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Cardiac Rehabilitation
Effects of Behavioral Weight Loss and Weight Loss Goal
Setting in Cardiac Rehabilitation
Kaitlyn V. Barrett, DO; Patrick D. Savage, MSc; Philip A. Ades, MD
Purpose: Obesity is prevalent among participants in cardiac
rehabilitation (CR). Establishing a weight loss goal is an
important strategy for promoting weight loss. We evaluate the
association between a pre-program weight loss goal and change
in weight during CR.
Methods: Body weight was measured at CR entry and at exit
from CR. Overweight/obese participants were categorized as
having: (1) established a weight loss goal and attended behavior
al weight loss sessions (G + BWL); (2) set a weight loss goal but
did not attend BWL (G); (3) and neither set a weight loss goal
nor attended BWL (NoG).
Results: The cohort consisted of 317 overweight/obese partici
pants; 52 of whom set a weight loss goal and attended BWL, 227
patients set a goal but did not attend BWL, and 38 did neither.
The G + BWL group lost more weight than the G group (6.8
+ 4.3 vs 1.1 + 3.5) (P < .0001). Both groups that established
a weight loss goal lost more weight than the NoG group.
Conclusions: For overweight/obese individuals in CR, partic
ipating in BWL classes and setting a weight loss goal leads to
more weight loss than G alone. Setting a weight loss goal alone
leads to greater weight loss than not setting a weight loss goal.
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O
verweight and obesity, metabolic syndrome (MetSyn), in
sulin resistance, and type 2 diabetes mellitus (T2DM) are
highly prevalent among participants in cardiac rehabilitation
(CR).1 Obesity increases the incidence of T2DM, cardiovas
cular disease, cancer, fatty liver disease, and a variety of other
conditions.2 In CR the prevalence of overweight/obese patients
is remarkably high at >80%, and the combined prevalence of
individuals with insulin resistance and T2DM is 67%.3 Life
style modification is the cornerstone of obesity management
and CR is an optimal opportunity for intervention.1 Behavioral
weight loss (BWL) programs consisting of exercise and hypo-
caloric diet are often effective in overweight/obese individuals
Author Affiliations: Divisions of Endocrinology, University of Vermont
Medical Center, and Larner College of Medicine, University of Vermont,
Burlington (Dr Barrett); and Divisions of Cardiology, University of Vermont
Medical Center, and Larner College of Medicine, University of Vermont,
Burlington (Mr Savage and Dr Ades).
Supported in part by a National Institutes of Health Center of Biomedical
Research Excellence award P20GM103644 from the National Institute of
General Medical Sciences.
Supplemental digital content is available for this article. Direct URL citation
appears in the printed text and is provided in the HTML and PDF versions of
this article on the journal's Web site (www.jcrpjournal.com).
The authors declare no conflicts of interest.
Correspondence: Philip A. Ades, MD, Cardiac Rehabilitation and
Prevention, 62 Tilley Dr, S. Burlington, VT 05403 (Philip.ades@uvmhealth.
org).
Copyright (c) 2020 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/HCR.0000000000000510
and are offered in CR programs.4 Participation in BWL pro
grams is associated with more weight loss than not attending
BWL and is an independent predictor of weight loss success in
CR.5 Establishing a weight loss goal is an important strategy
for promoting weight loss for overweight participants in CR.
A recent CR study by Aspry et al6 revealed that committing
to a goal of making healthier dietary choices and/or achieving
weight loss is associated with improved self-reported diet qual
ity and weight loss. There has been little study, however, of the
association between the magnitude of a specific, pre-program
determined weight loss goal and change in weight during CR,
especially in relationship to attendance at BWL interventions,
fitness measurements, T2DM diagnosis, and use of diabetes
medications. The purpose of this study was to evaluate specific
weight loss goals and BWL session attendance on subsequent
weight change in CR participants.
METHODS
The study population was derived from 771 consecutive
patients enrolled in CR at the University of Vermont Medi
cal Center, Burlington, VT, between January 2016 and De
cember 2017. This was a retrospective cohort study, which
received institutional review board (IRB) approval. Of the
entire cohort, 502 (65%) completed CR and among the
completers, 317 (63%) were overweight/obese at entry into
CR and comprised the study population. All patients had
recently experienced a coronary event including coronary
artery bypass or heart valve surgery, myocardial infarction,
percutaneous coronary or valve intervention, chronic stable
angina, or systolic congestive heart failure.
Body weight was measured at 2 time points: at entry to
CR and at completion of CR. At CR a digital calibrated
scale (Detecto) was used to measure body weight with shoes
removed and pockets emptied. Body mass index (BMI) was
calculated as weight (kg)/height (m2).
Classification of T2DM (fasting serum glucose of >126
mg/dL or hemoglobin A1c [HbA1c] >=6.5%) was based on
the American Diabetic Association recommendation.7 The
Adult Treatment Panel (ATP) III guideline was utilized for
classifying MetSyn as follows with 3 of the 5 criteria re
quired for a diagnosis of MetSyn.8
1. Abdominal obesity: waist circumference (WC) of >102
cm for men and >88 cm for women.
2. Hypertension: a history of hypertension, use of hy
pertensive medication, or a medically assessed blood
pressure of >=130 systolic or >=85 diastolic mm Hg.
3. Hypertriglyceridemia: triglyceride >=150 mg/dL or use
of triglyceride-lowering medication.
4. Low high-density lipoprotein cholesterol (HDL-C):
HDL-C <40 mg/dL in men and <50 mg/dL in women,
or use of lipid medication to increase HDL-C.
5. Hyperglycemia: use of antidiabetic medication or fasting
serum glucose of >=100 mg/dL or HbA1c>=5.7%.
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Weight Loss Goal Setting in Cardiac Rehab
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Individuals were categorized as normal weight if either
BMI was <25 or WC was <=102 cm for men and <=88 cm
for women. Individuals were categorized as overweight/
obese if BMI was >=25 and WC >102 cm for men and
>88 cm for women. Baseline HbA1c  (>=6.5%) was used
to classify patients as having T2DM. After T2DM status
was ascertained, the data were analyzed and separated by
T2DM medication usage and drug class. In patients with
an HbA1c>=6.5%, manual chart review was performed to
determine whether the patient was taking medications to
treat T2DM, and if so which class or classes of medications
were they taking: insulin, metformin, sulfonylureas, sodi
um-glucose cotransporter-2 inhibitors (SGLT2 inhibitors),
glucagon-like peptide-1 receptor agonists (GLP-1 agonists),
and dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors).

At entry to CR, cardiorespiratory fitness (VO2peak) was
measured with a graded symptom-limited exercise tolerance
test. Expired gas was analyzed during the exercise protocol
using an Ultima (Medgraphics) metabolic cart with patients

exercising to voluntary exhaustion. VO2peak was considered
to be the highest 30-sec average during the test. Respirato
ry exchange ratio was determined and heart rate (HR) was
monitored by electrocardiogram. Peak metabolic equivalents

(METspeak) was estimated, if directly measured VO2peak was
not available based on achieved treadmill speed and eleva
tion.9 Self-reported physical functioning was assessed using
the Medical Outcomes Study Short Form-36 (MOS SF-36)
survey questionnaire (0-100 scale) with 100 representing
excellent physical functioning.10 Depressive symptoms were
assessed using the Patient Health Questionnaire-9 (PHQ-9)
(0-27 scale), with higher numbers indicating more depressive
symptoms.11 A comorbidity score was determined by assess
ing for peripheral vascular disease, cerebrovascular disease,
chronic lung disease, or orthopedic limitations. If a comor
bid condition was present, it was quantified by severity as
follows: 1, present but not exercising-limiting; 2, present and
impacts on exercise performance; and 3, exercising-limiting.
A total comorbidity score ranging from 0 to 12 was thus
determined.12 The highest level of education that the partici
pant attained was recorded based upon self-reported patient
data. At the initial CR session, individual willingness to com
mit to consuming a heart healthy diet was assessed using the
Stages of Change model.13 This model describes five stages
that people go through on their way to change: pre-contem
plation ("not ready"), contemplation ("thinking about it
in the next 6 mo"), preparation ("planning to commit this
month"), action ("I'm here, let's go"), and maintenance ("my
diet has kept my weight and cholesterol normal").13
The method of delivering patient care in CR is a
case-managed model. Briefly, each patient is assigned a case
manager (registered nurse, clinical exercise physiologist,
or physical therapist). At the initial CR session, the case
manager meets with the patient and, collaboratively, a care
and treatment plan is developed. When weight loss is iden
tified as a goal, the patient, in consultation with CR case
manager, is asked to verbally commit to a short-term (ie,
during CR) and long-term weight loss goal. The recorded
weight loss goal is then used as a reference point for future
discussion regarding progress toward achieving the desired
weight for the individual.
The CR exercise training program consisted of <=3 ses
sions/wk over 3-4 mo (maximum, 36 sessions). Individuals
exercised for approximately 45-60 min/CR session on a va
riety of modalities, including treadmills, elliptical trainers,
and rowing, cycle, and arm ergometers.3 Exercise session
duration was gradually increased until approximately 45
min of aerobic activity on multiple modalities was achieved.
Overweight/obese participants were preferentially directed to
treadmill walking and elliptical trainers as the primary exer
cise modalities to maximize caloric expenditure.3,14 In gener
al, exercise intensity was between 70% and 85 % of HRpeak
obtained on the baseline exercise treadmill test (ETT) and/or
a Borg scale for rating of perceived exertion of between light
and somewhat hard (12-14 on a scale of 6-20).9
All patients, when appropriate, were prescribed high
er-intensity interval training.15 Generally, interval training
consisted of approximately a 5-min period of active warm-
up, followed by a 3-5-min period of training at 70-85%
HRpeak. This was followed by higher-intensity work inter
vals consisting of 4 min at approximately 85-95% HRpeak
followed by a 3-min active recovery period set at an in
tensity of 70% HRpeak. This pattern of higher followed by
lower-intensity intervals is repeated for the duration of time
on the treadmill except for a 5-min cool-down at a self-se
lected pace.
CR participants partook in 2 classroom teaching sessions
on a heart-healthy diet. Overweight/obese individuals were
also encouraged to attend 4 weekly, nurse facilitated, BWL
sessions.16 Briefly, behavioral strategies targeted dietary
changes including decreased caloric intake and increased
physical activity. Specific behavioral strategies included
establishing a daily caloric goal, self-monitoring of eating
habits and physical activity, stimulus control, problem-solv
ing, and social support.3
For analysis, participants were categorized as having: es
tablished a weight loss goal and attended BWL (G + BWL);
set a weight loss goal but did not attend BWL (G); and nei
ther set a weight loss goal nor attended BWL (NoG). Par
ticipants were considered to have attended BWL if they had
attended >=1 session. Statistical methods included nonpaired
t tests and a P < .05 was used to determine significance.
Bonferroni correction was used for post hoc analysis. Re
sults are presented as mean  SD. Analysis of variance was
used for analyzing differences between the three groups.
Variables included in the regression analysis of correlates of
total weight loss during CR included: age, sex, baseline body
weight, BMI, WC, handgrip strength (Jamar Technologies
dynamometer) and peak cardiorespiratory fitness, high
er-intensity interval training (yes/no), CR qualifying diag
nosis (surgery vs no surgery), participation in BWL classes,
specific weight loss goal, stating that weight loss is a goal
but not specifying an amount, diagnosis of T2DM, diabetes
medication use, stages of change status, total number of CR
sessions attended, and individual education level.
RESULTS
The study population was derived from 771 consecutive
patients (see Supplemental Digital Content 1, available at:
http://links.lww.com/JCRP/A171). Of the entire cohort,
502 (65%) completed CR. Among the completers, 317
(63%) were overweight/obese at entry into CR. For the
overweight/obese individuals, there were 52 participants
in G + BWL, 227 patients in G, and 38 patients in NoG.
Table 1 includes baseline values for the entire cohort and
separated by group classification. The groups were similar
at baseline by age, sex, HbA1c, diagnosis of T2DM, diagno

sis of MetSyn, VO2peak, handgrip strength, education level,
cardiac diagnosis, T2DM medications, -blocker therapy,
and total comorbidity score. Baseline weight, BMI, and WC
were all highest in the G + BWL compared with the other
groups. For the same variables, G was significantly high
er than the NoG group. The G + BWL established larger
short- and long-term weight loss goals than the G group.
The G + BWL attended more total CR sessions than in
dividuals in the G and NoG groups. A significant greater
384
Journal of Cardiopulmonary Rehabilitation and Prevention 2020;40:383-387
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Page 3
Table 1
Baseline Characteristics for the Entire Cohort and Separated Weight Loss Goal Statusa
All Overweight Completers
BWL + Goal
P Value
(n = 317)
(n = 52)
Goal No BWL (n = 227)
No Goal (n = 38)
Between Groups
Age, yr
65.9  10.5
67.1  8.8
65.1  10.8
68.6  10.4
.11
Male sex, %
74
73
75
74
.96
Weight, kg
94.0  16.6
99.9  19.6
94.0  15.6
85.5  14.3
.002
BMI, kg/m2
31.9  5.0
33.4  4.8
32.1  5.0
29.0  3.7
.001
WC, in
43.1  4.4
44.5  5.1
43.1  4.2
40.9  4.0
.0008
Short-term WL goal, kg
9.2  6.8
13.9  6.0
9.7  6.0
n/a
.0001
Long-term WL goal, kg
19.4  16.9
29.2  20.6
20.3  14.7
1.3  2.6
.0001
HbA1c, %
6.2  1.3
6.0  0.9
6.2  1.3
6.3  1.3
.5
V O2peak, mLO2 kg1 min1
18.5  5.6
18.7  4.3
18.7  5.9
17.5  4.7
.53
Handgrip, kg
35.9  11.1
35.7  11.5
36.6  11.1
32.2  9.7
.12
Interval training, %
39.7
57.7
38.8
28.9
.02
Education, yr
14.6  2.7
15.1  2.6
14.6  2.6
14.1  2.9
.25
Metabolic syndrome, %
66.9
71.1
66.5
71.1
.71
Cardiac diagnosis
105/212
15/37
75/152
15/23
.57
(surgery vs no surgery)
T2DM, yes/no
87/230
10/42
64/163
13/25
.26
Comorbid score
0.9  1.3
1.1  1.5
0.9  1.3
1.0  1.4
.32
MOS SF-36
61.9  25.8
63.3  27.5
63.4  25.3
56.4  24.1
.06
PHQ-9
4.1  4.1
3.1  3.6
4.2  4.2
5.1  3.7
.07
CR sessions, n
30.7  8.7
34.1  5.0
29.7  7.4
31.8  6.8
.003
Medications, yes/no
 Insulin
35/282
6/46
25/202
4/34
.99
 Metformin
40/277
8/44
31/196
1/37
.13
 Sulfonylurea
11/306
3/49
8/219
0/38
.33
 SGLT2
7/310
1/51
6/221
0/38
.59
 GLP-1
4/313
1/51
2/225
1/37
.13
 DPP-4
10/307
2/50
7/220
1/37
.94
-Blockers
273/44
45/7
191/36
37/1
.71
Abbreviations: BMI, body mass index; BWL, behavioral weight loss; CR, cardiac rehabilitation; DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide-1; HbA1c, hemoglobin A1c; MOS
SF-36, Medical Outcomes Study Short Form-36; PHQ-9, Patient Health Questionnaire-9; SGLT2, sodium-glucose cotransporter-2; T2DM, type 2 diabetes mellitus; WC, waist circumference;
WL weight loss.
aData expressed as mean  SD unless otherwise indicated.
percentage of patients in the G + BWL (87%) described
being in the action phase of eating a heart healthy diet as
compared with the G (67%) and NoG (51%) groups (P <
.002). Conversely, a greater percentage of patients in the
NoG (32%) reported to be in the maintenance stage com
pared with the G + BWL (4%) and the G (12%).
For the entire overweight/obese cohort, regardless of group
classification, mean weight loss was 1.7  4.4 kg (P < .0001).
The Figure depicts the weight loss for the three groups. The G +
BWL lost more weight than the G during CR (6.8 4.3 vs 1.1
 3.5 kg) (P < .0001). Both groups that established a weight
loss goal lost more weight than NoG. Weight change in the NoG
during CR was +1.6  4.3 kg. As a percentage, the BWL + G
group (6.8  4.3%) lost more weight than both the G (1.1
 3.5%) and NoG (+1.6  4.3%) groups (P < .0001). Mea

sures of VO2peak improved similarly for all three groups: NoG,
G + BWL, and G (+2.4  3.8; +4.0  3.1; +3.0  7.7 mLO2
kg1 min1, respectively; P = .09). A significantly greater per
centage of patients in the BWL + G (58%) did aerobic in
terval training compared with the NoG (29%) and G (39%)
(P < .03). Among all groups, insulin and/or metformin were
the most common T2DM medications used. In general, uses of
T2DM medications were similar among all groups and were
not associated with weight change. Significant univariate cor
relations with weight loss during CR are listed in Table 2 and in
cluded: BWL class attendance, weight loss goal (total amount),
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baseline weight, weight loss goal (yes/no), WC, BMI, handgrip,

baseline VO2peak, MOS SF-36, performing aerobic interval train
ings, and number of CR sessions attended. Negative correlation
with weight loss during CR included baseline PHQ-9 score and
a diagnosis of T2DM. Significant independent correlates with
CR weight loss included: BWL class attendance, weight loss

goal (total amount), baseline weight, baseline VO2peak, and MOS
SF-36 physical function score (stepwise r = 0.618; R2= 0.369;
P < .0001).
DISCUSSION
The prevalence of overweight/obesity in CR is remarkably
high, affecting >80% of patients.3 During CR is an optimal
time to intervene with BWL programs and weight loss goal
setting. In this study we find that, for overweight/obese indi
viduals in CR, setting a specific weight loss goal and attend
ing BWL classes leads to greater weight loss than not setting
a weight loss goal. To our knowledge, this is the first study to
report objective pre-program determined weight loss goals
in CR patients compared with actual weight loss at CR end,
especially in relationship to attendance at a BWL program
and fitness measurements. As such, this study highlights the
importance of setting weight loss goals for overweight/obese
patients as they enter CR. It also points out the importance
of having a well-defined BWL program in the CR setting.
Weight Loss Goal Setting in Cardiac Rehab
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Page 4
Figure. A bar graph depicting weight loss change during cardiac reha
bilitation (CR). The G + BWL lost more weight than G during CR (6.8
+ 4.3 vs 1.1 + 3.5 kg) (P < .0001). Both groups that established a
weight loss goal lost more weight than NoG. Weight change in the NoG
during CR was +1.6 + 4.3 kg. *Behavioral weight loss participation and
set weight loss goal (BWL + G) compared with both weight loss goal
only (G) and neither weight loss goal nor attendance at BWL (NoG), P <
.0001. G versus NoG, P < .01.
Independent factors associated with weight loss in CR
are establishing a weight loss goal, BWL class attendance,

baseline weight, baseline VO2peak, and MOS SF-36 physical
function score. The G + BWL lost more weight than pa
tients who set a goal but did not attend BWL. Both groups
that established a weight loss goal lost more weight than
patients who did not set a goal. Despite baseline weight,
BMI, and WC being highest in the G + BWL group com
pared with the other group, this group lost the most weight.
This finding is also consistent with the Aspry et al6 study;
those with a higher weight, BMI, and WC were also more
likely to set a weight loss goal. These participants chose
larger short- and long-term weight loss goals than the G
group. The G + BWL also attended more total CR sessions
than participants in the other two groups. It should be not
ed that participants in the BWL and goal-setting cohort
were a self-selected group and, therefore, may have recog
nized that they needed to lose more weight. To support this
postulation, a significantly greater proportion of patients
in this group (87%) reported being in the "action" phase
of eating a heart-healthy diet and 58% did aerobic interval
training compared with the other two groups.
The objective of this study was to evaluate weight loss goal
setting and BWL session attendance on weight change for
both overweight and obese individuals. While weight loss is
recommended for both, the potential implication for risk fac
tor reduction may differ between overweight and obese in
dividuals. Importantly, however, we have previously demon
strated that weight loss resulting from a BWL intervention
and exercise is associated with significate improvements in a
multitude of cardiovascular risk factors in both overweight
and obese individuals with coronary heart disease.17
There are limitations to our study. First, the study cohort
was predominantly Caucasian and the study took place at
a single center. Second, we did not have measurements of
caloric intake or physical activity-related caloric expendi
ture. We suspect that patients who partook in interval train
ing burned more calories than those who did not; however,
Table 2
Correlates of Weight Loss During Cardiac Rehabilitationa
BWL class attendance
0.512
0.260
.0001
Weight loss goal (total amount)
0.364
0.13
.0001
Baseline weight
0.287
0.08
.0001
Weight loss goal (yes/no)
0.273
0.072
.0001
WC
0.273
0.071
.0001
BMI
0.201
0.037
.0003
Handgrip
0.195
0.035
.0011
Baseline V O2peak
0.189
0.032
.0026
PHQ-9
0.17
0.026
.0027
MOS SF-36
0.157
0.021
.006
Interval
0.148
0.019
.009
Diagnosis T2DM
0.121
0.012
.0312
Number of CR sessions
0.12
0.011
.032
Abbreviations: BMI, body mass index; BWL, behavioral weight loss; CR, cardiac
rehabilitation; MOS SF-36, Medical Outcomes Study Short Form-36; PHQ-9, Patient Health
Questionnaire-9; T2DM, type 2 diabetes mellitus; WC, waist circumference.
aStepwise r = 0.618; R2= 0.369; P < .0001.
further studies are needed to examine this association. We
did not analyze the data for possible differences between case
managers in our CR program. In addition, patients self-se
lected for the BWL program and, as stated earlier, this led to
potentially more motivated patients in the BWL + G group.
Finally, patients in the NoG group had the lowest BMI and
were more likely to be in the maintenance phase of stages of
change and, therefore, may not have perceived the need to
lose weight.
CONCLUSIONS
There are several key findings from this study. First, the
BWL + G group lost more weight than the G group (goal
group) alone. In addition, setting a weight loss goal in gen
eral, regardless of attendance at BWL, leads to more weight
loss. Therefore, CR programs need to prioritize incorporat
ing BWL programming to assist patients achieve significant
weight loss. Pre-CR weight loss goal setting should be im
plemented for overweight patients as an integral compo
nent of CR programs alongside typical exercise programs.
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