The Global Prevention of Cardiovascular Disease Among People Living with Diabetes: Leading with Heart
- Diabetes is a metabolic, inflammatory, and vascular disease resulting in both microvascular and macrovascular complications. Cardiovascular disease (CVD) is the leading cause of mortality in the diabetic population, and patients with diabetes have a two- to four- fold risk for heart failure and strokes.
- As we move forward in an era where clinical evidence supports specific glucose-lowering therapies to lower cardiovascular disease risk, the American College of Cardiology (ACC) community should embrace the importance of comprehensive diabetes care.
- Despite the high burden of cardiometabolic disease world-wide, there continues to be fragmented care and lack of access to appropriate care, poor health literacy, and lack of ideal coordination at the public health level.
- The WHO Compact broadly sets the stage for the need for a global statement and an initiative for diabetes care by identifying major goals, needs, and stakeholders, whereas the WHF Roadmap breaks down each of these goals and needs to provide a framework with a step-by-step approach on how to implement diabetes care (to reduce CVD morbidity and mortality) at the global and local levels.
Type II diabetes mellitus (DM) is a rapidly accelerating global epidemic affecting 425 million people world-wide and this number is expected to increase to 629 million by the year 2045.1,2 In the United States (US), it is currently the seventh-leading cause of death, affecting 9.4% of the total population.3 The global economic burden of this chronic disease is projected to increase to $2.1 to $2.5 trillion by the year 2030.4 Thus, it is imperative that cardiovascular specialists better appreciate the impact of this epidemic and lead with heart to mitigate the resulting morbidity and mortality. Diabetes is a metabolic, inflammatory, and vascular disease resulting in both microvascular and macrovascular complications. Cardiovascular disease is the leading cause of mortality in the diabetic population, and patients with diabetes have a two- to four- fold risk for heart failure and strokes.5,6 In light of the intersection of diabetes and cardiovascular disease (CVD), the cardiovascular team is central to providing comprehensive diabetes care focused on event reduction. As we move forward in an era where clinical evidence supports specific glucose-lowering therapies to lower cardiovascular disease risk,7,8 the American College of Cardiology (ACC) community should embrace the importance of comprehensive diabetes care. The cardiovascular team should be able to screen patients for diabetes, aggressively treat risk factors with a focus on a healthy dietary pattern, regular moderate physical activity, encouraging weight loss, reducing tobacco use, optimizing blood pressure control, and initiation of lipid lowering and antiplatelet agents as per current guidelines. In addition, cardiovascular specialists must gain comfort in routinely prescribing evidence-based glucose-lowering agents to reduce CVD risk in patients living with diabetes.8,9 Despite the high burden of cardiometabolic disease world-wide, there continues to be fragmented care and lack of access to appropriate care, poor health literacy, and lack of ideal coordination at the public health level. In this analysis, we review the World Health Organization's (WHO) Global Diabetes Compact10 which lays the foundation for global diabetes care, as well as the World Heart Federation's (WHF) Roadmap on the Prevention of Cardiovascular Disease among People Living with Diabetes11 which paves the way to move this platform forward in adapting strategies at both global and local levels.
The WHO Global Diabetes Compact: A New Initiative to Support People Living with Diabetes
The major goals of the WHO Compact include: 1) increasing comprehensive, affordable, and quality access to treatment; 2) focusing on prevention of diabetes; and 3) reducing premature mortality associated with both type 1 and type 2 diabetes. The Compact highlights eight major components which revolve around increasing access and affordability of insulin, building resilient health systems, and engaging people and communities impacted by diabetes to co-create solutions. The WHO seeks to procure commitments from pharmaceuticals, health technology companies, and related industries to guarantee insulin supplies to lower-income countries. Furthermore, there is an identified need to train and deploy healthcare staff to areas which have fragmented diabetes care (now been exacerbated by the COVID-19 pandemic), while also focusing on diabetes health literacy. The Compact is an essential statement to mobilize a broad coalition of partners world-wide to move from "evidence to action".10
A Roadmap on the Prevention of Cardiovascular Disease Among People Living with Diabetes
The WHF Roadmap on the Prevention of Cardiovascular Disease Among People Living With Diabetes11 is a descriptive and prescriptive document that identifies roadblocks to and offers solutions for prevention of CVD in people living with diabetes. The roadblocks were identified from expert opinion and patient survey, and proposed solutions are grounded on evidence-based data and society guidelines. The intended goal is to provide a framework to optimize care world-wide with an ideal pathway. The Roadmap is nuanced when identifying roadblocks and offering solutions. It details the specific levels for the pathway of care (i.e., prevention, screening, diagnosing, risk stratifying, treating, or monitoring) and, for each level, identifies the corresponding stakeholders involved (i.e., patient, health care provider, or health care agency). The perspective of each respective stakeholder is felt to be important, and an integrated approach is recommended to achieve the goal. The Roadmap is also sensible as it recognizes that although it is a global document, its ideal pathway must be adapted to local contexts (i.e., the developed world vs. low-income countries or rural vs. urban settings).
Global Implications and Disparities
The Roadmap and the Compact effectively outline the clinical importance of the connection between diabetes and CVD. However, to achieve the ideal pathway of CVD prevention universally, a global focus is necessary, and acknowledgement of disparities is essential. As stated above, diabetes is rising in prevalence and is a major cause of cardiovascular morbidity and mortality. A global focus is important as three quarters of people living with diabetes live in low- and middle- income countries, and in a global estimate of individuals between the ages 20-79, only 50% were aware of the diagnosis of diabetes.2,12 Related to lack of awareness there are direct correlations to health disparities such as lack of insurance or family income below the poverty line.13 Both CVD and risk for diabetes are linked to poor diet, lack of physical activity, smoking, and obesity among lower socioeconomic classes, a trend that is widely reported at the global level and evident even in the US. Moreover, lack of quality housing, access to healthy food, green space, and increased air pollution have all been directly linked to the higher incidence of type II diabetes.14 The treatment of diabetes is also fraught with issues particularly related to the access to insulin in low- and middle-income countries, and to the cost of insulin in low-income populations in high-income countries, respectively.15 There are major health disparities that impact development of the disease, as well as access to glucose-lowering therapies, treatment, and effective management.
Conclusions and Future Directions
Both the WHO Compact and WHF Roadmap are essential to paving the way forward for diabetes care. The WHO Compact broadly sets the stage for the need for a global statement and an initiative for diabetes care by identifying major goals, needs, and stakeholders, whereas the WHF Roadmap breaks down each of these goals and needs to provide a framework with a step-by-step approach on how to implement diabetes care (to reduce CVD morbidity and mortality) at the global and local levels. There is need to focus on increasing awareness to advance health literacy in developing countries, as well as in our own backyards in the US, improving early detection by implementing screenings, creating access to evidence-based glucose-lowering oral agents and insulin, maximizing adherence with treatment plans, and reducing secondary complications of this chronic disease. Furthermore, there is need to consider the sustainability and relevance of these documents moving forward, especially given the COVID-19 pandemic has created additional hurdles related to preventive approaches and chronic disease management by delaying continuity of care and over-burdening health systems world-wide. In the post-pandemic recovery phase, it will be essential for governmental and healthcare sectors to come together to address management of chronic diseases such as diabetes.16,17 As displayed in Figure 1, to provide comprehensive and preventive cardiovascular care, it is vital to recognize the intersection of health disparities, chronic diseases such as diabetes, and the consequences of the COVID-19 pandemic. The WHO Compact and WHF Roadmap are two foundational documents that set the stage to mobilize evidence into action.
- NCD Risk Factor Collaboration (NCD-RisC) – Africa Working Group. Trends in obesity and diabetes across Africa from 1980 to 2014: an analysis of pooled population-based studies. Int J Epidemiol 2017;46:1421-32.
- Cho NH, Shaw JE, Karuranga S, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract 2018;138:271-81.
- National Diabetes Statistics Report, 2020 (CDC website). 2020. Available at: https://www.cdc.gov/diabetes/library/features/diabetes-stat-report.html. Accessed 05/25/2021.
- Ogurtsova K, da Rocha Fernandes JD, Huang Y, et al. IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract 2017;128:40-50.
- Cosentino F, Grant PJ, Aboyans V, et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2020;41:255-323.
- Sarwar N, Gao P, Seshasai SRK, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 2010;375:2215-22.
- Dhindsa DS, Mehta A, Sandesara PB, Thobani A, Brandt S, Sperling LS. Strategies for appropriate selection of SGLT2-i vs. GLP1-RA in persons with diabetes and cardiovascular disease. Curr Cardiol Rep 2019;21:100.
- Das SR, Everett BM, Birtcher KK, et al. 2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2020;76:1117-45.
- Sperling LS, Mechanick JI, Neeland IJ, et al. The CardioMetabolic Health Alliance: working toward a new care model for the metabolic syndrome. J Am Coll Cardiol 2015;66:1050-67.
- Hunt D, Hemmingsen B, Matzke A, et al. The WHO Global Diabetes Compact: a new initiative to support people living with diabetes. Lancet Diabetes Endocrinol 2021;9:325-27.
- Mitchell S, Malanda B, Damasceno A, et al. A roadmap on the prevention of cardiovascular disease among people living with diabetes. Glob Heart 2019;14:215-40.
- Global Burden of Disease Study 2016 (GBD 2016) Data Resources (Global Health Data Exchange website). 2016. Available at: http://ghdx.healthdata.org/gbd-2016. Accessed 05/25/2021.
- Bucholz EM, Gooding HC, de Ferranti SD. Awareness of cardiovascular risk factors in U.S. young adults aged 18-39 years. Am J Prev Med 2018;54:e67-e77.
- Méjean C, Droomers M, van der Schouw YT, et al. The contribution of diet and lifestyle to socioeconomic inequalities in cardiovascular morbidity and mortality. Int J Cardiol 2013;168:5190-5.
- Beran D, Hirsch IB, Yudkin JS. Why are we failing to address the issue of access to insulin? A national and global perspective. Diabetes Care 2018;41:1125-31.
- Dhindsa D, Wong ND, Sperling L. Cardiovascular and cardiometabolic prevention: high-level priority in the era of COVID-19. Cardiovasc Endocrinol Metab 2020;9:125-27.
- Sperling LS. The future of cardiovascular prevention: unprecedented times. Circulation 2020;141:1946-47.
Keywords: Diabetes Mellitus, Type 2, Cardiovascular Diseases, Heart Failure, World Health Organization, Health Status, Morbidity, Stroke, Glucose, Metabolic Syndrome X
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