Smoking in a person with diabetes is particularly harmful. It not only increases the already raised risk of macrovascular disease, but it also increases microvascular complications, particularly nephropathy and retinopathy. Patients with diabetes who smoke should be actively targeted for smoking cessation interventions.
Current evidence suggests that, despite their raised cardiovascular risk, people with diabetes may not in fact benefit from low dose aspirin as previous guidelines suggested, and further research is under way to clarify this issue.
There is increasing interest in the pharmacological treatment of obesity, but this approach should be part of a structured programme of monitoring and follow-up if it is to be effective. Licensed preparations available in the UK include orlistat and sibutramine. Obesity drugs are discussed further on pages 94-96.
Exercise and physical activity are important means of reducing cardiovascular risk and are discussed on pages 45-46. Without regular exercise, attempts to lose weight are much less likely to succeed. Any amount of physical activity is beneficial, but a regular habit of moderate exercise for at least 30 minutes on 5 days of the week is recommended for all patients if at all possible, as it is for the general public.
Most existing trial evidence concerns the effect of a single intervention on CVD outcomes. Very few well-designed studies on multifactorial interventions have been published to date. A seminal study in this regard was Steno-2, which provided evidence of the
Figure 5.6 Cumulative incidence of cardiovascular events (a), and of death (b) in the Steno-2 study. Reproduced with permission from Gaede P. N Engl J Med 2003;348:383-93.
cardiovascular benefits of multifactorial intervention in diabetes (Figure 5.6). One-hundred and sixty type 2 patients with microal-buminuria were randomised to receive conventional treatment in accordance to national Danish guidelines or to an intensive treatment arm. This involved stepwise implementation of behaviour modification and pharmacological treatment that targeted hyper-glycaemia, hypertension, dyslipidaemia, microalbuminuria and secondary prevention of cardiovascular disease with aspirin. At the end of the 7.8 year study period there were significant reductions in HbA1c%, systolic and diastolic blood pressure, serum cholesterol and triglycerides, and urine albumin excretion in the treatment group. Patients receiving intensive treatment had a significantly lower risk of cardiovascular disease by about 50%. At the end of the treatment period all the patients were offered intensive treatment and were further followed up for an additional 5.5 years. Despite convergence of most of the risk factors between the groups there was an additional 20% benefit in CVD-related deaths in the original intensive treatment group. This suggests that treatment of multiple risk factors should be started early.
The Alphabet Strategy is an 'ABC of reducing diabetes complications' published in 2002 and is summarised in Boxes 5.4 and 5.5.
Box 5.4 The Alphabet Strategy
An ideal management programme should as a minimum address the following issues in the Alphabet Strategy format:
• Advice: Education, self-management, compliance. Special focus on exercise, diet, weight reduction, cessation of smoking
• Blood pressure: Optimal control usually less than 130/80 mmHg, in most cases initial treatment will be with an ACE inhibitor/ARB often in combination with a diuretic
• Cholesterol treatment: Total cholesterol <4.0 mmol/l, LDL <2.0 mmol/l, HDL >1.0 mmol/l and triglycerides <1.7 mmol/l. Statin if cardiovascular disease risk >20% over 10 years
• Diabetes control: /deal HbAlc target 6.5% (48 mmol/mol), metformin first line in most patients. Early recourse to multiple therapy and insulin if targets not reached
• Eye care: Detailed yearly examination and appropriate referral. Aggressive management of vascular risk factors if retinopathy is present
• Feet care: Detailed yearly examination and appropriate referral. Aggressive management of vascular risk factors if neuropathy and peripheral vascular disease is present
• Guardian drugs: Microalbuminuria/proteinuria patients should be considered for ACE inhibitors or ARB. Statins for secondary prevention and primary prevention in those with cardiovascular disease risk >20% over 10 years.
• Heart disease/CVD score: To educate patients, guide treatment and as a surrogate clinical audit parameter to analyse the effect of multifactorial intervention
Box 5.5 Alphabet strategy advice for patients
2. Maintain ideal body weight for adults (body mass index 20-25 kg/m2) and avoid central obesity (waist circumference in white Caucasians <102 cm in men and <88 cm in women, and in Asians <90 cm in men and <80 cm in women
3. Keep total dietary intake of fat to <30% of total energy intake
4. Keep intake of saturated fats to <10% of total fat intake
5. Keep intake of dietary cholesterol to <300 mg/day
6. Replace saturated fats by an increased intake of monounsaturated fats
7. Increase intake of fresh fruit and vegetables to at least five portions per day
8. Regular intake of fish and other sources of omega-3 fatty acids (at least two servings of fish per week)
9. Limit alcohol intake to <21 units/week for men or <14 units/week for women
10. Limit intake of salt to <100 mmol/l day (<6 g of sodium chloride or <2.4 g of sodium per day)
11. Regular aerobic physical activity of at least 30 minutes per day, most days of the week, should be taken (for example, fast walking/swimming)
Table 5.3 Cardiovascular disease outcomes in the CARDS study.
Fatal myocardial infarction
Was this article helpful?
What will this book do for me? A growing number of books for laymen on the subject of health have appeared in the past decade. Never before has there been such widespread popular interest in medical science. Learn more within this guide today and download your copy now.