Medical evaluation and treatment of the obese patient with cardiovascular disease

Abstract

The incidence of coronary artery disease only weakly correlates with the percent of excess body weight; however, obesity in humans is not a homogeneous condition. Classification of obesity based on anatomic distribution of body fat allows for identification of a group of patients at increased risk for cardiovascular disease. Abdominal (upper body) obesity, measured as the waist/hip ratio, is a strong independent risk factor of cardiovascular disease and should be used to assess a subgroup in need of medical weight loss treatment. A focus on dietary fat intake and the magnitude of overeating “caloric intake” are central to the pathogenesis of cardiovascular disease observed in the obese person. Identification of the process of overeating (magnitude of recent weight gain, episodes of weight cycling) is important in the design of successful medical nutrition treatment programs. A nutrition/medical history that includes age of obesity onset and duration of obesity provides additional criteria for assessment of risk of disease. Childhood-onset obesity and prolonged obesity (>15 years) has been associated with increased cardiovascular disease risk. Recently, grades of obesity based on body mass index have provided a valuable marker for treatment. Each reduction in obesity grade (equal to Δ5 body mass index or Δ11.6 kg) is associated with a decrease in risk of medical illness. The new focus of obesity treatment should be to decrease body weight in 10% to 15% increments (equal to 1 grade) with emphasis on reducing the risk of medical illness and treatment intensity (e.g., number of existing medical visits, hospitalization). Rather than focusing on achieving “ideal body weight,” the goal of any treatment should be to achieve and maintain medically significant weight loss using these criteria.