Wendy M. Miller

Impact of Obesity on Cardiovascular Disease

Obesity promotes a cascade of secondary pathologies including diabetes, insulin resistance, dyslipidemia, inflammation, thrombosis, hypertension, the metabolic syndrome, and OSA, which collectively heighten the risk for cardiovascular disease. Obesity may also be an independent moderator of cardiac risk apart from these comorbid conditions. Rates of obesity and cardiac disease continue to rise in a parallel and exponential manner. Because obesity is potentially one of the most modifiable mediators of cardiovascular morbidity and mortality, effective treatment and prevention interventions should have a profound and favorable impact on public health.

Impact of obesity on cardiovascular disease.

The epidemiology of cardiovacular disease risk factors is changing rapidly with the obesity pandemic. Obesity is independently associated with the risks for coronary heart disease, atrial fibrillation, and heart failure. Intra-abdominal obesity is also unique as a cardiovascular risk state in that it contributes to or directly causes most other modifiable risk factors, namely, hypertension, dysmetabolic syndrome, and type 2 diabetes mellitus. Obesity can also exacerbate cardiovascular disease through a variety of mechanisms including systemic inflammation, hypercoagulability, and activation of the sympathetic and renin-angiotensin systems. Thus, weight reduction is a key strategy for simultaneous improvement in global cardiovascular risk, with anticipated improvements in survival and quality of life.

Awareness, knowledge, and perception of heart disease among adolescents

Background Perceptions of cardiovascular risk among adolescents have not been studied recently. The rise in unattended risk factors and the obesity pandemic have created calculable cardiovascular disease risk in the adolescent population. Design We sought to assess the awareness, level of knowledge, and perception of cardiovascular disease in an adolescent population. Methods We administered a survey designed to collect data on demographics, beliefs regarding risk factor importance, perceived future risk and other knowledge-based assessment questions about cardiovascular disease. Results Students, n = 873, (45.4% male, mean age 15.6 years) in grades 9–12, from four Michigan high schools completed the survey unassisted. Accidents were rated as the greatest perceived lifetime health risk (39.1%). A minority (16.6%) of respondents selected cardiovascular disease as the greatest lifetime risk placing it behind accidents and cancer. When asked to identify the greatest cause of death for each sex, 42.3% of respondents correctly recognized cardiovascular disease for men and 14.0% correctly recognized cardiovascular disease for women in the United States, P<0.0001. Forty percent of respondents incorrectly chose a substance abuse/use behavior, other than cigarettes, as the most important cardiovascular disease risk behavior. Conclusions Our findings suggest that adolescents lack knowledge regarding the risk of cardiovascular disease and do not perceive themselves at risk for cardiovascular disease. These data will be useful in designing future preventive strategies and interventions aimed at this target population.

Cardiorespiratory Fitness and Sedentary Lifestyle in the Morbidly Obese

Sedentary lifestyles and poor physical fitness are major contributors to the current obesity and cardiovascular disease pandemic.

Vitamin A Deficiency after Gastric Bypass Surgery: An Underreported Postoperative Complication

Introduction. Few data are available on vitamin A deficiency in the gastric bypass population. Methods. We performed a retrospective chart review of gastric bypass patients (n = 69, 74% female). The relationship between serum vitamin A concentration and markers of protein metabolism at 6-weeks and 1-year post-operative were assessed. Results. The average weight loss at 6-weeks and 1-year following surgery was 20.1 ± 9.1 kg and 44.1 ± 17.1 kg, respectively. At 6 weeks and 1 year after surgery, 35% and 18% of patients were vitamin A deficient, (<325 mcg/L). Similarly, 34% and 19% had low pre-albumin levels (<18 mg/dL), at these time intervals. Vitamin A directly correlated with pre-albumin levels at 6 weeks (r = 0.67, P < 0.001) and 1-year (r = 0.67,  P < 0.0001). There was no correlation between the roux limb length measurement and pre-albumin or vitamin A serum concentrations at these post-operative follow-ups. Vitamin A levels and markers of liver function testing were also unrelated. Conclusion. Vitamin A deficiency is common after bariatric surgery and is associated with a low serum concentration of pre-albumin. This fat-soluble vitamin should be measured in patients who have undergone gastric bypass surgery and deficiency should be suspected in those with evidence of protein-calorie malnutrition.

Effects of weight loss and pharmacotherapy on inflammatory markers of cardiovascular disease

Obesity is currently an epidemic, and the prevalence of cardiovascular risk factors is increasing dramatically as a result. Visceral adiposity is correlated with a proinflammatory and prothrombotic state that is believed to promote atherosclerosis and acute coronary syndromes. This article will review clinical trials on the effects of weight loss and pharmacotherapy on obesity associated inflammatory and thrombotic markers linked with cardiovascular disease.

Preventing weight regain after bariatric surgery: an overview of lifestyle and psychosocial modulators.

Bariatric surgery is being increasingly used as a treatment for obesity. With this weight loss intervention, obesity-specific disease remission and mortality reduction benefits are undeniable. After surgical weight loss is complete, one of the greatest challenges becomes long-term weight loss maintenance, which is largely behavior-ally based. The fundamental behavioral components to maintaining surgical weight loss include dietary control, commitment to regular physical activity, and behavior modification. Changing these longstanding lifestyle habits, however, is a serious challenge and, unfortunately, many formerly obese individuals ultimately experience weight regain due to noncompliance. Further research is needed to identify optimal treatment strategies for postoperative bariatric surgery patients to minimize weight regain.

Optimal diabetes management during medical weight loss for cardiovascular risk reduction

Obesity has long been recognized as a significant risk factor for type 2 diabetes. Both obesity and type 2 diabetes are associated with an increase in cardiovascular risk. As cardiovascular disease continues to be the number one killer in the USA and western adult populations, the rise in prevalence of obesity and type 2 diabetes is alarming. This is especially disturbing in the tripling of overweight children and adolescents, accompanied by the increase in prevalence of pediatric type 2 diabetes. Optimal strategies for long-term diabetes management aim at effectively controlling, reducing and ultimately preventing obesity. This review explores the clinical recommendations in place, new clinical investigations, diet therapy, medical nutrition therapy, meal replacements, behavior therapy, exercise therapy, pharmacotherapy and surgical therapy as strategies to achieve weight-loss success in diabetic patients and ultimately reduce cardiovascular disease.

Treating type 2 diabetes: incretin mimetics and enhancers

As a consequence of excess abdominal adiposity and genetic predisposition, type 2 diabetes is a progressive disease, often diagnosed after metabolic dysfunction has taken hold of multiple organ systems. Insulin deficiency, insulin resistance and impaired glucose homeostasis resulting from beta-cell dysfunction characterize the disease. Current treatment goals are often unmet due to insufficient treatment modalities. Even when combined, these treatment modalities are frequently limited by safety, tolerability, weight gain, edema and gastrointestinal intolerance. Recently, new therapeutic classes have become available for treatment. This review will examine the new therapeutic classes of incretin mimetics and enhancers in the treatment of type 2 diabetes.

Guidelines for Medical Evaluation and Exercise Testing in Persons with Diabetes Starting an Exercise Program

Because diabetes mellitus (DM) is considered a major risk factor for cardiovascular disease, the clinical evaluation of the patient with diabetes should include a thorough review of the patient’s medical history, current treatment regimen (oral agents, insulin), related comorbidities (hypertension, obesity, metabolic syndrome, coronary artery disease), resting electrocardiogram (ECG), selected laboratory studies (e.g., blood glucose, hemoglobin A1c, serum creatinine, estimated glomerular filtration rate, urine albumin/creatinine ratio), and ankle/brachial systolic pressure index, if available. A conventional or cardiopulmonary exercise stress test may also be conducted as part of this evaluation. In addition to the indications and contraindications and appropriate methodology (protocols) for exercise testing, key diagnostic and prognostic variables include the resting and exercise ECG, especially the provocation of significant ST-segment displacement and/or arrhythmias during or after exercise testing; anginal symptoms; dyspnea; chronotropic incompetence; abnormal heart rate recovery; exertional hyper- or hypotension; estimated or directly measured cardiorespiratory fitness, expressed as mL O2/kg/min or metabolic equivalents (METs; 1 MET = 3.5 mL/kg/min); and combined information (e.g., treadmill scores [Duke treadmill score]). Adjunctive echocardiographic studies may also be used to identify impaired left ventricular diastolic function, a condition that is common in DM, as well as systolic dysfunction. Collectively, these data should prove helpful in prescribing safe and effective exercise programs and delineating appropriate treatment targets to reduce the likelihood end-organ complications and cardiovascular events in this escalating patient population.