12-05-2025
CVD Risk Reduction in Diabetes: A Team Sport
Collaborative, interdisciplinary care, a strategy that relies on multiple specialties working together to coordinate a treatment plan, plays an integral role in disease prevention.
This approach is especially important in patients with diabetes, who carry a two- to fourfold increased risk for developing cardiovascular disease (CVD) compared with peers without diabetes. CVD is the primary cause of morbidity in these patients and accounts for as much as a 75% increased mortality rate, underscoring the importance of integrated, collaborative CVD risk prevention. The challenge lies in determining the best strategies to produce the best outcomes.
Michael Rakotz, MD
'There are so many factors that can increase cardiovascular risk, and having one person trying to manage all of them is nearly impossible to do well,' said Michael Rakotz, MD, group vice president of Improving Health Outcomes at the American Medical Association and clinical assistant professor of family and community medicine at Northwestern University's Feinberg School of Medicine in Chicago.
'So many people worry about the complications of diabetes, but the reality is that most die from heart disease,' added Heather Ferris, MD, endocrinologist and associate professor of medicine at the University of Virginia Health in Charlottesville, Virginia. 'We can manage people's blood sugars safely with medications, but there's still excess risk that needs to be aggressively managed.'
Collaboration, Coordination, and Communication
Integrated diabetes care has been shown to reduce mortality, improve physical and mental functioning, and drive self-management and blood pressure control. Collaboration, communication, and coordination are integral to successful outcomes, but they can also be challenging.
Sadiya Khan, MD,
'It's important to think of collaboration in two domains,' said Sadiya Khan, MD, a preventive cardiologist at Northwestern Medicine Bluhm Cardiovascular Institute in Chicago. The first — considering associated risks for inherent metabolic dysregulation in diabetes — is collaboration within and across specialties, Khan said.
'Collaboration between the clinician and patient, ie, shared decision-making, is just as important, however, especially now given so many different available therapies,' she said.
Heather Ferris, MD
Ferris noted that 'the complexity of care these days really necessitates collaboration, almost more so than it did in the past 20 years,' said Ferris, who, echoing Khan, provided the example of glucagon-like peptide 1 agonists and sodium-glucose cotransporter 2 inhibitors that are used by endocrinologists and cardiologists alike. In the past, 'the things that cardiologists and endocrinologists did were complementary and did not affect each other's respective management.'
Coordination and quarterbacking most often fall to primary care physicians (PCPs) since they are the first (and most frequent) points of contact for diagnosis and ongoing management of diabetes. Though 'it depends on the individual PCP and the culture of practicing within any given system, it can become complicated, especially when providers are in different institutions,' said Ferris.
The same rings true for the millions of patients who do not live in large cities with immediate access to tertiary care health systems. This is where the electronic health record and technology (eg, the ability to access care from anywhere via virtual telehealth visits) play important roles, as well as where communication becomes key.
'It's important to make sure that there's harmonization and a unified approach across the team because every touch with the patient is an opportunity to optimize care,' said Khan. 'Taking a collective responsibility approach is really important,' she said.
Duplicate Services, Multiple Specialties
The interconnectedness of CVD risk factors (eg, obesity/overweight, dyslipidemia, or hypertension) also highlights another challenge that arises in interdisciplinary care in diabetes: Duplicate service offerings across multiple specialties.
Rakotz provided an example:
PCP diagnoses diabetes, prescribes medical management
PCP then refers the patient to a Certified Diabetes Care and Education Specialist (CDCES) and a nutritionist, and an endocrinologist
The endocrinologist has their own CDCES, and might choose to manage CVD risk, take over comprehensive diabetes care and related comorbidities, or refer out to a cardiologist.
This is where communication and coordination can break down, leading to medication errors, care fragmentation, and conflicting advice to the patient. Sustained patient self-management and follow-up are at risk as well, underscoring the importance of the PCP's top wide receiver, ie, the CDCES.
Grace Derocha, RD, CDCES, spokesperson for the Academy of Nutrition and Dietetics, Chicago, said she combines medical nutrition therapy and lifestyle modifications — the cornerstones of CVD risk prevention and diabetes management — with education, health coaching, and psychosocial and behavioral support.
Grace Derocha, RD, CDCES
'Not only am I able to provide the patient information and knowledge as to best practices and evidence-based medicine, but I also consider social determinants of health, culture, tradition, language, and help patients focus on what they can change,' said Derocha. Diabetes care and education specialists are also able to keep patients accountable and motivated.
'I like to give patients some of the power over their healthy habits,' she said.
Derocha pointed out that although CDCES are often embedded into larger health systems, primary care doctors in smaller or more rural settings might not have ongoing relationships or know where to find them, which is where the Academy of Nutrition and Dietetics resources can help.
A Place for Upskilling
Upskilling, ie, the transfer of knowledge from a specialist to the PCP, is a strategy that provides opportunities to fill in knowledge gaps and foster team discussions. Derocha reinforced that it is a way for multiple disciplines involved in CVD risk reduction in these patients to speak the same language. 'We're saying the same thing so that the patient is hearing it not just from me, but from them and vice versa,' said Derocha.
For many established teams, upskilling is the rule, not the exception. For example, Ferris said that she runs regular teaching programs for primary care practices (especially rural practices) that cover topics like cardiometabolic care. Likewise, Khan emphasized the need for collective, ongoing medical education as new information (eg, guidelines, latest data) becomes available.
'I wouldn't necessarily call it 'upskilling,' but rather, learning from different encounters and making sure that what is being recommended and why is clear,' she said.
Studies have shown that additional benefits of upskilling include partnership and trust building (which facilitates timely referral to specialists) and improving practice capacity.
A Role for Early Interdisciplinary Intervention
Given the alarming trend of increasing rates of newly diagnosed diabetes among younger adults, adolescents, and children (many of which have been associated with serious complications such as hypertension), early intervention is warranted, as is considering additional team members, including pediatricians and cardio-obstetricians.
'It's never too late to begin prioritizing prevention and focusing on lifestyle and heart-healthy behaviors to prevent obesity, hypertension, or diabetes-associated CVD risks,' said Khan, also reinforcing the American Heart Association's PREVENT risk calculator to help guide care.
Rakotz, Ferris, Khan, and Derocha reported no relevant financial relationships.
