Cardioprotective Treatment Options for Diabetes - Episode 3
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: One of the problems in our society is that we don’t have health equity. There are differences based on race, ethnicity, socioeconomic status, and geography. Melissa, you’re in the middle of the country, so you get a chance to look at it from all angles. Do you think these disparities are real?
Melissa L. Magwire, RN, MSN, CDE: I do think they’re real, and I think that fortunately we’re seeing health care systems put a little bit more equity behind that. We’re doing a project where I work right now where we’ve identified our patients with the highest A1Cs [glycated hemoglobin levels], and then we actually looked at ethnic groups and found that our African American population were among those with the highest A1Cs. So we’re tailoring our approach to meet some of the specific ethnic needs.
But there’s also food disparity. There’s education disparity. So I think just being open across the line, and really looking at your patient segment not as a whole but as their individual characteristics can help drive treatment changes and algorithms and approaches.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Dallas is not too far Pete, and I know you have a lot of African Americans and Hispanics in that area. Do you see those high rates in those particular populations?
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Yes, those 2 groups come to mind as large minority groups that are predisposed to not only diabetes but diabetic complications. Worldwide one has to keep in mind, Asian Indians are at a very high risk of metabolic syndrome, type 2 diabetes at lower degrees of adiposity, and very high atherosclerotic cardiovascular….
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So it’s not enough just to do the BMI [body mass index] perhaps, you have to look at some other factors?
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: You have to take a look at the patient. Dr. Baum mentioned abdominal adiposity, which is consistently, at lower body weights, it’s consistently a reliable connector. At higher body weights it almost doesn’t matter because at that point the correlation is between abdominal adiposity and overall adiposity.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Chris, you’re in Boston. There’s a mixed population of Haitian immigrants there, and there’s a town called Framingham that started all of this, but Framingham is really not that heterogeneous—it wasn’t at the time, in 1948.
Christopher P. Cannon, MD: It’s true, and I think the Indian population is one where I’m seeing more patients presenting with metabolic syndrome and a lot of diabetes. I think the socioeconomic factors are key, and you mentioned food and access to healthy food is one. Another thing that’s been on my mind is time. That many people who are struggling to earn enough money don’t have time to go exercise for a half an hour, an hour. They’re busy trying to get their kids to where they need and then to a job, and transportation. I find trying to work with them and see what could fit in to their schedule to try and do healthy cardiac behaviors while they’re so busy trying to make ends meet…. But that’s been a factor I think also that makes it more difficult for them to try. I find they’re trying, but just not having enough time to do things.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: I’ve never thought of that. Has that been looked at, studied?
Christopher P. Cannon, MD: Not that I know of, but somehow it’s been in my consciousness.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: It makes good sense.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: It makes great sense.
Christopher P. Cannon, MD: I see the patients trying and then you hear what they’re trying to juggle and realize there’s no time. Versus, I try and wake up early and block out time, and I can drive straight to work and I don’t have to take a bus and lose time doing the basics. And so that factor then makes it more difficult to do what one would like.
Melissa L. Magwire, RN, MSN, CDE: How I remind my peers of that is to take out of our vocabulary, “noncompliance,” and replace it with “nonadherence.” And why can someone not adhere to a treatment algorithm. And a lot of times it’s individualized. I had a patient just last week who actually was working 3 jobs and had 2 children, and the last thing she had time for was to sit down and actually make a healthy meal for herself, or to take that 15- or 20-minute walk. So really individualizing, just like we do our medications and our prescriptions, is individualizing that healthy lifestyle plan for that patient.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: It should be said though, the best way to prevent type 2 diabetes is to prevent adult weight gain. There’s absolutely no doubt about it. Only 10% of type 2 diabetics are not obese.
Prevent pediatric weight gain. No?
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Yes. This is the great goal and hope that we can have for society.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: And the Diabetes Prevention Program showed that exercise, activity, was one of the best ways to maintain it.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Sure. And in fact, exercise habits, those studies in Sweden have shown this, exercise habits in both aerobic and strength training and characteristics in adolescents and early adulthood actually have a permanence over the course of time with respect to prevention. In fact, prevention of diabetes and heart failure with preserved ejection fraction, that’s been shown.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: I’m going to go into the treatment goals in a second, but before we go there, it’s not only time doing these lifestyle factors and having access to healthy food, but what about access to some of the newer medications that we’re going to discuss. I don’t want to do all the trials, etcetera, but just being able to get the SGLT2 [sodium-glucose cotransporter 2] inhibitor, GLP-1 [glucagon-like peptide-1] agonist, the PCSK9 [proprotein convertase subtilisin/kexin type 9] inhibitors, doesn’t socioeconomic status play a part in that? And even some people who have means, if they’re not approved by their particular health plan, it’s a real barrier. Seth, I know you’re sensitive to that.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Oh my God, very sensitive. The barriers to access, just from a payer’s standpoint, have been huge since 2015 when PCSK9 inhibitors were approved. It was so bad initially that approval rates were around 20%. Now it’s improved dramatically so that approval rates are now in the 40% range, and I say that somewhat comically, right? But we have to keep pushing and keep fighting for our patients and ensuring that they get the medications that we and they believe are appropriate for them.Transcript edited for clarity.