Ask a Cardiologist: What Do I Need to Know About Excess Weight?

Dato’ Sri Dr. Azhari Rozman, Senior Consultant Cardiologist, shares with us the do’s, don’ts and sustainable ways to manage it.

For many of us, excess weight is only understood as an aesthetic issue rather than a contributing factor to a disease. The health aspects are far more serious than this: disrupted hormones, inflamed blood vessels, a heart working harder than it should and a cascade of conditions that build silently over years before appearing as a disease.

Obesity is one of our nation’s most pressing concerns, with 1 in 2 Malaysians considered overweight or obese. Despite this, we continue to delay seeking help, held back by stigma or the mistaken belief that weight gain is simply a part of ageing.

It isn’t. The World Health Organization now recognises obesity as a chronic, relapsing disease—one that requires the same medical seriousness as any other. Seeking care is not an admission of weakness. It is, as Dato’ Sri Dr. Azhari Rozman would put it, a healthy investment in yourself.

A Senior Consultant Cardiologist, Dr. Azhari has spent his career treating the consequences of what goes unaddressed for too long. In this conversation, he traces the hidden cardiac risks of excess weight, dismantles some of the most stubborn misconceptions around food and exercise, and makes the case for acting early: combining lifestyle changes and regular follow-ups with modern, science-backed pharmacotherapy as a serious and viable path to long-term weight control and cardiovascular health.

What are some of the most overlooked early warning signs of cardiometabolic risk that primary care providers should actively screen for?

There are three ways to assess cardiometabolic risk. The first is overall appearance relative to the individual’s height and age. The second are measurements: waist circumference, weight, BMI, blood pressure.

The third are blood tests. A lot of people avoid blood tests because they’re afraid of needles. But get past it once, and then do it every year or every six months if you are at risk. Once you’re past 30, which is when we recommend starting, to make it a habit. If you have weight issues, a strong family history, or known medical conditions, start earlier. That’s the first step towards a healthy investment in yourself.

What do you mean by “at risk”?

Simple risk factors: a history of smoking; a family history of coronary heart disease before the age of 55; a previous hospital admission for heart problems; or a history of diabetes, high blood pressure, or high cholesterol. A previous heart attack puts you in a different category altogether.

Beyond medical history, lifestyle counts too. You should be doing about 150 minutes of moderate exercise a week. But start with what you can do and don’t set too many goals at once. If you’ve had no activity, you can’t jump straight into a programme. Activity can mean doing things around the house—gardening, cleaning, washing the car. Just get moving. Walking around a mall is not quite the same; you’re pacing yourself, stopping every few steps, sitting down. The point is to shift the body from passive to active. Disease prevention starts there.

What are some of the early warning signs that people tend to overlook?

Diabetes, hypertension, and kidney disease often have no symptoms in the early stages. Cardiovascular disease does. The key signal is a change in your effort capacity—being breathless, having chest pain, or both when doing things you’d normally manage. If that’s changed in the past two to three years, that’s a red flag.

Even if you don’t want to see a doctor, do simple tests yourself. Go to a pharmacy with a blood pressure machine. Participate in a screening programme. The first step is the hardest—part fear, part inertia, part ignorance. Young people today are so focused on how they look and their social standing that they forget to look inwards. What you do now sets the stage for five, ten, fifteen years from now. That has a long-term impact, and it’s very important.

So many people still view obesity as a matter of lifestyle or appearance. From a cardiologist’s standpoint, why is it important to recognise it as a chronic medical condition?

Obesity is now officially recognised in Malaysia’s Clinical Practice Guidelines (2023) as a chronic, relapsing disease, not a matter of willpower or aesthetics. Like any disease: if it’s present, it causes harm; address it, and you can expect positive outcomes.

There are essentially three culprit mechanisms. First, stress hormones—they raise blood sugar, cholesterol, and blood pressure. Second, fat tissue itself is hormonally active. Particularly the fat around the abdomen and the heart: these cells independently secrete hormones that compound the effects of the first mechanism. Third, and most critically, is low-grade inflammation—not the kind from a sprained ankle, but a persistent, slow-burning inflammation of the blood vessels, kidneys, and heart that accumulates damage over many years.

By the time these patients reach a cardiologist, it’s often too late. People don’t drop dead from diabetes or kidney disease as quickly as they do from cardiovascular problems. That’s why the message has to go out earlier.

What are the most common misconceptions about weight, fitness, and cardiovascular health?

The biggest misconception is that excess weight is harmless. It isn’t. It’s a potential disease state. It is important to note that exercise does not necessarily lead to weight loss. To burn the calories in one plate of nasi lemak, you’d need to walk about eight kilometres. What goes in is often much harder to burn off than people realise.

Be fussy about what you eat: less refined sugar and carbohydrates, more protein and vegetables. And be aware of what highly processed food does to your system. It spikes your blood sugar rapidly, then drops it below normal, making you hungry again faster. So you eat sooner, and the cycle repeats. Over time, this overworks your pancreas. In people who develop insulin resistance, the pancreas initially compensates by producing more insulin. Over time, its insulin-producing beta cells may no longer keep up with the body’s increased demands, contributing to the development of Type 2 diabetes.

Malaysia has some of the highest rates of obesity and heart disease in the region. What are the specific ways excess weight puts strain on the heart?

When you are overweight, the heart has to pump across a greater mass—you need a bigger engine to drive a bigger car. On top of that, the hormonal and inflammatory mechanisms I described cascade into downstream conditions: diabetes, hypertension, high cholesterol, and even increased cancer risk. Cardiovascular disease remains one of the leading causes of death in Malaysia, with almost 2.5 million Malaysians living with three or more of these non-communicable diseases.

Among Asians, disease risk starts to set in at a lower BMI than among Westerners. For the Asia Pacific population, overweight is defined as a BMI above 23, while obesity is defined as a BMI above 27.5, compared to 25 and 30 in the West. But BMI alone isn’t always the best indicator. Most Asians have smaller bodies but carry fat around their midsection. Abdominal fat is particularly dangerous. For men, a waist circumference above 90cm is a risk marker.

Malaysia is now the second most obese country in the region, after Brunei. Weight management is a behavioural change, not a quick fix. It helps to bring family members or a spouse on board so everyone is aligned. Fortunately, the medications available now have come a long way.

Lifestyle changes are the foundation of weight management, but we know that they aren’t always enough for everyone. How do you assess when medical therapy should be introduced for a patient struggling with excess weight?

I set specific time frames, and their duration depends on the severity of the condition and the patient’s age. I tend to be fairly aggressive about introducing pharmacotherapy earlier rather than later, because every month of delay increases cardiovascular risk, and once disease establishes itself, reversal is very difficult.

I typically give patients about six months to assess progress. If things are moving, we continue and review the next six months. But if by the second or third cycle there’s been no meaningful change, it’s time for medical help. Before you know it, five years have passed and the disease has set in.

I want to stress: health is dynamic and it is not permanent. Don’t take it for granted. Sixty percent of Malaysians are not healthy by the time they turn 60—often presenting with two or three medical conditions. And 60 is the new 40!

In recent years, new science-backed therapies have emerged for treating obesity. Could you explain how medications like GLP-1 therapies work in the body to support weight management and improve metabolic health?

GLP-1 therapies are, to me, a long-overdue and remarkable addition. What makes them notable is that they’re physiological; they mimic hormones that already exist naturally in your body, specifically gut hormones.

They work through two main mechanisms. The first is slowing gut movement—food stays in the stomach and intestines longer, so you feel full sooner and for longer. The second is acting on the hunger centres in the brain.

People with weight issues often experience what’s called “food noise”—a persistent, intrusive preoccupation with food that they can’t switch off. Even mid-task, they’re thinking about what they’ll eat next. Even while eating, they’re already planning the next meal. It’s not a lack of willpower; it’s a brain signal they can’t control.

One of the first things GLP-1 therapy does is silence this “food noise”. That alone is a significant contributor to weight reduction—people can suddenly concentrate on their work without the constant mental interruption. There is some nausea early on, as the stomach adjusts, but these are generally very well-tolerated drugs.

Beyond weight reduction, what has clinical research shown about the cardiovascular benefits of GLP-1 therapies, particularly for patients at risk of heart disease?Yes. These drugs also reduce inflammation, and when inflammation is reduced, there is organ protection across the board: the kidneys, the liver (particularly fatty liver, which is common in people who are overweight), and the cardiovascular system, including reduced stroke risk and benefits for certain types of heart failure.

So beyond the number on the scale, GLP-1 therapies offer genuine protection to the heart, liver, and kidneys. They are, in that sense, transformative drugs.

What would you say to those hesitant about medical treatment for weight? And is taking this drug a license to eat whatever you want?

Side effects are generally mild—mainly nausea or a feeling of fullness in the early stages. Very few people have serious reactions. If you’re struggling to control your weight, consider pharmacotherapy earlier in your journey, not as a last resort. But do it under proper medical supervision, combined with other modalities: diet, exercise, behavioural change.

One of the biggest challenges in weight management is weight regain, which can happen within a year if long-term strategies are not maintained. Losing gradually is more sustainable than losing fast. Whatever you do, remember this: if the weight is coming down, you’re on the right track; if it keeps going up, get proper advice.

And no—it is not a passport to eat without restraint. Healthy eating habits still matter. Eat small amounts, stop before you’re full, and be fussy. For those who drink alcohol: the body prioritises burning alcohol as its energy source. Food eaten at the same time gets stored as fat. That’s why regular alcohol drinkers accumulate abdominal fat even when they don’t feel like they’re overeating.

How do you see the future of obesity treatment and heart disease prevention evolving?

The government has made an important step by emphasising preventive cardiology—training primary care doctors and GPs, and making newer drugs available upstream, before people become seriously ill. We need more trained practitioners, greater industry involvement in education, and more affordable treatment options through public hospitals. That’s the direction we need.

But we’ve been promoting healthy lifestyles for fifty years, and it’s been a struggle. Think about this: in the last 24 hours, how many advertisements have you seen for exercise or balanced eating? And how many for fast food, layered burgers, ice cream? Not one mainstream ad asks, “Have you exercised today?” or “Have you eaten your vegetables?” As long as that imbalance persists, it’s an uphill battle.

That said, there is a growing group of young Malaysians who are genuinely interested in being active—hiking, running, outdoor activities. We need to support and enable them: safe trails, accessible information, proper infrastructure so that the healthy choice becomes the easiest and most sustainable choice for everyone. Heart disease doesn’t appear overnight. What we do in our 30s, 40s and 50s will determine how healthy we are decades later. Prevention is always easier and better than treatment.