Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name's Warrick Bishop and today I'd like to talk a little bit about obesity, pre-diabetes and diabetes and in particular the impact on heart attack prevention or risk of heart attack. Well, the last decades have really seen the widespread availability of high caloric, processed, quick, cheap meals broadly through our first world communities. And this has been disastrous, particularly in combination with increased automation and less activity. This is really underpinned to a large degree, the obesity epidemic that we're seeing in our first world countries. Well, the significance of this is the impact that carrying extra weight can have on cardiovascular health. And that is a number of main things. Once we see people with a BMI, which is over 30, then we know that there is significant increase risk of atherosclerotic coronary artery disease. That's heart attack. and stroke, we know there's increased risk of cardiac failure, particularly so the type of heart failure with preserved function of the heart. So the heart fails to relax well, and we know there's a significant increase of atrial fibrillation, let alone the associations with hypertension and diabetes. Well, the weight gain is obviously the problem. In the very first instance, the most important thing I think people can do is be aware of the impact of these high caloric processed, often sugar enhanced foods that are the easiest and quickest things out of convenience and out of price for us to reach for. Unfortunately, we need to recalibrate and look at better ways to eat natural foods, balanced foods, greens. meats, fruits, but not too many, and a realisation that a healthy, balanced diet with unprocessed food is going to really help us reduce the likelihood of progressing to obesity, prediabetes and diabetes. The challenge, of course, is once we get to a stage where the weight is too high, then weight loss really does become complex. It's a matter of all sorts of issues that need to be changed to allow that individual to reduce their weight and come back into a healthy range. There's a lot of guidelines around this, and most of those guidelines are centred on caloric restriction. But of course, there are things like socioeconomic aspects. particularly financial aspects. Whatever's going on within an individual's life, which will be psychological impact as well. So caloric restriction as a basis for discussion may be important, but there's a whole individual that needs to be dealt with. In my own practice, I tend to think it's important to reduce carbohydrate because many of the patients I see who have put on excess weight, are carbohydrate sensitive or insulin resistant and so caloric restriction may be one avenue but certainly carbohydrate restriction at least in my own experience is incredibly valuable and a great starting point. A lot of the research would tell us that face-to-face interaction with someone to support you losing weight makes the most sense and that would make sense to me in my own practice there's a number of key factors that I would see as important for someone to be able to achieve weight loss and sustain that weight loss the first of those factors is that the individual has to want to change it they have to be prepared to change if someone doesn't want to change then you're not going to be able to alter anything for them that person then needs to be able to be given information to help them with their journey. That information then needs to be turned into knowledge. The difference between information and knowledge is a fine year medical student has lots of information but you wouldn't let them look after you until they've been working for a number of years where their information becomes knowledge. I think it's really important for patients to have some sense of accountability and that's why face-to-face is so important. So I often will bring people back for some accountability generally on a two, three or six monthly basis depending on how much support I think they might need. And lastly, patients will over and above accountability need. the support that a coach might give them in any sort of sporting endeavor. And that reassurance or that support are things like, if they've done well, rejoice with them, give them that lavish approbation. If they've done badly, recognize that things come along in our lives and just stop us from time to time. And that's okay. We have to alter our priorities, but let's regroup and let's start again. So there's no question that food is incredibly important. Lifestyle is important. Exercise and activity are incredibly important. But this is difficult because if people don't enjoy exercise, they won't do it long term. Things like taking stairs rather than the lift are a great starting point. When individuals have had a go at lifestyle modification but still need a bit more help, then there are options for weight loss using medications. And there's a number of different agents that can be used. There's a thing called sexenda, liraglutide, which is a GLP-1 agonist. And that really turns off the... appetite sensors in the brain and it's a great tool to help people if you like break a meal, skip a meal or put in place intermittent fasting. Fenteramine or duramine can equally be used in a similar way but this tends to be a stimulant as it drives the sympathetic nervous system. So it may raise blood pressure, and this could be problematic. Certainly for people with high blood pressure, one would be careful. Orlistat can be used. This is an agent that binds fat within the bowel and will help people reduce the amount of calories they absorb from the bowel by holding onto the fat within the diet, and that gets passed out. through the bowels. Of course, if a patient eats too much fat, then the consequence of oral stab binding that fat really gives quite an unpleasant sort of side effect when those individuals go to the lavatory. And there is also naltrexone-bupropione. Naltrexone-bupropione is a combination which is also an appetite suppressant that works through the opiate receptors in the brain. So these are great supports for people who are looking to make change and can certainly help them advance and start to turn things around. Well, if dietary change, lifestyle change, and pharmacological therapy don't change, and an individual is still way over their 30-odd BMI, then there is a role for consideration of a conversation around bariatric surgery. This is pretty extreme. And in my own experience, I would really only see it as a last resort if we're just not winning in other areas. But it does work. It's incredibly beneficial in terms of weight loss. And with current gastric sleeve surgery, which seems to be better tolerated and carries less complication than gastric band surgery then these can be great long-term results dropping people's blood pressure sorry dropping people's weight consequently dropping their blood pressure dropping their insulin resistance improving their cholesterol levels and really seeing an enormous benefit we know that five percent or more of weight loss brings individual benefit in terms of blood pressure cholesterol blood sugar levels But over and above that, benefit in terms of sense of quality of life. Unfortunately, obesity is on the spectrum of pre-diabetes and diabetes, and that's when we start to see blood sugar levels increase and insulin levels increase. And in a simple way, type 2 diabetes is diagnosed when the hemoglobin A1C, which is a marker for the amount of sugar-affected protein in the blood is greater than 6.5 percent. We say this person has elevated sugars long term to such a degree we would define them as type 2 diabetes. Well we know about 10 to 15 percent of the population of major western economies have the condition of diabetes and that's diabetes 1 and diabetes 2. Diabetes 1 is the juvenile onset type of diabetes where there's an autoimmune or a self-generated problem with the pancreas and it stops producing insulin. They're type 1 diabetics who need to inject with insulin, often from a young age. It turns out the type 2 diabetics, which are the people or the individuals who tend to progress through obesity, prediabetes, insulin resistance, raised sugars, make up 90 to 95% of all diabetics in the community. There's no question that this condition is closely linked to atherosclerotic cardiovascular disease, which is heart attack and stroke. Interesting to note, though, that recent years has seen a decrease in the rates of atherosclerotic cardiovascular disease within diabetics. And this is really testimony to the enormous input into primary prevention in this group by treating elevated blood pressure, by really jumping on to the raised sugars with better agents all the time and judicious management of the cholesterol by lowering that using statins. So interestingly, although coronary disease and stroke has come down within type 2 diabetics through important primary prevention measures, it still remains a significant cause for mortality and morbidity. The overarching issue in this space, however, is to try and avoid that weight. gain in the first place and maintain a healthy weight from the very beginning. It is much easier to lose one, two, three, four or five kilos than it is to start on a journey trying to lose 15 or 20 kilos to get back to a healthy cardiovascular and healthy overall weight. There's no question that by attention to appropriate eating and lifestyle modification early on in a process that an individual can own their own future health outcomes and start to turn things around. So my strong advocacy is whatever situation you're in with regard to your weight, keep a close eye on it. If it's creeping up, do the things to get it to start creeping down. An early intervention is much, much better in so many ways for so many reasons than leaving it too late. So that's obesity, pre-diabetes and diabetes. I hope that all makes sense. If you've got any queries or questions, drop us a note. Take care and bye for now. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. 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