Highlight
– Obesity is rarely addressed in cardiac rehabilitation programs despite its cardiovascular significance.
– Most Canadian CR providers support integrating obesity management but cite concerns regarding training, time constraints, and weight bias.
– Effective obesity interventions include lifestyle modifications, pharmacotherapy, and bariatric surgery, but their implementation within CR is complex.
– Patient preferences and lived experiences are critical to designing feasible, personalized weight management in CR.
Study Background
Obesity remains a major modifiable risk factor for cardiovascular disease (CVD), contributing significantly to morbidity and mortality worldwide. Cardiac rehabilitation (CR) programs, designed to improve cardiovascular outcomes after events like myocardial infarction or heart failure, traditionally focus on exercise training, risk factor modification, and education. However, despite the clear interplay between excess adiposity and cardiovascular risk, obesity management frequently remains outside the scope of standard CR interventions. Given the high prevalence of overweight and obesity among CR patients, there is an unmet clinical need to consider integrating weight management as a standard component within CR programs to improve long-term cardiovascular prognosis and patient quality of life.
Study Design
The referenced work undertakes a narrative literature review alongside a survey of 80 Canadian CR healthcare providers to assess the current landscape on integrating obesity treatment into CR. The review synthesized evidence from behavioral, pharmacological, and surgical obesity interventions relevant to cardiovascular patients. The survey explored provider attitudes, perceived barriers, and readiness to incorporate obesity management in CR. The analysis was organized around three thematic areas: outcomes of obesity management in CR populations, complexity of implementing such interventions, and patient attitudes and preferences towards weight management during CR.
Key Findings
Outcomes of Obesity Management in CR: Evidence supports that weight loss can improve cardiovascular risk profiles, functional capacity, and symptoms among cardiac patients. Behavioral weight loss programs integrated within CR yield modest but clinically significant weight reduction and improved metabolic parameters. Adjunctive pharmacotherapy—such as GLP-1 receptor agonists—shows promise for enhancing weight loss and cardiometabolic control when combined with lifestyle changes. Bariatric surgery remains the most effective for substantial and sustained weight loss but is typically outside CR scope and eligibility criteria.
Complexities of Obesity Management in CR: Implementing obesity interventions in CR is challenging due to the multifactorial nature of obesity, requiring multidisciplinary expertise, patient adherence, and resources that exceed typical program timeframes. Providers expressed concern over insufficient training in obesity-specific counseling, medication management, and behavioral strategies. The limited duration of conventional CR programs (usually 8–12 weeks) may not align with the prolonged effort often needed for effective weight management. Providers also highlighted the risk of weight bias influencing patient-provider interactions, potentially undermining patient engagement.
Patient Attitudes, Experiences, and Preferences: Patients with obesity undergoing CR often have diverse goals beyond weight loss alone, such as improving function, reducing symptoms, and enhancing wellbeing. Weight stigma and past unsuccessful dieting experiences can influence motivation and openness to CR-based obesity treatment. Tailoring interventions to individual preferences and incorporating long-term support mechanisms were seen as critical for success. Yet, evidence on patient preferences specific to obesity management within CR remains limited, signaling a research gap.
Healthcare Provider Perspectives: Survey results indicated 71% of Canadian CR providers supported incorporating obesity management into CR programs. Nonetheless, providers identified training deficits, lack of multidisciplinary support, concerns about setting realistic expectations for weight change, and time constraints as major barriers. These findings underscore the necessity for educational initiatives, integrated care models, and program adaptations to feasibly implement weight management strategies in CR.
Expert Commentary
Integrating weight management into cardiac rehabilitation aligns with the principle of comprehensive cardiovascular risk reduction. Given the strong causal relationship between obesity and CVD, addressing excess adiposity alongside other modifiable risk factors could improve outcomes synergistically. However, effective implementation must consider the complexity of obesity treatment and address systemic barriers including provider education and program resources. Current guidelines suggest multidisciplinary approaches combining diet, exercise, behavioral therapy, and as appropriate, pharmacotherapy or surgery. The CR setting presents an opportune touchpoint for loss interventions but requires redefined scope, protocols, and possibly extended program duration.
Limitations of the current evidence include the predominance of short-term studies, variability in intervention components, and limited data on cost-effectiveness and long-term sustainability of obesity treatment within CR populations. Furthermore, patient-centered research is needed to elucidate preferences, barriers, and motivators to optimize program design.
Conclusion
Obesity management is an important yet underutilized component of cardiac rehabilitation. While most CR providers support its integration, practical implementation is hindered by educational gaps, resource limitations, and the complexity of obesity interventions. Tailored, evidence-based strategies—including behavioral, pharmacological, and possibly surgical options—should be considered in the CR context, coupled with long-term follow-up and patient-centered care. Advancing integration will require coordinated efforts in provider training, program restructuring, and further research on feasibility, efficacy, and patient preferences.
Funding and ClinicalTrials.gov
No funding disclosures were reported related to the referenced study. Further clinical trials are warranted to evaluate specific obesity management protocols within cardiac rehabilitation settings.
References
1. Rouleau CR, Moran C, Williamson TM. Obesity in Cardiac Rehabilitation: Considerations in Offering Weight Management As Part of Cardiac Rehabilitation Programs. Can J Cardiol. 2025 Sep 4:S0828-282X(25)01046-3. doi: 10.1016/j.cjca.2025.08.350. Epub ahead of print. PMID: 40914201.
2. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2016;37(29):2315-2381.
3. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults. J Am Coll Cardiol. 2014;63(25 Pt B):2985-3023.
4. Thomas JG, Bond DS. Behavioral treatment of obesity. Am Psychol. 2014 Mar-Apr;69(2):188-98.
5. Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192(31):E875-E891.