Gregory M. Weiss, MD

Obesity may be the most detrimental health problem of the modern era. Over the past half-century, the global burden of obesity and its effect on global health, in particular, the growing incidence of cardiovascular disease (CVD) has increased exponentially.

Beyond the direct association between obesity and CVD, it is known to be linked to other major risk factors such as hyperlipidemia, insulin resistance, and hypertension.

 The ultimate goal for both primary and secondary prevention of CVD in obese patients is weight reduction. The three major methods for weight loss are: pharmacologic or medical treatments, dietary and lifestyle modifications, and bariatric or weight loss surgery.

To spite a reasonable body of evidence that bariatric surgery works, controversy remains. After the initial weight loss, do patients realize long-lasting reductions in CV risk? Many clinicians believe that the way to meaningful and long-term weight loss is through putting in the work rather than cutting corners with a fast fix and there may be something to be said for developing healthy, long-lasting habits. Thankfully data exist that answers these questions.

Weight loss in the obese population has been studied extensively. While strong evidence exists, that bariatric surgery is a more reliable method of weight reduction than either pharmacological or lifestyle methods interest has now shifted to whether or not weight reduction surgery leads to long-term reductions in obesity-related comorbidities.

In a recent nested cohort study performed by Osama Moussa and colleagues in the United Kingdom a clear association was found between bariatric surgery with lower long-term risk for major cardiovascular events (MACE) and heart failure in obese patients.

In another retrospective, matched, controlled cohort study Dr. Singh and colleagues, also in the UK, looked at specific risk factors for CVD after bariatric surgery and found a reduced risk of hypertension, heart failure, and mortality when compared to medical management.

 Singh further found that patients with type 2 diabetes mellitus who underwent bariatric surgery also had a lower incidence of atrial fibrillation.

 In yet another recent study published in Current Opinion in Lipidology, Zohaib Iqbal, a biologist in Manchester, UK found that bariatric surgery led to improvements in obesity-related metabolic comorbidities including dyslipidemia, HDL functionality, hypertension, type 2 diabetes mellitus, insulin resistance, and inflammation.

A major study out of the Cleveland Clinic sought to put to rest further questions about the efficacy of weight reduction surgery and the long-term implications with regards to MACE. Ali Aminian, MD, reports in the Journal of the American Medical Association that among patients with type 2 diabetes and obesity, bariatric surgery led to a significantly lower risk of incident MACE when compared to non-surgical treatment.

 An interesting caveat to these data appeared in another prominent article published this year in The American Journal of Cardiology showing that while MACE is reduced both short-term and long-term in the general bariatric population, obese patients with concomitant coronary artery disease (CAD) that underwent weight reduction surgery realized an increase in MACE events over time.

From these data, it is clear that bariatric surgery offers lasting benefits to obese patients, especially those suffering from type 2 diabetes with regards to CV risk reduction and long-term MACE. However, do the benefits outweigh the risks of surgery? Here are some statistics. The average three-year weight loss following bariatric surgery is 62% of excess weight.

 Short-term and long-term mortality rates are 0.5% and 5% respectively.

 In a landmark study known as the Swedish Obese Subjects (SOS) study, more than 2000 patients undergoing bariatric surgery with more than 20 years of follow-up realized a 29% reduction in mortality irrespective of the amount of weight lost.

The verdict is in. While more prospective randomized studies may be needed the available evidence suggests that there are undeniable, substantial, and sustainable benefits to weight reduction surgery over traditional weight-loss strategies in obese patients with regards to long-term cardiovascular risk and the incidence of MACE. Armed with this information clinicians can have a frank discussion with patients about weight reduction surgery and if it is right for them.

Articles

Dr. Gregory Weiss reflects on data related to bariatric surgery and its subsequent impact on cardiovascular health. 

Is it Time to Consider Bariatric Surgery for Primary Prevention?

This year clinicians and researchers across all disciplines of medicine have witnessed many firsts. As we navigate a perilous landscape dominated by the global COVID-19 pandemic, we have seen an extraordinary adaptation in the academic community. Science, medicine, and humanity itself must go on.

In keeping with this idea, the American Heart Association (AHA) has just completed its first virtual annual meeting from which the global academic community has introduced the latest research and insight in the field of cardiovascular science. In light of the incredible strain the pandemic has had on the global economy we present four sessions from the AHA Scientific Sessions 2020 highlighting the cost versus benefit of the latest drugs that treat type II diabetes mellitus that are also known to reduce cardiovascular (CV) risk.

On November 13th, 2020, Joseph Azuri, MD, and colleagues from Tel Aviv, Israel presented, in session P2007, a comparison between empagliflozin, an inhibitor of the sodium-glucose cotransporter 2 (SGLT2) and oral semaglutide, the first oral glucagon-like peptide 1 (GLP-1) receptor agonist. In keeping with the AHA strategic goal of reducing cardiovascular mortality by 20% these two drugs have been shown to significantly reduce the incidence of CV mortality in patients with type 2 diabetes mellitus and known CVD.

In light of the potential cost burden adding a new drug to a diabetes treatment regimen creates, Azuri sought to determine which drug would be most cost-effective while still reducing CV risk in type 2 diabetics. The research team went on to calculate the cost needed to treat (CNT) and prevent one case of CV mortality using either drug. They found the annual costs for empagliflozin and semaglutide were $4,572 and $6,680, respectively.

 In light of the similarity between the drugs with regards to efficacy and CV risk reduction, Azuri’s team recommends empagliflozin as the more cost-effective treatment.

In a second session on November 13th, 2020, P2013, Azuri and colleagues went on to compare three popular GLP-1 receptor agonists. With regards to semaglutide, dulaglutide, and liraglutide, the American Diabetes Association recommends providing one of these GLP-1 therapies to patients with type 2 diabetes and established CVD regardless of glycemic control.

 Concerned about the staggering costs associated with these new drugs Azuri sought to compare the 3 drugs for cost-effectiveness.

Azuri again calculated the annual cost needed to prevent one major adverse cardiovascular event (MACE) utilizing each of the three drugs in patients with type 2 diabetes and established CVD. The relative costs were $557,000 for semaglutide, $1,179,360 for liraglutide and $1,605,904 for dulaglutide.2 The research team concluded that, for secondary prevention of MACE in patients with type 2 diabetes and established CVD, semaglutide provides more value than the other two medications.

In session P1146 on November 13th, a colleague of Azuri’s, Ronen Arbel, PhD, further breaks down the cost effectiveness of two different preparations of the GLP-1 drug semaglutide. With an oral preparation of semaglutide now available, Arbel imagined that patients may prefer it over a subcutaneous injection for prevention of MACE in patients with type 2 diabetes.

Following the previous model, Arbel calculated the average annual cost for both preparations needed to prevent one MACE. The research team found that the average costs per year were $641,823 and $855,040 for the subcutaneous and oral preparations respectively.

 They further looked at the cost relationship between the two preparations and the endpoints of MACE versus cardiovascular mortality (CVM) alone. They concluded that the subcutaneous preparation of semaglutide was more cost-effective for the prevention of MACE in patients with type 2 diabetes but that for the prevention of CVM the oral preparation provided a significantly better monetary value.

Finally, in session MP463, also on November 13th, Arbel and colleagues looked at the cost-effectiveness of icosapent ethyl, a prescription omega-3 fatty acid supplement known to aid in prevention of MACE in patients with hypertriglyceridemia. The team looked specifically at the difference in cost when used for secondary prevention in diabetic patients with known CVD and for primary prevention in those with risk factors for CVD.

Arbel analyzed the cost of icosapent ethyl to prevent one MACE per year when prescribed for either primary or secondary prevention. The average cost of icosapent ethyl annually was $874,500 versus $206,965 when used for primary and secondary prevention respectively.

 The team found that the cost needed to treat was four times higher in the primary prevention group when compared to the secondary prevention group concluding that prescribing icosapent ethyl for diabetic patients with known CVD is significantly more cost effective.

We as clinicians often overlook the cost of the therapies we prescribe focusing solely on the most effective and proven treatments for our specific patients. These reports show that, when given choices between equally efficacious treatments, cost can play a significant role in our decision making and should. Of final note, we should all consider the enormous monetary amounts reported above. Reread those annual costs and consider the relative burdens such numbers place on patients and the health care system overall. A discussion for another time.

Gregory Weiss, MD, examines 4 studies presented at AHA Scientific Sessions 2020 comparing the cost-effectiveness of antidiabetic agents for reducing cardiovascular events. 

Comparing Cost-Effectiveness of Antidiabetic Therapies with Cardiovascular Benefit

Good nutrition is good science. There is no question that most medical specialties are taking nutrition seriously these days with a veritable plethora of guidelines and recommendations hitting the peer-reviewed literature over the last several decades. The evidence that nutrition plays quite possibly the most important role in disease prevention, in particular, 

The American College of Cardiologists (ACC) and the American Heart Association (AHA) have taken a lead role in promoting heart healthy nutrition guidelines. A recent statement from the ACC calls for a diet comprised of high quantities of non-starchy vegetables, fruits, whole grains, and legumes plus moderate consumption of nuts, seafood, lean meats, low-fat dairy and vegetable oil.

 However, the ACC admits that many physicians lack the knowledge and require greater specificity regarding food choices.

While our knowledge about proper diet has increased, the rate of cardiovascular disease related mortality has plateaued. The most likely reason for this seeming contradiction is the increasing prevalence of obesity and type 2 diabetes in younger people.

So, if we know what good nutrition is why are patients becoming obese and diabetic?

Stephen Devries, MD, FACC, surveyed cardiologists and fellows in training and found that 31 percent of cardiologists and 21 percent of fellows in training did not recall receiving any nutrition education.

Despite obvious gaps in educating cardiologists about proper nutrition, 95% of them believe that their role includes personally providing patients with at least basic nutrition information.

Devries states, “The current report, while highlighting deficiencies in nutrition education and practice, can also be viewed as spotlighting tremendous opportunities to improve cardiovascular care.”

Devries comments are well taken. If the vast majority of cardiologists believe they should be counseling patients on nutrition, then it is up to us to learn and teach. So, what should we know? The American College of Cardiology recommends the following:

All adults should consume a healthy diet emphasizing the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish.

A healthy diet should minimize the intake of trans fats, red meat, processed red meats, refined carbohydrates, and sweetened beverages.

Overweight and obese adults should be counseled that caloric restriction is recommended for achieving and maintaining weight loss.

These recommendations published in the journal of the American College of Cardiology go on to clarify the meaning of processed meats to include any meat preserved by smoking, curing, or salting, or additional chemical preservatives

The American Heart Association further recommend a low sodium diet as well as the eating of fish at least twice a week along with high fiber whole grains

They go on to suggest drinking alcohol in moderation and reducing portion sizes for all meals.

Now that we know what to tell our patients it is up to us to treat this as the pillar of cardiovascular care that it is—Devries goes on to suggest that, “The urgency to act quickly is brought to light by the recent plateau in the previous declining trend in cardiovascular mortality – fueled largely by substantial increases in the prevalence of obesity and diabetes.”

I believe that discussions about what our patients are eating and how they can improve their health through their diet should be undertaken at every visit. Those of us working in academics should make sure that nutritional education begins at least in medical school with reinforcement throughout graduate medical training. Continuing medical education (CME) requirements should mandate nutritional education as a part of maintenance of certification. Next to primary care providers cardiovascular specialists with a solid background in nutrition are poised to deliver effective nutritional counseling as a part of a holistic approach to patient care.

Finally, we should be good role models. It is difficult to counsel patients to maintain a healthy weight and to eat right if we are overweight or obese ourselves. It’s hard to change behaviors in our patients and in ourselves, but it is clearly worth the effort.

Dr. Gregory Weiss reflects on a pair of addendums to 2019 guidance from the ACC/AHA on the primary prevention of CVD, which focus on the role of nutrition and diet in patients. 

You Are What You Eat: Guiding Patients Through the Heart Healthy Forrest

As life expectancies have risen so have the numbers of elderly Americans. Even before the COVID-19 pandemic as many as one in four adults 65 and older were considered socially isolated.

 There is a growing body of evidence that social isolation and loneliness affect more than just the mental health of our aging population.

According to the Centers for Disease Control (CDC) social isolation is not only associated with dementia, it significantly increases a person’s risk of premature death, heart disease, and stroke.

Elderly patients with heart failure who felt loneliness were four times more likely to die, three times more likely to be hospitalized and twice as likely to visit the emergency room.

 A study published in the Journal of the American Heart Association found that identifying those at risk creates opportunities to intervene.

Just how lonely are older Americans? According to the National Social Life, Health, and Aging Project as many as one-third of older adults report that they frequently feel lonely.

 Some causes of isolation and loneliness include retiring from work, losing a partner, and or losing mobility. Leaving the workforce can cause a drastic reduction in social interaction while losing a spouse or partner compounds the grief of the loss itself with loneliness.

Christian Hakulinen, PhD, a professor of psychology and logopedics at the University of Helsinki, Finland states, “Having social support from significant others or from persons who are in a similar situation is good for your health, and socially isolated or lonely individuals might not have possibilities for this kind of support.”

There is strong evidence for the notion that close relationships promote health. Harvard University has been conducting a study looking at health and well-being for the last 80 years. This study has found that healthy social relationships at age 50 are a better predictor of physical health at age 80 than midlife cholesterol levels.

In an editorial published in the British Medical Journal, Julianne Holt-Lunstad, PhD, and Timothy Smith, MD, PhD, explore the underlying causes of increased cardiovascular disease (CVD) and mortality in isolated and lonely seniors. Evidence suggests that social isolation and loneliness are associated with negative changes in biomarkers for CVD such as hypertension, body mass index, waist circumference and inflammation

 Furthermore, being isolated may lead to decreased exercise and increased negative behaviors such as smoking and drinking alcohol.

So, what can we do as clinicians to help the lonely hearted? The first step is to identify the problem. In a study published in the Journal of the American Heart Association, a four-question survey was used successfully to identify patients at risk.

 A 1 to 5 score corresponding to an answer of “Never”, “Rarely”, “Sometimes”, “Usually”, or “Always” was given for the following questions:

“I feel that people are around me but not with me.”

With scores ranging from 4 to 20 patients with higher scores could be identified as possessing greater perceived social isolation.6 Once identified a strategy should be made with the goal of reducing, not only the perception of isolation and loneliness, but also the comorbid behaviors and biomarkers associated with that isolation. A large portion of the increased CV risk in lonely adults can be attributed to the physical consequences of being alone.

When I encounter a patient with feelings of isolation, they often seem withdrawn and less interactive. When people are used to being alone, they often communicate less with clinicians. It is up to us to engage patients and offer strategies to mitigate the isolation we know can impact their health. One way we can help is by encouraging these patients to maintain existing relationships with family and friends which may involve, during the COVID-19 pandemic, assessing their ability to video call, zoom, or facetime others.

There is no doubt the pandemic increases the likelihood of loneliness and isolation especially in the elderly who are often times frightened due to their increased risk of dying from it. My suggestion is to get creative. There are many hobby groups, church activities, classes, and interactive games to be found on the internet. Just the same as prescribing the right drug for a medical condition or providing exercise and nutrition advice to a patient, we need to adapt and become educated about how to alleviate the widespread isolation and loneliness in our patients lest the owners of a lonely heart become owners of broken hearts.

Dr. Gregory Weiss reflects on the impact of isolation and loneliness on older patients during the COVID-19 pandemic.

Gregory M. Weiss, MD

Articles

Is it Time to Consider Bariatric Surgery for Primary Prevention?

Comparing Cost-Effectiveness of Antidiabetic Therapies with Cardiovascular Benefit

You Are What You Eat: Guiding Patients Through the Heart Healthy Forrest

Gregory Weiss, MD: Impact of Loneliness and Isolation on the Health of Elderly Americans