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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