HJNO Mar/Apr 2024

central adiposity, which is the most toxic and in- flammatory type of adipose tissue. Then, longi- tudinally over time and remotely across a large swath of a given population, digital data can be collected through a Bluetooth or cellularly en- abled scale, along with measured waist circum- ference, to detect for the emergence of CKM risk factors. Once a risk factor is identified, it in- dicates progression to stage 1 and the need for a fasting glucose assessment and/or a hemo- globin A1c assessment to identify prediabetes. My own health system has already designed a digital prediabetes solution that is meant to target this stage preemptively and uses a care- fully balanced combination of digitally enabled, human-centered interactions to cultivate a con- tinuous, connected relationship with our pa- tients. At this point, therapeutic intervention is targeted at achieving at least a 5% reduction in weight to facilitate regression back to stage 0. At stage 1, it is also imperative to identify other cardiovascular risk factors such as to- bacco, blood pressure, and lipids. As discussed in our part three article on lipids, a rising tri- glyceride-to-HDL ratio is correlated with insulin resistance, which in turn is often correlated with excess adiposity. If blood pressure is elevated consistently enough to warrant a diagnosis with hypertension, then it can be managed digitally according to well-designed clinical pathway that will ensure >90% of those patients will have their blood pressure controlled. If to- bacco use disorder is identified, then referral to smoking cessation programs and/or behavioral therapeutic interventions can be deployed to assist with cessation. And so far, none of these upstream interventions requires the traditional, often reactive, episodic encounters of fee- for-service medicine, but rather is delivered through digitally enabled, human-powered, relationship-based proactive interventions. Stage 2 of CKM syndrome is recognized when metabolic factors are present in addi- tion to moderate- to high-risk CKD, as defined by estimated glomerular filtration rate (eGFR) < 60 mL/min (via a simple lab test) and/or the presence of albuminuria (a type of protein that can spill into the urine when the functional unit of the kidney is damaged and that can be as- sessed via a simple urine test). Staging of CKD is in turn guided by the Kidney Disease Improv- ing Global Outcomes (KDIGO) heat map, de- picted in figure 1. CKD will be part nine in the next article of this series, but for now, suffice Figure 1: Kidney Disease Improving Global Outcomes (KDIGO) heat map