The Role of Obesity in Heart Health

Obesity is a serious, chronic condition, and in the US, more than 2 in 5 adults present with it. The disease is often linked to a host of other chronic and dangerous conditions, and according to CDC, obesity accounts for nearly $173 billion in medical expenditures. With numbers like that, it’s given you will have patients in your office presenting with obesity.

When that happens, one of your chief concerns and topics to address is how obesity affects your patient’s heart health.

“Obesity is often called the first domino with respect to cardiometabolic health because when patients are obese, other comorbidities usually exist, such as diabetes, hypertension, sleep apnea, and metabolic disease,” said Payal Kohli, MD, founder and medical director at Cherry Creek Heart, Aurora, Colorado, and associate professor in the Division of Cardiology at Johns Hopkins University in Baltimore. “That is why obesity can increase the risk for poor cardiovascular health through direct as well as indirect mechanisms.”

Obesity’s impact on health doesn’t end there, either. According to Kohli, other complications related to the condition include elevated blood sugar, high blood pressure, inflammation and elevated sympathetic hormones. In aggregate, she said, these compromise endothelial function and result in accelerated atherosclerosis.

It also affects obstructive sleep apnea and its severity, said Bradley Serwer, MD, chief medical officer at VitalSolutions. In fact, obesity is one of the main components of the dangerous condition. “Weight loss may not fix it entirely, but it can have a positive impact,” he said. “That’s often left out of the equation when we talk about the risks of obesity.”

With so many detrimental effects from the condition, finding the right approach to helping your patients with obesity is critical.

Addressing the Issues At Hand 

There is a lot of advice you need to give to your patients with obesity, but it all begins with coaching them on lifestyle changes. Gone are the days of diets that lead to yo-yo results and in the end, might cause more harm than good. You need to have the sometimes hard conversations about weight and how to go about losing it.

“Address the issue,” said Serwer. “Many times, PCPs [primary care physicians] don’t want to address the uncomfortable topics, but you must in a diplomatic way. Urge them to consider lifestyle issues and modifications for a long-term, healthy impact.” 

A comprehensive approach is what’s in order. This should include diet, exercise, counseling, and more. “The cornerstones are exercise and diet, but sometimes engaging these patients is like hitting a brick wall,” said Michael Silverman, MD, a cardiologist with Johns Hopkins Medicine. “So you have to go about it with baby steps and also figure out what’s going on psychologically.”

This is where therapy and counseling can play a key role. There can be a host of psychological conditions beneath the condition, and it’s essential to uncover them. Everything from depression and anxiety to poor home and/or work lives, to past trauma and abuse. For the PCP, it’s essential to have the mental health component in mind, and a team of therapists at ready for referring your patients with obesity.

One option, too, is a credible obesity clinic. These are set up with a full team ready to treat patients with obesity. From registered dieticians to counselors to physical therapists, a good obesity clinic can offer patients one-stop shopping, removing complicated barriers to accessing the many different clinicians. “Have these resources ready to go for your obese patients,” said Serwer. “That way they don’t have to make a million different phone calls and get to numerous locations for care. It can be an incredibly valuable resource.”

Even with these resources, there’s still a role to play. Your counseling approach to patients with obesity needs to have sustainability in mind.

“When talking about diet, help your patients identify easy things to give up,” said Silverman. “The first thing I’d have them get rid of is fast food — these establishments should be used for the bathroom and coffee and that’s it.” 

After that, Silverman recommends patients tackle sugary drinks, juices and even diet sodas. Data backs up the fact that artificial sweeteners can trigger hunger and cravings, so address this with your patients.

Beyond fast food, highly processed foods and sugary drinks, however, the approach to diet should lean toward additive versus restrictive. “Give your patients guidance on heart healthy foods, which in turn are weight-loss friendly foods,” said Silverman.

The Mediterranean Diet, for instance, is abundant in whole grains, fruits, vegetables, and healthy fats. These are all heart-healthy foods and when you coach your patients to try this eating approach, you’re giving them a valuable tool for heart health. The approach also features many foods that lead to feelings of fullness, which will help stave off cravings for unhealthier options.

Your patient’s approach to exercise should likewise begin small and build from there.

“This can look like walking to the mailbox every day, or around the dining room table several times, as a starting point,” said Silverman. “They can gradually increase their walking duration and eventually the intensity, and by then they should be engaged.”

But expect some pushback, Silverman said.

“They will find the barriers, so you have to have answers for that,” he explains. “If they won’t walk, suggest a stationary bike. If they won’t bike, try pool walking or water aerobics. There’s psychiatry involved here.” 

Obesity Drugs and Other Tools

No conversation surrounding obesity is complete today without addressing the role that GLP-1 drugs — Wegovy, Ozempic and the like — can play.

“Weight loss is instrumental in improving cardiometabolic health and it can have a tremendous impact,” said Kohli. “Specifically, in clinical trials of the glucagon-like peptide-1 (GLP-1) or GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonists weight loss was associated with an improvement in waist circumference, blood pressure, low-density lipoprotein (LDL) cholesterol, triglycerides, and a reduction in blood sugar.”

Kohli said the drug class should be considered an integral part of any weight loss toolkit and admits they have become the mainstay of therapy for obesity. “Newer evidence has shown GLP-1s improve cardiovascular outcomes as well, and reduce adverse kidney outcomes,” she adds.

There are some adverse issues surrounding the weight-loss drugs that PCPs should include when counseling and potentially prescribing them to patients, however.

“They address the symptom but still don’t get to the root cause of obesity,” Serwer cautions. “And patients can lose a significant amount of weight, but much of that will come from muscle mass, so they must offset that with strength training.”

Other potential pitfalls include GI distress, costs, and potential drug shortages. The drugs can sometimes cause food aversions, too, which isn’t helpful when patients are trying to eat better, more nutrient dense diets.

“The biggest problem is that they don’t address lifestyle changes,” said Serwer. “If we don’t address that, the weight will eventually come back.” 

The best news is that with patients with obesity, even small weight loss can have big impact on cardiovascular health. Said Silverman: “When the weight comes off, patients may be able to go off most of their medications, and that’s a huge benefit.”