Scott Webb (Host): We hear about weight loss in the news and on social media, but in addition to looking better in our Instagram photos, weight loss has many health benefits, especially to our hearts. And joining me to tell us more today is Dr. Waqas Malick. He's the Director of Lipids and Cardiometabolic Disease for the Valley Medical Group.

 Welcome to Conversations Like No Other: Heart Care, presented by the Heart and Vascular Institute of Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad everyday cardiac topics to discuss very real and very specific subjects that impact your heart health. We think you'll enjoy our fresh take. I'm Scott Webb. Thanks for listening. Doctor, it's nice to have you here today. I am in my fifties. I'm a little bit overweight. I think about things like, you know, weight loss and the impact that carrying the extra weight has perhaps on my heart. So let's start there. What is the connection between weight and heart health?

Waqas Malick, MD: Basically when I think about cardiovascular disease, I think of six cardiovascular risk factors. One that's not very modifiable, but five that are modifiable. The one that's not modifiable is your genetics, but then the five modifiable risk factors are smoking, your cholesterol, your diabetes, obesity, and hypertension.

A lot of these factors are driven by the genetics already, but a lot of the environment can also play a role. So obesity, which historically has been defined by, you know, BMIs greater than 30, has been associated with heart disease for a long time. But what we really think about it is that obesity itself, is a progenitor of the other risk factors. So for example, the more fatty tissue you have on your body, the more likely you will have diabetes and insulin resistance. The more likely you'll develop hypertension, the more likely you'll have sleep apnea, which will contribute to hypertension, and the more likely you'll have high triglycerides and high cholesterol and inflammation as well.

So when I think about weight, I don't think just about the obesity, I think about all the other risk factors that come associated with it, and so the better you can control your weight early, the more likely you are to prevent downstream heart disease.

Host: Yeah, that checks out in my brain, right? Because I'm like, okay, we can't outrun our family history and genetics, but there are things that we can control. And as you say, the downstream effects of carrying that extra weight, whether it's high blood pressure, diabetes, you know, the greatest hits if you will. So why does specifically carrying extra weight puts stress on our heart in the first place?

Waqas Malick, MD: Just to take a step back, the thing that we really worry about with weight is actually what we should really worry about is how much adipose tissue you have. Okay? So adipose tissue is what we define as like a conglomerate of fat cells in your body, and it can deposit really anywhere in the body.

So it can deposit on your muscles, you can deposit on your arms, pancreas, your intestines. We call that visceral fat specifically. Again, deposit on your hips. And that's called, more like truncal fat. So what we are concerned about overall is where this adipose tissue is depositing.

The more adipose you have, the higher the risk. So for example, you need to have the insulin be able to allow your muscles or insulin helps your muscles uptake glucose. Okay? And glucose is necessary for energy, but if you have more adipose tissue on those muscles, it makes the muscles more insulin resistant.

So you need more insulin to overcome that ability to get glucose in there. So the more adipose tissue you have, that means the more risk of diabetes and what we call hyperglycemia we have, which leads to cardiovascular disease. I mean, diabetes is probably the number one risk factor for cardiovascular disease.

Because it also plays a significant role in how cholesterol is trapped, how much inflammation you have, et cetera. So the main concern I have with weight actually, is how much adipose tissue you have. So one of the best examples I can give you is in South Asia, which is predominantly countries that include India, Afghanistan, Pakistan, Sri Lanka, Bangladesh, and Nepal; there's a high instance, of what we call central obesity. So the BMI, these people are relatively thin, is not very high, like, 23, 24. But if you look at their body type, the adipose tissue tends to accumulate a lot in the core. There's a lot more visceral fat and all of these factors contribute more to inflammation.

So why does carrying extra weight put stress in the heart? I don't like using the term weight, but I do worry about adiposity. That's what I call it.

Host: Okay. Yeah. I'm thinking about fitness, right? And I have some friends, uh, that work out a lot, but don't ever seem to lose weight. And it makes me wonder, like if we just improve our fitness level, does that have heart benefits even if we're not losing weight?

Waqas Malick, MD: That's a great question actually, because, I'm actually kind of struggling with that myself recently, um, where I've been exercising a lot, but not really losing the weight.

Host: Yeah. Right.

Waqas Malick, MD: I favor fitness and, like I said, than the weight itself, right? So for example, you see these guys that lift a lot of weights or bodybuilders, they're BMI is technically obese and their weight's very high for their heights. You know, you could be 5' 10", 225 pounds of all muscle and your BMI is technically obese. But that does not mean you're metabolically unhealthy necessarily. Assuming you're not using extra supplements and like steroids.

Host: Right. Yeah.

Waqas Malick, MD: Assuming you're doing all natural, I would not consider you unhealthy.

And you know, the other thing I was going to say about this is what we look for, or I look for specifically, is something called waist to hip ratio. So, if your weight is high, but your waist to hip ratio is low, meaning your waist is narrower than your hips, you're actually a metabolically healthy person. And so I am not necessarily that much worried about the weight itself in that person, if that makes sense.

Host: It makes me wonder like what changes happen inside the body and the heart when we are able to lose weight?

Waqas Malick, MD: Yeah, so if you have extra weight, and you are like, you know, let's say a 300 pound person, your heart needs to work harder to deliver blood to your, the body. You know, 'cause adipose is vascularized as well.

So you're putting a lot more stress on the heart to pump blood throughout the body, chronically every beat. This can drive what we call left ventricular remodeling so the heart can get enlarged. It can develop what we call heart failure like symptoms. And it can cause, you know, inflammation and stress by activating certain hormones in the sympathetic nervous system, which is a stress system, to make the heart work harder.

And so that's one of the reasons why being morbidly obese carries such significant cardiovascular risk, not just from a coronary disease perspective, just the arterial plaque, but also from like a heart failure perspective. I don't know if we're gonna talk about GLP-1s, but we know that because we've had a couple of trials now with these medications where we showed that if you lose the weight, in people with heart failure, you actually reduce the heart failure symptoms and actually improve some of the heart failure with preserved ejection fraction remodeling.

Host: Okay.

Waqas Malick, MD: So losing weight reduces a couple of things. Number one, it reduces the adipose tissue on your heart. It, it helps like, you know, keep your heart leaner. It reduces insulin resistance. Your arteries tend to be cleaner. You don't trap as much cholesterol, you reduce inflammation. So from my perspective, losing weight is usually beneficial. Or when I say lose weight, I mean losing adiposity. Losing adipose tissue is always beneficial from that perspective.

Host: Yeah. So obviously, benefits to the heart, benefits to our bodies, maybe even our minds. You mentioned the GLP-1s and so many folks on these medications, and so many folks losing weight, which seems like a good thing. I see the, you know, Instagram and Facebook and everybody seems to be losing weight, but is it possible to maybe lose weight too quickly and if so, can that be harmful to our hearts?

Waqas Malick, MD: It's a great question. I'm not entirely sure that losing weight too quickly can be harmful, but in relation to the GLP-1s, so what I worry about is if you lose weight too fast, it's that you're hurting the rest of your body as well. Okay? So what I mean by that is sometimes you see these patients that get their doses up titrated pretty quickly, right?

And so they lose 50 pounds within six months. And we see this with bariatric surgery as well, and that catabolic state of starvation can also affect your muscle mass. Obviously it's been reported that there's something called Ozempic face where you see, you know, people's skin sagging, and the other problem is with these drugs is that the way they work is by appetite suppression.

So if you're not eating anything to upkeep with the nutrients, these can cause problems. Having said that, we have bariatric surgery literature that, long-term weight loss with Roux-en-Y gastric bypass has positive effects on the metabolic risk and profile. Hypertension, diabetes, they're relatively cured and it's sustained for a long time with gastric bypass surgery.

So, it's hard to say what the long-term effect of the GLP-1s will be and if it's harmful, but in the short term, I do worry that if you lose it too quickly, you can't upkeep with the muscle mass and the nutrition that's needed to keep the rest of your body going as well.

Host: Right. You might be losing the weight, but you may be damaging other things in the process simply because you're not eating right. It's an appetite suppressant, of course. Is there a myth about weight and cardiovascular disease that you've just been dying to, uh, debunk, if you will?

Waqas Malick, MD: I do think that, weight and BMI is a little bit overrated as a marker. I think what we really care about is how much adiposity you have, how much adipose tissue, and we should move away from I think, weight. It's very damaging to be honest, that philosophy, like, you know, I, I see sometimes women, who are young and concerned about their risk and they're into lifting weights, you know, and they feel great and they feel strong, but they're very worried about their weight, but they're lifting weights and they're strong and are metabolically healthy, and I have to convince them that, you do not need a GLP-1 to lose weight just because your BMI is 28. But even then it's like, you know, psychologically in our society, that thinking is very pervasive. That weight number is what ultimately matters. And I would say that I would urge people to debunk that kind of thought process and think about just like relative fat distribution around your body.

Host: Right. Yeah, good stuff today. I'm glad we had this conversation. Just want to give folks a sense if they feel a little overwhelmed, Doctor, maybe like what's a small, realistic change that we can all make today to improve our weight and our heart health you know, in conjunction?

Waqas Malick, MD: First thing I want to say about this is we misunderstand weight loss and how to lose adipose tissue. A lot of people think it's like if I eat, you know, two meals a day or healthy eating, that I will lose weight and then they don't.

And the reason why is because what we don't really take into account is what we call our metabolic rate. For example, if you wear an Apple Watch, you can go to your health app and you can look up what your resting metabolic rate is. Now, it's a rough estimate, but I think it's pretty close. So for example, if you're in your twenties, you probably burn just if you sit on a couch all day about 2000 calories to 2100 calories just by sitting on a couch at age 25.

But that slows down dramatically over time. Okay. So by the time you're going to be 50, your resting metabolic rate will probably come down to 1400, 1500. Or really by the time you're 60 and then by the time you're in your seventies and eighties, it's probably going to be down to a thousand.

This is why the GLP-1s work because they make you not eat so you can achieve a calorie deficit to lose weight.

Host: Sure.

Waqas Malick, MD: So now that takes me to my second point, which is what is one small change they can make? One of the biggest sources of unnecessary calories I find is drinks. All right, regardless of like, you know, alcohol or non-alcohol, but just one can of regular soda is 140 calories. And one, 20-ounce bottle of Coca-Cola is about 260 calories, I think. So if you can find a way just to like convince yourself to switch drinks from regular calorie soda to even diet soda, water, or sparkling water. And a lot of people need the carbonation, I think. The American society's addicted to carbonation.

Host: Me too.

Waqas Malick, MD: Me too. I know. But if you make that switch just from that soda to like sparkling water, that's a big difference in just like your ability to achieve a calorie deficit or even come close to calorie maintenance, right. So that you don't gain weight.

So that would be a big difference. I think we are too used to being stationary. Too used to like taking elevators when we can take stairs. So if there's any opportunity you see to even climb one flight of stairs or two flights of stairs or get some extra steps, take it,

Host: Yeah, little longer walk at Costco. You know, I always park a little further away just so I can get that little extra, those few extra steps in.

Waqas Malick, MD: Exactly. You know, and that stuff makes a, you know, a difference at the New Valley Hospital. I mean, it's huge. So everyone's getting their steps in now, but like, you know, I remember at at Mount Sinai our cardiology floors were on like the fifth floor, sixth floor and seventh floor.

You could always take the elevator from seven to five or five to seven, but it just climbing those two flights of stairs, multiple times a day makes a difference, you know, because these habits built up over time. But those are the two suggestions I would have if you feel overwhelmed.

Just start with the drinks at the very least. If you eat fast food instead of getting the regular soda switch to diet soda, if you eat at home, don't have the can of Diet Coke or a juice, have water, that would make a big difference, you know, and trying to find a way to increase your steps here and there as you can.

Host: Yeah, I mean, I think that that's the thing. As we've established here today, you know, we can't outrun necessarily our family history and genetics, but there are things that we can do, maybe a little less fixation on the numbers and the weight, and more on just overall health, which obviously impacts our hearts and everything else, and as we're finishing up here, you know, just a few extra steps, right?

Anything that we can do will help our bodies, our hearts, all of that. I really appreciate your time today.

Waqas Malick, MD: Yeah, of course. My pleasure and thanks for having me.

Host: And we hope Dr. Malick's insights have helped you to better understand how maintaining a healthy weight can protect and strengthen your heart. Remember, your heart works tirelessly for you every day. Keeping it healthy is an investment in your future.

 And if you have concerns about your weight or heart health, don't wait. Talk to your doctor. For more information and resources, visit valleyhealth.com/heart. And as always, be sure to subscribe and share this episode, and take good care.