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In OW2018 Keynote, Steven Nissen Was All Heart

On Tuesday in Nashville, Steven Nissen delivered the opening keynote lecture. From beginning to end, he told us, obesity is all about the heart. “Heart disease is how obesity kills most of our patients,” he said. “It is still the leading cause of death, and we’re going to have to tackle this.”

Halting Progress Against Heart Disease

Back in 1997, Michael Brown and Joseph Goldstein wrote in Science that heart attacks might be “gone with the century.” We had the technology, they thought, to eliminate coronary disease as a major public health problem.

But they didn’t see the impact of obesity coming at us, said Nissen. Rising obesity stopped the trend toward declining deaths due to heart disease and strokes.

Measuring All Obesity Care by the Heart

Nissen all but said that cardiovascular outcomes render the final judgment on obesity treatments. Phentermine, in his view, has questionable value for obesity treatment because we have no cardiovascular outcomes data for it. Lifestyle therapy doesn’t produce enough weight loss to reduce heart attacks.

Bariatric surgery reduces cardiac events, so it gets a passing grade.

FDA recently changed the labeling for liraglutide (Saxenda), adding assurances of cardiovascular safety based on an outcomes study. Likewise, a major study of lorcaserin (Belviq) showed no effect on cardiovascular outcomes.

But rather than seeing these data as an assurance of safety, Nissen described it as a lack of benefit. No reduction in heart attacks? Then the value is questionable.

A More Complete View

No doubt, looking at obesity care through the lens of cardiovascular outcomes is helpful. The outcomes for bariatric surgery point to a need for higher utilization. Too many lives are cut short because access to care is difficult. And we see a bright future when obesity meds might reduce heart attacks and deaths due to heart disease.

But the perfect should not be the enemy of the good.

Lifestyle therapies can improve cardiovascular health and prevent diabetes. That’s a good thing. Obesity meds can add to those benefits and offer a better quality of life for many patients. And for some of these meds, we can be confident that they bring no added cardiovascular risk.

We must use the tools we have while we work toward even better options.

Click here for more from Nissen’s presentation.

I Heart Coffee, photograph © Allen Warren / flickr

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November 14, 2018

4 Responses to “In OW2018 Keynote, Steven Nissen Was All Heart”

  1. November 14, 2018 at 7:28 am, Allen Browne said:

    I was there. Lot’s of heart but not enough brain. He needs. to go to the Blackburn Course and learn of the physiology of the disease of obesity. Successful treatment of the disease cannot be done without recognizing the physiology of the disease and successful treatment of the disease will prevent heart attacks and strokes.

    Education is the key to getting smart, well meaning people up to speed.

  2. November 14, 2018 at 10:59 am, Angie Golden said:

    Thank you Ted for helping us see the bigger picture. Although I appreciated his CV view I felt distressed that someone would leave his presentation thinking our current meds in our toolbox are not beneficial and possibly left thinking they were dangerous for all patients.

  3. November 15, 2018 at 2:01 pm, John dixon said:

    I too was there and very disappointed by some aspects. He smashed weight management drugs suggesting none had an acceptable safety record. He also completely dismissed the massive epidemiological data that the nadir for mortality with BMI varies throughout the life cycle and is influenced by age and health status. His mantra was the thinner the better.

    I agree with him that there is no obesity paradox because there has never been data supporting a linear relationship between BMI and mortality.

    More brain and less heart and back to school.

  4. November 15, 2018 at 3:56 pm, Ted said:

    Good insight, John. Thanks!