Diabetes and cholesterol management -
Type 2 diabetes usually is not diagnosed until complications develop, and approximately one third of all persons with diabetes may be undiagnosed. Screening to detect prediabetes should be considered in persons 45 years and older, particularly in persons with a body mass index BMI of at least 25 kg per m 2.
Screening also should be considered in persons who are younger than 45 years if they are overweight and have an additional risk factor Table 1.
Screening for prediabetes and diabetes should be performed in high-risk, asymptomatic children Table 2 and adults. If test results are normal, repeat testing should be performed at three-year intervals in adults and at two-year intervals in children.
The two-hour oral glucose tolerance test OGTT identifies persons with impaired glucose tolerance levels, and thus, more persons who are at increased risk for developing diabetes and cardiovascular disease.
Although the effectiveness of interventions for primary prevention of type 2 diabetes has been proven in persons with impaired glucose tolerance, data for persons with impaired fasting glucose levels who do not also have impaired glucose tolerance are not available.
The fasting plasma glucose test is more convenient for patients, more reproducible, less costly, and easier to administer than the two-hour OGTT; therefore, the fasting plasma glucose test is recommended as the initial screening test for nonpregnant adults.
Once a patient has been diagnosed with diabetes, a complete medical evaluation should be performed to classify the patient, detect any complications, formulate a management plan, and provide a basis for continuing care. The management plan should recognize that diabetes self-management education is an integral component of care.
Glycemic control is best judged by the combination of results of blood glucose self-monitoring and A1C testing. Blood glucose self-monitoring allows patients to evaluate their individual response to therapy and assess whether glycemic targets are being achieved.
Patients taking multiple insulin injections should perform blood glucose self-monitoring at least three times daily to monitor for and prevent asymptomatic hypo- and hyperglycemia.
Patients who take less frequent injections and those who take oral agents or use nutrition therapy should monitor their blood glucose levels to help achieve glycemic goals.
To assess treatment effectiveness, the A1C test should be performed at least twice per year in patients who are meeting treatment goals and who have stable glycemic control.
Patients whose therapy has changed and those who are not meeting treatment goals should be tested quarterly. Conditions that affect erythrocyte turnover e.
Blood pressure should be measured at every routine visit. Patients with systolic blood pressure of at least mm Hg or diastolic blood pressure of at least 80 mm Hg should have blood pressure confirmed on a separate day.
Patients with hypertension i. Multiple agents generally are required to achieve blood pressure targets. Patients with a systolic blood pressure of to mm Hg or a diastolic blood pressure of 80 to 89 mm Hg should receive lifestyle and behavioral therapy alone for a maximum of three months; if targets are not achieved, they should be treated with pharmacologic agents that block the renin-angiotensin system.
Patients with diabetes and hypertension should be treated with a regimen that includes either an ACE inhibitor or an ARB. If one class is not tolerated, the other should be substituted. A thiazide diuretic may be added if needed to achieve blood pressure targets.
Adult patients should be tested for lipid disorders at least annually. In adults with low-risk lipid values, assessments may be repeated every two years.
Lifestyle modification focusing on the reduction of saturated fat and cholesterol intake, weight loss if indicated , and increased physical activity has been shown to improve the lipid profile in patients with diabetes.
In persons without overt cardiovascular disease, the primary goal is a low-density lipoprotein LDL cholesterol level of less than mg per dL 2. For persons older than 40 years, statin therapy to achieve an LDL reduction of 30 to 40 percent, regardless of baseline LDL levels, is recommended.
Persons younger than 40 years but at increased risk because of other cardiovascular risk factors who do not achieve lipid goals with lifestyle modifications alone should receive pharmacologic therapy. All patients with overt cardiovascular disease should be treated with a statin to achieve an LDL reduction of 30 to 40 percent.
A lower LDL cholesterol goal of 70 mg per dL 1. Triglyceride levels should be less than mg per dL 1. Combination therapy using statins and other lipid-lowering agents may be necessary to achieve lipid targets but has not been evaluated in outcomes studies for cardiovascular event reduction or safety.
Persons with diabetes should receive individualized medical nutrition therapy to achieve treatment goals. Prevention and treatment of chronic complications of diabetes can be achieved by attaining optimal blood glucose, A1C, LDL, HDL, and triglyceride levels, and optimal blood pressure and body weight Table 3.
Because of the complexity of nutrition issues, a registered dietitian who is skilled in implementing nutrition therapy in patients with diabetes should be part of the medical team.
Monitoring total grams of carbohydrate, whether by use of exchanges or carbohydrate counting, is a key strategy in achieving glycemic control. The use of the glycemic index may provide additional benefit. Low-carbohydrate diets i.
To reduce the risk of nephropathy, protein intake should be limited to 0. Saturated fat intake should be limited to less than 7 percent of total calories, and intake of trans fat should be minimized. Nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels established by the U.
Food and Drug Administration. Alcohol intake should be limited to one drink per day for women and two drinks per day for men. Routine antioxidant supplementation is not advised because of concerns about effectiveness and long-term safety.
Chromium supplementation has not been proven to benefit patients with diabetes and is not recommended. Overweight and obesity are strongly linked to the development of type 2 diabetes and can complicate its management. Obesity also is an independent risk factor for hypertension, dyslipidemia, and cardiovascular disease, which is the major cause of death in persons with diabetes.
However, this is an oversimplification as significant differences in terms of cardiovascular risk exist within diabetic populations, and clinical judgment should always be applied.
However, no specific target levels for HDL were established in the guidelines. The aim of dyslipidemia management is reduction of cardiovascular mortality.
Lipid lowering is widely regarded as a surrogate indicator of cardiovascular risk reduction; dyslipidemia management is therefore primarily aimed at lowering LDL cholesterol either by lifestyle measures or by a combination of lifestyle measures and pharmacologic therapy.
Lifestyle intervention includes diet, exercise, and weight management. Both diet and exercise can ameliorate diabetes-associated lipid derangements, namely decreasing triglyceride and increasing HDL cholesterol levels, and can even accomplish a moderate reduction of LDL.
Moreover, non-pharmacologic measures are characterized by modest implementation and poor long-term adherence. Diet also improves the effectiveness of pharmacologic therapy. Hydroxy-methyl glutaryl coenzyme A reductase inhibitors statins are first-line agents in the management of dyslipidemia in patients with diabetes given not only their efficacy in lowering LDL cholesterol but especially their efficacy in reducing cardiovascular morbidity and mortality, which is now supported by an overwhelming body of evidence.
Fewer studies have assessed the efficacy of fibrates or niacin in this regard, and the outcome data for fibrates are quite mixed. Several large randomized, double-blind, placebo-controlled clinical trials for both primary and secondary prevention have demonstrated the efficacy of statins in reducing cardiovascular morbidity and mortality, with similar relative but obviously greater absolute benefits in patients with and without diabetes.
The Heart Protection Study HPS 43 was the first statin trial to prospectively include enough patients with diabetes to infer adequate pre-specified subgroup analysis, and was soon followed by the Collaborative Atorvastatin Diabetes Study CARDS , 44 the first statin trial conducted only in patients with diabetes.
The primary goal of dyslipidemia management—lowering LDL cholesterol—will most likely be achieved with a statin. Ultimately, the choice of statin in patients with diabetes should be based on clinical judgment, taking into consideration evidence from major clinical trials, the safety and efficacy of individual statins, the effects of individual statins on non-LDL lipid profile, pharmacokinetic interactions, and, lastly, cost-effectiveness.
Statin therapy is not only effective but also safe, arguably providing one of the most favorable risk—benefit balances in cardiovascular pharmacology. Residual confounding factors such as the increased longevity of patients taking a statin rather than cellular and biochemical mechanisms have been proposed as predisposing factors.
The risk, however, is small—one extra case of diabetes for every patients treated with a statin for four years—but nonetheless should be considered, especially when prescribing statins in low-risk individuals.
Although early studies including subgroups of patients with diabetes suggested a reduction of cardiovascular risk with fibrate therapy, 49 two recent trials failed to demonstrate a substantial impact of fibrates on cardiovascular events in patients with type 2 diabetes.
The Fenofibrate Intervention and Event Lowering in Diabetes FIELD trial randomized 9, statin-naïve patients with type 2 diabetes 2, of whom had known cardiovascular disease to either mg micronized fenofibrate daily or placebo. The lack of substantial effects of fibrates on cardiovascular outcomes was corroborated by the recent Action to Control Cardiovascular Risk in Diabetes ACCORD Lipid trial.
ACCORD Lipid randomized 5, patients with type 2 diabetes on simvastatin to receive either fenofibrate or placebo. Over a mean follow-up of 4. However, a subgroup analysis suggested a possible benefit for patients with both high baseline triglyceride levels and low baseline HDL cholesterol levels.
Ezetimibe inhibits enteral absorption of cholesterol, therefore exerting lipid-lowering action complementary to statin therapy dual inhibition. Thus, addition of ezetimibe to a statin has been shown to lower LDL more efficiently and help to achieve LDL goals more often than statin monotherapy.
The rationale behind addition of a second or third agent to lipid-lowering monotherapy by default a statin is that further lipid lowering will translate into better clinical outcomes. Combination therapy will not only yield optimal LDL cholesterol, but will also more likely achieve all three lipid goals.
However, clinical trials have yet to prove that a persuasive efficacy of various combination therapies outweighs the risks and complexity of such an approach. In line with the primary goal of dyslipidemia management in preventive cardiology, a statin should always be the first-line therapy.
In patients at highest cardiovascular risk, a combination therapy aimed either at optimization of LDL levels statin plus ezetimibe or, in patients who already have optimal levels of LDL, at achievement of other lipid goals statin plus niacin seems plausible, provided the patient can be closely monitored for adherence and possible side effects.
Diabetes is a metabolic disorder associated with a specific type of atherogenic dyslipidemia. LDL lowering remains the cornerstone of preventive cardiology, and statin therapy the most useful tool to achieve it. Nonetheless, re-introduction of ancillary drugs such as niacin promises a revival of diabetic dyslipidemia management, which has been partially neglected because of the lack of effective therapies to counteract it.
Another challenge is lipid management in younger patients with diabetes. Patients with type 1 diabetes have traditionally been excluded from major trials of cardioprotective drugs; even the largest data set of statin efficacy in diabetic populations the HPS trial excluded patients below 40 years of age.
This is especially worrisome in light of the global pandemic of type 2 diabetes in younger adults. Probably the most challenging issue, however, remains an individualized approach to cardiovascular risk management. Categories of risk are becoming more and more complex, and managing patients solely based on presence or absence of diabetes or LDL above or below a certain cut-off is becoming obsolete.
Individualized preventive cardiology will demand a more complex yet more effective approach to cardiovascular risk reduction in patients with diabetes, including non-LDL lipid management and combination therapies.
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barclay radcliffe-group. Average ratings No ratings. Your rating Sign in to rate. Abstract Diabetes is considered to be equivalent to coronary artery disease in terms of cardiovascular risk.
Keywords Diabetes , cholesterol , diabetic dyslipidemia , low-density lipoprotein cholesterol , coronary artery disease ,. Citation ×. Select format. ris Mendeley, Papers, Zotero. enw EndNote.
bibtex BibTex. txt Medlars, RefWorks. Copyright Statement: The copyright in this work belongs to Radcliffe Medical Media. Diabetic Dyslipidemia Also referred to as atherogenic dyslipidemia, 16 diabetic dyslipidemia is characterized by a triad of lipid derangements: moderate elevation of triglyceride levels, decreased high-density lipoprotein HDL cholesterol levels, and presence of small dense oxidation-prone and thus extremely atherogenic low-density lipoprotein LDL particles.
Goals of Therapy Cardiovascular risk is a continuous variable. Management of Dyslipidemia in Diabetes The aim of dyslipidemia management is reduction of cardiovascular mortality.
Lifestyle Modification Lifestyle intervention includes diet, exercise, and weight management. Pharmacologic Management—Evidence from Clinical Trials Hydroxy-methyl glutaryl coenzyme A reductase inhibitors statins are first-line agents in the management of dyslipidemia in patients with diabetes given not only their efficacy in lowering LDL cholesterol but especially their efficacy in reducing cardiovascular morbidity and mortality, which is now supported by an overwhelming body of evidence.
Statins Several large randomized, double-blind, placebo-controlled clinical trials for both primary and secondary prevention have demonstrated the efficacy of statins in reducing cardiovascular morbidity and mortality, with similar relative but obviously greater absolute benefits in patients with and without diabetes.
Ezetimibe Ezetimibe inhibits enteral absorption of cholesterol, therefore exerting lipid-lowering action complementary to statin therapy dual inhibition. Combination Therapy The rationale behind addition of a second or third agent to lipid-lowering monotherapy by default a statin is that further lipid lowering will translate into better clinical outcomes.
Conclusions Diabetes is a metabolic disorder associated with a specific type of atherogenic dyslipidemia. Expert Panel on Detection E, Treatment of High Blood Cholesterol in Adults.
Executive Summary of the Third Report of the National Cholesterol Education Program NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults Adult Treatment Panel III , JAMA, ;— Crossref PubMed Ryde L, Standl E, Bartnik M, et al.
Crossref PubMed Juutilainen A, Lehto S, Rönnemaa T, et al.
Resource cholesteroll Cardiovascular diseaseComorbidities. M anagement Chokesterol diabetes accounts for a Lycopene and blood pressure proportion of the practice workload. Approximately 1. A Diabetes and cholesterol management population of is manatement to include — people nad diabetes and probably significantly more in parts of the country with higher proportions of people from black and ethnic minority groups. Diabetes is a chronic and progressive disease state characterised by a raised blood glucose level. It is associated with premature death, ill health and disability. Overall, life expectancy is reduced by an average of more than 20 years in people with type 1 diabetes and by up to 10 years in people with type 2 diabetes DoH, Eat cholestterol help Dynamic and practical weight loss your Diabetes and cholesterol management sugar while improving heart health with this Diabetes and cholesterol management managemnet plan for high cholesterol. Emily Lachtrupp is a registered dietitian experienced in nutritional snd, recipe analysis and meal plans. She's worked with clients who struggle with diabetes, weight loss, digestive issues and more. In her spare time, you can find her enjoying all that Vermont has to offer with her family and her dog, Winston. According to the Centers for Disease Control and Prevention38 million Americans—or about 1 in 10—have Type 2 diabetes.
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