Is obesity a cardio-renal burden we can slim down?

The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).

In this episode of For Kidneys'Sake, Dr Andrew Frankel and Prof Jeremy Levy are joined by Dr Khuldir Johal, a GP and clinical lead for the Harrow CRM Hub, to discuss the relationship between obesity and Cardio-Renal Metabolic (CRM) disease. Together, they examine how excess adipose tissue, particularly around the abdomen, can create a pro-inflammatory state that contributes to vascular and organ damage, influencing the development of heart, kidney, and metabolic disorders. The episode emphasises the need to move beyond managing diabetes, hypertension, and kidney disease as separate conditions, and instead adopt a joined-up, clinically integrated approach.

Dr Johal outlines how the Harrow CRM Hub identifies at-risk patients early, using indicators such as raised BMI and type 2 diabetes, then supports them through a longer consultation model, tailored advice, and multidisciplinary care. The focus is on empowering patients to understand and manage their own health through regular monitoring and education, rather than relying solely on medication. The episode concludes with a call for clinicians to recognise the interrelated nature of CRM conditions and intervene as early as possible to reduce the long-term burden on patients and the health system.

Key Takeaways

1. CRM disease is interconnected – Heart, kidney, and metabolic conditions share causes like obesity and inflammation and should be managed together, not in silos.
2. Obesity drives disease – Abdominal fat acts as an inflammatory organ, damaging vessels and accelerating heart and kidney problems.
3. Early detection can reverse risk – Identifying people early and supporting lifestyle change can slow or even reverse progression.
4. Holistic, team-based care works – Longer, integrated consultations involving GPs, coaches, and nutritionists empower patients and improve outcomes.
5. Empower patients – Give people access to their data and help them set realistic goals so they can take ownership of their health.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association | Circulation

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub

Chapters

• 2:52 Understanding Cardio-Renal Metabolic Disease
• 5:56 The Journey of Cardio-Renal Metabolic Disease
• 8:49 Innovative Approaches in the Harrow CRM Hub
• 10:06 Identifying At-Risk Cohorts
• 13:00 Holistic Patient Care in Primary Practice
• 16:03 Managing Obesity and Weight in Primary Care
• 18:00 Key Takeaways and Conclusion

Transcript

Andrew 
Hello everyone and welcome to another in this series of podcasts entitled For Kidneys' Sake. I'm Andrew Frankel, Consultant Kidney Doctor from Imperial College Healthcare NHS Trust.

Jeremy 
Hello, and I'm Jeremy Levy. I'm also a Neurologist Kidney Specialist at Imperial College Health Care NHS Trust. And this is the second of our podcast that is focusing specifically on Cardio Renal Metabolic Medicine or Cardio Kidney Metabolic Medicine, whatever you want to call it. So not just kidneys. We've really been keen to expand this to think about this whole spectrum of heart, kidney and metabolic disorders. And today we want to really start to look at some of the early aspects in the development of this disorder and particularly its relationship with obesity and fatness. And this has become a really, really important topic. And we're delighted today that we're joined by a local Hillingdon GP, Dr. Khuldir Johal, who's been doing a whole series of work on this topic for a number of years. She's had a number of roles across Northwest London, but most importantly now, she's the clinical lead in North London for the Harrow CRM Cardio Renal Metabolic Medicine Hub Programme which is specifically trying to help GPs tackle this issue. So, Khuldir welcome.

Khuldir 
Thank you, Andrea and Jeremy. It's great to join you again.

Jeremy 
So I'm going ask you Andrew to kick off. Can you start telling us really what do we mean by Cardio-Renal Metabolic Disease and think about what is driving it and why we're then going to talk on about obesity.

Andrew 
Well, Jeremy, we actually don't know for certain what it is that really links the development of cardiac, renal, and metabolic disease in all individuals. But there is considerable data that supports obesity as being one of the driving forces for the development of this disorder. And I think you referred to this in a previous podcast, Jeremy, when you reminded the audience that obesity isn't just white fatty flab, I think that's the way you described it, but an active organ system. And certain types of adipose tissue or fatty tissue around the abdomen produce substances that emulate an inflammatory environment. And it's believed that this inflammation is the driving force to the damage that occurs to the vasculature within the cardiovascular system and indeed also affecting the kidneys and their small blood vessels. Khuldir from the perspective of a GP trying to improve the health of your patients in the long term, how do you see cardio renal metabolic disease clinically?

Khuldir 
Thank you. So to me, CRM or Chloroereno-metabolic, as you said, really encompasses the bulk of everyday general practice. Why? Well, primary care has been working on this for over 20 to 30 years. The great example is the QoF or Quality Outcome Framework, which actually captures a number of the conditions that fall into this entity. For example, established heart disease, advanced chronic kidney disease and even earlier conditions which potentially increase your risk, for example, type 2 diabetes, pre-diabetes and hypertension. These are all disorders seen in primary care, but the tendency we tend to manage them in silos.

Jeremy 
That's been the problem, hasn't it, called in, as you say, diabetes, pre-diabetes, hypertension, chronic kidney disease. They've all been managed sort of the individual disorders. And that's one of the challenges. And it's been everybody's fault, hasn't it? There's no one person to blame. You've been doing it primary care, we've been doing it secondary care, and actually patients have been thinking about them as separate disorders. But I think you've made quite a big move, haven't you, to try and bring these things together to see how you can tackle them as sort of as a single entity with patients or what's the approach you're doing to try and get away from these silos?

Khuldir 
So you're right Jeremy, I mean at the end of the day, even as a GP or as clinicians, collectively we see a patient with multiple conditions. I'm really interested in this as the various conditions that affect the individual and their interrelationship and interconnections and treatments actually have a big influence on the individual's health. There's a great diagram in the American Heart Association Presidential Advisory in 2023. It's figure one, I think it's great because it absolutely shows you.

The different interconnections. Sometimes I say a picture speaks more than a thousand words. I use this graphic in my conversations with colleagues and patients. It brings together this overlapping of conditions, obesity, cardiac, renal metabolic, but more critically, actually, the reversibility the number of conditions and how even their progression can be slowed down. It doesn't mean that you have to move from stage two to three or four.

With the exception of stage four, you can come back, but we'll come back to that in a minute. It's about that potential journey in both directions. And critically, it's about changing our mindset around this understanding with the greatest influence being our approach in primary care, but more critically, in my view, empowering the patients to self-care on their own long-term journey.

Andrew Frankel 
Khaldhir I've seen that diagram and I agree with you, it is a really powerful and helpful diagram and indeed I think we put it in our show notes and it's one of the takeaways I'm going to say at the end that people really need to look at this and appreciate this journey. So tell us a little bit more about the journey that patients go on.

Khuldir 
Thank you. And you're right, it mustn't be confused with the CKD stages, which is completely separate. In the CRM spectrum, stage zero is actually optimal health. That's a time when there's no risk factors. So you may have a normal BMI, a normal blood pressure, cholesterol profile and sugar controlling kidney function will all be very good. That's the stage that you're trying to maintain throughout your lifestyle, with a healthy lifestyle, but we'll come back to that.

So stage one of this syndrome is the one associated with increased obesity. It's the adipose tissue, the insulin resistance that everybody reads about. Personally, I don't particularly like the term obesity because it's got such negative connotations. To me, it's the individual's health and understanding the influence of the adipose tissue around that individual health.

It's easy to see around the abdomen, but what other parts of the body does it influence and how does it affect the microvascular disease? So stage one to me is the early warning sign that things are beginning to develop and may get worse in your health in the future. It's about recognising it early so you can undertake lifestyle interventions sooner rather than later and stop any further progression to stage two. So stage two.

What's that? I've already touched on it. It's the number of conditions you're familiar with. Diabetes, pre-diabetes, hypertension, high cholesterol, even early chronic kidney disease. Yet, a lot of these conditions don't have any symptoms or presentations of organ damage at that stage. That's where the conundrum is. GPs will no doubt be familiar with the following scenario. For example, you may see a young gentleman in his 30s.

Slightly raised to ALT a few years later, develops pre-diabetes and fatty liver, and in some cases goes on to have type 2 diabetes. More critically, in their early 50s or even 60s, they may have established heart disease or even kidney disease.

But the question there is, then, what else could have been done? So stage three is what we already recognise as identifying QRISK. Is it the risk greater than 10 %? To individual patients, that's about your heart age and your early CKD diagnosis. Stage four is where it's already established cardiovascular problems. What you will already be familiar with, heart failure, chronic kidney disease, strokes, and increasingly my view, vascular dementia may have an influence. So the symptomatic changes are quite late in the process and quite rightly that patient will ask you, how can I stop that progression or reverse the changes? They wish to be able to alter their trajectories earlier.

Andrew
So, Khuldir, I understand that you've taken this concept of this journey and intervening early on into the work you're undertaking with the Harrow CRM Hub. And I understand there's a number of other innovative elements to the Hub and already focused on that early intervention. Perhaps you could now take us through how you determined who are the cohorts who you are looking at within that hub

Khuldir 
Thank you, and I guess it's about remembering how general practice works. In general practice, patients who are over the age of 40 are already invited for what they call the National NHS Health Checks. So if you get the invite, do follow it through. It helps to identify conditions such as high blood pressure. But do remember there's a lot of people under the age of 40. So primary care already has a wealth of information around these people when they come in for other health checks.

So we may get the information around the weight and the height information. So using that as a proxy, we can calculate the BMI. And if the BMI is greater than 27.5, depending on your ethnicity, we use that as a proxy of determining what the health is like. The other cohort we looked at, as we already mentioned about stage two, was your type 2 diabetic patients. So those were the two key cohorts that we thought we'd look at going forward to see if we could influence.

Using this approach, we then allowed number of PCNs in Harrow to get involved. We started a pilot process just looking at two PCNs. But here's the interesting point. If you look at all of the conditions that I've already mentioned and you amalgamate them, and for those patients over the age of 18, remember only for the ones that we've currently got the information, it's almost 40 % of your patient practice population. That's quite a lot of people already affected.

Jeremy
That's not quite a lot, Khuldir. It's a huge amount. I was staggered by that figure. So 40 % of essentially adults have got one aspect of cardiorenal metabolic medicine when you're only hunting by looking at BMI and diabetes. I mean, it's a really huge proportion of the population. it strikes me as being a very nice way to try and detect very early things. These people don't have overt disease, but they're at risk, aren't they? Moving along that pathway that you've described. So what are you telling them? You you've pulled them out.

They're a little bit fatter than they should be. Their BMI is slightly high. Some of them have got diabetes, but what are you then telling them?

Khuldir 
Well, I guess it's about our different approach. mean, too often in primary care, we're the first who will say, yes, alter your lifestyle and diet, but that's in a 10 to 15 minute consultation. what can we really expect individuals to pick up on that? What do we really mean by it? Well, in the HARO program, it's about giving a slightly longer consultation. So you really make the time to really listen and share realistic goals with the patients. You give them the tools and you also connect them to other members of your team is teamwork. You have your health coaches, you have your nutritionists. Remember this is about reminding people that it's a marathon not a sprint to maintain their long good health. The key measures as a part of this programme has been given to the individuals as well. They're everyday tools. Your take measure for your waste circumference, getting your blood pressure reading done. Remember that's not just on the GP anymore, you can get that done in your community pharmacies as well, and lot of patients actually have their own BP monitors. Understanding baseline checks around your sugar control and kidney function, but that's also including getting a urine check around that, as well as the liver test and cholesterol profile. Indeed, in our program, we are now beginning to pick up a lot more cases of early fatty liver disease as well. So, as I've mentioned, it's about that longer consultation so we can have a holistic approach. It's about...

Speaking together to understand what are the various conditions for them as an individual in relation to your sugar control, cholesterol and how that's changing over time. But more importantly, having that conversation to say what can they influence realistically then with that so they can improve things going forward. often we can talk about sugar control, blood pressure, cholesterol and weight management in separate consultations. So in this new model we're bringing it all together under the one umbrella, a truly holistic approach and we're starting early. More critically we're not just waiting for the annual review, we're asking people to come back at the three to six month interval. It's to keep the motivation going as well as encouragement and more importantly it's about optimising their individual health.

If we can't demonstrate the personalised care to them as an individual, how else can we progress? People are quite rightly asking what are the right numbers for them as an individual in a realistic way, so you can set the realistic blood pressure targets, as well as the sugar control targets. People do want to know what their numbers are.

Andrew 
So you're really talking about a holistic approach and moving away from that siloed approach in primary care. I was surprised by the fact that the programme was so widely adopted beyond those initial two PCNs. And I assume that this was because it was truly perceived to be effective, but perhaps more importantly for primary care, it was perceived as being a more efficient way of working.

Khuldir 
I agree. mean, the beauty about the programme in Harrow is that it's beginning to change mindset and about how we manage our collective time, as I've already mentioned. We're not calling people back multiple times for multiple appointments because actually of the conditions complement each other and equally we can have that one conversation on one occasion. Absolutely respecting the patient's time as well. But it also gives you the opportunities to discuss and share the learning.

And we've done that as teams. The beauty about the hub working, isn't as I've mentioned, just the GP or the clinical pharmacist is your collective team. We're also speaking to our secondary care colleagues about complex patients and therefore improving our confidence in how we can treat them. The hubs are about giving patients the tools to understand and influence and not just prescriptions for medication. Although of course we do now have a lot more newer medications easily available, clearly influencing the various elements of the pathway. However, if we do not identify and assist patients from the earlier stages, then the vicious cycle continues.

Andrew 
and the obesity challenge Khuldir since so many people are overweight, we also know that the tertiary centres obesity really can't manage this. This is predominantly being managed in primary care. What tools are available to you to help you manage this within the cohort, within the hub?

Khuldir 
So remember in primary care we're already linked into local exercise programmes, working with the health coaches, working with your local health authority, it's all part of the neighbourhood way of working. And your relation to the weight management is not just the tier 3, it's the other elements as well. Therefore it's about making sure that you can speak to your teams and be signposted accordingly. But this is a long term programme.

Remember a number of the programs may just be six weeks or 12 weeks but those are there to set the tools as your foundation going forwards. In addition we know as GPs a lot of patients are already getting weight loss medications privately. You just need to at the news or read it in the press. But as a part of the program in Harrow we do encourage patients who are being this way to be monitored as part of this going forwards because if we don't know what's going on

We can't monitor their individual progress. More critically, make sure it stays safe for them.

Jeremy 
Well, it is very interesting because exactly as you say, I mean, more and more people are just buying the drugs. Well, apart from the recent price hike, which is going to put people off, I think we'll get panicked and go to their GPs and say, should I do? But all these new medicines ozempic , Munjaro, they're being massively and widely used. And we know that within the NHS prescriptions have been quite tightly rationed for mostly financial reasons because the health benefits are significant. I think it's really important and good to hear how you're trying to tackle these very early stages of obesity, of being overweight. And it goes back to the beginning, we know that this is a driver of inflammation and that if we can get in there early to try and help people own this issue, work out what they can do long term, it's going to have a major influence in preventing heart disease, preventing kidney damage, preventing metabolic disorders, etc. It's a really important aspect of it, as we've alluded to.

Andrew 
Thanks, Jeremy and I agree completely. I suspect there'll be a podcast in the future with us talking about the GLP-1 receptor agonists. And thanks, Khuldir, that was incredibly helpful to hear. So let's think about some takeaways. I really want to reiterate how helpful I found that graphic, the diagram from the American Heart Association Advisory on Cardio-Renal Metabolic Disease published in 2023.

It's in our show notes. People should have a look at this and think about what it's telling you about the fact that people with CRM go on a journey from no disease all the way to stage four, which is established disease, and understand how to use that diagram to empower patients and to understand that they can move not just forwards towards worse health, but backwards towards better health.

And think that's really important. Secondly, and I think this is what the hub has already achieved, which is changing mindsets and approach, moving away from a siloed long-term condition management to a much more holistic personalised care approach. You talked about this so often, yet how many of us in healthcare are actually doing this? And you make sure that patients have access to their own data.

They own their own healthcare in this system, when we see any adult patients, we should be thinking CRM. Realistically, very many of the patients that you see in primary care and indeed we see in secondary care will have a facet CRM. So we should capture the height, weight, and let the individuals know what those figures are. Let them know their waist circumference. It's really useful as an early screen. That can both inform and empower. You know the journey they may be starting on and we need to try and ensure that we share this with patients.

Jeremy 
That was really great summary, Andrew, thank you very much. Khuldir, thank you so much for joining us. It's been really interesting to hear about this challenge about how you're trying to solve it in Harrow. And there is so much to learn about how we can engage with patients at this very early stage of this problem of cardio renal metabolic medicine. So thanks again for this conversation.

Khuldir 
Thank you, it's been a pleasure.