The following are key points to remember from a European Society of Cardiology (ESC) clinical consensus statement on obesity and cardiovascular disease (CVD):

1. Globally, the prevalence of obesity has increased more than two-fold over the past four decades, with approximately one in five adults being obese. An estimated 67.5% of obesity-related excess mortality is attributable to CVD. Obesity is preventable and treatable, with treatment based on multidisciplinary approaches including behavioral interventions, nutrition, physical activity, pharmacological therapies, and surgical therapies. The objective of the ESC statement is to raise awareness of obesity as a major risk factor and to review evidence-based practices for the prevention and management of obesity.
2. The World Health Organization (WHO) cut-points for weight include normal body mass index (BMI) of 20 to <25 kg/m², overweight (BMI 25 to <30 kg/m²), and obesity (Class 1 [BMI 30 to <35 kg/m²], Class 2 [BMI 35 to <40 kg/m²], and Class 3 severe obesity [BMI ≥40 kg/m²]). Lower country-specific cut-points apply to Asian subpopulations. Obesity is associated with socioeconomic disparities, including lower educational obtainment. Genetic and biological factors also influence individual development of obesity. However, the obesity epidemic is largely driven by environmental and societal factors (e.g., increased availability of low-cost, highly processed foods, changes in transportation, and sedentary jobs).
3. Metabolically unhealthy weight includes higher visceral fat mass, low leg fat mass, and low muscle mass. Visceral adipose tissue carries the largest burden of metabolically unhealthy obesity, while subcutaneous fat is metabolically inactive. Measures of waist circumference, waist-to-hip, or waist-to-height ratio may better reflect visceral adipose tissue, which is associated with CV risk, rather than BMI alone. Thus, adults with similar BMIs may have different cardiometabolic risk. For waist circumference, ESC guidelines advise no further weight gain for values of >94 cm (>37 inches) in men and >88 cm (>35 inches) in women.
4. Approximately 80% of adults with type 2 diabetes mellitus (T2DM) are also overweight or obese, while nearly all adults who are obese have an almost three-fold risk for developing T2DM compared to normal-weight adults. Weight loss with lifestyle interventions or surgical interventions is associated with improved glycemic control, including remission to a nondiabetic state. Given insulin resistance is associated with an increased risk for CVD, the ESC recommends adults with DM and overweight or obesity aim to reduce weight and increase physical activity to improve metabolic control and CVD risk (Class Ia).
5. BMI is linearly associated with increased blood pressure. Conversely, clinically significant long-term reductions in blood pressure can be achieved with even modest weight loss. Research supports weight reduction through lifestyle alone or in combination with surgical treatment. However, visceral fact accumulation is strongly associated with hypertension (HTN), suggesting that measurement of adipose beyond BMI may be clinically relevant.
6. Weight loss is associated with reductions in triglycerides and low-density lipoprotein cholesterol and increases in high-density lipoprotein cholesterol, with the greatest effects on triglycerides. A 5-10% reduction in body weight can decrease triglyceride levels by 20%. Apolipoprotein B measurement is recommended for risk assessment in adults with obesity (Class Ic).
7. Obstructive sleep apnea is a risk factor for HTN, heart failure (HF), and pulmonary HTN. Weight loss of 10% in obese adults is associated with significant improvement in the apnea-hypoxia index. Weight loss in combination with continuous positive airway pressure improved CV risk factors, including insulin resistance, triglyceride levels, and blood pressure.
8. Treatment strategies for obesity include lifestyle interventions targeting diet and physical activity. Dietary interventions generally aim for a 500-750 kcal/day energy deficit with recommended strategies, including portion control reduction of ultra-processed foods and alcohol, while increasing fruit and vegetable intake. Most dietary patterns resulted in similar, modest short-term weight loss with improvements in CV risk factors. Large-scale trials have generally combined dietary interventions with increased physical activity. A combination of dietary and physical activity interventions is recommended as the first-line treatment of obesity to achieve a sustained loss of fat mass with minimal loss of muscle mass.
9. Psychologic interventions can be important components of weight loss programs. Food is often a coping mechanism for managing emotions. Obesity is highly stigmatized in societies, including health care settings. Patients are more likely to lose weight when clinicians communicate using a supportive, nonjudgmental approach. Lifestyle programs are generally cost-effective, with an estimated 10-year cost savings of $5,280 per person.
10. Currently, six drugs are approved by both the European Medicines Agency and the US Food and Drug Administration. These include orlistat, naltrexone (ER)/ bupropion (ER), liraglutide, semaglutide, tirzepatide, and setmelanotide (for treatment of rare obesity-related monogenetic deficiencies. Caution is advised when using orlistat and naltrexone/bupropion in patients with CVD, given the lack of evidence among patients with CVD. Clinical trial evidence notes that semaglutide is associated with reductions in CV events compared to placebo.
11. Surgical treatments for obesity include intragastric balloons, endoscopic sleeve gastroplasty, and bariatric surgery (gastrectomy, Roux-en-Y). Bariatric surgery can be considered for individuals with a BMI ≥40 kg/m² or ≥35 kg/m² with at least one obesity-related disease. Long-term complications for bariatric surgery include internal hernia, marginal ulceration, malabsorption, osteoporosis, and depression. However, one meta-analysis of observational studies found reductions in all-cause and CV mortality and a lower incidence of HF, myocardial infarction, and stroke.
12. Obesity is strongly associated with development of atherosclerotic CVD, in part mediated by increases in CV risk factors (e.g., DM, HTN, and dyslipidemia). Furthermore, visceral adiposity in associated with development of atherosclerosis, in part due to increases in inflammation. Patients with obesity have elevated levels of pro-inflammatory cytokines and elevated levels of C-reactive protein. Interestingly, patients with moderately increased BMI and heart disease may have a more favorable prognosis compared to those with a lower BMI, while those with more advanced obesity have a worse prognosis. Underlying mechanisms of this observed ‘obesity paradox’ remain incompletely understood.
13. Obesity is a well-known risk factor for HF, including HF with preserved ejection fraction. In addition, conditions which are more frequent in the setting of obesity, such as HTN, DM, and coronary artery disease, can lead to HF through myocardial remodeling and diastolic dysfunction. HF may be a challenge to diagnosis among obese patients, given the lower B-type natriuretic peptide levels in the setting of obesity, along with the symptom of dyspnea frequent in both obesity and HF. Observational studies support weight loss in the management of HF in obese patients, although nonintentional weight loss is associated with increased mortality.
14. Obesity is associated with incident atrial fibrillation (AF), largely mediated by structural and functional cardiac changes. Weight loss may also reduce AF burden. However, it should be noted that increased BMI is associated with a lower risk of stroke and embolic events but increased risk for major bleeding. Current recommendations include weight loos for risk factor management in overweight and obese patients with AF to reduce symptoms and AF burden (Class Ib).
15. Obesity is associated with increased risk for venous thromboembolism (VTE). Furthermore, obesity can interact with other predisposing factors (e.g., age, prior VTE, immobility) to increase the risk of VTE. No dose adjustments are required for antiplatelet medications in patients with obesity. In patients who have an indication for chronic anticoagulation therapy and have undergone bariatric surgery, it is reasonable to prefer vitamin K antagonists over direct oral anticoagulants. In patients receiving warfarin and a glucagon-like peptide-1 receptor agonist, the international normalized ratio should be carefully monitored. It is reasonable to avoid edoxaban or dabigatran for the prevention or treatment of VTE in patients with a BMI ≥40 kg/m² or body weight >120 kg (>265 lbs).

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention

Keywords: Cardiovascular Diseases, Obesity, Weight Loss, ESC24, ESC Congress

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