Cardiometabolic disease is the number one cause of death in the world – so why haven’t you heard about it? Maybe because its components, (including hypertension, high triglycerides, insulin resistance, obesity, and low LDL cholesterol), have traditionally been treated individually, instead of as a related cluster of conditions that, when combined, significantly increase a person’s risk of heart disease, diabetes and stroke.
Medical providers are assembling multidisciplinary teams of experts to address the disease with a combination of lifestyle changes and medical therapies.
Guest Theodore Feldman, M.D., medical director of community health at Baptist Health's Miami Cardiac & Vascular Institute (MCVI), joins host, Jonathan Fialkow, M.D., to explore what a diagnosis of cardiometabolic disease entails, and how it can be prevented and treated.
Cardiometabolic disease is the number one cause of death in the world – so why haven’t you heard about it? Maybe because its components, (including hypertension, high triglycerides, insulin resistance, obesity, and low LDL cholesterol), have traditionally been treated individually, instead of as a related cluster of conditions that, when combined, significantly increase a person’s risk of heart disease, diabetes and stroke.
Medical providers are assembling multidisciplinary teams of experts to address the disease with a combination of lifestyle changes and medical therapies.
Guest Theodore Feldman, M.D., medical director of community health at Baptist Health's Miami Cardiac & Vascular Institute (MCVI), joins host, Jonathan Fialkow, M.D., to explore what a diagnosis of cardiometabolic disease entails, and how it can be prevented and treated.
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Dr. Jonathan Fialkow:
Welcome Baptist HealthTalk podcast listeners. I'm Dr. Jonathan Fialkow. I'm Chief Population Health Officer at Baptist Health, as well as Deputy Director of Baptist Health's Miami Cardiac and Vascular Institute. We're all aware of individual risk factors that lead to disease. What is becoming more and more established is that there are underlying physiological alterations in our body from these risk factors that are related. The term cardiometabolic disease, while established many years ago, has been developed as a means of incorporating all these seemingly disparate, but ultimately related conditions. Cardiometabolic disease is, in fact, the number one cause of death in the world. To help us better understand this important condition, its components, how to recognize it and what we are doing at MCVI Cardiology to help educate and treat is my friend and colleague, Dr. Ted Feldman. Ted's the Medical Director of Prevention and Community Health at Baptist Health's Miami Cardiac and Vascular Institute and the Co-Medical Director of MCVI Cardiology, Lipid, and the Cardiometabolic Disease Program. Welcome to the podcast, Ted.
Dr. Ted Feldman:
Good morning, John. It's great to be here.
Dr. Jonathan Fialkow:
So, Ted. For the listeners, let's get started with just some basic definitions, a little education. Then, we'll start talking about some newer ways of thinking about cardiometabolic disease and ways we are addressing people with this condition. Let's start with the basics. What is cardiometabolic disease? What does that term, which I think our listeners will be hearing more and more about, what is it when we refer to that term, what are we talking about?
Dr. Ted Feldman:
Okay. Well, thank you for the introduction. And I think first, the most important thing is to reiterate what you've already said in the introduction, is that cardiometabolic disease as a syndrome and a constellation of syndromes is still in the number one cause of death worldwide. It includes the bulk of cardiovascular disease, particularly coronary artery disease, components of heart failure and arrhythmias, like atrial fibrillation. It also encompasses all of the diseases associated with obesity and diabetes, as well as chronic kidney disease. And cardiometabolic diseases are primarily caused by unhealthy lifestyle, a very high processed food diet, sedentary lifestyle, that is physical inactivity, cigarette smoking, but mostly comes back down to an unhealthy diet, a lack of physical activity, and those factors that lead to obesity. So, to summarize cardiometabolic syndrome or cardiometabolic diseases is a combination of a variety of metabolic abnormalities. That is, how the body's chemistry works.
Dr. Ted Feldman:
That's characterized by the body's inability to use insulin appropriately, which can lead to pre-diabetes and diabetes, dyslipidemia, which is the term we use for abnormalities of cholesterol metabolism. So high, bad cholesterol, LDL, low HDL cholesterol, which is the good cholesterol, elevated triglycerides. It's also associated with high blood pressure, which we know now to become epidemic as the obesity rates have increased. And this sort of obese syndrome that we described as central adiposity, which is just simply the medical term for belly fat. So it's the combination of a variety of factors that lead to a whole host of diseases that when you combine the components of heart disease and diabetes and chronic kidney disease and non-alcoholic fatty liver disease and a variety of these other diseases represents the number one cause of death worldwide.
Dr. Jonathan Fialkow:
So, very well stated. It's kind of like the string theory of a lot of cardiovascular disease events. It's the underlying components. And you did a great job at unpacking a lot of the things which I think our listeners have been hearing about for a long time, high blood pressure, weight gain, especially in the belly. So, maybe let's go through those components one by one, a little bit, with everyone understanding these are just one of many components that lead to the cardiovascular disease, but they are related. So you mentioned dyslipidemia, you talked about the components. I know you and I rail a little bit when people just talk about purely high cholesterol. Cholesterol is natural in the body and not everyone with high cholesterol has cardiac risk. So talk about that term dyslipidemia. You mentioned the components, but what are we really talking about when we differentiate between dyslipidemia, D-Y-S, abnormal cholesterol versus high cholesterol.
Dr. Ted Feldman:
Yeah, and I think that's a really important point. Clearly, high cholesterol has been associated with an increased prevalence of atherosclerotic heart disease or what we describe as coronary artery disease, which is the disease that leads people to get coronary stents or coronary bypass or have what we describe as a heart attack. There are lots of other different forms of heart disease that are not necessarily related to the cardiometabolic syndromes, but the number one cause of heart disease in the United States, it's still directly related to metabolic abnormalities, which is coronary artery disease. And the term dyslipidemia, though, we've known for a long time that elevated levels of bad cholesterol or LDL cholesterol are associated with a disproportionately high incidence of cardiovascular disease. As you correctly point out, not everyone who has high levels of bad cholesterol develops heart disease and many people who have heart disease actually have relatively normal values of LDL cholesterol.
Dr. Ted Feldman:
It's just, when you talk about building a house of bricks, LDL are the bricks of the development of atherosclerotic cardiovascular disease. So though not all people with LDL cholesterol have heart disease or though most people who have coronary artery disease have normal cholesterol, one of the things that's the hallmark of treatment over the last 30 years during our careers in cardiology, is this fundamental notion that statin drugs, that lower LDL cholesterol, regardless of whether it was high to begin with, medium to begin with, or low to begin with, is the mainstay of preventing future complications of heart disease. But we also know that the term dyslipidemia, which is not only associated with high levels of bad cholesterol, can also predispose to the cardiometabolic syndrome. And that is people who have low levels of good cholesterol. So some people are born with very low levels of good cholesterol, things like cigarette smoking and other inflammatory diseases, like obesity, can lower the levels of HDL cholesterol. And we know that lower levels of HDL cholesterol or abnormal functioning of HDL cholesterol is often associated with coronary artery disease.
Dr. Ted Feldman:
So hence, the term dyslipidemia would be a term used to describe abnormalities of cholesterol metabolism. That's not only associated with high levels of bad cholesterol but also low levels of good cholesterol, which are also associated with high levels of triglycerides in the blood, which is a way the blood carries fat. So there are three different components to the dyslipidemia: high levels of LDL cholesterol, low levels of HDL cholesterol. So that's high levels of good, low levels, I'm sorry, high levels of bad, low levels of good and then triglycerides. If you recall the Clint Eastwood movie, the good, the bad and the ugly, that's often how I remember the three components of cholesterol and teach my patients. The good is HDL. You want H high. The bad is LDL cholesterol. You want L low. And triglycerides are the ugly because when you spin down your blood and you look at people at very high triglycerides, it looks this milky white and not exactly what you want your blood to look at. So that's one of the ways in which I remember the different components of cholesterol is the good, the bad and the ugly.
Dr. Jonathan Fialkow:
Again, taking a very complex situation and boiling it down to a couple of take-home points is fantastic. Again, it's not how much cholesterol you have in the cardiometabolic syndrome, in the assessment of the person's risk of cardiac disease. It's more than just the LDL cholesterol, which is what you're bringing up. And that's where doctors who understand this and certain specialists can further evaluate one's risk and decrease the risk recognizing what are those components beyond just a single lab result. 30 seconds on hypertension only because it is so extremely important, but at the same way, we've done a lot of work on hypertension. It's not really the main premise of the podcast.
Dr. Ted Feldman:
Sure. Well, again, hypertension is critically important. It's a risk factor that's been defined over 50 years as being associated with an increased incidence of coronary artery disease and stroke. We know that hypertension in and of itself leads to a certain degree of insulin resistance. You'd want to hear that term consistently in the description of it and how the body metabolizes insulin and how insulin helps metabolize blood sugar is clearly impacted in those people who have high blood pressure. So high blood pressure is an important contributing factor to the cardiometabolic syndrome. And the most important concept to take away I think here, John, is that when you add risk factors, you don't simply add risk. So one plus one plus one doesn't equal three. As you add high blood pressure to a high cholesterol, to obesity, to pre-diabetes, the risk for developing coronary artery disease goes up exponentially.
Dr. Ted Feldman:
So it goes up as a factor of multiplying risk factors. So one plus one plus one doesn't equal three, but as you add three different risk factors, the risk may go up eight to 10 fold. And thereby hypertension is such an important component of accelerating cardiometabolic disease when all of these other inappropriate lifestyle factors come to play. So it's an extremely, and it's almost like putting kerosene on an open flame in that the flame may be small to begin with but when you add hypertension to the mix of cardiometabolic abnormalities, you get a marked acceleration of the development of coronary artery disease and stroke.
Dr. Jonathan Fialkow:
And of course, to our listeners, many people don't know if they have hypertension, unless they get their blood pressure checked regularly. And if, in fact, your blood pressure is high or creeping up the tendency is to deny it, oh, I just had coffee or oh, I... So, but the reality is this is a significant driver of disease, as you're talking about. And going back to the original premise, the underlying cardiometabolic syndrome raises your blood pressure, creates this abnormal cholesterol. Let's get to the third component, which is the sugar. So the question and getting a little bit into, again, insulin resistance. You mentioned it a couple of times, which is the hallmark of this, but describe why we as cardiologists, when someone crosses the threshold to diabetes, it kind of doesn't mean anything to us, because we've already identified that cardiovascular risk in that pre-diabetic state. So speak a little bit more about the pre-diabetes to diabetes, if you would.
Dr. Ted Feldman:
Sure. And I think the simplest, I'm real big on analogies in helping to describe things. So when you talk about what sank the Titanic, that great movie and famous ship that sank in the early 1900s, there was an iceberg floating above the surface of the ocean. And we think of that iceberg as the thing that cut the hull of the Titanic and caused it the sink. But if you look at an iceberg, 95% of the iceberg is below the level of the surface of the ocean. And the best analogy between pre-diabetes and diabetes is that diabetes is the part of the iceberg that's above the surface, which is clearly a situation of increased risk, but that risk begins well below the surface of the water. And that's the pre-diabetes component. And that's a component in which the body, as we begin to age and accumulate belly fat from inappropriate diet, lots of processed foods, a sedentary lifestyle, the body, as we age, loses the ability to use insulin in the same efficient manner that it does when we're younger in life. And thereby the blood sugar starts to increase, further increasing insulin.
Dr. Ted Feldman:
Insulin levels, we know, increase the development of plaque in the arteries. That in and of itself helps to accelerate more fat build up. And we get into this vicious cycle of insulin resistance, the development of visceral or belly fat, belly fat leading to further insulin resistance and more weight gain. And it's that fundamental component of insulin resistance leading to weight gain, leading to more insulin resistance, leading to more weight gain, that we feel to be at the center of the clinical syndrome associated with all of these cardiometabolic diseases. And then ultimately, and I'm sure we'll have an opportunity to talk about treatment, but effective weight loss is really the hallmark of reducing the risk around all of these syndromes that are related to cardiometabolic disease.
Dr. Jonathan Fialkow:
So again, well said. Insulin is a hormone of storage and it's precipitated mostly by carbohydrates, a little by protein. As we consume a lot of processed foods, sedentary lifestyle, great lifestyle things you mentioned, as well as certain kinds of foods, the insulin doesn't work well. So your body produces more insulin, which makes you store more energy and gain weight, which makes you more insulin resistant. So we're trying to educate our listeners to start looking at those early signs, which might be the drop in the HDL and the raise in the triglycerides, the blood pressure keeping up, maybe the fasting sugar going up a little, but not at the diabetic range, but that means you're already developing the insulin resistance. What we always say is when someone, when a patient's belly is the first thing that walks into the, is the first part that enters the room when they come to the office immediately start saying, I bet your sugar is high, I bet your triglycerides are high, I bet your HDL is low. And how do you know, is this is the syndrome.
Dr. Jonathan Fialkow:
So again, great points. We can talk about some of the other subtle ones of fatty liver and sleep apnea. But for the premise of the time, let's go through a couple of other questions that I think the listeners may have. First point is, is there a genetic component to this? Are some people predisposed to this and others can either eat what they want and be thin, or eat what they want and not have insulin resistance. What do you see in your practice? What are we seeing?
Dr. Ted Feldman:
Well there is no question that family history is an important component of many diseases. The issue around cardiometabolic disease is there is clearly predisposition around things like high blood pressure. There's genetic predisposition to the development of diabetes, though we think of diabetes as a disease primarily of the overweight and obese. We know that there's a good percentage of diabetics who are of normal weight. Those generally are more associated with family histories of diabetes. So there are extremely important genetic components to many of the risk factors, certainly many cholesterol abnormalities have a familial component. But I think the important point is in those who have increased family history or genetic risk for the development of components of the metabolic syndrome, we can't lose sight of the fact that many, many people do not have significant family histories of these cardiometabolic diseases, but as a result of improper lifestyle, again, poor diet, fat-laden diets, lots of inflammatory types of foods, processed foods, people who smoke, people who are physically inactive. That is, the lifestyle components can have an extremely overwhelming impact on the development of cardiometabolic disease in people who have no genetic history.
Dr. Ted Feldman:
And in those who have a family history lifestyle becomes even that much more important to prevent your genes from manifesting itself in the development of these diseases. So yes, there is an important component of family history, but there's probably an even greater component of lifestyle that can help counterbalance those who have a family history, as well as produce the disease in those who don't, if their lifestyle is sufficiently inadequate around things like proper nutrition, not smoking, and regular physical activity.
Dr. Jonathan Fialkow:
Before we get onto some of the therapies and some of the recent developments of therapies, which certainly excites us, also note, unfortunately, we're seeing this more and more in younger people and adolescents and even children. So obviously this is something we're going to be dealing with is cardiometabolic syndrome. These medical conditions that lead to cardiovascular disease, renal disease, kidney failure, et cetera, we're going to be dealing with this for a long time, unfortunately.
Dr. Ted Feldman:
Well, I think the really important point to emphasize here is that when you look back into the early '80s, the incidence of obesity in the United States was around 11% in 1981. That happened to be the year that I finished my internship. We're now looking at obesity rates of around 40% nationwide. And it's now estimated by the year 2030, which is less than about eight and a half years away, that 50% of the states in America, that is 25 of the 50 states, will have obesity rates in excess of 50%. So much of this epidemic of cardiometabolic disease that has occurred over the last 30 to 40 years seems to parallel the development of obesity as it relates to the development of all of these cardiometabolic diseases. So anything that's focused on successful weight loss and improving the quantity and quality of our diets while we increase our physical activity, manage our weight and not smoke can have a huge impact upon overall reducing the risk in association with appropriate medical therapy, around things like high blood pressure, abnormal cholesterol, and abnormal blood sugar.
Dr. Jonathan Fialkow:
I mean, it's fascinating, Ted, it's something you and I, we speak about all the time. Hence, building the programs that we're building. But something's changed, right? 40, 50 years ago, we did not have this level of obesity and cardiometabolic disease and even diabetes. And it's not just, we're getting older because we're seeing it in higher levels of the younger people. So clearly there's things out there. You mentioned quite a few, which we can speculate, more sedentary lifestyle, more processed foods, et cetera, et cetera. But we do know that we're a less healthy population. To that end and not to denigrate the lifestyle components, let's talk about some of the agents. Briefly, what are the standard therapies, and then maybe, and again, keeping it relatively brief, the newer therapies, the real excitement regarding the new families of medications and what, and the reason why we're excited about it, what the data shows, specifically, heart failure, heart attacks, and renal disease. You know, the things that we want to prevent when we're talking about preventative cardiology.
Dr. Ted Feldman:
No, no question, really important. And again, if the four lifestyle factors around nutrition, physical activity, smoking status and weight, then the three, what I would call medical dashboard, which are where the focus of most treatment are, is around abnormal cholesterol metabolism, high blood pressure, and high cholesterol and diabetes or pre-diabetes. So the mainstay of preventing coronary artery disease and stroke over the last 40 years has been statin drugs that lower LDL cholesterol. Because even though the majority of people who have coronary artery disease, don't have elevated levels of LDL cholesterol, we know that by dramatically reducing LDL cholesterol in people who already have plaque in their arteries dramatically reduces complications related to that. So statins clearly a number one. Managing blood pressure with a variety of different medications, and I know you've covered this exhaustively in prior podcasts, but getting that blood pressure down below 130/80 on a consistent basis is extremely important to reducing overall cardiovascular risk.
Dr. Ted Feldman:
And now drugs that really impact upon blood sugar are extremely important. And we have a couple of new drugs that not only reduce blood sugar and A1C, which is correlated with many of the complications of diabetes, but the major complications around heart attacks and strokes have only recently been impacted by some of the newer diabetic therapies. And those are the ones we're excited about because they not only have a beneficial effect on lowering blood sugar, but in terms of also reducing cardiovascular risk and have an important effect as a additive effect on significantly reducing weight without increasing cardiovascular risk. So some of the new medicines in the diabetes space, we're very excited about it, and we think will be an important component of that driving down some of the obesity, which has been really fueling this cardiometabolic epidemic.
Dr. Jonathan Fialkow:
I want to emphasize that it's a great segue into our last couple of points to discuss, that historically medications lowered blood sugar have not necessarily impacted cardiovascular risks. They've not really decreased heart attacks. They've lowered your blood sugar, which has other benefits, but the recent medical therapies, which we now have as part of our armamentarium and part of our programmatic approach, have both a glucose lowering effect, which is good, but they can also help you lose weight, which makes you more metabolically normal as well as have cardiac impacts. So to that end, which is kind of the philosophy, talk a little bit about the MCVI Cardiometabolic Program and where your thoughts are in terms of building this and leading it.
Dr. Ted Feldman:
Sure. Well, I mean, this is something you and I have been passionate about over the decades of our career. And we began to realize, I began my career as an interventional cardiologist, where I was the one, as are many of our colleagues, are the ones who were putting out the fires, so to speak. You know, my dad was a New York City Fire Chief, so I often relate the fact that when the fire goes off and you're having a heart attack and you call 9-1-1, we can do some amazing stuff through the years. And over the last 40 years, there's been tremendous benefits in the acute treatment of people who have heart attacks and the ability to get arteries open. But it was very clear to me from my career that we could do a lot better by preventing people from developing heart disease, than in simply putting out the fires.
Dr. Ted Feldman:
And I think, I mean, towards that end, the ability to use drugs like statins and drugs like aspirin lowering blood pressure and now several of these diabetes drugs that also favorably impact on cardiovascular risks, things like fish oils, which also will lower triglycerides and raise HDL. There is a variety of medical therapies now, both through statins, through blood pressure medications and some of the newer diabetes drugs, that can really have a dramatic and additive impact upon reducing the overall cardiovascular risk. And despite the benefits of lifestyle, we know that many, many people will fall through the cracks, so to speak, have inadequate lifestyle adjustments, or even with maximal lifestyle adjustments, will still exceed the threshold by which they will need medications. And the combination of statins, blood pressure medications, and some of the newer diabetes medications, drugs like the SGLT-2 inhibitors, as well as the GLP-1 receptor agonists, drugs that end in -flozin for the SGLT-2s or -glutides for the GLP-1 RAs are now becoming the hallmark of a much more aggressive multi-pronged multi-drug therapy to reduce cardiometabolic disease and coronary artery disease.
Dr. Jonathan Fialkow:
The host of weapons available can sometimes be overwhelming to the primary care doctor, many other doctors, and to the patients. So if someone has cardiometabolic risk, someone has cardiometabolic disease. Someone's primary care doctor says, "Hey, you got a lot of complicated stuff" and they're referred to the program, what does the program look like? Or what are the unique aspects in that we're looking to achieve?
Dr. Ted Feldman:
Yeah, no, no, for sure. Well, obviously when you're seeing patients as we are every 15 minutes all day long, and you have someone who needs aggressive lifestyle intervention and a multi-pronged drug impact, and someone could be able to sit down and go over proper diet and a regular exercise prescription, getting people to stop smoking, getting people to manage and reduce their stress. That's a lot to get done in a 15 minute visit. So the development of a multidisciplinary approach with multiple experts who have specialty in drug therapy, in stress management, in weight management, in smoking cessation, in nutritional counseling, in exercise prescription, are the pillars of expertise that we're building in this multidisciplinary approach, because simply in a 15 minute visit to tell people that they need to lose weight, stop smoking, start exercising regularly and take these four or five medications to reduce their risk doesn't resonate with people.
Dr. Ted Feldman:
And until people really understand and get educated around all of the important components, they're not going to be successful in terms of long-term success. So building a multidisciplinary program of expertise where people can actually begin to dig in topic by topic about the multiple cardiovascular risks that they have is a much more effective way to get at ultimately preventing and treating the cardiometabolic syndrome than what we're capable with simply in a one-on-one during a rapid suit office visit, where we know it is difficult to even focus on one or two major problems, let alone on a multiplicity of problems that most of these patients have.
Dr. Jonathan Fialkow:
As we've started the conversation with asking our listeners to recognize this is a complex disorder. It's not just my blood pressure is five points high, give me a pill. And we put it, we have a programmatic approach to addressing the complex disorder in an individual and making sure we give them the best opportunity to avoid these cardiometabolic consequences, heart attacks, heart failure, renal failure, as you said. Last point. And again, I really appreciate your time and expertise. Tell us a little bit about the Cardiometabolic Center Alliance.
Dr. Ted Feldman:
Sure. Well, I mean, you've been instrumental in helping us here at Baptist be participating with a group of pioneering programs around the country who have begun to organize themselves around this multidisciplinary approach to cardiometabolic disease. Our colleagues at the St Luke's Hospital in Kansas City, the Mid America Heart Institute, have been instrumental in coordinating and inviting us to participate as one of several centers in the country that are really focusing all of our efforts around the best ways to treat cardiometabolic disease. We've developed, this Alliance is allowing us to develop a registry or allowing us to develop best practices, allowing us to share data as to the most effective forms of treatment, begin clinical trials to figure out what parts of this multidisciplinary approach are the best part, moving into the virtual space now, which, we believe, an important way to impact upon many more people than those that can be seen in person.
Dr. Ted Feldman:
So this Alliance of which Baptist is very fortunate to be one of the founding members under your leadership is, I think, really at the cutting edge in the 21st century approach to what ultimately is the leading cause of death, not only in the United States, but worldwide. And it's going to take this most multidisciplinary focus and multicenter focus that's going to be focused on clinical excellence, education, as well as clinical research that will, for the next generation, hopefully be able to take this epidemic from the number one cause of death worldwide, to something substantially less.
Dr. Jonathan Fialkow:
Well, this is really a very helpful podcast episode, Ted. I really thank you for your expertise and your leadership, and most importantly, your passion. So it's helping to educate our community and community includes our physicians as well as get people evaluated and treated to prevent this important cardiovascular consequence related to cardiometabolic disease. Thanks for listening. As you've learned, cardiometabolic disease is a syndrome, a constellation of various previously treated separately medical conditions. It's a major medical problem. Much scientific research is focusing on addressing the diverse constellation of risk factors and identifying new care models that take an integrated approach to treating these risk factors across really diverse populations. The MCVI Cardiology Cardiometabolic Disease Program is one such innovative approach. As usual, if you have any thoughts, comments, or ideas for future topics, email us at BaptistHealthTalk@baptisthealth.net. That's BaptistHealthTalk@baptisthealth.net. Stay safe, all.
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