The Epidemic of Weight loss
We all see the social media comments that are for, and also against, the concept of good health being associated with someone who has a lean physical appearance. The main factor for the debate against it, has been in recognition of the obvious mental health crisis we face here in the United States. Although it is undebatable that mental health crisis is a very real and genuine concern, particularly for those who face bullying and body dysphoria as a result of their weight, so too is cardiovascular disease. To date, cardiovascular disease remains the #1 cause of death for those living in the United States of America.
That said, which one is more important?
Although I agree that mental health remains woefully under addressed, so too is cardiovascular disease (CVD). CVD is not only the leading cause of death in the United States, but CVD has been shown to have a significant and direct impact on morbidity as well as mortality. As a clinician, I find it extremely concerning that my colleagues across the table are embracing this notion of normalizing obesity. Why might you ask? Because, simply stated, it’s a deadly game of roulette. And, it needs to stop. Enter in the period with a “t” and a dot.
This debate that embraces obesity and poor lifestyle choices is dangerous. It is more difficult than it ever has been to effectively manage obese patients who have embraced obesity as a normality. Far too many obese patients view clinicians who promote weight loss and healthy lifestyle habits as being overly critical; and reject our recommendations. When in fact, we are only trying to help our patients to lead a long, healthy, active and happy life through awareness of the facts. Unfortunately, it feels as though clinicians have been losing this battle for quite some time.
Here are some staggering quick facts from the National Institute of Health’s (NIH) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK):
According to 2017–2018 data from the National Health and Nutrition Examination Survey (NHANES)
Nearly 1 in 3 adults (30.7%) are overweight.
More than 1 in 3 men (34.1%) and more than 1 in 4 women (27.5%) are overweight.
More than 2 in 5 adults (42.4%) have obesity (including severe obesity).
About 1 in 11 adults (9.2%) have severe obesity.
The percentage of men who are overweight (34.1%) is higher than the percentage of women who are overweight (27.5%).
The percentage of women who have severe obesity (11.5%) is higher than the percentage of men who have severe obesity (6.9%)
According to 2017–2018 NHANES data
About 1 in 6 children and adolescents ages 2 to 19 (16.1%) are overweight.
Almost 1 in 5 children and adolescents ages 2 to 19 (19.3%) have obesity.
About 1 in 16 children and adolescents ages 2 to 19 (6.1%) have severe obesity.
(NIH, September 2021).
Obesity directly contributes to the prevalence of cardiovascular risk factors such as dyslipidemia (high cholesterol), type 2 diabetes, hypertension, and obstructive sleep apnea. Central obesity is also an independent risk factor for cardiovascular disease. Studies have shown that an increase in visceral adiposity (belly fat and a fatty liver) is associated with an increased risk in the development of significant cardiovascular disease. (AHA, April 2021).
Furthermore, obesity has been linked to an increased risk of, and poorer outcomes for those with, underlying atherosclerotic cardiovascular disease, heart failure, and arrhythmias such as atrial fibrillation. As well as sudden cardiac death. Particularly in those with visceral obesity and fatty liver. Whereas studies in bariatric patients have demonstrated a significant reduction in coronary artery disease risk with weight loss after surgery. (AHA, April 2021).
A meta-analysis of >300 000 adults with 18 000 CAD events demonstrated that BMI in the overweight and obese ranges was associated with elevated CAD risk. (AHA, April 2021)
As any of you who know me would know, I am a huge advocate for patient awareness, education, and engagement in making well-informed decisions. Because, no matter how well we get at medicine, we are not God. So, let’s get to helping you take control of your cardiovascular health…
Did you know, that a higher BMI decreased the accuracy of non-invasive cardiac testing? This includes multiple types of non-invasive tests. Which means that significant disease can be missed in obese patients.
So, what exactly is a normal BMI? A healthy adult should have a BMI of 18.5 - 24.9. Adults who are considered overweight will have a BMI of 25 - 29.9. Obesity starts with a BMI of 30 or more. Yes, there are some issues with using BMI alone. However, that is a much more complex topic that deserves it’s own blog post. That said, BMI is still the best widely accepted indicator of obesity in relation to most adults. In children, we utilize growth charts to determine obesity. Any child with a weight in the 85th - 95th percentile is considered overweight. Greater than the 95th percentile is obese.
Unfortunately, cardiovascular disease begins in childhood. Autopsies have shown arterial fat streaking in young children and teens. Even in children with a normal weight. This is felt to largely be a result of children consuming an increasingly more unhealthy diet, and in combination with leading a more sedentary lifestyle.
You might say, well can’t we just treat these things with medicines and cardiac stents? The answer is long, but is also an overall no. For example, platelet aggregation is higher in obese patients, with less pharmacokinetic/pharmacodynamic benefits of antiplatelet drugs (i.e. aspirin). (AHA, April 2021). Not to mention increased risks associated with invasive testing and cardiac interventions.
This reminds me of a case some years back. I was on a multidisciplinary team, caring for a patient who had undergone necessary open heart surgery at another facility. This patient had so much ectopic fat that, not only was the case more high risk and required additional medical resources but, this patient had a prolonged hospitalization with subsequent development of fat necrosis and breakdown of the sternotomy site. Directly as a result of excess fat. Ultimately, this patient ended up with not only rehospitalization, but with many months of ongoing care, resulting in chronic complications that would require lifelong care and inability to ever lead a normal life. Not to mention the added healthcare costs and resources that needed to be utilized. All as a result of obesity, which is completely avoidable. The facility that performed the surgery did an excellent job. However, this patient’s lack of awareness, self-care, and subsequent development of obesity was the central cause for this patient’s morbidity.
There is no debate, that the global epidemic of obesity is well-established. However, it is only getting worse. This means that the prevalence of cardiovascular disease is not only influenced by genetics, but also greatly influenced by lifestyle. The average adult living in the United States overestimates their subjective level of activity, performance, and cardiovascular health. Not to mention the normalization of unhealthy food choices; even in those who have access to higher quality foods.
From 1999 to 2018 there was a 12% increase in obesity rates, and and additional nearly 5% increase in severe obesity. According to USAFacts.org, obesity rates in the United States has tripled in the last 60 years, with approximately 43% of adults in the United States classified as overweight. Here is a chart of the annual trends in obesity rates:
Yes, like it or not, it is true that non-obese patients have improved mortality and less morbidity. Meaning, they live longer lives with less medical diagnoses. Our hearts beat approximately 100,000 beats a day, and circulate approximately 2,500 gallons of blood, carrying vital oxygen to our tissues. It is an impressive organ that is vital to our survival. Although the human heart is tough and endures, it is not immune to the negative impact of obesity.
REFERENCES:
https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000973
https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity
https://usafacts.org/articles/obesity-rate-nearly-triples-united-states-over-last-50-years/
