One of the reasons that preventing diabetes is so important is that people with diabetes have a higher risk of developing heart disease. Observational studies have found various lifestyle factors that are associated with an increase in risk of heart disease, and many overlap with factors that increase the risk of diabetes:
• Low activity levels are associated with increased risk of atherosclerosis and death from heart disease and stroke.
• Higher activity levels are associated with decreased risk of cardiovascular disease and death. In most studies, those who exercise regularly have a 23 to 29 percent reduction in death compared with those who exercise least.
• Better fitness—a more direct measure of physical fitness and ability to perform exercise—is associated with a 46 percent decrease in death, comparing the 25 percent who are most fit with the 25 percent who are least fit.
• Any combination of obesity, sedentary lifestyle, smoking, and high-fat, low-fiber diets increases the apparent risk of developing diabetes and heart disease.
• A "Western" dietary pattern that includes more red meat, french fries, high fat consumption, refined grains, and sweets is associated with increased risk, while a diet with more fruits, more vegetables, less fat, and more poultry and fish and fish oils is associated with lower risk for atherosclerosis.
• Some types of fat, such as polyunsaturated and monounsaturated fats, decrease risk for atherosclerosis, while higher dietary intake of saturated fat and trans-fatty acids (these are created with partial hydrogenation, a process used to increase the shelf life of polyunsaturated fatty acids, such as margarine) increases risk.
• Moderate alcohol intake—one to two drinks per day—is associated with decreased risk for atherosclerosis.
• Smoking increases risk for heart disease, stroke, and especially vascular disease affecting the lower extremity.
Based on the results of observational studies, noted previously, several randomized controlled clinical trials have been conducted to see if changes in lifestyle can reduce risk factors for heart disease or can reduce the risk of heart disease itself, along with other diseases caused by atherosclerosis. (See Appendix A for more information about such types of studies.) Those studies have shown the following:
• Maintaining a weight loss diet and exercise, reducing salt, or both over three to four years decreased the development of hypertension by approximately 20 percent.
• A diet low in salt (less than eighteen hundred milligrams per day) and two or fewer drinks of alcohol per day, aiming for weight loss of ten pounds, allowed 39 percent of people with high blood pressure to discontinue their hypertension medications (compared to only 5 percent of the control group).
• A diet that emphasized greater quantities of fruits and vegetables, low-fat food choices, or both decreased blood pressure by about as much as a blood pressure pill usually
38, does (11 mmHg systolic and 6 mmHg diastolic).
• Eating two fish meals a week, or taking fish oil capsules daily, reduces the risk of sudden death in patients with a prior heart attack and is recommended in patients with risk factors for heart disease (such as high blood pressure, elevated total cholesterol and LDL cholesterol, diabetes, or cigarette smoking, or having fathers or brothers who develop heart disease before age fifty-five, or mothers or sisters who develop heart disease before age sixty-five).
• In the United Kingdom Lipid Program, a decrease in body weight of only 2 percent was associated with a 5 to 7 percent decrease in LDL cholesterol levels.
The take-home lesson of these studies, and others, is that for people who have modest elevations in blood pressure or cholesterol, which affects as much as 50 percent of the population, simple modifications of lifestyle work: they can reduce the need for medications and will probably decrease heart disease and stroke. Ongoing studies, such as the Look: AHEAD study, are examining whether a lifestyle program, similar to the one used in DPP, will reduce heart disease and stroke in people with diabetes.
Lifestyle interventions should not be viewed as a substitute for medications. Many controlled clinical trials have established the powerful effects of cholesterol- and blood pressure-lowering drugs to decrease the development, or recurrence, of heart disease. In some people, both lifestyle changes and medications will be needed.
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