Type 1 and Type 2 diabetes are already challenging diseases to handle, never mind the added burden of other diseases to which they predispose people. But, as Sage60 found out, though cardiovascular disease is one such related disease, there are steps diabetics can take to mitigate the odds of developing it.
The connection
“Diabetes and heart disease are tightly connected chronic diseases that impact a large proportion of Canadians,” says Kirstin Clemens, assistant professor in the department of Epidemiology and Biostatistics at the University of Western Ontario’s Schulich School of Medicine & Dentistry in London. “[In both men and women], diabetes brings high blood sugars, and high blood sugars can be damaging to blood vessels, and they can make the blood vessels build up plaque in the arteries and the heart and that is what causes heart disease. [Also,] high blood sugars lead to inflammation, and inflammation isn't good for the body and it's not good for the heart vessels either.”
In addition, diabetes makes blood more prone to clotting, and if blood clots get into the small vessels around the heart, that can also lead to heart troubles. Alternatively, if clots get into small vessels around the brain, they can lead to stroke. Newer research shows that diabetes also can affect the heart itself.
“We often think of diabetes in connection with heart attack and stroke, but it can also lead to heart failure,” Clemens says. “It can directly affect the heart tissues and make them not pump as well as they once did, [potentially] leading to congestive heart failure.”
“Then there's another type where [diabetes] makes the heart walls kind of thick and stiff, and it can't pump effectively,” Clemens says, adding that both of these conditions can result in patients with Type 1 and Type 2 diabetes.
Type 2 patients can develop heart disease “because of the company that diabetes keeps. Type 2 patients' diabetes is often associated with obesity. It can also be associated with high blood pressure and cholesterol problems, and those can also be linked with heart disease."
Mitigating the compounding effects
In keeping with much health advice, Clemens says the best way to avoid getting heart disease if you’re a diabetic is being conscious of lifestyle choices.
“Whenever we're treating people, we’re always thinking about prevention first, and the best way to prevent heart disease is to work on maintaining a healthy weight and trying to manage obesity,” she says. “These things would not only help with diabetes control, but with lowering blood pressure and cholesterol, which can then help to reduce the risk of diabetes progression and heart disease. Lots of research studies have investigated the role of lifestyle interventions.”
Physical activity is also important. Clemens recommends diabetics do at least moderate exercise most days of the week, and add in regular resistance training.
“[Exercise] can help with high blood pressure, cholesterol and blood sugars as well,” she says. “Diet and exercise alone we think can reduce the risk of cardiovascular disease by about a third compared to people who don't do these activities. That can be pretty powerful.”
There are also some exciting new medications becoming available, mostly for people with Type 2 diabetes.
“They can certainly help with weight, but they also protect the heart, and they protect people with diabetes from stroke. We use them quite a bit, and they've made a big difference for people living with the disease.”
The GLP-1 class of drugs, which have been just found to be cardiovascular-safe according to Erin Mulvihill, director of the Energy Substrate Metabolism Research Laboratory at the University of Ottawa Heart Institute, are drugs those with diabetes can take.
There are other drugs — known as SGLT2 inhibitors — that help the body rid itself of blood sugars through urine, rather than re-absorbing them, and as such, they help protect against heart failure and kidney disease.
“These are kind of game changers for people with Type 2 diabetes,” Clemens says.
Women at a higher risk
Heart disease is the leading cause of death in women, and those with Type 2 diabetes are at particular risk. Compared with men, having Type 2 diabetes brings a much higher risk of heart attack, heart failure and strokes in women. She says it may be due to hormones or differences in physiology, or even gaps in women’s treatment.
“Women may not be using some of these new medicines, like the SGLT2s and cholesterol pills as often as men due to a variety of different reasons,” Clemens says. “We’re trying to understand whether [these] differences in sex are apparent across Canada. And then, more importantly, [we'll] work with women to understand how we can equalize that risk, or not have that disparity.”
Josep Iglesies-Grau, a cardiologist at the Montreal Heart Institute, says women are underrepresented in research.
“I think it's important to pass the message that, in general, women are less diagnosed, less treated, underrepresented in research, and that more efforts should be put on all these issues, particularly aged women living with Type 2 diabetes and heart disease.”
He says when diabetes hits women, it causes atherosclerosis (the building of plaques in the arteries) which accelerates rapidly, diminishing lifespan and healthspan.
“So it’s not only the number of years you live, but the quality of those years, too,” he says.
Mulvihill says menopause also plays an aggravating role in women with diabetes for several reasons, one of which is lack of sleep.
“Exercise is really important, but you also need the energy to exercise, so if you can improve your quality of sleep, improving some of these other factors can be easier,” Mulvihill says, adding that a drug called Fezolinetant has been shown to help menopausal women sleep. “I think sometimes we just think, ‘This is just the aging aspect,’ and it is, but it's also, this very sex specific shift in cardiovascular risk and it's multifactorial.”
She says women may feel heart attacks differently than men — so not the chest-clutching pain, theirs are more subtle, such as pressure or squeezing in the chest, extreme fatigue, jaw and back pain, feelings of indigestion, heartburn or left-arm pain to name a few. But women at risk can protect themselves by advocating for traditional therapies for managing issues such as hypertension.
“Don’t be afraid to ask for [these drugs],” Mulvihill says.
And on the subject of changes in menopausal women that become risks for heart disease, she says it’s important to understand that they are indeed natural changes.
“This is not a failure of discipline. There's a shift in physiology that accelerates risk that we want to mitigate. We really want women to advocate for themselves, and not feel like they’re failing by aging.”