One of the cliches about treating diabetes is that having diabetes puts you in the same risk category as that of a person who has already had a heart attack.
Because of this, your doctor may treat you more aggressively for factors such as blood pressure and cholesterol levels than if you had no risk factors for heart disease.
For example, the guidelines for cholesterol levels suggest an LDL level below 100, even better, below 70, for people at very high risk of heart attacks, meaning people with diabetes or those who have already had heart attacks, especially those with other risk factors such as high blood pressure or smoking. For those at risk of heart disease, the LDL level should be below 130, better, below 100. For those without special risks of heart disease, LDL levels of up to 160 mg/dL are considered acceptable.
This means that people with diabetes are often given high dosages of statin drugs, which are not without side effects, especially muscle pains or weakness and memory problems. One of my doctors criticized my LDL level of 84, saying he'd like it to be below 70 and suggesting higher doses of statins to achieve this. I said no.
But now a study suggests that this common wisdom about diabetes is not true in all populations.
In the current study, a group of Spanish researchers studied 4,410 patients aged 30 to 74 years, about half of whom had type 2 diabetes without known coronary heart disease and the other half of whom had already had a heart attack but did not have diabetes. They compared the incidence of heart disease and heart disease deaths in both groups over a period of 10 years.
They found that the long-term (10-year) cardiovascular risk in the type 2 patients was lower than that in the patients with pre-existing heart disease, even though on average the heart disease patients were younger and had less high blood pressure and dyslipidemia. Only stroke deaths and, in men, unstable angina rates were similar in both groups.
The authors note that this study was done in southern Europe, an area that has lower rates of heart disease than more northern European areas (I wonder if this could be related to vitamin D levels). There are some studies in northern climates showing that people with type 2 are at similar risk to those who have already had heart attacks, but other studies show the opposite.
What does this mean for us? Could it be that having diabetes means we have no increased risk of heart disease after all?
Unfortunately, no. People with diabetes are still at greater risk of heart disease than the general public, just not always as great as people who have already had heart attacks. We still need to pay attention to our heart health, making sure our blood pressure and other risk factors for heart disease are under control.
But perhaps our doctors should not impose the most aggressive heart disease prevention measures on us as long as we pay attention to these other risk factors and keep them under control. For example, the Spanish study confirmed other studies showing lower heart attack rates among the patients who had A1c levels below 7.
Someone with type 2 who has never smoked, who has an A1c of 5.1 and a blood pressure of 100/65, and who gets regular exercise should not be treated as aggressively as a couch potato who has an A1c of 8 and a blood pressure of 150/90.
Medicine is an art as well as a science, and the current tendency to treat to numbers regardless of individual patient differences could cause harm. If a treatment is totally benign, then one might think it prudent to impose regardless of risk. But most drugs are not benign and hence one must always balance the benefits vs the risks.
Eating less, eating fewer carbs, especially high-glycemic-index carbs, getting regular exercise, and minimizing stress are pretty benign treatments, assuming you don't starve yourself or fall off a cliff while jogging.
Powerful drugs are another story.
Published On: September 02, 2010