Despite advances in our knowledge and understanding of cardiovascular health, cardiovascular disease (CVD) remains the No. 1 killer of men and women in the United States.
Charles German, M.D., M.S., FAHA, FASPC
Assistant Professor of Medicine, Georgetown University, Director of Preventive Cardiology, Medstar Georgetown University Hospital, Medstar Heart and Vascular Institute, Washington, D.C.
For more than 50 years, we have seen declines in CVD deaths, but over the past decade, these trends have stalled, and now CVD rates are on the rise. This upswing is largely due to increasing rates of obesity and diabetes, one of the most potent risk factors for the development of heart attack and stroke.
The rising tide of diabetes
Roughly 38 million, or 1 in 10 U.S. adults, have diabetes, and about 20% of those with diabetes don’t know they have it. This translates to $413 billion in healthcare costs, leading to an increased risk of serious complications outside of the heart, including blindness, kidney failure, loss of limbs, and premature death. By 2045, the prevalence of diabetes is expected to grow by 16%, affecting a staggering 783 million people across the globe. Additionally, rates of both type 1 and type 2 diabetes among children are also increasing, reflecting the worsening cardiovascular health of our youth.
Cardiovascular diseases, including heart attack and stroke, are the No. 1 cause of death in people living with diabetes, reflecting a two to fourfold increase in risk compared to individuals without it. Early, aggressive treatment of diabetes and its risk factors is essential to improve cardiovascular health.
Healthy lifestyle: the foundation of prevention
In order to turn the tide of diabetes and its downstream complications, healthy lifestyle habits remain the foundation of prevention. National guidelines recommend at least 150 minutes per week of moderate or 75 minutes per week of vigorous intensity physical activity (or an equal combination of both) per week, plus two days of strength training.
In addition, organizations like the American Heart Association (AHA) advocate for a heart healthy diet, which includes a wide variety of fruits and vegetables, whole grains, healthy proteins such as fish and seafood, nuts, and legumes, while limiting the intake of processed foods, sugar sweetened beverages, salt, and alcohol. Maintaining a healthy weight is also important, while aiming for seven to nine hours of sleep.
State-of-the-art diabetes therapy
In 2008, the US Food and Drug Administration issued guidance for pharmaceutical companies developing treatments for diabetes to study how these drugs affect heart health. Two classes of medications, SGLT2 inhibitors and GLP-1 receptor agonists, have consistently demonstrated beneficial effects for the heart in key clinical trials and are now considered first-line therapy for high-risk individuals living with diabetes. Emerging evidence also supports the use of both medication classes, with additive benefits for overarching cardiovascular health.
Blood pressure control and cholesterol management are also essential. Hypertension, defined as systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg, is common among individuals with diabetes and should be treated aggressively. Additionally, guidelines from the AHA recommend that all individuals with diabetes 40-75 years of age should be on a statin to lower their risk of heart attack and stroke. For those at highest risk, both the AHA and American Diabetes Association recommend targeting a goal LDL cholesterol <55 mg/dL.
Tackling the diabetes epidemic
Rates of diabetes are now at the level of a public health emergency, and both physicians and patients need to start focusing more on prevention to avoid the downstream risks of heart failure, heart attack, stroke, and early death.
Policy change is needed to ensure we can provide access to healthy, nutritious food at an affordable price for all. Public parks, with sidewalks and proper lighting, are also crucial to ensure neighborhood walkability in a safe environment. Coverage for heart-protective medications such as SGLT2 inhibitors and GLP-1 receptor agonists needs to expand, given these are life-saving medications that improve morbidity and mortality.
A multifaceted, patient-centered approach is necessary for patients living with diabetes. Fortunately, diabetes and cardiovascular disease are both largely preventable; we have the tools to reverse these concerning trends, and cooperation across all healthcare sectors is needed to ultimately improve the health of our population.
