Published on April 30, 2012
Weight and BMI are giving way to new methods for determining Obesity, a major factor making heart disease our number one killer. Dr. Nehal Mehta also explains the correlations between Psoriasis, an inflammatory skin condition, and vascular health.
Transcript | The Connection Between Obesity, Inflammation and Heart Disease
Andrew Schorr on location in Chicago where heart specialists from around the world are gathered to discuss fighting heart disease. Of course, one of the biggest problems is obesity. Here in America, it’s estimated that 33 percent of Americans are obese. It’s a big cause, of course, for an epidemic of diabetes. And it helps sustain heart disease as our biggest killer. One expert in obesity and heart disease is Nehal Mehta from Penn Medicine in Philadelphia.
So here we are. Heart disease is our biggest killer, right? Our country is getting overweight. It is an epidemic, and diabetes along with it. So fat is just this tremendous bad guy is what I hear you saying.
That’s right. Over the course of the last 10 to 15 years, this community has done a lot to really understand what it is about fat. When I was in medical school, fat was thought to be this empty vacuole and did nothing but store extra calories. What we’re now noticing is that adipose is an endocrine organ. It has paracrine and endocrine effects where it itself, once stored and once stimulated, will make a lot of these mediators which I said are bad for all of those parts of the body.
Secondly, we’re looking at distribution of adipose tissue. So there are places, such as the arms or the legs, where adipose tissue may form, but that is not the norm. That is called subcutaneous adipose tissue. The more threatening form is actually called visceral adipose tissue. Viscera is your organs. So fat around your organs is very metabolically active. In fact, one of the presentations that we are giving here is looking at the distribution of fat and the molecules that come out of that fat, and how those predispose to higher burdens of vascular disease in the heart.
Let me see if I have this right. So if I, or someone in my family, goes to the doctor, he or she makes an assessment, kind of looks at us, says, “You’re overweight, but you have a lot of fat around your belly.” Would that give them a different risk than somebody who has fat on their arms? Is that what you’re saying?
Precisely. It used to be, if you look at the old national statistics and enhances which were derived from the MetLife Insurance Corporation data, they would judge body types based on looking at people. We started realizing that the looking at people was important. Before that, they used to just weigh people. Weight itself is not a good marker of obesity because people have muscle and other distribution of fat which is what you reiterated.
Now, when you look at one’s body mass index which is simply a measure of your waist to your height, now we’re starting to get more of the looking, the “eyeball test.” But now, as of about three or four years ago, a large-scale epidemiological study of 30,000 showed that, in fact, BMI is not still the best measure. It’s actually your waist-to-hip ratio. That waist-to-hip ratio is independently predictive of having a myocardial infarction over a seven-year period in over 30,000 people.
So the assessment that your doctor may do of you then, looking at fat, gets more sophisticated.
That’s correct. It takes about one minute to do in an office. A lot of offices now are doing it. So the BMI is auto-calculated. Right when you visit your doctor, most doctors will assess a BMI. But what we’re trying to do in this meeting, a really good place to disseminate this information, is really urge providers to do a waist-to-hip ratio, or even just a waist measurement because, as you alluded to earlier, that waist around the middle portion of the body, or that measure of the middle portion of the body, that is the most significant predictor of bad things that adipose tissues does. One of those is predispose to diabetes.
Okay. So just to reiterate, when you are overweight, then where is this fat or adipose tissue? Let’s carry it further as you look at certain subgroups of patients. You’ve been doing research of people who have other conditions. We know about diabetes. We know there’s a tremendous correlation with heart problems, and it often comes with obesity or obesity leads to it. But you’ve been studying another condition that a few million Americans have: psoriasis, inflammatory skin condition. Where does that come into play?
It’s an interesting question. What we got very interested in is psoriasis is an inflammatory disease of the skin which the predominant inflammatory cell that’s involved in the skin disease is the same cell, or one of the two same cells, that’s involved in atherosclerosis, or hardening of the arteries. So that was the first link that really interested me.
Secondly, on a large-scale population-based study, we have shown that psoriasis predisposes to myocardial infarction as well as stroke and cardiovascular death. So I got very interested in understanding this population which has a tremendous amount of inflammation, or an overactive immune system, which, we have previously shown, is associated with obesity and diabetes.
So when we put the two together and you look at the psoriasis population, there’s an overwhelming proportion of psoriasis patients, especially with severe disease, defined as more than 10 percent of their body covered with psoriasis, with obesity. In fact, the numbers are astounding.
In a recent study, which we haven’t published yet, Dr. Gelfand and I, at the University of Pennsylvania, have shown that in over 20,000 patients, psoriasis, as it gets more severe, 40 to 60 percent of those patients have obesity. That obesity, again, rolls with bad players. Those patients tend to have high blood pressure. They tend to have more diabetes. They tend to have more metabolic syndrome, which we can talk about, which is just a clustering of all these things or the pre-diabetic state. So psoriasis has provided us, if you will, an in-the-body model to study a lot of things that we were doing as externally but now it’s within people living with a very common skin disease.
Okay. People are listening, and they say, “I’m one of these Americans who’s been putting on weight, and I just can’t get it off. You tell me it leads to tremendous heart problems, diabetes. Maybe I have psoriasis, and there’s a correlation. What am I to do? How can I change?”
It is one of the most common questions that we will get at our practice. The answer is actually fairly simple. It is activity and moderation. We do understand that life is extremely busy. So grabbing the fast food or grabbing something convenient that comes out of a crinkly bag is easier than bringing something that you have prepared from home. But there is an encouragement when you hear what we advise in our practice which is – we have a multi-pronged approach to sit down with a physician extender, a nutritionist and myself.
The first thing that one should do is assess their eating habits and their frequency of eating. We recommend small, frequent meals. We recommend – the food pyramid – we don’t want to sit and preach. We want to teach. The food pyramid is a little bit outdated in the sense that people cannot get all of those calories in that fashion. So what we recommend is eating in moderation.
What do I mean by that? Although calorie consumption from fat has gone down over the past 15 years, obesity continues to rise. Why is that? Carbohydrate consumption. So one of the things that we will very adamantly state is, by your kilogram body weight, we will give you a number of carbohydrates that you can eat. So really looking at your diet is the first thing that we recommend.
Try to avoid eating out more than five times a week for all your meals. So if you do a work week of 15 meals, 33 percent or less is what you’re trying to do to eat out. Bring your lunch. We have our own small pilot study going on in our practice of people who we have advised to bring their lunch. Over a four-month period of time, the average person loses five pounds.
Smaller quantities because you bring, usually, a sandwich or a wrap, maybe some baby carrots or even a bag of baked potato chips, it’s fine. But you end up eating what you know you’re eating. There’s a tremendous amount of salt and fat hidden in most foods, even despite this calorie listing. Evaluate your diet.
Secondly, activity. Steady activity is very important, whether it’s just walking 20 minutes a day. We recommend to some of our older patients to go to the mall. The mall is great. Now a lot of the malls actually have – and leave your wallet at home or in your car – they have these mile markers. So just go ahead and walk two miles around the mall. Before you know it, it’s about 35 minutes you’ve window shopped. Don’t stop to window shop, just keep a good pace five times a week.
We’ve done another small pilot study in our practice. People lose about five pounds in one month because the effect of exercise is not immediate. What it does is raise your basal metabolic rate, or your BMR. All of us are born with a BMR, but we can change that.
So the third thing, look very closely at other sources of calorie consumption. People tend to forget that drinks that are concentrated in sugars, as well as side dishes, they have a lot of extra calories.
Stress reduction is the fourth-pronged approach. What we will do is we will go through these things very closely with each patient. Stress reduction is not possible in most people’s lives. It’s not. But what we do know is that evaluating where the high-stress situations are and trying to avoid those, or trying to understand that after a high-stress situation going and eating an ice cream bar, although it may make you feel better, is probably not the best source of comfort. Actually going out and taking that activity for the next half hour of walking and clearing your head is a better solution. There are answers.
The biggest problem that we are having, and what I think is called T3 translation, is what we’ve found in the research community and getting it out to the population is this idea of education and awareness. The American Heart Association has done a tremendous amount of – a high amount of – effort to get this out. By 2020, we would like to have the scope of obesity and diabetes go down. The way to do this is education and prevention.
Well, we’re talking about it here. Thank you for your expertise. I hope we can make a difference. In your career, I hope you can see those rates go down and health go up. Thank you for being with us.
Thank you very much for having me.
Heart specialists like Dr. Mehta are worried there’s an even bigger problem waiting to happen. That’s because of the fact that 40 percent of American children are judged to be overweight. That can lead to more significant heart problems. The hope is that understanding new medicines and education can turn that around. In Chicago, I’m Andrew Schorr.