CardioSource WorldNews December 2014 - Page 52

Sponsored content Eisai Inc. provided guidance and funding for this content. CONVERSATIONS with EXPERTS Obesity and Cardiovascular Disease: The Endocrinologist’s Perspective With Christopher P. Cannon, MD, and Harold E. Bays, MD Dr. Bays is a paid consultant to Eisai Inc. Obesity is an independent risk factor for cardiovascular disease, and like cardiovascular disease, contributes to a greater mortality and morbidity risk. So, should fat mass-related cardiovascular disease be treated by an endocrinologist or a cardiologist, and how can the two specialties work together to improve outcomes for patients? In this edition of Conversations with Experts, Christopher P. Cannon, MD, speaks with Harold E. Bays, MD, about the relationship between obesity, “sick fat,” and cardiovascular disease. Dr. Bays is an endocrinologist at the Louisville Metabolic and Atherosclerosis Research Center in Kentucky. Christopher P. Cannon, MD: Harold, it’s wonderful to have this discussion with you. Obesity is a big topic these days—it has been recognized as a medical disease similar to other cardiovascular disease as a chronic and progressive disease. We have to ask, though, why has it taken so long to get to that point? Why do health care providers—and I’m including cardiologists—tend to exclude obesity as a separate disease that we manage with our patients? Harold E. Bays, MD: Thank you Chris, I appreciate the opportunity to discuss this timely topic. This is a rapidly evolving area of medicine. In discussing the challenges facing patients with overweight or obesity, I think we need to first recognize that many non-medical issues may lead to reluctance on the part of health care providers to aggressively assist in the management of patients with overweight or obesity. These non-medical issues include medical bias, 50 CardioSource WorldNews as well as challenges with reimbursement for medical services rendered. From a purely medical standpoint, I agree obesity is a disease, but the question often becomes, “whose disease?” Should obesity be treated solely by the primary care physician, or the endocrinologist, or the obesity specialist, or the surgeon? If we look to how other metabolic diseases are managed in real-life clinical practice—like diabetes type II mellitus or dyslipidemia—it’s interesting how often cardiologists play an active role in management of metabolic diseases. As an endocrinologist, it is common to hear cardiologists say that type 2 diabetes mellitus is a cardiology disease. I think another challenge can be attributed to the history of past weight loss agents, as some of these past weight loss agents had adverse cardiovascular experiences that I think are especially well known to cardiologists. So many challenges exist that I think help explain the reluctance of clinicians to really become actively engaged in the management of overweight or obese patients. Regarding management, let’s first talk about infrastructure: cardiologists have the office infrastructure to manage cardiology patients, while obesity medicine specialists and bariatric surgeons have the infrastructure to provide things like appropriate nutrition, physical activity advice, behavioral therapy, surgery follow-up, and expertise in pharmaceutical options. These are all infrastructure-type things that may not be available in every clinician’s office. Beyond a lack of infrastructure, while most people probably recognize obesity as a disease, many clinicians have received inadequate education regarding the pathogenic potential of adipose tissue— including all the known endocrinopathies and immunopathies of dysfunctional adipocytes and adipose tissue. Many clinicians don’t recognize that an enlargement of the fat cells and the fat organ that cause adiposopathy, which is analogous to the enlargement of the heart and heart cells that cause cardiomyopathy. All these factors taken in totality help explain the challenges that we have had in aggressively managing patients who are overweight or obese. Dr. Cannon: Yes, it’s a frustrating and fascinating combination of factors. There have been many attempts over the decades to solve this problem, but it remains a challenge. Now, exactly how is it that obesity is bad for you? We know that this would be a risk factor for cardiovascular disease, but is it mediated through hypertension, dyslipidemia, insulin resistance, or diabetes? Or are there other mechanisms through which these fat cells or other hormones contribute to the risk more directly? Dr. Bays: That’s an excellent point. Generally speaking, if you look at the American Society of Bariatric Physicians’ Obesity Algorithm™, obesity December 2014