Interview: The Role of Primary Care in the Management of Cardiometabolic Disease
Citation:
Interview: the role of primary care in the management of cardiometabolic disease. Consultant. 2017;57(5, Suppl.):S2-S3.
Cardiometabolic risk reduction is at the core of nearly every clinician’s practice, given the prevalence of these conditions—hypertension, diabetes, dyslipidemia, and obesity—among the US population. Nearly 10% of American adults have diabetes, nearly 30% have high blood pressure, and nearly 35% are obese, meaning that helping patients manage their cardiometabolic health is one of the most common components of daily practice.
Consultant sat down with Daniel Einhorn, MD, and Peter H. Jones, MD, to discuss their perspectives on key issues contributing to the growth of the cardiometabolic disease epidemic, why primary care clinicians are critical to the management of patients with these conditions, and what the future holds for improving the health of Americans who have cardiometabolic disease or who are at risk for it.
Drs Einhorn and Jones are cochairs of the Cardiometabolic Risk Summit (CRS), the official meeting of Consultant, taking place October 20-22, 2017, in Dallas, Texas.
1. What key issues contribute to the growth of the cardiometabolic disease epidemic in the United States?
Dr Einhorn: The impact of early-life antibiotic exposure on the microbiome, which may impact inflammatory pathways for life, and the interaction of all metabolic diseases. A better understanding of the effect of the high prevalence of fructose throughout the processed food chain, and the changing ethnic mix of America. That being surrounded by obesity creates an interesting paradigm with psychological and physiological aspects.
Dr Jones: The convergence of inexpensive, calorie-dense, nutrition-poor food availability and a lack of daily physical activity has led to a greater incidence of obesity across the US population. This results in more metabolic disturbances, such as hypertension, diabetes, and dyslipidemia, and can lead to premature cardiovascular events. Racial and socioeconomic disparities are factors that also need to be addressed.
2. What is the biggest misconception about cardiometabolic syndrome?
Dr Einhorn: That it’s just diabetes, obesity, fats, and blood pressure. It’s perhaps as much about everything else we know about chronic disease in the modern age. Specifically, it’s also about stress, sleep, environmental change, disruption of natural living rhythms and diet, and physical activity. It’s also a misconception that our drug therapies alone can reverse all aspects of cardiometabolic syndrome.
Dr Jones: Cardiometabolic syndrome has genetic influences, but patients and providers need to understand that the manifestations of insulin resistance, dyslipidemia, obesity, and hypertension are also strongly influenced by modifiable lifestyle habits.
3. Why are primary care clinicians so crucial in the management of patients at cardiometabolic risk, particularly in rural areas and/or special populations?
Dr Einhorn: Because they are the front lines, primary care providers are the ones who see the most people in need. The specialists help define the path, because that’s what they do. The primary care clinicians make it real. They teach the rest of us what’s important and what’s doable in daily practice.
Dr Jones: Primary care providers are the front-line practitioners responsible for screening and identifying at-risk patients at a young age. This is the prime time for education about optimal diet and physical activity to be most likely to result in sustainable metabolic benefits, rather than trying to institute changes at a later age after a medical event has already occurred.
4. Can you elaborate on the importance of a multidisciplinary team approach to the management of cardiometabolic disease in patients?
Dr Einhorn: No one clinician alone has perfected the full spectrum of skills and knowledge needed to manage cardiometabolic disease. It is a complete team effort. Each patient responds differently to various approaches and personalities of their primary care team. We learn from each other, and we work together to lead our patients on the path to success.
Dr Jones: Since there is a strong need for patients with cardiometabolic disease to have education and support that will facilitate long-term lifestyle and behavioral change, a team of providers (physicians, physician assistants, nurse practitioners, registered dietitians, certified diabetes educators, exercise physiologists, and licensed counselors) is crucial for patient success.
5. What are some of exciting recent pharmacologic and nonpharmacologic developments in the approach to and our understanding of cardiometabolic disease?
Dr Einhorn: From a clinical standpoint, there are 2 fronts. One is that lifestyle therapy can’t be something short-term, and that very restrictive programs—such as those used on the TV series The Biggest Loser—are doomed to failure and may cause permanent negative changes of metabolism. Two, therapies can now be designed that are easier to live with than ever before, assuming they can be affordable. From an understanding standpoint, the contribution of the microbiome throughout the life cycle, as the way many drugs actually work, is opening up a new frontier.
Dr Jones: In the lipid field, the recent demonstration of cardiovascular benefit and safety of achieving low levels of low-density lipoprotein cholesterol with the add-on use of monoclonal antibodies to PCSK9 [proprotein convertase subtilisin-like kexin type 9] inhibitors proves that both drug and lifestyle approaches to target dyslipidemia are very important in patients at high cardiometabolic risk. I am also excited to learn more about the evolving science of the intestinal microbiome and its effect on cardiometabolic health.
6. What does the future hold for cardiometabolic disease management? Can you describe some of the emerging treatments or approaches in development?
Dr Einhorn: The near future will have enhancements in medications for diabetes such as promoting weight loss, avoiding hypoglycemia, being more convenient (monthly, yearly, oral, etc). There is also more awareness about early intervention and achieving targets more easily.
Dr Jones: I hope we can learn more about the cardiovascular benefit of the SGLT2 [sodium-glucose cotransporter 2] inhibitors in patients with diabetes, and how to identify which patient group derives the most benefit (independent of glucose effects). In the lipid field, novel drug delivery methods will soon be able to target triglycerides and lipoprotein (a) in patients with polygenic influences in dyslipidemia.
7. Can you offer suggestions for primary care providers as they attempt to apply the numerous expert guidelines on cardiometabolic disease in their practice?
Dr Einhorn: There is real consensus among guidelines from medical societies, even if the language used or what is emphasized seems different. Remember, you know your patients best. Clinical trials and guidelines will never substitute for a health care provider’s clinical judgment.
Dr Jones: The key for primary care providers is to expand their clinical judgment by incorporating not only randomized clinical trial (evidence-based) information, but also the entire database of experimental, observational, and meta-analysis information that can guide a patient-centered treatment strategy. This is the value of “expert consensus” guidelines in daily patient care.
8. What is the greatest challenge in helping patients achieve cardiometabolic health in primary care?
Dr Einhorn: Access to the best newer treatments is increasingly a hassle. Also, fake news is still a reality.
Dr Jones: The greatest challenge is being able to provide sound medical advice on dietary patterns, exercise, and weight control in a very busy digital world full of conflicting and confusing information.
9. If you could give primary care providers only one piece of practical advice about integrating the management of patients’ cardiometabolic disease in daily practice, what would it be?
Dr Einhorn: Make it a win-win for you and your patients. Focus on aspects of treatment that are readily achievable, and build on those. Make patients feel good about themselves and want to come back to see you.
Dr Jones: You should focus on building trust with your patients that is grounded in shared decision-making for all drug and nondrug recommendations. There is no way adherence to any of your recommendations will occur without that trust.