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Weight gain can lead to high blood pressure, type 2 diabetes, and dyslipidemia, a metabolic disorder of abnormal lipids. As the body gets bigger, cardiac changes occur and the left ventricle — the heart’s main pumping chamber — enlarges too. The ventricle thickens and it can be more difficult to pump blood effectively, which increases the risk for heart failure.
Research suggests that weight loss can sometimes reverse the cardiac remodeling that takes place after weight gain, improving heart structure and function.
“Evidence shows that lifestyle-mediated weight loss can improve cardiac risk factors, such as diabetes and dyslipidemia,” said Ian Neeland, MD, director of Cardiovascular Prevention and co-director of the Center for Integrated and Novel Approaches in Vascular-Metabolic Disease at University Hospitals Harrington Heart and Vascular Institute in Cleveland. However, he cautioned, “no randomized controlled trials show that the lifestyle change approach to weight loss directly reduces cardiovascular events.”
Neeland, associate professor of medicine at Case Western Reserve University School of Medicine, Cleveland, cited the Look AHEAD trial, which examined lifestyle changes to reduce cardiovascular events in about 5000 people who were overweight or obese and had diabetes. The intervention failed to meet its primary outcome — a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for angina during a 13.5-year follow-up.
The trial was stopped early at 9.6 years on the basis of a futility analysis.
Diet and Exercise Changes“It’s true that in a subanalysis, people who lost more than 10% of their body weight had an associated reduction in cardiovascular events. But that was post hoc, so it’s observational data, and not really great evidence,” said Neeland, chair of the American Heart Association’s Obesity Committee.
It’s “very difficult in today’s society to make the lifestyle changes necessary to maintain weight loss or get someone who’s severely morbidly obese down to a healthy weight,” said Catherine Benziger, MD, MPH, director of Heart and Vascular Research, Essentia Health, and adjunct associate professor, University of Minnesota Medical School, Duluth, Minnesota.
Because lifestyle interventions aren’t always effective and sustainable, “we have and often need to utilize additional options, such as bariatric surgery or anti-obesity medication,” she said. “Both have been shown to improve glucose management, diabetes, high blood pressure, lipids, and to reduce sleep apnea. Both improve cardiovascular risk factors. The question is which is most effective?”
Bariatric Surgery Trusted and TriedThe 2013 American Heart Association, American College of Cardiology and The Obesity Society Guidelines for the Management of Overweight and Obesity in Adults recommends bariatric surgery for patients with a body mass index (BMI) ≥ 40 or a BMI ≥ 35 plus two other cardiovascular risk factors.
However, the 2022 guidelines issued by the American Society for Metabolic and Bariatric Surgery and International Federation for the Surgery of Obesity and Metabolic Disorders recommend metabolic and bariatric surgery for individuals with a BMI ≥ 35, “regardless of presence, absence, or severity of obesity-related conditions.” It should be considered for people with a BMI of 30-34.9 and metabolic disease and those with a BMI ≥ 30 who don’t achieve substantial or durable weight loss by nonsurgical approaches.
“Bariatric surgery has been around for a long time and current evidence shows that it has long-term benefits and leads to weight loss that can be sustained,” Benziger said.
Several studies have found that bariatric surgery can successfully address cardiovascular risk factors.
The GATEWAY trial compared medical therapy with antihypertensive agents to medical therapy plus Roux-en-Y gastric bypass surgery in 100 patients with a BMI of about 36.9. At 5 years, hypertension remission was 46.9% in the surgery group vs only 2.4% in the medical therapy group.
A retrospective review of 475 patients with a preoperative BMI of 43.6 ± 7.0 who underwent bariatric surgery found that, at 12-month follow-up, their systolic and diastolic blood pressure were reduced by 11.4 mm Hg and 4.4 mm Hg. There were 4-year absolute and relative risk reductions of 20.1% and 63.7% (P < .01 for both), based on the Framingham Hypertension Risk Score. A meta-analysis of 80 studies — encompassing about 3300 patients — found that bariatric surgery led to reverse cardiac remodeling and improvements in cardiac geometry and function. A Canadian study compared 1319 patients with cardiovascular disease or heart failure who had bariatric surgery to a matched cohort who did not have surgery. After a median follow-up of 4.6 years, close to one fifth of those who didn’t have surgery experienced a major adverse cardiac event — myocardial infarction, stroke, heart failure hospitalization, or mortality — compared with 12% who had surgery, which translated into a 42% reduction in cardiac risk in those who had surgery. Can Glucagon-Like Peptide 1s (GLP-1s) Beat Bariatric Surgery?The GLP-1 receptor agonists seem to be catching up to bariatric surgery in reducing risks for cardiovascular events. In March 2024, the US Food and Drug Administration (FDA) approved semaglutide for reducing the risk for cardiovascular death, heart attack, and stroke in adults with cardiovascular disease and either obesity or overweight. “The GLP-1s aren’t the only medications that are FDA-approved for weight loss,” Neeland pointed out. “Other weight-loss medications have also been tested for cardiovascular benefits. Lorcaserin was found to be neutral, but that’s no longer relevant to prescribers because it’s off the market now for other reasons.” Naltrexone-bupropion, and phentermine-topiramate likewise showed no cardiovascular benefits. “The GLP-1s are the only agents in the medical obesity space that have clearly shown cardiovascular benefits.” Benziger said she agrees. “In my experience, I've seen that most people would rather take a pill than have an injection, because it's less invasive. But the oral medications haven't been as effective as the GLP-1 drugs, which have transformed the medical management of weight loss.” Several trials highlight these promising results, Neeland said. For example, compared with placebo, taking semaglutide led to greater relief of symptoms, physical limitations, and exercise function and reduced inflammation and body weight in the STEP-HFpEF trial. These improvements were seen across all categories of heart failure, regardless of left ventricular ejection fraction status. The SELECT trial randomized 17,604 patients (mean age, 61.6 years, mean BMI, 33.4) to receive either semaglutide or placebo. Of these, roughly a quarter had a history of heart failure at enrollment. All patients had overweight or obesity and atherosclerotic cardiovascular disease. Treatment with semaglutide reduced major adverse cardiovascular events and composite heart failure endpoints compared with placebo, regardless of heart failure subtype. And the SUMMIT trial randomized 731 patients with heart failure and obesity to receive either tirzepatide or placebo, with a median follow-up time of 104 weeks. The two primary endpoints were composite of adjudicated death from cardiovascular causes or a worsening heart failure event and the change from baseline to 52 weeks on the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score. Treatment with tirzepatide resulted in a lower risk for the primary outcome compared with treatment with placebo and also led to improved health status. Which Strategy Is Best?Many clinicians wonder what strategy to choose for their patients as both bariatric surgery and medication can lead to improvement in cardiovascular symptoms. Neeland said the treatment approach for each individual patient should “take into account the degree of weight loss desired, patient factors such as comorbidities and risk for individual treatments, patient preferences, cost, and long-term durability.” Ultimately, he added, “the best treatment is the one that works, that the patient can sustain, and that doesn’t increase risk for harm or adverse effects.” Several studies investigating both approaches might help inform the decision. An observational study of Medicare-enrolled patients with heart failure and obesity examined associations between bariatric surgery and all-cause mortality, hospitalizations for heart failure and incident atrial fibrillation (AF) in patients with a BMI ≥ 35. Secondary analyses examined the association of anti-obesity medications including semaglutide, liraglutide, naltrexone-bupropion, and orlistat with these outcomes. Bariatric surgery was significantly associated with reduction in all three outcomes. Anti-obesity medications were associated with improvement in two of the three outcomes — decreased all-cause mortality and decreased hospitalization — but not with decreased incidence of AF. The findings both regarding bariatric surgery and regarding pharmacotherapy were consistent, regardless of the ejection fraction of the patients (preserved vs reduced). Some research suggests that bariatric surgery may have longer-term, sustainable benefits compared with GLP-1 drugs, Benziger said. A matched cohort study of patients with severe obesity and type 2 diabetes compared both strategies and found that surgery was associated with a lower risk for major adverse cardiovascular effects or all-cause mortality compared with medical treatment, during an 8-year period. And a meta-analysis encompassing 427 patients including randomized controlled trials that followed patients for 5-10 years found surgery superior to medical weight loss for several cardiac parameters, including systolic and diastolic blood pressure, as well as cardiovascular risk. Cost is a major factor to consider when deciding which approach to choose. The study of Medicare-enrolled patients with heart failure and obesity found that initiation of both types of anti-obesity treatment following the index heart failure hospitalization was substantially delayed. Many who qualified for bariatric surgery or treatment with GLP-1 drugs didn’t receive them due to a variety of systemic barriers, including socioeconomic factors. The role of treatment cost is important because once people discontinue GLP-1s, they tend to regain the weight. To maintain the benefits, patients may have to take these drugs on a chronic basis, Benziger said. And as they can be expensive, long-term treatment might be out of reach for many. They might discontinue use and regain the weight and any cardiovascular benefits they had accrued might dissipate. Neeland said he agrees that cost is an obstacle to treatment with GLP-1 drugs. “There are many patients I’d like to start on a GLP-1, but their insurance doesn’t cover these medications and they can’t afford the out-of-pocket costs.” There are also barriers to receiving bariatric surgery, Benziger pointed out. “One big issue with weight-loss surgery has been the strict criteria surrounding who does and doesn’t qualify. Nowadays, it’s easier to walk into a doctor’s office and say, my sister lost weight on Wegovy and the doctor can prescribe it.” Back to Diet and ExerciseNeeland and Benzinger said they agree that, while lifestyle interventions may not be sufficient to fully confer lasting weight loss with cardiovascular benefits, they’re necessary components of any weight-loss strategy. The standard American diet, which is high in sugar, saturated fat, ultra-processed foods, and animal products promotes weight gain, metabolic dysregulation, and systemic inflammation. Caloric reduction and moderate to vigorous physical activity (≥ 150 minutes/wk of aerobic exercise and 2 days/wk of muscle strengthening activity) are important components of an overall program to improve cardiovascular health and reduce risk. “With either approach — whether bariatric surgery or GLP-1 — it’s important to keep working on diet, lifestyle, and physical activity,” Benziger said. “But some people need that extra ‘boost’ to get to that 10%-30% weight loss.” Neeland said he prefers to recommend treatment with GLP-1s before suggesting bariatric surgery when lifestyle interventions aren’t sufficient. “I recommend bariatric surgery in settings in which the patient isn’t responsive to the combination of lifestyle changes plus medication, or the patient cannot tolerate medication, or the other categories for which the guidelines recommend it,” he said. Benziger added that it’s difficult to be physically active with morbid obesity because of the mechanical strain of the weight on the joints and other effects, such as shortness of breath. “But once a patient has started losing weight by medication or bariatric surgery, it becomes easier to have a healthy lifestyle and maintain the weight loss,” she said. Neeland is a speaker and consultant for Boehringer Ingelheim, Eli Lilly, Novo Nordisk, and Bayer. He reported receiving grants from the National Institutes of Health and the American Heart Association. Benziger reported no relevant financial relationships.
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