Getting to the Heart of the Matter

In 1978, after prolonged hospitalization, my father died from consequences of diabetes associated with abnormal lipids and high blood pressure.

Ten years earlier, he had visited his primary care doctor with an A1C of 9%. He also had an LDL cholesterol level of 180 mg/dl (the goal set by the American Diabetes Association [ADA] is less than 100 mg/dl), low HDL cholesterol (the ADA goal is greater than 40 mg/dl) and a high blood pressure reading of 140/90 mmHg (the ADA goal is less than 130/80).

My father is not alone.

Eighty percent of people with diabetes will die from the complications of vascular disease such as heart attacks, congestive heart failure, strokes, leg artery insufficiency or kidney disease resulting from arterial disease.

The major cause of these problems is not high blood glucose. It is abnormal cholesterol and high blood pressure.

Both conditions, however, are entirely treatable.

LDL Cholesterol

LDL (“bad”) cholesterol is first made in the liver by combining fats (triglycerides, cholesterol) and a protein to make it soluble in blood.

Triglycerides are then shaved off this glyceride-rich molecule, eventually producing LDL cholesterol. LDL is taken up by your cells to make cell walls, by glands such as the adrenal and ovaries to make hormones and by the liver to be removed from circulation. When levels of LDL cholesterol are excessive, it is deposited in the arterial wall—a bad thing.

What Can I Do?

Reduce your intake of saturated fats (the fats found in dairy products, red meat, processed foods and, often, in restaurant food). Increase your intake of polyunsaturated or monounsaturated fats (most vegetable, olive and nut oils).

It’s also advisable to exercise on a regular basis, after a medical clearance from your doctor.

What Pills Can I Take?

You can now take medications that can nearly always help you reach the goal of lowering your LDL levels below 100 mg/dl. The new statin rosuvastatin (Cres-tor), for example, is more powerful than previous statins (which were pretty powerful themselves). Ezetimibe (Zetia), a different kind of medication, blocks the gut from absorbing cholesterol.

If you are hesitant to take these medicines because of possible side effects, you might want to do some math. Your chance of dying from a heart attack is 1 out of 2; your chance of dying because of a side effect is less than 1 out of 10,000. And remember that your doctor can help by carefully monitoring your liver enzyme levels and any signs of muscle pain.

Non-HDL Cholesterol

This lipid is the new “hot topic” in diabetes literature.

It is calculated by subtracting your HDL cholesterol from your total cholesterol value. For someone with diabetes, an abnormal level would be greater than 130 mg/dl. Non-HDL cholesterol is just as bad as LDL, and elevated levels of non-HDL are found more often than high LDL in people with diabetes.

Recall that the liver makes a glyceride-rich molecule, from which tri-glycerides are shaved. During this process, it produces many early forms of LDL that are not yet LDL cholesterol per se. These are also bad guys.

What Can I Do?

These fats respond to dietary change, exercise and weight loss. Correcting high blood glucose may restore the glycerides to normal.

What Pills Can I Take?

Besides pills for LDL cholesterol, other medications that primarily lower triglyerides may work. These include the fibrates (such as fenofibrate, or Tricor), nicotinic acid (for instance, Niaspan) and pioglitazone (Actos), or combinations of these medications.

Low HDL Cholesterol

Why should a low level of fat be considered harmful?

The HDL (“good”) cholesterol molecule is involved in “reverse cholesterol transport.” In other words, it takes cholesterol from the arteries and deposits it in the liver, where it is destroyed—a good thing.

What Can I Do?

Weight loss, exercise and nicotine withdrawal will increase your levels of HDL. Drinking alcohol in moderation also raises HDL cholesterol.

What is moderation?

In men, moderate drinking is defined as about two drinks a day and no more than 14 drinks a week; in women, it is one drink a day and no more than 7 drinks a week.

Remember that alcohol can cause hypoglycemia, impair your judgment and, for some individuals, elevate triglycerides.

What Pills Can I Take?

Fibrates such as Tricor may increase HDL cholesterol, but only slightly. Nicotinic acid does a nice job, but it can cause flushing, stomach upset and worsening of blood glucose control.

In addition, Actos and Avandia (rosiglitazone) can raise HDL cholesterol, although they may also lead to weight gain and edema (fluid retention).

Further, it is true that simply lowering LDL cholesterol with a statin may reverse the harm caused by low HDL cholesterol.

Blood Pressure

The top number in a blood pressure reading (the 130 of 130/80) is called the systolic blood pressure. It is the resulting pressure in the artery caused by the force of the heart’s contraction and by the ability of the arterial wall to absorb this pressure.

The bottom pressure (the 80 of 130/80) is called the diastolic blood pressure. It is the remaining pressure dependent on the blood draining out of the arteries into the veins.

Both are important. New studies report significant improvement in vascular disease among people with diabetes when blood pressure is adequately treated. In our clinic, we have set the following priorities:

  1. Get to the goal of less than 130/80 mmHg. Reaching this goal is more important than how you got there.
  2. Use angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in your treatment.
  3. Use small doses of diuretics—for example, 12.5 mg/day of hydro-chlorothiazide. These medications have few side effects (in particular, they do not cause excessive urination) and have a profound effect on lowering blood pressure.
  4. Before raising the dosage of a particular medication, try adding another.

What Can I Do?

First, you should know your numbers.

We recommend self-monitoring. For less than $100, you can buy a blood pressure cuff and check your own blood pressure. Always bring your cuff to your doctor’s office to check it against the office model.

Second, weight loss, exercise and dietary changes may help. The dietary changes include improving fat intake and reducing salt if you have been taking in too much.

What Pills Can I Take?

The newer medicines are potent and are not associated with the side effects some of the older ones have had. ACE inhibitors and ARBs are the mainstays for most doctors today because of their additional protective benefits for the arteries and kidneys. Hydrochlorothiazide and similar diuretics are often added to potentiate the angiotensin medications.

Although beta blockers can worsen insulin resistance and have other side effects, they have proven their worth in treating high blood pressure in patients who have also suffered a heart attack.

Parting Comments

Whatever treatment you and your doctor choose, do not forget these basic principles of diabetes care:

  • Awareness
  • Education
  • Self-empowerment

First, you need to know where you are. Your doctor should check your lipids and blood pressure, and you might want to measure your own blood pressure.

Second, you need to know what to do with this information. The education you receive from nurses, pharmacists, dietitians and especially certified diabetes educators is essential if you are to play this role as a caregiver for yourself.

Third, only you should make the final decisions about your care. Seek a physician who provides support for self-awareness, education referral and an environment in which you can make intelligent decisions about how to lower your risk of vascular disease

With so many excellent choices of treatments, do not choose the course my father had to take.

Leave a Reply

Your email address will not be published. Required fields are marked *

Time limit is exhausted. Please reload CAPTCHA.