Ask Dr. Pat

Dr. Pat Consults: Diabetes and Its Link to Heart Disease

Elevated levels of insulin not only stimulate the ovaries but also can have a profound effect on the cardiovascular system. Insulin serves as a trigger that causes a “cytokine cascade,” leading to harmful inflammatory changes in the cardiovascular system. Research at the Joslin Diabetes Center has demonstrated that the inflammatory cells called macrophages found in the adipose (fatty) tissue could be the link between diabetes and cardiovascular disease. Measuring inflammatory markers such as high sensitivity C-Reactive Protein, tumor necrosis factor, fibrinogen, interleukin levels, and, most importantly, performing a glucose tolerance test with insulin levels can identify patients who are prone to a high inflammatory environment (Arteriosclerosis, Thrombosis, and Vascular Biology. 2012; 32: 1771-1776).

In order to diminish the effect of insulin resistance, several medications encourage the muscles to become more insulin sensitive. None of these options are yet FDA approved for weight management or appetite control, but they are FDA approved for the treatment of Type 2 diabetes and should be used only after discussing the risks and benefits with your physician.  These drugs are effective in two ways.  First, they reduce excessive glucose production by the liver. Second, they activate insulin receptors on the muscle so that when insulin binds to muscle, the glucose absorption pathway opens up and glucose metabolism becomes more effective. Metformin is the classic example of an insulin sensitizer; it is taken orally at mealtime. The dose, from 500 mg up to 2000 mg, can be taken daily; gastrointestinal side effects like nausea and upset stomach can be minimized with food intake. A newer class of medications are the glucagon peptide (GLP-1) analogues. The FDA first approved GLP-1 in 2005 for the treatment of type 2 diabetes. These medications go by the trade names Byetta, Victoza, Bydureon, Tanzeum, and Trulicity. Their mechanism of action is similar to that of metformin, but these are medications that are far more powerful and have a profound effect on insulin sensitivity. They also reduce appetite (and, particularly, carbohydrate cravings), so they can be effective for changing eating behavior as well. Nausea is a common initial side effect, and the medications do carry warnings regarding pancreas and thyroid disorders that must be discussed at length with your physician.   

My medical advice to you is to start the work now to bring that hemoglobin A1C down to at least 5.7 percent or below. Fasting glucose should be 90 or less.  You need to achieve an initial weight goal of 150 pounds in order to reach a BMI of 25.  A long-term weight goal of 140 pounds will place you in a BMI category of 23, which is realistic for you to achieve but will be hard to maintain without significant lifestyle changes. Midlife weight loss maintenance is hard, so make dietary changes and discuss the possible use of metformin or a GLP-1 analogue for a fixed period to help with appetite control, glucose metabolism, and the desired reduction in heart disease risk.

The management of a complex set of medical and hormonal problems like yours often requires significant behavior change and a good health care team to prevent the bad outcomes of poorly managed diabetes and cardiovascular disease. You are clearly motivated, however, and that will be a great asset in the work facing you.

Andrew Martorella, M.D.


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