‘This is going to take all of us’: Creative partnerships can reduce cardiometabolic risk
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Key takeaways:
- Unique approaches to diabetes treatment can reduce cardiovascular risk.
- Academic, community, government and industry partnerships are key.
BOSTON — Lowering cardiovascular risk for people with type 2 diabetes requires effort from far beyond the clinician’s office, leveraging creative community partnerships that address social determinants of health, according to a speaker.
There remains a large gap between existing evidence on how best to lower CV risk for people with type 2 diabetes and the reality for people living with type 2 diabetes, Joshua J. Joseph, MD, MPH, FAHA, associate professor of internal medicine at Ohio State University College of Medicine, said during a plenary presentation at ENDO 2024. Recommended approaches to diabetes treatment that reduce CV risk — including proven therapies like SGLT2 inhibitors and GLP-1 receptor agonists but also lifestyle changes — are often out of reach for the most vulnerable or marginalized people, Joseph said.
“We have medications that we never had before impacting pathways that, 20 or 25 years ago, we didn’t even know about,” Joseph said. “To improve cardiovascular outcomes with diabetes. That is clearly the best of times. So, with that in mind, how are we doing as endocrinologists?”
Current state of cardiometabolic risk in diabetes
Fewer than two in 10 people in the United States with type 2 diabetes but without atherosclerotic CVD are meeting the American Diabetes Association’s recommended targets for HbA1c, blood pressure, LDL cholesterol and not smoking, according to Joseph. Fewer than one in 10 people with type 2 diabetes and CVD meet those same targets.
“We know that significant socioeconomic and racial/ethnic disparities exist, and that for people from lower socioeconomic backgrounds or from historically marginalized populations, there are even lower rates of meeting these targets,” Joseph said.
Similarly, data from National Health and Nutrition Examination Survey and the U.S. National Diabetes Statistics Reports from 2024 show about 11% of people are meeting more stringent targets for HbA1c, BP, non-HDL cholesterol and smoking, meaning 89% of people are not, Joseph said.
“These data underscore the need for greater efforts for composite risk factor control,” Joseph said. “This is important because we know that with greater risk factor control there are lower rates of CVD events.”
There are also differences in the use of SGLT2 inhibitors and GLP-1 receptor agonists by race and income, with Asian, Black and Hispanic adults and people reporting lower incomes less likely to be prescribed and utilizing the medications.
“We know that we need new and novel solutions to get these great medications and great therapies to the people that need them the most,” Joseph said.
Real-world solutions
The American Heart Association unveiled a new term in 2023 to reflect the interplay of several metabolic and renal conditions driving risk for CVD, along with an updated algorithm and guidance for screening, management and collaborative care. The term, cardiovascular-kidney-metabolic (CKM) syndrome, was created to underscore the connection between obesity, type 2 diabetes, chronic kidney disease and the CV system, Joseph said.
Stage 0 applies to people attaining and maintaining ideal CV health; stage 1 applies to people with overweight or obesity who could benefit from lifestyle interventions, weight loss or bariatric surgery; stage 2 applies to people with metabolic and renal risk factors including hypertension, metabolic syndrome, type 2 diabetes or CKD; stage 3 applies to people with subclinical atherosclerotic CVD or subclinical HF; and stage 4 is the highest-risk category reserved for those with CVD or kidney failure.
“What we want to think about is how do we keep more people to the left, over at stage 0, with no risk factors?” Joseph said. “To do this, we must look at a patient-centered implementation focus: consideration of social determinants of health, access to pharmacotherapies, addressing research gaps, interdisciplinary care, CKM education, enhanced obesity management, implementation within and across health care centers and supporting healthy lifestyles in communities. This is going to take all of us in the room.”
Joseph cited several examples of community outreach programs within Ohio created to improve cardiometabolic health, including the Exercise is Medicine program at the Ohio State University Wexner Medical Center, a global initiative to make physical activity and exercise a standard part of disease prevention and treatment.
“Any provider can put ‘exercise’ into the [electronic medical record] as an order,” Joseph said. “That gets transmitted to our Exercise is Medicine team and people can undergo an 11-week physical activity program with guided physical therapy. This is incredible, because some people have not been active in 15, 20 or 30 years. They need that support.”
Other programs include Cardi-OH, a statewide collaborative of health care professionals who share best practices to improve CV and diabetes outcomes and eliminate disparities.
As an example of community-based participatory research, Jospeh highlighted Black Impact, created by the African American Male Wellness Agency, Ohio State University researchers and community partners in the greater Columbus, Ohio, area. The goal of Black Impact is to improve metrics and reduce CVD risk for Black men, who have lower AHA Life’s Essential 8 scores than all other races. The single-arm, lifestyle intervention program combined weekly physical activity and health education with trainers and coaches.
“We were able to reduce BMI, weight, glucose, cholesterol, improve diet, and saw a 19% lower risk for CV mortality over 24 weeks,” Joseph said. “The next frontier is opening a healthy community center, so we can take these evidence-based paradigms and apply them to the people who need them.”
Joseph said research is still needed to improve “pharmacoequity” to ensure that everyone, regardless of race, ethnicity or socioeconomic status, has affordable access to the highest-quality medications required to manage their health needs.
“Advancing diabetes and cardiometabolic risk reduction takes all of us — every single one of us in this room,” Joseph said. “The academic, community and government partnerships and team science are the keys to our future success.”
References:
Black Impact. https://medicine.osu.edu/about-us/annual-report/black-impact-100-a-community-effort-to-heal-a-community. Accessed June 12, 2024.
Cardi-OH. https://www.cardi-oh.org/. Accessed June 12, 2024.
Exercise is Medicine. https://wexnermedical.osu.edu/health-and-wellness/exercise-is-medicine. Accessed June 12, 2024.
Joseph JJ, et al. Circulation. 2022;doi:10.1161/CIR.0000000000001040.
Ndumele CE, et al. Circulation. 2023;doi:10.1161/CIR.0000000000001186.
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Joseph JJ. Diabetes and cardiometabolic risk: From people to populations. Presented at: ENDO annual meeting; June 1-4, 2024; Boston.
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