Cardiovascular disease continues to be the #1 killer of Americans, both men and women.
Obesity and being overweight increase the risk of cardiovascular risk factors such as high blood pressure, high cholesterol, and diabetes, but beyond these are independent risk factors for developing cardiovascular disease.
Unlike hypertension, which has been called the “silent killer” as its presence is too often unknown to people who have high blood pressure, Americans are rarely unaware when they are overweight or obese.
The social stigma attached to being overweight or obese in America has resulted in a “diet industry” worth a record $78 billion in 2019 (pre-COVID-19, before FDA approval of semaglutide for weight loss in 2021), so overweight or obese patients seeing their physician are almost uniformly aware of their elevated body weight and almost uniformly have tried diet and/or exercise for weight loss in the past without achieving sustained remission.
The natural history of losing weight through lifestyle changes is that nothing works for everyone, most everything works for someone, most attempts to lose weight fail, and most successful weight loss episodes are only temporarily successful as evident by the term “yo-yo dieting,” which describes the pattern of restricting food intake to lose weight, then stopping the diet, and subsequently regaining the lost weight in recurring cycles.
Obesity therapeutics vary in effectiveness regarding weight loss and cardiovascular disease mitigation. Over the duration of the studies that have been performed, weight loss with lifestyle changes has resulted in approximately 5 percent weight reduction and has been associated with decreased blood pressure, triglycerides, fasting glucose, and incidence of type 2 diabetes. But the weight loss thresholds required for risk reduction of actual events have been found to be 10 to 15 percent for cardiovascular disease and more than 15 percent for cardiovascular mortality, which far exceed what lifestyle measures have been able to achieve. Current pharmacotherapy can result in 10 to 20 percent weight loss with a proven reduction in cardiovascular events. Bariatric surgery can achieve approximately 25 percent weight loss with a proven reduction in all-cause mortality in addition to the reduction in other cardiovascular consequences of obesity. (See Figure.) IMHO the cardiovascular benefits of successfully achieving and then maintaining a healthy weight are likely to increase with the duration of successful weight management, so starting sooner is likely to increase the total cardiovascular benefit compared to starting later, which also argues for avoiding delay to starting effective treatment for obesity.
Viewed narrowly, the recommendation of the American College of Cardiology is to cardiologists who are seeing patients with established heart disease or at risk for heart disease, the supermajority of whom are (1) aware that their body weight is too high and (2) have already failed the lifestyle measures that they have been willing to try, that the cardiologists begin effective medical therapy to decrease the risk of cardiovascular events without delay.
Viewed more widely, in the setting of overweight or obesity being a chronic or chronic recurrent condition that can be accurately self-diagnosed, for which lifestyle measures are ineffective at achieving sustained remission in a country where heart disease is the number one killer, the American College of Cardiology now recommends that all health care providers should begin to treat overweight or obesity as a medical condition that benefits from medical therapy and initiate medical therapy without delay.
The fact that pharmacotherapy works is proof that obesity is not a failure of will power, but the result of biochemistry that is functional when recurrent food scarcity is common, but dysfunctional in the setting of persistent food abundance.
IMHO the currently available medications are too expensive, too inconvenient, and have too many potential side effects, but will be replaced in time by less expensive, convenient, low side effect alternatives, and the 75 percent of Americans who currently are overweight or obese will nearly all be medicated, as well as the majority of desirable body weight people who were previously overweight or obese and who struggle to maintain healthy weight in defiance of their biological urges.
Disclosure: I have struggled throughout my adult life to achieve and maintain a healthy body weight but have cycled up and down across 50 pounds and never successfully maintained any substantial weight loss for more than a brief period. As I have shared with my patients, “Every day that I am not hungry, I gain weight.” While I am seemingly unafflicted by cardiovascular disease, I do have a family history of my paternal grandfather dying of a massive heart attack at age 51 and paternal uncle surviving his first heart attack at age 49, which does increase my risk for heart disease. After Thanksgiving 2024, I was halfway back to my high weight, so under the supervision of my primary care physician, I began injecting tirzepatide/vitamin B12 once weekly. As I did not qualify for insurance coverage, using a compounding pharmacy and injecting less than the prescribed dose decreased the daily cost significantly. The result has been miraculous. I’ve lost 12 percent of my body weight, which is in the range required in the studies to decrease cardiovascular events, but the improvement in my quality of life has been the most impactful to me, as I no longer must be hungry every day to avoid gaining weight. In 2012, I posted on Facebook a graph of my successful weight loss and promised myself that I wouldn’t post my weight graph again until I had been able to maintain any weight lost for six months; in the subsequent 13 years, I haven’t been able to repost my weight graph due to failing to meet this standard, but am hopeful that I will be able to do so in early 2026. (Stay tuned.)
Ted Dodge is a cardiologist.
