The “Cardioprotection” Aspect of Treating Diabetes

By: Zachary T. Bloomgarden, MD

Treating diabetes is complicated – but a major aspect is called “cardioprotection,” referring to the multiple ways in which every person with diabetes needs to work with their physician to prevent ASCVD – atherosclerotic cardiovascular disease.

Here’s what I do for my patients:

1. I discuss exercise with every patient at every visit. How much exercise are they doing, taking into account what they can do. Can they do exercise every day? If not, how about walking? How about rolling out a yoga mat every morning and doing light stretching and strengthening?
2. I discuss diet with everyone. What is their BMI, or body mass index? The goal is 25 – but, realistically, the goal for everyone is to lose 7-10% of their present weight – this degree of weight loss has been shown effective in prevention. What are some approaches? Vegetables! Low-carb diets! “Intermittent fasting” may be a gimmick – but it may work! I explain that most people eat when they wake up, and then at lunch, once or twice in the afternoon, and at the evening meal and a later evening snack, for a total of about 16 hrs – while with “Intermittent fasting” the plan is at most to have a very light breakfast, with an egg or fruit, nuts or seeds, then to have lunch at 1PM, dinner at 7PM, stop eating at 9PM–Total–8 hours of eating time, so reducing the time of eating from two thirds of the day to one third.
3. We discuss diabetes goals. What is the HbA1c level, the home glucose level, should we do continuous glucose monitoring – and what does all of this mean? We discuss the diabetes medicines which have been shown to be cardioprotective – the SGLT2 inhibitors, the GLP-1 receptor activators, and also the older medicine, pioglitazone. How can people with diabetes use these and other medications to achieve goal?
4. We discuss cholesterol goals based on each person’s level of CV risk. Coronary artery calcium score testing is an important way of assessing this for many people – what is it, and who should have it? We discuss cholesterol-lowering treatment approaches, some old ones (that are still very good), and some new ones that might offer important benefits.
5. We discuss triglyceride goals, with new evidence for a specific type of fish oil called eicosapentaenoic acid (EPA), and also new understanding of the older medicine, fenofibrate.6
6. We discuss blood pressure goals, in particular whether we are aiming for 140 or 130 for the systolic pressure (the “top number”). How can people accomplish this? How can diet make a difference?
7. We discuss issues with taking medications – what is called “adherence.” We go over all the medicines each person takes at each visit, and go over issues.

I practice what I preach! Here’s what I do myself:

1. I exercise every day for at least an hour, on weekends for 2 hours, with stretches and strengthening for 20 minutes, and I swim 1600 yards (8 to 9 tenths of a mile) 3-4 times a week
2. My BMI is 25, so I have not been using the intermittent fasting approach, but I work hard to eat healthy food! I eat apple slices with peanut butter as my favorite snack, and I have plenty of other fruits and vegetables, and try to minimize meat and poultry products.
3. I had a positive coronary artery calcium score in my 40s, and take a statin and blood pressure medicines – I use a pill-box to put together a week’s supply at a time so that I can follow my plan!

Zachary Bloomgarden, MD is a Clinical Professor of Medicine at the Icahn School of Medicine in NY, Editor of the Journal of Diabetes, and a member of the Board of the American Society for Preventive Cardiology. In 2012, Dr. Bloomgarden was awarded the title of Master of the American College of Endocrinology. He has written more than 550 professional articles about various aspects of diabetes.