Robert Kushner, MD: An Emphasis on Obesity as CV Risk Factor

Obesity is a risk factor for cardiovascular disease, but preventive cardiologists may face challenges in counseling a patient on a healthy body weight and strategies to achieve this goal.

At the 2022 American Society for Preventive Cardiology Meeting, Robert Kushner, MD, Feinberg School of Medicine, Northwestern University, presented a talk on how to treat obesity as a cardiovascular risk factor, referring to it as ‘the one that got away.’

The talk highlighted data that support obesity as a risk factor, including disability-adjusted life years (DALYs) and the effects on the heart, such as heart failure with preserved ejection fraction (HFpEF).

“I am also talking about the benefits of weight loss, not only on reducing cardiovascular risk, but also improving metabolism as it relates to insulin sensitivity and reducing insulin resistance as it relates to metabolic syndrome,” Kushner added.

He additionally discussed how clinicians can better help patients manage their weight by using targeted strategies, such as self-monitoring, meal plans, support and accountability. Kushner described the foundation of obesity treatment as lifestyle management, including diet and exercise, as well as stress reduction and lack of substance abuse.

However, the excitement for Kushner has come in the form of adjunctive pharmacotherapy. He noted that the field is at the verge of a second generation of medicines for obesity, primarily mimicking gut hormones, such as GLP-1s. In addition to treating diabetes and lowering blood sugar, the effects of these agents on appetite have led to double digit weight loss, including up to 20% weight loss, Kushner noted.

“It's not only an incretin hormone for diabetes, but in improving appetite, but also affecting other cardiovascular risk factors, effects on the kidney blood pressure and blood clotting,” Kushner added.

Kushner discussed the continuum of options in obesity management, from lifestyle changes to diet and exercise, but also noted the more aggressive treatments for obesity. The first, as noted above, is pharmacotherapy, but the other is bariatric surgery. He added that the surgery is the most effective treatment for patients with obesity, and that typically leads to significant endurable weight loss.

“I think it's important when we see individuals and we present all the options to them really from the very beginning about what is going to be the most effective treatment,” he said.

For a patient with high risk of cardiovascular disease and a corresponding body mass index (BMI) of ≥40, Kushner is potentially thinking about bariatric surgery for that individual.

“They don't have to fail lifestyle management and then fail pharmacotherapy to then bring up bariatric surgery,” he added. “We want to bring the most effective treatment for that patient as early as possible.”

Kushner further discussed the awareness of social determinants of health in obesity treatment. These social determinants are particularly affecting those who suffer from obesity or excessive weight due to a lack of resources, access to healthy foods, and others necessary to promote health in a community.

He noted that those who are most affected are often of lower socioeconomic status, particularly African-American females who have the highest prevalence of severe obesity in the United States.

“When we make recommendations to individuals and minority groups, we have to think about access and affordability when we're recommending treatments,” Kushner said. “Unfortunately, due to health care resources, a lot of the exciting medications that are being developed, are not affordable or not covered under certain health plans, so we have to be very aware of that and sensitive to the needs.”