Strategies for Trimming Your Waistline and Improving Heart Health

For several decades, obesity and type 2 diabetes have been rising steeply in tandem so that today they are worsening global pandemics with debilitating, expensive, and often lethal complications. The prevalence of diabetes in the U.S. has risen more than tenfold, from 2.5 million people in 1959 to more than 25 million in 2022. During the same timeframe, obesity has risen fourfold, so that now it affects 4 out of 10 U.S. adults and is the leading cause of preventable disease and premature death. About 9 out of 10 individuals with diabetes are overweight or obese, and some traditional glucose-lowering agents, including insulin and glimepiride, may cause further weight gain. Even when blood sugar levels are under ideal control using these older glucose-lowering therapies, about two-thirds of type 2 diabetes patients die from cardiovascular (CV) causes.

Lifestyle Improves CV Risk

Lifestyle strategies can produce weight loss and improve long-term health outcomes for people who have diabetes. Dr. Y.B. Zhang and colleagues in a recent issue of the Journal of Mayo Clinic Proceedings reported that people with diabetes who followed a healthy lifestyle had much lower risks of CV disease and death from any cause during a 10-year study. This was a large international study that included more than 100,000 individuals living with diabetes (about 50% were from the U.S., and about 25% each from China and the United Kingdom); 93% of the participants were over age 30 when diagnosed, indicating that the vast majority likely had type 2 diabetes.

The five healthy lifestyle factors assessed were: having an optimal body weight with a waist measurement of less than 33.5 inches for women and less than 35.5 inches for men; following a healthy diet; performing regular physical activity (at least 150 minutes per week of moderate exercise, like walking); being a nonsmoker; and drinking a low-to-moderate amount of alcohol regularly (not more than seven drinks per week for women and not more than 14 drinks per week for men). Study participants following four or five healthy lifestyle factors compared to those following only one or none, had a highly statistically significant 40% lower risk of death during the decade-long study. Attaining each one of the healthy lifestyle factors was associated with a statistically significant 16% lower risk of death during the study. People following four or five healthy lifestyle factors, compared to those following only one or none, also had a significant 33% decreased risk of heart attack and stroke.

Clearly, healthy lifestyle habits are essential for longevity and robust heart health. However lifestyle-based weight loss strategies, such as diet and exercise, though often effective in the short term, tend to be less effective in the long term because most people with obesity tend to regain their excess weight over time. For this reason, safe and effective medications to help people lose weight and keep it off are desperately needed.

New Wonder Drugs

In 1921, Dr. Frederick Banting discovered the first effective drug for diabetes by extracting insulin from the pancreases of young cows and using it in his diabetic patients. One century later, we have 13 classes of glucose-lowering drugs, including hundreds of FDA-approved medications for the management of type 2 diabetes. Though all these drugs reduce blood glucose, not a single one had been proven to lower the frighteningly high risk of CV death among people with type 2 diabetes until 2015, when a study called EMPA-REG Outcome showed that Jardiance (empagliflozin) reduced risk of CV death by 38%.

In the past seven years, many randomized outcome trials of medications called sodium glucose cotransporter 2 (SGLT2) inhibitors (examples include Jardiance, Farxiga, and others), and glucagon-like peptide 1 (GLP-1) receptor agonists (examples include Ozempic, Trulicity, and others), have proven that these two classes of anti-diabetic drugs bestow important benefits, including lower risk of heart failure, heart attack and stroke, as well as kidney disease. Because of these benefits, professional societies across the world recommend these medications in individuals with type 2 diabetes who already have—or are at high risk for—heart and kidney complications. Notably, these drugs are also effective for promoting weight loss for overweight and obese individuals.

These agents also help lower blood pressure and decrease the risk of chronic kidney disease progression. Importantly, SGLT2 inhibitors have now been found to be effective for improving outcomes in patients with heart failure and kidney disease even if they don’t have diabetes. Similarly, GLP1- RAs have been shown to result in substantial weight loss in individuals with overweight and obesity, but no diabetes (and are being evaluated for potential CV benefits in such individuals).

Here at the Haverty Cardiometabolic Center of Excellence and the Duboc Cardio Health & Wellness Center, we specialize in using these potentially lifechanging new treatments to improve the outlook for our patients with diabetes, prediabetes, and other cardiometabolic conditions, and help people get back to a healthy weight and waistline.

Safe and Effective for Weight Loss

Half of American adults have either diabetes or prediabetes, conditions that are frequently linked to overweight and obesity. Getting rid of excess weight around your abdomen can improve many CV risk factors, including high blood pressure, high cholesterol/triglycerides, fatty liver, and sleep apnea. Substantial weight loss can significantly improve diabetes control, and occasionally can even make type 2 diabetes go away.

When patients ask us how much they should weigh, we tell them, “You don’t need to focus on weight as much as waist measurement. Ideally, your waist should measure not more than half your height in inches.” So, if you are 6’ tall (72 inches), your waist should be no more than 36 inches; if you are 5’6” (66 inches), your waist should be no more than 33 inches.

Semaglutide (Ozempic) and liraglutide (Victoza) are GLP-1 receptor agonists that are FDA-approved for weight loss. These agents lower body weight by up to 5–15% by reducing appetite and slowing the rate at which your stomach empties thus increasing the feeling of fullness after you eat. Most people find that their cravings for junk food, sweets, and sometimes even alcohol are diminished. The weight loss is gradual, as the dose is increased slowly over three to six months in order to maximize their tolerability.

Empagliflozin (Jardiance) and dapagliflozin (Farxiga), the SGLT2-inhibitors most commonly prescribed in the US, are medications taken by mouth that generally produce relatively modest drops in body weight, typically 3–4% in obese people, and blood pressure, about 4 mm/Hg in people with high blood pressure. Importantly, the weight loss is additive when these two classes of drugs, SGLT2-inhibitors and GLP-1 agonists, are used together (and importantly their cardiovascular benefits may be additive as well).

Best Drug Ever For Weight Loss

Tirzepatide (Mounjaro) is a new once-weekly injection that represents a novel class of drugs that is now available for type 2 diabetes and is being studied for the treatment of obesity. This medication binds to the receptors in the body for two natural incretin hormones, GLP-1 and glucose-dependent insulinotropic polypeptide (GIP). So far, it’s approved for treating type 2 diabetes; however, tirzepatide looks to also be a highly effective drug for weight loss.

A randomized placebo-controlled clinical trial published in the New England Journal of Medicine studied tirzepatide for weight loss among obese individuals. Low-dose tirzepatide (5 mg injected subcutaneously once per week) caused a 15% decrease in body weight; full-dose therapy (15 mg/week) lowered weight 21%, or about 50 pounds on average. Tirzepatide also reduced waist measurement, blood levels of cholesterol, triglycerides, insulin, and glucose, and improved blood pressure. Side effects were limited to gastrointestinal symptoms, such as nausea, diarrhea, and constipation, which tended to diminish after a few days to a few weeks.

Take Home Message

Lifestyle strategies like diet and exercise are effective for improving heart health and life expectancy, and these remain first-line strategies for conferring well-being. You should always consult your physician before starting any prescription drug. But now, for the first time, we also have safe and effective drugs for improving CV outlook for patients with diabetes and for getting weight down to healthier levels in people with obesity. At Saint Luke’s Mid America Heart Institute, in the Haverty Cardiometabolic Center of Excellence and the Duboc Cardio Health & Wellness Center, we use these medications routinely in our patients, and we have been observing truly impressive results. Most importantly, our patients tend to come back happier and feeling better than they have been in years. In the future, many more cardiologists and other health care providers will be using lifestyle modification along with appropriate use of SGLT2-inhibitors and GLP1-RAs to treat people with obesity and/or diabetes, especially if they have established heart disease or are at high risk for complications. For us and our patients at the Haverty and Duboc Centers, the future is now.

In Good Health,

James O'Keefe, MD