COMMENTARY

Teaming Up to Prevent Heart Disease in People With Diabetes

Interviewer: Ileana L. Piña, MD, MPH; Interviewee: Stacey E. Rosen, MD

Disclosures

October 15, 2018

Ileana L. Piña, MD, MPH: Hello. I'm Ileana Piña, from Albert Einstein College of Medicine in the Bronx and Montefiore Medical Center, also in the Bronx. This is my blog.

I am really happy today to have a friend of mine with me to talk about a very important topic that I've blogged about before, which is diabetes and the intersection between diabetes and heart disease. I want to welcome Stacy Rosen. Stacey is a professor of medicine in cardiology at Hofstra and the vice president for women's health at Northwell, so we are neighbors. She is in Long Island, and I'm in the Bronx. Welcome, Stacey.

Stacy E. Rosen, MD: Great to be here. Thank you.

Piña: Stacey, you have had a really big role at the American Heart Association, and you chaired this committee that I was fortunate to [be a member of as well]. It was called "PIC." Tell me about that committee.

Rosen: Sure. I've been an American Heart Association volunteer for most of my career. PIC, which actually is being evolved into another committee at the American Heart Association, stands for "Program Integration Committee." The American Heart Association has so many roles.

It is quite a complex and exciting organization. There are quality initiatives and quality programs. There are consumer-facing programs or education, and there are programs that look to affect policy. All of those would come into PIC to keep physicians and volunteers organized on the exciting initiatives.

Diabetes: A System Issue

Piña: It was during your tenure that the American Heart Association forged a relationship with the American Diabetes Association, which I found rather exciting. Do you want to tell us more about that?

Rosen: Yes, absolutely. Diabetes is one of the most important controllable risk factors for heart disease and stroke. It is not really an individual issue—one doctor and one patient; it is a system issue. Bringing the strength of the American Heart Association and the American Diabetes Association together with well over 150 million volunteers and professionals really lent strength to this strategic initiative.

Piña: Why is it so important now?

Rosen: It is important because as our world is getting heavier and more sedentary, so much of the positive impact we've seen in lessening the dangers of heart disease is going to turn around. Type 2 diabetes affects well over 100 million Americans. There are over 7 million Americans with diabetes who don't even know they have it.

Piña: The waiting room is the metabolic syndrome.

Rosen: Absolutely. Everywhere we walk on a daily basis—to our places of work, throughout communities—you can see that we are becoming a nation and a world of people who sit and don't protect against diabetes.

Piña: I was teaching a course this last week out in Anaheim, so I got to go to Disneyland. Mickey is still thin, but the rest of the population is not. It's amazing—father, mother, the grandparents—you can see the obesity runs through all the generations. All the staff working in the hotel were obese.

Rosen: You look at the obesity belt and there are demographic slides of the United States population. Then if you look at certain populations, such as African American women in the south, the predominance of that ethnic or demographic group is obese.

Piña: In the Bronx, 60% have diabetes if you look at the Centers for Disease Control and Prevention (CDC) map. We deal with it every day. Are you excited about something other than the relationship?

Rosen: I'm excited about every aspect of it because diabetes is the classic example of the importance of collaboration, systems approach, empowering partners, the patients, and our communities to really work together for a goal. We know that doing the right things is going to have an enormous impact on these bad outcomes.

Piña: I think we have to stop concentrating only on hemoglobin A1c levels. I am really struck on television, there are all these ads now that are interviewing people on the street and are asking, "Did you know that diabetes puts you at higher risk for heart disease?" Of course, they're probably actors and they say, "No, I didn't know that."

We need to get our primary care colleagues to really tell the people with diabetes who are at risk. This is not just blood sugar—this is their hearts.

Rosen: Absolutely. Hearts and minds.

Piña: That's right—and kidneys.

Rosen: Kidneys and vision. What's so neat about this initiative is that it brings together anyone in any area who can affect the negative outcomes. As a women's health physician, I think of our ob/gyn colleagues as people whom we should bring into this conversation.

Piña: They're seeing the women through their pregnancy, especially if they have diabetes in pregnancy.

Rosen: Absolutely. We know that gestational diabetes is a lifelong risk factor. We also know that until middle age, women's primary and sometimes only physician visit each year is to their gynecologist. All of these aspects of bringing in, again, a systems approach, a multidisciplinary approach, a collaborative approach, are so exciting.

Piña: I find that even with the electronic health record, we are missing that conversation. I see it. I try to get one of our primary care colleagues, I can't get them on the phone, I get the run-around with the phone system, and I can't talk to that individual. It's very frustrating.

Rosen: It's very exciting that this effort really spans community-based initiatives, patient education, professional education, and quality improvement aspects so that we are looking at the totality of ways to make an impact.

Piña: I think we're going to start to see some measures—I'm hoping for some performance measures. I'm particularly excited because the new drugs, that whole category of sodium-glucose cotransporter 1 (SGLT1) and SGLT2 inhibitors, are changing outcomes. For years, we have been telling our patients to keep their hemoglobin A1c down and if they get their sugar controlled, they are going to feel better and they are going to do better, but we really didn't have the data. Now we do.[1]

Rosen: We had conflicting data in the past. What do you do with our older populations, and what do you do with your patients with hypertension and diabetes? Now, we're really seeing tremendous improvement in outcomes, which is really all that matters—not numbers.

Team Approach: Who Should Lead?

Piña: We're seeing outcomes changes in the heart failure population.[2] Now we're going to be studying these.

We have one of the trials for at least three companies that are prospectively looking at the SGLT1 and -2 inhibitors on heart failure outcomes. The American Heart Association will have a paper coming out on heart failure and diabetes. It is so common and so concerning.

I have some young female patients in their 40s with large myocardial infarctions (MIs) who end up in heart failure. I have some young men who we've been taking care of for several years, so I've gotten to see this progression. Really, it's heartbreaking to watch. I think it's a very important time. We are sending our patients back to their primary care doctors. Do you think it should be the primary care doctor that should start these drugs?

Rosen: Yes. I do think that when you look at the optimal way to care for individual patients in communities, the team-based approach with the patient playing an essential role, truly a partner, is key. In so many of our initiatives, the cross-pollination of education is needed so that these findings, such as [those] you will be publishing, get out to the endocrine and primary care specialties.

Somebody's got to own it, honestly. I think that's important. In some communities, I think it could be the cardiologists. In others, it could be the primary care doctors or the gynecologists. That is what is exciting about this initiative. There will be platforms for performance improvements that will put these kinds of approaches in that almost make it easy and somewhat systematic.

Piña: We have to make it easy. If it's not, they're not going to do it.

Rosen: Right. It's not sustainable.

Piña: The diets around us are not conducive to better eating. You walk into a McDonald's or a Wendy's and they taste wonderful, but you spend 99 cents for a whole meal. If you walk into a Fresh Market or these wonderful markets with greens, you can't get them for 99 cents.

Rosen: Absolutely. Not to feed a family of four. We also talk about making the healthy choice the default choice. Where can you walk? Where is it easy to have your blood pressure checked? Where is it easy to choose this food as opposed to the inexpensive but heavily salted, heavy carbohydrate meals?

Piña: I told this audience before that we, and the American Heart Association, are very concerned about the fact that mortality is going back up in the wrong direction. For years, we had seen that dip. Women were lagging behind. Now it's plateaued. The men? Going up.

Rosen: Yes. We are afraid the women will too.

Piña: Yes. We have a paper coming out on that with some national data that we've acquired. It seems like the African American men are probably leading the pack. I am deeply concerned about that, because it's a lot of the population that I treat. What are we not doing, or what are we doing not enough of? I question our actions first.

Rosen: I think we got a little bit away from appreciating the social determinants that have an impact on chronic conditions such as diabetes. You make as much impact as you can with better medications and better access, but at the end of the day, 80% of our health is determined outside of our offices.

Piña: We are 1 hour, 2 hours...

Rosen: Then you go home. They would cook or go to the fast-food restaurant. I think as such organizations as the Heart Association and Diabetes Association start to see the potential for impact outside of our investigative labs or our clinical offices, that's where we'll be able, hopefully, to stop this reversal of all the good that we've done over the past decades.

Piña: It's an exciting time, too, for blood pressure, because now we have the SPRINT trial with a systolic of 120 mm Hg actually reducing heart failure by 50%.[3] It's impressive. Now we have two important risk factors that we can really affect by following the guidelines. The hypertension guidelines were there. Number one, taking your blood pressure correctly.

Rosen: Absolutely. It's so funny. I actually hand out that little infographic from the American Heart Association. My practice is predominantly women, so I hand out the female version. To see educated clinicians for patients...

Piña: Who don't know how to take a blood pressure.

Rosen: Yes, even just the importance of home monitoring. Then you are empowered to be part of the process.

Piña: You can control it.

Rosen: Absolutely. That brings optimism to diseases that otherwise had terrible impacts, and an education and empowerment to each of us.

Heart Smart for Women

Piña: That's what excites me—that I now would have an option to really make a difference.

One last question: Tell me about your new book.

Rosen: My colleague Jennifer Mieres and I, along with an additional coauthor named Laurie Russo, have written a book called Heart Smart for Women. Our theme is that it should not be so hard to take care of your heart health. We know heart health leads to brain health. It is a very fun, usable book.

Piña: Practical?

Rosen: Practical. In fact, what we hope is that our readers will underline things, put little stickies on, and share it. It's a 6-week program that we think really will jump-start. It is also published in Spanish.

Piña: You're going to give me a copy of that?

Rosen: Absolutely.

Piña: Wonderful. Congratulations on the book. Thank you for your time today.

To our audience, I really hope that you pay attention to this, because I am sure that you have diabetics in your office every day. Now we need to stop looking only at the hemoglobin A1c. It is important, but we need to start looking at what else is ahead.

Our patients with diabetes mostly die of heart disease. By the time the heart's gone, very often the kidney is gone. It's still one of the number one causes of dialysis in this country. Now we have some tools so we can actually do something about it.

I am hoping you take this back to your office and remember our conversation. Thank you for joining me today. This is Ileana Piña, signing off.

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