Tackle Obesity to Drop Risk for Secondary Cardiac Event

Marlene Busko

August 09, 2021

Patients who had been hospitalized for heart attack or cardiovascular revascularization procedures commonly were overweight (46%) or had obesity (35%), but at a follow-up visit, few had lost weight or planned to do so, say researchers conducting a large European study.

The findings emphasize that obesity needs to be recognized as a disease that has to be optimally managed to lessen the risk for a secondary cardiovascular event, the authors stress.

The study, by Dirk De Bacquer, PhD, professor, Department of Public Health, Ghent University, Ghent, Belgium, and colleagues was published recently in the European Heart Journal — Quality of Care and Clinical Outcomes.

The researchers analyzed data from more than 10,000 patients in the EUROASPIRE IV and V studies who were hospitalized for acute myocardial infarction (MI), coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) and answered a survey on average 16 months later.

Although 20% of the patients with obesity had lost 5% or more of their initial weight, 16% had gained 5% or more of their initial weight.

Notably, "the discharge letter did not record the weight status in a quarter of [the patients with obesity] and a substantial proportion reported to have never been told by a healthcare professional [that they were] overweight," the researchers report.

"It seems," De Bacquer and colleagues write, "that obesity is not considered by physicians as a serious medical problem, which requires attention, recommendations, and obvious advice on personal weight targets."

However, "the benefits for patients who lost weight in our study, resulting in a healthier cardiovascular risk profile, are really worthwhile," they point out.

Cardiovascular Rehabilitation Should Include Weight Loss Intervention

"The safest and most effective approach for managing body weight" in patients with coronary artery disease and obesity "is adopting a healthy eating pattern and increasing levels of physical activity," they write.

And their findings that "patients who reported reducing their fat and sugar intake, consuming more fruit, vegetables, and fish and doing more regular physical activity, had significant weight loss," support this.

De Bacquer and colleagues recommend that cardiovascular prevention and rehabilitation programs "should include weight loss intervention, including different forms of self-support, as a specific component of a comprehensive intervention to reduce total cardiovascular risk, extend life expectancy, and improve quality of life."

Clinicians should "consider the incremental value of telehealth intervention as well as recently described pharmacological interventions," they add, but noted the study did not look at these options or metabolic surgery.

Invited to comment, one expert pointed out that two new observational studies of metabolic surgery in patients with obesity and coronary artery disease reported positive outcomes.

Another expert took issue with the "patient blaming" tone of the article and the lack of actionable ways to help patients lose weight. 

Medical Therapy or Bariatric Surgery as Other Options?

"The study demonstrated how prevalent obesity is in patients with heart disease " and "confirmed how difficult it is to achieve weight loss, in particular, in patients with heart disease, where weight loss would be beneficial," Erik Näslund, MD, PhD, told Medscape Medical News in an email.

Even though "current guidelines stress weight-loss counseling, some patients actually gained weight," observed Näslund, from Danderyd Hospital and Karolinska Institutet, Stockholm, Sweden.

On the other hand, patients who lost 5% or more of their initial weight had reduced comorbidities that are associated with cardiovascular disease.

"The best way to achieve long-term weight loss in patients with severe obesity is metabolic (bariatric) surgery," noted Näslund, who was not involved in the study. "There are now two recent papers in the journal Circulation that demonstrate that metabolic surgery has a role in the secondary prevention of cardiovascular disease in patients with severe obesity" — one study from Näslund's group (Circulation. 2021;143:1458-1467), as previously reported, and one study from researchers in Ontario, Canada (Circulation. 2021;143:1468-1480).

However, those were observational studies, and the findings would need to be confirmed in a randomized clinical trial before they could be used as recommended practice of care, he cautioned. In addition, most patients in the current study would not fulfill the minimum body weight criteria for metabolic surgery.

"Therefore, there is a need for intensified medical therapy for these patients," as another treatment option, said Näslund.

"It would be interesting," he speculated, "to study how the new glucagon-like peptide-1 (GLP-1) receptor agonist therapies could work in this setting as a weight loss agent and perhaps have a positive independent cardiovascular benefit."

Obesity Is a Disease; Clinicians Need to Be Respectful

Meanwhile, Obesity Society fellow and spokesperson Fatima Cody Stanford, MD, MPH, MBA, MPA, told Medscape she didn’t think the language and tone of the article was respectful for patients with obesity, and the researchers "talked about the old narrative of how we support patients with obesity."

Lifestyle modification can be at the core of treatment, but medication or bariatric surgery may be other options to "help patients get to their best selves."

"Patients with obesity deserve to be cared for and treated with respect," said Stanford, an obesity medicine physician scientist at Massachusetts General Hospital and Harvard Medical School, Boston.

Treatment needs to be individualized and clinicians need to listen to patient concerns. For example, a patient with obesity may not be able to follow advice to walk more. "I can barely stand up," one patient with obesity and osteoarthritis, told Stanford.

And patients' insurance may not cover cardiac rehabilitation — especially patients from racial minorities or those with lower socioeconomic status, she noted.

"My feeling has always been that it is important to be respectful to all patients," Näslund agreed. "I do agree that we need to recognize obesity as a chronic disease, and the paper in EHJ demonstrates this, as obesity was not registered in many of the discharge notes.

"If we as healthcare workers measured a weight of our patients the same way that we take a blood pressure," he said, "perhaps the [stigma] of obesity would be reduced."

Study Findings

The researchers examined pooled data from EUROASPIRE IV (2012-13) and EUROASPIRE V (2016-17) surveys of patients who were overweight or had obesity who had been discharged from hospital after MI, CABG, or PCI to determine if they had received lifestyle advice for weight loss, if they had acted on this advice, and if losing weight altered their cardiovascular disease risk factors.

They identified 10,507 adult patients in 29 mainly European countries who had complete survey data.

The participants had a mean age of 63 at the time of their hospitalization; 25% were women. Many had hypertension (66%-88%), dyslipidemia (69%-80%), or diabetes (16%-37%).

The prevalence of obesity varied from 8%-46% in men and from 18%-57% in women, in different countries. Patients with obesity had a mean body weight of 97 kg (213 lb).

One of the most "striking" findings was the "apparent lack of motivation" to lose weight, De Bacquer and colleagues write. Half of the patients with obesity had not attempted to lose weight in the month before the follow-up visit and most did not plan to do so in the following month.

Goal setting is an important aspect of behavior modification techniques, they write, yet 7% of the patients did not know their body weight and 21% did not have an optimal weight target.

Half of the patients had been advised to follow a cardiac rehabilitation program and two thirds had been advised to follow dietary recommendations and move more.

Those who made positive dietary changes and were more physically active were more likely to lose at least 5% of their weight.

And patients who lost at least 5% of their initial weight were less likely to have hypertension, dyslipidemia, or diabetes compared with patients who had gained this much weight, which "is likely to translate into improved prognosis on the long term," the authors write.

EUROASPIRE IV and V were supported through research grants to the European Society of Cardiology from Amgen, AstraZeneca, Bristol-Myers Squibb/Emea Sarl, GlaxoSmithKline, Hoffmann-La Roche and Merck, Sharp & Dohme (EUROASPIRE IV) and Amarin, Amgen, Daiichi Sankyo, Eli Lilly, Pfizer, Sanofi, Ferrer, and Novo Nordisk (EUROASPIRE V). De Bacquer, Näslund, and Cody Stanford have no disclosed no relevant financial relationships.

Eur Heart J Qual Care Clin Outcomes. Published online July 27, 2021. Full text

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