Diabetes is such a potent risk factor for heart disease that it is often called a heart disease risk equivalent. By that, we mean that a person with diabetes with no previous history of coronary heart disease has a future risk of a heart attack or other cardiovascular event similar to a person without diabetes who has already been diagnosed with coronary heart disease.
Why is the risk so high? No one knows all the reasons. Some of it is related to elevated blood glucose (sugar), which is the defining characteristic of diabetes. But patients with diabetes also have abnormal processing of other foods, like lipids (fats) and protein. They tend to have higher triglycerides and lower HDL (good) cholesterol. And their LDL particles tend to be smaller and denser, making them more atherogenic (the tendency to cause plaque development in arteries).
Furthermore, diabetics are more likely to have central (rather than peripheral) obesity, which makes the fat tissue more pathologic to the body. And they tend to have greater degrees of inflammation, which is known to play a role in the development of atherosclerosis and acute coronary syndromes (acute cardiac events like unstable angina and heart attacks). There are certainly other, less well-described, aspects of diabetes that contribute to its dangers.
These ill effects of diabetes not only affect the heart, but can cause dysfunction of the kidneys, the brain, the nerves and the gastrointestinal tract, just to name a few organ systems. So, controlling or preventing diabetes is crucial to your health. Prevention can take the form of maintaining optimal body weight, exercising regularly and eating a healthy diet, one that avoids excess carbohydrates (starches and sugars). In particular, strive to get your starches and sugars in the form of complex carbohydrates, foods that have a low glycemic index—a lower tendency for that food to quickly drive up your glucose levels.
Treatment involves all the prevention above, as well as the utilization of medication that can control glucose. There are many types of medication, but the ones that have the best track record for preventing the cardiovascular complications of diabetes are metformin, and the categories of drugs called SGLT2 inhibitors (including the drugs Invokana®, Jardiance®, and Farxiga®) and GLP-1 agonists (including the drugs Victoza® and Byetta®). Some diabetic patients require subcutaneous insulin to control their blood sugar levels.
And, one more thing—we now know that diabetes is at the far end of a continuum of glucose intolerance, which is categorized by hemoglobin A1C (abbreviated Hgb A1C) levels. People can have normal handling of glucose (Hgb A1C < 5.7), pre-diabetes (Hgb A1C 5.7-6.4), or frank diabetes (Hgb A1C ≥ 6.5). The higher the Hgb A1C, the worse the diabetes is. So, if you haven’t had yours checked lately, ask your physician to order a Hgb A1C blood test so you know what your tendency to diabetes is. And eat healthfully, keep your weight down and exercise!
Greg Koshkarian, MD, FACC