by Barb Schreiner, PhD, APRN, CPLP, CDE, BC-ADM
His blood glucose was 220, his blood pressure was 160/95 and his weight was 240. Her medication history included atorvastatin, metformin, and lisinopril. He wanted to add more exercise to his daily routine; she wanted to eat fewer salty snacks and sugar-laden drinks. As we collaborated, it became clear that my patients’ lifestyle changes would improve both metabolic and cardiovascular health and reduce both metabolic and cardiovascular risks.
The boundaries across therapeutic interventions are blurring as we manage diabetes and its cardiovascular comorbidities. Increasingly, diabetes care and education specialists are addressing cardiovascular health in our persons with diabetes. But what is driving this intertwining of metabolic and cardiovascular conditions?
Scientists are better understanding the fundamental physiologic connections — inflammation, fat metabolism and obesity. The link between diabetes and cardiovascular disease has never been so strong.
First, the link between diabetes and cardiovascular consequences was first described more than 80 years ago (Root et al, 1939). More recently, scientists are better understanding the fundamental physiologic connections — inflammation, fat metabolism and obesity (Leon & Maddox, 2015). The link between diabetes and cardiovascular disease has never been so strong.
By 2008, the FDA required cardiovascular risk studies in its approval process for new diabetes drugs. We are beginning to see the results of those regulations as new drugs claim cardioprotective effects. Currently, three diabetes medications (canagliflozin, empagliflozin, and liraglutide) are permitted to claim cardiovascular benefit. As a result, cardiologists are taking heed about the possibilities of diabetes medications in their therapeutic toolbox (Young, 2018). In fact, in a 2018 consensus document endorsed by the ADA, the American College of Cardiology (ACC) noted that “the arrival of these new agents proven to reduce adverse CV outcomes in patients with type 2 diabetes has triggered a major paradigm shift beyond glucose control, to a broader strategy of comprehensive CV risk reduction” (Das, et al, 2018). The ACC further suggested that cardiovascular disease specialists work toward “a collaborative, interprofessional, and multidisciplinary approach to managing this high-risk patient group” (Das, et al, 2018). Diabetes care and education specialists stand ready to participate in this collaboration.
As patient educators and advocates, diabetes care and education specialists have promoted the interconnectedness of metabolic and cardiovascular conditions by incorporating the nonpharmacologic approaches of nutrition, activity, and coping for our people with diabetes. As behavior change experts, we recognize that healthy lifestyles are beneficial for managing both diabetes and related conditions, such as cardiac or vascular disease. What better time to formally blend diabetes and cardiovascular health?
Every day, as diabetes care and education specialists we see the merging of diabetes and cardiovascular comorbidities in the people we teach and support. We apply the AADE7 Self-Care Behaviors® as we help people with diabetes, hypertension, hyperlipid states and obesity. We embrace a holistic approach, addressing the interconnections as we help people make safe activity plans, choose heart-healthy foods or stop smoking. We are at the intersection of lifestyle approaches for both metabolic and cardiovascular conditions. And we excel at lifestyle and behavioral counseling and support.
There is a connection. We make the connection real for people with diabetes. How can diabetes care and education specialists extend their scope to also help people with related cardiovascular conditions?
Examine the evolving connections and anticipate that a new approach to preventive cardiology care is emerging. It is likely that preventative cardiologists “will become part of collaborative teams"
First, expand your professional world. Explore resources for yourself and for people with cardiovascular and metabolic conditions. For instance, the American Diabetes Association and the American Heart Association recently launched “a joint, multiyear partnership to raise awareness about the increased risk for cardiovascular disease among those living with type 2 diabetes” (ADA, 2018). The initiative, Know Diabetes By Heart provides patient-centric tools and information. The infographic on the website is particularly instructive.
Next, extend your lifelong learning to incorporate evidence-based care for people with hypertension, lipid disorders, and vascular disease. Cross-pollinate with other professional organizations such as the Preventive Cardiovascular Nurses Association, the American College of Cardiology and the American Heart Association.
Also, examine the evolving connections and anticipate that a new approach to preventive cardiology care is emerging. It is likely that preventative cardiologists “will become part of collaborative teams — an approach already widely deployed in heart care settings — that include diabetologists, internal medicine specialists, interventional cardiologists, dietitians and other healthcare professionals who collectively provide comprehensive care” (Young, 2018). Can you imagine yourself a part of such a team?
It is an exciting time for expanding our reach to people with cardiovascular risks and to our cardiology colleagues. It is time to expect a new vision for our profession — a vision which welcomes cardiovascular education, support and collaboration.
American Diabetes Association. (2018, November 8). American Heart Association and American Diabetes Association launch landmark health initiative—Know Diabetes by Heart. Retrieved from http://www.diabetes.org/newsroom/press-releases/2018/health-initiative-know-diabetes-by-heart.html http://www.diabetes.org/newsroom/press-releases/2018/health-initiative-know-diabetes-by-heart.html
Das, S.R., Everett, B.M., Birtcher, K.K., …, & Sperling, L.S. (2018) ACC expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes and atherosclerotic cardiovascular disease: A report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology, 72(24), 3200-3223. https://doi.org/10.1016/j.jacc.2018.09.020
Leon, B.M., & Maddox, T. M. (2015). Diabetes and cardiovascular disease: Epidemiology, biological mechanisms, treatment recommendations and future research. World Journal of Diabetes, 6(13), 1246-1258. DOI: http://dx.doi.org/10.4239/wjd.v6.i13.1246
Root, H. F., Bland, E.F., Gordon, W.H., & White, P.D. (1939). Coronary atherosclerosis in diabetes mellitus: A postmortem study. JAMA, 113(1), 27–30. doi:10.1001/jama.1939.02800260029008
Young, R. (2018, January 18). Cardiology and diabetes: Collaborating to defeat a dangerous duo. Cardiovascular Business. Retrieved from https://www.cardiovascularbusiness.com/topics/lipids-metabolic/cardiology-diabetes-collaborating-defeat-dangerous-duo