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CMHC PULSE

Cardio Metabolic Health Congress – Official Blog

How the Burden of Chronic Diseases and COVID-19 Create a Syndemic Environment 

The emergence and overlap of the novel coronavirus with a continued global rise in chronic diseases – including persistently high rates of obesity, diabetes, and cardiovascular disease – as well as those driven by deteriorating environmental conditions have drastically exacerbated the COVID-19 death toll. While we are currently living in the midst of an unprecedented global public health crisis, the COVID-19 pandemic has highlighted the many structural elements that have been consistently failing in the background.

Ranging from racial health disparities and health access inequities to gaps in education and medically siloed communities, systemic public health failures drive our continuous battle against the virus. Critical sociopolitical and public health factors that have allowed many nations to successfully contain the viral outbreak are falling short in the United States. The burden of disease is growing exponentially as the devastation of the COVID-19 pandemic meets the underlying hot bed of chronic disease, further contributing to widening preexisting health gaps. Capacity constraints in healthcare facilities, widespread shortages of personal protective equipment, and vast disparities in mortality rates by race are symptoms of a much larger problem.

Syndemic of Chronic Diseases and COVID-19 

Rising rates of chronic disease, persistent infectious diseases, and public health failures have been largely responsible for the growing number of deaths during the COVID-19 viral outbreak, resulting in what The Lancet’s medical journal editor-in-chief, Richard Horton, refers to as a “syndemic.” Defined as the aggregation of two or more concurrent or sequential disease clusters, a syndemic or synergistic epidemic, attacks populations from multiple vulnerable levels – it will not be solved with the discovery of an effective treatment or the development of a COVID-19 vaccine.

In an article recently published in The Lancet, Horton argues against treating COVID-19 as a singular viral epidemic. Instead, he urges the scientific community along with public health officials to approach the current crisis with a multi-pronged strategy taking into consideration the aggregation of diseases at hand.

In his text, Horton writes: “Two categories of disease are interacting within specific populations—infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs). These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities.”

The Global Burden of Disease

Per data from a global study of human health, consistently rising rates of chronic diseases coupled with the surging COVID-19 outbreak have resulted in a situation much graver than a pandemic. As the most comprehensive study of its kind, the Global Burden of Disease Study analyzes 286 causes of death, 369 diseases and injuries, as well as 87 risk factors in 204 countries across the world to provide an overview of global population health. Currently, it is also proving valuable in determining the impact of COVID-19 – a virus that cannot be viewed as existing in a vacuum separate from the diseases it exacerbates.

The study reports that the leading causes of poor health in individuals aged 50 and above worldwide are cardiometabolic conditions namely, ischemic heart disease stroke, and diabetes.

While in younger demographics, those aged between 10 and 49 years, the primary causes are road injuries, HIV/AIDS, lower back pain, and depressive disorders.

Cardiometabolic conditions and immunodeficiencies are particularly dangerous when coupled with the novel coronavirus. Driving the more than 1 million deaths caused by COVID-19 to date are chronic health conditions that weaken population health, such as high blood pressure, high blood sugar, obesity, and high cholesterol. These in turn, result from unhealthy diets and poor physical activity levels, which will continue to shape population health across the world even after the pandemic subsides.

Looking to the Future 

The rise in chronic disease prevalence worldwide combined with public health failures have left many populations vulnerable to health emergencies such as the COVID-19 pandemic. Thus, approaching the virus outbreak from a syndemic perspective is vital to its successful eradication; targeting biological and societal factors is essential to improving prognosis, treatment, and public health policy.

Societal factors such as the vulnerability of older and minority citizens faced with disparities in healthcare access will not be solved by the introduction of a biomedical solution. Comprehensive policies are needed to reverse the many inequities plaguing the healthcare system per the syndemic approach, which prioritizes an integrated strategy to understanding and treating diseases. This will ultimately prove more successful than any attempt at merely controlling an epidemic of disease.

Combating the novel coronavirus will require focused attention on the non-communicable diseases and socioeconomic inequality increasing susceptibility and the likelihood of poor health outcomes. Addressing the COVID-19 pandemic means addressing the array of chronic diseases burdening the U.S. population. This includes improving obesity and diabetes management, optimizing cardiovascular and cancer care, as well as targeting preventative medicine strategies toward mitigating the health risk factors abundant in the population. Any other singular approach will leave individuals just as vulnerable to future iterations of COVID-19 or the next viral outbreak; a post-pandemic future will not be possible without the solution of the multitude of problems fueling it to begin with.

Telemedicine Care Post-Pandemic in Type 1 Diabetes Patients 

The COVID-19 pandemic has forced providers and patients specialty-wide to shift to a model of virtual care in an effort to avoid unnecessary person-to-person contact; for some, telemedicine appointments were a completely novel concept. Digital healthcare delivery has proved vital to preserving the health of the population during an ongoing pandemic, allowing healthcare providers to continue the routine monitoring of their patients – which is especially important for those with chronic conditions. Of those, type 1 diabetes has proven to be one of the fields more suitable to telehealth visits with the support of remote glucose monitoring data and other novel technologies.

Type 1 Diabetes Telemedicine Appointments 

Per data from an emerging study published in Endocrinology, Diabetes & Metabolism reported that patients with type 1 diabetes who had attended a telemedicine appointment throughout the pandemic found them favorable and would consider future remote visits. Researchers distributed an online questionnaire between March 24 and May 5, 2020 and collected data from over 7,000 people in 89 countries across the world. The highest proportion of respondents were from the United States at 40.6% and 68% were women. Data were analyzed descriptively, while results were stratified according to age, sex, and HbA1C.

Overall, 75% of participants reported planning to use remote appointments in the future, with 86% reporting the visits useful with little variation across age groups and no differences by educational level were observed. The majority of respondents over the age of 65 viewed telemedicine positively.

However, patients with A1c greater than 9%, 45% of men and 20% of women felt that visits were not beneficial, revealing differences by glycemic control. Further study is needed to understand why this particular group was significantly more against telemedicine than others.

Telephone Appointments Versus Video Conferencing 

“Worldwide, 30% reported that the pandemic had resulted in canceled in-person medical appointments, while 32% reported no change in medical follow-up,” the researchers wrote. “Of the 28% reporting use of telemedicine, 72% were via telephone while just 28% were video calls.” Indicating that a large proportion of respondents may have not been able to utilize full potential of video technology, such as screen sharing of glucose monitoring data.

Experts believe that the high reported use of telephone calls over video technology may be a reflection of the global population cohort, as data in the United States reveals a preference for video appointments. This raises the question of health equity, making sure that certain populations are not left behind due to technological access. Further, the data was gathered electronically which may exclude certain groups and favor more tech-forward patients; additional study is needed as the sample was not representative of the whole population.

The future of telemedicine in the United States will largely depend on health insurance processes and reimbursement protocols, including making temporary Medicare waivers permanent and expanding access to virtual care nationwide. Despite the benefits of remote medical appointments, the choice between in-person and telehealth visits is a matter of individual preference; some patients and providers may be more open to maintaining a largely digital practice than others.