Do people with diabetes need to worry about heart health?

We all know that diabetes and heart health go together – heart disease is one of the most common diabetes complications. But does that mean all people with diabetes need to worry about heart health?

We asked endocrinologist Dr. Zane Stevens to help us better understand diabetes and heart health.

Diabetes and heart health

So I must be honest, I know very little about heart health and diabetes. I can rattle it off as one of the main long-term complications of diabetes – amputation, blindness, kidney failure, heart disease – but I don’t know too much more detail than that. Which worries me, because as we all know: the more knowledge we have, the better prepared we can be.

I asked our community on Facebook – South Africans with Diabetes – if heart health is something they’re aware of, and the responses were really varied.

Riaan said, “My road with diabetes and heart health came to my shock awareness at the age of 38 in 2012 with my first heart attack. Prior to that diabetes was just diabetes, I didn’t know what complications diabetes would have on my body.”

Kerry-lea said, “Thankfully, as my condition is being managed by an endocrinologist, all necessary health issues related to diabetes are carefully monitored. My heart, cholesterol, liver function, kidney function, thyroid and total blood sugar panel are checked 6 monthly. It is so important to know your numbers!”

Madalen said, “Diabetes is demanding too much assorted medical education. So I concentrate on the correct menu twice daily.”

And Heidi said, “Nope, knew nothing then boom had a massive heart attack.”

Questions about heart health

So I wanted us to get to the bottom of this. Is cardiovascular health – heart health – something that everyone with diabetes needs to be aware of? Why do people with diabetes need to care about this? And what can we do about it – are there any primary preventative measures we should be taking? What is a primary preventative measure? I do not know the answers to these questions, so I asked Dr. Zane Stevens to unpack them for us.

Why is heart health something that everyone with diabetes needs to be aware of?

The majority of people with diabetes are living with Type 2 diabetes (90% of the population of people with diabetes). But both people with Type 1 and Type 2 diabetes really need to be concerned about heart health, because these are the leading causes of death, unfortunately, for individuals living with diabetes.

Do people with diabetes need to care about heart health because it’s a major risk factor?

The risk factor definitely applies to both Type 1 and Type 2 diabetes. But the mechanism by which people with different types of diabetes develop heart disease is quite different. Most people living with Type 2 diabetes are more likely to develop other conditions that raise the risk for heart disease – such as high blood pressure and cholesterol.

“The risk factor definitely applies to both Type 1 and Type 2 diabetes. But the mechanism by which people with different types of diabetes develop heart disease is quite different.”

Dr Zane Stevens

While we never used to think about this as a big risk factor for individuals with Type 1 diabetes, we are seeing that many of these individuals do develop heart disease over time. But this seems to be quite closely linked to the level of blood sugar control. And especially in those individuals who end up developing a kidney complication are at very high risk.

We call that accelerated atherosclerosis – the deposition of plaques of cholesterol in the blood vessels that result in blockages of blood vessels. And that is a bigger problem in somebody who’s developed kidney disease with Type 1 diabetes. So glucose control remains a key focus in people living with type one.

Is heart health the same as heart disease?

So when we talk about heart health, we’re not really just talking about the heart itself, we probably mean cardiovascular disease. And that’s the whole spectrum of heart disease itself. So then we are talking about people presenting with heart attacks, we’re talking about strokes as sort of central vascular disease, we’re also talking about peripheral vascular disease.

We know that amputations and blood flow problems in the lower limbs especially are a big, big problem in both people with Type 1 and Type 2 diabetes. So we’re talking about that whole spectrum. And then included in that is the impact of the blood vessels supplying the kidneys. And chronic kidney disease is also part of the spectrum.

I always explain diabetes as a vascular disease, because all of its complications are related to blood vessel problems. And that’s what we’re trying to avoid by good control.

Diabetes is a vascular disease, because all of its complications are related to blood vessel problems. And that’s what we’re trying to avoid by good control.

Dr Zane Stevens

What can we do about it – are there any primary preventative measures we should be taking? What is a primary preventative measure?

When we talk about primary preventive measures, what we mean is doing something before you actually develop the disease. You’re living with diabetes, and you don’t want to have a heart attack, or stroke or develop chronic kidney disease or lose a limb. We want to do things to prevent those things from happening, as opposed to what we refer to as secondary preventative measures. That’s when you’ve unfortunately already had an event – heart attack or stroke, or you’ve developed chronic kidney disease.

As doctors, we should be asking patients questions that might point towards the fact that they’ve got underlying heart disease. So those would be things like:

• Do you experience any chest discomfort? It’s not always pain, it might be a heavy sensation.
• When you’re exerting yourself, have you found that you’ve become more easily breathless over the last couple of months? Because that might point towards underlying heart disease.
• If we think about the legs, we’d be asking questions like, if you walk a distance, do you get a cramp-like sensation in your calf? So that points towards the fact that blood flow is impaired.

So we really should be taking a good history, and based upon that history deciding do we need to refer this patient for any specialized investigations? Do they need to see a cardiologist?

GLP1s as a primary preventative measure

We now have newer agents in diabetes, some of them which actually have evidence for the primary prevention of heart disease in Type 2 diabetes.

GLP1s are the newest kids on the block in terms of Type 2 diabetes management. GLP is actually a hormone that all of us have, but it tends to be low in individuals living with Type 2 diabetes, especially if they present with being overweight. And so what we’re doing with these therapies is boosting these levels back to normal.

Some studies have shown that if we treat individuals with GLP1s, we can actually prevent a heart attack or a stroke or the development of chronic kidney disease in a primary preventative kind of strategy.

Dr Zane Stevens

In our bodies, this hormone would essentially do three important things.

1. Regulate the blood sugar
   The first thing is: when you eat food, which is going to be converted into sugar (carbs or sugar itself), it nudges the pancreas to make insulin at that appropriate time. And it suppresses the hormone which is opposite to insulin (glucagon), which tends to push your sugars up. So it helps to regulate the blood sugar in that way.
2. Keep you full for longer
   It’s also supposed to slow down the rate at which food passes through the stomach. Meaning that if we raise that level, a smaller portion of food is going to keep you full for longer.
3. Suppress the appetite
   And thirdly, it talks to the part of our brain that gives us that feeling of satiety, or fullness. So it also suppresses your appetite. And we know that that can be abnormal in people living with Type 2 diabetes.

So those three mechanisms are why it’s really a useful glucose lowering drug that controls the sugar. We’ve got a couple of GLP1s available in South Africa and around the world. Some studies have shown that if we treat individuals with this medication, we can actually prevent a heart attack or a stroke or the development of chronic kidney disease in a primary preventative kind of strategy.

What a relief to finally understand heart health and diabetes! Do you have any other questions that we should ask Dr Stevens?

Please remember to discuss any changes you want to make to your diabetes treatment with your doctor.

Would you rather listen to this information?

Here’s an episode of our podcast about it!

Photos by Kelly Sikkema, Jamie Street and Kelly Hudson on Unsplash

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This article was sponsored by Lilly. Lilly is the leading provider of insulin in South Africa, supporting people with diabetes through high quality, affordable products. Lilly unites caring with discovery to create medicines that make life better for people around the world.