Obesity is a chronic, serious health condition affecting more than 1 billion adults worldwide, and rates are rising. It increases the risk of heart disease, stroke, heart failure, type 2 diabetes, and other health problems. In the United States, over 40% of adults are obese, and nearly 10% have severe obesity. Severe obesity can shorten life expectancy by 7–9 years. Managing obesity is crucial for improving overall health, especially heart health.

Causes and Diagnosis of Obesity
Obesity is caused by a complex mix of factors including genetics, psychological and neurological conditions, hormonal imbalances, social and environmental influences, certain medications, and medical conditions. The most common method for diagnosing obesity is through the use of Body Mass Index (BMI), which is calculated based on a person’s height and weight. However, BMI does not always reflect body fat or health risks for every individual, especially in people from different ethnic backgrounds. Other measurements, like waist circumference or waist-to-height ratio, can also help assess health risks.

Health Risks of Obesity
Obesity is a major independent risk factor for many types of cardiovascular disease, such as coronary artery disease, heart failure, atrial fibrillation, sudden cardiac death, blood clots, and heart valve disease. It also increases the risk of high blood pressure, high cholesterol, type 2 diabetes, and sleep apnea, all of which further raise the risk of heart disease.

Treatment Options
Traditional approaches to weight loss include lifestyle changes (diet and exercise) and, in some cases, bariatric surgery. However, lifestyle changes alone typically result in only modest weight loss (~5%), which may not be sufficient to significantly improve heart health. Bariatric surgery is effective, but not suitable or desirable for everyone.

Medical Therapies: NuSH Therapies
A new generation of medications, called nutrient-stimulated hormone (NuSH) therapies, has transformed obesity treatment. These medications target hormones that control appetite and metabolism.

The main NuSH therapies currently approved are Liraglutide (daily injection), Semaglutide (weekly injection), and Tirzepatide (weekly injection).These drugs are more effective than older medications, with average weight losses of 8% (liraglutide), 15% (semaglutide), and 21% (tirzepatide) at maximum doses. They also help reduce the risk of heart attacks, strokes, and cardiovascular death, even in people without diabetes. The most common side effects are mild digestive issues, such as nausea or diarrhea, which can often be managed by adjusting the dose.

Who Should Get These Medications?
NuSH therapies are recommended for people with obesity (BMI ≥30 kg/m², or ≥27 kg/m² with weight-related health problems) who need more than lifestyle changes to achieve meaningful weight loss and improve health. Patients do not need to “fail” lifestyle interventions before starting medication, but healthy lifestyle changes should always be encouraged alongside medication.

Multidisciplinary and Individualized Care
Effective obesity management requires a team approach, involving doctors, dietitians, pharmacists, behavioral therapists, and other specialists. Treatment plans should be personalized, taking into account the patient’s overall health, preferences, and goals. Reducing weight stigma and supporting patients in a respectful, person-first manner is essential.

Barriers and Access
Despite their benefits, NuSH therapies can be expensive and are not always covered by insurance, especially for people without diabetes. This limits access for many patients. Advocacy for better coverage and lower costs is ongoing. Patients are warned against using unregulated or compounded versions of these drugs due to safety concerns.

Conclusion
Obesity is a complex, chronic disease that requires long-term management. New medications offer hope for effective weight loss and improved heart health, but access and affordability remain challenges. A comprehensive, patient-centered, and multidisciplinary approach is key to successful obesity care.

Prof Dr Sanjay Rampal

Source: https://www.jacc.org/doi/10.1016/j.jacc.2025.05.024

AI models were used during the preparation of this post.