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MedEvidence! Truth Behind the Data
The Protean Manifestations of Obesity Ep. 328
Proteus was a Greek sea god who could change his form, much like obesity is able to in the body. Doctors Michael Koren, Victoria Helow, and Michael Bernhardt come together in front of a live audience for a discussion on the myriad effects obesity has in and on the body. The doctors move through how excess weight affects the heart, skin, inflammatory systems, and more. They also explain that even when obesity doesn't directly cause a disease is can make other diseases worse. Join these three physician experts to learn why obesity matters
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Music: Storyblocks - Corporate Inspired
Thank you for listening!
Welcome to the MedEvidence podcast. This episode is a rebroadcast from a live MedEvidence presentation.
Dr. Michael Koren:Okay, well, thank you very much everybody, and thank you for Dr. Helow for jumping in. I was very impressed by the number of people who've been involved in research before. Thank you again. Our hearts out to you, because you are the people that make a difference, you're the people that advance medicine, and Dr Hilo and I have been doing this for quite a while, and Dr. Helow and I have been doing this for quite a while, and Dr. Helow has been amazing to just jump in.
Dr. Michael Koren:So this originally was going to be a discussion between me and one of my colleagues, Micaiah Jones, who's a fellow cardiologist, and unfortunately Micaiah called me yesterday and said that he was not going to be able to make it because he had to cover the hospital for heart attacks Because the guy that was supposed to cover the hospital for heart attacks had an out-of-town emergency. So this is the real world of medicine and we are real doctors. Just so you know, we do see patients. We are real doctors and part of our goal is to bridge the gap between scientific research and real medicine, because we are real doctors and we do both scientific research and real medicine, because we are real doctors and we do both. Dr. Helow, Victoria Helow is a pediatrician, adolescent medicine specialist, works the ERs seeing sick kids and teenagers, and she's also been an amazing researcher over the course of the past 20 years now, and so it's always a pleasure for us to do a program together. But she's kind of jumping in on something that we all deal with in all of our specialties, which is obesity. So, although we wanted to focus on the cardiovascular elements of obesity because Dr. Jones isn't here and you're here, and I think Dr. Bernhardt, who's a dermatologist, will join us we're going to talk a little bit more about the protean manifestations of obesity.
Dr. Victoria Helow:All of them
Dr. Michael Koren:Yeah. So thanks for being part of this, vicky, sure, sure. So let's just jump right in.
Dr. Michael Koren:So, as you know, we do not believe in a free lunch here at WJCT. We believe you have to work for your lunch, and so I'm just curious before I get into the first question when you heard this advertised as the protean manifestations, did that make you more interested in this lecture? Yes, did it make you less interested in the lecture? Okay, all right. So we're going to start with protean.
Dr. Michael Koren:So have you heard of the word protean? A: No. B: I learned it for 10 minutes when I studied for the SATs. C: of course, I've heard of it, but have no idea what it means. D: I have a feeling I'm going to learn the meaning of the word during this lecture. Or E: isn't it a typo for the word protein? Okay, so there's really no right answer here, but I was just curious to see how people reacted to this. It is a word we use in medicine and it's actually a great word, and let's jump into it a little bit more in terms of the fact that obesity is something that has protean manifestation. So, Vicky, you can just give everybody a little bit of a sense for all the elements of obesity and stuff that you deal with in your practice and when you see people in the ER.
Dr. Victoria Helow:So protean, as this shows, is, in other words, all of the possible consequences of that condition, and, as we know, obesity is complex and it can have a lot of consequences. We were originally going to do, as he said, the cardiovascular consequences, and we all know, though, it increases your risk of stroke, increases your risk of heart attack, increases your risk of kidney disease. It's obviously a psychological condition as well, especially in this. You know society and all of the manifestations of Facebook, etc. What you're supposed to be, skinny and active, etc. It can create all of that and, like I said, the cardiovascular ones. And one of the big things that we talk about now, as we're beginning to understand obesity, is obesity increases the risk of inflammation throughout your body, so anything that can be complicated by inflammation which is everything, is complicated, more complicated in the obese individual.
Dr. Victoria Helow:And that's crucial.
Dr. Michael Koren:Yeah. So getting to the protean word, there's a picture here and that guy's clearly not obese. He has a six-pack going on there. He's a pretty impressive guy
Dr. Victoria Helow:-Eight-pack!
Dr. Michael Koren:Eight-pack. Yeah, maybe an eight-pack, but this is actually where the word protean comes from. So it's actually of Greek origin and it comes from Proteus, who is a Greek sea god who can change his shape at will.
Dr. Michael Koren:So obesity is one of those things that can change and have many, many different manifestations, and so what it means in the English language is displaying great diversity or variety. So when we talk about the protean manifestations of any disease, these are diseases that present with great diversity or variety. All right, next question what is the formal definition of obesity? A: the inability to fit into your wedding dress. B: the ability to rest a beer can on your belly. C: 20% or more above the upper limit of healthy body mass index. D: that uncomfortable pause after someone asks does this make me look fat? Or E: clothes with horizontal stripes that don't flatter
Dr. Victoria Helow:Still don't flatter.
Dr. Michael Koren:So what's the answer, Vicky?
Dr. Victoria Helow:20% or more above the upper limit of a healthy BMI.
Dr. Michael Koren:So, moving on the growing prevalence of obesity Among affluent nations, the US has the highest obesity rate, affecting approximately 42% of the population
Dr. Victoria Helow:42%!
Dr. Michael Koren:I'll tell you what the rest of the world is catching up. Yes, so I've had some recent trips to India. A lot of obese people in India now
Dr. Victoria Helow:Again, that's a sign of affluence.
Dr. Victoria Helow:So they encourage that, especially in the females. So interesting.
Dr. Michael Koren:In May I was in Saudi Arabia and Morocco. More and more obese people there. In Morocco there were three McDonald's restaurants within walking distance of my hotel.
Dr. Victoria Helow:Sad, is that unbelievable Sad?
Dr. Michael Koren:Well, again, it depends on what you eat there. No one's forcing you to eat there or what you choose to eat once you go there, but this is a phenomenon that's affecting the rest of the world as well. Obesity-related deaths from ischemic heart disease increased threefold from 1999 to 2020 in the United States, but that's pretty significant, and the World Obesity Federation predicts obesity will affect 1 billion people globally in 2030, one in five women and one in seven men.
Dr. Victoria Helow:And again, being a pediatrician, this has been a huge issue in the pediatric realm. The ages are getting younger and younger and younger.
Dr. Michael Koren:What percent of the people who you see, say during a typical emergency room outing, would you say, are people who are overweight, and these are people all 18 or less, I assume, right.
Dr. Victoria Helow:Yes, I would venture to say truly, in pediatrics it's pushing that 30%. I see again, depending on which ER I'm working in, I can see higher than that 30% and some of the ERs may be a little bit lower depending on the demographics.
Dr. Michael Koren:Interesting and that's the obesity paradox that you're alluding to is that obesity in the United States is actually a marker of poverty, and that was not the case 100 years ago. 100 years ago, wealthy people overweight because they indulge themselves in rich foods, and now it's the opposite.
Dr. Victoria Helow:Because the higher calorie foods are cheaper.
Dr. Michael Koren:So the dual role of adipose tissue in disease. So adipose tissue causes health complications in two distinct ways. One, it initiates harm through chronic inflammation and insulin resistance, and you mentioned that We've done a lot of discussions about this concept of inflammation and elements of our day-to-day lives that trigger inflammatory responses, which have multiple negative consequences. Then it also exacerbates or worsens existing health conditions, making them harder to manage. So there's some mention about the COVID booster study that we're doing here in northeast Florida. It's actually a really exciting study that's running at three different locations in northeast Florida in the Fleming Island area, on the west side, on the south side. It's funded, as mentioned, by BARDA, which is part of the Department of Defense, specifically for bioterrorism preparation.
Dr. Michael Koren:A lot of concerns about that, but the point that's really important here is that being overweight doesn't make it more likely that you're going to get COVID, but it makes it more likely to get really sick when you get COVID
Dr. Victoria Helow:Right.
Dr. Michael Koren:So that's this concept of exacerbating an illness. Okay, adipocytes and obesity. Adipocytes are actually cells in your body that are designed to hold onto fat. So fat is something we actually need, right, obviously, if too much of a good thing is not good, but we actually need fat, and fat is a source of energy for our bodies and it's the way our bodies store energy. And if you look at the history of mankind, we probably needed our fat stores a lot more thousands of years ago, when we didn't have as much to eat and we needed to have a place where, when we had a big meal, we could store some of that energy.
Dr. Victoria Helow:For the times when we didn't have a meal and starvation times.
Dr. Michael Koren:Exactly, but that's of course with the ready availability of food these days has become something that's now a liability rather than something that gives us an advantage. So the adipocytes increase the release of free fatty acids into the circulation, which is one of the chemicals that promotes inflammation and fibrosis in tissues. Hormones from the adipocytes interfere with normal anti-inflammatory and protective effects, and adipocytes activate immune cells, which further fuels inflammation and tissue remodeling and also our ability to fight infection. So when you have immune cells that are just promoting inflammation, they may not be on the ready for actually fighting infections as well as they should.
Dr. Victoria Helow:Yeah, but I just wanted to give a little explanation of adipocytes in general. And basically they are kind of like gas tanks in our body, and when we fill our car with gas and we don't use that gas, imagine if it just had a ton of gas tanks on it. We would just keep filling those and if each one could expand, it would just sit there. And that's kind of what happens to us when we take in gasoline for our body. And gasoline for our body is carbohydrates. And I think it's an important point, because part of what we're doing with all of this fat phobic zero, zero fat. A hundred calorie items, it's just a hundred calories of carbohydrate that your body's going to store. It's worse for you than if you ate 100 calories of good fats,
Dr. Michael Koren:Right.
Dr. Michael Koren:very important point.
Dr. Victoria Helow:Yeah just yeah, just something to think about when trying to do some dietary management
Dr. Michael Koren:Yeah, so you don't have to eat fat to be fat or to get fat into the adipocytes.
Dr. Michael Koren:Your body will make fat out of any energy source, which is most commonly carbohydrates. So I don't know if you want to comment on all of that.
Dr. Victoria Helow:So all of you know obesity we talked about. It ends up affecting everything. So sleep apnea is. You know, just the simple fat being here can end up leading to sleep apnea. Obviously, lung diseases are again. Lung diseases are primarily an inflammatory problem. Also, your lungs require are there so you can increase the oxygen to your body parts. Well, if your body is excess weight, you're going to increase the demands of the lung even if you don't have the inflammatory components. So it's double and triple the effects of the negative things.
Dr. Victoria Helow:Stroke we talked about the inflammatory things that you get in the vessels because of this. You know these inflammatory markers running around. Same thing with heart disease, liver disease. We have article, we have a whole book back there put out by MedEvidence, on fatty liver disease, which is known as NASH or MASH. Non-alcoholic steato hepatitis. Steato- is fat and the hepatitis you literally -itis on the end of the word means inflammation. So you literally get liver inflammation because of all this fat sitting in there as it's being stored. And then, as fat sits there and it causes inflammation, then causes scarring. And then, as fat sits there and it causes inflammation, then causes scarring. So you literally can get cirrhosis of the liver by being too fat and never drink a drop of alcohol in your life.
Dr. Michael Koren:So the research office. We cover all these areas. So show of hands. You see all these diagnoses on this chart. Who in the room has at least one of those concerns? So, like virtually everybody.
Dr. Michael Koren:So that's really the important take-home message is that obesity makes all these things worse, and there's a lot of interest and research about dealing with obesity and hopefully making these things better, and that's what we do day to day. So let's jump in. It's a little bit about obesity with cardiovascular disease and that was going to be our primary focus today. But again, thank you for jumping in and bringing some of these other really important points into the discussion. But we know from the cardiology world that obesity is a strong risk factor for other conditions that independently contribute to congestive heart failure. So one of the major ones that we deal with is high blood pressure, and you probably have a little bit of exposure to high blood pressure in your patient population. But I see this all the time and it's so interesting. When people lose weight, it's very common that we actually reduce the number and dose of their medications to the point where we have some people that actually get off of all their blood pressure medications when we get them down to a normal body weight. Dr Bernhardt, they are.
Dr. Michael Bernhardt:All right, nice to see you. Thanks for joining us.
Dr. Michael Koren:Dr Bernhardt is an extraordinary dermatologist who's also going to talk to us about some of those manifestations, but we'll give him a second to catch his breath. I know he just got in from clinic and we do appreciate he's also been a fabulous clinical investigator that's running studies on acne vaccine as we speak Some really cool stuff, but we'll get into that in a second. But anyhow, getting back to obesity, when you're overweight your blood pressure is higher. When you lose weight, your blood pressure comes down. Blood pressure is the force against which your heart has to work. Higher the blood pressure, more heart work, More heart work, worse heart performance. So that's one way to think about it.
Dr. Michael Koren:Type 2 diabetes it causes a number of things, including this concept of diabetic cardiomyopathy. So you've heard of heart attacks, of course. Well, that's when the big blood vessels to the heart get blocked up. But when the little blood vessels get blocked up, it has all these little, what we call micro infarcts and although your heart looks like it's working okay, it's really not functioning the way it should and sometimes it has a real hard time with relaxation, which leads to accumulation of fluid and breathing problems. Dyslipidemia. My favorite topic is cholesterol issues and, of course, when you're overweight, you're much more likely to have higher cholesterol, particularly triglycerides. Triglycerides are really driven by this carbohydrate craze that we have in this country and it's less of an effect, but it also affects LDL cholesterol. It doesn't affect lipoprotein(a) very much, which is your little favorite subject to talk about
Dr. Michael Koren:But there are a lot of dietary elements to cholesterol issue, but not all of them, and that's why you really need to talk to an expert, because some people say, oh, I'm just going to change my diet and everything is going to turn out right. Well, you can starve yourself and you'll still have a high Lp(a).
Dr. Victoria Helow:Yes, and therefore a high LDL.
Dr. Michael Koren:Right, but if you starve yourself, chances are your triglycerides will be normal.
Dr. Michael Bernhardt:Deal. I used to run marathons back in the day when I was about 30 pounds lighter.
Dr. Michael Koren:Well, you just ran one to get here today.
Dr. Michael Bernhardt:Well, yeah, because my GPS had me going around the stadium and so it took me on.
Dr. Michael Koren:Yeah, he caught a few plays of the Jaguars practice. Yeah.
Dr. Michael Bernhardt:But I used to do long-distance running for about 25, 30 years and I thought I was bulletproof because I was doing banking 80, 90-mile weeks and nope, the numbers were still high.
Dr. Michael Koren:Yeah, another area that we've worked on as a research group is sleep apnea, and you're probably familiar with that. It's normally when you stop breathing for a period of time and everybody does that. Dr Rothstein, Mitch Rothstein, did a fabulous lecture, really a master series lecture on this recently
Dr. Victoria Helow:-t hat you can look up-
Dr. Michael Koren:yeah, which is online, check it out. It's on MedEvidence. But some degree of sleep apnea is kind of normal.
Dr. Michael Koren:But when that becomes excessive.
Dr. Michael Koren:it leads to cardiovascular complications, most commonly atrial fibrillation, but also worsening of congestive heart failure and an increase in blood pressure. All right, so perfect timing the skin side of obesity. So, Mike, several skin conditions are commonly associated with obesity due to changes in hormones, inflammation, increased skin folds and impaired skin barrier function. So the stage is yours, my friend.
Dr. Michael Bernhardt:Thank you, you know. It's interesting because some of these things are actually associated with elevated fasting. Not glucose, but the insulin. Elevated. Yes, A lot of these people have hyperinsulinemia and I've started checking some of my HS patients, my acanthosis and agaric cancer patients.
Dr. Michael Koren:Yeah, explain that to people, because we're doing an HS study.
Dr. Michael Bernhardt:Okay, yeah, this is kind of interesting because HS hydradenitis we call it HS for short is one of my areas.
Dr. Michael Koren:It's right here on the slide, if you see it right there.
Dr. Michael Bernhardt:Yeah, it's one of my areas of excessive interest because before I came back to Jacksonville I was helping on the dermatology residency clinic in Tallahassee. So we were getting a lot of the end-stage referrals and we were seeing about, well, about five to seven really bad hydradenitis patients per day. And what happens in hydradenitis? It's frequently misdiagnosed as quote-unquote boils. So people will get boils typically in the areas of fusion plan on the body the inguinal crease, the axillary crease, the inframammary crease and they'll come and go, remit and resolve, remit and resolve and typically starts early to mid-teens and as a rule it goes about eight to ten years before the person's properly diagnosed. The patient will bounce from urgent care to urgent care to urgent care and then wind up either in a primary care office or a derm office. That's savvy to what's going on and then they'll get the electron on hydradenitis.
Dr. Michael Bernhardt:We know that a lot of these people have elevated fasting insulin levels, hyperinsulinemia, which is tied in to the whole Obesity cascade is one of the driving forces not just of hydradenitis but also acanthosis and agaricans. We see that patients with psoriasis usually are 100 kilograms. So obesity is part and parcel-
Dr. Michael Koren:-100 kilograms is 220 pounds.
Dr. Michael Bernhardt:Yeah. So you know, for years we always thought that this whole conundrum was kind of a sidebar. And then some really smart researchers, particularly a group up in Howard University, started putting all this together, and a researcher at Penn, Joel Gelfand, started putting this whole metabolic syndrome, as it affiliates to skin, together and what we found is that fat cells are called adipose cells right, and there are amazing little cells because they're pluripotent, they can kind of transform into multiple different cell types and they secrete all sorts of inflammatory triggers.
Dr. Victoria Helow:We talked about it a little while ago in the adipose. When we talked about that.
Dr. Michael Bernhardt:Right Adipose cells. They secrete interleukin-17. Interleukin-17 is one of the little Ferraris, shall we say, that drives a lot of these inflammatory cascades.
Dr. Michael Koren:And Vicky used the metaphor of cars, so you guys are on the same page here, because it's boom Of course you're talking Ferraris and she was talking Teslas, or Kias Kias.
Dr. Michael Bernhardt:I've been watching a lot of Magnum lately. I've been hooked on these.
Dr. Michael Bernhardt:Ferrari things.
Dr. Michael Bernhardt:But it's a fast driver. So interleukin-17 gets transformed, the adipose cell gets worked on by tissue macrophages, which drives release of interleukin-17, TNF and those are the inflammatory mediators that drive HS and also psoriasis. So that there's been studies that have been done, particularly in Europe, where people have lost significant body mass. A lot of times they don't need medication.
Dr. Michael Koren:That's great. I love that, and we'll talk more about that, because we do have studies that are looking at that as we speak.
Dr. Victoria Helow:And I can tell you that in the emergency room we do see a lot of the hydradenitis patients and they are many times diagnosed as boils and many times people have actually opened these up to try to drain them out and given them volumes of antibiotics and it's not an infectious problem.
Dr. Michael Bernhardt:Yeah, so antibiotics are helpful. Tetracyclines downregulate some inflammatory meters, but really over the short term they're Band-Aids and patients really need to be on more aggressive therapy.
Dr. Michael Koren:So we don't do animal studies here in our clinics. We're only about humans. But there is a lot of things we can learn from these animal models, including mice models, which is the most common model that people use when they look at things scientifically. And what's interesting is that everything we're saying has been documented in mice, and there's actually studies where we force feed different species and the same bad things happen. So mice and other animals can actually develop congestive heart failure based on overeating. And here we have this. I don't know if that's a Kitkat bar, what it is that mice are eating.
Dr. Victoria Helow:Chocolate bananas.
Dr. Michael Koren:The reason I say kit-kat bar is because this is how mice can get back at the cats that chase them by eating the kit-kat bar Anyway Payback, and then, in obesity-prone rats, a high-fat diet for just 12 months leads to metabolic syndrome and progression of this heart failure. H-f-p-e-f stands for heart failure with preserved ejection fraction, and that's that diabetic cardiomyopathy that we were just talking about.
Dr. Michael Koren:We have these little micro infarcts, even though your heart looks like it's pumping normally, it's really not because the relaxation functions are impaired. The American Heart Association still debates with people about should we focus on fats, grams of fats or just calories?
Dr. Victoria Helow:Calories, just healthy foods, real food.
Dr. Michael Koren:There you go All right back to audience questions. So all of the below are medically accepted methods to lose weight, except A: calorie restrictive diets. B: bariatric surgery such as a partial gastric bypass. C: medications such as approved classes like opioid-antidepressant combos, fat blockers and GLP-1s. D: the Ronco binge-eating cleansing diet of popcorn, colonics and moonshine, or intensive physical activity program with standard meals.
Dr. Michael Bernhardt:I didn't realize. Moonshine helped you lose weight.
Dr. Michael Koren:You haven't been on the Internet lately, no, so of course the answer is D. It's not been medically accepted, but do you want to jump in and just talk about these different ways of losing weight?
Dr. Victoria Helow:Yeah, so you know we have some again publications back there that talk about the whole obesity problem and using calorie restrictive diets. And you know it means restricting your calories. In certain ways it doesn't mean no calories, it means being careful with what you eat. And we had a fabulous presentation yesterday of a horrible kidney disease called polycystic kidney disease and then expert from Mayo Clinic was talking about restricting the diet by only 10% of your calories helped with this genetic problem that is aggravated by obesity. So anything that you can do to help decrease the fat is going to help, even like 10%. Not having seconds decreasing your portions, the bariatric surgery what that's doing is bypassing the part of the intestinal tract that rapidly absorbs your sugars so that it takes a little longer to absorb those sugars Can in fact help you with not having so many of those bioavailable so quickly.
Dr. Victoria Helow:And of course, we know that the medications have been very successful. We've done lots of research from the beginning on these ozempic et cetera type of medications. We have many active studies right now looking at these medications that are proven to be safe, proven to be effective, and now we're using them in different combinations with patients with heart failure. Hey, if we can help them lose some weight, help normalize some of their insulin issues. Would it also prove to be helpful for their heart failure? The obvious answer would be yes. So we have studies that are looking at that so that then people can be prescribed these because of these conditions, not necessarily just diabetes, which is what the original intention was. We need to prove that they in fact have an effect on heart failure and, um, you know, other situations that are affected by the obesity issues.
Dr. Victoria Helow:And intensive physical therapy program with standard meals, even a just a physical therapy, a physical activity program in general, with, again, standard meals. And a standard meal is a well-balanced meal Doesn't mean just cutting out the fats or just cutting out the carbohydrates or reducing those. We need all of those things in our diet but they need to be on a proper timing, which we know when you eat your meals and how you eat your meals. And again, it's in some of our literature about eat your protein first, then your carbohydrates, partly that bariatric surgery it doesn't give you that sugar load immediately absorbed et cetera. So all of those can be effective and little bits of each can help.
Dr. Michael Koren:Yeah, so everything but D has been proven to work in scientific studies, and what's interesting, though, is that the GLP-1s are getting all the attention these days, and they get the attention because they're really effective. Yes, and they also have been shown to actually improve cardiac parameters and other parameters, and just a couple of historical things. So when I was doing my residency at Cornell, there was a guy named Lou Aroni who became a very famous diet person, and he actually brought people into the hospital and confined them. We were doing this in a confinement unit in the hospital, where they can only get 400 calories a day-
Dr. Victoria Helow:-not enough.
Dr. Michael Koren:And that was the first to show yeah, if you give people only 400 calories a day, they will lose weight. Unfortunately, when they leave they tend to not eat only 400 calories a day. And I remember they had all these shakes and whatnot to try to get people to just eat one meal, and then the shakes that were low-calorie. So that works, but you got to stick with it. Gastric bypasses and things like that work, and that was, I remember when we first came to town. There was a lot of surgeons that actually had abandoned their general surgery practice, just to do bariatrics because it was working and then moving down.
Dr. Michael Koren:as you mentioned, at the end of the day, it's calories in versus calories out.
Dr. Victoria Helow:Gasoline in usage out.
Dr. Michael Koren:Right. So if you're like Mike and running 80 miles a week and you just ate your 1,200 or 1,800 calories, you're going to lose weight. And then, of course, as I mentioned, we have lots of drugs, and the really interesting thing about the drugs, particularly GLP-1s, is we learned about them by accident. Interesting. About 20 years ago, the FDA got concerned that drugs that were being developed for diabetes could have adverse effects on the heart. So the FDA in its wisdom said okay, if you get a drug approved for diabetes, you have to do studies with cardiologists to show they're safe for the heart.
Dr. Michael Koren:So starting around 2006, 2008, our center started doing those studies just to show that they were safe, and we actually worked with Ozempic back then Smaglutide is the generic name of it and we were blown away. So of course we put people on these drugs that were for diabetes. They weren't even for weight loss. Then they were just to control the glucose. And they're on it and people are losing weight and they're getting excited about that.
Dr. Victoria Helow:Their heart's getting better
Dr. Michael Koren:And their blood pressure's going down and their cholesterol's getting better, and then when we start to look at whether or not they have heart attacks, there's a 20% to 30% reduction in heart attacks in the people that are taking these drugs.
Dr. Michael Bernhardt:Whoa.
Dr. Michael Koren:And that was all by accident. So now GLP-1s are actually considered a standard of care for congestive heart failure, and it started out as a diabetes drug that we were worried might not be safe for the heart. So this just shows you how research progresses and how we learn, and we learn because of people like you that get involved in these programs. So thank you for that.
Dr. Victoria Helow:So the GLP works because basically it's acting like a normal hormone that we have in our body that helps control our sugar levels. So that's an important point. We're not trying to do something abnormal to the body, we're just trying to help the body work in its normal way. And so they help with the insulin release because, although some problems are hyperinsulinemia, we know that an obesity issue many times is not an adequate insulin release, and I explained to you before that insulin is what takes that sugar that's in your bloodstream, those calories that you ate, and puts them into the cells so that the cells can be energized to do whatever their job is, whether it's a muscle or a heart or lung.
Dr. Michael Koren:And this is the key box right here, just to highlight for the audience how GLP-1 activation affects our bodies. So really remarkable. And to Vicky's point, it's just mimicking what our bodies are supposed to do, so we have an audience question here. The use of GLP-1 drugs such as Ozempic and Manjaro has led to the following in research programs Okay A: the side effect of weight loss. I talked about these originally diabetes drugs.
Dr. Michael Koren:B: the side effect of reduced heart disease and blood pressure. C: the side effect of improved skin conditions. D: the side effect of reduced compulsive behavior in preliminary studies. That's really interesting. Or E: all the above protean manifestations? Yes, sounds like all the above to me.
Dr. Michael Koren:Yeah absolutely all the above for sure, so I don't know if you just want to. You mentioned actually already that there were studies showing that when people lose weight their skin conditions get better, and I'll just mention. I think we covered everything else. But we're finding that these drugs actually help people that have problems with alcohol, that the urge for alcohol goes away when you activate the incretins, the GLP-1 and the GIP systems. So again, these are mechanisms in our body that are supposed to be functioning that sometimes need a little help, and the GLP-1 agonists, like unzipping and Manjaro, help activate those systems. That help us in many ways.
Dr. Victoria Helow:Just normalizing all of these complex interactions.
Dr. Michael Koren:And then I'll just jump in and just let people know that the issue of congestive heart failure is a growing issue and there are 6.7 million Americans over the age of 20 who are now living with heart failure and this number is anticipated to rise. So Americans have about a 24% lifetime risk of developing heart failure, so they'll affect one in four people. More than 50% of heart failure patients have heart failure with a preserved ejection fraction. And again, there are two flavors of heart failure One where the heart muscle is not contracting like it should and that typically happens after a heart attack. Or the flavor where the heart muscle gets thickened and becomes dysfunctional because of these little microinfarcs and the effects of diabetes and metabolic syndrome and it leads to higher pressures in the heart which goes back into the lungs. That causes edema in the lungs and problems with breathing. So you're just as likely to end up in the hospital if your heart muscle function is preserved versus reduced, which is an important point. And, as mentioned, heart failure is very, very common. It's the most common hospital admission after age 50 and probably the third most common. I think childbirth is still the most common and probably the third most common. I think childbirth is still the most common, but it's very, very common in people over 50. And it's 9.3% of the hospital visits in the United States. So we talked about this, I think, pretty well at this point.
Dr. Michael Koren:Weight loss is effective in a lot of ways, particularly for people with heart disease I mentioned. Blood pressure comes down, your heart's function goes up because of reduced inflammation and better utilization of glucose and insulin, and it just lets work for your heart. So if your heart is a little bit impaired from a previous heart attack and you got to move 200 pounds around, that's harder than moving 160 pounds around, simple as that. So there are very, very practical reasons why we strongly advise weight loss in people that have any history of heart disease, particularly heart failure. And this gets into the vicious cycle that you see that when you have a heart problem, you reduce your activity. You reduce your activity and I'm just starting from here and moving along you reduce your activity and then you're more likely to get overweight. You're overweight, the work of the heart goes up. Heart failure worsens as the work of the heart goes up. Obesity reduces your physical activity. Physical activity is required for weight loss and heart failure makes exercise difficult, and it goes on and on and on and on. So you've got to break this cycle, and sometimes we need medications to break this cycle.
Dr. Michael Koren:And we talked a little bit about this study. I mentioned this study about semaglutide and cardiovascular outcomes in obesity without diabetes. Now, so that was the second generation. The first generation of these studies were with patients with diabetes, and now we're using these drugs in people without diabetes. In fact, they're clinically indicated in heart failure for all patients, whether or not you have diabetes. And we also highlight these studies because all these studies were performed in Northeast Florida. So again, shout out to everybody in the audience that was part of these studies and there are many of them. At this point, there are several dozen studies that we've been involved with through patients here in our community. So you guys make the difference.
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