Skip Navigation LinksHome > November 2007 - Volume 1 - Issue 4 > Triple Threat: Diabetes, Hypertension & Heart Disease
HEART Insight:
doi: 10.1097/01.HEARTI.0000300685.96266.c1
Features: Related Risk/The Perfect Storm

Triple Threat: Diabetes, Hypertension & Heart Disease

Haupt, Jennifer

Free Access

I have three deadly diseases: diabetes, high cholesterol and high blood pressure,” says Vilma Rivera, 58. She has been taking medication to control all three conditions for nearly 30 years and thought she was doing enough, even though the doctor had advised her to lose weight and to increase her physical activity.

“I guess I wanted to believe the medications were enough. Even after I had a minor heart attack at age 46, I still couldn't stick to a diet and exercise plan,” says Vilma.

People with diabetes are at significantly higher risk of developing cardiovascular disease (CVD) than people without this metabolic disorder. Though at least 65 percent of people in this country who have diabetes die from CVD, Vilma is hardly alone in not doing enough to manage her heart risk.

“Many people — patients and physicians — think that controlling insulin levels is all that's needed to treat diabetes,” says Elliott Antman, M.D., professor of medicine, Harvard Medical School and Director of the Coronary Care Unit at Brigham and Women's Hospital. “Diabetics should be treated as aggressively as if they are known to already have coronary heart disease.”

“[C]holesterol and blood pressure levels [should be] monitored and treated as carefully as insulin levels,” adds Antman, who is co-author of a recent study showing diabetics who have a heart attack, unstable angina or other acute coronary syndromes (ACS) are at significantly increased risk of death at 30 days and one year after being admitted to the hospital, as compared to ACS patients without diabetes.

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Elevated blood pressure and high cholesterol are the common and potentially lethal links between diabetes and CVD, yet many diabetic patients have a difficult time making healthy lifestyle changes beyond taking the medications prescribed by their doctors. As a result, a recent study by the Centers for Disease Control and Prevention (CDC) concludes that two in five people with diabetes have poor cholesterol control, one in three have poor blood pressure control and one in five have poor glucose control.

“It's really up to patients to take charge of their treatment outside of the doctor's office,” says Prakash Deedwania, M.D., Professor of Medicine, University of California School of Medicine, San Francisco. “If diabetes is caught early on, a combination of the proper medication and lifestyle changes can greatly improve the patient's longevity and quality of life.”

The first step is to understand that recommended blood pressure and cholesterol levels for people with diabetes are lower than for people without diabetes. The American Heart Association (AHA) recommends that someone who has diabetes keep his or her systolic blood pressure under 130 mmHg and diastolic blood pressure under 80 mmHg. And anyone over age 40 who has diabetes plus one or more major CVD risk factors, such as overweight or high blood pressure, needs to keep LDL (“bad”) cholesterol level below 100 mg/dL.

To get you to the target levels, doctors may prescribe an ACE (angiotensin-converting enzyme) inhibitor, an ARB (angiotensin II receptor blocker) or other medicine to control blood pressure, a statin to lower LDL cholesterol and low-dose aspirin to help prevent blood clots.

Luckily, one set of lifestyle recommendations control all three conditions: maintain a healthy weight, get regular physical activity and don't smoke.

While making these changes may be difficult, you will quickly see benefits. For example, losing just five pounds can significantly reduce your risk for heart disease. And just a few days after quitting smoking — once the nicotine and carbon monoxide are cleared from your body — your blood pressure probably will go down, and levels of oxygen and carbon monoxide in your blood should return to normal.

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Earlier this year, Vilma had a huge wake-up call: Her doctor told her she had life-threatening plaque building up in her arteries, despite the statins she was taking to lower her LDL cholesterol.

“At the time, my daughter had just gotten pregnant, and I realized that I might not be around to see my grandchild,” says Vilma, whose weight had crept up to more than 200 pounds over the years. “I knew that, no matter how difficult it was, I had to finally take off the excess weight and get in better physical shape.”

When someone who is obese loses weight, all CVD risk factors associated with diabetes decrease, and symptoms associated with hyperglycemia (high blood sugar), such as dry mouth and itchy skin, improve. Experts recommend a moderate rate of weight loss (seven to 10 percent of body weight in one year) to enable you to stick to your diet and then to maintain your healthier weight.

“Low-carb diets aren't recommended for diabetics because insulin levels can crash, leading to fatigue or even loss of consciousness,” says Deedwania. Diets that restrict carbohydrate intake to less than 130g a day are not recommended for patients with diabetes because a well-balanced, heart-healthy diet includes fruit, vegetables, grains, legumes and low-fat dairy products for vitamins, minerals, fiber and protein. The AHA recommends checking with your doctor to work out an upper and lower range for carbohydrate intake that's appropriate to your weight- and insulin-management goals.

Last March, Vilma's daughter, Elizabeth, took her to a health fair for women with diabetes, where she learned how to put her doctor's advice into practice. She started with changing her eating habits, switching from cooking with lard to olive oil and other healthy fats; eating more fish and chicken and less red meat; and filling up on veggies and whole grains, instead of carbo-loading on white starchy foods.

Vilma also started exercising. “I walk on the treadmill every other day, 10 minutes at a time, then bicycle 10 minutes, as well as walking outside,” she says. “I'm finding that I'm feeling stronger and I don't feel my heart palpitating so fast — that motivates me.”

As little as 30 minutes — at least five days a week — of moderate-intensity physical activity (brisk walking, dancing, weightlifting, raking leaves or washing a car) can reduce your risk of heart disease and lower insulin levels. If you're not up to 30 minutes of physical activity in one shot, Deedwania recommends three 10-minute periods.

“Start with leisurely daily activities, such as household chores and a brisk walk, and make sure you consult with your physician before beginning a more vigorous program,” advises Deedwania. “Diabetics need to be mindful that blood glucose levels drop with exercise. Before you begin, make sure to eat something. And if you are consistently exercising, your physician may need to readjust your medications.”

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Image Tools

Diabetes killed 72,815 people in the U.S. in 2004

15.2 million U.S. adults have physician diagnosed diabetes

1.5 million new cases are diagnosed every year

Roughly 73% of adults with diabetes have blood pressure greater than or equal to 130/80 mmHg

The risk for stroke is two to four times higher among diabetics than nondiabetics

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Most people with diabetes are unaware of how high blood pressure, elevated cholesterol, obesity and insulin resistance conspire to dramatically increase risk of heart attack and stroke. The American Heart Association has created “The Heart Of Diabetes,” an awareness campaign to help people with type 2 diabetes take action to lower their risk for cardiovascular disease. The program includes a health history family tree, free monthly newsletters, recipes and a 12-week fitness and exercise program. To enroll, call 800-AHA-USA1 or visit

© 2007 American Heart Association, Inc.