Cholesterol How To Decrease

Lower Your Cholesterol in 30 Days

Is it possible to lower your cholesterol without harmful drugs? Thats the claim made by the e-book Beat Cholesterol in 30 Days by Scott Davis. Through this e-book you can learn the all-natural secrets that he used to lower his cholesterol 100 points in less than a month. Some of Davis' suggestions are lesser-known herbal remedies for high cholesterol: the most ubiquitous, of course, is the author's suggestion to buy red yeast rice. Red yeast rice is in fact a natural source of monocolin K, known in medical circles as lovastatin. In fact, the prescription version of lovastatin is nothing more than a concentrate of monocolin K. Davis' ability to collect such an astounding array of oftentimes obscure information and arrange it in a way that is easy for people of all ages to follow and apply to their lives immediately is itself quite an achievement. Read more here...

Natural Cholesterol Guide Summary


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Lifestyle Treatments for High Cholesterol and Other Blood Fats

Several types of fats circulate in the blood and are commonly measured by doctors total cholesterol, LDL (bad) cholesterol, HDL (good) cholesterol, and triglycerides. In people with diabetes, total cholesterol and LDL cholesterol may be high. However, the most characteristic lipid changes in diabetes are increased triglyceride levels (triglycerides are another circulating fat in the blood) and a decreased HDL cholesterol level. Of the specific types of fat that circulate in the blood, both high LDL and low HDL cholesterol appear to be the most important with regard to future heart disease. Although LDL levels in people with diabetes tend to be in a similar range as in people without diabetes, the LDL particles are small and more likely to cause vascular disease. This combination of low HDL levels and small LDL particle size contributes to the increased risk of heart disease in the setting of diabetes. The availability of powerful new cholesterol-lowering drugs, called statins,...

Analysis Comparison Drug therapy versus placebo for Fluoxetine FT fixed model random mode wks rho Outcome HDL

Comparison 03 Drug therapy versus placebo for Fluoxetine (FT 1-7, fixed model 8-l4, random mode 8-l6 wks. rho 0.75) Outcome 06 HDL cholesterol Comparison 03 Drug therapy versus placebo for Fluoxetine (FT 1-7, fixed model 8-l4, random mode 8-l6 wks. rho 0.75) Outcome 07 Triglycerides

Analysis Comparison Drug therapy versus placebo for Sibutramine FTAB fixed model random model rho Outcome HDL

Comparison 25 Drug therapy versus placebo for Sibutramine (FT+AB l-l3, fixed model l4-26, random model. rho 0.75) Outcome l2 HDL cholesterol Comparison 25 Drug therapy versus placebo for Sibutramine (FT+AB 1-13, fixed model l4-26, random model. rho 0.75) Outcome 13 Triglycerides

Why change what you eat

What you eat has an effect on your general health and well-being. Many people think that they already have a healthy diet but, on average, people in the UK eat too much fat and too many calories. This can result in high cholesterol levels and weight problems and lead to many heart attacks each year. Heart disease by reducing cholesterol levels, blood pressure, weight.

Discovering drugs and chemicals that may cause or Worsen diabetes

1 Nicotinic acid Commonly used to treat high cholesterol levels. In the 1990s, this agent was found to raise the blood glucose in patients with diabetes treated for high cholesterol, whether type 1 or type 2. More recently, it has been found to cause no deterioration of blood glucose control and can safely be used in people with diabetes.

Shopping for Life Insurance

With the Internet, you can quickly find and compare the cost of insurance at numerous companies based on your age your habits (warning if you smoke, you pay through the nose) and the presence of conditions such as diabetes, high blood pressure, and high cholesterol. Many companies will take a standard rate for a healthy person with no diseases and add 50 percent more if you have diabetes. Of course, your actual cost is dependent on your specific circumstances, including your age when you first buy the insurance.

Using Other Medications

Most of this chapter is devoted to medications that lower the blood glucose, but diabetes involves more than elevated blood glucose levels. People with diabetes often have high blood pressure and high cholesterol, and they suffer more sickness when exposed to influenza or pneumonia. It is important to consider this fact in the overall management of your disease.

Vitamin E and Creactive protein

C-reactive protein (CRP) is extremely important because it is emerging as a major risk factor for atherosclerosis and cardiovascular disease (Folsom, 1999). Patrick and Uzick (2001) have written an excellent review on the relationship of cardiovascular disease to CRP. The association between atherosclerosis and CRP is strong even in the absence of classical risk factors such as high cholesterol, triglycerides, and blood pressure (Ridker et al., 2001).

Latent Autoimmune Diabetes in Adults LADA

Another feature of LADA patients is that they usually don't have the high cholesterol and high blood pressure often found in people with T2DM. As a result, their tendency to get coronary artery disease and heart attacks is less than that of T2DM patients once the blood glucose is controlled.

It takes time and effort but intensive diabetes management can increase your freedom and flexibility and help you avoid

The results of these two studies are very clear. The researchers in the DCCT found that after 10 years, intensive management reduced the risk of developing diabetic eye disease (retinopathy) by 76 percent. Among individuals who already had early signs of eye disease before entering the trial, intensive management slowed the progression of retinopathy by 54 percent. Tight blood glucose control also reduced the risk of kidney disease by 50 percent and that of nerve disease by 60 percent. Study volunteers, who ranged in age from 13 to 39, were too young to develop many heart-related problems, but were monitored for some of the signs of cardiovascular disease. The study found that those on intensive management had a 35 percent lower risk of developing high cholesterol levels, a major contributor to heart disease. Before the DCCT, many people with diabetes thought that complications would progress no matter what they did. After the DCCT, we know that way of thinking is wrong keeping...

Diabetes And Circulatory Problems

Even though people with type 1 diabetes generally do not have high blood pressure and high cholesterol problems, they can develop heart disease after many years. This is especially likely to occur if they have diabetic kidney disease. Improve your lipid profile. People with type 2 diabetes frequently have abnormalities of their lipid profile a collective term for cholesterol, triglycerides, HDL cholesterol, and LDL cholesterol levels. Almost all people with type 2 diabetes and many with type 1 diabetes need to take medicines for the lipid abnormalities. Triglycerides are an energy source of the body made in the intestine and the liver. They consist of three fatty acid chains combined with glycerol. Cholesterol and triglycerides combine with proteins to form lipoprotein particles that circulate in the blood. These particles include the following High-density lipoproteins (HDL), which are made in the liver and intestines HDL cholesterol is known as the good cholesterol In people with...

Key points of the guidelines

Accurately determine the actual makeup of everything you eat. Maintaining an optimal diet requires an accurate analysis of daily intakes. Whether your goal is weight-loss, glucose control, high cholesterol or any other diet plan, you will reach your goals much quicker if you know the composition of your meals. The failure of many plans is in their efforts to make it easy. Using the palm of your hand, the size of your fist, a deck of card or many of the other strategies can produce wildly inaccurate results. The only truly accurate method is to weigh and measure Everyone should consume between 20-35 grams of fiber per day. Fiber is a form of carbohydrate that is not absorbed by the human body. Fiber has been shown to aid in maintaining a healthy digestive system, slow the rise in blood glucose, aid in lowering cholesterol and in maintaining a healthy heart.

Standard Treatment

The most common treatment for coronary artery disease consists of a class of cholesterol-lowering drugs known as statins. These drugs currently include Lipitor (atorvastatin), Mevacor (lovastatin), Pravachol (pravastatin), and Zocor (simvastatin). However, elevated cholesterol is more a symptom than a cause of coronary artery disease, so these and other drugs merely alter symptoms without addressing the underlying causes. Surgical treatments such as bypass and balloon angioplasty also are used to correct blocked arteries but do not change the underlying disease process.

Taking a Statin for All People With Diabetes

Some diabetes specialists suggest that all people with diabetes should be taking a cholesterol-lowering drug from the group of drugs known as statins. The drugs in this class include Atorvastatin (brand name Lipitor) Lovastatin (brand name Mevacor) Pravastatin (brand name Pravachol) Simvastatin (brand name Zocor)

HMG CoA Reductase Inhibitors

Large clinical trials have determined that hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) significantly reduce cardiovascular morbidity and mortality. Furthermore, lipid-lowering therapy has been shown to improve endothelial function in several studies (204,205). Attempts to ameliorate the impaired endothelium-dependent vascular relaxation that occurs in diabetic patients with dyslipidemia are few and the results mixed. Impaired endothelium-dependent vasodilation in patients with type 2 DM with dyslipidemia has been reported to improve with fibrate therapy (206) (which lowers the serum triglyceride level) but not with simvastatin (206,207). 66. Clarkson P, et al. Impaired vascular reactivity in insulin-dependent diabetes mellitus is related to disease duration and low density lipoprotein cholesterol levels. J Am Coll Cardiol 1996 28(3) 573-579. 77. Gilligan DM, et al. Selective loss of microvascular endothelial function in human hypercholesterolemia. Circulation 1994...

Which medicines are used in the treatment of diabetic dyslipidaemia

LDL-cholesterol HDL-cholesterol Triglycerides Statins* -20 to -60 +5 to +10 Bile acid sequestrants -15 to -30 0 to slight (cholestyramine) increase *Atorvastatin and rosuvastatin are more powerful than the other statins and decrease LDL-C by 60 at high doses. For Type 2 diabetic patients with LDL-C levels > 100mg dl (2.59 mmol L), the statins are recommended as medicines of first choice, since it is proven that not only do they decrease the LDL-C levels with safety and more effectively than any other category of hypolipidaemic medicine, but moreover they decrease the mortality of these patients (both in primary as well as secondary prevention studies). There are nowadays six different statins on the market (Table 23.3), with very good tolerance and effectiveness, although there are differences among them regarding the effective dosage (the most effective statins are rosuvastatin, atorvastatin and simvastatin). These medicines act by inhibiting the hepatic enzyme...

Cognitive Functioning

Multiple diabetes-related comorbid conditions (i.e., hyperinsulinaemia, hypertension, hypercholesterolaemia) may individually and synergistically impact learning and memory skills see review by Ryan and Geckle (104) . For example, hyperinsulinaemia may independently affect the central nervous system. Insulin levels usually rise with age, and are strong predictors of cognitive impairment in adults without diabetes. Data from the Framingham study showed that both hypertension and diabetes independently affect cognition generally, and memory skills in particular. Given their high rates in type 2 diabetes, it is notable that hypertension and hypercholesterolaemia interacts with hyperinsulinemia to disrupt memory. Generally, there is evidence to support the view that verbal learning and memory skills are particularly vulnerable to disruption in type 2 diabetes compared with other cognitive skills as a result of diabetes and its comorbidities. Recent data has indicated a link between...

What is the natural history of diabetic nephropathy

Stage of clinically overt nephropathy (clinical proteinuria) The main characteristic of this stage is macroalbuminuria or proteinuria (that is, an albumin excretion rate > 200 mg min or > 300 mg 24 h and a total quantity of protein in the urine > 500 mg 24 h). In this stage the urinalysis is usually dipstick positive for protein in the urine. There are two evolutionary phases the early phase, which is characterized by intermittent proteinuria and incipient decline in glomerular filtration and the late or advanced stage, where proteinuria is persistent and gradually increasing, there is a greater decline of renal function (greater decrease of glomerular filtration rate), while at the same time hypertension develops. Usually 10 years elapse from the stage of persistent proteinuria to the final stage of chronic renal failure (CRF), if patients are not treated properly. Glomerular filtration rate declines by about 8-12 ml min year, and coexistent hypertension plays a detrimental...

Treating dyslipidaemia

Large randomised placebo-controlled clinical trials that included patients with diabetes and CHD have clearly demonstrated that cholesterol lowering with statins significantly reduces the risk of cardiovascular events. Evidence has also accrued on the benefit of statins on primary prevention of cardiovascular events in patients with diabetes. The recent CARDS trial, for example, randomised 2338 patients with type 2 diabetes without high LDL-cholesterol to placebo or atorvastatin, 10 mg daily (Colhoun etal., 2004). While this trial excluded patients with severe PAD (defined as warranting surgery), stroke risk was reduced by 48 suggesting that the statins had extra-cardiac effects on the progression of atherosclerotic disease elsewhere in the circulation. Data are also available in the subgroup of patients with PAD in the Scandinavian Simvastatin Survival (4S) study. Although only 4 of the participants in 4S had intermittent claudication at baseline, the number of cases of new or...

Type diabetes and CHD

The increased risk of CHD in type 2 diabetes is not entirely explained by traditional risk factors, though the diabetic population tends to have lower HDLc, higher total cholesterol HDLc ratio and more hypertension. In the Multiple Risk Factor Intervention Trial (MRFIT), increasing the number of traditional risk factors like hypercholesterolaemia, smoking or hypertension increased the cardiovascular mortality, but the diabetic patients had approximately three times the risk compared with non-diabetic subjects for the same given number of risk factors (Stamler et al., 1993). The CHD mortality of diabetic patients without a history of myocardial infarction was found to be similar to that of patients without diabetes who had a previous myocardial infarction (Haffner et al., 1998).

Dietary strategies to prevent the development of heart disease

For several decades, the prevention of CHD (including the prevention of ischaemic recurrence after a prior AMI) has focused on the reduction of the traditional risk factors smoking, HBP, hypercholesterolaemia. Priority was given to the prevention (or reversion) of vascular atherosclerotic stenosis. As discussed above, it has become clear in secondary prevention that clinical efficiency needs to primarily prevent the fatal complications of CHD such as SCD. This does not mean, however, that we should not try slowing down the atherosclerotic process, and in particular plaque inflammation and rupture. Indeed, it is critical to prevent the occurrence of new episodes of myocardial ischaemia whose repetition in a recently injured heart can precipitate SCD or CHF. Myocardial ischaemia is usually the consequence of coronary occlusion caused by plaque rupture and subsequent thrombotic obstruction of the artery.

Dietary control of conventional risk factors cholesterol blood pressure type diabetes and obesity

Cholesterol is a determinant of CHD mortality, and its blood level is at least partly regulated by diet. However, few epidemiological studies have prospec-tively included analyses of the dietary habits of the studied populations in the evaluation of their risk.119 In the Seven Countries Study, marked differences in CHD mortality, dietary habits and cholesterol distribution were observed in the different cohorts.119 Cholesterol levels were high in Northern Europe and in the USA (an average level of 7mmol L), and low in rural Japan (an average of 4mmol L), and population cholesterol levels were positively associated with CHD mortality. Secondary prevention trials with statins in Northern Europe120 and Australia121 confirmed the importance of cholesterol by demonstrating a reduction by 25-30 per cent of the relative risk of CHD death in patients taking these drugs. Whether the effect of statins was entirely related to their effect on cholesterol remains unknown. This was the basis of a...

Drug Nutrient Depletion

Many of the side effects from drug therapies may not be directly due to the drug itself, but rather the result of nutritional deficiencies caused by the drug when taken over time. Drugs given to treat conditions such as type 2 diabetes or cardiovascular disease, such as diuretics for hypertension, statins for hypercholesterolemia, or met-formin for blood sugar regulation, may actually be causing a cascade of biochemical changes in the body due to drug nutrient depletion, further complicating the metabolomic chemistry of the individual. These biochemical changes can imbalance the homeostatic body system, leading to the cascade of inflammatory signaling.

If TGL mgdL nonHDLC total C minus HDL is a secondary target of therapy with a goal of mgdL higher than the LDL goal

HDL cholesterol ( ) Triglycerides ( ) Statins Bile acid sequestrants *, may increase in patients with high triglycerides. Adapted from Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in adults (Adult Treatment Panel III). JAMA 2001 285(19) 2486-97, with permission and Gagne C, Bays HE, Weiss SR, Mata P, Quinto K, Melino M, et al. Efficacy and safety of ezetimibe added to ongoing statin therapy for treatment of patients with primary hypercholesterolemia. Am J Cardiol 2002 90(10) 1084-91 with permission. *, may increase in patients with high triglycerides. Adapted from Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in adults (Adult Treatment Panel III). JAMA 2001 285(19) 2486-97, with permission and Gagne C, Bays HE, Weiss SR, Mata P, Quinto K,...

Angiographic And Autopsy Data

Angiographic and autopsy evidence shows that compared to nondiabetic controls, subjects with type 1 diabetes have more diffuse coronary lesions and more severe stenosis (7). Valsania (8) compared the coronary angiograms from 32 type 1 diabetic subjects to those of 31 age-, gender-, and symptom-matched nondiabetics. Subjects were presumed to have type 1 diabetes based on age of onset prior to 30 yr of age. Severe (> 70 narrowing of lumen) multivessel disease was more common in the diabetic than the control subjects. Moreover, diabetic subjects tended to have multiple lesions within a given vessel. In those with left coronary lesions, 37 of the diabetic subjects had proximal, as well as distal, stenosis of > 70 compared to only 10 of control subjects. For the right coronary artery, proximal and distal narrowing was found in 44 of diabetic and 33 of control subjects. This study did not match for hypertension and hypercholesterolemia in the two groups, but based on a multiple logistic...

Hyperglycaemia as a Risk Factor for Cardiovascular Disease

Our understanding of the role of traditional risk factors for cardiovascular disease (CVD), such as hypertension, hypercholesterolemia, smoking and diabetes, has evolved significantly over the last decade. Rather than viewing these risk factors as 'all or nothing' phenomena with pathogenic thresholds at particular levels, we now regard them as continuous variables, each contributing to overall CVD risk. In this paradigm, 'targets' for risk factor reduction are artificial, since they do not describe a clinically relevant threshold, and should vary depending on the cumulative risk for individual patients. However, this method of approaching CVD risk assessment runs into difficulties when one considers diabetes and hyperglycaemia. Unlike type 1 diabetes, where chronic hyperglycaemia is the hallmark of the disease process, type 2 diabetes (T2D) exhibits much more complex pathophysiology while glucose levels still define the diagnosis, hyperglycaemia is only one of several metabolic...

Angiotensin Converting Enzyme Inhibitors

Angiotensin-converting enzyme (ACE) inhibitors have been shown both to improve endothelial function and to reduce the development of atherosclerosis in various animal models of hypercholesterolemia (192,193), independent of its BP-lowering effect. Similarly, the Heart Outcomes Prevention Evaluation (HOPE) study has demonstrated the utility of the ACE inhibitor ramipril in preventing cardiovascular events in diabetics (194) although the mechanism of this effect remains obscure. Clinical trials have demonstrated that the ACE inhibitor quinapril improved endothelial function in nondiabetic patients with CAD (195). Studies evaluating the effect of ACE inhibitors on type 1 diabetic subjects have resulted in conflicting conclusions. Two studies have demonstrated that ACE inhibitors have no effect on vascular function in patients with type 1 DM, even after 6 months on the drug (196,197). However, O'Driscoll and colleagues found improvement in endothelial function by ACE inhibition in...

Risk factors for PAD in patients with diabetes Table

The high PAD risk in patients with diabetes is due to the complex interplay between the various haemodynamic and metabolic components of the metabolic syndrome. Diabetes is no longer considered to be a disease confined to hyperglycaemia but rather part of a syndrome comprising various risk factors, all of which confer an increased risk of atherosclerosis and cardiovascular events (see also Chapter 2). Hence, although the diagnosis and symptoms of diabetes are still defined by hyperglycaemia, other features of the syndrome, especially hypertension and dyslipidaemia, are equally if not more important in the pathogenesis of diabetes-related macrovascular complications such as PAD. Thus, the development of atherothrombotic complications in larger lower limb arteries is multifactorial, reflecting interactions between high glucose, lipids and blood pressure. For example, hypercholesterolemia and hypertriglyceridaemia have been associated with the increased risk of intermittent claudication...

Inhibitors of AGE Production

Conversely, hyperglycemia, which increases oxidative stress, can convert even elevated levels of NO to peroxynitrite, which is deleterious to vascular function (179). A decrease in oxidative stress can restore vascular function rather than increase the NO supply. Prolonged hyperglycemia and hypercholesterolemia both cause a depletion of tetrahydrobiopterin (BH4), an essential cofactor for NOS, resulting in an uncoupling of eNOS and lowered production of NO (180). Studies using both diabetic animal models (113) and hypercholesterolemic patients (112) have demonstrated that tetrahydrobiopterin

Guidelines For Exercise

The participants in this study were young white and black men and women (ages 1830) who completed treadmill testing and then were followed from 1985 to 2001. Glucose, lipids, and blood pressures were measured and physical activity was assessed by interview and self-reporting. Outcome measurements included hypercholesterolemia, metabolic syndrome, hypertension, and type-2 diabetes. 3. Hypercholesterolemia 11.7.

Fisoprostanes and overweight and obesity

A role for oxidant stress in the development and progression of atherosclerosis has been hypothesized for more than two decades.27-29 In recent years, however, the quantification of F2-IsoPs has allowed investigators to explore, for the first time, the extent to which humans undergo enhanced oxidant stress under patho-physiological situations associated with the development of atherosclerotic cardiovascular disease. These studies have found that increased levels of plasma and or urinary F2-IsoPs are associated with most of the risk factors for atherosclerosis, including hypercholesterolemia,30 diabetes mellitus,31-33 hyperhomocys-teinemia,34 and chronic cigarette smoking.35-37 This suggests that certain populations at risk for the disease are under increased oxidant stress.

Unique Characteristics Of Coronary Artery Disease In The Diabetic Population

These patients often lack other traditional coronary artery disease risk factors such as hypercholesterolemia, hypertension, tobacco use, and family history of premature coronary artery disease. In contrast, type 2 diabetes patients typically have several cardiovascular risk factors and present in the fifth or sixth decade of life, or later (26). A number of mechanisms may contribute to the increased atherosclerosis in diabetics in addition to conventional risk factors such as hypertension and hypercholesterolemia. These mechanisms include endothelial dysfunction, increased platelet activation and aggregation, coagulation abnormalities and abnormal plaque composition.

Taking Advantage of Agave Nectar

Additionally, agave nectar, sometimes called agave syrup, is full of other health benefits, including improving bacterial balance in the gut. When mixed with salt, it's a beneficial treatment for wound care. Inulin, one of the components of agave, may help lower cholesterol, reduce the risk of some cancers, and improve the absorption of nutrients, like isoflavones, calcium, and magnesium.

Nutrients That Can Help

Vitamin C and the B vitamin niacin (a form of B3, which causes a temporary flushing sensation) have been found to lower cholesterol levels and to lower levels of lipoprotein (a), a cholesterol fraction that increases the risk of heart disease. In addition, magnesium plays a crucial role in heart rhythm, and supplements can sometimes reduce arrhythmias.

Correction of dyslipidaemia

The evidence for cholesterol reduction in diabetes comes predominantly from subgroup analyses of clinical trials that included people with diabetes. In those with established cardiovascular disease, gemfibrozil and statins have shown significant reduction in coronary heart disease and cardiovascular events (Frick etal., 1987 Pyorala etal., 1997 Goldberg etal., 1998 Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group, 1998 Rubins etal., 1999 Heart Protection Study Group, 2002). In primary prevention, benefits have been shown with gemfibrozil (Frick etal., 1987 Koskinen etal., 1992) and a statin in a hypertensive population (Sever etal., 2003). In the only trial of primary prevention exclusively in diabetes, there was reduction in acute coronary events and strokes with atorvastatin (Colhoun etal., 2004). The primary target is lowering LDL-cholesterol and recent evidence supports rigorous goals (Heart Protection Study Group, 2002 Sever etal., 2003 Colhoun...

Impact Of Lipidlowering On Cardiovascular Endpoints

There are sufficient numbers of patients with diabetes in the major secondary prevention trials with statins to allow meaningful subgroup analyses. In the Scandinavian Simvastatin Survival Study (4S) (26) an initial analysis described the impact of simvastatin (20-40 mg day) on 202 patients with diabetes out of a total of 4444 patients with established CHD and raised cholesterol concentrations (212-309 mg dL, 5.5-8.0 mmol L). In the diabetic subgroup, simvastatin produced similar effects on serum lipid and lipoprotein concentrations over the course of the trial as in non-diabetics, with reductions in total and LDL cholesterol of 24 and 34 , respectively, an 8 increase in HDL and a 9 reduction in triglyceride. It should be pointed out that the entry criteria for 4S stipulated total serum triglycerides 220 mg dL (< 2.5 mmol L). These changes were associated with a significant reduction in major coronary events - relative risk (RR) reduction 0.45 (p 0.002). The reduction in the primary...

Macrovascular Disease

Cardiovascular disease, that includes coronary heart disease (CHD) rebrovascular disease, and peripheral vascular disease, is the leading cause of mortality in people with diabetes. The majority of deaths are due to CHD, where the risk is two- to fourfold greater in patients, especially women with diabetes, when compared with age-matched subjects without diabetes (11). The relative importance of the problem has been highlighted by recent studies. Gu et al. compared adults with diabetes with those without diabetes for time trends in mortality from all causes, heart disease, and ischemic heart disease. They based the data on the First National Health and Nutrition Examination Survey (NHANES) conducted between 1971 and 1975 and the NHANES follow-up conducted between 1982 and 1984. The nondiabetic men had a 36.4 decline in age-adjusted heart disease mortality compared with a 13.1 decline in diabetic men. In the nondiabetic women it declined 27 but in the diabetic women the rate increased...

The Collaborative Atorvastatin Diabetes Study

Effects of simvastatin on first major vascular event in patients who do or do not have diabetes according to presenting features and baseline blood lipid concentrations. CI, confidence interval. The numbers in columns two and three represent the number of individuals with a given characteristic total number in that group ( of total with the given characteristic). The last column represents the proportional reduction in risk (and CIs) the size of the rectangular box varies according to the relative number of subjects. (Adaptedfrom Collins R, Armitage J, Parish S, Sleigh P, Peto R. MRC BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes a randomised placebo-controlled trial. Lancet 2003 361(9374) 2005-16 with permission.) Fig. 1. Effects of simvastatin on first major vascular event in patients who do or do not have diabetes according to presenting features and baseline blood lipid concentrations. CI, confidence interval. The numbers...

Low Carbohydrate Diets

Carbohydrate, high-protein diet had indeed lost more weight than the people on the low-fat diets, but by twelve months both groups had lost the same amount of weight. A significant proportion of subjects in both groups dropped out of the study by one year (up to 50 percent in some studies). Since the studies were for one year only, it is hard to determine if one diet or the other would be detrimental to health. What was noted was that those on the Atkins diet had lower triglycerides and higher HDL cholesterol, whereas those on the low-fat diet had lower LDL cholesterol levels. There are no studies, however, that look at long-term benefits or hazards of the low-carbohydrate, high-protein diets, and so the ADA does not recommend them.

What Are The Potential Adverse Effects Of Highcarbohydrate Diets

During the 1980s and 1990s, a number of controlled intervention studies in healthy individuals who maintained their body weight showed that high-carbohydrate diets often resulted in higher blood TG levels and lower HDL-cholesterol levels - changes that are atherogenic and increase the risk of coronary heart disease - despite improved total and LDL-cholesterol levels (29). These findings sparked particular concern for people with diabetes because their lipid abnormalities tended to be higher TG and lower HDL-cholesterol level rather than the high total and LDL-cholesterol typically observed in non-diabetic individuals (18). Hence the magnified risk of atherosclerosis in people with diabetes might be related to blood lipid risk factors that are specifically worsened by high-carbohydrate diets. The mechanisms by which high-carbohydrate diets decrease HDL-cholesterol are also unknown and should be a priority in future research. In two recent cross-sectional studies of healthy adults, a...

Type diabetes and dyslipidaemia

Dyslipidaemia is common in type 2 diabetes and contributes significantly to the increased risk of CHD. The characteristic dyslipidaemia consists of elevated TG and low HDLc (Syvanne and Taskinen, 1997 Haffner, 1998). The Framingham Heart Study reported no difference with regards to total and LDL cholesterol levels between diabetic men and women compared with their non-diabetic counterparts. People with diabetes, however, have an increased proportion of small dense atherogenic LDL particles and twice the prevalence of low HDLc with high TG compared with non-diabetics (Tchernof et al., 1996 Laakso, 1997). of HDLc. For each 1 mmol l increase in LDL concentration, there was 1.57fold increase in the risk of CHD and for each increase in 0.1 mmol l of HDL cholesterol the risk was decreased by 0.15-fold (Turner et al., 1998).

Evidence For Sucrose Restriction In Diabetic Diets

Fructose has also been used as a sweetener in diabetic diets because it has a smaller blood glucose (GI 20) and insulin-raising effect than isocaloric amounts of sucrose. Concerns about its potential to raise TG and LDL-cholesterol levels have limited its use (20), but in amounts up to 12 of energy, no untoward effects have been seen in subjects with diabetes (79).

Cardiovascular Disease

The lower rate of myocardial infraction and angina in African Americans compared to whites with Type 2 diabetes is consistent with their lower serum triglycerides and higher HDL cholesterol levels (adjusted for BMI) (9). African American men and women with diabetes versus those without had significantly lower total LDL-cholesterol and triglycerides and higher HDL-cholesterol (NHANES II) (69) (Figure 9A.8). In contrast, LDL-cholesterol was slightly higher in white diabetics versus non-diabetics (68). These epidemiologic data showing lower rates of macro vascular disease and favorable lipids are consistent with the heterogenous pathophysiology of Type 2 diabetes in African Americans up to 30 of African American diabetics are insulin-sensitive with lower triglyceride and LDL-cholesterol levels (67,72). Also, non-diabetic African Americans compared to whites have higher HDL cholesterol levels and lower triglyceride levels (175-178). Panel A total cholesterol > 240 mg dl, (B)...

Obesity and dyslipidaemia

Obesity is associated with alteration in lipoprotein metabolism resulting in increase in total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDLc), very-low-density lipoprotein cholesterol (VLDL) and reduced level of high-density cholesterol (HDLc) (Hubert et al., 1983 Grundy and Barnett, 1990). Epidemiological studies such as the Framingham Heart Study and the Multiple Risk Factor Intervention Trial (MRFIT) showed a significant positive correlation between plasma cholesterol levels and increased risk of death due to CHD (Stamler et al., 1993). In the PROCAM study, involving 4407 German men aged between 40 and 65 years, without cardiac disease at the start of the study, the combination of high TG, TC and low HDL levels for example was associated with the increased risk of coronary heart disease. In men with plasma cholesterol levels above 6.5 mmol l with HDLc less than 0.9 mmol l, the risk of myocardial infarction over 6 years was as high as 20-30 per cent...

Overview of Diabetes Management Combined Treatment and Therapeutic Additions

In obese-diabetic patients who need to lose weight, a new nonsys-temically acting antiobesity drug, orlistat, may be a useful add-on. It possesses an inhibitory activity against gastrointestinal lipase A, thus selectively reducing the absorption of dietary fat in the gastrointestinal tract. After drug withdrawal, the lipase activity is rapidly restored, due to the continuous enzyme secretion. Orlistat has little or no effect on gastrointestinal enzymes other than lipase A such as amylase, trypsin, chymotrypsin and phospholipases. About 30 of dietary triglycerides remain undigested and is not absorbed, producing an additional caloric deficit compared to diet alone. Orlistat treatment also decreases the solubility and subsequent absorption of cholesterol, so improving lipid levels (both total and LDL cholesterol levels are reduced). More than 4,800 patients have received orlistat in clinical trials (the recommended dosage is 120 mg t.i.d. taken during meals), and the results...

Effects of Estrogen on Lipids and Lipoproteins

Oral estrogen reduces plasma total and low-density lipoprotein (LDL) cholesterol by 5 -15 , increases high-density lipoprotein (HDL) cholesterol by 10 and reduces lipoprotein(a) Lp(a) levels. A potentially adverse effect of oral estrogen is an increase (20 -25 ) in plasma triglycerides (50). The mechanisms of estrogen actions involve enhanced catabolism and clearance of LDL by increasing the number of LDL (apo-B E) receptors in hepatocytes, decreasing hepatic HDL receptors and reducing activity of hepatic lipase, thereby raising levels of HDL-cholesterol (HDL-C, mostly HDL-C2) and enhancing biliary excretion of cholesterol (59,60). The overall effect, therefore, is to reduce cholesterol accumulation in peripheral tissues and to increase its biliary excretion. In contrast to oral estrogens, the effects of transdermal preparations on serum lipids are negligible, probably related to the absence of a first-pass hepatic effect (61). Progestogens, especially the more androgenic ones, tend...

Blood Lipid Abnormalities

There are several kinds of lipids in your blood. HDL cholesterol is sometimes called good or helpful cholesterol. This lipid helps remove deposits from the insides of your blood vessels and keeps them from getting blocked. The target levels for HDL cholesterol in your blood are above 40 mg dl for men and above 50 mg dl for women. You can raise your HDL cholesterol level by getting more exercise, avoiding saturated fats, choosing more omega-3 and omega-6 fats, and lowering your triglyceride levels. LDL, or bad, cholesterol can narrow or block your blood vessels, which can lead to a heart attack or a stroke. The target level for LDL cholesterol in your blood is below 100 mg dl. High levels of LDL cholesterol are usually treated with medications called statins. Triglycerides are another kind of lipid in the blood. It is recommended that you keep your triglyceride level below 150 mg dl. Triglyceride levels are closely linked to blood glucose levels and can usually be lowered by making...

Dyslipidaemia diabetes and stroke

The relationship between dyslipidaemia and cardiovascular disease is qualitatively similar in diabetic and non-diabetic patients, but for any given level of cholesterol the absolute risk is higher for diabetics. The evidence that dyslipidaemia is a risk factor for stroke is conflicting, with a recent meta-analysis showing no apparent association (Prospective Studies Collaboration, 1995). Many studies, however, fail to distinguish between strokes caused by cerebral infarction or primary intracerebral haemorrhage. Evidence from Caucasian and Asian population studies confirms a positive association between total cholesterol levels and risk of cerebral infarction, which may be offset by a negative correlation between cholesterol and risk of intracerebral haemorrhage (Iso etal., 1989 Yano etal., 1989). Epidemiological evidence of such associations does not prove cause and effect, but leads to concern that extrapolation from such data to clinical practice may put patients at risk. Indeed,...

Role of combination therapy in diabetes and dyslipidemia

Despite the known pharmacologic effects of fibrates and nicotinic acid in ameliorating the underlying defects of diabetic dyslipidemia (increased triglyceride-rich lipoproteins low HDL cholesterol small, dense LDL particles), the role of combining these agents with statins remains uncertain and further clinical trials are needed. Trials like the VA-HIT and DAIS are supportive of the potential of adding fibrates to statins because combined lipid disorders are common in patients who have insulin resistance and type 2 diabetes. In short-term studies, statins and fibrates were more effective in normalizing all lipid abnormalities than either agent alone without significant risk for adverse events, including myositis 51,52 . Caution should be exercised in patients who have potential drug interactions (eg, cyclo-sporin, antifungal agents, protease inhibitors, erythromycin) or renal disease. Long-term trials of combination therapy with statins and fenofi-brate are in progress (Table 5). In a...

Improvement of endothelial function

Endothelial dysfunction leads to defects in insulin-mediated glucose uptake. Blockade of vascular nitric oxide synthesis with L-arginine analogue also impairs endothelial dependent va-sodilation. Endothelial function improves with exercise, a low-fat, low-carbohydrate diet, and with use of statins and ACE inhibitors (Table 5) 29,59,67 . Angiotensin I blockade has not shown any improvement of endothelial dysfunction, but benefit has been noted with peroxisome pro-liferator activated receptor gamma (PPAR-y) stimulator, antioxidants, hormone replacement therapy, and L-arginine 66,68,69 . In addition, the ACE inhibitor quinapril significantly improved endothelial function in multiple studies, both in normotensive volunteers and in subjects with coronary artery disease 70-77 .

Reactive protein and the etiology of atherosclerosis

Additional evidence suggesting that the lowering of CRP could be important in preventing CVD comes from recent research on the use of statin therapy in the primary prevention (i.e. in people who have no obvious heart disease when enrolled in the study) of acute coronary events (Ridker et al., 2001). Statins are very popular and effective drugs that reduce plasma-cholesterol and LDL-C levels. It is very interesting, however, that statins also reduce CRP levels. Work by Ridker et al. (2001) found that statin therapy could reduce the risk of acute coronary events associated with CRP even in the absence of elevated blood lipids.

Evidence from lipid lowering trials in diabetes

Past 10 years, a variety of randomized, controlled trials with hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) established the efficacy of these LDL-lowering agents in reducing cardiovascular outcomes. In four of these large trials (Scandinavian Simvastatin Survival Study 4S , Cholesterol and Recurrent Events CARE , Long-term Intervention with Pravastatin in Ischemic Disease LIPID , and Air Force Texas Coronary Atherosclerosis Prevention Study AF-CAPS TexCAPS ), subgroup analyses revealed similar coronary artery disease risk reductions in smaller numbers of diabetic patients compared with the general population. (Table 1) 15-21 . The most recent and largest trial (more than 20,000 subjects) was the Heart Protection Study (HPS) which randomized 5963 patients who had diabetes 22,23 . Of these, approximately 2000 had preexisting CHD 1000 had other occlusive vascular disease (including cerebrovascular disease), and 3000 had no evidence of CHD or other vascular disease....

Involvement Of Redox And Glycooxidative Mechanisms In The Pathogenesis Of Dn In Vivo

Evidence to support a role for oxidative and or glycooxidative stress in the pathogenesis of DN in vivo has come largely from studies of the effects of inhibitors of AGE formation and those of conventional exogenous antioxidants on renal function and structure in experimental diabetes. There are only limited data on the effects of these same interventions on renal injury in human diabetes, and on the impact of genetically induced alterations in antioxidant enzymes on renal injury in diabetic animals. However, there is increasing recognition that the renoprotective actions of interventions of proven efficacy in human DN, notably those of ACEIs and ARBs, may involve or at least are associated with, reductions in oxidative stress and AGE formation (142,143). Similarly, though not yet assessed with respect to DN, vascular protection afforded by statins in diabetics may be linked to antioxidant and anti-inflammatory, as well as lipid-lowering actions of these agents (155). Thus, at least...

Management of dyslipidaemia

Several large-scale, controlled, randomized clinical trials have established that intervention with statins reduces CHD risks. This is seen in both the primary and secondary prevention settings and it is mediated mainly by reducing the LDL cholesterol (Table 9.2). MANAGEMENT OF DYSLIPIDAEMIA 187 Table 9.2 CHD prevention trials with statins in patients with diabetes - subgroup analysis The link between increasing LDL and CHD is well established in statin trials. There is a roughly linear relationship between CHD events rates and LDLc levels on treatment with statins. Those at the highest CHD risk experience the greatest benefit from the decrease in LDLc and tends to plateau at lower LDLc level. The lowest event rate is in the CARE pravastatin group, who achieved a mean LDLc of less than 2.6 mmol l, which is in accordance with the NCEP guideline of LDLc target < 2.6 mmol l. The baseline LDLc level in 4S was 4.88 mmol l, in CARE 3.6 mmol l, and 3.88 mmol l in LIPID. In all these...

Metabolic control

Neuroischaemic patients should be regularly taking statins, angiotensin-converting enzyme (ACE) inhibitors and antiplatelet agents and these should be continued if the patient is admitted to hospital. Aspirin should not be stopped before angiography or angioplasty although if the patient is taking aspirin and clopidogrel, the latter should be stopped.

Recent Developments

1 The benefits of aggressive lipid-lowering treatment with statins in stable CHD patients were further supported in the Treating to New Target (TNT) study.3 In this study, 10 001 patients with clinically evident CHD and LDL-cholesterol concentrations of under 130 mg dl were randomized to daily doses of atorvastatin, 10 mg or 80 mg, for an average of 4.9 years. Over this time, a primary cardiovascular event occurred in 8.7 of individuals taking high-dose atorvastatin, compared with 10.9 taking low-dose treatment (22 relative reduction). A subanalysis of the study, involving 753 patients with diabetes, showed that high-dose statin significantly reduced the risk of individuals suffering a first major cardiovascular event by 25 compared with the low-dose (hazard ratio HR 0.75). The 80 mg dose also reduced the time to first cerebrovascular event by 31 (HR 0.69). On the basis of these results, clinicians should consider aggressive use of lipid-lowering therapies in all patients with...

Lipid changes during pregnancy and preexisting diabetes

Cholesterol levels and LDL-C levels increased up to 50 during normal pregnancy (107). Triglycerides may increase threefold during normal pregnancy (115, 116). Especially among women with DM2 who have increased triglycerides prepregnancy, the risk of progressive elevation in triglycerides to > 2,000 mg dL increases the risk for pancreatitis during pregnancy (117, 118). The goals of managing dyslipidemia during pregnancy are similar to those of nondiabetic patients with cardiometabolic risk, since diabetes is considered a cardiometabolic risk (119). Management includes dietary recommended limits of saturated fat < 7 of calories, cholesterol < 200 mg day, and eliminating trans-fatty acid-containing foods (119,120). Although specific exercise recommendations for lipid lowering during pregnancy with preexisting diabetes have not been established, postprandial walking among pregnant women with and without DM1 has been reported to significantly reduce triglyceride and cholesterol...

Preventing Microalbuminuria In Diabetes

Now there seems to be a very good foundation for substantial improvements of the prognosis for patients with type 2 diabetes (22, 25), and early treatment of hypertension leads to better prognosis, as does, but maybe to a lesser extent, improved euglycemic control. Clearly treatment with statins is also important, as documented in many studies, among others the Steno 2 study (17, 70). Now we have apparently completed the paradigm shift it is essential to normalize glycemia, blood pressure, and dyslipidemia in all patients with type 2 diabetes.

Studies examining nonglycemic therapies

No area of CVD research in diabetes has received more attention than lipid management. Numerous studies in primary prevention and secondary intervention with statins and fibrate lipid-lowering agents are underway 33 . The guidelines regarding lipid management are in flux based on the rapidly evolving landscape of clinical trials that have recently and soon will be reported. Recent guidelines discussed elsewhere in this issue reinforce prior recommendations that in high-risk patients like those who have type 2 diabetes mellitus, the low-density lipoprotein cholesterol (LDL-C) goal is less than 100 mg dL, but suggest that in the highest risk patients, such as those who have acute coronary syndrome or diabetes mellitus and clinical CVD, further lowering to an LDL-C level of 70 mg dL or less is ''a therapeutic option, ie, a reasonable clinical strategy'' 34 . A remaining question is how low should one go in managing lower risk patients who have diabetes mellitus Several trials addressing...

Multiple Riskfactor Reduction

The Heart Outcomes Prevention Evaluation (HOPE) trial, which was a nonhypertensive trial, showed the superiority of 10 mg of the ACE inhibitor, ramipril with statistically significant reductions in myocardial infarction, stroke, and overall cardiovascular mortality and morbidity, independent of blood-pressure effect and medications that were concomitantly used, including aspirin, statins, and other antihypertensive drugs. This data was especially impressive in the diabetic subgroup, where there was a 22 reduction in combined cardiovascular events that was statistically significant. Additionally, the HOPE trial demonstrated a 24 reduction in total mortality, a 24 reduction in overt The HPS (16) involved almost 6000 patients with diabetes. This represented more patients than all other studies with statins and diabetic patients combined. Of the close to 2000 patients with diabetes and known coronary disease, tremendous benefit was derived by simvastatin therapy at any level of LDL. The...

Metabolic Syndrome Definition and classification

Triglycerides > 1.7mmol l HDL-cholesterol Triglycerides > 1 .7 mmol l HDL-cholesterol Triglycerides > 1.7mmol l and or HDL-cholesterol shifted the focus from purely glycaemic control in the treatment of patients with type 2 diabetes to a more generalised approach in order to address treatment of cardiovascular risk factors with agents such as ACE inhibitors, statins and aspirin.

Multifactorial intervention

Eighty patients were randomly assigned to receive conventional treatment and 80 to receive intensive treatment, with a stepwise implementation of behavioural modification and pharmacological therapy that targeted hyperglycaemia, dyslipidaemia and microalbuminuria, along with secondary prevention of cardiovascular disease with aspirin. The goal of dietary intervention was a total daily intake of fat < 30 of the daily energy intake. Light-to-moderate exercise for at least 30min 3-5 times weekly was recommended. Smoking cessation was encouraged. All patients were prescribed an ACE inhibitor or angiotensin II receptor antagonist, and a daily vitamin-mineral supplementation. All patients received aspirin therapy, if not contraindicated. Hypoglycaemic agents were introduced if a patient was unable to maintain glycosylated haemoglobin A1c values below 6.5 . If a patient had hypertension, thiazides, calcium channel blockers and beta-blockers were added as needed on ACE inhibitor (or...

Approach To Treatment

130 80 mmHg is now accepted for most patients. It is also clear that patients with diabetes respond well to lipid-lowering therapy with HMG CoA reductase inhibitors (statins) and fibric acid derivatives, often showing better reductions in cardiovascular events and death rates than patients without diabetes. Detailed approaches to treatment of diabetes and reduction in cardiovascular risk are presented in subsequent chapters and will not be discussed here.

Triglyceride and highdensity lipoprotein intervention

Unlike the plethora of trial evidence of CHD risk reduction with statins, the evidence from drugs to decrease triglycerides or increase HDL cholesterol is sparse. A meta-analysis of 17 observational studies suggested a significant relationship of triglycerides with CHD, even after adjustment for HDL cholesterol, especially in women 33 . In the 4S trial, in post hoc analyses, patients who had the lipid triad (elevated LDL, elevated triglyceride, decreased HDL cholesterol) had the highest event rates in the placebo arm and the greatest risk reduction with simvastatin 34 . Despite a mechanistic plausibility of increased risk with these lipid abnormalities in patients who had metabolic syndrome and diabetes, few long-term randomized trials have been completed (Table 2). The largest, randomized clinical trial of fibrate therapy in patients who had diabetes was the Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial (VA-HIT) 38 . In this trial, 2531 men who had CHD were...

Cerebral Arteriosclerotic Vascular Disease

Patients with diabetes who have cerebral vascular arteriosclerotic disease should be on ACE inhibitors, statins, and platelet antagonists. Stroke is the third leading cause of death in this country, with more than 160,000 deaths occurring each year, and diabetic patients are at significantly increased risk. Triglycerides have also been shown to inhibit the progression of early carotid arteriosclerotic vascular disease, and the Losartan Intervention For Endpoint Reduction in Hypertension study (45) has demonstrated that losartan (Cozaar) can be effective in reducing stroke in hypertensive diabetic patients.

Revascularisation for Acute Coronary Syndromes Revascularisation in STEMI

One recent prospective cohort study from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) between 1995 and 1998 included data from 61 Swedish hospitals using 1-year mortality data from the Swedish National Cause of Death Register for 21 912 individuals with an index registry-recorded acute MI who were < 80 years old and survived to day 14 (Stenestrand and Wallentin, 2002). Early coronary intervention (< 14 days post-MI) was performed in 1245 (12 ) of STEMI patients, and the relative risk of death at 1 year was reduced (hazard ratio 0.65, 95 CI 0.46-0.91 P 0.012) (Stenestrand and Wallentin, 2002). Diabetic patients benefited similarly from early intervention (hazard ratio 0.36, 95 CI 0.22-0.61 P < 0.001). Furthermore, the benefits of revascularisation were independent of treatment with other secondary prevention therapies, such as with statins or beta-blockers.

Significance and treatment of individual risk factors

The mechanism of the hypertriglyceridemia is understood to result from varying sensitivities to insulin in the tissues in the individual's body. Defects in the ability of insulin to mediate muscle use of glucose and to inhibit lipolysis in adipose tissues seem to be the primary abnormalities causing the insulin-resistant state 10 . The resistance at the level of the muscle and adipose tissue leads to persistently higher ambient levels of insulin and free fatty acids. In response to the higher levels of free fatty acid, the hepatic tissue increases the rate of conversion of free fatty acids to triglycerides. This increased conversion is accentuated by the normal insulin sensitivity of the hepatic tissues in the face of compensatory hyperinsulinemia. The appreciation of the differences in the insulin sensitivity of the various tissues has led to better understanding of the abnormalities caused by insulin resistance. Although the classical diabetic dyslipidemia...

Efficacy of treatment

Statins Three studies, the 4S 28 , CARE 29 and LIPID 30 trials, evaluated the effect of statins in reducing morbidity and mortality in patients with an history of Finally, in the HPS trial 32 , comparing simvastatin 40 mg daily to placebo in high risk patients irrespective of their cholesterol levels, the rate of first occurence of any major vascular event (non-fatal myocardial infarction or coronary death, non-fatal or fatal stroke, coronary or non-coronary revascularisation) was significantly reduced by simvastatin. The beneficial effect was maintained also in the different subgroups of high risk patients and particularly in diabetics with prior MI or other CHD (33.4 vs. 37.8 ). Statins

Zeroing in on cholesterol

These days, just about everyone knows his or her cholesterol level. You usually find out your total cholesterol level, a combination of so-called good cholesterol and bad cholesterol. If your total is high, much of that cholesterol may be the good kind HDL (high-density lipoprotein) cholesterol. If you're interested in knowing the balance between good and bad cholesterol in your body, talk with your medical practitioner, who may recommend a lipid panel that delivers more details. The Framingham Study, an ongoing study of the health of the citizens of Framingham, Massachusetts, has shown that the total cholesterol amount divided by the good cholesterol figure gives a number that is a reasonable measure of the risk of a heart attack. People who had results that were less than 4.5 were at lower risk of heart attacks, while those with results of more that 4.5 were at higher risk. The risk increases as the number rises. More recently, another component of the total cholesterol in your...

The Benefits of Exercise for People with Type Diabetes

People with T1DM usually die of cardiovascular disease due to arteriosclerosis (narrowing of the arteries). Exercise reduces the frequency of all forms of arteriosclerosis by increasing good cholesterol (HDL), decreasing bad cholesterol (LDL), making the heart more efficient, and improving lung function.

Tracking Cholesterol and Other Fats

A second kind of fat found in the lipoproteins is triglyceride. Triglyceride actually represents the form of most of the fat you eat each day. Although you may eat only a gram or less of cholesterol (an egg yolk has one-third of a gram of cholesterol), you eat up to 100 grams of triglyceride a day. (For more on the place of fats in your diet, see Chapter 8.) The fat in animal meats is mostly triglycerides. As you might imagine, we need to know which particle your cholesterol comes from in order to understand whether you have too much bad cholesterol (LDL) or a satisfactory level of good cholesterol (HDL). You do not have to fast to do a test for total cholesterol and HDL cholesterol. However, you do need to fast for eight hours to find out your LDL cholesterol, because the blood has to be cleared of chylomicrons, which rise greatly when you eat. You should have a fasting lipid panel at least once each year. A fasting lipid panel gives you your total cholesterol, your LDL cholesterol,...

Glycemic Effect of

Total dietary fat intake in type 1 diabetes should be driven by serum lipid and body weight goals. As a rule, general guidelines for lowering cholesterol, total fat, and saturated fat are sufficient to maintain a healthy fat intake unless LDL cholesterol is elevated. However, individuals in the DCCT gained weight as glycemic control improved. This well-accepted phenomenon results from reduced glucosuria, improved metabolism, and, potentially, an enhanced ability to eat ad libitum with flexible insulin dosing schedules. Although adjusting insulin to carbohydrate intake can improve blood glucose control, total calories, and, particularly, fat calories associated with sweets can increase and need to be considered if weight is to remain stable.

Benefits Of Early Detection Of Coronary Artery Disease

Modification of cardiovascular risk factors beside diabetes may reduce morbidity and mortality from future events. Perhaps the most striking example is the recent demonstration of mortality reduction in lipid lowering trials. In the Scandinavian Simvastatin Survival Study, 2200 patients with coronary artery disease receiving simvastatin were compared to patients receiving placebo. Lowering cholesterol was associated with a 42 reduction in cardiovascular mortality and a 30 reduction in overall mortality. In the 5 of patients in the trial with diabetes, simvastatin treatment was associated with a 55 reduction in major coronary events (26,103). In the cholesterol and recurrent events (CARE) trial, in which diabetic patients comprised approximately 14 of the study population, there was a 25 reduction in coronary heart disease events (104). Based on secondary prevention trials such as these, the present National Cholesterol Education Program guidelines distinguish lipid-lowering therapy...

The Scientific Basis For Recommending Highmufa Diets For Diabetes

Many diabetes experts argue in favour of allowing a higher MUFA intake for people with diabetes, on the grounds that high-carbohydrate diets can increase blood glucose, insulin and TG levels and reduce HDL-cholesterol levels. A meta-analysis of nine studies with a total of 133 subjects comparing these two approaches to diet therapy in patients with diabetes revealed that high-MUFA diets (22-33 of energy intake total fat 37-50 energy) improved lipoprotein profiles as well as glycaemic control (19). Compared to high-carbohydrate diets (50-60 energy intake), high-MUFA diets reduced fasting TG and VLDL-cholesterol levels by about 20 and caused a modest increase in HDL-cholesterol (4 ) but had no effect on LDL-cholesterol. There was no evidence that high-MUFA diets induced weight gain in these tightly controlled studies. However, there are several limitations that need to be raised before deciding whether they provide sufficient evidence to formulate recommendations for therapeutic diets

HRT and Genetic Factors

Thus the estrogen associated risk for thrombosis may be increased in the presence of the prothrombin 20210 G A variant, the factor V Leiden mutation or platelet antigen-2 polymorphisms (95-97). A common sequence variation of the ER gene is associated with the magnitude of the response of HDL cholesterol levels to HRT in women with coronary disease (19). The same ERP genotype is also related to changes in the levels of SHBG, another index of estrogen action (95). It is also interesting that in the HERS trial high levels of Lp(a), which is largely genetically determined, were an independent risk factor for CHD events in the placebo group. HRT lowered Lp(a) levels and the cardiovascular benefit of HRT was significantly related to the initial Lp(a) levels and the magnitude of the reduction in the level (98). It appears therefore, that genetic factors may also contribute to the net clinical effect of HRT regarding CVD in postmenopausal women.

Nafld As A Cardiovascular Risk Factor

Data is emerging that NAFLD is an independent risk factor for vascular disease, which is the most common cause of death among patients with diabetes (1). Patients with NAFLD have a greater carotid intima-media thickness as well as a higher prevalence of carotid atheromatous plaques (51). The presence of NAFLD among patients with type 2 diabetes is associated with an increased risk of developing vascular disease, which is only partly associated with the presence of the metabolic syndrome (52,53). Similarly, ALT is independently predictive of the development of coronary heart disease (54). The mechanisms through which NAFLD may result in increased vascular disease are unclear and it is difficult to distinguish whether this is an association with the abnormal metabolic milieu that occurs in association with NAFLD or whether it is related to the increased lipid oxidation, inflammation and abnormal hepatic lipid metabolism that occurs with NAFLD. Certainly, lipid profiles among diabetics...

Lipid Changes in Diabetes and GDM

Compared with healthy pregnancy, in pregnancy complicated by type 1 diabetes (DM1) some observers, using small sample sizes (< 15), have found similar levels of plasma lipids including plasma triglyceride and HDL cholesterol levels (74, 75). However, a large longitudinal case (n 312) control (n 356) comparison found a significantly lower plasma cholesterol throughout pregnancy and a significantly lower plasma triglyceride by the end of the third trimester in women with DM1 (76). A more detailed investigation of the reduction in plasma cholesterol found that the lower total cholesterol in pregnancy complicated by DM1 was due to lower HDL, specifically the HDL-3 subfraction (77). The main apolipoproteins (apo) associated with HDL, apoAI and apoAII, were also lower in DM1. Nonesterified fatty acids were lower in mothers with DM1 than in controls (75). In GDM there was a higher total triglyceride and an increased triglyceride content of the lipoproteins (particularly VLDL and HDL) and...

Quantitativequalitative abnormalities of lipoproteins

VLDL levels has been attributed to increased hepatic production or decreased clearance of VLDL (111) and may be very significant in the development of arteriosclerosis in diabetes and in women (112). HDL levels in diabetes vary with the type of diabetes and, in some groups, with glycemic control. In type 2 diabetic patients, HDL levels are usually low and do not necessarily increase with improved metabolic control (107,110,113). The low HDL levels are secondary to an increased clearance rate by hepatic triglyceride lipase (114). In type 1 diabetic patients it has been shown that HDL cholesterol levels are low during poor glycemic control and increase to normal or above normal when adequate control is attained (108,110,115). Changes with improved glycemic control are less marked in women than in men (108). In type 1 black diabetic women, little association is observed between plasma lipid levels and glycemic control (115). Abnormalities in LDL lipid composition may also lead to altered...

Other Types Of Diabetes

If you have limited beta cell function, using prescription medicines that either decrease insulin effectiveness and or further decrease beta cell function can cause diabetes. For example, steroids such as prednisone and dexamethasone, which are used to treat inflammation, can cause blood glucose to rise in some people. Niacin, a drug used to lower triglyceride levels and raise HDL cholesterol levels, reduces insulin effectiveness and can cause an increase in blood glucose.

Polycystic Ovary Syndrome and Cardiovascular Risk

Women with PCOS have higher serum triglycerides, total and LDL cholesterol and lower HDL cholesterol levels than weight-matched regularly menstruating women (190). These findings however, vary and depend on the weight, diet and ethnic background. In a large study of non-Hispanic white women, elevated LDL-C was the predominant lipid abnormality in women with PCOS (191). An additional parameter contributing to the elevated cardiovascular risk is hypertension. Obese women with PCOS have an increased incidence of hypertension and sustained hypertension is threefold more likely in later life in women with PCOS (192). It is not clear whether this increase in hypertension is because of the PCOS status, obesity or both. PAI-1 concentrations in blood are higher in women with PCOS as compared to those not affected. PAI-1 levels have been shown to be positively correlated with triglycerides, basal insulin and abdominal obesity (193). It was shown that impaired fibrinolysis and particularly the...

Program for Early Diabetics

The total fiber content is between 25 and 50 grams daily. The HCF diet produces many positive metabolic effects, including the following lowered post meal hyperglycemia and delayed hypoglycemia increased tissue sensitivity to insulin reduced low-density lipoprotein (LDL) cholesterol and triglyceride levels and increased high-density lipoprotein (HDL) cholesterol levels and progressive weight loss. Dr. Anderson provided me some valuable information Yet, I found I could optimize my diet even better and get better results.

Use of Lipid Altering Therapy

Total cholesterol and LDL cholesterol, normal triglycerides, and established CAD, M The Veterans Affairs-HDL Intervention Trial (VA-HIT) showed that gemfibrozil, administered to male veterans with established CAD and whose only lipid abnormality was ''isolated low-HDL cholesterol'' (mean baseline LDL cholesterol 111 mg dL), resulted in a 22 reduction in the trial primary endpoint of coronary heart disease death or nonfatal MI during a mean 5.1-year follow-up. The beneficial effects were observed equally among diabetic and nondiabetic subjects. More recently, a once-daily, extended-release formulation of niacin (Nias-pan) has been approved by the U.S. Food and Drug Administration. This agent has been tested extensively in unselected patients with dyslipidemia as well as in diabetic patients with dyslipidemia and or features of the metabolic syndrome. Niaspan was shown to be efficacious in lowering elevated triglycerides and raising HDL cholesterol levels. Further, Niaspan was safe in...

Risk factors for diabetes

Elevated triglycerides HDL cholesterol metabolic syndrome. Other risk factors for type 2 diabetes mellitus include age of 45 years or older, family history of diabetes (parent or siblings), physical inactivity, ethnicity (eg, Afro-American, Hispanic, Native American, Asian American, or Pacific Islander), impaired glucose tolerance, history of gestational diabetes or delivery of a baby weighing more than 9 lbs, hypertension (blood pressure > 140 90 mm Hg in adults), high-density lipoprotein (HDL) cholesterol level below 35 mg dL and triglyceride level above 250 mg dL, polycystic ovary syndrome, and history of vascular disease 10 . Park and Edington 11 applied a prediction model using sequential multilayered perception neural network architecture. High BMI was the most significant risk factor other significant factors that predicted risk over time with variations in trajectory were elevated blood pressure, stress, elevated cholesterol levels, and fatty food intake.

Pathogenesis And Treatment Of The Macrovascular Complications Of Type Diabetes

Unlike patients with type 2 diabetes who have, if anything, a superabundance of CAD risk factors, patients with type 1 diabetes have a scarcity of traditional CAD risk factors. Lipid profiles are generally normal or even quite good with high levels of high-density lipoprotein (HDL) cholesterol when glucose is well controlled. Triglycerides and low-density lipoprotein (LDL) cholesterol are rarely elevated unless the diabetes is poorly controlled (13). Alterations of LDL particle size distribution are common in type 2 diabetes, in which small dense phenotype B LDL particles of increased atherogenic potential predominate as the consequence of insulin resistance (14). This shift in LDL particle size is rarely seen in type 1 diabetes. However, as in type 2 diabetes, glycation of apolipoproteins with an increased potential for lipid oxidation is noted in type 1 diabetes. This undoubtedly contributes in part to the excess atherosclerosis of poorly controlled type 1 diabetes (15). Oxidized...

Lifestyle Treatments for Hypertension

High blood pressure, or hypertension, goes hand in hand with diabetes and obesity, affecting about 75 percent of people with type 2 diabetes. The combination of the two increases your risk of developing eye, kidney, and heart disease and stroke. If you throw in abnormal cholesterol levels, which will be discussed later in this chapter, you have a potentially lethal combination that increases the risk of heart disease and stroke even more.

Hormone Replacement Therapy and Diabetes

Have your A1C tested two to four times a year. This test tells you about your blood glucose levels over the long term. Have your cholesterol and triglyceride levels checked as recommended by your provider. The progesterone in hormone replacement therapy can sometimes cause cholesterol levels to rise.

Fish Oils Protect the Heart

Early Arctic explorers made note of the rarity of coronary artery disease in Eskimos, despite their consumption of a high-fat and high-cholesterol diet. It wasn't until 1973 that two Danish researchers compared the diets of Arctic Eskimos to that of Greenland Eskimos, who ate diets similar to other Danes. The Greenland Eskimos, who consumed more saturated fat and cholesterol from meat and dairy products, had a higher rate of heart disease. Since then, many other studies have confirmed the heart-protective effect of omega-3 fatty acids, especially EPA. For example, a twenty-five-year study of dietary and health data of almost thirteen thousand men in seven countries found that elevated blood cholesterol levels were associated with heart disease only in areas where intake of omega-3 and omega-9 fatty acids were low. A separate study of four hundred people, conducted by Michel de Lorgeril, M.D., of Saint- tienne, France, found that adoption of a Mediterranean-style diet can greatly lower...

Diabetic Cardiomyopathy

Patients with diabetes have a four- to fivefold increased risk for developing heart failure thus, diabetes has a greater influence on the incidence of congestive heart failure than CAD. Using multivariate analysis, it has been shown that patients with diabetes have substantially higher incidence of congestive heart failure even after accounting for CAD, arterial blood pressure, cholesterol levels, and body weight. While it is common for many patients with diabetes to have various other contributing factors for heart failure, such as hypertension and ischemic heart disease, diabetic cardiomyopathy as a disease entity should be strictly limited by definition to the manifestation of myocardial dysfunction stemming primarily from diabetes. Studies have suggested that approximately one-third of diabetic patients have subclinical or asymptomatic myocardial dysfunction that is primarily attributable to the metabolic derangements of diabetes.

Nutrients And Cardiovascular Risk Factors

With the advent of the DCCT and a focus on intensive blood glucose control, the glycemic effect of the diet has been the central focus in the nutritional management of diabetes. Clearly, optimizing blood glucose levels is paramount to preventing the microvascular and macrovascular complications of diabetes, yet the risk of cardiovascular disease in diabetes is great. Elevated triglycerides, low high-density lipoprotein (HDL), and elevated LDL levels are common in untreated type 1 diabetes but normalize with intensive glucose control. Normal LDL concentrations generally characterize Individuals with type 1 diabetes respond to lipid lowering as well as persons without diabetes therefore, the National Cholesterol Education Program (NCEP) and ADA nutrition guidelines for altering dietary fat intake seem prudent (see Table 1). Dietary fat, however, is not the only nutrient impacting cardiovascular risk. Dietary fiber has shown a slight correlation with serum cholesterol levels and reduced...

Lipid Changes in Normal Pregnancy

Pregnancy is marked by hyperlipidemia (64, 65). There is a hypertriglyceridemia with very low density lipoprotein (VLDL) triglyceride concentrations increasing threefold from 14 weeks, gestation (66) to term. Postheparin hepatic lipase and lipoprotein lipase activities are decreased from the first and third trimesters, respectively (64). The increase in plasma triglyceride concentration results in the appearance of small dense low density lipoprotein (LDL) particles in late pregnancy (67). Plasma cholesterol levels rise to a lesser degree due to an early decrease in LDL followed by a modest continuous rise in high density lipoprotein (HDL) (particularly the HDL-2 subfraction) by over 40 after 14 weeks, gestation (66). A fall in plasma HDL after the end of the second trimester has been observed by some researchers (68). These changes in lipoprotein concentrations are associated with the progressive increases in the levels of the major pregnancy hormones estradiol, progesterone, and...

Combination Therapy Is Mandatory For Most Patients To Reach Target Values

As clearly stated by recent guidelines (80,81) most patients with diabetes will require two or more antihypertensive therapies from different classes with complementary mechanisms of action to control their blood pressure. Thiazide diuretics, BB, or CCB can be added to ACEi or ARB treatment to achieve target BP, either as an individual drug component or as part of a fixed-dose combination product. Combining an ACEi or an ARB with a thiazide diuretic may be particularly effective, as such combinations provide additive reductions in blood pressure compared with individual monotherapies, and counteract many of the adverse events that may be associated with the use of high doses of thiazide diuretics (82,83), and abolish any interracial differences in the response to ACEi or ARB monotherapy (84,85). For example, coadministration of irbesartan and hydrochlorothiazide, either as individual components or in a fixed dose combination, leads to additive reductions in blood pressure in a diverse...

What are the targets for reduction of blood lipid levels in the diabetic patient

The current guidelines from the USA National Cholesterol Education Program - Adult Treatment Panel III (NCEP-ATP III, 2002) determine that initially the concentration of LDL-C (a level of LDL-C < 100mg dl, and not the level of other lipids such as HDL-C, triglycerides, etc.) should be taken into consideration before therapy is initiated, since abundant data exist from analyses of diabetic subgroups of large clinical studies (and recently from studies exclusively in diabetic patients as well), that the reduction of LDL-C improves these patients' survival. The treatment target for LDL-C in diabetic individuals is the same as for non-diabetics with a history of coronary heart disease (CHD), since DM is considered equivalent to CHD. Thus, the objective is to achieve an LDL-C level < 100 mg dl (2.59 mmol L), while an LDL-C level > 130 mg dl (3.36 mmol L) is considered to be an indication to start pharmaceutical hypolipidaemic treatment. For LDL-C levels 100-129 mg dl (2.59-3.34 mmol...

Epidemiological studies weakening the iron hypothesis

Possible confounding factors are important to be taken into account before concluding any results from epidemiological studies. For atherosclerosis studies, it is necessary to involve an older population, since atherosclerosis progresses with age and the effect of iron on the incidence of severe atherosclerotic events can only be expected in such a population. In addition, excess iron alone as a risk factor may not be sufficient to demonstrate statistically significant different in cardiovascular events, as atherosclerosis is a multifactorial disease. The most recent study (Wolff et al. 2004) identified a relationship between serum ferritin levels and carotid atherosclerosis, and this correlation was even stronger when low-density lipoprotein (LDL)-cholesterol levels were taken into account.

Historical Perspectives On Carbohydrate

By the 1970s pharmaceutical treatments had expanded with the introduction of oral hypoglycaemic drugs and the average carbohydrate intake rose to about 40 energy. Prohibition of sucrose was now the main message. With extreme caution, several experimental studies compared higher carbohydrate diets (> 50 energy) with the traditional diabetes diet and found improved glucose tolerance or insulin sensitivity (12-14). In the late 1970s, there was a revolution in thinking about diabetic diets and a spurt of experimental studies indicated that high-carbohydrate diets were no worse, if not better, for people with diabetes because they lowered blood cholesterol levels (see below). By then, low-fat, high-carbohydrate diets were being recommended for the prevention and treatment of cardiovascular disease in the general population.

What other sexual disturbances apart from erectile dysfunction can occur

A 55 year old man has suffered from Type 2 DM for 5 years, and is treated with oral antidiabetic medicines. He does not regularly monitor his blood sugar levels (he is rather negligent). He has smoked since the age of 37 years (1 -2 packs day), and has high blood pressure and cholesterol levels. He was recently prescribed an ACE inhibitor with diuretic combination and a statin for this reason. Recently, he also complained of pains in his calves when walking. He visited his family doctor, who detected decreased peripheral pulses in the lower extremities bilaterally. When asked by the doctor, the patient admitted to recent, significant problems with achieving and maintaining an erection, which he attributes to the blood pressure medicines, and which he contemplated stopping. What is the proper management of the patient

Current state of affairs and future directions

Although the wisdom of addressing multiple risk factors seems to be intuitively obvious, this approach is not what transpires in practice. Data from National Health and Nutrition Enhancement Survey 1999-2000 reveal that only 37 of adults with diagnosed diabetes in the United States are achieving the ADA goal of glycosylated hemoglobin levels less than 7 44 . In addition, 37 of adults with diagnosed diabetes have glycosylated hemoglobin levels greater than 8 . Only 36 of individuals with diabetes have achieved the current goals for blood pressure set in the JNC 7. More than half the individuals with diagnosed diabetes have cholesterol levels above

CVD Morbidity and Mortality in Diabetic Women The Evidence

Well-designed population-based studies have shown an increased risk for fatal and nonfatal CVD among women with DM. Analysis of data from the Framingham Heart Study and the Framingham Offspring Study evaluated the gender-specific effect of DM and established CHD on subsequent mortality in adults. Risk for CHD was adjusted for age, hypertension (HTN), cholesterol levels, tobacco use, and body mass index (BMI). The increased risk ratios for death from CHD were 2.1 in men with diabetes only, and 4.2 in men with CHD only, compared with nondiabetic men without CHD. The diabetes-related increased ratio for CHD death was 3.8 in women with diabetes and 1.9 in women with CHD. Thus, these data indicate that men with established CHD have higher risk for CHD mortality than diabetic men. In contrast, in women the presence of DM was associated with a greater risk than established CHD for subsequent CHD mortality (10).

Recent studies on diabetes and the benefit of good glucose control

It is important that people with diabetes not make any changes to their treatments or adjust their blood glucose targets without speaking to their healthcare team. In addition to blood glucose control, people with diabetes can reduce their overall cardiovascular risk by controlling their blood pressure and cholesterol levels and by adopting a healthy lifestyle that includes quitting smoking.

The Homo sapiens Genotype

One common theme seems to be that fats and sugars were generally scarce. Even though protein intake was high, the intake of fats was remarkably lower than anticipated. Game tends to be leaner than farmed animals on account of the animals' diets and yields a more favorable polyunsaturated saturated (P S) ratio. Although the total cholesterol contained in such diets has been estimated to be higher than present-day ideal levels, it is quite likely that cholesterol levels in blood proved low -thanks to the combination of the polyunsaturated fatty acids mentioned and the exertion of physical activity, which amply exceeded present levels (12). Ross (13) points out that the limitations set by energy led hunters to opt for species rich in fats. Perhaps that explains the high protein intake as a way to obtain enough calories.

Metabolic Syndrome see also Chapter

Hypertension is frequently associated with insulin resistance (and concomitant hyperinsulinaemia), central obesity and a characteristic pattern of dislipidaemia (high triglycerides and low HDL-cholesterol) (Reaven etal., 1996 Reaven, 2002). The relation between insulin resistance and hypertension is well established (Modan etal., 1985 Ferrannini etal., 1987 Swislocki etal., 1989 B hler etal., 1990 Ferrari and Weidmann, 1990) but, despite this association, insulin resistance contributes only modestly to the prevalence of hypertension (Hanley etal., 2002). This constellation of risk factors is known as the (cardiovascular) metabolic syndrome. There are various definitions but all agree on the essential components - glucose intolerance, obesity, hypertension and dyslipidaemia. High triglyceride or low HDL-cholesterol Goals reduced intakes of saturated fats, trans-fats and cholesterol Recommendations saturated fat, 7 of total calories dietary cholesterol < 200mg daily total fat 25-35 of...

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