As much as we'd like to believe exercise alone keeps our hearts healthy and wards off chronic disease, there's just too much evidence to the contrary. The good news is The Women's Health Study strongly supports current physical activity guidelines recommending 30 minutes of moderate activity daily, and suggests additional physical activity will further reduce coronary heart disease (CHD) risk.

On the downside, however, even high quantities of physical activity are not likely to fully reverse the CHD risk in women who are overweight or obese, unless those women also lose weight. (Weinstein, A.R., et al., Archives of Internal Medicine 2008, April 28)

Well-Versed in Nutrition

Stephanie Madeira, RD, CDE, outpatient nutritionist at Robert Wood Johnson University Hospital at Rahway (RWJUH-Rahway), NJ, emphasized the need to appropriately manage calories in and calories out to achieve and maintain a healthy weight.

"Exercise for weight loss and maintenance doesn't mean 3 times a week like we used to believe; it's more like 5-7 days a week," she said. "And calorie restriction means looking at your diet and reducing the amount you eat."

Kimberly Cole, MSN, RN, CNS, concurrent intervention specialist and bariatric clinical nurse coordinator at Sutter Roseville Medical Center, understands the uphill battle many middle-aged women face when they address their cardiovascular risk factors.

"Obesity is a disease process, and you can talk until you're blue in the face about diet and exercise, and it just won't make a difference for some individuals, especially if they have been identified as having metabolic syndrome," she said. "Most of the patients who come to us for bariatric procedure for weight management are well-versed in nutrition, and know they need to be healthier." [See Menopause Matters]

Most patients want to lose weight for the right reasons, Cole pointed out.

"What patients do realize is increased physical activity and watching what they put in their mouths does make a difference," she said. "Many of them are able to cut their prescriptions in half after weight loss surgery. Many of my patients say they wish they'd done it years ago. They don't choose these procedures because they want to look like a model on television; they make the decision because they want to live healthier lives with their families."

Statistics Make a Difference

If women do indeed have a handle on the improvements needed in their lifestyle, what can healthcare professionals do to spark the desire for change? Cole believes numbers and visual aids are good starting points.

"When you start providing statistics and facts, people start to pay attention," she said. "We can show how obesity shortens the lifespan; we just don't see a lot of obese older adults! Once people are ready to lose weight, we can provide the tools for losing weight and then maintaining a healthy body weight."

Cole uses a powerful visual in her classes to help women understand the burden extra weight places on the cardiovascular system.

"I tell them the heaviest bag of dog food you can buy is 50 pounds, and I can't lift that bag," she said. "When I see patients carrying the equivalent of two or three of those bags on their frames, it's no wonder they have trouble moving around!"

At RWJUH-Rahway, staff nurse Susan Lasko, BSN, RN, has found a picture is worth a thousand words. "A lot of patients come in hoping to lose 5 pounds a week, but we let them know a slow and steady pace is the most effective way to lose weight and keep it off," she explained. "After all, a quarter pound a week represents a stick of butter, and adds up over time. Thinking about that stick of butter provides a great visual."

Cardiac Events Trigger Readiness

At Palmetto Health Heart Hospital, Columbia, SC, Sandra Dickson, MS, RN, nurse manager for cardiac and pulmonary rehabilitation, works with a highly motivated group of outpatients.

"Our patients are more willing to 'turn over a new leaf' in terms of regular exercise, smoking cessation and learning more healthy diet habits after a cardiac event," she said. "We exercise these patients wearing a cardiac monitor and gradually increase their exercise tolerance. We also provide structured classes on heart disease, nutrition, stress, exercise and risk factor reduction."

Patients who attend cardiac rehab programs reluctantly are often won over when they see solid results.

"Some come because their doctors make them, and that's clear up-front," said Helen Peare, BSN, RN, coordinator of ambulatory cardiac services at the Nicholas Quadrel Healthy Heart Center for Cardio-Pulmonary Rehabilitation at RWJUH-Rahway. "As they go along and see their pants fitting better and their endurance increasing, we do see a better attitude on their part."

Tailored Nutrition

At Palmetto Health, Tara Bridges, BS, RD, helps patients achieve and maintain a healthy weight by crafting individualized nutrition prescriptions outlining how many grams of protein, carbohydrates and good fats should be eaten each day.

"Before entering the program, participants provide Tara with food frequency information, letting her know what they eat and how often," Dickson said. "She tries to incorporate that information into her personalized teaching. She goes over how to choose good sources of these nutrients, and reviews portion control; calories are factored into their food budget as well as the number of servings per day."

Palmetto Health cardiac rehab participants also attend six 30-minute classes that provide real-life information designed to improve diet and nutrition.

"Tara explains how to grocery shop for healthy foods, how to select the right meals in restaurants, and how to reconstruct recipes to make them healthier," Dickson said. "For example, this is the South and we love our fried chicken. She teaches participants how to bake chicken in a way that tastes fried."

At RWJUH, Madeira focuses on the pitfalls that let the calories pile up.

"The women I talk with definitely know what they should be eating, but still have a tendency to overeat," she said. "I let them know, 'This is where you're making mistakes in terms of portion control, or with that 200-300 calorie snack you think won't make a difference.'"

To empower women, Madeira encourages them to view eating as something vital to their health. "When you pick up that cookie, ask yourself, 'Do I want to be 160 pounds or 200 pounds?' and then put the cookie back down," she recommended.

Taking Control

While women can't change CHD risk factors such as their personal and family history, Madeira wants them to understand they can control other factors such as physical activity and weight.

"We encourage women to achieve and maintain a healthy weight after a cardiac event, emphasizing that's something they do have control over," she said. "We reinforce the message they can help themselves a great deal by losing 10-15 pounds."

Education goes a long way toward inspiring women to take control of their own health. "Most of them have multiple risk factors for metabolic syndrome, including elevated blood pressure, hyperlipidemia and abdominal obesity," Dickson said. "We teach them about CHD risk factors, and show them how to reduce their risks. When they don't control their risk factors, we tell them they're on a slippery slope that leads to CHD, but remind them they have time to turn that around with diet and exercise."

Sandy Keefe is a frequent contributor to ADVANCE.

Menopause Matters

For middle-aged women, menopause and coronary heart disease present a double whammy at a time in life when change isn't always easy.

"It's so difficult for women, especially during menopause, to maintain an appropriate weight," acknowledged Stephanie Madeira, RD, CDE, outpatient nutritionist at Robert Wood Johnson University Hospital (RWJUH) at Rahway, NJ. "If they manage to get through menopause without gaining a lot of weight, they're in luck. If they've already gained the weight, it's really difficult to take it back off."

Be Realistic

Madeira empathizes with women who are bombarded by mixed messages about weight and well-being. "Weight management is not an easy thing," she acknowledged.

"While we're not all supposed to be a size 2 or 4, a BMI over 30 is clearly unhealthy. So I do use BMI because it's the best indicator of a healthy weight, but I make allowances for the fact it doesn't take into account someone who exercises quite a bit and has a lot of muscle mass. I encourage our patients to strive for a BMI under 27, especially those who are in cardiac rehab following an event."

Susan Lasko, BSN, RN, a staff nurse in the cardiac rehab program at RWJUH-Rahway, is familiar with some of the unrealistic expectations women bring to the table.

"When patients come in here, Stephanie asks them what their weight goal is, and it's interesting to hear a 200-pound woman talking about getting down to 120 pounds," she said. "Stephanie works with them to set a realistic goal, so they're more motivated to lose weight and maintain a healthy weight over time."

Healthy Weight

Kimberly Cole, MSN, RN, CNS, concurrent intervention specialist and bariatric clinical nurse coordinator at Sutter Roseville Medical Center, also takes a pragmatic approach to weight management with her clients.

"We need to establish realistic goals with overweight and obese adults," she emphasized. "I tell them they're probably not going to be 120 pounds like they were in high school, but they can achieve and maintain a healthy weight."

And Helen Peare, BSN, RN, coordinator of ambulatory cardiac services at the Nicholas Quadrel Healthy Heart Center for Cardio-Pulmonary Rehabilitation at RWJUH-Rahway, encourages patients to look ahead.

"I always tell them, 'The weight gain didn't happen overnight, and it's not going to go away overnight,'" she said. "It's very important to set realistic goals."