039) LDL (p = 0.02) SBP (p = 0.021) Fitness parameters calculated using a shuttle walk (p < 0.001)(distance and METS) PA questionnaire score and METS (p < 0.001)

18. Noeleen Fallon MSc TCD 18 Results from study PrePostSig Body weight84.1483.29(p = 0.021) BMI29.7329.43(p = 0.029) WC99.7398.22(p = 0.003) TC4.183.78(p = 0.039) LDL2.321.93(p = 0.02) SBP133.24127.27(p = 0.021) Distance Mets shuttle walk 402.47523.04(p<0.0001) IPAQ Mets/mins per week 1202.894958.65(p<0.0001)

19. Shuttle walk distance 0 100 200 300 400 500 600 Distance In Meters PrePost P<0.0001

20. IPAQ Mets/min per week 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 Mets/min PrePostpost -CR IPAQ Mets Minute P <0.0001

21. Noeleen Fallon MSc TCD 21 Discussion Results demonstrate the clear benefit of the program itself Fitness parameters improved as demonstrated by the shuttle walk test and IPAQ results Antropometric measurements improved as demonstrated by Body weight, WC and BMI

22. Noeleen Fallon MSc TCD 22 Why was there no significant difference in parameters between the intervention and the control groups?????

23. Noeleen Fallon MSc TCD 23 Answers Small study sample Short time frame of program No target weight loss program 2-3 weeks to become familiar with program Intervention group may not have adhered to additional exercise or dietary advice Both groups overlapped for education so shared information Control group adhered to program and lost weight and reduced BMI Control group may have exercised more than recommended (30 x 5)

24. Noeleen Fallon MSc TCD 24 Recommendations Recommended that overweight / obese patients will exercise for 60 min/day, increasing time and intensity gradually. Exercise diaries to encourage self report and monitoring of exercise. Body fat analyses will continue and liaison with the dieticians Definite weight loss program during cardiac rehabilitation phase III with input from psychology towards behaviour change

25. Noeleen Fallon MSc TCD 25 Conclusion Obesity remains a significant health problem for cardiac rehabilitation patients (Shubair 2004). Targeted interventions toward weight management in cardiac rehabilitation programs are important (Bader, 2001). Intervention in obesity, in addition to the well established risk factors, appears to be an advisable goal in prevention of cardiovascular disease and diabetes (McGill 2002).