Matters of the heart: why combatting obesity is about protecting your cardiovascular health, more than the number on the scale

Obesity rarely exists in isolation. People living with obesity frequently present with what Dr Choo describes as the “Triple Threat”—diabetes, hypertension and high cholesterol—three major risk factors that often coexist and significantly increase the risk of cardiovascular disease.

In Malaysia, this combination is becoming increasingly common. Almost 2.5 million Malaysians are living with three or more cardiometabolic conditions, such as obesity, diabetes, hypertension and high cholesterol. And over half a million live with four of these are major risk factors for heart disease.

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Findings from the Multiethnic Lifestyle, Obesity and Diabetes (MeLODY) Registry further illustrate this overlap. Among Malaysian adults with type 2 diabetes, 69.4 per cent were overweight or living with obesity, 62.6 per cent had hypertension, and 87.1 per cent had dyslipidaemia (abnormal cholesterol levels).

Excess body fat affects the cardiovascular system in several ways. It raises blood pressure, worsens cholesterol levels, increases insulin resistance and fuels chronic inflammation, placing sustained pathological stress on the heart and blood vessels.

“Imagine if you have to carry a backpack that weighs 20 to 30 kilograms; that’s what obesity is asking your heart to do every day,” Dr Choo says. “It’s a lot of burden, a lot of stress on the heart.”

“When you carry excess weight, the heart needs to work harder to provide oxygen and nutrients to a larger body mass,” he adds.

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When obesity occurs alongside diabetes, hypertension and high cholesterol, the cardiovascular burden becomes even greater. Together, these conditions accelerate damage to the arteries, increasing the likelihood of narrowed or blocked blood vessels over time.

Hypertension, in particular, places persistent pressure on the heart muscle, causing it to become thickened and stiff—a process associated with chronic inflammation, scarring and, eventually, heart failure.

At the same time, plaque gradually builds up within the arteries, restricting blood flow and reducing the supply of oxygen and nutrients to the heart.

“For the heart to function optimally, it’s not just that it has to pump blood; it also must relax well so it can refill before the next heartbeat,” Dr Choo explains. “A thickened and stiff heart does not relax well, and this may lead to lung congestion and heart failure.”

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At the same time, plaque gradually builds up within the arteries, restricting blood flow and reducing the supply of oxygen and nutrients to the heart.

“When the vessels are blocked, they are unable to provide oxygen and nutrients for the heart to function well,” he adds.

Furthermore, obesity also increases the risk of atrial fibrillation (AF), the most common type of sustained heart rhythm disorder. Left untreated, atrial fibrillation can significantly increase the risk of stroke.

The encouraging news, says Dr Choo, is that many of the cardiovascular changes associated with obesity can be improved—and, in some cases, even reversed—with timely intervention.

“Even a modest weight loss of five to 10 per cent has been shown to improve blood pressure, cholesterol levels, glucose control, heart function and overall cardiovascular risk,” he says. “Some of these problems with the heart, like stiffening, can improve—even recover.”

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However, he cautions that success in reducing weight is not a simple addition/subtraction equation.

“It’s not like the law of energy, whereby you take in less energy and expend more, creating a negative energy balance, then you’ll lose weight,” he explains. “By telling someone to ‘eat less’ and ‘move more’ to lose weight is like telling someone with asthma to breathe harder. It doesn’t work that way. The human body is not that simple.”

Obesity, he explains, is far more complex than a simple equation of calories in versus calories out. It is also a misconception to regard obesity as a simple matter of lack of willpower to lose weight.

Today, we recognise obesity as a chronic medical condition. It is not a cosmetic or character flow. It is a disease that affects the way our brain regulates hunger—how our body stores energy and how our metabolism functions.

Besides healthy eating and regular physical activity, early detection and intervention are equally important in preventing long-term cardiovascular complications.

“Obesity doesn’t just happen overnight—it develops over time,” Dr Choo says. “The same is true for many of its related conditions.”

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That is why routine health screening should become part of everyone’s long-term healthcare, even for those who feel otherwise healthy. Monitoring blood pressure, blood glucose, cholesterol levels, BMI and waist circumference can help identify cardiovascular risk factors long before symptoms appear.

“When these are detected early, we have a window of opportunity to manage and treat them,” he says. “Many of these concomitant conditions are much easier to manage when identified early than when they are diagnosed at an advanced stage. For some patients, early treatment may even reduce the need for more medications in the long run.”

Healthy eating and regular exercise remain the foundation of obesity management, Dr Choo emphasises, but they are only one part of a much bigger picture, as there are a lot of other biological factors that are working against us.

As scientists have gained a deeper understanding of obesity as a complex chronic disease, the way doctors approach treatment has also evolved. Today, the goal is no longer simply to help patients lose weight, but to improve their overall metabolic health and reduce long-term cardiovascular risk.

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One example is GLP-1 (glucagon-like peptide-1) therapy, which works by targeting some of the biological pathways involved in appetite regulation and metabolism.

GLP-1 is a naturally occurring hormone released by the gut after eating. It helps regulate appetite, slows the rate at which the stomach empties and signals fullness to the brain. GLP-1 therapy mimics these effects but last much longer in the body, helping patients feel satisfied with smaller portions while supporting gradual, sustained weight loss.

“These therapies help patients feel fuller with smaller portions and reduce what many describe as ‘food noise’,” Dr Choo elaborates.

Combined with nutritious eating, regular physical activity, adequate sleep and behavioural support, GLP-1 therapies can help reduce overall calorie intake without patients feeling constantly deprived.

Initially developed to improve blood glucose control in people with type 2 diabetes, researchers later discovered that certain GLP-1 therapies also offered important cardiovascular benefits beyond weight loss.

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While GLP-1 therapies are not a replacement for healthy lifestyle habits, nor are they suitable for everyone, the American College of Cardiology and the European Society of Cardiology have also highlighted its expanding role in the management of cardiovascular disease, chronic kidney disease and type 2 diabetes.

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“As a cardiologist, it’s about how these agents are able to improve patients’ outcomes whilst assisting in gradual and sustained weight loss,” Dr Choo says. “This is increasingly one of the tools in our armamentarium that we’re using today to help a lot of patients lose excess fat, and we expect that we can actually prevent a lot of cardiovascular problems downstream.”

“Under the supervision and guidance of healthcare professionals, such therapies are determined if appropriate, based on a patient’s overall health profile, cardiovascular risk and treatment goals,” he continues.

Ultimately, perhaps the biggest shift lies in reframing how success itself is measured—that the end goal should be a healthier, longer life, with a lower number on the scale serving as a welcome by-product rather than the measure of success itself.

“The goal is not going to be just fitting into a smaller clothing size,” Dr Choo says. “We have to look at it as achieving a healthier heart, so that we can live longer, with, more importantly, a better quality of life.”

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With a reminder that longevity is rarely determined by luck or genetics alone, Dr Choo concludes: “It’s often the result of these small choices and habits that we make along the way.”

“I always remind my patients that a lot of us go through life working very hard to invest in a successful career. In the same way, we must also invest in our health,” he says.

That investment does not have to begin with dramatic lifestyle overhauls. Rather, it starts with recognising obesity for what it is—a chronic medical condition that deserves early attention, regular monitoring and, where appropriate, evidence-based treatment.

“There’s no one-size-fits-all treatment for overweight or obesity, and improving health doesn’t require dramatic changes,” he concludes. “Small, consistent habit changes can actually work out better in the end.”

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