Diabetes and Heart Disease (Published November 9, 2000)

Diabetes seems to be on the increase, probably unmasked by the booming economy and proliferation of fast food consumption. Diabetes has a strong genetic component, but can be greatly influenced by lifestyle, perhaps most readily measured by one's weight. Overweight is one of the most potent contributors to Type 2 diabetes, otherwise known as adult onset diabetes.

Most people know that diabetes is a disease of the body's metabolism. What people don't seem to know is that eighty percent of diabetics don't die of their blood sugars being out of control, but instead die of cardiovascular disease. Three quarters of those die of coronary artery disease, and one quarter die of peripheral arterial disease including strokes and loss of limbs.

This unfortunate situation is not inevitable. In the last several years, important clinical research work has focused on what can be done to positively change the outcome of those afflicted by diabetes. Surprising information has come out of this body of work and I would like to briefly summarize what has been uncovered.

The most important message is that controlling blood pressure and blood fats in diabetic patients seems to have more impact in saving lives and protecting quality of life than controlling blood sugars. Another finding was that doctors have been not been successful in getting diabetic patients properly managed. For example, according to the third National Health and Nutrition Examination Survey done in the U.S. from 1988 to 1994, 71% of diabetics have high blood pressure, but just 57% are being treated, and only 12% are actually controlled, defined as a BP of <130/<85 mm Hg. Also, 97% of diabetics have some blood fat abnormality, but only 32% are on cholesterol lowering medications.

Research from studies with such names as the Hypertension Optimal Treatment (HOT), Simvastatin Scandinavian Survival Study (4S), and Cholesterol and Recurrent Events (CARE) have shown doctors that getting blood pressures and cholesterol levels down even lower than previously thought desirable reduced cardiovascular complications significantly.

The United Kingdom Prospective Diabetes Study (UKPDS) was a landmark study suggesting that tight control of blood pressure and cholesterol afforded patients the best outlook. This is not to say that blood sugars can be forgotten, but that attention to other risk factors may play an even more important role in ameliorating the common cardiovascular complications of diabetes.

But it gets better. A large clinical trial was reported early this year called the Heart Outcomes and Prevention Evaluation (HOPE). In patients felt to be at high risk for developing progressive cardiovascular disease, a drug belonging to the class of medications known as ACE inhibitors showed about a 30% reduced risk of developing diabetes compared to those who did not get the medication. This striking finding suggests that we may be able to refine our therapies to prevent the disease from developing, and not just to treat it once it has declared itself.

But don't forget that exercise and not being overweight by eating right and in correct portion sizes are perhaps the best preventive strategies one can do without seeing their doctors. Even if medications are prescribed and adjusted to get the patients to the new and lower levels suggested by the recent research, lifestyle still plays a huge role in determining the eventual outcome.


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