CardioNerds Dr. Rick Ferraro (cardiology fellow at Johns Hopkins Hospital) and Dr. Eunice Dugan (cardiology fellow at the Cleveland Clinic) join episode lead Dr. Tiffany Brazile (cardiology fellow at the University of Texas Southwestern Medical Center and postdoctoral fellow at the Institute for Exercise and Environmental Medicine) to discuss the impact of obesity on cardiovascular disease risk, differential risk in specific populations, and effective strategies for counseling patients. They are joined by expert Dr. Jaime Almandoz, Medical Director of the Weight Wellness Program and an Associate Professor of Medicine at the University of Texas Southwestern Medical Center. Audio editing was performed by CardioNerds Academy Intern, student Dr. Tina Reddy.

This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit.

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1. The durability of metabolically healthy obesity (i.e., normal A1c, lipids, LFTs, BMP, normotensive) is limited. Within 5 years, a third of adults with “metabolically healthy” obesity will develop a cardiometabolic complication.
   
2. The biomechanical and psychosocial complications of obesity are just as important as the cardiometabolic complications. Biomechanical and psychosocial complications, including obstructive sleep apnea, joint pain, and mood disorders also influence cardiovascular disease risk.
   
3. Weight loss is not always the patient’s goal. Meet patients where they are and understand their challenges, concerns, and long-term goals with respect to their cardiovascular health and obesity. This information provides an opportunity to frame the conversation in a supportive and engaging way that allows for patient education.
   
4. Body mass index (BMI) is a screening tool for obesity, but is not sufficient for providing individualized care.
   
5. Obesity management methods that result in rapid weight loss may not be appropriate for all patients. These methods, such as bariatric surgery and GLP1-receptor agonists, require regular monitoring, follow-up, and multidisciplinary care (e.g., nutritionist, exercise physiologist, endocrinologist, cardiologist, psychologist, etc.).
   

Is it possible to be healthy at any size?

• Whether an individual can be healthy at any size depends on the definition of health and its durability.
  
  • Approximately 10-15% of adults with obesity are metabolically healthy.
    
    • The risk for developing cardiometabolic disease is higher in obese versus non-obese adults. One in three adults with metabolically healthy obesity will develop cardiometabolic complications (i.e., insulin resistance/diabetes, hyperlipidemia, hypertension) within five years. Thus, metabolically healthy obesity may represent a transient phenotype with adverse long-term consequences.
      
    
    
  • Consider non-metabolic health consequences of obesity that also influence cardiovascular disease risk.
    
    • Obstructive sleep apnea, joint pain leading to decreased physical activity, and mood disorders are key considerations here and encompass the biomechanical and psychosocial consequences of obesity.
      
    
    
  
  

Does large, rapid weight loss result in poorer long-term weight loss than slower, gradual weight loss?

• When approaches to weight loss are not sustainable, such as extremely low-calorie diets or extreme fitness regimens, the results and associated health benefits are less likely to be durable.
  
• Rapid, large-magnitude weight loss is appropriate for some adults with obesity and can be achieved through bariatric surgery and/or anti-obesity medications. Safety and sustainability are supported by regular follow-up, monitoring, and multidisciplinary care to incorporate nutritional and physical activity recommendations.
  
• Obesity management must be individualized to meet patient needs and goals while accounting for comorbid conditions (e.g., frailty, fall risk, disordered eating, etc.)
  

What are some best practices for incorporating the diagnosis of obesity into a patient’s assessment, including cardiovascular disease risk?

• Seek to understand what the patient wants to achieve during the office visit.
  
• Inquire about the patient’s health journey, goals, concerns, and challenges.
  
• In addition to addressing the patient’s expressed goals, frame the conversation in terms of concerns you have about the patient’s health.
  
• Incorporate objective measures, such as body composition, waist circumference, cardiorespiratory fitness, and biomarkers that can help support your concerns and management goals.
  

Does obesity impact men and women differently?

• Prevalence: of adults with obesity, women are more likely than men to have severe obesity. Obesity is also more prevalent in women of certain racial/ethnic minorities as compared to men.
  
• Fat distribution: men tend to have more visceral or central adiposity, which is associated with increased cardiometabolic risk. Earlier in adulthood, women tend to have more body fat in the gluteofemoral region. With advancing age and menopause, the distribution of excess adipose tissue in women often shifts to the visceral/central region and may enhance cardiometabolic risk.
  

What are the practical methods for evaluating and measuring obesity during a patient visit?

• BMI is a screening tool for obesity. It is blind to body composition and fat distribution. Cut points for BMI and the association with cardiovascular disease risk vary by race/ethnicity. Consideration of different BMI cut points for patients of various racial/ethnic backgrounds is important when evaluating candidacy for bariatric surgery or anti-obesity medications.
  
• Waist circumference is a useful measure to estimate visceral/central adiposity. Cut points for men and women have been established that are associated with increased cardiovascular disease risk across multiple studies.
  
• Measures of body composition provide valuable information about fat and lean body masses. DEXA scans and MRIs also provide data on fat distribution; however, they are impractical and expensive for regular use in the clinical setting. Bioelectrical impedance can provide body composition data efficiently during a clinic visit.
  

What are alternative validated tools beyond the Pooled Cohort Equation that can be used to estimate ASCVD risk in various ethnic/racial groups?

• The QRISK3 calculator is an alternative assessment tool for 10-year ASCVD risk that has been validated in 9 different ethnic groups. The calculator includes novel variables, such as chronic kidney disease, history of migraines, severe mental illness, erectile dysfunction, and family history of premature ASCVD. https://www.qrisk.org/
  

What are the mechanisms by which obesity impacts the development of cardiovascular disease?

• Obesity and lipotoxicity can impact cardiovascular disease development through multiple mechanisms, including inflammation that can lead to a prothrombotic state, insulin resistance, and alterations in lipid metabolism that can promote atherosclerosis.
  
• The distribution of body fat is highly heterogeneous and is partially driven by genetics. Brown adipose tissue has a high mitochondrial load and is involved in adaptive thermogenesis. White adipose tissue is considered more of a storage form of adipose tissue that also functions as an endocrine organ and provides insulation/protection for vital organs. 
  
• Ectopic fat depots, such as hepatic steatosis or epicardial adipose tissue, are metabolically active and can influence adjacent tissues through humoral and neurohormonal signals. These fat depots may also exert mechanical effects on the organs they surround. The ways in which individuals accrue fat in these different locations, the specific mechanisms by which they may increase cardiovascular disease development, and whether targeted therapies to reduce specific fat depots are incompletely understood.
  

• Wilding JPH, Batterham RL, Calanna S, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med. 2021;384(11):989-1002. doi:10.1056/NEJMoa2032183 https://pubmed.ncbi.nlm.nih.gov/33567185/
  
• Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med. 2016;375(4):311-322. doi:10.1056/NEJMoa1603827 https://pubmed.ncbi.nlm.nih.gov/27295427/
  
• Marso SP, Bain SC, Consoli A, et al. Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med. 2016;375(19):1834-1844. doi:10.1056/NEJMoa1607141 https://pubmed.ncbi.nlm.nih.gov/27633186/
  
• Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial. Lancet. 2019;394(10193):121-130. doi:10.1016/S0140-6736(19)31149-3 https://pubmed.ncbi.nlm.nih.gov/31189511/