ACC 2023: Anti-Obesity Medications: Practical Approaches to Improved Weight Health (Clinical Spotlight Series)
The session discusses obesity, medications, practical approaches to improved weight, and health.
Obesity is a disease as it fulfills all the criteria for a disease such as diagnosis, morbidity, mortality and treatment. Body mass index (BMI) is an insufficient measure of obesity, especially with respect to cardiovascular risk factors. There is uniqueness with regard to black population in terms of visceral adiposity. In women, there are differences in cardiovascular risk factors with respect to body composition and body fat distribution. Adipose tissue is a very active endocrine and immune organ and with adipocyte hypertrophy there is accumulation of adipose tissue which can lead to’ Fat mass disease’ and 'Sick Fat Disease’ with CVD risk factors. Nutrition plays an important role in managing several conditions as the same principles apply to all of them. In addition, proper caloric nutrition with 150-300 minutes or more of moderate intensity aerobic activity per week or 75-150 minutes or more vigorous intensity aerobic activity per week with resistance training/muscle strengthening at least twice a week is helpful. Data has shown that increasing number of steps per day up to 10,000 steps per day reduces cardiovascular risk in inactive people. To start with 5000 steps per day in physically inactive people is also helpful. Mental stress is a large contributor to factors that affect behavior and thus causing obesity. With respect to nutrition the brain reacts differently (healthful way) to natural foods and ultra-processed foods (unhealthful way).
Efficiency mindset regarding achievements in life may not prove to be of advantage regarding healthful nutrition and physical activity. The medications that help treat diabetes, hypertension and dyslipidemia are recommended as adjuncts to healthful nutrition and appropriate physical activity.
Weight loss is an important step in managing obesity. Bariatric surgery is the most effective mechanism of achieving a high amount of weight loss which can be sustained. Pharmacological therapy is much more effective, sustainable and the newer drugs have more cardiovascular safety and benefit.
An overweight patient must be evaluated with reversible metabolic causes. Medications can also cause weight gain. So, we could try to simplify the regimen and eliminate the medication causing weight gain. Comorbidities associated with obesity can be prevented if intervened at very early stage. Right time to intervene would be when patients shows signs of subtle reversible metabolic syndrome. Combining pharmacotherapy and lifestyle changes improves overall cardiometabolic health. The patients can also be referred to endocrinologists to find out if there are comorbidities contributing to weight gain.
The currently used GLP1 agonists for weight loss include Liraglutide, Semaglutide and Tirzepatide. About 50% adults qualify for weight loss medication; however, most patients are not prescribed these drugs; cardiologists form only a small fraction of these prescribers. Lack of familiarity, competing demands, low confidence that the patients will change their behavior, belief that obesity is a personal failure are some of the barriers to the use of weight loss medication. In conclusion, weight loss through any mechanism can potentially reduce the risks of atrial fibrillation, heart failure, myocardial infarction, stroke and may improve overall survival.
There are several lifestyle approaches however not all are evidence based. In patients with obesity, the initial approach must be evaluation for reversible metabolic causes, factors that cause weight gain, address obesity early. There are some cardiometabolic parameters that are associated with obesity. They include adiposity and waist circumference. The practical approach to manage patients with obesity is to show them compassion. After initial assessment, psychological factors such as stress should be assessed in obese patients.There are some reversible causes of obesity which may be neurological or endocrine in nature. Among drugs, Insulin, sulphonylureas and Pioglitazone are diabetes medications that cause weight gain. Beta blockers when used to treat palpitations in women during their peri-menopausal period experience weight gain. Lifestyle is not about what and how much you, it is also about when you eat, sleep and move on a daily basis.
GLP1agonists promote weight loss mainly by mechanisms that delay gastric emptying, centrally regulate appetite and satiety and inhibit postprandial glucagon release or blocking aldosterone receptors.
American College of Cardiology (ACC) International Congress 2023, 4th March - 6th March 2023, New Orleans
