Authors’ reply

We thank Patoulias et al1 for their interest in our recent paper on the ongoing pandemic of obesity in patients with coronary artery disease.2 We fully agree that obesity represents an independent, strong cardiovascular risk factor with increasing prevalence, and appropriate treatment options are needed. Moreover, we agree that new pharmacologic treatments which have become available recently, as well as modern bariatric surgery constitute valuable options for some patients. However, we deeply believe that education and lifestyle modification, including intervention on diet and physical activity in particular, remain the most important, and drugs or surgery should not be considered as a panacea for increasing prevalence of obesity, even if their use, as correctly pointed out by Patoulias et al,1 is related to improved prognosis. Indeed, we cannot imagine long-term high-level efficacy of any pharmacologic or surgical treatment if it is not accompanied by an effective education and lifestyle modification program. Education-based secondary prevention programs may improve survival.3 Moreover, their cost-effectiveness is proved.4 Unfortunately, many health systems fail to provide education and rehabilitation programs of sufficient high quality for all patients with coronary artery disease.5 In addition, access to healthy food is limited in many countries similarly to exercise and recreational facilities.

The current guidelines recommend rehabilitation programs for all patients with coronary artery disease. Such programs should not be focused on physical activity in a short period after the event, but rather should aim at modification of patients’ lifestyle in a longer perspective. This includes change of diet, regular exercising, and avoiding smoking, including second-hand smoking. Also, the intervention to increase adherence to prescribed therapies should be considered as important as lifestyle change. Finally, the sustained care over the life course after the event seems to be essential to prevent the deterioration of the direct effects of the program.

We agree with Patoulias et al1 that the use of new drugs with weight loss potential and bariatric surgery is likely to increase in the future. However, it is questionable whether such an increase should be considered as a success of a health care system.