Nov

Diabetes, Obesity and Cardiovascular Health

The incidence and mortality rates associated with cardiovascular disease are a growing concern. For patients also facing diabetes, heart disease is a serious threat. We can help patients with prediabetes and type 2 diabetes improve their risk factors for cardiovascular disease.

People who have diabetes are at greater risk for heart disease and stroke. The risk is even greater for people with diabetes who smoke, have high blood pressure, have a family history of heart disease, or are overweight.

Definitions and risks
How do we define “overweight” in an era of skyrocketing obesity and the sensitive nature of discussing weight? While any BMI of 25 or above is consistent with overweight or obesity, this may not appropriately identify all individuals with increased health risks. Women who are postmenopausal and/or people of Asian ethnicity may underestimate risks at lower BMI’s, and muscular individuals may have lower risks despite higher BMI’s. Therefore, adding a simple waist measurement into the assessment is useful. A waistline of more than 35 inches in women and 40 inches in men is a marker for worsening cardiometabolic health.

Several studies have demonstrated that diabetes is more strongly associated with cardiovascular risk in women than it is in men. The underlying causes for the diabetes-related sex difference in cardiovascular risk are still unclear. Although roles of sex hormones and menopause have been hypothesized, sex differences in diabetes-associated cardiovascular risk factors are mainly believed to be responsible for this increased risk. Current evidence indicates that there is room for improvement of cardiovascular risk factor control in women with diabetes.

Lifestyle interventions
We family physicians know that many pharmacological interventions are available available such as antihypertensive, anticoagulation and antiarrhythmic medications. I’m going to focus on lifestyle interventions as your first option.

Treating diabetes by treating obesity is the most effective first step in improving cardiovascular risk factors. Imagine how gratifying it is to tell someone that their sugars are so much better, they can cut back on medications to treat diabetes or stop taking insulin! As patients make better lifestyle choices, they take control of their diabetes and they see improvement, including weight loss. Healthy weight loss also improves cardiovascular risk factors. It reduces high blood pressure, waist circumference, lowers the A1C, TGA, TC:HDL, TGA:HDL, and increases HDL. In fact, healthy weight loss can treat and prevent sleep apnea, osteoarthritis, and reduce the risk of many cancers.

So, where do we start?
We now know that type 2 diabetes can be treated and often put into remission with weight loss and lifestyle choices. Dietary adjustments can improve insulin sensitivity and lead to healthy weight loss that in turn, improves diabetes control.

Intensive programs

The best evidence for achieving successful lifestyle changes comes from intensive intervention programs. Lifestyle change is hard, and it is reasonable that patients might need more intensive help to achieve long-term success. That said, family physicians often play a significant role in patient’s lifestyle change journey, and a specific recommendation from a trusted doctor can make a substantial difference. Not all patients can access intensive programs, and not all are interested in them. Family physicians need a large and varied toolbox for counseling for lifestyle changes.

Nutrition and exercise
Health coaches, registered dietitians or medically supervised weight management programs can help your patients with appropriate diets and exercise plans. For patients on Medicare, nutrition counseling with a registered dietitian is a covered benefit which is currently underutilized. Let’s get those older patients directly connected to help with their nutrition management.
Exercise is the best - and most cost-effective prescription we can give to our patients. Exercise improves insulin sensitivity, blood pressure, triglycerides and HDL cholesterol, weight loss and boosts longevity. When food intake is optimized, the body is properly fueled and in return, the human body actually wants to move!

Walking, biking and jogging are great in good weather, but during those Midwestern winters? What about ballroom dancing, line dancing or square dancing? Suggest patients download and use a workout app (examples Samsung Health, Apple Health, Map My Run- which can be used for any kind of workout – view a list here ) or use good old exercise DVDs. There are many options that can be done at home and only require a few minutes of time and proper shoes.

Rest for recovery
Sleep heals and repairs the body. Adequate sleep (at least seven hours per night) improves glycemic control, blood pressure and well-being. Glucose tolerance and insulin sensitivity improve, and cortisol levels come down.

Role of bariatric surgery
If the patient’s BMI is 40 or greater, or 35 or greater and the patient has obesity-related medical conditions like diabetes, but diet and exercise recommendations haven’t worked so far, consider referring a patient for consultation for bariatric surgery. Bariatric surgery is not the right choice for all patients, but it is the most effective method of weight loss for patients with obesity and obesity-related medical conditions. More than 80% of patients in one study who underwent bariatric surgery experienced remission of their type 2 diabetes following surgery. Patients who have bariatric surgery experience a reduction in mortality of about 30% compared with those who do not have surgery. The process of pursuing bariatric surgery typically includes a team-based evaluation of the patient’s motivations, ability to adapt to long-term changes in diet, and overall health. The preop period is usually months and a year or more is not uncommon.

Be sure to address the universal risk factor: Tobacco use
For people who currently smoke, connect them to the Illinois QuitLine at 866-QUIT-YES. Visit their website at www.quityes.org and enroll as a Quitline referral partner. The quitline counselors can take it from there and connect your patient with up to six weeks of nicotine replacement therapy and local cessation programs.

These simple changes can greatly improve overall health, cut the risk of cardiovascular disease and reverse the impact of type two diabetes. Check out all the links and resources for each of these topics on the Dialed in on Diabetes website at www.iafp.com/DID