Medicine Just Caught Up…
… to something I’ve been watching for 25 years.
by Dr. Chuck Svendsen
A new national guideline finally treats heart, kidney, and metabolic disease as one problem. Here is why that matters, and the one place I think it still falls short.
My 25 years as a bariatric surgeon gave me a ringside seat to watch metabolic dysfunction at every stage. And it taught me one thing above all else: the dysfunction comes first, and the chronic diseases follow. Heart disease, kidney disease, fatty liver, type 2 diabetes, and even a dozen different cancers are not separate problems that happen to show up in the same person. They are the same fire, breaking out in different rooms.
For a long time that was not how medicine was organized. Your heart was the cardiologist's job. Your kidneys belonged to the nephrologist. Your weight and your blood sugar were someone else's problem, usually in a 15-minute visit once a year. Different doors, different waiting rooms, different problem lists. The trouble is, your body never read that memo. It only has one set of plumbing.
This month, four of the largest medical organizations in the country did something they had never done before. The American Heart Association, the American College of Cardiology, the American Diabetes Association, and the American Society of Nephrology came together and published the first-ever guideline for what they are calling cardiovascular-kidney-metabolic syndrome, or CKM. In plain English, they finally put it in writing that the heart, the kidneys, and metabolism can suffer from one connected disease. I read it and thought, welcome. We saved you a seat.
Why this is genuinely good news
Naming the connection changes how we act, and that is worth celebrating.
Think of your body's fat storage like an overflow tank. When you take in more energy than you burn, your body does the sensible thing and stores it. That system works fine until the tank is full. Then the extra spills into places it does not belong: around your organs, into your liver, into your pancreas. That spillover is where the real trouble starts, and it is the quiet engine behind most of the chronic diseases that shorten lives.
The new guideline pushes doctors to catch that process early, before the heart attack, before the kidney failure, when it is still the most changeable. It sorts risk into stages, and here is the part I love most. The goal is not just to slow you down as you move through those stages. The goal is to reverse the process. Where you are today is not where you have to stay. I have watched real people reverse this disease across 25 years as a bariatric surgeon, and it never gets old.
It also, for the first time, gives a real endorsement to the GLP-1 medications for the right patients. These drugs have changed the conversation around obesity almost overnight, and that is a good thing. More awareness means more people finally getting help.
The one place I think it falls short
Now for the courageous conversation.
The guideline still leans on BMI – essentially your weight scaled for your height –- to measure obesity. The problem with BMI is that it does not tell you where you carry your weight, and that is a critical distinction. The guideline uses it because it’s simple, but it is a blunt instrument.
I will tell you what I actually care about, because it is not the number on the scale. I care about visceral fat, the fat packed deep around your organs. I care about your muscle mass, because muscle is what keeps you strong and independent as you age. And I care about the ratio between them. Two people can weigh exactly the same and be in completely different amounts of trouble. Someone can even have a perfectly normal BMI and still be carrying dangerous visceral fat. BMI never sees them coming.
There is a second reason this matters, and it is one people rarely hear. When you lose weight, especially quickly on a GLP-1, a large share of what you lose can be muscle. Up to 40% of the weight loss can actually be from muscle. Losing weight while quietly losing your strength is not the win it looks like on the scale. If no one is measuring, no one is protecting you from it.
How we do it differently at Astride
At Astride, I do not want to guess, so we do not.
For years, the DEXA scan, which is the best practical way to see visceral fat and muscle mass, was my pie-in-the-sky dream, the thing that should be done but was hard to do at scale. So we built the practice around actually doing i. Through our partnership with Human Powered Health, essentially every patient who is willing gets a DEXA scan. I will go one step further. I will not write a prescription for a GLP-1 until I have seen that scan.
Here is why I am that firm about it. You would never let a financial advisor invest your money without first seeing your full balance sheet. Prescribing a powerful medication without knowing what your body is actually made of is the same kind of gamble, and the stakes are your strength and your long-term health. The scan tells me where your fat is, how much muscle you have to protect, and exactly what we are aiming at. Then we build the plan around your real biology, we protect your muscle with the right protein and training while the medication does its job, and we track real progress as you move back down those stages.
The bottom line
The new guideline is a milestone, and I am genuinely glad to see it. It puts the full weight of mainstream medicine behind an idea I have watched play out for 25 years:, that heart, kidney, and metabolic health are one story, and that acting early, with the goal of reversing diseasemoving backward toward health, is the entire point.
I read it as the field catching up to where preventive, longevity-focused medicine already was. The next step is doing it precisely, measuring what actually matters, for every patient we can.
If you have ever been told your labs are "fine" but you sensed there was more to the story, that is exactly the conversation we want to have with you.
Guideline: 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (Circulation and JACC, June 2026). https://www.jacc.org/doi/10.1016/j.jacc.2026.03.056