Interview with Professor Francisco Lopez-Jimenez
Ahead of SCOPE School Global event in October 2021, which focused on the links between obesity and cardiovascular disease (CVD), we interviewed Professor Francisco Lopez-Jimenez on all things obesity & CVD.
The event has now taken place, but you can still sign up to "Obesity and CVD: A Complex Relationship", a new online course developed in partnership with the World Heart Federation. The six modules were authored by an expert group co-chaired by Prof Lopez-Jimenez and Prof John Wilding, and explore how obesity correlates with CVD risk, considering the impact of obesity on the heart and the interaction of CVD with obesity-related complications.Find out more
How common are cardiovascular diseases (CVD) and how prevalent is obesity in CVD patients?
Well, cardiovascular diseases are very common, common enough to represent the number one cause of death. In the United States of America, in Europe, pretty much all over the world, they are the number one cause of death. Obesity is very common in people with cardiovascular disease - as common as 30-50% of patients, depending on the region of the world. But anything from 30-50% of the patients with cardiovascular disease live with obesity.
What are the benefits of weight loss in patients living with obesity and CVD?
The benefits are many. It has been shown that when people lose weight, the chances of developing diabetes will go down significantly. For multiple reasons, they don't have to lose a lot of weight. Even losing five kilograms, or three kilograms can make a huge difference in the risk of developing diabetes. Losing weight also helps to control blood pressure and controlling blood pressure is the best way to prevent hypertension. When people lose weight, their daily power expenditure increases.
For example, consider atrial fibrillation, which is one of the most common irregular heartbeats that leads to stroke, disability is actually very common. It is a terrible disease, because when people have atrial fibrillation, everything changes, because then they're unable to move around, they may lose the strength of one leg, one arm. They might lose the sight of one eye; they might lose memory or other things. So, it's a very dramatic thing. A number of studies have shown that when people with atrial fibrillation lose even a small amount of weight, the likelihood of the negative effects and symptoms can go down significantly. It seems like it's a therapy that is rarely used for people with this condition and we can go on and on with patients with different heart conditions.
Another example is heart failure. Heart failure is a condition where the heart is unable to send enough oxygen to the whole body; it is just because it's too stiff, or too weak. Well, study after study has shown that when people with obesity and heart failure lose some weight, the symptoms will improve significantly. So, the quality of life improves, and very likely they will be able to live longer and better lives.
What are the challenges in weight regain after losing weight? How do you think the older population can be motivated to lose weight as metabolism slows with age?
It is very important to recognise that weight, that obesity, per se, is a chronic condition, and as such, it means that whatever we do to improve obesity is something that will be required to be sustainable, and not just only for a short-term effect. For example, when somebody has hypertension or high blood pressure, if that person takes medications, the blood pressure will become normal. This might stay for a year or two years, but at the moment that the patient stops taking the medicine, the blood pressure will go up again. The same thing goes with somebody with diabetes, a patient taking the appropriate medications and the glucose, or the sugar level is going to improve. When the patient stops taking the relevant drugs, the sugar is going to go up again. That's one of the reasons why physicians do not feel motivated to help patients to lose weight, because they say: “Well, you know, they will regain the weight anyway”.
So why should I bother to recommend weight loss if they will regain the weight? Well, why do you prescribe medications for blood pressure, because if you stop the medicine, the blood pressure is going to go up again. So, it is the same approach. We have to consider obesity as a chronic condition, and therefore, wherever patients do lose weight, a lot of those changes have to be maintained. Now, the second question is, if elderly people can lose weight, and if they will benefit, losing weight is harder. Because the older we get, the metabolism gets slower. Therefore, the patient might feel disappointed that they try and try, and they don't lose any weight.
I believe that when people are 60 or 70 years of age, they might still benefit when losing weight, particularly to improve mobility. One of the things that keeps older people living longer is the ability to take care of themselves, the ability to move around, to go to the kitchen, prepare breakfast, and go to a friend's house, etc. So that's something that we try to consider when we're trying to convince older people with obesity to lose some weight.
How would you describe the concept of the ‘obesity paradox’?
The obesity paradox is defined as this phenomenon where in some populations, individuals with overweight or obesity live longer than people with a healthy weight, and especially live longer than people who are very low weight, or very skinny. This has been experienced especially in people with heart disease, people with coronary disease, people who are getting very sick. The obesity paradox is very complex. Because one thing is what we see, and the other thing is how we interpret those findings.
So, what we see is what we see, and I think that's unequivocal, that when people have advanced heart disease have obesity, they might live longer. The problem is with the interpretation of that, so the wrong interpretation is saying: "Oh, if people with obesity who have heart disease live longer than skinny people with heart disease, then obesity as a factor does not matter. Then let's make the skinny people gain weight so they can live longer. " That is a wrong interpretation. Why? Because the real question is, several studies have shown that people with obesity and heart disease who can lose weight, benefit in the long term compared to those who don't lose weight.
A similar paradox has been seen with smokers. People who smoke and have a heart attack live longer than those who don't smoke. It doesn't mean that smoking is a factor to live longer. It's just that smokers who have a heart attack are very different from non-smokers, they tend to be younger, they tend not to have a major health issue. Not only that, when they quit, their chances to have a second heart attack go very, very low. So, they have a modifiable risk factor. That obviously means that if you modify, then the raise goes away.
Again, it doesn't mean that smoking helps, it is just telling you that smokers are different from non-smokers. So, the same happens with obesity. People with obesity are more likely to have high blood pressure, high cholesterol, and therefore they're more likely to get treatment for those risk factors. In addition, they will be better in the long term compared to those who are very skinny, who get a heart attack. Sometimes we don't know what happened or what is the risk factor in that case, because we still don't understand how this is possible. I think the most important thing to remember is that the obesity paradox is an observation. But we should not be concluding that losing weight is not good, because indeed, studies have shown that losing weight in the presence of heart disease is very good to improve the quality of life.
How should we approach patients living with obesity and CVD and what are the challenges for physicians in their clinical practice?
I think we can probably agree on the fact that obesity is a risk factor that we must treat and tackle when we see patients with heart disease. But the reality is that in people with heart disease, their concern is more about the heart disease than obesity. The patients are more concerned about having another heart attack the next month and dying. If they had a cardiac arrest, and were lucky to survive the cardiac arrest, you can imagine that the main concern would be not to have another cardiac arrest. Because they knew that they might have died a month ago, and their main concern is how can I stay alive, taking care of the heart. Therefore, they will be more likely to take heart medications. They will be less motivated to think about obesity as a problem. So that's one issue.
The second problem is patients with heart disease take a lot of medications and some of those medications may lead to weight gain. We have to be mindful of the side effects of the drugs. People with heart disease might be out of breath when they try to exercise. So therefore, they may not be motivated to exercise as much since they don't feel well because they feel out of breath or have chest pain. So, it's tricky, but that's why in people with heart disease living with obesity, we strongly recommend patients to attend something that is called cardiac rehabilitation, which is a programme where they are supervised during the training and have motivational interviews.
So they would be better equipped to exercise and motivated. They usually do very well. But otherwise, because they feel very tired and short of breath when exercising, the natural reaction is: “You know what, forget it, I don't want to do this because I don't feel good”. We know that physical activity is one of the foundations for the management of obesity, so I think those are the main challenges we face with patients with obesity and heart disease. The fact that they have they are more concerned about the heart disease itself and the fact that they may be taking medications which may cause them to gain weight.
What are your top tips for healthcare professionals to help patients living with obesity and CVD?
Well, number one would be to give them hope. Give them hope that they can lose weight, and also be very clear that the expectation is not to achieve ideal weight. I think the concept of ideal weight is the enemy of losing weight. Because when you calculate an idea with most people, it means losing 20 or 40 kilograms. So, when people have a hard time losing three kilograms, you tell them that they need to lose 30 kilograms. At that point, you do lose the battle, because they will not pay attention to you.
It is very important to clarify that even very modest amounts of weight loss help a lot. I usually use the example of the Diabetes Prevention Program, which was a randomised clinical trial showing that by losing about three to five kilograms, you were able to reduce the risk for diabetes by about 75%. So, there was a huge benefit with very modest weight loss. So that will be the second recommendation.
The third recommendation is you need to have the obligation as a health care provider to underscore the importance of obesity with your patient. Because when we don't say anything about obesity, patients leave the office with the misunderstanding that because we didn't say anything, obviously it is not important. So, they validate their misperception that obesity doesn't matter. Because the doctor didn't say anything about it and they have spent half an hour with the doctor where they didn't say anything about obesity. So, we have to increase awareness before and we have to facilitate the process of losing weight. That means that we either take upon ourselves the responsibility to help the patient to lose weight by providing tools and recommendations and setting up a program, an exercise program, a weight loss program, nutritional advice, etc. Or we refer the patient to the appropriate provider who will be able to help the patient. I understand that sometimes, providers are just exceedingly busy seeing their patients, and they have to see the next one and the next one and the next one. And therefore, they may decide to just spend those 20 minutes talking about how to take care of the heart, and taking the medicines, etc., and might not have the time to recommend exercise and a good diet.
But at the very least, we must refer those patients to a provider that will be able to help them; that might be a dietitian, that might be an exercise physiologist, or maybe even a general practitioner who specialises in weight loss, or an obesity clinic. When we recognise patients with heart disease who are severely overweight, which means a body mass index above 40, those individuals need to have a referral to a bariatric surgery clinic. One that has a good reputation, one that has good outcomes, one that has shown to be ethical and one that has shown good numbers in terms of safety and perioperative complications. The reason is because when people get a BMI of 40-50, at that point it actually becomes exceedingly difficult to lose weight and sometimes those patients, what they need is just to have bariatric surgery. Bariatric surgery has shown to improve cardiovascular outcomes and has shown to prolong life. We must see patients with a BMI above 40 as having a very serious condition.
Having a BMI above 40 has a worse prognosis than having colon cancer in general and that's serious. So, we must take that with the same degree of seriousness as if we were seeing a patient with a new diagnosis of lung cancer. So, referring patients with severe obesity to get surgery is the best we can do for them.
Why do you think obesity and CVD training and education are important?
Well, because it's important that we as providers feel confident dealing with those patients, that we have the knowledge and the tools to address those issues, that we understand the importance, that we understand the fundamental principles behind obesity and, and how losing weight can improve many of the cardiovascular disease mechanisms related to heart disease. When providers feel empowered to recognise and manage obesity, at least to recognise the importance and how to talk to the patient about the importance of addressing obesity, I think that makes us more likely to talk about these with our patients. So, feeling or being empowered is important, feeling confident that we can talk about those things with our patients is good. I will say that's perhaps the most important reason why it is always good to learn something about it.
But the reality is that heart disease and obesity are two very common conditions and therefore, many providers will be facing those patients almost every day. Seeing people with cardiovascular disease and obesity is so common, that honestly, I will say that a program like this or an educational program addressing those two problems should be mandatory in every medical school and in every residency programme.
I hope people can join us in our different modules and educational opportunities to spread the message that helping patients with obesity and heart disease is important and feasible. We might be surprised to see the great results for just trying.