CRS 2017: Managing Diabetes in Rural Locations: A Q&A With Dr James Gavin

Cardiometabolic risk reduction is at the core of nearly every clinician’s practice, given the prevalence of these conditions - hypertension, diabetes, dyslipidemia, and obesity - among the US population. Nearly 10% of American adults have diabetes, nearly 30% have high blood pressure, and nearly 35% are obese, meaning that helping patients manage their cardiometabolic health likely is one of the most common components of daily practice.

Consultant recently spoke with James R. Gavin III, MD, PhD, who is a professor of medicine at the Morehouse School of Medicine in Atlanta, Georgia, about managing patients with cardiometabolic disease.

Consultant360: What do you feel are the key issues contributing to the continued growth of the cardiometabolic disease epidemic in the United States?

James Gavin: The evolution and dynamics of our social and cultural environment have encouraged less activity and easier access to calorie-dense nutrition. The societal mantra has been the quest for ever-increasing levels of convenience, and this has completely distorted the energy equation, beginning in early childhood. This unimpeded growth of overweight/obesity and increased inactivity have been major drivers of the continued growth of the cardiometabolic disease epidemic in the United States and, increasingly, in the world.

C360: In your opinion, what is the biggest misconception about cardiometabolic disease?

JG: I think the biggest misconception about cardiometabolic disease is that it can be conquered or controlled by understanding and treating the biology of the individual components. I think this is a gross simplification of the complexity and heterogeneity of expression of cardiometabolic disease, and it underestimates the enormous contribution of cultural and behavioral factors to the development, progression, and response to treatment of cardiometabolic disease. To adequately assess and clinically address cardiometabolic disease, it is as important to know “what makes patients tick” as it is to know “what makes them sick.”

C360: Why are primary care clinicians so critical in the management of patients with cardiometabolic risk factors? Particularly in the management of diabetes in rural areas and/or special populations?

JG: Primary care clinicians constitute the earliest detection system in our overall health care system for determining the presence and severity of cardiometabolic risk factors. They are also the sources of the foundational items of education and awareness regarding early intervention, lifestyle changes, and the array of possible therapies for control and improvement of these risks and avoidance of adverse outcomes. It must be the primary care clinicians who “set the perception and manage the expectations” around the role and impact of cardiometabolic risk factors and the urgency for their timely and appropriate control. It is also the primary care clinician’s role to establish the rationale for the role and potential impact of specialists and subspecialists in the care of cardiometabolic risk factors.

C360: What are some challenges primary care providers may face when managing patients in rural locations?

JG: There are unique challenges for the primary care clinician with rural populations, especially in the management of chronic diseases. The major obstacles to appropriate management of cardiometabolic risk factors are often non-biologic in nature and include cultural, geographic, financial, and policy barriers. The strategies for effective management of cardiometabolic risk factors must accommodate the enormous heterogeneity of the expression of these conditions in rural populations and must leverage technology.

C360: What are some recent pharmacologic or nonpharmacologic developments in the clinical approach to, or our understanding of, diabetes treatment in rural areas and/or special populations?

JG: The power of telehealth technology can be used to mitigate the disadvantages of scarce health care personnel, limited access to resources, and significant distances from health care sources that are often encountered in rural populations. Wireless remote self-care and monitoring technologies offer great promise for improved management of cardiometabolic risk factors in rural populations.

C360: What do you feel is the greatest challenge for primary care clinicians in the prevention and treatment of cardiometabolic disease in rural populations?

JG: One of the greatest challenges is the lack of assurance to persistent access to the most effective tools and treatments, including comprehensive, up-to-date information for the management of cardiometabolic risk factors.

C360: If you could give primary care providers one piece of practical advice to improve the management of cardiometabolic risk in daily practice, what would it be?

JG: I would advise primary care providers to make management of cardiometabolic risk a team/family undertaking and emphasize the requirement of continuous refreshment and learning as an essential element of the mandatory self-care that characterizes optimal management of these conditions.