Cardiometabolic disease increasingly challenges conventional boundaries between endocrinology, cardiology and nephrology. Clinical care is moving beyond the management of isolated downstream markers towards earlier recognition of shared drivers, including visceral adiposity, and more integrated treatment across obesity, dysglycaemia, cardiovascular risk and kidney disease.
Newer therapies are also reshaping expectations in obesity and type 2 diabetes, with treatment goals extending beyond glycaemic control or weight loss alone to encompass organ protection, complication reduction and, for some patients, remission.
Against this background, Dr May discusses how clinicians can identify risk sooner, intervene more proactively and apply evolving evidence in ways that remain practical for individual patients.
In the first instalment of Specialist Forum’s new Q&A series, endocrinologist Dr Wayne May discusses earlier cardiometabolic risk recognition, advances in obesity treatment, cardiorenal protection and the importance of patient-centred care. Readers can look forward to further conversations with specialists in future issues.
Dr Wayne May is a UCT graduate and specialist endocrinologist in full-time private practice at Kingsbury Hospital, Cape Town. He practises at the multidisciplinary Diabetes Life Clinic and has a longstanding interest in obesity and metabolic medicine. He helped establish the Cape Town Bariatric Clinic in 2005, holds International SCOPE Certification in obesity management, is a director of the South African Metabolic Medicine and Surgical Society, and co-chaired South Africa’s first adult obesity management guideline, published in 2025.
Cardiometabolic risk: Are we intervening too late?
Q
Endocrinology and cardiology increasingly overlap in everyday practice. What do you think clinicians still tend to underestimate about the relationship between metabolic disease and cardiovascular risk?
A: We now recognise a close relationship between metabolic disease and cardiovascular disease, with excess visceral adiposity playing a major role in driving cardiometabolic risk. Although this relationship has been understood for some time, only recently has it been incorporated more explicitly into treatment frameworks, including the American Heart Association CKM Guideline and the Obesity Medicine Association’s statement on obesity and cardiovascular disease.
Despite this, clinicians still tend to focus on traditional downstream risk factors (HbA1c, blood pressure and LDL cholesterol) rather than identifying the metabolic disease that precedes them.
As a result, intervention often occurs only once diabetes, hypertension or cardiovascular disease has developed. We need to look earlier for visceral adiposity and associated abnormalities such as prediabetes, elevated blood pressure, hypertriglyceridaemia, low HDL cholesterol and fatty liver disease. The opportunity is to treat cardiometabolic risk upstream, rather than simply managing its complications once they appear. We need to become more proactive and less reactive.
Q
Obesity management has changed considerably in recent years, particularly with newer pharmacological options attracting enormous attention. What do you see as the biggest opportunity (and the biggest misconception) in the way we are approaching obesity today?
A: After many years of frustrating and relatively ineffective treatment options, the biggest opportunity is that we now have medications that can fundamentally improve the management of people living with obesity. They achieve substantial weight loss, improve weight-related complications and, importantly, target one of the key biological drivers of obesity, a dysregulated appetite, which helps explain their effectiveness.
The biggest misconception is that obesity management is still primarily about weight loss. The real objective should be improvement or resolution of obesity-related complications and reduction in future health risk. There is also still a tendency to view treatment as temporary, something that can be stopped once a target weight is reached. Obesity is a chronic, relapsing disease, and for treatment to be effective, it will require long-term use.
Q
In patients with type 2 diabetes, the conversation has moved beyond glucose control alone towards protecting the heart, kidneys and overall metabolic health. How has this changed the way you approach treatment in your own practice?
A: Over the years, our approach to diabetes has moved from being glucose-centric to cardio-renal focused, and increasingly towards weight and overall metabolic health. Newer therapies such as GLP-1 receptor agonists, dual GIP/GLP-1 receptor agonists and SGLT2 inhibitors allow us to achieve glucose control while also reducing cardiovascular and kidney risk, promoting weight loss and improving other weight-related complications such as MASLD.
More excitingly, substantial weight loss now allows us to aim for diabetes remission in some people with recently diagnosed type 2 diabetes. We are also increasingly able to intervene during prediabetes and potentially prevent or substantially delay progression to diabetes. That may ultimately provide the greatest benefit by preventing complications before they develop. My own approach is therefore becoming increasingly proactive and preventative, rather than simply waiting for established disease.
Q
What is one metabolic or endocrine warning sign that you wish healthcare professionals and perhaps patients themselves would take more seriously before complications develop?
A: Earlier we mentioned that visceral adiposity is an upstream driver of cardiometabolic disease, and I think this is an area where both patients and healthcare professionals can identify risk much earlier. Traditionally, we have relied heavily on BMI, but BMI does not tell us where excess fat is stored. Simple measures such as waist circumference, and particularly the waist-to-height ratio, can provide useful information about central adiposity and cardiometabolic risk. Waist-to-height ratio is especially practical because it is less dependent on sex and ethnicity than waist circumference. A ratio of 0.5 or above should raise concern. Identifying this early gives us an opportunity to intervene before diabetes, cardiovascular disease and other metabolic complications develop.
Q
After years of treating patients with complex endocrine conditions, what has clinical practice taught you that textbooks and guidelines cannot?
A: Textbooks and guidelines give us excellent advice for situations where the evidence is clear, and treatment choices have been tested in clinical trials. The reality, however, is that many patients do not fit neatly into guideline protocols. They arrive with unique combinations of disease, symptoms, priorities, concerns and practical limitations that require a more individualised approach.
Clinical trials also operate within fairly rigid protocols, whereas real-world patients often need greater flexibility. Over the years, I have learnt that listening carefully to what matters most to the patient is often as important as knowing the guideline. The best treatment is not simply the one recommended on paper, but the one that is evidence-based, appropriate for that individual, and realistic enough for them to follow long term.
