[Editorial] Who owns cardiometabolic disease?

Who owns cardiometabolic disease? Article Info Publication History: Published July 25, 2026 DOI: 10.1016/S0140-6736(26)01497-2 External LinkAlso available on ScienceDirect External Link Copyright: © 2026 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies. Linked Articles - ArticlesMetabolic traits in obesity and normal BMI in industrialised countries: a multi-country analysis of national population-based studiesThe LancetJuly 1, 2026 - CommentConvergence of metabolic risk in obesity and normal BMI: does risk disappear?The LancetJuly 1, 2026 A person with obesity, type 2 diabetes, chronic kidney disease, metabolic dysfunction-associated steatotic liver disease, and heart failure might receive five different diagnoses, attend five different clinics, and be managed according to five different guidelines. But these conditions are not independent, they often accumulate along connected pathways shaped by adiposity, insulin resistance, inflammation, and vascular dysfunction. This shared trajectory is increasingly difficult to ignore, as the Lancet Series on cardiometabolic multiple long-term conditions shows. Given the advances in biological understanding and cross-cutting treatments, isn’t it time for a cohesive cardiometabolic medicine? Cardiometabolic conditions are becoming more common, leaving many patients on often complex (and sometimes conflicting) drug regimens. Fragmentation of care can mean repeated histories, duplicated monitoring, and competing priorities and advice that many patients must try to reconcile for themselves—with measurable costs. In one study in the USA, among adults with diabetes and chronic kidney disease, each 0·1-unit rise in an index of care fragmentation was associated with 15% more emergency department visits. Training has not kept pace: as the Series points out, newly qualified doctors report feeling ill-prepared to manage multiple long-term conditions. What no one owns becomes a burden for patients, clinicians, and services. The usual solution to such problems is better integrated care; however, integration alone is insufficient. Integrated care can align decisions and reduce duplication, but coordinating five specialists still leaves five specialists, each with a guideline, target, and budget. Multidisciplinary meetings can reconcile decisions once distinct diagnoses have been established, but they do not resolve the question of overall responsibility for the patient's wellbeing. Generalism is indispensable, but rapidly evolving treatments demand specialised knowledge. Systems can only improve what they are designed—and assigned—to manage, and the absence of a dedicated, more holistic, consideration of cardiometabolic health leaves many people at risk. An Article by the NCD Risk Factor Collaboration in this issue of The Lancet shows that older adults with obesity have increasingly attained similar blood pressure and non-HDL cholesterol levels to those without obesity, whereas younger adults retained adverse profiles. As the accompanying Comment notes, convergence in two mediators is not disappearance of risk. For older adults, measurements, thresholds, treatments, and established pathways exist, but young people are less often reached by short-term risk-based care pathways and their metabolic wellbeing is overlooked. There has been progress. The 2026 US multisociety guideline on cardiovascular–kidney–metabolic syndrome recognises connected biology, incorporates kidney and metabolic factors into cardiovascular risk estimates, and aligns recommendations across specialties. However, a distinct clinical discipline of cardiometabolic medicine would help bring together a coherent body of knowledge, competencies, and credentialled expertise. A patient identified in primary care with obesity, dysglycaemia, kidney dysfunction, or fatty liver disease could receive one connected assessment and one longitudinal plan. A cardiometabolic clinician or team could do more than convene specialists or route referrals: they would manage therapies that act across the cluster, monitor their combined effects, and reconcile competing organ-specific recommendations; cardiology, nephrology, hepatology, and obesity specialists would add expertise when required. They would also provide a point of responsibility and accountability for a patient's overall cardiometabolic care—ownership, not just better coordination. Such an approach has precedents. For example, geriatric medicine organises specialist expertise around a complex patient and connected trajectory rather than a single organ. Establishing a new discipline carries risks: duplication, complication, territorialism, and the creation of another referral boundary. And it would entail changes from training bodies, primary care and specialist colleges, guideline developers, and health systems that should not be undertaken lightly. Clinical redesign, moreover, cannot substitute for action on the upstream drivers of obesity and metabolic disease. But so much more is now known about cardiometabolic disease—its shared biology, risk factors, prevention, management, and rising burden. This knowledge needs to prompt a reconsideration of how cardiometabolic disease is thought about and how care is organised accordingly. Most patients do not need another appointment; they need fewer, better-owned decisions.