For years, the focus of diabetes care was on blood sugar management. Today, especially for people with type 2 diabetes or older individuals with type 1, managing cholesterol and blood pressure is equally important, as are therapies that also offer heart, kidney, or weight management benefits.
As early as possible after being diagnosed with diabetes, identify your risk factors for heart and blood vessel problems with a thorough medical exam, including relevant lab tests. Work with your healthcare provider to understand the results and establish an appropriate care plan for managing glucose, blood pressure, and cholesterol levels, which frequently includes medications.
For example, when Anna Norton, who has lived with type 1 diabetes for 29 years, discovered that she had high blood pressure, she immediately began taking proactive steps to maintain her heart and blood vessel health. Those included consistently taking medication, incorporating exercise into her daily routine, checking her blood pressure at home periodically (and getting it checked at every medical and dental appointment), checking her lipid levels at least annually, managing stress, fitting in fun activities, and eating as nutritiously as possible.
Norton, who is the former CEO of DiabetesSisters, also encourages others to take a proactive stance with healthcare professionals, asking them for details on risk factors and actionable steps, as well as support whenever possible.
“My endocrinologist and I also discuss the relationship between my glucose management, physical activity, lipid and blood pressure measures at nearly every appointment,” Norton said. “Our approach is proactive and preventative. She assures me that when I reach the age of 50, she’ll refer me to a cardiologist as a preventive step. As a woman with diabetes, I know I’m at higher risk of heart disease than women without diabetes, so I appreciate her proactiveness.”
Risk factors for cardiovascular complications
Risk factors for diabetes-related heart and blood vessel problems include:
- High blood sugar (hyperglycemia)
- High blood pressure (hypertension)
- High cholesterol and blood lipids
- Abnormal blood lipid levels (dyslipidemia)
- Smoking or tobacco use
- A body mass index (BMI) greater than 30, especially with increased waist circumference (weight around the waist or abdomen)
- Inactivity, excess caloric intake, and other risk factors
Statistics reveal a bleak reality regarding the number of people who reach their desired glucose, blood pressure, and lipid targets. Data show that only 25% of U.S. adults diagnosed with diabetes who were nonsmokers met their target goals for A1C, blood pressure, and cholesterol. People who already had heart disease were even less likely to meet these goals. Several reasons, from challenges with lack of access to healthcare to affordable medications and food, may explain this.
Common diabetes-related heart and blood vessel problems
Atherosclerotic cardiovascular disease (ASCVD) describes several conditions that affect blood circulation in the body, all of which begin with the buildup of deposits or plaque in the walls of arteries.
People who have diabetes tend to develop ASCVD at a younger age and with more frequency than those without diabetes. Because ASCVD can occur without any symptoms, it often goes undiagnosed, making it especially important for people with diabetes to get the appropriate tests. ASCVD includes the following conditions:
Coronary heart disease
Heart disease includes heart attack and other conditions of the coronary arteries caused by atherosclerosis (thickening of the arteries). A heart attack occurs when the flow of blood to the heart from an artery is blocked because a plaque deposit has ruptured and formed a clot, causing a minor or major blockage.
Stroke
A stroke occurs when the flow of blood to the brain is blocked due to a clot, which deprives brain cells of oxygen. A stroke may result in many problems, including issues with movement of the arms and legs, speech, coordination, eyesight, cognition, permanent brain damage, or even death.
Peripheral artery disease
Peripheral artery disease (PAD) occurs when a buildup of plaque on the walls of blood vessels causes them to narrow. Peripheral arteries carry blood from the heart to the legs or arms. PAD is most often diagnosed when it causes pain in the legs with walking. Lifestyle changes like diet and exercise are important for the prevention and management of diabetes-related complications like PAD.
Heart failure
Heart failure occurs when the heart cannot adequately pump blood. Fluid can build up in the lungs, and blood can back up in the veins, causing shortness of breath and/or swelling (edema) in the legs. There are many causes for heart failure, including narrowed or blocked arteries from atherosclerosis, blocked small arteries from diabetes, high blood pressure, heart valve disease, viral inflammation of the heart muscle (myocarditis), irregular heart rhythms (arrhythmias), and other conditions. Heart failure can leave the heart too weak or too stiff to pump blood properly.
How to reach your glucose, blood pressure, and blood lipid targets
To keep your heart and blood vessels healthy, the American Diabetes Association (ADA) and American Heart Association (AHA) recommend certain targets. It’s worth discussing these with your healthcare provider, as they may vary based on a number of individual factors.
A healthy lifestyle is at the heart of decreasing your risk of experiencing heart problems. This includes getting regular exercise, following nutritious eating patterns, and managing weight. It is important to continue these behaviors regardless of any medications you’re prescribed.
Weight management
If you carry excess weight, particularly in the abdominal area, losing weight can help improve many heart and blood vessel disease risk factors. Medications are available to help with weight loss. Speak to your healthcare team about whether medication is appropriate for you. Just as important is healthy eating, consuming fewer calories day to day, and more physical activity. All of these can lower blood pressure and improve abnormal blood lipids. If possible, you may want to consider seeking assistance from a registered dietitian nutritionist or certified diabetes care and education specialist (CDCES).
Prioritize a healthy diet
Making changes to your food choices to consume fewer calories is hard work. Think about these changes as tweaks to your current eating plan rather than a rigid “diet.” Make doable changes one step at a time and focus on choosing a wide variety of nutrient-rich foods rather than foods with lots of fat (especially saturated fat) and added sugars.
Research shows that the Mediterranean diet and DASH (Dietary Approaches to Stop Hypertension) diet are healthiest for diabetes and reducing risk factors for heart disease. These eating plans have a lot in common and are also aligned with the ADA’s nutrition recommendations and the U.S. Dietary Guidelines. They both emphasize the consumption of non-starchy vegetables and minimizing added sugars and refined grains. Instead, they encourage whole grains and other unprocessed foods over highly processed and packaged foods. They also suggest replacing sugar-sweetened beverages or juice with water.
Exercise regularly
It’s imperative to fit in exercise to improve heart health. Generally, the ADA recommends people with diabetes increase activity levels by decreasing time spent sitting and getting in different types of physical activity, including:
- Moderate to vigorous-intensity aerobic activity – 150 minutes or more per week, over at least three days (preferably more) with no more than two consecutive days without activity.
- Resistance exercise or strength training two to three times per week for at least 30 minutes on nonconsecutive days.
- Get up every 30 minutes and walk around for a few minutes.
- Flexibility and balance training two to three times per week.
Even if you live with complications such as peripheral artery disease, incorporating movement into your daily routine can still be done in a safe manner and may even help reduce the progression of the disease.
Quit smoking and vaping
Both smoking and vaping increase the risk of heart disease and death, as tobacco, nicotine, and other chemicals found in cigarettes and vapes can increase heart rate and blood pressure. In people with type 2 diabetes, smoking worsens lipid levels, increases chronic inflammation, and worsens glucose management. If you’re having trouble quitting, there are many resources and healthcare professionals who can help.
Take your medications as prescribed
In recent years, SGLT-2 inhibitors like Jardiance (empagliflozin) and GLP-1 medications such as Ozempic (semaglutide), which were originally approved only for blood sugar management, have also been approved to reduce cardiovascular risk in people with type 2 diabetes. Talk to your healthcare team regarding whether any of these medications are right for you.
Take your medications according to your doctor’s instructions. If you do not understand why you need a medication that is prescribed or believe the medicine will harm you, discuss your concerns with them. If you have trouble taking any of your medications due to the side effects, cost, or other factors, discuss those with your healthcare provider, too.
Blood sugar management
Diabetes is considered a progressive condition. Most people with type 2 diabetes will need an increasing number of glucose-lowering medications to keep their blood sugar levels within their target range. There are multiple types of glucose-lowering medications that can also help lower the risks of cardiovascular and kidney disease.
One type is GLP-1s, which reduce appetite, stimulate insulin release, and inhibit glucagon release in the pancreas. They also slow the digestion of food in the stomach, delaying glucose absorption and increasing glucose levels. GLP-1s are also prescribed for weight management in people with overweight and obesity, who are at higher risk for heart-related issues.
Another type of medication called SGLT-2 inhibitors lowers blood sugar levels by reducing the amount of glucose reabsorbed by the kidneys and increasing the amount of glucose released in the urine. SGLT-2 inhibitors also improve heart and kidney outcomes, including reducing hospitalizations for heart failure and reducing the risk of chronic kidney disease (CKD).
Blood pressure management
People with diabetes are twice as likely to have high blood pressure compared to people without diabetes. Managing your blood pressure reduces cardiovascular events like stroke and heart failure. Blood pressure readings should be taken at home and at every healthcare visit, and at least every six months. How you and your healthcare team manage your blood pressure depends on your individual situation and other risk factors.
Regardless of your blood pressure reading, you should also aim to reduce the amount of sodium you consume and increase potassium intake from food and beverages. Your target blood pressure should be lower than 130/80 mmHg.
If your blood pressure is at or greater than 130/80 mmHg, speak to a healthcare provider who may recommend additional lifestyle changes in addition to blood pressure medication to bring levels down.
Blood lipid management
Many people with diabetes have abnormal blood lipid levels. For example, it’s typical for people with type 2 diabetes to have lower levels of HDL (“good”) cholesterol and higher levels of LDL (“bad”) cholesterol. The LDL cholesterol targets in people with diabetes vary from:
- Less than 100 mg/dL in younger people without heart problems
- Less than 70 mg/dL in people ages 40-75 years with diabetes and risk factors for heart disease
- Less than 50 mg/dL for people with diabetes and heart disease
If your triglycerides are greater than 500 mg/dL, your healthcare provider needs to evaluate the cause and determine the optimal approach to minimize the risk of heart disease and other conditions, such as pancreatitis. Here are some tips for keeping cholesterol and other blood lipids in check:
- Get your blood lipid levels checked regularly: You should get a lipid panel to check triglyceride and cholesterol levels when you’re first diagnosed with diabetes and every five years after if you are under 40 years old. You may need a lipid panel every year or more frequently.
- Keep your blood glucose well-managed: Improving blood sugar management also improves lipid levels.
- Make your lifestyle as healthy as possible: To improve your lipid levels, try to incorporate as many healthy lifestyle modifications as you can, including following a healthy eating plan, limiting sugar-sweetened beverages, and reducing alcohol consumption.
- Ask your doctor if starting a statin could help: People with diabetes often need to take a statin medication. Statins work to lower LDL levels, protect the heart and blood vessels, and decrease your chance of death from cardiovascular events. Whether a statin is appropriate depends on your age and other risk factors. Note that statin medication should not be used in pregnancy.
Aspirin to reduce cardiovascular risks in diabetes
The guidance on taking low-dose aspirin each day has changed over the years. At this time, neither ADA nor AHA encourages the use of low-dose aspirin as a prevention strategy against events like a heart attack or stroke in people without or not at risk for cardiovascular disease. Depending on your level of risk for heart disease, however, the risk of bleeding caused by aspirin may outweigh the benefits. Talk with your healthcare provider to fully evaluate the risks and benefits of taking aspirin and other similar medications.
Taking care of your heart with diabetes: The bottom line
With so many targets to keep in mind and medications to consider, managing heart health when you have diabetes can be overwhelming. However, many of the recommendations for heart health overlap with those for blood sugar management – like eating nutritiously, exercising regularly, managing weight, and working with a healthcare provider if medication is needed. What’s good for your blood sugar is often good for your heart and other organs, too.
Editor’s note: Recommendations in this article are aimed at adults with type 1 and type 2 diabetes and exclude children and adolescents as well as pregnant people with diabetes.
About this series
Each year, the American Diabetes Association updates its Standards of Medical Care in Diabetes based on current science. We’ve translated key points of the up-to-date Standards into plain English so you know how to stay healthy and minimize diabetes complications.
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