Treating Obesity as a Cardiovascular Risk Factor!

The following article was written by Dr. Devesh Rai as a CardioNerds Conference Scholar for The American Society for Preventive Cardiology (ASPC) 2022 Congress on Cardiovascular Disease Prevention.

“We need to identify obesity as a cardiovascular risk factor and treat it promptly,” said Professor of Endocrinology at Northwestern Medicine, Feinberg School of Medicine,  Dr. Robert Kushner, during his talk at the American Society of Preventive Cardiology conference 2022 at Louisville, Kentucky. There is a prevalence of 41.9% obesity in the US, as per recent statistics.

Obesity and increased adiposity leads to a spectrum of complications, including diabetes mellitus, non-alcoholic fatty liver disease, steatohepatitis, cirrhosis, obstructive sleep apnea, osteoarthritis, gastroesophageal reflux disease, chronic kidney diseases, coronary heart disease, stroke, and congestive heart failure.1 Traditionally, obesity has been defined as the basal metabolic index(BMI) > 25 kg/m2. However, Dr. Kushner suggested looking for other factors associated with metabolic syndrome (waist circumference, high triglycerides, low HDL, high fasting glucose, high blood pressure) as early identification and intervention in patients with central and visceral adiposity will help prevent future complications.2

Ideal cardiovascular health metrics consist of 4 behaviors and 3 biometrics described as never or quit smoking more than 12 months ago, BMI of less than 25 kg/m2, more than 150 mins/wk of moderate or more than 75 mins/wk of vigorous-intensity exercise, healthy diet, total cholesterol less than 200 mg/dl, blood pressure less than 120/80 mm Hg and fasting glucose less than 100 mg/dl.3 Dr Kushner stressed that it is essential for all patients to aim to achieve ideal cardiovascular health metrics to decrease the risk of future cardiovascular complications.

Furthermore, he said lifestyle counseling with dietary modification focused on whole plant-based food, nuts, whole grains, and healthy source of proteins.4 Encouraging patients to meet ideal cardiovascular health metrics can help achieve the target weight and promote weight loss. A study has shown that walking patients who walk only 2000 steps/day have three times higher mortality than those who walk 10,000 steps/day.5  In addition to lifestyle intervention, pharmacological therapies should be considered for weight loss with semaglutide if needed. Semaglutide helps in weight loss, better blood pressure, fasting lipid profile control and decreased fasting CRP.6 A similar effect has also been seen with a newer agent, tirzepatide, which can be considered for weight loss.7

Dr. Kushner emphasizes the following key takeaways:

  • Obesity increases the risk for cardiovascular disease.
  • Patients at the highest risk present with an increased waist circumference phenotype. All patients with obesity should be provided lifestyle counseling that includes adopting a heart-healthy diet, increased physical activity, and weight loss.
  • Pharmacological management should be considered for patients who meet treatment indications.
  • Hormonal treatment of obesity (e.g., GLP-1, GIP, amylin, glucagon) represents a new paradigm in obesity therapeutics.

Finally, Dr. Kushner stresses that “It is incumbent that you become competent in the management of obesity and use of pharmacotherapy for chronic weight management for “the one that got away””

References.

1.Heymsfield SB, Wadden TA. Mechanisms, Pathophysiology, and Management of Obesity. New England Journal of Medicine. 2017;376(3):254-266.

2. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. Jama. 2002;287(3):356-359.

3. Hasbani NR, Ligthart S, Brown MR, et al. American Heart Association’s Life’s Simple 7: Lifestyle Recommendations, Polygenic Risk, and Lifetime Risk of Coronary Heart Disease. Circulation. 2022;145(11):808-818.

4. Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation. 2021;144(23):e472-e487.

5. Saint-Maurice PF, Troiano RP, Bassett DR, Jr, et al. Association of Daily Step Count and Step Intensity With Mortality Among US Adults. JAMA. 2020;323(12):1151-1160.

6. Wilding JPH, Batterham RL, Calanna S, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. New England Journal of Medicine. 2021;384(11):989-1002.

7. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide Once Weekly for the Treatment of Obesity. New England Journal of Medicine. 2022;387(3):205-216.