Written by: Jon Vredenburg, MBA, RD, CDE, CSSD, LD/N
Individuals with diabetes are often educated that they are at an increased risk for heart disease. The numbers certainly support that claim as it is the leading cause of morbidity and mortality among people with diabetes. People with diabetes also develop heart disease at a much earlier age than others. A careful understanding of the etiology as it relates to blood sugar control and arterial plaque formation, along with prioritizing the risk factors can enable diabetes care and education specialists to provide more effective messaging.
Diabetes is influential in promoting cardiovascular events in ways that are just beginning to be understood. While the gradual obstruction of the blood vessels certainly plays a role, with insulin resistance there is also an enhanced formation of clotting factors that can trigger heart attacks and stroke. Post-prandial hyperglycemia is also correlated with cardiovascular risk based on epidemiological data. The results of recent intervention studies have suggested that postprandial spikes in blood sugar may be just more important to assess than average or fasting blood glucose.
The mechanisms of tissue damage that stem from chronic hyperglycemia are in part due to advanced glycation end products, or AGEs. This group of compounds forms at an accelerated rate when blood sugar levels are increased. AGEs affect almost every type of cell in the body. Among their impacts, is a change in structure and function of both high and low-density lipoproteins, also known as HDL and LDL. Glycosylated LDL is more readily deposited into the blood vessel walls, which accelerates plaque formation. In addition, when HDL succumbs to the effects of AGEs it is no longer able to move cholesterol out of the blood vessels which further minimizes the protective effects of HDL. The primary means to reduce the formation of these problematic AGEs is quite simply, better glycemic control.
Control of blood glucose, along with blood pressure and blood lipids are critical to the prevention of cardiovascular disease. Outside of smoking cessation, management of these factors provides the great potential for long-term benefit. Patients should be monitored at least on an annual basis for these risk factors, in addition to their weight status and overall medical history.
It is critical to engage patients in understanding their role in managing their health, which is where education provided at various points across the patient’s experience through diagnosis and ongoing management can be critical to helping them manage critical areas from blood pressure to cholesterol as well as impacting their risk factors. According to the 2020 Standards of Medical Care in Diabetes, blood pressure should be treated to a minimum target of <140/90 mmHg. Anything less than that target, if it can be achieved safely, is also encouraged. Lipid management should focus on reducing LDL and triglycerides, while boosting HDL.
Numeric targets for each value should be individualized, along with decision to implement statin therapy, but lower-risk targets include an LDL of less than 100 mg/dL, triglycerides less than 150 mg/dL and an HDL greater than 50 mg/dL. Along with lifestyle therapy to reduce weight and boost physical activity, the 2020 Standards advocate liberal use of statins including moderate doses for persons aged 40-75 even without cardiovascular disease.
Standards of Medical Care in Diabetes, Diabetes Care, January 2020.
The Art and Science of Diabetes Self-Management Education Desk Reference, 4th Ed.