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Treating Cardiometabolic Disease When It's Not the Only Problem
An AJMC Peer Exchange with Peter Salgo, MD; David Calabrese, RPh, MPH; Kenneth L. Schaecher, MD, FACP, CPC; Yehuda Handelsman, MD, FACP, FACE, FNLA; and Michael Weber, MD

Treating Cardiometabolic Disease When It's Not the Only Problem

An AJMC Peer Exchange with Peter Salgo, MD; David Calabrese, RPh, MPH; Kenneth L. Schaecher, MD, FACP, CPC; Yehuda Handelsman, MD, FACP, FACE, FNLA; and Michael Weber, MD
Physicians Ask: Can New Drugs and Healthcare Reform Bring Better Results for Patients With Obesity and Diabetes?
Earlier this year, The American Journal of Managed Care convened 5 experts for an installment of its Peer Exchange Editorial Video Series, titled, The Burden of Comorbid Cardiometabolic Disease in Cardiovascular Health: Identifying Optimal Therapeutic Strategies in a Dynamic Managed Care Landscape. The program addressed a confounding issue in managed care: the rise in cardiovascular health problems is inextricably tied to rising rates of obesity and diabetes, which in turn are the result of unhealthy diets and sedentary lifestyles.

New therapies abound for diabetes, which today affects 26 million Americans and is the seventh leading cause of death in the United States. However, the best “medicine” for many of these patients would be to eat differently and exercise more. Getting patients to do that, according to the panel, is easier said than done. The following transcript has been edited for clarity, adherence to American Medical Association style, and readability for a print audience. Taking part were:

Peter Salgo, MD, who served as moderator, a professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at NewYork-Presbyterian Hospital, New York City.

David Calabrese, RPh, MPH, vice president and chief pharmacy officer of Catamaran Corporation, Lisle, Illinois.

Kenneth L. Schaecher, MD, FACP, CPC medical director, Select Health, Murray, Utah.

Yehuda Handelsman, MD, FACP, FACE, FNLA medical director and principal investigator, Metabolic Institute of America, IP president, American Association of Clinical Endocrinologists, Tarzana, California.

Michael Weber, MD, professor of medicine at the SUNY Downstate College of Medicine in Brooklyn, New York.

Salgo: We’re discussing the rising burden of comorbid cardiometabolic disease from a clinical and economic perspective. Let’s start with Dr Handelsman. Diabetes often does not strike alone. So how often are patients with diabetes presenting with other comorbid cardiometabolic conditionsn and which types?

Handelsman: When we look at diabetes, we have to recognize that we generally look at 2 types of diabetes; type 1 diabetes usually strikes the young population, maybe younger kids. They’re usually thin, and they usually do not present comorbid conditions like hypertension or lipid disorders. The majority of people who are creating this epidemic have type 2 diabetes. This is diabetes associated with obesity and insulin resistance. Diabetes appears together with hypertension; I would say that anywhere from 50% to 70% of people with diabetes also have high blood pressure. Also, there’s dislipidemia, the lipid disorder of people with diabetes. Anywhere from 70% to 90% of people with diabetes also have high triglycerides, lower HDL (high-density lipoprotein cholesterol), and even though the LDL (low-density lipoprotein cholesterol) does not seem so high, it’s still bad enough to cause a lot of disease. Thus, most people with type 2 diabetes are at high risk for cardiovascular disease, hence the issue of comorbidities.

Salgo: Let me get this straight. Because type 1 diabetes presents younger, perhaps more acutely, you pick it up pretty early. It’s the type 2 that sneaks up on you and by then, if I understand what you’re telling me, everything else is going wrong, too.

Handelsman:
Absolutely. Type 2 actually may start 20 years before when insulin resistance starts up and then on top of it, very slowly increasing glucose, and slowly increasing blood pressure, and some atherosclerosis developing. By the time people have prediabetes, they already may have a lot of cardiometabolic morbidity on top of that. And, typically, because traditionally we used to check glucose fasting, people are being diagnosed 5 years after diabetes has started.

Schaecher: That’s certainly true, and I think that’s among the somewhat mistaken beliefs with regard to diabetes—that diabetes is an end point. It’s really a point along a spectrum of disease that often starts many years earlier. Although we may be focusing on the diabetes as a disease state, really it’s the prediabetic conditions, the obesity in particular, that may lead to the development of the diabetes that we fail to focus on adequately.

Salgo: If I hear what you’re saying, this is a very profound point: The diagnosis of diabetes is not binary. It’s not one day you don’t have it, the next day you do. It creeps up on you. Is that your experience too?

Calabrese: Yes. The statistics that are out there today say a third of our US adult population is prediabetic.

Salgo: One-third?

Calabrese: One-third.

Handelsman: Yes, just about.

Calabrese: And the reason why we’re seeing 8 to 10% increases in the numbers of people that are being diagnosed annually, which has been consistent over the last 20 to 30 years, is largely the result of what Dr Schaecher is talking about. It’s not only the increasing age of our population but poor nutrition, poor exercise, and obesity as an epidemic within this country.

Salgo: I want to get to all of that. We’re fortunate that today’s panel brackets the country from east coast to west coast. It raises the issue that you all can address: predisposing regional variation and patient characteristic in various regions. How does that affect the incidence of diabetes and other comorbid conditions?

Schaecher: It’s fairly apparent from the statistics that where you find obesity is where you find more diabetes. So in the South and Southeastern portions of the country, which have the highest obesity rates, we see the highest incidence of diabetes, too (see Figures 1-4). You also have other areas of the country where you have subsets of populations that are more predisposed. Arizona, for example, where the lifestyle and obesity rates are not the same as they are in the rest of the Southwest, includes a large Native American population, an ethnic group with increased predisposition to diabetes. Areas with a high Polynesian population tend to have a fairly high rate of diabetes among that subset. So geography does play a role, but I think the key thing there is that diabetes tends to follow obesity.

Handelsman: It follows a timeline. So it’s true, it can start in the Southeast; it can start in Mississippi, and Alabama, and Georgia, and then it goes to West Virginia, but then you go up to Michigan, and then you go down to New Mexico, and then you go to Washington State, for example. There is a lag between the increase in obesity and the increase in diabetes, so Washington State today is maybe where Mississippi was 8 years ago. We have states where we see 50% obesity and maybe 13% diabetes. Now, the other states that appear to pale in comparison are at the same place where the states with high diabetes rates were 5 to 8 years ago.

Salgo: We’re all on the road to the same spot.

Handelsman: You can see (it on) the maps …

Schaecher: We are, although there are certain aspects of different demographics and geographies that will dictate, to some degree, that that won’t continue. Not every state will continue on the same trajectory. In Utah, for instance, where I’m located, we’re the sixth least obese state in the country, and yet we’re a very young state and we also have (a lot of) activity; (being active) is a very high focus of people. It also depends upon the food you’re eating. You look at the South and what they eat; it contributes to the obesity because they’re eating foods with high glycemic index, very fatty foods. Compare that with California, Colorado, or other places where people are much more active outdoors in a physically demanding way, not just hunting, boating, and fishing.



Handelsman: Part of the issue (does involve) ethnicity. … For example, when people from India or Far East Asia come to this country … they do have an explosion of diabetes. If you go to Minnesota, and you find communities of people from India, you see higher rates of diabetes. You go to Michigan, (in the) Detroit area, where there are a number of people who come from the Middle East. They’ve got a huge amount of diabetes, so it’s beyond a state like Utah which is, by far, more homogeneous than other states.

Salgo: We’re going to move along, but I can’t let this one just lay on the table unasked: We always hear that when people come to the United States and eat as Americans, they get as sick as Americans do. So if one-third of all Americans have diabetes, how does that compare worldwide?

Calabrese: Prediabetes.

Salgo: Prediabetes. How does that compare worldwide?

Handelsman: So let’s talk numbers. The country with the most diabetes today in the world is China. They have now 92 million people with diabetes. It’s still “only maybe 7% of population,” but if you think what happened in China 15 years ago, this figure is just unbelievable. What you have in the US is what you will see 10 years from now in China, what you’re already seeing in India, what you see in the Philippines. So we’re seeing (the effects) of the Western lifestyle and maybe technology is coming to these countries. It used to be first- or second-generation immigrants to this country who displayed these (health effects). … They’ve got it in their own countries now.

Salgo: And that’s too bad.

 Calabrese: We introduced it with fast food, that’s how.

Handelsman: Part of it is the fast food, but I also believe it is technology. How many years did it take us to go from walking to riding a horse to then driving your Mercedes? How many years did it take us? When you go overseas, they don’t (take that amount of time). They go directly from bicycles to a nice car; all of a sudden they have jumped 10 generations in a short time.

Salgo: So everything gets accelerated, which brings us to the management of what is often a group of diseases. Let’s talk about the challenges that clinicians and managed care providers are encountering.

Calabrese: Well, obviously, the challenges are numerous. I think when patients are presented with multiple comorbid conditions, the issues that you run into involve disjointed care. It’s all of the things that healthcare reform today is trying to address. There’s fragmentation, there’s lack of coordination, there’s ineffective communication among members of the healthcare team, which translates into adherence issues. It translates into polypharmacy issues with these patients, which in turn can translate into adverse drug events. We know today we spend almost as much in this country managing drug misadventures as we do on the drugs themselves—which is a frightening thought.

Salgo: That’s terrifying, isn’t it?

 
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