A study published in the Journal of the American College of Cardiology revealed that just 6.8% of Americans are in optimal cardiometabolic health. As a family nurse practitioner practicing lifestyle medicine, I am extremely concerned about the other 93.2% of Americans who are not in optimal cardiometabolic health.
Our healthcare system should be concerned too. I was first introduced to the concepts of value-based care and accountable care organizations in 2013 as a performance improvement nurse. In 2022, as we continue to slowly move away from fee-for-service, improving cardiometabolic health will be a crucial component to improving population health.
What Is Optimal Cardiometabolic Health?
So, what exactly is cardiometabolic health and what is optimal? Good questions. Optimal cardiometabolic health is the absence of a series of disorders that increase a person’s risk for heart disease or type 2 diabetes. These include hypertension, high fasting blood glucose, abnormal cholesterol levels, excess abdominal weight, and high triglycerides.
The journal study was based on results from the National Health and Nutrition Examination survey. The cardiometabolic risk factors analyzed in this study included body weight, blood glucose, cholesterol, blood pressure, and clinical cardiovascular disease. According to the research, changes in average body weight and blood glucose were the two factors with the greatest impact on decreasing the cardiometabolic health of the population between 1999 and 2018. Optimal body weight was considered a body mass index (BMI) of less than 25 and a waist circumference of less than or equal to 88 cm for women and 102 cm for men. The criteria for optimal blood glucose included not requiring medications for diabetes, having a fasting blood glucose level of less than 100 mg/dL, and a hemoglobin A1C of less than 5.7%. Poor level for body weight was considered a BMI over 30 and a waist circumference larger than the cutoff measurements above. Poor level for blood glucose was a fasting level greater than or equal to 126 mg/dL or a hemoglobin A1C greater than or equal to 6.5%.
Approaches to Improving Cardiometabolic Health
Nine of the top 10 leading causes of death in America have obesity and excess body weight as a risk factor. These include heart disease, certain cancers, COVID-19, stroke, chronic lower respiratory diseases, Alzheimer’s disease, diabetes, influenza, and nephrotic syndrome. Heart disease alone costs the U.S. hundreds of billions of dollars each year between treatments, medications, and lost wages due to death. In fact, 90% of healthcare spending in America is related to chronic disease and mental health.
The good news for the 73.6% of U.S. adults who are considered overweight or obese, many of whom are not in optimal cardiometabolic health, is that there are FDA approved weight loss medications available that can help supplement diet and lifestyle changes — especially when these alone are unsustainable or ineffective at improving various health conditions.
The bad news? Insurance coverage of these medications vary by state, insurance type, and employer plan. These medications are generally not covered by Medicaid or Medicare, including where I practice in Illinois. Even for patients with an employer-based commercial plan, weight loss medications are often not covered.
I’ve had the opportunity to witness the power of lifestyle modifications coupled with access to medications to help patients meet their health goals. For example, one patient who had been diagnosed with diabetes 11 years prior was struggling with controlling her diabetes and losing weight. We worked together for 6 months, primarily making lifestyle adjustments such as increasing her water intake, reducing her sodium intake, adding vegetables into her daily diet, going to the gym four to five times per week, reducing her carbohydrate intake, and including more protein and healthy fats in her diet. I also referred her to an endocrinology specialist to optimize her medications, such as reducing her diabetic medications associated with weight gain, and to include a GLP-1 agonist, a class of diabetic medications associated with weight loss.
These lifestyle changes along with adjustments in her medications allowed her to reach her health goals. In 6 months, she was able to lose 25 lbs and 6.7 inches (17 cm) off her waist circumference. Her hemoglobin A1C was down to 5.6%, below the diagnosis level for pre-diabetes. She got her diabetes under better control than it had been in the past 11 years. She cried joyful tears in my office because of how good she felt. She thanked me, but I told her that she was the one who put all the hard work in.
Unfortunately, this is a success story not everyone gets to experience.
For this particular patient, the GLP-1 receptor agonist medication was covered by her insurer because it is indicated for the treatment of type 2 diabetes. But there are other GLP-1 receptor agonists, such as liraglutide (Saxenda) and semaglutide (Wegovy), that are FDA approved but often not covered by insurance because their specified use is for weight loss.
This is just one example of how our healthcare system is reactive instead of proactive. Obesity has been recognized by the American Medical Association as a chronic disease since 2013. We need to start treating it as such by providing appropriate coverage for medications and increasing the availability of comprehensive programs with lifestyle medicine, behavioral health, and preventive cardiology. To be sure, primary prevention of obesity and morbid obesity would be optimal and initiatives targeted at that should also be prioritized.
Obesity is a complex chronic disease with roots in metabolic dysfunction, and is impacted by social determinants of health, socioeconomic status, access to healthy food, subsidies to corn and sugar companies, the convenience of fast food, stress, genetics, and so on. It is often not as simple as “eat less and exercise more” — and that’s where medication can provide another line of support.
We have safe and effective medications that are FDA approved for weight loss and have been rigorously tested prior to approval. We need to expand access to these medications by providing universal coverage.
Elizabeth Simkus, DNP, FNP-C, is a family nurse practitioner practicing lifestyle medicine at Rush University Medical Center, instructor in the Department of Community, Systems, & Mental Health Nursing at Rush University College of Nursing, and a Public Voices Fellow through The OpEd Project.