An article written by Dr Edward Leatham, Consultant Cardiologist © 2025 E.Leatham
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Why VAT Reduction — Not Weight Loss — Is the Real Target in Cardiovascular Care
At Surrey Cardiovascular Clinic (SCVC), our approach to GLP-1 mimetic therapy in coronary heart disease prevention is different from the standard weight-centred pathways used in obesity medicine. As cardiologists, our goal is not simply to change the number on the scales but to reduce the visceral adipose tissue (VAT) that drives inflammation, insulin resistance, lipid abnormalities, and long-term cardiovascular disease.
Recent evidence — including the landmark 2024 SELECT trial — has shown that semaglutide reduces major cardiovascular events even in people without diabetes, despite only modest changes in total body weight¹. This strongly suggests that the benefits extend beyond general weight loss. A growing body of mechanistic research indicates that a major reason for this effect is reduction in metabolically active VAT²˒³˒⁶.
VAT is not just storage fat — it is a biologically active organ in its own right. It releases inflammatory cytokines, floods the bloodstream with free fatty acids, worsens hepatic insulin resistance, raises triglycerides and increases the production of small dense LDL, one of the most harmful lipid particles²˒⁷. For patients attending a cardiology clinic, reducing VAT is one of the most logical and clinically meaningful interventions we can pursue.
Why VAT Matters More Than Weight
Many people assume that overweight equals unhealthy and that slimmer equals safer. But this is often untrue.
You can have:
A “normal” BMI while carrying dangerously high VAT, or
A higher BMI but low VAT and low cardiovascular risk.
That’s because total waist circumference is a mixture of subcutaneous fat (the pinchable external layer) and visceral fat (the internal, harmful layer wrapped around the organs).
Subcutaneous fat is not strongly linked to cardiovascular outcomes.
VAT is.
VAT is associated with:
- Chronic inflammation (via cytokines such as IL-6 and TNF-α)²˒⁷
- Insulin resistance and hyperinsulinaemia²
- Release of harmful free fatty acids into the liver
- Increased small dense LDL, highly associated with plaque formation
- A greater risk of atrial fibrillation and hypertension
- Poorer metabolic resilience
This is why SCVC’s programme is VAT-first. Weight change is simply a visible marker of a deeper metabolic process.
The SCVC Advantage: Starting With a VAT Scan
One of the most valuable elements of our clinic model is that for cardiac patients with waist to height ratio over 0.5, we can offer a highly accurate low dose CT VAT scan which identifies a high risk subgroup of overweight patients that have a metabolically unhealthy central adipose depot. By offering a choice of vat-reduction programs with or without pharmacological support, patients are immediately empowered.
Those at highest risk enter a 8 month GLP-mimetic programme, where lifestyle, exercise and diet are combined with weekly self injection of a semaglutide or tirzepatide, while lower risk patients are offered the choice of either pharmacological or non pharmacological programmes. The latter provides senior nurse practitioner and dietician oversight with tracking and food analysis apps that support lifestyle and dietary change, with the option to escalate to GLP-1 mimetic if necessary.
This gives patients a major advantage over weight-only pathways.
Most programmes set goals based on:
- BMI
- Clothes size
- A generalised “target weight”
However, none of these can tell you how much VAT you have — or how much you need to lose to become metabolically healthy.
With a VAT scan, we can:
✔ Measure your actual internal fat burden
✔ Establish a baseline risk profile
✔ Use AI-supported tools to calculate your personalised target waist
✔ Determine the target weight associated with healthy VAT
✔ Provide a clear and medically meaningful destination
This allows us to say:
“You do not need to lose weight until you look different — you need to reduce your VAT until your internal risk returns to a safe, healthy level.”
Without VAT scanning, this is impossible to determine accurately.
Why GLP-1 Mimetics Work So Well on VAT
For those patients unable to make adequate progress in reducing waist /weight metrics with diet and exercise alone, medical therapy can then be initiated. GLP-1 receptor agonists such as semaglutide and tirzepatide, consistently show a greater reduction in visceral fat than subcutaneous fat, even when total weight loss is modest²˒⁴˒⁶.
Key documented effects include:
- Reduced VAT volume in both diabetic and non-diabetic adults²˒⁴
- Reduced metabolic activity within VAT depots⁶
- Improved hepatic fat and insulin sensitivity⁸
- Reduction in triglycerides and small dense LDL²˒⁷
These mechanisms align closely with the cardiovascular benefits observed in large outcome trials¹.
When cardiologists prescribe GLP-1 therapy, we do so not for cosmetic reasons or general weight loss — but to modify the internal fat that drives cardiovascular risk.
How We Operate GLP-1 Mimetics at SCVC: The Choice Model
For patients initiating or escalating to GLP-1 mimetic support, Instead of following the standard “monthly dose escalation to maximum tolerability”, our consultants will often recommend a more flexible, patient-led model designed specifically for cardiovascular health and VAT reduction.
Each week the patient makes one key decision:
👉 Increase the dose of their GLP-1 mimetic injection fractionally
OR
👉 Increase lifestyle adjustments
This weekly micro-choice is the core of our approach.
It acts as a behavioral lever, putting the patient in charge while keeping the focus on achieving their VAT target, not a cosmetic goal.
Patients may choose to:
- Add an extra resistance training session
- Introduce short bursts of HIIT
- Increase daily steps
- Prioritise higher protein and fibre intake
- Adjust meal timing
- Improve sleep
- Reduce refined carbohydrates
These lifestyle interventions stimulate natural GLP-1 release, build skeletal muscle mass, enhance insulin sensitivity and accelerate VAT reduction.
If a patient is struggling despite good lifestyle engagement, a slight dose increase can unlock progress without pushing them into the side-effects seen with rapid dose escalation.
This dynamic approach balances efficacy, safety and patient empowerment.
Why We Avoid Rapid Dose Escalation
The standard obesity regimen increases the dose of GLP-1 mimetic every four weeks. While effective for rapid weight loss, this approach is less suited to cardiology practice because:
- Rapid escalation can increase the risk of nausea, vomiting and dehydration
- Quick weight loss includes muscle mass and subcutaneous fat, not just VAT
- Very fast loss can degrade metabolic flexibility
- Side effects may reduce physical activity
- Patients may become fully reliant on medication instead of undertaking necessary lifestyle and dietary measures
VAT does not need to be lost quickly to be lost effectively.
Our slower, fractional titration allows:
- Better tolerance
- Continued exercise
- Build skeletal muscle
- Fewer side effects
- Stronger metabolic adaptation
- A focus on internal fat rather than numbers on the scale
Our metabolic reset/ body remodelling program aims to swap VAT for skeletal muscle to support long-term cardiovascular benefit rather than short-term cosmetic change.
Patient Outcomes So Far
Although long-term data for this model are still developing, early indicators are very encouraging:
- High adherence to treatment programmes
- Lower side-effect burden due to lower starting doses and gentler titration
- Consistent VAT reduction, even when weight loss is modest
- Improved metabolic markers (glucose stability, triglycerides)
- Reduction in VAT-driven symptoms such as breathlessness and fatigue
- Patients feel more in control, not “done to”
Most importantly:
Patients reach their personalised VAT-based target waist in a safe and structured way.
Where to Learn More
This blog summarises the philosophy and clinical approach behind our GLP-1 mimetic service at SCVC. For readers who want the underlying science, mechanisms and references, our accompanying short paper provides a deeper explanation. If you have coronary heart disease, or think you may be at risk from coronary heart disease and are interested in a proactive preventative approach, get in touch.
More information see short paper
Visceral Adipose Tissue as a Therapeutic Target in Cardiovascular Prevention and the Role of GLP-1 Mimetics
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References
- Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 2023;389(24):2221-2232. doi:10.1056/NEJMoa2307563.¹
- Liao C, Ren K, Cao Y, et al. Effects of GLP-1 receptor agonists on visceral fat and liver: systematic review and meta-analysis. PLoS One. 2023;18(6):e0289616. doi:10.1371/journal.pone.0289616.²
- Akoumianakis I, Campbell DJW, Badimon L. GLP-1 analogues and regional adiposity: methods for visceral adipose tissue analysis. Obes Rev. 2023;24(5):e13574. doi:10.1111/obr.13574.³
- Liao C, Liang X, Zhang X, et al. GLP-1 receptor agonists and visceral fat in adults with and without diabetes. PLoS One. 2023;18(8):e0289616. doi:10.1371/journal.pone.0289616.⁴
- O’Donnell C, Ryan O, Hogan AE, et al. GLP-1 therapy increases visceral adipose tissue metabolic activity: randomised trial in sleep apnoea. Obesity (Silver Spring). 2024;32(11):2077-2081. doi:10.1002/oby.24126.⁵
- Cesàro A, et al. Visceral adipose tissue and residual cardiovascular risk. Front Cardiovasc Med. 2023;10:1187735. doi:10.3389/fcvm.2023.1187735.⁶
- Bu T, et al. Glucagon-like peptide-1 as a regulator in lipid metabolism. Diabetes Metab J. 2024;48(1):1-15. doi:10.4093/dmj.2023.0277.⁷
