At the level of popular perception – which often shapes public policies – the 20th-Century ‘stories’ of vascular disease (including ischaemic heart disease and all forms of stroke) and type 2 diabetes in countries like the USA and the UK appear to stand in stark contrast to one another. In age-standardized terms, the mortality caused by circulatory conditions as a whole has fallen continuously since its peak soon after World War II. In UK today, for instance, vascular disease deaths occur at only a third or so of the rate recorded in the 1950s [1,2]. But the prevalence of type 2 diabetes climbed dramatically during the same period. Even allowing for changes in diagnostic criteria, it is now higher than in any other time in history.
The number of diagnosed type 2 diabetes is currently around double that recorded in the UK 25–30 years ago. This reflects increases in obesity rates. Notwithstanding, the harm caused by opiate and opioid use in USA and the impacts since 2010 of public spending cuts in UK, recent declines in life expectancy among more vulnerable groups in both countries have on occasions been attributed to the ‘diabetes pandemic’ and its seemingly paradoxical onset after the ‘heart attack epidemic’ of the 1940s to the 1980s.
One rational response to such observations involves shifting the focus of investment and healthcare effort further towards offsetting the social determinants of ill health. The core goal of this is to protect those living with or at high risk of diabetes via lifestyle changes that will foster better weight control and prevent or reduce insulin resistance. There is good evidence that blood pressure levels can also be successfully controlled through such actions . Research demonstrating that type 2 disease is more reversible than previously believed and that many people respond well to interventions involving intensive low-calorie diets has further highlighted the potential value of such health policy approaches [4–6].
Towards a balanced narrative
However, the reality of the 20th century was not actually that the cardiovascular mortality and type 2 diabetes morbidity ‘stories’ were separate, contradictory health phenomena. They were intimately related, socially and biologically. It is also the case that alongside the promotion of protective lifestyles there are many other important challenges to be faced in the cardiovascular and related metabolic disease context that cannot be addressed by public health measures alone .
Reductions in tobacco smoking, coupled with surgical advances and the growing capacity of medicine and medicines to control blood pressure, blood glucose and low-density lipoprotein cholesterol levels and inhibit platelet aggregation, masked the consequences of increased population-wide adiposity and the impacts of dietary and activity changes between the 1950s and the present. But the downward trend in vascular disease death rates has now slowed, and around a quarter of all deaths are still directly linked to the cardiovascular/diabetes nexus. At the same time, there remain major avoidable health problems to be overcome in contexts such as living with heart failure  and in relation to the linkage between vascular pathologies and the dementias.
Further reducing the burden of harm and distress linked to macro and microvascular disease will not only require vulnerable people to ‘live healthily’. It will also require cardiologists and diabetologists (and nephrologists) to work collaboratively to share knowledge and therapeutic expertise and to gain a more fundamental understanding of the genetic and epigenetic origins of the linked conditions at the centre of their expertise . Health professionals – working with people living with cardiometabolic conditions – will need to use existing treatments to better effect and positively accept new therapeutic opportunities as and when they evolve.
Realising opportunities, overcoming barriers
From a broad public policy perspective, it is important that future healthcare developments should seek to extend healthy life expectancy at least as rapidly as they contribute overall life expectancy increases. The key to success in this is most likely to lie in understanding the early causes of disease and in being able to intervene biologically and behaviourally before frank morbidity develops.
There is a reason to look forward to progress in relation to all forms of diabetes and vascular disease. For example, the discovery that sodium-glucose transporter 2 inhibition can not only reduce blood glucose levels but extend the life expectancy of people living with heart failure and type 2 diabetes (and also improve their kidney function) has significant implications for cardiologists and endocrinologists alike .
Of perhaps even greater long-term importance, the application of Mendelian randomization research methods promises new insights into the scale of the lifetime benefits to be derived from identifying genetically based vulnerabilities early, and the value of taking timely action to offset risks before they translate into overt ill health (I. Graham, personal communication, 2019) [11–12]. Yet against such reasons for hope the barriers to achieving better preventive use of medicines and better health outcomes for vulnerable individuals and communities should not be understated. They range from political resistance to spending on research which is ‘unfashionable’ or related to illnesses seen as the result of self-care failures. The fact that, unlike curative interventions, prevention does not have visible beneficiaries can also drive popular preferences and political decisions.
Related professional limitations also slow progress. Doctors, like everyone else, tend to behave tribalistically and to pursue sectional rather than collective economic interests by seeking to defend interdisciplinary boundaries long after their scientific logic and value to patients has faded. There is also an extended medical history of failing to adopt biologically based preventive approaches to disease in a timely manner and place undue reliance on the promotion of ‘virtuous’ behaviours without prudent biomedical backup.
For example, even in the 1940s and 1950s, a proportion of doctors argued that blood pressure levels of up to 200/100 mmHg were benign and did not require treatment . It was not until the later 1980s that the effective mass use of antihypertensives was initiated in either the USA or the UK. This is partly why myocardial infarctions rate did not fall until then. Even today such medicines are arguably underused. There has also been considerable opposition to the optimum use of statins among some health professionals, especially in the primary prevention context (N. Wald, personal communication, 2019) . This includes arguably inappropriate resistance to allowing innovations such as pharmacy prescription and supply and encouraging statin use in middle and later life. Similar points may also apply to metformin in the context of early-stage insulin resistance.
In conclusion, there is a strong case in favour of researchers and clinicians working in the field of ‘cardiometabolic medicine’ collaborating more closely, and a good reason to hope that if they more effectively integrate their disciplines significant benefits will result. Achieving this will demand not only a robust commitment to improving public health. It will also require the skills needed to communicate the benefits of existing and new biological science-based approaches to the prevention and treatment of type 2 diabetes, heart attacks and heart failure to not only policymakers but to members of the wider public. In the final analysis, it is they who not only decide as individuals whether or not to accept professional recommendations, but who collectively create the belief and political action frameworks within which research funds are allocated and service developments approved.
Conflicts of interest
There are no conflicts of interest.
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