Cardiometabolic Care: The Role of Diet & Medications

Podcast Transcript

Announcer:
Welcome to Cleveland Clinic Cardiac Consult brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Betsy Stovsky RN, MSN:
Welcome to our video and podcast about cardiovascular disease and diet and medications. And here, I'm joined today with Julia Zumpano and Dr. Bruemmer from our Preventive Cardiology Clinic. And I'm very excited for you guys to be here to have a discussion today. We actually oftentimes think that medical professionals have all the answers. And when it comes to diet and medications and prevention, there are so many unanswered questions. And we actually had a conference in the fall, and it was left with a lot of questions from the providers that joined there. And I wanted to first start out with... Maybe you could describe what is cardiometabolic because I think that that really is the foundation of what some of these questions were.

Dennis Bruemmer, MD, PhD:
Yeah. Thank you for having us and thank you for organizing this. I think this is really important to add towards our previous discussion. Cardiometabolic is sort of a new understanding of the interface of certain risk factors that have become, over the past years, highly prevalent in the US and, ultimately, lead to cardiovascular disease. And the word metabolism combined with cardiology kind of integrates, I think, to two aspects, of course. Metabolism, in general, meaning weight and weight-related problems like diabetes and how do these ultimately contribute to heart disease? And I think this concept has received much attention in the past few years because for many years, we really had not a good armamentarium of medications affecting metabolism, particularly diabetes to reduce cardiovascular disease, which we now have. So we now have two classes of medication that clearly reduces cardiovascular disease in patients with diabetes. So this is sort of a very dynamic and evolving understanding, not just in terms of mechanisms that link metabolism with cardiac diseases, but also from the treatment side of what we can actually offer to patients.

Betsy Stovsky RN, MSN:
So Julia plays a big important part in a lot of this because these patients have... There may be overweight or obesity, diabetes, cardiovascular disease. What type of diet do you talk to patients about?

Julia Zumpano, RD, LD:
Well, each individualized patient gets a specific plan that would work best for them. It would work best for their medical history, what we're currently trying to achieve, which is weight loss or blood sugar management, cholesterol reduction, blood pressure control. So there are various diets that would help the patient meet those needs. So it may be a reduced-sodium diet, a lower-carbohydrate diet, a Mediterranean-style diet. So it's a combination of those diets that we use to help meet the end, outcome, and goal. And it may be a combination of those diets, it may be low-sodium and low-carb, so calorie controlled, so it's very, very individualized.

Betsy Stovsky RN, MSN:
And there were a lot of questions about different types of diets, and people are always looking for that special, that magic thing that's going to make a change. There were questions about the keto diet, intermittent fasting, vegetarian diet. Can you talk about that a little bit?

Julia Zumpano, RD LD:
Sure. So there are several diets being marketed and a lot of them we have to consider, are they research-based? Is there data that proves the successful outcomes to some of these diets? So with the ketogenic diet, from a cardiovascular standpoint, we don't encourage it very often. We have seen levels of LDL, bad cholesterol, come up with that type of diet. Now that being said, we can encourage a low-carbohydrate diet. So that would be under a dietician supervision with lean sources of protein, mainly carbohydrates are coming from vegetables. Where you're not creating ketosis, if you're on a diet, the goal is not to create ketosis, then you can have some fruit, you can have some grains; but again, those can be limited, especially if blood sugars are poorly managed or we're looking at aggressive weight loss.

Julia Zumpano, RD LD:
But a traditional ketogenic diet, which tends to be very high-fat, moderate protein, extremely low-carbohydrate that creates a state of ketosis, we're not generally encouraging that diet, but something similar, which would create ketosis, we can encourage, and that is called a protein-sparing modified fast diet, where the majority of the calories are coming from protein instead of fat. And it's extremely lean protein and then very little fat percentage of calories and, of course, low carb. So that is a medically supervised diet that we provide in our clinic. Throughout the Cleveland Clinic, we do provide that, a diet with the supervision of a physician as well as a registered dietician.

Julia Zumpano, RD LD:
In regards to intermittent fasting, that's a very general term. So it can include several forms of fasting. The most common form of fasting that I have used with patients are where they fast overnight for an extended period of time. We've shown through research that if you give your body some rest and not eat, you're going to consume less calories, your insulin level will drop and your appetite will actually go down. So what we try to encourage is eating in a smaller window. So eating within anywhere between a 6- to 10-hour window and fasting the remainder of the day, which we do encourage overnight being the majority of the fast, so you can rest and repair.

Julia Zumpano, RD LD:
There are other forms of fasting, not necessarily ones that I use regularly or routinely but, again, that can be a per-patient basis based on maybe other factors that may play a role, work schedule, religious preferences, things like that, that we can work around other forms of fasting and make them successful as well as a healthy form of restricting your diet and making sure you're meeting your needs.

Julia Zumpano, RD LD:
So another thing that I do want to talk about with fasting is that fasting is not the only criteria of weight loss. So if you fast and eat fast food for those eight hours a day, you can't expect the benefits to be as strong as if you really follow an anti-inflammatory Mediterranean-style diet that you can really help reap the full benefits of fasting. Some of the benefits of fasting are to reduce inflammation. So if you're giving your body the time to heal and reduce that inflammation in the body, and then you're adding the inflammation during the day by drinking soda, eating fast food, or sweets, then you're really not working towards an overall benefit. So it really does go hand in hand with changing the diet. It can't really be a stand-alone process.

Betsy Stovsky RN, MSN:
So when you're seeing patients who also need to lose weight, what are the medical management strategies as well? There were a lot of questions about medications to bariatric surgery and how that plays a role in cardiovascular disease.

Dennis Bruemmer, MD, PhD:
Yes, so I think first of all, we have a wonderful group of colleagues that all works very complimentary. So we have nutrition program, we have an exercise physiology program, smoking cessation program. We have cardiology and endocrinology combined in our prevention programs. So I think we try to... One of the most important steps, I think, as physicians, we have to take is in managing the patient in a most comprehensive way, and there's abundant evidence and data to support that. So we need to address the diet, we need to address the weight, we need to target those in the socioeconomic context of every patient, we need to treat the blood pressure, the lipids, the diabetes, and smoking cessation, and of course, cholesterol. Those are the main approaches. And I think it's important to tailor whatever we discuss with patients specifically to the individual patients.

Dennis Bruemmer, MD, PhD:
So we do use medications for weight management, but they have a secondary role I would say. We first encourage lifestyle changes, meaning diet and exercise, and I try to convey to the patient that it's most effective to consider this as a life change, not a three months date and then after three months, I look at the scale, and then I go back to whatever I've been doing before. That will not work and that's the most common problem with weight management. So I think it's important to develop small steps at a time, change in life, and that includes diet, and integrating daily activity into the patient's life, which is, of course, very challenging to do. And look at the success and see how patients do and tell the patient, "Go on the scale, write down your weight every day, try to lose one pound a week, and be committed to that, and be accountable for that weight strategy because you start on Sunday and next Sunday, you want to see one pound less." And if it's gone to pound up, you'd say, "Oops."

Dennis Bruemmer, MD, PhD:
So I think patients need to I understand to be accountable for that. And the first step always, I think, for weight management is patients actually have to weigh themselves. And patients need to do small steps, and some patients are really good at that. They will go for it and come back and write it all down every day or every week. I think patients need to have structured environments, structured program, and there's an abundant evidence for that, frequent encounters to nutrition, to the physician, maybe alternating. And if the patient is not successful, then we can integrate medications. The medications that we have available are extremely limited, I would say. There is no pill that works. It doesn't exist.

Dennis Bruemmer, MD, PhD:
We have long-term data over one year with GLP-1 receptor agonists that we use in certain patients, even at a lower BMI that falls still in the overweight category. If patients have more risk factors associated with their weight, we push the target BMI where we can actually use medications a little bit lower. So I think it's, again, very individualized. I think we have good data for, as I mentioned, the GLP-1 receptor agonists, which are approved all the way down to adolescents now, so they are injectable medications typically. I think, from my perspective, it is a class of medications we have best evidence for as opposed to some of the other weight loss medications that are only indicated for short term and really don't work very well long term.

Dennis Bruemmer, MD, PhD:
And when we use medications, we have to teach the patient that once you're done with your medications, you have to swim on your own, right? So you have to put away the floaties and then you swim by yourself. So if we don't do that, patients will drown, so I think the tools need to be there. And I think our environment and society's not very conducive to provide guidance and help for patients. So I think that's a whole different topic for discussion, but I think the medications that are available, our support tool, the tool that we, unfortunately, can use very rarely because they are very expensive and frequently not covered by health insurance. So the more standard approaches like diet or exercise and lifestyle changes play, I think, a much more important role. And again, I think if patients really want to be successful, structured programs are very important, like the ones run in endocrinology here or in other programs that are commercially available.

Betsy Stovsky RN, MSN:
I was thinking when you were saying this how complex this is, it's not a simple solution where sometimes people who are seeing their community doctor, whatever, who does a great job, that they may not think that this is something that they need to refer to. But really, to have that support of a structured program that can provide somebody with an individual program that will work with them, specifically on that, seems like a really good idea. I mean, what would you say to outside providers? When's a good time to refer to a program like this?

Dennis Bruemmer, MD, PhD:
Anytime is a good time. The sooner, the better. There's no reason to wait. Now, again, I think the biggest problem... This is a commitment, this is a financial commitment from the patient, but there have been numerous studies that list even the financial benefit of joining a weight loss program are in terms of cost savings for copays for medications are enormous. So it becomes very cost-effective and that's been studied, so I think we should encourage this. And again, I think there are numerous commercial programs that work extremely well. We have programs here at the clinic that are physician-supported in various departments, across campus, which are very successful. So the goal is to provide less choices to the patient because typically, when we talk about food, we tend to make the wrong choices and that is because how we have evolved.

Dennis Bruemmer, MD, PhD:
I go back to my evolutionary concept that I talk about so frequently. Having more pounds is a clear evolutionary benefit. Humans can live longer if they have weight. So through this, the brain metabolism, gut axis, the hormonal changes have become so effective that the brain is always trying to trick ourselves to defend our current weight. And this is where the breakthrough has to occur and that's very challenging. So that's where some of these medications work on that particular axis to suppress appetite, for example, so it's very challenging to do that. And the best way to do it is in a structured environment where there are few choices.

Betsy Stovsky RN, MSN:
Julia, some of these questions are related specifically to diabetes. Does the Mediterranean do you change the way that your focus is when somebody also has diabetes?

Julia Zumpano, RD LD:
Yeah. So if I have a patient that comes in with diabetes, I would definitely look at their current carbohydrate intake, look at their blood sugars, their hemoglobin A1c, and see where I can adjust their diet further to reduce those values if needed, which at the time it is. So I would put them on a little bit of a lower-carbohydrate diet, really look at the type of carbohydrates they're having, and maybe make some modifications on the type, the portion, of course, the timing of them, what they're pairing those carbohydrates with. So all of that would be extensively researched and looked into, and then a plan would be developed to help reduce the blood sugars as well as with the Mediterranean focus in mind.

Julia Zumpano, RD LD:
One thing I did want to add on to Dr. Bruemmer's wonderful comments is that with diet, just on its standalone, there are so many things that go into what people eat. It's not just what they choose to put in their mouth. It's also what their family's eating, what's available to them, what they can afford, what level of comfort they have in cooking or preparing meals or even purchasing meals. So you have to keep it very simple and very restricted. And really, that does work the best and support is extremely important. So whether it's a group, or a program, or a physician, or a dietician, support is essential. So I think those things are really key in setting up a patient to be successful in whatever plan we choose to put them on, or they choose to follow on their own. It just has to be feasible, reasonable, and adjustable, and restricted.

Dennis Bruemmer, MD, PhD:
Yes. I think, Julia, that's a wonderful comment. We deal with this a lot when we talk to patients. It's couple's therapy, right? So there's no point if the husband needs to lose weight, if the husband goes to the nutritionist talks, while the housewife goes home and buys the ice cream, right? So that does not work. So it is like a couple's family therapy. And oftentimes, I would say it is not infrequent that when the parents need to lose weight, the children need to lose weight as well. I would say that's quite common. So it becomes very important to make this a family approach absolutely.

Julia Zumpano, RD LD:
Absolutely.

Betsy Stovsky RN, MSN:
So I'm just going to leave one more question, and then we're almost out of time, but for patients with diabetes, as an endocrinologist as well, there were questions about choice of meds from prediabetes up to diet, having really high sugar and diagnosed with diabetes. Do you have a philosophy about that?

Dennis Bruemmer, MD, PhD:
Yeah. Yeah. There are two questions, I think. One is the questions at which point do we start to actually treat prediabetes? And most of the medications that we like to use for patients with diabetes that have, for example, proven cardiovascular benefit are not approved for prediabetes. So in prediabetes where we can use Metformin, I think we can use GLP-1 receptor agonists for weight loss if the patient is obese, but our tools are somewhat limited. I would like to point out the most important aspect when we think about prediabetes. Prediabetes is clearly associated with increased cardiovascular risk and with worse outcomes than not having prediabetes. I would say in our laboratory testing, it's probably one of the more commonly overlooked diagnosis that I think needs to be taken seriously. So the main goal for prediabetes is, guess what? Lifestyle change.

Dennis Bruemmer, MD, PhD:
So, because that is frequently a condition that is still reversible or at least can be kept stable for a long time, I think when we talk about the medications that we use for treating then overt diabetes, the US guidelines still use Metformin as first-line therapy. European guidelines have shifted already. They have shifted to SGLT2 inhibitors or GLP-1 receptor agonists as first-line treatment for diabetes because of their efficacy and because of their beneficial cardiovascular outcomes. Here, payers will frequently mandate that we start with Metformin and then shift to other medications which, again, those newer classes of medications that have good data for chronic kidney disease, for heart failure, for cardiovascular outcomes with limited side effects are infrequently used because of costs being prohibitive, poor coverage by health plans, so we are limited in the medications that we actually can use. And we encourage those medications, those newer agents, because again I think they're safe, efficacious, and protect adverse outcomes like cardiac outcomes, so those would be always my first choice.

Betsy Stovsky RN, MSN:
Well, we've come to the end of our discussion today. We've covered a lot. Do you have any last thoughts for the providers that may be listening to this?

Julia Zumpano, RD LD:
Refer to see a dietician or preventative cardiologist or both.

Dennis Bruemmer, MD, PhD:
Yeah, I think I couldn't have said it better. And I think my comment would probably be we need to be aggressive in treating risk. Hemoglobin A1c above 7 is not okay. And lifestyle, obviously, has to be combined with comprehensive and aggressive treatment of risk factors which we, as physicians, often say, "Well, yeah. The hemoglobin A1c that's 7.2, come back in six months." And I think that's not something we should be doing, so we need to be more aggressive in preventing cardiac outcomes.

Betsy Stovsky RN, MSN:
Well, thank you so much for spending time with us today.

Julia Zumpano, RD LD:
Thank you for having us.

Dennis Bruemmer, MD, PhD:
Thank you for having us. Yeah.

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