As we learn more about diabetes it is becoming more and more clear that in order to prevent the complications of diabetes, and to improve both length of life and quality of life for diabetic patients, we need to target all cardiovascular risk factors. Now when I see a patient with a new diagnosis of diabetes I emphasize right up front that in order to prevent the large and small blood vessel (macrovascular and microvascular) complications of diabetes we need not just good, but excellent control of their cholesterol and blood pressure, that we need them to quit smoking if they smoke, and that we need to control their blood sugars. I tell them that blood sugar control, though important, is no more important, and possibly less important that these other factors. The Birdges to Exceellence web tutorial suggests that cost savings to the health care system, a surrogate for hospitalizations and poor health outcomes is more influenced by blood pressure control and LDL cholesterol control than by blood sugar control.
What do diabetic patients die from? They die from cardiovascular diseases, primarily coronary artery disease and strokes, but also peripheral vascular disease. An amazing 2/3 of diabetic patients will die of heart attack or stroke. This seems to be why we need to control hypertension and cholesterol levels in our diabetic patients. If we let our patients die of cardiovascular disease with excellent blood sugar control we have not done them a service.
The good news is that now we recognize the importance of blood pressure and lipid management in diabetic patients. We have many excellent medications to lower blood pressure so that most of these patients can get to goal blood pressures of less than 130/80. We also have many excellent and proven medications to allow them to get to goal LDL cholesterol levels of less than 100, and often to the ideal of less than 70. Many of these medications for both the cholesterol and blood pressure control are now inexpensive generic medications.
The goals of good diabetes care include:
Blood pressure of < 130/80
LDL cholesterol of <100, with the aggressive goal of <70
Hemoglobin A1C of <6.5%
These are listed in the likely order of importance. Most of the data suggests that a Hemoglogin A1C of 7.5 in a diabetic is less concerning that a blood pressure of 150/92 or an LDL cholesterol of 145.
I see many diabetic patients who feel really good about their diabetes management because they have a nice low Hemoglobin A1C. They take great pride in checking their blood sugars at home frequently, even though there is no evidence to show that frequent or even infrequent home blood sugar testing in type 2 diabetes improves outcomes. This said they are far less motivated to aggressively control their blood pressure and lipid disorders. We have a big reeducation process facing us to help our patients understand the need to address all of these issues to give them the best chance of a long and healthy life with diabetes.