For decades, diabetes care has focused primarily on managing blood-glucose levels. However, as cardiovascular disease (CVD) remains the leading cause of death among people living with diabetes, global experts are urging earlier, more integrated care that goes beyond traditional glucose metrics. From risk prediction tools to therapy guidelines, the message is clear: effective diabetes care must break disciplinary silos, especially between cardiologists and diabetologists.
This evolving paradigm was recently spotlighted at the International Diabetes Federation (IDF) World Diabetes Congress 2025 in Bangkok, during a scientific session that brought together experts from IDF, the American Heart Association (AHA), the European Society of Cardiology (ESC) and the wider diabetes care community. What emerged was a vision of diabetes care rooted in early action, person-centred risk assessment, and a renewed focus on prevention that includes—but is not limited to—glycaemic control.
Understanding who is at risk and at what stage allows us to intervene with the right therapy at the right time
At the heart of this shift is a deeper understanding of how type 2 diabetes develops and its early, often invisible links to cardiovascular risk. Risk factors such as insulin resistance, visceral and liver fat can emerge years before diagnosis, sometimes beginning in early adulthood.
By the time a person is diagnosed with type 2 diabetes, they may have been living with significant risk factors for decades. This delayed diagnosis undermines opportunities for early intervention, when preventive strategies are often most effective. In contrast, cardiologists have embraced a more proactive model. Their emphasis on early identification and intervention based on cardiovascular risk – regardless of blood glucose levels – offers a model diabetologists are increasingly encouraged to follow.
This convergence of perspectives has given rise to a novel concept known as cardiovascular-kidney-metabolic (CKM) syndrome, introduced by AHA. CKM is a health disorder that reflects a more holistic understanding of how heart disease, kidney disease, obesity and diabetes are interconnected. Rather than treating these conditions in isolation, CKM promotes integrated care strategies that assess and address risk across systems.
Dr Sadiya Khan, representing AHA at the IDF 2025 session, described CKM syndrome as a progressive condition, beginning with excess adipose tissue and evolving through metabolic dysfunction to subclinical and ultimately overt cardiovascular disease. “Understanding who is at risk and at what stage allows us to intervene with the right therapy at the right time,” she explained.
One of the most promising developments is AHA’s new risk prediction tool (PREVENT equations) which surpasses older models by incorporating kidney function markers, body mass index (BMI) and glycaemic status (HbA1c). Developed with data from over six million people, this tool provides accurate, inclusive and actionable cardiovascular risk assessments across diverse populations, including those living with diabetes and chronic kidney disease.
We don’t wait for target HbA1c levels to justify therapy. If a person with diabetes is at high cardiovascular risk, we start treatment based on that risk
The European Society of Cardiology has also adopted a markedly proactive stance. ESC guidelines now recommend the early use of SGLT2 inhibitors and GLP-1 receptor agonists , originally developed for glycaemic control, based on their proven cardiovascular benefits, even in individuals without diabetes. Prof Francesco Cosentino, representing ESC, reinforced this message. “We don’t wait for target HbA1c levels to justify therapy. If a person with diabetes is at high cardiovascular risk, we start treatment based on that risk,” he explained. This approach is supported by a robust body of evidence showing these medications reduce major cardiovascular events, hospitalisation for heart failure, and progression of kidney disease.
Crucially, the 2023 ESC guidelines introduced the Systematic Coronary Risk Evaluation 2-Diabetes (SCORE2-Diabetes), a tool designed for people with diabetes to estimate their 10-year cardiovascular disease risk. It considers age, glycaemic levels measured by HbA1c, and kidney function to generate the estimate. This tool supports person-centred decision-making, enabling healthcare professionals to tailor treatment to a person’s specific risk rather than relying on a one-size-fits-all approach.
Why do we hesitate? We wait for complications before we act, while our cardiology colleagues are already preventing them
The contrast in approach between cardiology and diabetology is marked. While cardiologists tend to favour early intervention based on risk, diabetologists tend to take a more cautious approach, often reserving advanced therapies until after other treatments have proven unsuccessful.
“Why do we hesitate?” We wait for complications before we act, while our cardiology colleagues are already preventing them,” Said IDF President Prof Peter Schwarz.
This discrepancy raises an uncomfortable question for the diabetes community: Is it time to abandon the glucose-first mindset? While no one is suggesting that glycaemic control is irrelevant, the consensus is growing that cardiovascular and renal risk must be prioritised in treatment, especially since many modern therapies provide dual or even triple benefits.
Despite the enthusiasm for pharmacological advances, lifestyle remains the cornerstone of effective prevention. Speakers repeatedly emphasised that the most powerful interventions are often the simplest: moving more, eating well and reducing weight.
Walking, for example, can have a profound effect. Just 1,000 extra steps after a meal can lower post-meal blood glucose levels more than 1,000 mg of metformin. The message is clear: medication should support, rather than replace, foundational lifestyle strategies.
Technology presents new opportunities for prevention, even in low- and middle-income countries (LMICs). . Affordable glucose sensors and digital tools, especially those accessible through smartphones, have the potential to identify individuals at risk earlier and promote behavioural change. Using glucose variability as an early marker of cardiovascular risk, rather than relying solely on average glucose levels, was discussed as a potential breakthrough for global screening strategies.
The idea of using glucose variability, not just average glucose levels, as an early marker of cardiovascular risk—perhaps detected through inexpensive sensors—was proposed as a game-changing direction for research and innovation.
Just 1,000 extra steps after a meal can lower post-meal blood glucose levels more than 1,000 mg of metformin
Another intriguing avenue for prevention is fasting. While still under investigation, various fasting strategies may help reduce liver and pancreatic fat, key contributors to insulin resistance and beta-cell dysfunction. Early findings suggest that certain types of fasting may restore insulin sensitivity, promote diabetes remission and reduce cardiovascular risk. The International Diabetes Federation is currently reviewing evidence to develop guidance on medical and religious fasting for people living with diabetes.
The underlying theory is physiologically compelling: fasting shifts the body from glucose metabolism to ketone production, providing an alternative fuel for the heart and brain while mobilising fat stores from the liver and pancreas. However, more research is needed to confirm the safety, effectiveness and accessibility of this approach, especially across diverse global populations.
Despite medication advances, a sobering reality remains: most people living with diabetes reside in LMICs where access to new therapies and technologies is limited. Metformin has long been regarded as a cost-effective treatment. However, even this basic medication can still be challenging to obtain for many people in low-resource settings. This can be due to stock shortages, out-of-pocket costs, difficulty accessing healthcare services, underfunded health systems, and low rates of diagnosis and follow-up care.
While cardiologists and diabetologists in high-resource settings debate treatment strategies, millions struggle with basic access. GLP-1 therapy can increase treatment costs 22-fold, raising the question of how to scale treatment in low-resource settings. The solution must not only include innovation but also equity, ensuring that all people living with diabetes benefit from the progress.
The future of diabetes care lies in dismantling silos between disciplines, biomarkers and prevention and treatment
Rather than viewing the increased involvement of cardiologists in diabetes therapy as competition, the call was to embrace collaboration. Cardiologists have demonstrated that treating cardiovascular risk directly and early improves outcomes. . Diabetologists can adopt and adapt this model to serve their communities better.
A person with diabetes faces twice the risk of developing cardiovascular disease. As health systems confront this dual burden, coordinated care is no longer optional; it is essential.
The future of diabetes care lies in dismantling silos between disciplines, biomarkers and prevention and treatment. Glycaemic control remains vital, but it must be part of a broader, integrated approach that includes cardiovascular and kidney health from the outset.
From innovative risk calculators to updated treatment guidelines and renewed lifestyle strategies, the tools to transform outcomes are already here. What remains is the will to use them.
