Disclosures: Lavie reports speaking and consulting for AstraZeneca and PAI Health. Michos reports serving on an advisory board for Novo Nordisk. Neeland reports receiving consultant fees from Bayer, Boehringer Ingelheim/Eli Lilly and Nestle Health Sciences. Nissen reports leading an upcoming trial of tirzepatide sponsored by Eli Lilly.
Many patients who cardiologists see have obesity, which has become widely prevalent in the United States.
According to the CDC, 42.4% of U.S. adults had obesity in 2018, and numerous officials and experts have voiced concern that the obesity epidemic got worse during the COVID-19 pandemic, during which many people became more sedentary.
Obesity has traditionally been considered the purview of endocrinologists, obesity medicine specialists and primary care providers, but cardiologists may need to take a more active role in its management because endocrinologists and obesity medicine specialists are few in number and primary care providers are tasked with addressing many patients and health issues.
Healio and Cardiology Today asked leading cardiologists: What can cardiologists do to combat the obesity epidemic, which may have gotten worse during the COVID-19 pandemic?
Carl J. Lavie Jr. , MD
Although maintaining ideal weight and high physical activity (PA) and cardiorespiratory fitness (CRF) throughout the life span, from childhood to old age, would be ideal, this is hardly what is happening in modern society, where most gain weight and reduce PA/CRF with aging.
Clinicians and cardiologists should at least stress increasing PA, which in turn would increase CRF, for their patients, which may be more important than weight for long-term prognosis, as I have published in many of my research papers, including on the obesity paradox in patients with established CVD.
Additionally, the increased PA could lead to a few pounds of weight loss, but at least prevent the progressive weight gain and prevent patients from developing more severe forms of obesity that are particularly associated with a poor prognosis.
A few decades ago, the cardiology community became the leaders of lipids, taking over for the endocrinologists, and with a shortage of diabetes specialists and primary care physicians being overwhelmed, cardiologists, especially with the SGLT2 inhibitors and GLP-1 receptor agonists showing clinical event reduction, are becoming very involved clinically with treating diabetes. I believe the same will hold true for obesity, especially with the emerging safety and efficacy of the GLP-1 receptor agonists and bariatric surgery even in cardiac patients. These efforts will go a long way in the primary and secondary prevention of CVD.
Although obesity is associated with an increase in almost all CVD, this seems especially the case for atrial fibrillation and for HF, more so for HF with preserved ejection fraction than for HF with reduced EF.
Lavie is medical director of cardiac rehabilitation and prevention and director of exercise laboratories at the John Ochsner Heart and Vascular Institute, Ochsner Clinical School – The University of Queensland School of Medicine , New Orleans .
Erin D. Michos, MD, MHS
Obesity should be viewed as a chronic disease. Unfortunately, because of stigma, obesity does not receive the same level of attention as other conditions but is associated with many things that increase risk for heart disease, such as hypertension, type 2 diabetes, sleep apnea and fatty liver, as well as increased risk for HF and atherosclerotic CVD. People with obesity are often marginalized and do not receive the same adequate health care.
There is a misperception that obesity is solely the result of lifestyle choices. It is far more complicated than simply calories in, calories out. It cannot be disentangled from other social determinants of health and societal pressures. There is certainly an interplay with modern food choices and personal habits; however, there is also interplay with biochemical and hormonal pathways and insulin resistance. We put entirely too much blame only on the individual.
This is an issue where cardiologists must get involved. Obesity is a major driver of HF, a big scope of our practice. From 1999 through 2018, obesity increased from 30% to 42% of the population — with over 70% of adults being overweight or obese. We need a team-based approach to care. Patients need access to good information and team members who can provide them with that good information, including information on diet and physical activity.
This is also an exciting time. We have new pharmacotherapies that can help. In the past, in the era of fenfluramine and phentermine (fen-phen) and stimulants, so many weight-loss drugs were CV toxic. Now, we have drugs that show promise and even CV benefit in patients with type 2 diabetes, but also confer significant weight loss even for those without type 2 diabetes. We also have bariatric surgery as a possible option, though that is not for everyone. The GLP-1 receptor agonist semaglutide (Wegovy, Novo Nordisk) is now approved for weight loss. Additionally, the SURMOUNT trial showed participants lost up to 23% of their body weight, up to 52 pounds with the highest doses, with tirzepatide (Eli Lilly). That is incredible and very encouraging. Now, we have many ways to help our patients who struggle with their weight.
This is in the sphere of cardiologists and should not be relegated to only endocrinologists or obesity medicine specialists. There simply are not that many of those specialists out there, and these patients are much more likely to see a cardiologist. If cardiologists do not yet feel comfortable prescribing these drugs, cardiologists need to at least recognize these agents are out there and provide referrals and help patients with access. I encourage cardiologists to learn more about these drugs and get comfortable prescribing these drugs. I prescribe semaglutide for the purpose of weight loss in my cardiology practice. As a cardiologist, treating obesity with the associated comorbidities is a part of prevention and part of my scope in my field of preventive cardiology.
Following a healthy lifestyle throughout the lifespan is the foundation. It is much easier to prevent unhealthy weight gain than to lose weight. We need to think about primordial prevention. Many of the challenges our patients face involve societal pressures, and the food industry needs to take responsibility as well. But the earlier in life we can start focusing on healthy habits, the better. Focus on good, quality food. Total calories matter, but we should have our patients focus on the nutritional quality of their food. Encourage intake of fruits, vegetables, legumes, nuts, unprocessed whole grains, lean meats and poultry and fish and moderate intake of nut butters and olive oils. Discourage things like highly refined grains and simple sugars or sugar-sweetened beverages. Avoid processed foods, which are highly palatable but much more enriched with sugars, fats and other additives.
Regular physical activity is key. It does not have to be intense exercise. At least 30 minutes per day. Brisk walking is a moderate-intensity activity that most people can do, or moderate yardwork or gardening. The rest of the time, having less sedentary time — even light activity has benefit over being sedentary.
We can help our patients. Resorting to some of these agents does not mean they “failed.” Sometimes, they are doing everything they can and that is not enough. We now have agents that can help.
Michos is director of women’s cardiovascular health and associate professor of medicine at Johns Hopkins Medicine and a member of the Cardiology Today Editorial Board.
Ian J. Neeland, MD
There is a large, unmet need for care for patients living with overweight and obesity. Many patients with overweight or obesity have CVD or multiple risk factors and routinely see a cardiologist; therefore, it is important for cardiologists to be aware of the severity of obesity outcomes and take the opportunity to screen, counsel and treat.
Much like we have seen with diabetes, where cardiologists have taken over prescriptions of SGLT2 inhibitors and GLP-1 receptor agonists and they are no longer exclusively under the purview of the endocrinologist, obesity treatment may become a tool for the CV physician, especially in preventive cardiology. As ongoing CV outcomes trials for obesity treatments may demonstrate CV benefit, this becomes an opportunity for cardiologists to make a difference and intervene.
Often when patients consider lifestyle modification, they want to discuss it with the cardiologist. Patients may associate exercise activities like exercise on a treadmill with their heart health. They already consider cardiologists to be knowledgeable and proficient in that area; yet, we are not. Most cardiologists are not certified in obesity medicine. However, it is incumbent upon all of us to be aware and open to having the conversations with patients to make the right referrals.
This is an amazing time to be a cardiologist in the field of cardiometabolic medicine. We have many more opportunities and options than we ever have had.
Neeland is associate professor of medicine and director of cardiovascular prevention and co-director of the Center for Integrated and Novel Approaches in Vascular-Metabolic Disease for University Hospitals Harrington Heart and Vascular Institute in Cleveland.
Steven E. Nissen, MD
This is a very important issue and one I have been thinking about a lot.
This situation is about to change. There are now more effective drugs for treating obesity than we have ever had before. One, semaglutide, is approved. Another, tirzepatide, was just approved to treat type 2 diabetes and is likely to be approved to treat obesity soon. I think we should make every effort to get patients on these effective drugs. The drugs we have had in the past have simply not been effective, so it was hard to recommend them. But the landscape has changed significantly just in the last year or 2.
With regard to what people can do short of medications, I tell people to get off the couch, get out and walk and find a way to reduce your calorie intake by just a little bit, even 100 calories per day. Because over time, if you reduce intake by a little bit and exercise more, you will lose weight. That is what we can do from the lifestyle point of view.
Occasionally we will get people into a cardiac rehabilitation program where they will learn exercise skills. The confidence you build when you put people through cardiac rehab allows them to sustain the effort after they leave the rehab program.
These are some of the tactics we have used to get patients with obesity back on track.
Nissen is c hief a cademic o fficer of the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute and the Lewis and Patricia Dickey Chair in Cardiovascular Medicine at Cleveland Clinic and is a member of the Cardiology Today Editorial Board.
For more information:
Carl J. Lavie Jr., MD, can be reached at firstname.lastname@example.org.
Erin D. Michos, MD, MHS, can be reached at email@example.com; Twitter: @erinmichos.
Ian Neeland, MD, can be reached at firstname.lastname@example.org.
Steven E. Nissen, MD, can be reached at email@example.com.