Mar 12, 2019

The Unrelenting Burden of Cardiometabolic Diseases

Cardiometabolic diseases are a highly prevalent and interrelated set of conditions that include cardiovascular diseases, such as coronary heart disease (CHD), stroke, and hypertension, as well as metabolic diseases, such as type 2 diabetes, obesity and non-alcoholic fatty liver disease (NAFLD). At present, one out of every two American adults is living with one or more cardiometabolic diseases.

Just four of these conditions (CHD, stroke, hypertension, and diabetes) are present in 122 million adults and account for over 810,000 deaths each year. CHD remains the # 1 cause of death in America. And while death rates from cardiovascular diseases have meaningfully declined over the past 4 decades, its strain on the health care system remains unparalleled, with over 88 million office visits, 9.5 million hospitalizations and ER visits, and 8 million surgical procedures performed each year.

At the same time, diabetes rates (14% of adults) have reached epidemic numbers and continue to increase as our obesity epidemic (40% of adults) remains unmitigated. Diabetes, like all cardiometabolic conditions, is a major contributor to disability, medical costs and loss of productivity, leading to $526 billion in direct and indirect costs each year. CHD, stroke, dyslipidemia, and hypertension add another $1.5 trillion in total costs per year. This collective health and economic burden is expected to grow as the population ages and prevalence of other cardiometabolic conditions, like NAFLD, blossom.

These sobering statistics fail to capture the day-to-day experience of our patients and their families. To manage cardiometabolic conditions, 40% of adults will take 5 or more meds daily by age 65. As the number of medicines grows with age, so too does the daily experience of side-effects, increased risk of adverse drug reactions and rapidly increasing medication co-pays. All this ignores the strain on families coping with the inevitable hospitalizations and death of their loved ones that result from cardiometabolic disease.

How did we get here? 

Why, in this age of technologically advanced medicine, do we have a seemingly unstoppable and incredibly costly pandemic of cardiometabolic disease? The answer is that we have invested our resources in addressing the consequences of these diseases, rather than treating their causes.

We know that at least 70% and as much as 90% of cardiometabolic conditions are directly attributed to modifiable behaviors, like poor diet, sedentary activity, smoking and excess alcohol intake. The grouping of many conditions under a single name, cardiometabolic, is intentional. It reflects our current understanding that these conditions share common pathophysiology and root causes. For example, addressing just 3 behaviors (poor diet, sedentary activity and smoking) and maintaining a normal weight would prevent 70% of stroke, 80% of heart disease and 90% of type 2 diabetes. It is also known that making comprehensive behavioral changes can effectively treat, and in some cases fully reverse, cardiometabolic diseases.

So why hasn’t this happened already? 2 reasons. First, we have a legacy health care system designed to treat acute ailments not chronic conditions. Second, behavioral change is difficult to initiate and sustain. These 2 factors reinforce each other. For example, effecting behavior change in a clinical encounter requires that medical providers are given the specialized training, time and reimbursement for providing comprehensive behavioral therapy. None of this is afforded in our health care system. Not too surprisingly, when patients fail to make behavioral changes in the face of insufficient support, and a deeply coercive environment, it reinforces the collective dogma that behavior change is impossible and justifies our policy of minimal training and negligible reimbursement.

Of course, this dogma neglects the reality that behaviors have clearly changed (and therefore, are changeable). It is the collective change in behaviors, albeit for the worse, that underpins the massive surge of cardiometabolic disease in the country today.

We need a radically different approach if we are to solve this problem. 

We need to stop pretending that small, incremental changes in our health care system will sufficiently address the causes of cardiometabolic disease and relieve its burden on patients, primary care providers, and payers. There is a major gap in treatment that needs to be rapidly addressed - the delivery of comprehensive behavioral therapy to a massive number of patients who need it.

This therapy cannot and should not be principally based in the clinic. It needs to be implemented within the daily lives of our patients, in the setting where behaviors actually happen.

Fortunately, we already have the tools and know-how to fill this treatment gap. The overwhelming majority of our patients have access to one of the most powerful behavioral tools ever invented: the smartphone. And our understanding of how and why humans adopt specific behaviors has advanced. Together, this means that deploying software designed to treat disease, known as digital therapeutics, has great potential.

We also have a more comprehensive understanding of why behavior change is difficult and requires support. Humans, being social creatures, learn patterns of behavior. This is a neurobiological process that requires a specific learning environment that includes physical, cognitive and social influences. Through practice and continual reinforcement, we learn to initiate and ultimately automate important behaviors.

Changing behaviors requires us to address the complex array of neurophysiological, cognitive, environmental and situational barriers that is unique for each person. Digital therapeutics offer enormous potential to do exactly that. With digital therapeutics, we can meet a patient suffering from cardiometabolic disease where they are at (physically, cognitively), be available continuously, and initiate behavioral change through tailored, evidence-based behavioral therapy.

We can also support primary care providers who are hungry for tools to treat their patients, not just their patients’ numbers. Together, we can reinvent the cornerstone of a high-functioning medical system: the delivery of primary care. The time to help our patients live a life free of the burden of cardiometabolic disease is now.

Mark Berman, MD

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