Cardiometabolic risk: New chronic care models

Higher neighborhood disadvantage is associated with weaker interactions among cardiometabolic drivers

Background

Adiposity, dysglycemia, and hypertension are metabolic drivers that have causal interactions with each other. However, the effect of neighborhood-level disadvantage on the intensity of interactions among these metabolic drivers has not been studied. The objective of this study is to determine whether the strength of the interplay between these drivers is affected by neighborhood-level disadvantage.

Methods

This cross-sectional study analyzed patients presenting to a multidisciplinary preventive cardiology center in New York City, from March 2017 to February 2021. Patients' home addresses were mapped to the Area Deprivation Index to determine neighborhood disadvantage. The outcomes of interest were correlation coefficients (range from -1 to +1) among the various stages (0 - normal, 1 - risk, 2 - predisease, 3 - disease, and 4 - complications) of abnormal adiposity, dysglycemia, and hypertension at presentation, stratified by neighborhood disadvantage.

Results

The cohort consisted of 963 patients (age, median [IQR] 63.8 [49.7-72.5] years; 624 [65.1 %] female). The correlation among the various stages of adiposity, dysglycemia, and hypertension was weaker with increasing neighborhood disadvantage (P for trend <0.001). Specifically, the correlation describing adiposity, dysglycemia, and hypertension interaction was weaker in the high neighborhood disadvantage group compared to the intermediate neighborhood disadvantage group (median [IQR]: 0.34 [0.27, 0.44] vs. median [IQR]: 0.39 [0.34, 0.45]; P < 0.001) and compared to the low neighborhood disadvantage group (median [IQR]: 0.34 [0.27, 0.44] vs. median [IQR]: 0.54 [0.52, 0.57]; P < 0.001), as well as weaker in the intermediate neighborhood disadvantage group compared to the low neighborhood disadvantage group (median [IQR]: 0.39 [0.34, 0.45] vs. 0.54 median [IQR]: 0.54 [0.52, 0.57]; P < 0.001).

Conclusions

Interactions among the various stages of abnormal adiposity, dysglycemia, and hypertension with each other are weaker with increasing neighborhood disadvantage. Factors related to neighborhood-level disadvantage, other than abnormal adiposity, might play a crucial role in the development of dysglycemia and hypertension.

Telehealth and cardiometabolic-based chronic disease: optimizing preventive care in forcibly displaced migrant populations

The number of migrants, which includes forcibly displaced refugees, asylum seekers, and undocumented persons, is increasing worldwide. The global migrant population is heterogeneous in terms of medical conditions and vulnerability resulting from non-optimal metabolic risk factors in the country of origin (e.g., abnormal adiposity, dysglycemia, hypertension, and dyslipidemia), adverse travel conditions and the resulting stress, poverty, and anxiety, and varying effects of acculturation and access to healthcare services in the country of destination. Therefore, many of these migrants develop a high risk for cardiovascular disease and face the significant challenge of overcoming economic and health system barriers to accessing quality healthcare. In the host countries, healthcare professionals experience difficulties providing care to migrants, including cultural and language barriers, and limited institutional capacities, especially for those with non-legal status. Telehealth is an effective strategy to mitigate cardiometabolic risk factors primarily by promoting healthy lifestyle changes and pharmacotherapeutic adjustments. In this descriptive review, the role of telehealth in preventing the development and progression of cardiometabolic disease is explored with a specific focus on type 2 diabetes and hypertension in forcibly displaced migrants. Until now, there are few studies showing that culturally adapted telehealth services can decrease the burden of T2D and HTN. Despite study limitations, telehealth outcomes are comparable to those of traditional health care with the advantages of having better accessibility for difficult-to-reach populations such as forcibly displaced migrants and reducing healthcare associated costs. More prospective studies implementing telemedicine strategies to treat cardiometabolic disease burden in migrant populations are needed.

Challenges and Opportunities in Diagnosis and Management of Cardiometabolic Risk in Adolescents

PURPOSE OF REVIEW

This review aims to elucidate the limitations of diagnosing metabolic syndrome in adolescents as well as challenges and opportunities in the identification and reduction of cardiometabolic risk in this population.

RECENT FINDINGS

There are multiple criticisms of how we define and approach obesity in clinical practice and scientific research, and weight stigma further complicates the process of making and communicating weight-related diagnoses. While the goal of diagnosing and managing metabolic syndrome in adolescents would be to identify individuals at elevated future cardiometabolic risk and intervene to reduce the modifiable component of this risk, there is evidence that identifying cardiometabolic risk factor clustering may be more useful in adolescents than establishing a cutoff-based diagnosis of metabolic syndrome. It has also become clear that many heritable factors and social and structural determinants of health contribute more to weight and body mass index than do individual behavioral choices about nutrition and physical activity. Promoting cardiometabolic health equity requires that we intervene on the obesogenic environment and mitigate the compounding effects of weight stigma and systemic racism. The existing options to diagnose and manage future cardiometabolic risk in children and adolescents are flawed and limited. While striving to improve population health through policy and societal interventions, there are opportunities to intervene at all levels of the socioecological model in order to decrease future morbidity and mortality from the chronic cardiometabolic diseases associated with central adiposity in both children and adults. More research is needed to identify the most effective interventions.

Large scale application of the Finnish diabetes risk score in Latin American and Caribbean populations: a descriptive study

Background

The prevalence of type 2 diabetes (T2D) continues to increase in the Americas. Identifying people at risk for T2D is critical to the prevention of T2D complications, especially cardiovascular disease. This study gauges the ability to implement large population-based organized screening campaigns in 19 Latin American and Caribbean countries to detect people at risk for T2D using the Finnish Diabetes Risk Score (FINDRISC).

Methods

This cross-sectional descriptive analysis uses data collected in a sample of men and women 18 years of age or older who completed FINDRISC via eHealth during a Guinness World Record attempt campaign between October 25 and November 1, 2021. FINDRISC is a non-invasive screening tool based on age, body mass index, waist circumference, physical activity, daily intake of fruits and vegetables, history of hyperglycemia, history of antihypertensive drug treatment, and family history of T2D, assigning a score ranging from 0 to 26 points. A cut-off point of ≥ 12 points was considered as high risk for T2D.

Results

The final sample size consisted of 29,662 women (63%) and 17,605 men (27%). In total, 35% of subjects were at risk of T2D. The highest frequency rates (FINDRISC ≥ 12) were observed in Chile (39%), Central America (36.4%), and Peru (36.1%). Chile also had the highest proportion of people having a FINDRISC ≥15 points (25%), whereas the lowest was observed in Colombia (11.3%).

Conclusions

FINDRISC can be easily implemented via eHealth technology over social networks in Latin American and Caribbean populations to detect people with high risk for T2D. Primary healthcare strategies are needed to perform T2D organized screening to deliver early, accessible, culturally sensitive, and sustainable interventions to prevent sequelae of T2D, and reduce the clinical and economic burden of cardiometabolic-based chronic disease.

Revised Case Finding Protocol for Dysglycemia in Chile: A Call for Action in Other Populations

OBJECTIVE

Guidelines recommend case finding for dysglycemia (prediabetes and type 2 diabetes [T2D]) in adults or youth older than 10 years with overweight/obesity, but increased adiposity has not been associated with dysglycemia in some Hispanic populations. This study aims to determine the prevalence of dysglycemia in this population using simplified criteria independent of BMI and age to request an oral glucose tolerance test (OGTT).

METHODS

Cross-sectional retrospective analysis of medical records from a clinical center in Chile (2000-2007). OGTT was obtained from any patient with one cardiometabolic risk factor (CMRF) independent of age and BMI.

RESULTS

In total, 4,969 adults (mean age ± SD) 45.7 ± 15.9 years and 509 youths 16.6 ± 3.0 years were included. The prevalence (%, 95%CI) of prediabetes doubled that of T2D in youths (14.1%, 1.4-17.4 vs. 6.3%, 4.5-8.7) and tripled it in adults (36.0%, 34.7-37.4 vs. 10.7%, 9.8-11.5). In underweight and normal-weight adults, 22% (12.0-36.7) and 29.2% (26.4-32.1) had prediabetes, whereas 4.9% (1.3-16.1) and 8.8% (7.2-10.7) had T2D, respectively. In normal-weight youths, 10.5% (6.7-15.9) and 2.9% (1.2-6.6) had prediabetes and T2D, respectively. In adults, but not in youths, most dysglycemia categories were related to overweight/obesity.

CONCLUSION

This study supports a public health policy to identify more people at risk for cardiovascular disease by implementing a revised case-finding protocol for dysglycemia using OGTT in even normal-weight patients over 6 years of age when there is at least one CMRF. Re-analysis of case-finding protocols for cardiometabolic risk in other populations is warranted.

Lifestyle Medicine in Diabetes Care: The Lifedoc Health Model

Introduction

The relevance of lifestyle medicine in diabetes treatment is now incorporated in clinical practice guidelines but finding an exemplar for the creation of a Lifestyle Medicine Program (LMP) is a difficult task.

Aim

To use Lifedoc Health (LDH) as a LMP exemplar by describing their multidisciplinary team (MDT) approach to diabetes care along with tactics to address sustainability challenges.

Results

The LDH model facilitates early activation of patients with diabetes and other cardiometabolic risk factors, MDT approaches, and protocols/policies that are able to overcome barriers to equitable healthcare in the community. Specific programmatic targets are clinical outcomes, effective dissemination, economic viability, and sustainability. Infrastructure centers on patient-driven problem-based visits, shared medical appointments, telemedicine, and patient tracking. Further discussions on program conceptualization and operationalization are provided.

Conclusion

Even though strategic plans for LMPs that specialize in diabetes care are well represented in the literature, implementation protocols, and performance metrics are lacking. The LDH experience provides a starting point for those healthcare professionals interested in translating ideas into action.

The syndromic triad of COVID-19, type 2 diabetes, and malnutrition

The coronavirus disease 2019 (COVID-19) pandemic challenges our collective understanding of transmission, prevention, complications, and clinical management of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Risk factors for severe infection, morbidity, and mortality are associated with age, environment, socioeconomic status, comorbidities, and interventional timing. Clinical investigations report an intriguing association of COVID-19 with diabetes mellitus and malnutrition but incompletely describe the triphasic relationship, its mechanistic pathways, and potential therapeutic approaches to address each malady and their underlying metabolic disorders. This narrative review highlights common chronic disease states that interact epidemiologically and mechanistically with the COVID-19 to create a syndromic phenotype-the COVID-Related Cardiometabolic Syndrome-linking cardiometabolic-based chronic disease drivers with pre-, acute, and chronic/post-COVID-19 disease stages. Since the association of nutritional disorders with COVID-19 and cardiometabolic risk factors is well established, a syndromic triad of COVID-19, type 2 diabetes, and malnutrition is hypothesized that can direct, inform, and optimize care. In this review, each of the three edges of this network is uniquely summarized, nutritional therapies discussed, and a structure for early preventive care proposed. Concerted efforts to identify malnutrition in patients with COVID-19 and elevated metabolic risks are needed and can be followed by improved dietary management while simultaneously addressing dysglycemia-based chronic disease and malnutrition-based chronic disease.

Impact of a Multidisciplinary Approach on Cardiometabolic Risk Reduction in a Multiracial Cohort of Adults: A 1-Year Pilot Study

Evidence examining specific effects of a multidisciplinary team (MDT) on cardiometabolic risk factors (CMRFs) among multi-ethnic patients in real-world clinical settings is lacking. This one-year retrospective chart review (2018) analyzed 598 adults (African American 59%, Hispanic 35%, and Caucasian 6%) with mean age of 43.8 ± 14.0 years. Qualifying patients with primary inclusion criteria of having body mass indices and blood pressure (BP) measurements in the first and last quarter of the study period were treated under an MDT protocol and compared to those qualifying for MDT but treated solely by a primary care provider (PCP). MDT included endocrinologist-directed visits, lifestyle counseling, and shared medical appointments. MDT patients experienced a greater reduction (β; 95% CI) in weight (−4.29 kg; −7.62, −0.97), BMI (−1.43 kg/m2; −2.68, −0.18), systolic BP (−2.18 mmHg; −4.09, −0.26), and diastolic BP (−1.97 mmHg; −3.34, −0.60). Additionally, MDT patients had 77%, 83%, and 59% higher odds of reducing ≥5% of initial weight, 1 BMI point, and ≥2 mmHg DBP, respectively. Improvements in hemoglobin A1C measurements were observed in the MDT group (insufficient data to compare with the PCP group). Compared to PCP only, MDT co-management improves CMRF related to adiposity and hypertension in a multiethnic adult cohort in real-world clinical settings. Patient access to best practices in cardiometabolic care is a priority, including the incorporation of culturally adapted evidence-based recommendations translated within a multi-disciplinary infrastructure, where competing co-morbidities are better managed, and associated research and education programs can promote operational sustainability.

Healthy lifestyle changes favourably affect common carotid intima-media thickness: the Healthy Lifestyle Community Programme (cohort 2)

Common carotid intima-media thickness (ccIMT) progression is a risk marker for cardiovascular disease (CVD), whereas healthy lifestyle habits are associated with lower ccIMT. The objective of the present study was to test whether a healthy lifestyle intervention can beneficially affect ccIMT progression. A community-based non-randomised, controlled lifestyle intervention was conducted, focusing on a predominantly plant-based diet (strongest emphasis), physical activity, stress management and social health. Assessments of ccIMT were made at baseline, 6 months and 1 year. Participants had an average age of 57 years and were recruited from the general population in rural northwest Germany (intervention: n 114; control: n 87). From baseline to 1 year, mean ccIMT significantly increased in both the intervention (0⋅026 [95 % CI 0⋅012, 0⋅039] mm) and control group (0⋅045 [95 % CI 0⋅033, 0⋅056] mm). The 1-year trajectory of mean ccIMT was lower in the intervention group (P = 0⋅022; adjusted for baseline). In a subgroup analysis with participants with high baseline mean ccIMT (≥0⋅800 mm), mean ccIMT non-significantly decreased in the intervention group (-0⋅016 [95 % CI -0⋅050, 0⋅017] mm; n 18) and significantly increased in the control group (0⋅065 [95 % CI 0⋅033, 0⋅096] mm; n 12). In the subgroup, the 1-year trajectory of mean ccIMT was significantly lower in the intervention group (between-group difference: -0⋅051 [95 % CI -0⋅075, -0⋅027] mm; P < 0⋅001; adjusted for baseline). The results indicate that healthy lifestyle changes may beneficially affect ccIMT within 1 year, particularly if baseline ccIMT is high.