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In this episode, obesity medicine specialist and OMA clinical education executive director, Nicholas Pennings, DO, FOMA, Dipl. ABOM interviews Eduardo Sanchez, MD, MPH, FAAFP, the keynote speaker from Obesity Medicine 2019, about treating obesity as an important key to managing cardiometabolic health. They also discuss effective clinical strategies in partnering with patients with obesity toward better cardiovascular health, as well as how rising pediatric obesity may impact the future of heart disease. Dr Sanchez serves as Chief Medical Officer (CMO) for Prevention and Chief of the Center for Health Metrics and Evaluation for the American Heart Association (AHA). You can purchase the full recording of Dr Sanchez's Keynote presentation on the chronic care model and access more information about Obesity Medicine podcasts and other resources from the clinical leader in Obesity Medicine at www.obesitymedicine.org/podcasts.
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Mark Labriola: Welcome to Obesity: A Disease, the official Obesity Medicine Association podcast. On this podcast, we're going to explore the many facets of the disease of obesity. I'm Mark Labriola. And in this episode, Dr Nicholas Pennings interviews Dr Eduardo Sanchez, the keynote speaker from Obesity Medicine 2019, about the connection between obesity and heart disease. This podcast is brought to you by the Obesity Medicine Association, a clinical leader in obesity medicine. We hope you enjoy today's episode.
Nicholas Pennings: Hi, this is Dr Nick Pennings, Chair of Family Medicine at the Campbell University School of Osteopathic Medicine and executive director of clinical education at the Obesity Medicine Association. And I'm here with Dr Eduardo Sanchez, who serves as the Chief Medical Officer of the Center for Health Metrics and Evaluation of the American Heart Association. Dr Sanchez is also keynote speaker here at the OMA conference, speaking on applying chronic care model for prevention and management of obesity. Thank you for being here, Dr Sanchez.
Eduardo Sanchez: Pleased to be here.
NP: So, I want to start with just getting your thoughts on the role that obesity has played in the risk of heart disease.
ES: Well, I'm a big disciple of the American Heart Association's life's Simple 7. Life's Simple 7 is our definition of cardiovascular health. And it's seven factors: smoking, healthy eating, physical activity, weight, blood pressure, cholesterol, glucose. Weight, obesity, is one of those. So, the simple answer is from a heart association's perspective, obesity is absolutely among the cardiovascular risk factors that we should assess and address.
NP: Well, that's great because a lot of those Simple 7 components are also important part of obesity treatment. And that is something that we focus on in identifying different disease processes associated with obesity and then intervening and trying to reverse as much of that disease process as possible. What role do you see for the future treatment of obesity as a treatment for cardiovascular disease?
ES: Well, now that we have all agreed that obesity is a disease, I think it's time to think about "How do we treat and reverse that disease, if possible?" I'm a family physician by training. In my time, I took care of people with high blood pressure and was able to take them off of medications. I took care of people with type 2 diabetes and was able to get them off of medications. And while we may not be talking about people on medications, how we reverse obesity is critically important on a patient-by-patient basis and in ways that make sense. Certainly, addressing nutrition, what we're eating and how much of it; and physical activity, how much we're doing and with what intensity, are two things that we ought to be talking to all of our patients about, never mind where their BMI is or is not.
ES: And so, it is very much the way the American Heart Association is thinking about cardiovascular disease risk management. If we can do the things that we can do to address and reverse obesity, there's a good chance that that will have a downstream positive effect on the likelihood of a person developing prediabetes or diabetes, the likelihood of a person needing to be on lipid-lowering agents to address what would put them at higher risk if they were people with obesity; and then lastly as it relates to high blood pressure. High blood pressure is going to be better at a lower weight. But also if one is eating healthfully and being physically active, that's the Holy Grail for all of those diseases: obesity, diabetes, hyperlipidemia, and hypertension.
NP: Absolutely. That's right on target. Tell me a little bit about what you were doing to help people get off of medications.
ES: As a clinician? Well, first and foremost, I was the patient's champion. So, so often what we hear or what we are led to believe is that kind of patient can't dot, dot, dot. And I just refused to accept that any kind of patient couldn't go from where they were to a better place. And so much of that, I've learned subsequently, whether it's about education in school settings, whether it's about sports in athletic setting, or about medical conditions in clinical settings, is about giving people, individuals, the sense that they can do it and then backing that up with a kind of support they need and the tools that will get them there. And so, so much was about applying the specific technical knowledge on the one hand, but really it was about being a champion for each of my patients and just helping them along. If they stumbled? "Oh well, get up and let's get going again." And if they were doing fantastic things, sometimes small measures of fantastic things, an "attaboy" or an "attagirl" went a long, long way.
NP: Absolutely. You want to be the champion for your patients. And I, too, found that patients did not want to be on medications; they wanted to get off of medications. And very often, when they would ask me about… When they'd start a blood pressure medication, they'd asked me, "Am I going to be on this for the rest of my life?" And my old answer used to be, "Well, probably. Most people who start on a medication, end up staying on a medication." And one of the things I found as an obesity medicine specialist, is, as I was helping people lose weight and adopt a healthy lifestyle, that as their weight was going down I was able to reduce medications.
NP: In fact, I find that's a hard thing, even within the medical profession, is to stop a medication. For most physicians, they're very comfortable with adding but very uncomfortable with taking away medications. Any thoughts on that? And how do we guide our colleagues to help them with that?
ES: I think we got to change that. So, it's interesting. The one thing that we are challenged with adding are the lifestyle recommendations that should be part of any discussion with any patient. If we could get patients to not smoke, to move even a little bit more, and to adjust some of how they eat, we could begin moving them along that trajectory without necessarily adding a new, expensive co-pay-associated medication. So, we have work to do on two fronts: one, getting comfortable with adding lifestyle; and then two, getting comfortable with monitoring what's going on with our patients and realizing that there are times where, even if it's just a test, a drug holiday could make some sense because what you may find is that drug isn't adding value anymore. Let's eliminate it.
NP: Right. Looking for those opportunities to do that and doing lifestyle in a meaningful way. For some, it's just sort of a box to check that, "Well, I discussed lifestyle. Let's move on to the real treatment, which is the medication." And recognizing that lifestyle could be a very effective tool, and is the cornerstone of treatment for all conditions, but we sort of gloss over it, or at least many of our colleagues gloss over it.
ES: Yeah. I couldn't agree with you more. And it's not because they're paying attention to the science because there's plenty of studies out there that are beginning to show us… I mentioned Life's Simple 7 before. There is a cottage industry of Life's Simple 7 studies around a variety of things, some in persons who already have diagnosed conditions. And a couple of studies that come to mind are in individuals who have already had a stroke. How well you are doing on Life's Simple 7… And admittedly, some of those requires some treatment with medications, but three of those are absolutely about lifestyle. The degree to which you're doing well on Life's Simple 7 is a prognostic predictor in a positive way. So, the higher your score, the better off you're going to be. So, whether you are naive to any disease, that is, you are just a healthy person, Life's Simple 7 makes sense to continue being that healthy person. But if you are on any part of the continuum of disease, however we want to define that, the lifestyle parts of Life's Simple 7 play a role in improving the health of our patients. And again, I think sometimes we forget that, whether it's heart failure, obesity, atrial fibrillation, stroke, post MI, getting right on Life's Simple 7 has a positive effect on your cardiovascular health. And at the end of the day, heart disease and stroke are still the number one and number five killers of people in the United States. Those numbers are going down. A recent study showed that the number of folks with myocardial infarctions showing up in emergency rooms has gone down almost 40% in the last 20 years. I think that's a sign that, despite everything I've said, maybe we're doing a little bit better on lifestyle modification and certainly doing better overall on cardiovascular risk management and modification.
NP: In some studies, higher weight categories are associated with better outcomes for cardiovascular disease, sometimes referred to as "the obesity paradox." What are your thoughts about this data? And how do you interpret that data?
ES: So, the data probably is what the data is. And what I would say is that we probably need to do some degree of subanalysis and better understand how each of the different factors that are Life's Simple 7, and maybe there's a handful of others, how they correlate. Because I think that when we just focus on one thing, and not pay attention to perhaps that person is more fit than they might've been otherwise, perhaps that person had the other cardiovascular risk factors managed. And then just this morning, I heard a very interesting idea, I'm not a basic science person, that the origins of adipose cells is the same origin as heart cells, and that somehow or other there may be a as of yet unrecognized cardioprotective effect when you have an event. So, that's the other thing, is that if we're measuring this based on whether people survive bad things or not, that's important, but we might want to do some subanalysis to see if the incidents of those bad things that they're protected from are different in two different populations.
NP: That was very interesting, how adipose STEM cells may play some role in helping heart disease.
ES: Yeah. The presenter said, "This doesn't mean that we should be encouraging people to put on more weight." And my analysis of some of this data also is that some of that protective or paradoxical effect begins to go away when you shift from milder levels of obesity to more severe obesity. And at the severe obesity levels, all of that protection is negated by the negative effects of carrying that much weight and having that much adiposity.
NP: Right. Typically, that's found in overweight and class one categories and not beyond that.
ES: That's right.
NP: We've seen a rise in obesity in our children. How do you see this impacting the future of heart disease in the United States?
ES: I'm very, very worried. And in fact, earlier today, I mentioned that in a couple of weeks, it may be… I'll use qualifying language because I don't want to give away what might be an embargoed secret. It may be that a report is going to show that the health of people who are millennials at this stage of their lives is less healthy than older generations were at that same stage of life. That can't be a good thing. I think it reminds us that we need to double down on health promotion, and we need to double down on disease prevention and on cardiovascular risk management. It also reminds us that we need to take that back as far as we possibly can. And it's never too early to get started, whether that's making sure that potential mothers are healthy before they become pregnant, that they're healthy, and fathers probably too, and that mothers stay healthy during pregnancy, and that babies are offered the right mix of healthful nurturing, feeding, et cetera; and then in schools, children have the opportunity to be physically active, eat healthy foods, both of which are important for academic performance. So, there's no harm in doing that. It probably reminds us that we are not doing that as well as we could. We're doing less of it now than maybe some of us who have gray hair, no hair or dyed hair, when we were kids, and need to go back to… That's one place where going back to recess every day, PE every day. Maybe the food could be a little bit healthier than when some of us were younger. But that's the message. Scary. Scary. We need to do something about it.
NP: Yeah. Scary. Especially when we see reports of the potential life expectancy of our children being less than those who are older now.
ES: Absolutely. And if indeed their life expectancy isn't lower, the burden of disease is going to come sooner. And the cost, not even to society, the cost to an individual to be labeled as having a disease, that has stigma associated regardless what the disease is. And then the cost just in terms of family relationships and your ability to get your work done effectively, all of those things I think are sometimes underestimated and critically important.
NP: And the impact on quality of life is a huge factor as well.
ES: Yeah. And again, I don't want to say that if you've got any of the cardio-metabolic diseases that you can't have a high quality of life, but I'd like to think that all of us would agree that not having a disease, probably better than having a disease.
NP: As a family physician, what role do you see family physicians and other primary care providers playing in the treatment of obesity?
ES: I love that question because what we keep learning as we look at what we think of as being very challenging health conditions, diseases that need to be treated, what we find over and over and over again, whether it's high cholesterol, high blood pressure, congestive heart failure, diabetes, I'm going to put obesity on that list, primary care is primary because that's where people go. That's where people present early in whatever it is that's going on. That's where people present for prevention. No one goes to a cardiologist who's in perfectly good health. You go to a cardiologist, generally… I'll correct that. You go to a cardiologist when something is not going quite right. People don't go to the endocrinologist when they are perfectly healthy human beings. And so, family physicians are the place where perfectly healthy human beings should be seen because perfectly healthy human beings need to be regularly assessed for what might be a detectable early disease. Cancer would be in that category. That's places where they can get the kinds of preventive treatment that's going to keep them from getting bad things. Vaccines fall into that category. And it's also the place where the opportunity, while someone is there for those things, to discuss cardio metabolic health, eating healthy, being physically active, not smoking as very important, lifelong steps to prevent, delay or mitigate what will be the downstream consequences that might manifest as obesity, high blood pressure, high cholesterol, diabetes, or a combination of the four.
NP: That's great. How effective are our medical practice care models for treating chronic diseases? And how should they change to more effectively handle chronic diseases like obesity?
ES: That is a really, really astute question because I think that we are collectively getting to the point that more science about pathophysiology, more science about disease is not what we need. What we really need is more science about how to translate the knowledge into action and how to translate that effectively. There are some models out there around… Obviously, the Wagner chronic care model is one model to have a look at. It doesn't have the kind of specificity I think that would be really, really valuable, but I am finding tools and programs. The American Medical Association has developed a MAP framework for taking care of high blood pressure. MAP stands for measure accurately, act quickly, partner with patients. And it may be that we can borrow from already existing programs and perhaps the OMA, in addition to an algorithm which is critically important to guide the clinical decisions that need to be made, can add to what was part of this spring/summer summit in workshops and begin putting together the practice guides. What do you need? You probably need, what we're learning out there in general, a clinical champion on site. You need to make sure that you are measuring the things that should be measured, that you are reviewing the things that you're measuring and seeing if the actions you're taking to maybe address what you're measuring are making a difference, that you are using a team-based approach to do it so that the physician or the nurse practitioner or the PA is not carrying 95% of the load of work, when it can be distributed. Part of that probably takes physicians like you and I to also have a little bit of an attitude adjustment about what we ought to be doing and more importantly what others can and should be doing in our practices. And it requires all of that in a quality-improvement framework that is regularly looked at, regularly tweaked, and is about ultimately providing evidence-based care in the most effective way.
NP: And I think your Simple 7 framework is a good framework for monitoring progress and making sure the team is looking at that whole patient, and looking at the whole picture, and looking at the important things. We get a lot of metrics from insurance companies that say, "You should follow this result or that result," but I think that Simple 7 is a better framework around which we can monitor our patients and monitor their progress, as well as assess their current status.
ES: Well, I would be so conflicted if I just said, "I totally agree," but I'm going to totally agree with you. I do think that Life's Simple 7 affords us the opportunity to have a fixed set of things that we're tracking. The evidence, very compelling evidence, that in the case of persons with type 2 diabetes, when you get their diabetes controlled, their lipids controlled, and their blood pressure controlled, the degree of lifesaving, reducing the likelihood of an adverse cardiac event is very, very low compared to the risk. Yeah, the risk is low compared to those where only one of those three are adequately controlled.
ES: Our colleagues and our clinical teams know how to do the control of everything. We just haven't figured out how to package it and deliver it effectively, comprehensively, consistently. That's what we need to do.
NP: Yes. Integrating those concepts into one. So, where can our listeners find out more about Life Simple 7?
ES: Sure. So, the American Heart Association's website is heart.org. H-E-A-R-T.org. And if you search "Life's Simple 7," you will find it. One other important thing to search is the "2019 prevention guidelines." The 2019 prevention guidelines or compendium. It captures the recommendations for clinicians to address the Life's Simple 7 based on the science to date.
NP: Well, thank you very much for being here. I think it was a pleasure talking to you about these interesting topics.
ES: Oh, pleased to participate. Anything that can move the needle forward is a good thing for me.
ML: Thank you, Dr Pennings and Sanchez. For more information about obesity medicine podcasts and other resources from the clinical leader in obesity medicine, please visit obesitymedicine.org/podcasts. The views expressed in this podcast episode are those of the show hosts and do not necessarily represent the opinions, beliefs, or policies of the Obesity Medicine Association or its members. Please check back next month for another episode of Obesity: A Disease. Have a great day.
Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
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