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Maintain the Health of your Heart and Blood Vessels – Latest ADA Standards of Care

Published: 2/22/22
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By Hope Warshaw

Having diabetes puts you at risk for heart and blood vessels problems. Learn about the steps you can take, as recommended in the latest ADA Standards of Care to maintain the health of your heart and blood vessels.

Each year the American Diabetes Association (ADA) updates their Standards of Medical Care in Diabetes. These, so-called, Standards of Care or Standards are updated by the ADA’s Professional Practice Committee (PPC) with reviews of recent research and consults with subject matter experts. ADA publishes revised Standards each January as a supplement in their journal Diabetes Care as well as online. ADA also maintains “living Standards.” These interim updates are published as necessary based on new science, regulatory changes, new medication or technology approvals, etc.  

This series of articles translates the what’s and how to’s on diabetes complications based on the ADA Standards. Our goal at diaTribe is to help you be in the know so you may take actions to prevent or slow the progression of any and all complications as soon as possible. Research shows the central tenets to prevent diabetes complications are to keep your glucose levels, blood pressure and blood lipids in the recommended target ranges as much of the time as possible. Plus, get the regular recommended diabetes-specific exams, and, if a problem is detected, take the recommended actions to prevent or delay further progression and problems.

When people hear about diabetes complications, their first thought is often blindness, kidney failure and amputations. The truth is, problems related to the heart, blood vessels and circulatory system are the leading causes of diabetes-related illness, disability and/or death. In fact, the diagnosis of diabetes alone is considered a risk factor for these problems. If you identify and address your risk factors early and evolve how you manage problems over the years, you are far less likely to experience any major health consequences! Don’t delay. Take action today!  

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Maintaining Heart and Blood Vessel Health – An Overview

For years, all eyes in diabetes care were on glucose control. Today, especially for those with type 2 or older individuals with type 1, the management lens has widened to include equal attention on managing blood lipids and blood pressure. This is because we now have a deeper understanding of how diabetes progresses, in addition to newer medications and treatments to tackle these problems.   

As early as possible after being diagnosed with diabetes, identify your risk factors and take steps to reduce, or manage, them. Identify your risk factors with a thorough medical exam that includes relevant lab work. Based on these results, work with your healthcare provider to establish an appropriate care plan for healthy lifestyle changes, glucose and blood pressure lowering, and lipid medications, if necessary.

Make sure you know the glucose, blood pressure and lipid targets to aim for. Try your best. Be open and honest with your healthcare providers about what parts of your plan are working and what needs to change. Assess how your plan is working at regular intervals and evolve your plan with your healthcare provider as you need to continue meeting your targets.  

Statistics from two sources reveal a bleak reality regarding the numbers of people who reach the desired glucose, blood pressure and lipid targets, among others. The CDC reports that merely 1 in 4 U.S. adults with diagnosed diabetes met the target goals for A1C, blood pressure, and cholesterol, and were currently non-smokers. People who already have cardiovascular disease were even less likely to meet these goals.

Why is this data so grim despite the availability of effective and newer medications? First, your healthcare team may not move your care along as speedily as is advised in the recommendations. Second, the person with diabetes may not make the lifestyle changes and/or take prescribed medications as they are encouraged to. This may be for a host of reasons, including lack of access to health care, cost of medications, food insecurity, unwillingness to change unhealthy behaviors, just to name a few. 

Risk Factors for Diabetes-Related Heart and Blood Vessel Problems  

  • Having diabetes

  • High glucose levels (hyperglycemia, not within target range)

  • High blood pressure (hypertension)

  • Elevated blood lipids 

  • Smoking/Tobacco use 

  • Having excess weight or obesity (Body Mass Index >30), especially with increased weight circumference (weight around the abdomen or belly)

  • Insulin resistance that is exacerbated by inactivity, excess caloric intake and other risk factors 

Common Diabetes-Related Heart and Blood Vessel Problems 

Let’s define what’s actually referred to as Atherosclerotic (hardening of the arteries) Cardiovascular Disease (ASCVD). ASCVD begins with the laying down of deposits in the walls of arteries. These deposits include lipoproteins and fats that travel in the blood and form atherosclerotic plaque in the arteries around the heart. Cardiovascular events including heart attack and stroke tend to occur at a higher rate and at a younger age in people with diabetes.

  • Heart attack (known as myocardial infarction): Occurs when the flow of blood to the heart is blocked because a plaque deposit in an artery has ruptured and has formed a clot. This plaque travels to a coronary (heart) artery heart and causes a minor or major blockage. 

  • Stroke (known as a cerebrovascular event): Occurs when the flow of blood to the brain is blocked because a plaque deposit in an artery has ruptured and has formed a clot. This plaque travels to a part of the brain and causes a minor or major blockage.

  • Heart failure: Occurs when the heart (a muscle) cannot adequately pump blood. Blood then backs up in the heart, and fluid can build up in the lungs, causing shortness of breath or in the legs causing swelling (edema). Narrowed or blocked heart arteries or high blood pressure can leave the heart too weak or stiff to pump blood properly.  

  • Peripheral artery disease (PAD): Occurs when buildup of plaque on the walls of blood vessels causes them to narrow. Peripheral arteries carry blood away from the heart to the legs or arms. PAD is most often diagnosed when it causes pain with walking, numbness, or tingling in the legs and feet.

Note: You’ll see the terms “primary prevention” and “secondary prevention” used. Primary prevention refers to preventing an initial event, like a heart attack or stroke. Secondary prevention means to prevent a second or additional event. 

Essential Healthy Lifestyle and Self-care Behaviors

Actions to live a healthier lifestyle are the cornerstones of decreasing your risks of experiencing cardiovascular problems. It is important to continue practicing all these actions over time regardless of the medications prescribed: 

  • Weight management: If you carry excess weight, particularly in the abdomen area, try to lose 10 to 20 pounds and keep them off. This action can help you improve many heart and blood vessel disease risk factors. Weight loss through healthy eating, consuming fewer calories day to day, and more physical activity can lower blood pressure, improve abnormal blood lipids, and more. You may consider seeking assistance and support to accomplish this. 

  • Healthy eating: Making changes to your eating habits and food choices to eat fewer calories can be hard work. Think about these changes as tweaks to your current eating plan rather than a rigid “diet.” Make doable changes one step at a time and focus on choosing a wide variety of foods that are packed with nutrition rather than lots of fat, especially saturated fat, and added sugars. Research shows that two eating patterns are healthy for diabetes and risk factors for heart disease – the Mediterranean eating pattern or DASH – Dietary Approaches to Stop Hypertension. These eating plans have a lot in common and are also aligned with the ADA’s nutrition recommendations and the U.S. Dietary Guidelines. Here are the four commonalities:  

  • Emphasize consumption of non-starchy vegetables

  • Minimize consumption of added sugars and refined grains

  • Choose whole grains and other natural foods over highly processed foods

  • Replace sugar-sweetened beverages or juice with water 

  • Physical activity: It’s imperative to fit exercise into your healthy lifestyle to improve heart health. Generally, ADA recommends people get four types of physical activity:

  • Moderate to vigorous intensity aerobic activity: 150 minutes or more per week, over at least 3 days, preferably more, with no more than 2 consecutive days without activity. 

  • Resistance exercise: 2-3 sessions per week of at least 30 minutes on nonconsecutive days

  • Less sedentary activity: decrease time spent sitting. Get up every 30 minutes and at least walk around a few minutes. 

  • Flexibility and balance training: 2 to 3 times per week. 

  • Quit smoking: Smoking increases your risk of cardiovascular diseases and death. In people with type 2 diabetes, smoking worsens lipid levels, increases chronic inflammation, and worsens glucose management. You should be asked whether you use tobacco at every medical visit, consider it a vital sign. You should be encouraged to quit and if requested referred for assistance.  

  • Take your medications as prescribed: If you have trouble taking any of your medications due to their side effects, costs or other factors, discuss this with your healthcare providers. There may be alternatives. If you do not understand why you need the medication or believe the medicine will harm you, ask your healthcare providers.

To help you develop a diabetes self-care plan to make and maintain these lifestyle and healthcare behaviors and get support, request a referral to Diabetes Self-Management Education and Support as well as Medical Nutrition Therapy. Both are services covered by Medicare and many private health plans. This is the guidance from both ADA and AHA.

How to Hit Your Glucose, Blood Pressure and Blood Lipid Targets

To keep your heart and blood vessels healthy, ADA and AHA recommend you achieve and maintain glucose, blood pressure and blood lipid targets with the following guidance on each.

Glucose Management

Take a look at the targets for glucose management. Most people with type 2 diabetes over the years need an increasing number of glucose-lowering medications to keep glucose within their target. There are now two classes of glucose-lowering medications that also lower your risks of cardiovascular and kidney disease. One class is called GLP-1 receptor agonists. These medications stimulate insulin release and inhibit glucagon release in the pancreas. They also slow stomach emptying and in turn slow glucose absorption. GLP-1 receptor agonists also reduce the risk for cardiovascular diseases. 

The other class of medication, SGLT2- inhibitors, work by reducing the amount of glucose that is reabsorbed by the kidneys and increases the amount of glucose put out in the urine. Research shows this class of medication reduces hospitalizations for heart failure and reduces chronic kidney disease among people at high risk for heart disease and/or with existing heart disease. Discuss the use of one or both of these medications with your diabetes care providers based on your individual medical situation and other factors. 

Blood Pressure Management

People with diabetes are twice as likely to have high blood pressure compared to people without diabetes. Keeping your blood pressure under control reduces cardiovascular events, stroke, and heart failure (see definitions above). Your blood pressure should be taken at every visit with a health care provider. If you have high blood pressure, you should also monitor your blood pressure at home. How you and your healthcare providers manage your blood pressure depends on your individual situation and other cardiovascular disease risk factors as detailed below:

  • If your blood pressure is greater than 120/80 mmHg (but lower than 140/90 mmHg), put the healthy lifestyle and self-care behaviors (see above) into action. Also reduce the amount of sodium you consume and increase potassium intake from foods and beverages. Your target should be lower than 130/80 mmHg (if it can be safely attained). 

  • If your blood pressure is at or greater than 140/90 mmHg, add to the healthy lifestyle and self-care behaviors (see above), starting a blood pressure medication and working to achieve a target below 140/90 mmHg. 

There are several classes of blood pressure lowering medications. Two types of medications, ACE inhibitors (generic names of these medications typically end in “pril”) and ARBs (generic names of these medications typically end in “sartan”),  are recommended as best initial blood pressure medicine for people with diabetes. To adequately manage blood pressure to the goals noted above, some people will need to add another class or classes of blood pressure medication, such as a calcium channel blocker or diuretic. 

Blood Lipid Management

A large percent of people with diabetes have abnormal blood lipid levels. In type 2 diabetes, it is typical to have a lower than desirable HDL-C and a higher than desirable LDL-C and triglycerides. See target goals for these measures. Initial management of blood lipids should include the same healthy lifestyle and self-care behaviors detailed above. Improving glucose management also improves lipid levels. People with diabetes often need a statin medication (generic names of these medications end in “statin”). Statins aim to lower LDL-C. Having a low LDL-C protects the heart and blood vessels and decreases death from cardiovascular events. Statin medication should not be used in pregnancy.

How you and your healthcare providers manage your blood lipids depends on your age and other cardiovascular disease risk factors as detailed below. 

  • If you are between the ages of 40 to 75 and do not have heart and blood vessel disease, use a moderate-intensity statin medication. 

  • If you are between the ages 20 to 39 with heart and blood vessel disease risk factors, there is research to suggest you start taking a statin medication. 

  • If you are between the ages of 50 to 70 with multiple heart and blood vessel disease risk factors, research suggests you start a high-intensity statin medication. 

  • If you can’t tolerate statin medication or if a statin medication is not sufficient to hit your lipid level targets (particularly LDL-C), there is now another class of medication to use called PCSK9 inhibitors – though these tend to be more expensive medications. 

Here’s guidance on when and how often to get blood lipids checked. For starters, when you are diagnosed with diabetes and every five years thereafter if you are under 40 years old or more frequently if indicated. Also, get your blood lipids checked when you start taking a statin or other lipid-improving medication, then again 4 to 12 weeks after starting the medication, when there is a change in dose, and annually. 

How you and your healthcare providers manage your triglyceride levels depends on how high they are, and other cardiovascular disease risk factors as detailed below. 

  • If your triglycerides are moderately elevated (175 to 499 mg/dL) initially, focus on the same healthy lifestyle and self-care behaviors detailed above. As part of a healthy eating plan, limit sugar-sweetened beverages, refined sources of carbohydrate, and reduce alcohol consumption. In addition, get your glucose levels to target levels

  • If your LDL-C is under control taking a statin medication but your triglycerides are still elevated (135-499 mg/dL), consider with your healthcare provider the addition of a prescription level of omega 3- fatty acid, such as Vascepa or Lovaza. Research shows they can reduce cardiovascular events. 

  • If your triglycerides are greater than 500 mg/dL, your healthcare provider needs to evaluate the causes and determine the optimal approach.

Should You Take Aspirin?

Good question! The guidance on taking a low-dose aspirin each day has changed over the years. Aspirin is used to decrease blood clotting. At this time neither the ADA nor AHA recommendations encourage the use of low-dose aspirin as a primary prevention (see definition above) strategy. These organizations do state that aspirin use (75-162 mg/day) remains beneficial in reducing cardiovascular disease and death in people with diabetes as secondary prevention (see definition above).  

However, depending on your level of risk for heart disease, the risk of bleeding caused by aspirin may outweigh the benefits of taking the medication. Talk with your healthcare provider to fully evaluate the risks and benefits of taking aspirin.

In summary, you can see that there are many actions to take and medications to use to maintain your heart and blood vessel health. It can seem overwhelming. Work with your healthcare providers to consider your risk factors and actions you can take to reduce them. Remember, act early and don’t delay. 

Perspective from a Person with Diabetes

To gain insights into the practical and emotional aspects of preventing and managing diabetes-related heart and blood vessel diseases, we talked to Anna Norton, MS. Anna has had T1D for 28 years and is the Chief Executive Officer of DiabetesSisters. We realize that what Anna does to address these issues may not work for you. What’s most important is that you find what works for you. 

“Since my pregnancy 15 years ago, my healthcare providers, including my endocrinologist, have always discussed actions I can take to maintain a healthy cardiovascular system. While pregnant, I developed high blood pressure,” said Anna. “This put me on the road to needing medication to manage it to this day. I get my blood pressure check at every medical and dental appointment. Annually I have bloodwork to check my lipids levels.”

“I’m aware of the health effects of long-term high blood pressure, such as heart and kidney damage. Because of this, I faithfully take my medication, eat as healthy as possible, adjust my Cuban family’s recipes to be more heart healthy, and incorporate exercise into my daily routine. I try to manage stress by doing activities that are important to me, from reading, connecting with friends, and when possible, traveling.” 

“My endocrinologist and I also discuss the relationship between my glucose management, physical activity, lipid and blood pressure measures at nearly every appointment. Our approach is proactive and preventative. She assures me that when I reach the age of 50, she’ll refer me to a cardiologist as a preventive step. As a woman with diabetes, I know I’m at higher risk of heart disease than women without diabetes, so I appreciate her proactiveness.” 

To view other diaTribe articles about diabetes related complications

Note: The content and recommendations in this article reflect guidance from the American Diabetes Association and the American Heart Association.

Guidance and recommendations in this article are aimed at adults with type 1 and type 2 diabetes who are not-pregnant. While heart and blood vessel disease affect people with type 1 diabetes, there is far less research in this area on this population. This guidance is also not aimed at children and adolescents with diabetes. 

About the authors

Hope Warshaw, MMSc, RD, CDCES, BC-ADM, is a nationally recognized registered dietitian and certified diabetes care and education specialist. She has spent her career, now spanning more than 40 years,... Read the full bio »

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