Controlling Risk When You Have Diabetes
Type 2 diabetes mellitus, more commonly referred to as “diabetes,” occurs when our bodies fail to use blood sugar (glucose) effectively. This can happen because either the pancreas doesn’t produce insulin or our bodies don’t use it very well. Insulin is a hormone that helps our cells take up glucose.
We don’t know what causes diabetes. We do know that obesity/overweight and physical inactivity increase the riskof it. We also know that an estimated 21.1 million adults in the United States have been diagnosed with diabetes. It’s estimated that another 8.1 million adults have it but aren’t diagnosed. More than 80 million adults are estimated to have prediabetes, which often leads to diabetes.
Type 2 diabetes is the most common form, accounting for 90-95 percent of diagnosed cases in the United States. Cardiovascular disease (CVD) is the most common cause of death among adults with diabetes. In Type 2 diabetes, the body may develop “insulin resistance” which is when the body is unable to make efficient use of the insulin it makes, and the pancreas gradually loses its ability to produce insulin.
The risk of CVD for people with diabetes is two-fold that of people without it. In 1999 and 2007, the American Heart Association and the American Diabetes Association (ADA) published statements focused on preventing CVD in diabetes patients. Since then, there have been changes in how doctors help patients manage their CVD risk, and in 2015 the AHA and ADA issued a new scientific statement.
Another Way to Diagnose
Historically diabetes was diagnosed with screenings for fasting glucose (above 126 mg/dL) or 2-hour glucose (above 200 mg/dL). These tests are still considered valid. But in 2010, the ADA included glycated hemoglobin (A1c) among the tests recommended for the diagnosis of diabetes and prediabetes.
According to the National Institute of Diabetes and Digestive and Kidney Diseases, “the A1c test is based on the attachment of glucose to hemoglobin, the protein in red blood cells that carries oxygen. In the body, red blood cells are constantly forming and dying, but typically they live for about three months. The A1c test reflects the average of a person’s blood glucose levels over the past three months.The A1c test result is reported as a percentage. The higher the percentage, the higher a person’s blood glucose levels have been.” ADA’s clinical practice guidelines state that an A1c value above 6.5 percent is considered diabetic. The higher the A1c number, the greater the risk of CVD. In a large, multiethnic study, for every 18 mg/dL increase in fasting glucose, there is a 17 percent increase in risk of future CVD events or death.
Helping People with Type 2 Diabetes Control CVD Risk
Live Your Best Lifestyle
Lifestyle factors are a key to managing CVD risk in those with diabetes. Proper nutrition, physical activity and weight management are the basics, as usual.
The types of exercise may be as important as the amount of exercise in diabetes. A recent randomized, controlled trial of 262 sedentary people with diabetes demonstrated that those who followed a program that combined resistance and aerobic training achieved lower A1c levels than others who either didn’t exercise, did only resistance training or only aerobic training.
A 2001-2012 study called Look AHEAD (Action for Health in Diabetes) compared the weight loss success of two groups, each with over 2,500 participants. The first was a control group receiving the usual care. The other group participated in an intensive lifestyle intervention program that included:
- A weekly goal of moderately intense activity that started at 50 minutes per week and gradually increased to 175 or more minutes per week by week 26.
- A focus on lifestyle activity, like using the stairs instead of elevators or walking instead of riding.
- Participants getting a pedometer in week seven and being instructed to increase their daily steps by 250 each week until they reached the goal of at least 10,000 steps a day.
At one year, the intervention group had an 8.6 percent weight loss over the control group’s 0.7 percent. By the end of the multi-year study, they were still more successful, having achieved a 6 percent weight loss over the control group’s 3.5 percent. But weight loss wasn’t the only win. Their physical fitness had improved as had their HDL (good) cholesterol levels, their A1c levels and waist circumference. In addition, they required less medication for control of glucose, blood pressure and cholesterol.
The current dietary recommendations for people with Type 2 diabetes mellitus focus on a dietary pattern that emphasizes fruits and vegetables, low-fat dairy and reduced saturated fat. This type of pattern can be modified to fit an individual’s calorie, carbohydrate, and medical nutritional therapy needs. There is evidence that the DASH, Mediterranean, low-fat or modified carbohydrates diets were effective in controlling blood sugar and lowering CVD risk. People with diabetes often have trouble with higher triglycerides (fats in the blood) and lower HDL (good) cholesterol, but some lifestyle changes (such as moderate alcohol intake, eat less saturated and trans fats, eat less added sugar, as well as being regularly physically active and losing excess weight) can help reduce triglycerides.
Practicing the dietary and physical activity recommendations above is the first way to go about trying to achieve a healthy weight. Restricting calories and increasing daily physical activity, including regular aerobic activity three to five days a week, are practical and proven steps to losing pounds. There is also evidence that self-monitoring by weighing more often is associated with better weight loss and maintenance.
But for some, other strategies may be needed. When lifestyle changes don’t result in meeting desired goals, a person with diabetes and their doctor may want to consider alternatives, including medications or surgery. A BMI of 30 kg/m2 or more (or 25-30 if the person is managing another condition) may indicate that weight loss medications could be tried.
When weight loss medications are prescribed, it’s important for the patient to know about the drugs and their side effects. Patients should also receive lifestyle support along with the prescription. Patients should be re-evaluated after three months, and if they have not lost 5 percent of their body weight, a new plan should be tried.
In cases of severe obesity, weight loss surgery, also called bariatric or metabolic surgery, should be considered. New guidelines from the AHA, the American College of Cardiology and The Obesity Society recommend any diabetes patient with a BMI over 35 who is motivated to lose weight should be considered for referral to a bariatric surgeon.
High blood pressure is a major concern for diabetes patients and increases the risk of heart attack, stroke, heart failure, and kidney damage. Following the lifestyle recommendations for nutrition and physical activity may help keep blood pressure under control. The American Heart Association recommends people aim to eat no more than 1,500 milligrams of sodium per day. That level is associated with a significant reduction in blood pressure, which in turn reduces the risk of heart disease and stroke. Because the average American’s sodium intake is so excessive, even cutting back to no more than 2,400 milligrams a day will significantly improve blood pressure and heart health.
Lowering LDL (bad) cholesterol decreases CVD risk in diabetes patients. People with diabetes should have their cholesterol checked at least once a year. Lifestyle changes — eating less saturated and trans fat, losing weight, eating more dietary fiber and being active — are recommended. These lifestyle changes, especially weight reduction, have been shown to improve most components of the cholesterol profile in diabetes patients.
Patients between 40 and 75 years of age with diabetes and LDL-C levels between 70 and 189 mg/dL are most likely to benefit by taking a statin.
There have been significant improvements in CVD risk factors in the general population, and that improvement has also occurred in people with diabetes. However, people with diabetes are still at higher risk of CVD so it’s important to understand the risks and do everything in one’s power to manage them.