The Future of Treatments for Obesity Management in Lowering Cardiovascular Risks

With the ever-growing obesity epidemic in the United States, there are many approaches to continue to properly counsel patients on obesity management, including surgery, diets, and medications, according to a session presented at the American College of Cardiology 2022 Scientific Sessions.

Domenica Rubino, MD, started the session discussing GLP-1 receptor agonists for weight loss and the goal of health care professionals to bridge the gap in this area and help more patients avoid surgery.

Rubino provided an overview of the role of GLP-1s, which can significantly decrease food intake and energy intake in the brain. Specifically, the agonists act as a signal from gastrointestinal tracts in responses to food and affects appetite and regulation while acting as a neurotransmitter.

Rubino noted that incorporating exercise into lifestyle changes is very important when putting a patient on medication, because this will not only improve an individual’s weight but their cardioembolic risk as well. She emphasized how semaglutide is the new generation of medical therapy and can move health care professionals forward in the future of weight loss.

“Semaglutide moves us toward a much higher degree of weight loss,” Rubino said.

As for non-GLP1 therapies for weight loss, Jamie Kane, MD, director of Northwell Health Center for Weight Management, explained that although the same medications have been used for weight loss for a number of years, there is still a larger picture surrounding cardiovascular risk.

He shared how these medications have 4 mechanisms for each patient: reducing calorie consumption/absorption, increasing energy expenditure, improving insulin sensitivity, and increasing fatty acid oxidation/reducing lipogenesis. No medication can have all 4 reactions, with Kane sharing that 2 or 3 occur in each patient.

Weight loss medications such as orlistat and phentermine most frequently prescribed; however, Kane noted that other medications can counteract with weight loss, such as psychiatric or anti-epileptic medications, diabetic medications, corticosteroids, beta-blockers, antihistamines, and hormone manipulation. Looking at these factors before counseling a patient may help lead to other anti-diabetic alternatives, such as metformin and DPP4, which are considered the “gold standard,” according to Kane.

Dieting and diets can be complicated for patients, and according to Danielle Belardo, MD, preventive cardiologist, the key is to reduce the risk factors for atherosclerotic cardiovascular disease, which are hyperlipidemia, diabetes, hypertension, and smoking cessation/obesity/exercise, while considering each patient we counsel.

“We can’t beat general physics, so all diets when in a calorie deficit result in weight loss regardless,” Belardo said.

Sustainability is what lasts with each patient’s weight loss journey, and Belardo mentioned certain clinical trial examples that analyzed this concept, such as the CALERIE, POUNDS, and Look Ahead trials. Each of these examined different lifestyle modifications, calorie deficits, or exercise techniques to further determine what helps patients sustain a healthier lifestyle as a result.

In all, Belardo emphasized how health care professionals need to meet their patients at their health level and find a diet that works for them to best reduce the risk of any cardiovascular events. Additionally, this means considering any social determinants of health, such as food access and food security, that could impact their journey.

“Doing this in any way that is helpful for the patient and helps them to achieve their goals is what we recommend, and there are many ways to do this without a patient feeling too restricted in their diet,” Belardo said.

Lastly, Sean Heffron, MD, MS, MSc, discussed the surgical approaches to obesity and how modern bariatric surgery can improve cardiovascular outcomes. He explained that although there are lower rates of cardiovascular outcomes in each surgery group that has been studied in the past, the type of surgery that is being completed is important in terms of how much weight is being lost on each patient.

Further, Heffron described how bariatric surgery can lower the risk of cardiovascular disease (CVD) beyond expectations offer a resolution of obesity-associated CVD risk factors alone.

Although these surgeries are efficient, Heffron emphasized how underutilized they are due to only 15% of the obesity population getting the proper referral from a physician. This also includes men, Hispanics, non-white, and low-income populations who are not given enough attention early enough to get the proper treatment for their weight loss goals.

“Our lack of noticing this and referring to bariatric surgeons is probably a part of this shortcoming,” Heffron added.

Heffron concluded that bariatric surgeries improve many obesity-related comorbidities and has many other underappreciated effects for a lower risk of cardiovascular issues.

REFERENCE

Beyond Lifestyle: Next Steps in Obesity Management. ACC 2022. April 2, 2022. Accessed April 2, 2022.