In this Grand Rounds presentation, noted author and cardiologist Carl J. Lavie, MD, discusses the current epidemiology and effects of obesity in the United States and offers an overview of studies he co-authored that tracked the link between obesity and the dramatic decline in physical activity in the US, and evidence for the "obesity paradox." A concept for which Lavie, MD, was an early investigator, the obesity paradox holds that elevated BMI may act as a precedent to better survival in heart failure in some patient populations. Lavie, MD, is the Medical Director of Cardiac Rehabilitation and Preventive Cardiology at the John Ochsner Heart and Vascular Institute in New Orleans.
Oh All right, good morning. We'll give everyone a couple of minutes to finish logging in. Uh in the meantime. The CMI code for today is 78134. That's 78134. All right, good morning everybody. Welcome to cardiology. Grand rounds today. The CMI code again is 78134. It's my great pleasure to introduce our speaker today. Dr Carl Chip Lavie is a professor of medicine at the john Ocean Her heart and vascular institute in New Orleans Louisiana. Chip attended medical school at L. S. U. Medical Center in New Orleans and then did an internal medicine training at Ocean er in cardiology at the Mayo Clinic. He is currently professor of medicine and medical director of cardiac rehab and prevention and the director of the exercise lab at the john Ocean Heart and vascular Institute In New Orleans. He's authored over 1600 medical publications. Um several cardiology textbooks serves on over 40 editorial boards including Journal of the American College of Cardiology and the American Journal of Cardiology. He's the associate editor and the cardiovascular section editor for the Mayo clinic proceedings. And many of you may have seen his book which is available on amazon and in bookstores on the obesity paradox. So it's with my great pleasure that I will turn things over to Dr Chip Lavie to take it from here. Thanks to me. Thanks Harvey. It's a pleasure to be here this morning with you and and to get a chance to talk on one of my favorite topics that is obesity and and and the obesity paradox and cardiovascular diseases. I really have no disclosures on this particular topic. Uh this morning we're gonna review the relationship between obesity and cardiovascular risk factors and outcomes of patients with obesity. We'll discuss the obesity paradox and patients would establish cardiovascular disease. I'll summarize the medical evidence that treating obesity with physical activity and exercise particularly that improves cardiorespiratory fitness, lowest cardiovascular disease risk and improves outcomes. Will apply some strategies to prevent and treat cardiovascular disease and patients with obesity. And as Samir mentioned, I am the author of the obesity paradox. This book came out in 2014. So it's really not a conflict of interest today because it's certainly the sales have dwindled but it is on Amazon if anyone wants to add to my conflict. I became editor in chief of progress in cardiovascular diseases in 2014 as well. And my very first issue is my most cited issue of all time. That was on obesity and obesity paradox in cardiovascular diseases in January 2014. And this issue was so um Impactful that several years later we had another, I teamed up with Francisco Ortega from Granada Spain and we did an update on this topic with 18 articles with leaders across the world in the field of obesity and cardiovascular diseases. I was very pleased several years ago when Valentin Fuster, the editor in chief of Jack, our flagship cardiology journal asked me to to lead the healthy weight and Obesity prevention article for his Jack health promotion series, which was a very successful series. And uh and this paper was also very, very heavily cited. I think most of you know that obesity has been in epidemic proportions in the United States and really most of the Western world right now, 3/4 of adults in the United States are either considered overweight or obese by B. M. I. Criteria and 42% have B. M. I. S over 30 I think. What's even more concerning is that severe or class three previously called morbid obesity? That's not used anymore because it's kind of a mean sounding word. But uh this is now present in in 9% of the adult population have BMS over 40. That's one in 11 adults in the United States, which is I think is scary. Obesity is now second only tobacco abuse is number one cause of preventable death in the United States. And due to obesity has been suggested that we may see soon see a reversal in the steady increase that's been occurring in life expectancy. We know obesity has many adverse effects on the cardiovascular risk factors. It certainly increases insulin resistance which leads to glucose intolerance metabolic syndrome and is by far the leading driver of type two diabetes. It raises blood pressure uh and certainly increases the prevalence of hypertension and even independent of blood pressure. Uh I have done many studies with colleagues franz measly previously at Washington Hector ventura um richard Melanie showing that obesity causes abnormalities in left ventricular geometry, concentric remodeling and left ventricular purchasing. Both the concentric any centric type independent of its effect on arterial blood pressure. It certainly worsens the lipids especially raises the V. L. D. L. Uh particles and which carried the triglycerides. It doesn't really increase LDL very much but changes the LDL into a smaller, more dense particle that's more easily oxidized and more afra genic and it has adverse effects on HDL reducing HDL in the april april protein 81 which coats the cardio protective HDL. It leads to many abnormalities and endothelial function. Um It causes abnormalities in both systolic but particularly diastolic. Left ventricular function because they had emphasized produce cytokines that then stimulate the liver to produce proteins like c reactive protein and other inflammatory proteins. Obesity ends up being a very pro inflammatory state and certainly approach from biotic state and all of this certainly has adverse effects on cardiovascular disease. And if you consider then what obesity does to both the left and the right sides of the heart. I think it's no surprise then that obesity is a tremendous cause of of left ventricular failure uh and and right ventricular failure and has adverse effects to increase almost all cardiovascular diseases hypertension, coronary heart disease. Probably the two biggest things that it increases is heart failure. Heart failure with preserved ejection fraction particularly and atrial fibrillation but has adverse effects to increase the prevalence of almost all cardiovascular diseases. Now this argument that still goes on and what is the fundamental cause of obesity. I think many people put the blame on the sugary beverages, coca, cola, Pepsi cola dr pepper. Uh They put the blame on the fast food industry, Mcdonald's burger king, Taco Bell etcetera. And this certainly is involved. But my colleagues and I have really focused on that. We believe that the fundamental cause of obesity is the very marked decline that has occurred over time in physical activity. And this is a study that we published a decade ago that got a lot of publicity and it wasn't all good publicity. And just for example, we measured five decade trends in household management, energy expenditure and women in this paper. And this is basically a fancy way of saying housework and women And this guy this there was this was on Fox News three times in one night. I don't think up in Pen Y'all probably watch too much Fox News, but it's on every night here in Louisiana. We were on three different shows that night. We were on one of Jay Leno's last monologues. Um My there was a a major newspaper had a picture of me and right next to my picture and said women are getting fat because they're not doing enough housework. You can imagine how well that went over on the home fund and my my my daughter who was a medical student at time at L. S. U. Medical student came home and told me that my sister who was a social worker was very upset about this paper. But basically we showed what you would predict over five decades, there were very marked declines with industrialization um in the household management energy expenditure in the in the range of about 1800 calories per week uh that women were burning in the present time by household management housework compared to five decades earlier. Now, if you use the simple formula that about 100 calories burned per mile traveled by foot, that would mean that the average woman today would have To walk or Jog 18 more miles per week to make up for the calories not being burned by housework that were being burned five decades earlier. Not to mention the fact that this plays such an important role in cardio respiratory fitness. Yeah, we we measured house working women, we didn't measure housework and men and and really honestly uh can joke about. My joke is that men don't do housework, but they certainly do today. They probably weren't doing much housework five decades ago. But we didn't measure occupational energy expenditure and both men and women. And as you'd expect marked declines in both genders on occupational physical activity over these five decades. And when you plug this into what was occurring at the time in the increase in obesity and obesity pandemic epidemic. Uh it almost totally tracked with the increase in obesity. And as I mentioned, because physical activity is the is the leading driver of cardio respiratory fitness. And we'll discuss this a lot more. It not only affects the prevalence of obesity, but it certainly worsens uh cardio respiratory fitness. Now, no question if you're going to markedly reduce physical activity and energy expenditure, you have to cut your calories from sugars, carbohydrates and really all sources. But we believe that the fundamental causes really the marked decline in physical activity because people ate a lot of calories five decades ago. Now, once you develop obesity, there's been controversy of what the outcomes are. And I'm gonna discuss the obesity paradox in patients with cardiovascular disease. But this is a paper that came out in Jama cardiology by Khan and colleagues in 2018 of 10 us cohorts with 3.2 million person years of follow up That clearly showed that higher BMS were associated with increased lifetime risk of cardiovascular disease and compression of mobility. This study did not show an increase in mortality associated with obesity, but a paper at the same time in the European Heart Journal of 300,000 White Europeans showed not only an increased cardiovascular disease, but also cardiovascular disease, mortality and all cause mortality related with obesity. Uh more so uh they showed it with the B. M. I. But they showed it more so with the waist circumference and the waist to hip ratio, meaning that central at a possibility was even more of a risk factor uh than was total obesity by B. M. I. Now I've actually published the most in the world in the in the field of obesity paradox. And this means that in the patients that we're all seeing in our cardiovascular practices that we've seen in obesity paradox, meaning that despite the fact that I mentioned that obesity worsens almost all of the cardiovascular risk factors and increases the prevalence of most cardiovascular diseases when patients are showing up in our office and in our hospital with hypertension, coronary heart disease, heart failure atrial fibrillation. These patients would overweight and obesity are actually having a better prognosis, short term and medium term at least than the patients with lower body weights. And this has been term the obesity paradox. I'm not gonna uh concentrate just on this today, but I would like to at least briefly show this, for example, in hypertension. We know obesity. I mentioned early increases blood pressure, it increases geometric abnormalities like concentric remodeling left ventricle hypertrophy independent of its blood pressure effect. It increases metabolic cardio metabolic abnormalities in patients with hypertension, which then lead to more atherosclerosis. But despite this increased prevalence, it seems that patients with hypertension and obesity are actually having a more favorable prognosis than the lean patients With hypertension. One of the best studies I think to show this was 15 years ago by your it's key and Franz Meslin colleagues from the invest study of 22,500 patients that this is a study of ace inhibitors and calcium channel blockers in in in hypertension. But they showed that overweight and obese despite the fact that they had less control of their blood pressure, they had uh lower mortality and almost all cardiovascular both in men and women in the overweight obese hypertensive compared to the lien hypertensive. Many other studies have shown either the same thing or they've shown a U shaped curve, meaning that the highest risk was at the very low weights and very high weights. But none of the hypertensive studies have shown that the overweight and mildly obese of having a worse prognosis now. So in aggregate although obesity is a powerful risk factor for developing hypertension. In L. V. H. Patients with hypertension, obesity seems to paradoxically have a better prognosis, possibly because of having lower systemic national resistance, maybe having lower plas marine activity. The mechanism is not totally clear. There's probably been more on obesity and heart failure. This is a review article that we published in progress in cardiovascular disease, reviewing all the evidence in 2016. 1 of the first studies uh from this was now two decades old and the New England Journal of Medicine. But colleagues of 5881 subjects from the Framingham cohort that showed that across the spectrum of B. M. I. Um there was an increased prevalence of heart failure basically for every one kg per meter squared increase in B. M. I. The heart failure prevalence increased by 5% in men and 7% in women. Amber's pandy down in Dallas texas has published a lot on heart failure, particularly with preserved ejection fraction and showed that that both overweight and obesity markedly increased heart failure but Lower fitness also was a very significant contributor to heart failure. And he showed in this Jack Paper 2017 that this was particularly true in heart failure with preserved ejection fraction. Physical activity and fitness was protective against heart failure with reduced ejection fraction too. But just a little bit but particularly a driver of heart failure with preserved ejection fraction. Likewise, obesity by B. M. I. Criteria slightly increases the prevalence of heart failure with reduced ejection fraction but is a tremendous driver of heart failure with preserved ejection fraction. Now, once you develop heart failure though there appears to be an obesity paradox. This was first I think reported over two decades ago by Tamara Hardwick and Greg fonda Roy from U. C. L. A. Of over 1000 1203 advanced heart failure patients at U. C. L. A. With an average ejection fraction in the low twenties, they showed during follow that the best prognosis in these patients was in the overweight cohort followed closely by the obese and the worst prognosis was in the underweight, followed closely by the normal B. M. I. Patients with heart failure. And they showed in this paper that having a low B. M. I was an independent predictor of mortality in this heart failure population. Greg fonda Roy. A few years later uh studied 100 and 10,000 patients with decompensating heart failure and showed that a higher B. M. I. Was associated with lower in hospital mortality. Every five unit increase in the B. M. I. Heart failure mortality was 10% lower. And subsequently in his journal cardiac failure paper from this cohort, he showed that this was true in both heart failure with the s above 40 and ef less than 40% that we did a meta analysis several years ago that we actually uh if you remember Jack heart failure started in 2013. And the first paper was by Eugene, brune wall. And then the second issue of Jack heart failure. I had an obesity paradox paper and these two papers became the most cited papers ever in Jack heart failure. Well, two years after that I sent the meta analysis to Jack heart failure and it was rejected without even being sent out for review. And subsequently chris O'Connor told me uh that they had stats that our paper that was delayed, published in american general cardiology, which has been I think cited something like 500 times, became the most cited paper that was ever rejected by Jack heart failure always reminded him, but even rejected it without sending it out for review. But this is a meta analysis of about six studies of heart failure with reduced ejection fraction. That also showed that that overweight and obese had an even severely obese and short term follow up had a lower total and cardiovascular mortality. But there was a difference for heart failure. Hospitalizations, heart failure, hospitalizations did increase with more severe obesity whereas major clinical events uh Willow. Subsequently this was shown in the paper in the International Journal of Obesity, which we wrote the editorial for in heart failure would preserve the ejection fraction, essentially the same type of data as with reduced ejection fraction showing an obesity paradox for major events, cardiovascular mortality and all cause mortality, but a difference with a higher rate of of re hospitalizations associated with more obesity. Now, years ago we did a study that was published in Jack, where we were basically people were at that time were using cardiopulmonary stress testing to predict prognosis and heart failure. And this was everyone used Donna Mancini's classification uh 14 CCs of oxygen per kilogram per minute. If you were less than this, you are rated high for transplant. And if you were higher than this, you were rated lower for transplant. But we we we theorized it was really, I say we it was really my colleague Richard Melanie and Mandic Mayra um we theorized that if you corrected the peak oxygen consumption for lean body mass, it would have a better predictor of prognosis because we thought that the fat, which has now been proven to be a very important endocrine organ, but we knew the fact didn't get much profusion and didn't have high metabolism. And when we did this study published in Jack, we showed that lean adjusted peak VO two was a very uh important predictor of prognosis and much better than just total peak VO two. But when we did this study we had to measure lean weight. And so we measured body fat. And when we did so, we found that the fellow doing the study, I met Austin at the time was now an electro physiologist in florida. He brought me to data and it showed that the higher mortality were those with low B. M. I. And low percent body fats. And when I first saw that my first start and this was in the late nineties, my first thought was they basically had basically reversed the columns. And of course that wasn't the case that it was exactly as that that the that the lower B. M. I. And lower body fats had higher mortality. We subsequently did a paper on this that was very difficult to get published. But in this paper we showed that those who were in the highest quintiles of both percent body fat and B. M. I had a much better survival than those in the lowest quintile. Now, some of you may say, well maybe this is due to cardiac cachexia, which is known to be a big part of advanced heart failure. Well, I can tell you that this was done in New Orleans Louisiana. We don't have much cock xIA, even our homeless, not very context sick in New Orleans. RQ one patients that present body fats in the low twenties and B. M. I. S in the low twenties. So hardly cachexia. In this paper, we showed that for every 1% increase in body fat in advanced heart failure patients, There was a 13% lower risk of mortality or need for urgent cardiac transplantation. Um Some have theorized that maybe it's that when people develop heart failure they lose weight. And so it was actually in the in the ARIC study, they studied 1500 patients where B. M. I. Was measured six or more months, an average of 4.5 years before heart failure developed and mortality in this population over 10 years was 43% showing you how many cancers have a much better survival than this heart failure is a deadly disease. They showed in this Jack paper in 2014 that pre heart failure, overweight and obesity had 28 30% respectively, lower mortality than the normal B. M. I. Patients who later developed heart failure. So being overweight and obese even before heart failure was associated with better survival after heart failure developed. The reasons for all of this is not clear. Certainly we know that advanced heart failure is a cata bolic state. So that may be metabolic reserve may be greater with obesity. We know that at a post tissue produces TNF alpha receptors that may neutralize TNF alpha that could have adverse effects and heart failure. We know that, as I mentioned with with with hypertension, obese have lower A NPS atrial natural peptides, BMPs and plas marine activity. Obese have higher blood pressures which may allow them to tolerate more about cardio protective medications used in uh in heart failure like beta blockers and ace and A. R. Bs. And now the army's. And there may be other mechanisms. It's it's not totally clear. And several years ago we reviewed all the data, particularly in in in coronary heart disease. And this is from one of our papers from the Mayo clinic proceedings over a decade ago of 581 patients who were followed for three years, all had coronary heart disease entering the cardiac rehab program. And we measured both B. M. I. And percent body fat. And we called low B. M. I. Less than 25 and low percent body fat, less than 25% in men, less than 35% in women. And we showed that both B. M. I. And percent body fat were independent predictors of survival. Low B. M. I. Low percent body fat were increasing mortality by about 3.5 fold. And almost all of our mortality during follow up were in our coronary patients who had both a low B. M. I. And a low percent body fat. And we excluded the underweight patients and found exactly the same thing in the paper. Later in Jack, we looked at both body fat and lean mass. Now we called it lean mass. It was really non fat mass because we we called everything that wasn't body fat to be um lean mass. And we showed in this paper that both a low body fat and a low lean mass were associated with about 2.5 fold, increased mortality. In fact, the best survival in our coronary population were in the biggest of the big those who had both the high body fat and a high lean mass and the worst survival. And this is about a seven times higher mortality. Uh Well, in those who had both a low body fat and a low lean mass. And if you had one of the two, you had an intermediate three year survival. Now it makes sense that having a high lean mass, which is mostly muscle mass, it's not all muscle mass is also skeletal mass, but mostly muscle mass. That this would be a good thing and increases body strength. And we know that muscular strength is a predictor of cardiovascular disease and survival. Um But again, what's the mechanism for the for the body fat. Um And it's not totally clear now, we've done a lot of work on the fit versus fat hypothesis. And this is in my first issue of progress and cardiovascular disease is a guy named von Berry wrote one of the papers for this issue, where he did a meta analysis of 10 studies that were prospective and objectively measured cardio respiratory fitness on the treadmill and B. M. I. And jointly assessed their impact on all cause mortality. And compared with the non normal compared with the normal weight fit. And they defined fit in most of these studies as not falling in either the bottom quintile, the bottom quartile and a couple of them in the bottom kershaw of cardio respiratory fitness for age agenda that those who didn't fall into that low fitness category, the normal weight fit. The unfit. Those who fell in the lowest fitness category had basically twice the all cause mortality regardless of their B. M. I. Regardless of they had normal B. M. I. Overweight or high B. M. I. The overweight fit and the obese fit basically had normal survival or similar survival as those who had normal weight fitness. So they concluded in this paper that fitness Was more important than that capacity for long-term survival. Now, we have assessed this in cardiovascular disease patients. This is a paper in the Mayo clinic proceedings a decade ago of 10,000 coronary patients who were followed on average for 13 years. And we assessed their fitness on the treadmill and we defined fit being not falling in the bottom. Ter shawl of age and gender related fitness. And we measured body composition by B. M. I. Percent body fat and waist circumference. And we showed in this paper that those who were relatively fit and this isn't super fit. This just means that they def it the patients did not fall in the bottom ter shaw that the relatively fit had good prognosis, good survival. This is all cause mortality during 13 year. Follow up uh regardless of their B. M. I. Regardless of the waist circumference, regardless of their percent body fat. But if you are unfit falling in the bottom Ter shop, you had a higher mortality and a little bit heavier had a better prognosis meaning a little bit higher B. M. I, a little bit higher waisted conference, a little bit higher body fat did better than those who were in the lowest showing a strong obesity paradox. And this is for all cause mortality. We basically showed the same thing in this paper with cardiovascular mortality several years ago. Ross arena. Um who's now in university of Illinois Chicago allowed me to use his cardiopulmonary stress testing data bank in heart failure. 2066. Systolic heart failure patients with ejection fraction is less than 40. The average ejection fraction was around 30 followed for three years. And we measured fitness, of course on the cardiopulmonary stress test. And we defined fitness based on the Donna Mancini criteria for 14 CCs of auction for kilogram permitted in this paper. Um, And and we and again, 14 CCs of action kilogram permitted is not any kind of super fitness, but that's been used for three decades for heart failure since she introduced this 35 years ago. Um, And we showed in this paper that if you're relatively fit with systolic heart failure, you had a good survival and it didn't matter what your B. M. I was. Now, I should say this is mostly a mild obesity paper because we didn't have many people with Class two obesity, very few people would be M. I. S. Over 35 we had none with B. M. I. S. Over 40 because it was a cardiopulmonary stress testing study. But in this cohort of at least mod obesity, we showed that it didn't matter what your B. M. I was uh, if you had relative fitness. But if you had low fitness, less than 14 CCs of auction per kilogram permitted, you had a much higher mortality. And there was a strong obesity paradox in the low fit the obese had the best survival followed by the overweight. And the worst survival was in the normal B. M. I patients. And we had already excluded the underweight because the underweight almost always have a worse survival whether it's cardiovascular disease, no matter what almost you're looking at. Several years ago, I teamed up with the group from Norway in their hunt study and we published this in American Journal of Medicine in 2017 of 6500 coronary patients Who were followed on average for 13 years. And we showed in his paper and again, another strong obesity paradox. But the obesity paradox was only present if they didn't meet their physical activity requirements. The physical activity guidelines set 100 and 50 minutes of moderate physical activity per week or 75 minutes of vigorous physical activity or some combination. If they met the physical activity requirements, they had a much better survival and there was no obesity paradox. But if you didn't meet the physical activity requirements, they had a worse survival. And there was an obesity paradox, meaning that the heavier patients had a better survival than did the thin inactive patients. And a couple of years later we published this in Jack of 3500 patients. We looked at changes in physical activity. And uh B. M. I. Over time in a 15 year study and assess mortality and cardiovascular mortality. We showed in this paper that changes in physical activity were much more important than changes in B. M. I. In fact, there was no group where falls in B. M. I were associated with better survival. And in the normal B. M. I patients, those who lost weight uh actually had a worse survival and those in the normal B. M. I. Group, those who gained weight had a better survive but maintaining or increasing physical activity which is much stronger predictor of survival than was weight in this study. So what all of these studies? Bacon basically show, I think is that cardio respiratory fitness and physical activity markedly alter the relationship between an apostrophe and subsequent prognosis in patients would establish cardiovascular disease such as uh coronary heart disease and heart failure. The atrial fibrillation is also epidemic proportions in our society right now. Um along with obesity and obesity seems to be a very significant drive of atrial fibrillation. This paper by franz messily and guanica and american Heart Journal showed 100 25,000 subjects obesity increased the prevalence of A. 50 by 50%. But then once you develop atrial fibrillation, the affirmed studies and several others show that the obese are having a better prognosis, and B. M. I. Was an independent predictor of better survival that those who are overweight or obese had lower cardiovascular and all cause mortality or to combine at that point the best survival was this is a hazard carried the best survival was in the high B. M. I. S. Followed by the overweight B. M. I. The worst survival was in the normal B. M. I. And again, they excluded the underweight because who always have a worse prognosis. So here in this, what can we say about weight loss and cardiovascular disease. We know obesity increases most of the risk factors. There is an obesity paradox though. We know that weight loss improves the risk factors. But there's very little data on weight loss and cardiovascular events and the obesity paradox makes this controversial. Certainly with vigorous some vigorous diets that can have adverse effects. Pharmacologic agents have had limited efficacy. But now with the GLP one agonist uh they appear to be producing quite significant weight reduction in a safe and if you combine this with G. I. P. Drugs you can get 22% B. M. I. Reductions. We need long term clinical events on this and the trials are going on for clinical events. I'm concerned that they're gonna stop at four or five years and probably we're gonna need 10 year studies to show that benefits uh with purpose for weight loss there is some data that calorie restriction associated with exercise training can reduce diabetes. Two papers in the new England journal boat showed the same thing. We've shown reductions in metabolic syndrome with this in uh in our cardiac rehab patients. But they're the studies that have assessed clinical events with weight loss have been very small. We know in hypertension. Weight loss reduces blood pressure and L. V. H. Um probably better than pharmacologic agents in heart failure. Weight loss certainly improves LV. Mass improves systolic and diastolic function and improves functional class. Um but there's no major clinical event data. Obesity surgery, we know reduces the risk factors and in type two diabetes uh actually can improve survival. This these curves usually diverged in around five years. Bariatric surgeries seem to be safe and coronary heart disease and heart failure. And there is some retrospective data that suggests that those morbidly obese severely obese who had previous heart failure after they get bariatric surgery, they have less hospitalizations for recurrent heart failure. But no randomized studies like this In coronary disease. Quinn packed reviewed a large amount of data, 12 studies and 14 cohorts, 35,000 patients and actually showed that weight loss and coronary disease was associated with more cardiovascular events. But the problem is is separating intentional versus unintentional and so that it presumed intentional weight loss in four cohorts, which intentional was with cardiac rehab associated with 33% reduction in risk. Whereas the observation alli weight loss was associated with a marked worsening in risk, 62% increase in risk. So the problem is, there's no randomized studies of purposeful wait lost. The the obesity and heart failure is certainly a major driver but the major societies have not said much about weight and actually the most recent heart failure recommendations only talk about the more severe obesity is a very significant risk factor, but not much about weight loss because we certainly need more data on this. We we've certainly been focusing on uh um at a post tissue distribution. Visceral fast certainly seems worse skeletal muscle body composition with muscle mass is an important predicted, particularly in heart failure. So muscling up to improve heart failure. Prognosis is something that could be important and certainly muscular strength is important. Protector against all cardiovascular diseases. Body composition may matter in advanced heart failure. We know that in heart transplant, obesity associated with more heart transplant complications including wound healing infection, pulmonary complication. DVT pulmonary embolism is associated with more early high grade rejections and high of five year mortality and class three obesity is especially as high complications. And generally now heart transplantations, there's no listening with class two and higher heart failure and L VADs. Obesity is associated with more driveline infections but overall similar outcomes. Obesity would be migrated. 35 was associated with higher device related complications leading to higher heart transplantation classifications and therefore earlier complications. Earlier heart transplant with more than heart transplant complications. Uh, obesity with L VOD who went to heart transplant had worse outcomes. And we know now weight loss strategies are needed in the L bad heart transplant candidates including with bariatric surgery. And we've published papers on using the sleeve procedure combined with L bad and it seems to be improving the prognosis. This is actually very small. Studies, much bigger numbers are needed. We're still in the Covid epidemic. We're getting a lot of covid here in new Orleans right now, we published this paper early in Covid. The mayo clinic proceedings quote from Val foose to said, let us learn from the past, a profit in the present and from the present to live better in the future. Obesity certainly has many factors that worsen Covid. Uh an increase inflammation. Covid is certainly an inflammatory state. At least the more immune dysfunction. Certainly more ventilatory dysfunction. More kidney disease. Early in Covid, we thought we were going to run out of ventilators. We were actually coming close to running out of dialysis machines, heart failure and atrial fibrillation with obesity of big risk factors in covid. And we know that obesity worsens and ethereal function. And papers early in Covid, in the Lancet showed that the end of theory were filled with the coronavirus and we now know that that that covid attaches to the ace two coronavirus attaches to the ace two receptors. And there's actually more ace two in the adipose tissue than there actually is in the in the lung tissue. And that's why the fat tissue can serve as a reservoir for the uh coronavirus. And probably increased uh worsen the prognosis in obese patients. Early on in Covid, we published this paper showing that the obese had a 39% higher worse complications in covid more, more uh admission to the icu mechanical ventilation and death compared to the leaner uh covid patients. Fitness also matters in Covid. This is a paper early in the mayo clinic proceedings. A small paper of 246 paper patients from uh Detroit and showed that higher fitness fitness measured before Covid was associated with less hospitalizations with Covid. Uh And actually there was for everyone met increase in the fitness, there was a 15% lower need for hospitalization and even after they corrected for baseline factors, it was 13%. So fitness seems to be protecting against Covid. We did the editorial for this paper and really focused on the fact that the african american population are particularly prone having worse complications from Covid. But we've published papers from Austin showing that the African american population have lower fitness more obesity. And we did a randomized study with people at the Pennington Medical biomedical Research Center in in baton rouge showing the African american actually had less improvement in their fitness after an exercise training program. So, particularly for racial disparities, we should be focusing on trying to improve the fitness level in the african american population. So, in summary and conclusion, I think there's overwhelming evidence that supports the importance of obesity in the pathogenesis and progression of most cardiovascular disease, probably especially heart failure with preserved ejection fraction and atrial fibrillation. But an obesity paradox exist at present. There is little evidence supporting purposeful weight reduction. I purposely, I actually believe in this. But there's more substantial data than increasing physical activity exercise training that improves fitness certainly has a better prognosis. And if the current obesity epidemic continues, we may soon witness an unfortunate end to study increasing life expectancy. And this is particularly concerning with the obesity now. And Children's and adolescents, both fitness and fatness are important. I think in a perfect world, everyone would remain lean and fit throughout the lifespan from childhood to old age. But this is hardly the case in our present society where most are gaining weight and losing fitness. I believe the guarantee to suggest that it would be actually better to gain some weight and maintain fitness than vice versa because fitness seems to be considerably more important than that capacity for long term health. And so this is a quote that I think we all deal with in our practices. Give it to me straight doc. How long do I have to ignore your advice? And particularly exercise advice? Everyone says that they're not exercising because they don't have time. The answer is what fits your busy schedule better exercising for so many minutes per day. I used to have 30 minutes on this side. I think earlier, I had 60 minutes. Uh you know, they've been studies showed at 10 and 15 minutes of exercise or improving mortality. But I think that doing some exercise certainly supports improving fitness And improving survival. So we got to get patients to exercise. And so the answer is what fits your busy schedule better exercising so many minutes per day or being dead uh for 24 hours a day. Thank you very much. And it was a pleasure speaking here today. Um and I hope you all have a great day in in pen fantastic talk. And thank you very much for joining us via zoom for for today's talk. Um as a reminder, everybody, the cmi code is 78134. I think we may have been having some issues with the chat and Q. And A. Tab. So if folks have any questions or comments, please feel free to submit them. I think it should be working now. Or you can always just text me um and I can convey that on. But in the last few minutes chip, hopefully if you got a little bit of time, we can go through some Q. And a questions here. You know, I guess the first question is great talk and I have to admit, I'm a little confused about what to think of obesity. Now. Clearly you paint the picture of how obesity leads to certain cardiovascular problems, but at the same time obesity may be protective from some cardiovascular problems. How do we wrap our heads around? So I think to me, I think, you know, it's hard to know exactly the mechanism but what my prediction is, you know, so you you told me earlier you're gonna be in the Cath lab today, which is gonna, you know, probably be dealing with some coronary disease that that we know that for example, that, let's say that, you know, most, most a lot of men in the United States, you know, let's say they finished high school at 100 and £60 and then they gain 50 or £60 over the next 30 years or 35 years. And those 30 those 50 to £60 leads them to develop increase inflammation, uh elevated triglycerides and low HDL high blood pressure, elevated sugars and metabolic syndrome or type two diabetes. And this may all lead to their coronary heart disease. And they're atherosclerosis. And then when they show up with coronary heart disease, if you compared them with an obese group, I'm sorry if you compare them with a group of who developed coronary disease. But at a at a at a low weight, maybe they continued at 100 and £60 or maybe only gained 10 or £15. Almost everyone gained some weight after high school. But maybe they only weigh 170 175 instead of 2, 10 to 20. That on paper, the obese look healthier. I'm sorry. The obese look more unhealthy. They have high triglycerides. Lower HDL higher crp s higher blood pressure, higher glucose, more metabolic syndrome or diabetes. But yet they end up having a better prognosis. They end up dying less than they end up uh you know, getting less cardiovascular mortality. And I think the mechanism probably is is that the lean person that the lean person who develops their coronary disease developed it for another reason from genetic predisposition. Whereas many of the obese may not have developed a coronary disease in the first place. Had they remained, you know, then during the next 30 or 40 years if they had not gained that 50 or £60 and developed all the Disl epidemiology and blood hypertension and L. V. H. And inflammation and glucose abnormalities. They may have not developed the coronary heart disease. So I think that that if it, so one thing that gets confusing about this talk is that on one hand, people here, just parts of it, they think that I'm saying that being overweight or obese is actually better. I clearly don't want to say that I want to say that remaining lean and fit throughout the lifespan would be the ideal situation. But I think the fact is when many of the people that we're seeing in the office and we're seeing in the hospital with heart attacks and unstable angina and heart failure and atrial fibrillation, their weight is high and it's not doomsday for those people, they actually can have a pretty good prognosis. In fact, I think that if I was seeing two patients in the office 30 years ago, one with a B. M. I. Of 22 the other one with A. B. M. I. Of 32. I would have thought that the B. M. I. Of 22 would have a better prognosis and it's actually the opposite of that, you know. So I think that uh that we probably should be more worried about the patient who developed significant heart disease at a low B. M. I. Than with with with the high beam. So the message for the high B. M. I. If they can prevent further weight gain and prevent themselves from moving into the very high B. M. I. Classes and if they can increase physical activity and prove their fitness, they can really have a very good prognosis. There actually is data in atrial fibrillation at least that improve lowering weight and improving fitness, particularly if you do both. You can lessen the recurrence of atrial fibrillation. There's actually no data on that for heart failure and uh and coronary heart disease at the at the present time. But at least in atrial fibrillation we know not for survival, but it can actually weight loss and and improving fitness can actually lessen your chance of having atrial fibrillation recurrence in several randomized trials. Well, chip what a wonderful talk in eye opening in in many ways and confusing message for patients in some ways. I mean, I think what I'm hearing loud and clear was when I see my overweight patients with coronary disease. I should spend maybe more time on exercise than I have on weight loss. But then what's the takeaway message for that patient from their Children who we don't want to get, we want to remain active and not get obese. Yeah, I think again, I think telling them that that if if they would have never gained all the weight, they may not have developed heart disease in the first place. And so if their kids can prevent the weight, the weight gain, maybe they would be in better shape a few decades, you know, from now than they are. But for them sitting there with you, I think, I agree. You know, that if they increase physical activity, one that will go a long way and prevent for the weight gain, I'm I'm perfectly fine from trying to lose 5, 10 or £15. You know, most of them have a hard time losing, you know, £50. Uh, and and and and some of them are pretty successful with losing a few pounds. But if they at least increase their physical activity and uh, and and and improve their fitness, they'll make their prognosis better. And that will prevent uh, at least a marked weight gain. Some people will start walking, you know, two or three miles a day and still gain a few pounds over the years. But they will gain a lot less if they're doing regular physical activity than they would have. Uh, you know, if they if they would have continued in their sedentary lifestyle, be nice to get cardiac rehab approved for people with stable coronary disease as opposed to the limited window we have now because I think that kind of, I don't know how you feel about that, but I think some people that organized start would be beneficial. It is honestly, it is, it is honestly approved, stable angina is approved for Medicare. The issue is getting it actually improved by many of the insurance companies and uh you know, certainly the evidence is strong of uh for for patients who've had a myocardial infarction and api ci uh in a you know, so, so, but I I do think that I think many people would would would would benefit from cardiac rehab. And cardiac rehab is very, very underutilized. Many of the stats say 2030% attend cardiac rehab. I really believe in the United States. The number is probably only 5 to 10% because many places don't even have cardiac rehab. And you know, many patients don't uh don't attend the program. And even even in our own center, which we're very focused on it. Um you know, we probably only have a third, you know that the candidates actually attend and complete the program which is, which is probably very high nationally. So, I do think we need to do a better job of getting cardiac rehab out in the community, making it probably remote, you know, so we gotta, you know, many places are in the process of trying to develop remote cardiac rehab where they don't have to go to the center, we can have the cardiac rehab in the home uh making it more convenient for patients um doing using apps using uh you know fitness devices. Um and even even sometimes doing monitoring remotely all of this can be done. And I think right now people realized that when covid hit when the cardiac rehab closed down almost everywhere that many places if they had remote cardiac rehab, they could have just continued it like nothing had happened. But for the future we don't need just for covid but we needed really to to reach a much greater percentage of the population. And then maybe it can be more cost effective and then maybe it would be more attractive for health plans and and uh and for for insurance companies uh to fund, you know, lower cost cardiac rehab program. But thanks harvey for that comment. You know the other comment I make when I grew up there was you remember the JFK exercise program that kids had to go through in school and pass certain levels of exercise, they have to be able to swim. They had jim my senses now in this country. There's less emphasis on that. Which man, I just wonder how that can be turned around. Yeah. You know, so so I really believe that that's the you know when when when you and Iowa kids harvey there was hardly any heavy kids when they want it. Maybe a little chunky but not the very heavy kids that you know that you see today and the kids now, you know, there are so many things that have happened. One is that they're, you know, people are more more afraid of letting their kids just run the streets because they, you know, it's sensationalized in the media when you have a kid gets, gets kidnapped or gets, You know, abused. Um, so kids are not, parents don't just let their kids run, you know, and and say, see you see you at 8:00 AM and then they come back in at five in the evening. You know, they want to know where they are every minute of the day. Then you have the kids on their, on their phones and on the computer and on, you know, watching video games and not out doing physical activity, Probably also eating more fast food, you know, sitting doing, doing low, a lot of sedentary behavior with fast food. And so you're seeing the weight go up and the kids and adolescents at, at, at the proportions that were way more than when we were kids. Uh, and, and this is, you know, so, so if you look at our obesity in our age group right now, it's tremendous and a lot of cardio metabolic disease. Well, the people our age that obese with cardio metabolic disease. They weren't obese when they were in high school and when they were in college, you know, they, they gotta became obese later. Well now the kids are already overweight and obese. This is gonna be a very, very bad sign going forward. And certainly, uh, reversing the physical activity issue would be a big, would be a big thing. And, and maybe we have hope with, you know, you know, with more use of the, of the obesity medications and and and bariatric surgery for the future. But really the key would be doing it with the physical activity and and really physical activity in the schools. But that's really not happening, you know, to nearly enough right now, you know, there's been some efforts and, and you know, certainly there are some communities will make an effort and putting, getting, getting it more, you know, you know, pe is not even in the curriculum, you know, in many schools now, you know, and so it really, uh, you know, it really is, is going to be even more of a problem if we don't reverse it, you know, in our kids and adolescents. Yeah, incredible. Well, I appreciate your comments. Um, there's one question, if we have one more minute here, uh, and the question is, can you expand on the role of sleep apnea on the risk of heart disease and obesity. Yes, so, so, yeah, so certainly, certainly it seems that, uh, that sleep apnea, you know, 11 obesity is certainly a big cause of obstructive sleep apnea. Uh, there may be some role that sleep apnea is actually worsening obesity. I think that that that and and and certainly sleep apnea probably is a significant factor in atrial fibrillation. There's very little data. You know, we would have thought that doing treatment for sleep apnea would have significantly changed cardiovascular disease events. And the studies, I think of sleep apnea treatment are showing better quality. But I don't think there's very much evidence that sleep apnea treatment is actually reducing cardiovascular disease right now. Things like hypertension. Um, you know, and occasionally some people might get better control of blood pressure, but certainly there's not evidence that's reducing coronary heart disease and heart failure events, at least in the short term studies that have been done with sleep apnea right now. I do think there's many reasons to treat to, to treat sleep apnea for quality of life. But I think right now for coronary heart disease and heart failure. Uh, there's, there's not a lot of evidence uh, that supports it accepted anecdotal isolated patients. Not the big studies are not showing the clinical event reduction that we would have predicted. Well, well, what a wonderful eye opening talk tip. I really, really, really appreciate. It sounds like lots of opportunity in our country to change lifestyle at a young age to prevent some of the diseases that we're gonna live through for some time now. On the other hand, your emphasis to patients on the importance of exercise in addition to some reasonable weight loss. But that that major major importance of exercise, even if people have disease uh is certainly um you know, important part of the care we're gonna live with our patients. So thank you for this incredibly informative grand rounds. Uh and I think um I think we all learned a lot and we'll probably have significant changes in the way we practice the result of this talk. So, thank you so much and smear any other comments from you also would be great. And again, thanks so much for taking the time. Chip eye opening fantastic talk. Thank you for joining us once again. And uh for all the work that you've done in this field, it's really been educational and I think on a population level, so important and and will hopefully make a huge impact in the future of of people. So, congratulations. Harvey, it was a pleasure being with you all this morning. You all have a great day. We're we're almost as cold in New Orleans this morning as y'all are in in philadelphia. I think that I was heard it was 40 degrees there and it was 46 here now, 46 here, people think it's freezing, you know? So uh anyway, y'all have a great day. Bye now