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Obesity and Cardiovascular Disease: What are the Challenges and the Weight Management Strategies to Mitigate Risk?

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Obesity and Cardiovascular Disease: What are the Challenges and the Weight Management Strategies to Mitigate Risk?

— By Dawn Sweet, Ph.D.

The risks of cardiovascular disease related to obesity can be managed via intentional weight loss.

Obesity and cardiovascular disease (CVD) are each considered a chronic health condition by the World Obesity Federation, a group that has partnered with the World Heart Federation to offer educational resources for health care professsionals.1,2 There are both direct and indirect links between obesity and CVD, and despite some controversy surrounding normal weight obesity, the obesity paradox, and metabolically healthy obesity, there is consensus regarding intentional weight loss as a beneficial for mitigating the risk of CVD.

Indirect and Direct Links to Cardiovascular Disease

Research has shown an indirect link between BMI and waist circumference (WC) associated with increases in adipose tissue. High levels of adipose tissue increase one’s mortality risk because conditions such as sleep apnea, hypertension, type 2 diabetes, thromboembolic disease, and dyslipidemia can be exacerbated.2 Evidence for a direct link between CVD and obesity is evinced through the 140+ chromosomal regions that predisposes one to increased adiposity. Genes have been shown to be implicated in this, thus suggesting there are neuronal mechanisms that drive obesity via appetite dysregulation and satiety pathways.3,4 For adults with lifelong high BMI, there is a causal link between an elevated risk of CVD-related mortality, e.g., aortic valve stenosis, deep vein thrombosis, and arterial hypertension to name just a few CVDs, while genetic-based cohort analyses found a direct relationship between adiposity and high risk cardiovascular conditions such as heart failure, aortic disease, atrial fibrillation.3,4

Obesity and Its Effect on the Heart

It’s been established that cardiovascular changes or abnormalities are associated with obesity.5 Obesity has been connected to changes and abnormalities such as: 1,5

  • Electrocardiographic examples include increased PR interval, increased QTc interval, ST-T wave abnormalities, flattening of the T waves, and left-axis deviation.
  • Hemodynamic examples include increased blood volume, increased cardiac output, increased arterial pressure (systolic and diastolic), increased ventricular stiffness, and increased pulmonary artery pressure.
  • Structural examples include left ventricular remodeling and hypertrophy, left arterial enlargement, right ventricular hypertrophy, and myocardial steatosis, apoptosis, and fibrosis.
  • Functional examples include hypoxia related to sleep apnea, coronary obstruction, myocardial ischemia, right ventricular failure, and deep vein thrombosis.

Controversies and Cardiovascular Disease

Cardiovascular disease related to obesity has led to a few controversies: 1

“Normal weight” Obesity

“Normal weight” obesity is characterized by the presence of sarcopenia. Patients may fall within the normal BMI range for their height, but they may have increased body fat and little muscle mass. The normal range BMI can be misleading, particularly if adiposity is centralized; this puts patients at greater risk of CVD. It is recommended that WHR be used to measure adipose tissue because it better captures a patient’s risk for CVD.6

Metabolically Healthy Obesity (MHO)

MHO is characterized by a BMI of >30 kg/m2 in patients who do not present with an elevated risk of CVD. The MESA study found that patients with MHO were not at an increased risk of death from CVD compared to patients who with a metabolically normal weight.7 In the MESA study, 48 percent of MHO patients did develop metabolic syndrome over time and that these patients had a 60 percent greater chance of experienced a major cardiovascular event compared to patients without obesity.7 Data from more than 380,000 adults in the UK biobank found that those with MHO were at a greater risk of heart failure [HR, 1.60 (95% CI, 1.45–1.75)] and respiratory disease [HR, 1.20 (95% CI, 1.16–1.25)], though not atherosclerotic cardiovascular disease (ASCVD) compared to adults without obesity. Adults with MHO are also at greater risk of all-cause mortality [HR, 1.22 (95% CI, 1.14–1.31)], incident ASCVD [HR, 1.18 (95% CI, 1.10–1.27)], and respiratory disease [HR, 1.28 (95% CI, 1.24–1.33)].8

Intentional Weight Loss for Mitigating the Risks of Cardiovascular Disease

Intentional weight loss for patients with obesity can reduce CVD risk factors such as hypertension, type 2 diabetes, and dyslipidemia. Lifestyle interventions that include dietary changes, exercise, behavioral changes, and anti-obesity medications can help patients lose weight and keep it off.

Dietary changes

The Dietary Guidelines for Americans (DGA)9, developed by the U.S. Department of Agriculture (USDA), offers a framework for helping patients with obesity meet their daily nutritional needs for a balanced diet. The DGA presents guidelines based on age, sex, and activity level. A nutritionally dense and well-balanced diet should include lean protein (which also preserves muscle mass during active weight loss), seafood, fruits, vegetables, legumes, and whole grains.

Exercise

Adding exercise to a weight loss program has yielded positive results. Research has shown that including a variety of exercise types, e.g., aerobic exercise, resistance training, circuit training, are beneficial in improving overall cardiometabolic health and inducing weight loss. Even participating in low-impact exercise such as yoga and Pilates have demonstrated efficacy for weight loss, anthropometric measures, and BMI reductions.10,11,12

Behavioral changes

Another approach to mitigate CV risk factors is working with patients to modify their behavior. For example, working with patients to identify psychological triggers that may lead to emotional eating can help them identify suboptimal eating patterns that lead to overeating and the consumption of empty calories. For example, research has found that depression, anxiety, and stress can lead to unwanted weight gain. Distracted eating,13 eating mindlessly while performing another task, has also been shown to lead to unwanted weight gain. Another modifiable behavior is sleep. Lack of sleep and poor-quality sleep has been shown to not only be linked to stress, but also weight gain. Lack of sleep and poor-quality sleep hinder one’s ability to emotionally self-regulate and lead to increased energy intake and irregular eating behaviors.14

Anti-obesity medications

While anti-obesity medications, e.g., GLP-1 RAs, may not be right for all patients, they have been shown to reduce some CVD risk factors. GLP-1 RAs have been found to lower blood pressure and lower cholesterol and triglycerides. In the 2023 SELECT study, the risk of death from cardiovascular disease was reduced in patients with obesity and CVD with a weekly 2.4mg subcutaneous injections of semaglutide.15

Implications for Clinical Practice

Obesity and cardiovascular disease are recognized as chronic conditions that increase a patient’s mortality risk. By working with patients to identify long-term, sustainable strategies for weight loss can lower their risk of mortality. These strategies include lifestyle changes related to diet and exercise as well as modifying behaviors and pharmacological interventions.

Conversations with patients should include the benefits of nutritionally formulated meal replacements and how they could help jumpstart weight loss. Nutritionally formulated pre-packaged meal replacements provide necessary proteins, fiber, vitamins, and minerals offers patients convenience and essential nutrition.

Sources:

1 Obesity and cardiovascular disease: Mechanistic insights and management strategies. A joint position paper by the World Heart Federation and World Obesity Federation

2 BMI and all-cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants

3  Body mass index and all-cause mortality in HUNT and UK biobank studies: linear and non-linear Mendelian randomisation analyses

4 Body mass index and body composition in relation to 14 cardiovascular conditions in UK biobank: a Mendelian randomization study

5 The impact of obesity on the cardiovascular system

6 Normal-weight central obesity: implications for total and cardiovascular mortality

7 Metabolically healthy obesity, transition to metabolic syndrome, and cardiovascular risk

8 Are people with metabolically healthy obesity really healthy? A prospective cohort study of 381,363 UK biobank participants

9 Dietary Guidelines for Americans 2020 – 2025

10 Resistance training effectiveness on body composition and body weight outcomes in individuals with overweight and obesity across the lifespan: A systematic review and meta‐analysis

11 Psychophysiological adaptations to Pilates training in overweight and obese individuals: A topical review

12 Twelve weeks of yoga or nutritional advice for centrally obese adult females

13 Associations between body mass index and episodic memory for recent eating, mindful eating, and cognitive distraction: A cross-sectional study

14 Sleep is essential to health: an American Academy of Sleep Medicine position statement

15 Semaglutide Effects on Cardiovascular Outcomes in People with Overweight and Obesity (SELECT)

About the Author: Dr. Dawn M. Sweet has over 20 years of experience in the field of communication. Dr. Sweet has given several invited talks to and workshops for academic and private sector audiences on the role of nonverbal and verbal communication in achieving positive outcomes and mitigating bias. Her research has been published in several top ranked peer-review journals, and it has been featured on NPR’s River to River / All Things Considered, Buzzfeed, and Science Daily. Her research has also been used to inform expert testimony.

About Robard: For 45 years, Robard Corporation’s medical obesity treatment programs and nutrition products have been utilized by physicians, surgeons and hospitals across the United States to successfully treat patients living with obesity. To learn more about us and how we can help your practice and patients, visit us online at www.Robard.com, email us at info@robard.com, or call (800) 222-9201.

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