In people diagnosed with dyslipidemia, if they have comorbid diabetes, is lipid-modifying therapy affected by blood glucose and what are the considerations?
How are lipid-regulation goals set?
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Dyslipidemia in people with diabetes is usually characterized by elevated triglycerides, decreased “good” cholesterol HDL-C (high-density lipoprotein cholesterol), and elevated or normal “bad” cholesterol LDL-C (low-density lipoprotein cholesterol). Lipid-modifying therapy can significantly reduce the risk of cardiovascular events such as myocardial infarction in patients with diabetes, so it is an integral part of the treatment strategy for patients with diabetes.
So, with diabetes, is it enough to lower the lipid target to the same range as the labs? In fact, most people with diabetes need to have their LDL-C lowered. Doctors usually base their decision on the risk of cardiovascular disease in the next few years. Patients ≥40 years of age with diabetes are considered to be at high risk, with a risk of future cardiovascular disease of no less than 10%, and the recommended LDL-C control goal is <2.6mmol/L, and HDL-C can be controlled above 1.0mmol/L. If a patient with diabetes already has atherosclerotic disease such as coronary heart disease or stroke, he or she is at "very high risk" and LDL-C should be controlled even lower, down to <1.8 mmol/L.
How to choose a fat-adjustment strategy?
Both dyslipidemia and diabetes require exercise, but dietary control is also fundamental to treatment because of the impact that fat and calorie intake can have on blood glucose and lipids. In simple terms, the dietary strategy is “control calories and fat and consume a balanced diet. In addition to following a dyslipidemic diet, people with diabetes can consider the following low-fat diet tips.
- Avoid fatty cuts of meat and choose poultry, fish, and lean meats. When cooking such foods, avoid frying them and instead bake or poach them. You can also choose proteins from plant sources, such as beans.
- Consider low-fat dairy products such as low-fat cheese, skim milk, skim yogurt, skim evaporated milk, and buttermilk when choosing dairy products. Be sure to consider dairy products when calculating your daily caloric intake.
- Use low-fat cooking sprays when preparing foods.
- Choose low-fat dressings and sauces and pay attention to the carbohydrate content of the dressings and sauces.
- All fruits and vegetables are excellent low-fat foods. Remember to include fruits and starchy vegetables in your daily calculated carbohydrate content.
- Healthy fats such as polyunsaturated and monounsaturated fatty acids may help reduce the risk of heart disease. Consider almonds, pecans, cashews, peanut butter, cold-water fish high in omega-3 fatty acids (such as mackerel, salmon, and tuna), and olive, safflower, and canola oils.
Patients with diabetes usually require lipid-modifying drugs on top of dietary control and lifestyle improvement because LDL-C needs to be controlled at lower levels. Statin is usually the drug of choice, and when control is suboptimal, your doctor may recommend adding a drug such as a cholesterol absorption inhibitor. If triglycerides are significantly elevated or if the “good cholesterol” HDL-C (or high-density lipoprotein cholesterol) is too low, a combination of fibrates may also be indicated.
What are the precautions?
What are the precautions?
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Like the general population, people with diabetes need to be reviewed while on lipid-modifying therapy to observe the effects of treatment and to facilitate timely detection of liver and muscle adverse effects. Within 6 weeks of the first dose of lipid-regulating medication or the addition or change of medication, blood lipids, liver function, and muscle-related markers are typically reviewed. Thereafter, the physician will recommend the frequency of rechecking based on lipid levels.
It is important to note that long-term statin use has an increased risk of new-onset diabetes, with an incidence of about 10% to 12%, which is a common effect of statins as a class of drugs, independent of which drug is chosen. During the application of a statin, physicians also pay attention to the effect of the drug on blood glucose and develop a monitoring program accordingly. Because the overall cardiovascular benefits of statins far outweigh the risk of new diabetes, both those at high risk for diabetes and those with diabetes should be adherent to statins when they are appropriate.