A Heart-Healthy Size: Does Weight Impact Your Heart? Leslie Cho, MD

Podcast Transcript

John Horton:

Hello and welcome to another Health Essentials Podcast. I'm John Horton, your host.

If someone spends hours a week on a treadmill, in a weight room or riding a bike, you'd probably consider them healthy and fit. But what if that person also qualified as having obesity? We're going to work out this issue today with cardiologist Leslie Cho. Dr. Cho is one of the many experts at Cleveland Clinic who join us weekly to help us better understand how our bodies work. So with that, let's take a closer look at the complicated question about BMI, weight, fitness and your heart.

Dr. Cho, thank you so much for dropping by the podcast and hanging out with us today.

Dr. Leslie Cho:

Oh, thank you for having me.

John Horton:

Now, weight and body fat are pretty sensitive issues to talk about, but I know they're pretty critical when it comes to our overall health and heart health in particular. I'm guessing that you tackle these topics quite a bit with your patients.

Dr. Leslie Cho:

In America, we often associate weight and moral failing, which I really dislike. There's so much science now about weight and why we become overweight with time. It's more than just lack of willpower. And so I'm so excited to talk to you today about BMI and weight and how to think about weight and how to think about our BMI so that we can get better cardiac fitness.

John Horton:

So Dr. Cho, I know a lot of us look in the mirror and we see that we might have a few extra pounds, but we wave it off because we exercise a lot and we feel fit. But are we fooling ourselves when we do that? I mean, is it possible to be fit and fat to use, I guess, a common but not quite “pc” phrasing?

Dr. Leslie Cho:

I mean, BMI is a very good measure of our obesity, whether we're underweight, overweight or obese, or truly “morbidly obese” is what the medical term is. It does have many problems. It's very centered on Caucasians. It is not very good for people who are super muscular. It's not good for the elderly. It's really not good when you're pregnant. There are many problems, but BMI for most people, I think is reasonable. I do think that BMI needs to be in together with other things like waist-to-hip ratio and things like that, to really give a true idea of someone's weight and whether it's in an obesity zone or not.

As far as whether you can be overweight and still be fit. For sure, there are people who are avid exercisers and they're overweight. But the problem is when you follow these people for many years, what the studies have consistently shown is that for a long period of time, if they maintain their obesity, they tend to have high blood pressure, cardiovascular disease, they have sleep apnea, they go on to have diabetes and of course arthritis. But also very importantly, they have increased risk for cancer. So even though we could be fit when we're overweight, the long-term implication of obesity, unfortunately, is not good for our body.

John Horton:

Well, and in particular, if you do have these extra pounds on you, and even though you're working out a lot and you're doing things, it sounds like you're just putting a lot of extra strain and stress on your body and, in particular, your heart.

Dr. Leslie Cho:

Absolutely. I mean, for sure, you do definitely put a strain on your heart. And I really think that it has nothing to do with fat shaming or body shaming or whatever. Some of the trials and the studies in the past have been confounded because they follow people for a very short period of time — but when you follow people for a longer period of time, which is what we're really talking about, because you're living a whole long life hopefully, being overweight for a long period of time, unfortunately, can do damage to your heart, increase your risk for cancer, as well as causing you joint problems.

John Horton:

Yeah. Dr. Cho, you said it very eloquently right when we started talking about how, I mean, there's so much judgment passed on having some excess weight. And we're not looking at it from that point of view. There's also a very health-focused way to look at it. And there's some realities that if you have this extra fat or extra pounds, you're just putting this added stress on your body.

Dr. Leslie Cho:

Yeah, absolutely. Being overweight really is more than just willpower. And I think that's been the problem of even physicians because we've often said to patients, "Hey, just eat less or exercise more." Whatever we said. When it's so much more than that, there are patients ... the reality is it's much harder and more expensive to eat healthy in America. It's much cheaper to eat unhealthy in America — and that's a cold hard fact. There are patients that are living in food deserts across the U.S. The other important thing we don't think about or talk about is that there are people who genuinely … their metabolism has slowed down because of age, because of menopause, because of whatever, and they're having difficulty. So it's more than just willpower that makes someone overweight.

John Horton:

So when we talk about the fitness aspect and balancing that with your weight and maybe BMI and all that, obviously if you're fit, you're better off, I'm guessing is the answer no matter what.

Dr. Leslie Cho:

I mean, yes, if you are fit, you're better off. If you exercise regularly, you're definitely better off. If you are thin, but you don't exercise and you're a couch potato, that's not good, obviously. So exercising is good, not just good for the heart, but it's good for the mind, too. There definitely is that connection between your brain and your heart. That whole heart and brain connection that's so critically important. And our mood.

And I think the message I really want to get out there is we want you to exercise because it's good for the heart, it's good for the brain, it's good for our souls. We want you to try to be at a normal weight or where that BMI is of normal range because, consistently, that has shown that when you are in that normal range, your cholesterol level is better, your blood pressure is better, your risk of diabetes is significantly lowered. And so whenever we can and given all the social determinants of health, for some people it's very hard, but whenever we can to try to make good choices about our diet and our lifestyle. And the reason we want to do this, and this is truly the No. 1 reason, is that in 2023, the great news is that heart disease is preventable. It's preventable for 90% of our patients. Can you imagine? Isn't that amazing? Regardless of who your-

John Horton:

…If you can get 90% of anything, it's good.

Dr. Leslie Cho:

Yeah. Regardless of your family history, regardless of where you live, 90% of heart disease is preventable. And we do that by eating right, exercising, not smoking. And even though there are some of us that live perhaps in areas where getting healthy food is not easy and perhaps we need to find some creative ways to deal with that situation — whether we buy as a co-op — I've heard patients who buy in mass together because that's much cheaper than if they were to buy it alone. I mean — just having some creative ways to think through to choose healthy lifestyle over unhealthy lifestyle makes a real big difference in terms of lowering your cardiovascular risk.

John Horton:

It's the answer to so many things on this podcast. It always comes down to, it seems like, eating a little healthier and exercising a little more.

So a lot of our questions so far have been focused on this concept of BMI and body fat. But I know most people associate obesity with weight since it's the measurement that we're all familiar with and is the easiest to get because you just step on the scale and it spits out a number for you. But the reality is, it's not that simple, right?

Dr. Leslie Cho:

Oh, it's really not that simple. My God, there's a whole science dedicated to it. So it has to do with your height, it has to do with your weight, but it also has to do with how much muscle you carry and also has to do with where that weight is distributed — because we've all heard of the pear shape and the apple shape and that's a really important distinction, where you're carrying that weight and fat.

John Horton:

Tell me a little more about that, about the shapes and what you look for.

Dr. Leslie Cho:

Yeah. So the apple shape, which is, you carry all your fat in the midsection — those patients tend to have higher rates of heart attack and cardiovascular risk. And the reason is that it is a marker for visceral adiposity. That means fat deposition inside your organs.

People who carry their weight in their hips — so those are the pear shape — they tend to actually do better because they don't have all that fat in their internal organs.

We used to think fat was an inert, inactive thing, but it's actually very active. It causes inflammation. It can lead to a lot of unstable compounds that can cause heart attack and can lead to even cancer. And so where you carry your fat is very important. And that's the reason why it's BMI plus waist-to-hip ratio. And the waist circumference is based on your ethnicity because different ethnicities have different normal ranges.

John Horton:

And this is where it obviously gets so hard because people can be different shapes, different sizes, everything else, and come out differently as far as where their overall health is.

Dr. Leslie Cho:

Yeah, absolutely. I'll give you a very interesting example, and that is East Asian — so I'm Korean — but in China, Korea, India and Japan, if you are even five pounds overweight, the increased risk for diabetes is double. Yeah. And the reason is that they think that it's because we're more prone to visceral adiposity. Whereas if you look at Western Europeans, they could be carrying 30, 40 pounds extra weight and yet their risk of diabetes is not as great as East Asians. And so there's a huge genetic component to weight. And so that's the reason why I think our cultural fixation on weight is a little bit misplaced.

John Horton:

And it gets very difficult, as you said, to try to square away what's what. So as we're looking at this, and if you're somebody who … you work out regularly and you exercise a lot and you're feeling a little more fit, yet you still have some of those extra pounds, maybe a little extra fat in the midsection, things like that — what sort of things should you try to do to reduce your long-term health risk?

Dr. Leslie Cho:

So there's been a lot of data about what makes you lose weight and what maintains weight loss. And the data's pretty clear. It is calorie restriction that makes you lose weight. Exercise maintains weight loss. It's very interesting and a lot of people say, "That's not true for me." But for the most part, the scientific data is pretty clear. There are some people who really benefit from going more on protein and less carbohydrate to try to lose weight. These are very body-specific things. Some people think intermittent fasting is best for them. It's whatever works for certain people. I think, there's recently been studies showing that it doesn't matter whether you're intermittent fasting versus calorie restriction, you lose about the same weight.

But it's whatever works for you. But the unfortunate fact is that for most people, it's calorie restriction. And that's the reason why when people cut out things like bread or when they cut out a whole food group like sugar, they lose weight because that's calorie restriction. What is also clear from science is that exercise, while it maintains weight loss, really doesn't cause weight loss unless you're really exercising vigorously and really restricting your calories. It's like a bank account, in and out kind of thing. But if you are fit and you are overweight and you want to try to lose some weight, calorie restriction is probably what we would recommend. Now, calorie restriction sounds terrible. There are great apps out there that help you track calories. Many of them are free.

John Horton:

Do you ever look at just even refocusing fitness routines? If you do have this excess fat in areas where it shouldn't be, if you target that specifically, can that help? And just if you switch the composition around a little bit, it makes things a little better long-term?

Dr. Leslie Cho:

Changing your exercise regimens certainly can help. There's some good data out there about cardio lower intensity, but longer duration for weight loss. That makes sense. In terms of focused exercise, so just doing pushups or crunches, that really doesn't do weight loss as much like some of the trials have shown, but I think, any exercise is good. I mean, honestly, when patients of mine tell me they are exercising and one of their exercises is they get off the elevator one floor before and they walk up, I'm like, "Wonderful. That's great." We park further away just-

John Horton:

…Any little bit helps.

Dr. Leslie Cho:

Yeah. Incorporating that extra activity throughout the day is very important. I think for most Americans, we all know what to eat, but really focusing, truly focusing on portion control, that's critical. And oftentimes, a lot of our empty calories come from drinks like coffee that's mostly not coffee, but mostly cream and things like this that are mostly dessert, not really coffee. Alcohol is an empty-calorie, fruit juice — there are lots of stuff out there, we just have to become, I think, a little bit mindful.

John Horton:

It's great advice as always, Dr. Cho. Now, we've navigated a pretty difficult topic here for our entire chat. So before we say our goodbyes, is there anything else you'd like to add when it comes to, I guess, managing your weight, your exercise routine, diet and just helping your heart?

Dr. Leslie Cho:

It's really not about the culture or the number on your dress size or your dress shirt or your pants size. It's about living a long time, living with a high quality of life without heart attack or stroke or dementia. And so when we think about weight — we have so much baggage because we live in America with all the cultural burdens we bring to weight — but if we can think about it as helping our heart, not having heart attack, not having a stroke, not needing that blood pressure medicine or that cholesterol medicine, I think we can start to come to a better relationship with our weight.

John Horton:

Those are all very good incentives. So Dr. Cho, thank you so much for coming on today. It's always wonderful and informative when you join us.

Dr. Leslie Cho:

Thank you so much for having me.

John Horton:

Being physically active is good for a body no matter what shape it is in. And fitness is a great foundation for better health. But don't overlook your body composition either. Excess fat and weight can take a toll on even the most fit person as the years go by. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.