An Apple or a Pear?

At the food court in the mall there are three people in line waiting to buy pizza. The first person in line is a man who is 6 feet tall and weighs 250 pounds. He is very muscular and has no discernable body fat. The second is a woman who is 5 feet 2 inches tall and weighs 131 pounds, but has a lot of belly fat.  The third person is a woman, 5 feet 6 inches tall and 149 pounds, with heavy legs.  What is the risk for heart disease for these three people?

Obesity is a well-known risk factor for heart disease. There are a variety of ways to measure obesity. The body mass index  (BMI, derived from a formula using weight in pounds and height in inches) is the standard measure used to define whether patients are normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9) or obese (BMI > 30).  There is a strong relationship between BMI and heart disease. An elevated BMI (obesity) significantly increases the risk for developing heart artery disease.  However, BMI is only a crude measure. It doesn’t distinguish the total fat content of the body, the body shape or the distribution of the fat. Waist circumference can detect abdominal fat and the presence of central obesity (a “fat belly” or “love handles”).  Obesity is defined by a waist circumference >40 inches in men and > 35 inches in women.  An elevated waist circumference is associated with heart artery disease and increased risk for cardiac death. Other measures to assess the body’s fat content and distribution include CT scan, MRI and nuclear imaging. While very accurate, these tests are expensive and not used routinely.  So BMI, may not be the best measure to assess cardiac risk. For example, take our muscular mall man.  His BMI is elevated at 34, but he has no body fat and the high BMI may be due to increased muscle mass.  His risk for heart disease may be the same as someone with a normal BMI. What about the two ladies? They both have a normal BMI (24), but is one more at risk than the other?

It turns out that where the fat is located is just as important as how much fat a person may have.  The Framingham Heart Study showed that patents with increased abdominal fat, fat around the midsection or central obesity, had higher risk for heart disease than those with fat elsewhere.  This was true for both men and women and independent of the BMI. In other words, even if the BMI is normal, an increased amount of stomach fat confers a higher risk for heart disease. The Women’s Health Initiative adds to the data. In postmenopausal women with normal BMIs, the presence of excess abdominal fat was associated with a higher risk for cardiac death compared with women without central obesity. In addition, they found that postmenopausal women with normal BMIs and high abdominal fat were at risk for heart artery disease, while those with elevated leg fat were at low risk for heart artery disease.  The combination of low leg fat and high abdominal fat conferred the highest risk for heart disease. Why does the distribution of fat matter? The biologic function of fat depends on where it is located. Abdominal fat interferes with blood sugar regulation and lipid storage, leading to diabetes, elevated triglycerides, high blood pressure and subsequent heart disease.  Leg fat is associated with less metabolic disturbance and thus lower risk for diabetes, cholesterol problems and heart disease. 

Body shape is a stronger predictor than BMI for heart disease.  The regional distribution of fat is more important than the total amount of fat. An increased waistline and excess abdominal fat can lead to heart disease in both men and women, regardless of BMI. Older women with normal BMIs and with fat around the midsection (“apple-shaped”) are at higher risk for heart disease than women with fat around the thighs (“pear-shaped”). 

Like a Heat Wave, Burning in My Heart

On a nice sunny California day, you find yourself hiking through the redwood forest in Yosemite National Park.  As you come around a bend to a small opening among the trees, you find a husband and wife in the clearing. The wife comes up to you, she is frantic and says that her husband is not acting right and may have had a seizure.  You approach the husband and note that he is very sweaty, flushed in the face, confused and not answering questions coherently. You suspect that he has a heat related illness. Despite his protestations, you are able to coax him into the shade and apply cold-water compresses. The park rangers are notified and they transport him to an Emergency Room. 

Heat related illnesses range from benign heat cramps, to heat exhaustion, to heat stroke, a life-threatening emergency. Our Yosemite hiker likely had heat stroke. Heat related illnesses are becoming more prevalent with global warming and heat waves that occur more often and that are more intense.  In fact, last month, June 2019, was the warmest June ever recorded. The hot June was mostly driven by a heat wave in Europe.  Temperatures in France topped 110 degrees and in Athens the Acropolis was closed due to the heat.  There seemed to be no escape from the heat in June as Anchorage Alaska hit 90 degrees for the first time ever.

Heat stroke is a medical emergency and must be recognized and treated immediately. There are two types of heat stroke. In classic heat stroke, there is exposure to excess heat, as during a heat wave. The body cannot dissipate the heat in the environment. It occurs in the elderly, in chronically ill patients and in those who cannot take care of themselves (for example an infant in a hot car).  Exertional heat stroke occurs with excess production of heat. The body’s ability to dissipate the heat is overwhelmed by the heat produced. It strikes those who do strenuous physical activity, such as athletes, farm laborers, firefighters and soldiers. It does not always occur in hot weather and can happen at any time. Often overmotivation from peers or coaches drives the victim beyond what they can handle. In both types, there is a very high body temperature (often over 104 degrees), which leads to break down of tissue within the body, followed by multiorgan failure and, if not treated, death. 

Symptoms of heat stroke include high fever, fast heart rate, fast breathing, and low blood pressure. In exertional heat stroke there is sweating but the skin is dry in the classic form, reflecting the fact the body can’t adapt to the heat. The brain is very sensitive to high fever and heat stroke victims can have confusion, dizziness, agitation, combativeness, slurred speech, nausea, vomiting, seizures and loss of consciousness. The muscles of the body can break down and there is often kidney and/or liver damage as well.  The treatment of heat stroke is to cool the patient as quickly as possible. In the exertional form, immersion in cold water is often used.  In elderly, classic heat stroke victims, immersion is not practical so strategies include infusing a cool solution via an IV line, application of cold packs and using a cooling blanket. Promptly diagnosing heat stroke and rapid cooling often reverses heat associated organ problems, without long-term consequences. Staying indoors, in air conditioning, during heat waves, may prevent classic heat stroke. Prevention also includes checking on elderly or vulnerable persons frequently during heat waves to ensure that they are coping. 

Heart patients and patients with peripheral arterial disease are especially vulnerable to the heat. Cardiovascular problems can impair the body’s ability to open up blood vessels. If blood vessels cannot open up, heat cannot be dissipated through the skin and heat stroke results.   In addition, many heart medications can make handling the heat more difficult. Patients with high blood pressure and those with heart failure are often on diuretics (“water pills”).  These medications tend to dehydrate patients. If exposed to extreme heat while on a diuretic, the salt and water lost through sweat exacerbates dehydration, leading to low blood pressure, loss of consciousness or kidney problems. Other medications, such as calcium channel blockers, ACE inhibitors (for example, lisinopril) and ARBs (for example, losartan) coupled with excess heat can lead to low blood pressure. The best advice for heart patients in a heat wave is to stay inside, in air-conditioning. In addition, it is best not to walk, exercise or work in the yard in the middle of the day during hot days. Go outside early in the day or after sunset, when the temperature is generally lower. 

Enjoy the summer, but be cool and be careful on those hot humid days, don’t let a heat wave burn your heart.

Chios

My grandmother, Mary Kostomenos (later Mary Thomas) was born on the island of Chios in either 1899 or 1903. She left the island with her sister Margarite (Rita) and emigrated to the United States in August 1920 with her future father-in-law (John Thomas) and sister-in-law (Penelope Thomas).  Here is log book from Ellis Island documenting her entry into the US (in the log her last name is spelled Costomenu).

She returned to Chios for a visit in 1974. Except for her, no one in our family has ever visited Chios until I had the opportunity to go from June 30 2019 to July 4 2019. This is a summary of what I learned before leaving and while on the island of Chios.

My great-grandparents were born and spent their lives on Chios. My great grandfather, George Kostomenos, was born on Chios in 1851. He had a grocery store. He married my great grandmother in 1881 (around the time a great earthquake hit and devastated Chios in March 1881). He died in 1918. My great grandmother, Harikleia Vorria, was born on Chios in 1853. She was a housewife. She died in 1916. They had nine children: Irene, Nicholas, Angelo, John, Stanley, Rita, Demetrios, Michael and of course, Mary. (From the family tree generously supplied by George and John Thomas). Before leaving for Chios I wrote to the General Archives on Chios asking for information about the family. Here are their replies:

Mr Georgeson

Here in General Archives of Chios we have notary books from all the villages of Chios from 1700 ci. to 1914, we found the surname Kostomenos in the villages below: in town of Chios, Pyrgi, Kalamoti, Karyes. 

Sincerely

GAK-Archives of Chios

Mr Georgeson

I attach the documents of the marriage pre-agreement of George Kostomenos and Harikleia Vorria and the receipt of dowry,  from the 991 notary book of town of Chios.  

Here are the documents:

Prior to going to Chios, I met my cousin Efie Georgakopoulos in Athens. I asked her to help translate the documents. Even she had trouble due to the fact that they are hand written and hard to understand and they were written in Katharevousa, an earlier form of Greek not used today. This is what she was able to discern.

This document is from October 1880. It is an agreement to marry, apparently written by George. In it he agrees to marry Harikleia within one month, otherwise there is a fine! My understanding is that this was an arranged marriage. 

This document is a receipt of the dowry, written in January 1881. I am not sure when they were married, presumably between October 1880 and January 1881. It talks about George receiving a house, furniture and utensils.  There is mention of 40 pounds English (the currency), so there may have been a monetary exchange as well. This was also written by George.

To find out more about the family, Efie suggested going to the kafeneio in Pyrgi (the village where my grand mother was born, more about that later). She said "pick the old one"- referring to the kafeneio- and ask if there is family in town. Also she suggested going to the church, asking for the priest and and asking for baptismal records. Lastly, she said go to the municipality in the capital city of Chios and ask for the records from Pyrgi.

Pyrgi is in the Mastichochoria, a series of villages in southern Chios. This area is known for, and is the almost exclusive world producer of, masticha. Masticha is a resin that drops from the lentisk tree. These trees thrive in the hot dry climate of southern Chios and are found everywhere in the region- behind fences, presumably as part of family farms, but also by the side of the road. 

Pyrgi is the largest and most important village in the Mastichochoria. The village is known for its beauty and the intricate grey and white patterns seen on almost every building in town.  These patterns are produced by a technique called Xysta which uses cement, volcanic sand and lime to produce these wonderful patterns.

Here are some pictures from Pyrgi:

The church and the main plateiea (town square).

Here are some good examples of the xysta on the buildings around town:

 When Sue and I arrived in Pyrgi, we parked and walked to the town cemetery, seeking gravestones for George and Harikleia. We walked around the cemetery for a few minutes (I really know how to have fun on vacation), but all of the stones were much more recent.  We later learned that after 5 years, old graves are dug up and the bones moved to an ossuary (no cremation for the Orthodox). I didn't inquire at a kafeneio (my Greek is not good enough to describe what I was looking for), but we had a long discussion with the local souvenir shop owner. Neither she nor the locals in the shop knew of any Kostomenoi in town. We tried the church in town, but it was closed at mid-day so I could not ask about records.

The next day, we drove into the main town of Chios (also called Chios) and luckily we found their Town Hall (the names of the buildings were all in Greek. I had asked out hotel manager and he drew a great map of the town and showed me where the Town Hall was. He was a wonderful source of information). In the Town Hall, my Greek was good enough so that I found the records department and a young, very helpful gentleman who spoke very good English. He searched on his computer and found a Mary Kostomenos, born in 1899, but this was the person's married name. In addition, she died in 1982 (my grandmother died in 1984). It seemed that it was not the right person. I asked him to  print out the records anyway, but he said he couldn't, citing privacy policies! So, unfortunately, I could not gather any more information about the family on Chios.

Just a quick bit about masticha. Masticha was known and valued since ancient times. The sultans and rulers of the Ottoman Empire enjoyed it so much that they left southern Chios alone when they over ran and took over the island in the medieval era. The Turks left the people alone to produce masticha and took and used the yearly output of masticha for themselves. Today, masticha is used in just about everything- gum, soap, liquor, lotions, shampoo. It is also felt to have medicinal properties as well. There is a great, new Mastic Museum just outside of Pyrgi, which we visited. The views were stunning and the history of masticha was very interesting. 

Here is the museum, with Pyrgi in the background.

The lentisk tree, with surrounding white crystals. The crystals are the resin, the masticha. We would see these all around the area.

My Computer is Killing Me!

It's summer time. The weather is getting better and outdoor activities beckon. It is time to stop sitting and start working off those pounds gained over the winter. Unfortunately, sitting has reached epidemic proportions. What is contributing to the longer sitting times and what can be done to combat a sedentary lifestyle?

It seems that people are sitting more and sitting for longer periods of time. A large study compared sitting times from 2001 to 2016. During that time, the total time spent sitting in a day increased by one hour per day, in both adolescents and adults. Total sitting in time in adolescents went from 7 hours per day to 8.2 hours per day while adults went from 5.5 hours per day to 6.4 hours per day. In breaking down the cause for the increase, the researchers found that the time watching television or videos was the same, about 2 hours per day. However, the time spent sitting in front of a computer during free time, not for work or for school, rose significantly. In 2001, 43% of children and 29% of adults used a computer for more than one hour per day. By 2016 those numbers rose to 56% in children and 50% in adults.  

All of that computer clicking can be deadly. There is an increased risk for death and heart disease in those who sit for prolonged periods. This risk is even higher if those who sit many hours per day don’t do the recommended weekly activity (the recommended amount of activity is 150 minutes per week for moderate exercise, 75 minutes per week for vigorous exercise). For perspective, 65% of the US population report spending less than 150 minutes per week in leisure time activity. The combination of sitting and no activity is especially deadly. How much activity is needed to offset the risk of prolonged sitting? Meeting the 150-minute/week threshold reduces the risk and the more activity, the lower the risk for death and heart disease.  However, for those who typically sit 8 or more hours a day, at least 300 minutes per week of activity are needed to reduce the risk. Therefore, to lower the risk for heart disease and dying, less sitting and more physical activity is needed. In a week filled with work and home obligations, how can that be achieved? Here are some possible strategies.

There is a whole chunk of the day that is committed to commuting. The average commuting time in the US was 27 minutes one way in 2017 with larger cities having longer commute times (the average commute time in the New York City area is 38 minutes one way). For most people that time is spent sitting in a car. Changing commuting habits can help meet or exceed the recommended physical activity goals. It has been shown that walking or biking to work can lower the risk for heart disease by 11% and the risk for dying by 30%. If you must use a computer for work, or you like to spend your free time on computer, try a stand up desk. Better yet, put a treadmill under the stand up desk and do some walking while you do your clicking.  This would go along way towards hitting that weekly physical activity target. If you have a dog at home, take the dog out for walks! Studies have shown that dog walkers are four times more likely to reach the weekly physical activity goal than people who do not have dogs. On average, dog owners do more physical activity than non-dog owners; about 200 minutes more per week! In addition, dog owners (and especially dog walkers) have a lower risk for heart attack and heart deaths. If you can’t walk or bike to work and don’t have a dog, try doing a simple, low-cost exercise.  A study showed that young men who could complete 40 pushups had a lower risk for heart disease than those who could do 10 or less pushups.  

If you don’t have a dog and don’t like to do pushups, start a walking regimen.  A goal of 10,000 steps per day is thought to be associated with good health. Why 10,000 steps? How was that number derived? What is the data?  Despite the fact that 10,000 steps per day is touted in the media and is the goal set on wearable devices and smartphones, no one really knows where the number came from.  It is thought to have originated in Japan in the 1960’s by a company trying to promote their pedometers, but there was no hard data to support it.  More recently, the Women’s Health Study (16,000 women, average age 72 years) was able to provide some clarity.  In the study, women who took 4400 steps per day had a lower death rate than those who walked less (2700 steps per day or less), For every additional 1000 steps per day, the risk decreases by about 10%. This leveled off at about 7500 steps per day. This means that the minimum number of steps per day needed to lower the risk for death and heart disease is 4400 steps per day and there is no further benefit beyond 7500 steps per day.  How does this fit into the goal of 150 minutes per week of activity?  Calculations show that about 7000 steps per day may be sufficient to achieve the 150-minute per week goal. 

So, stop sitting. Stop clicking. Start biking to work. Or walking the dog. Or doing pushups. Or start a walking program with a goal of at least 4400 steps per day and ideally 7500 steps or more per day.  Remember, however, that if you sit for 8 hours a day, a higher number of steps, about 14,000 steps per day, are needed to offset the detrimental effects of prolonged sitting. Don’t let your computer do you in!

Does Dairy Deserve Designation as Heart Healthy?

In 1977 an advertising campaign was launched featuring the first American commercials produced in the Soviet Union.  The ads depicted older individuals from Soviet Georgia, several of whom were over 100 years old, eating yogurt.  One scene showed an 89-year-old man eating yogurt. Beside him was his 114-year-old mother who was looking quite pleased with his dietary choice. The obvious implication is that yogurt was responsible for the spectacular longevity in these Georgians. The ads were quite memorable and very successful, launching a little known yogurt company to prominence and starting the yogurt consumption craze in the US.

Dairy products are a good source for essential vitamins (A and B12), minerals (such as calcium and potassium) and high quality protein. On the other hand, dairy products are a leading source of saturated fat, cholesterol and sodium, all of which are detrimental to heart health. The American Heart Association/American College of Cardiology, the DASH (Dietary Approach to Stop Hypertension) Diet and Mediterranean Diet all recommend avoiding full fat dairy products and substituting fat free or low fat sources of dairy. What is the recent data on milk, yogurt and cheese and heart disease?

The PURE study evaluated 136,000 people from 21 countries and five continents.  The study showed that those who consumed 2 or more dairy products (milk, yogurt and cheese) per day had a lower risk for dying and lower risk for cardiovascular death than those who did not eat dairy. Even in those who consumed only high fat dairy, there was a lower risk for dying, which seemingly contradicts all of the previous dietary recommendations. Another large analysis of several dairy trials confirmed these findings concluding that high fat milk did not increase heart disease or mortality.  So it seems that dairy fat may not increase the risk for heart disease and death.  The lesson from theses studies is the importance of evaluating dairy products not just on their fat content, but on their total nutritional value. 

What about yogurt, can it prevent heart disease? One study evaluated 1900 middle-aged men without heart disease and followed them for 20 years. The study found that consuming yogurt cut the risk for heart attack in these men.  It has also been shown that higher intake of yogurt decreases the risk for type 2 diabetes.  In choosing a yogurt, it is important to choose a sugar free or low sugar product as many yogurts have added sugar. 

Next up is cheese. Can eating a small amount of cheese every day benefit heart health?  A major study of 200,000 participants sought to answer this question. The enrollees were monitored for 10 years and most did not have heart disease. The study showed that eating around 1.4 ounces of cheese every day lowered the risk for heart disease, heart deaths and stroke.  However, not all cheeses are equal. For example, feta cheese is a low fat low calorie cheese favored in the Mediterranean diet. One ounce of feta is lower in fat (6 grams) and calories (74) than one ounce of cheddar or parmesan cheese (110 calories and 7 grams of fat).  Skim mozzarella is another low calorie cheese (72).  High calorie cheeses include gouda (101), swiss (111) provolone (98) and brie (95).  

One thing to keep in mind is that the research supplying all of this data is not the strongest.  Many of the studies are observational (they can observe an effect but not prove cause and effect) and many are sponsored by the dairy industry (so bias cannot be excluded). Despite this, a couple of things are clear. One is that eating a yogurt a day will not guarantee that you will live to one hundred. The other is that, in general, dairy is quite healthy. Dairy products provide significant nutritional value and may reduce the risk for cardiovascular disease and dying. It seems prudent to follow the guidelines of the Mediterranean diet and consume two servings of low fat dairy per day. This should come mostly from low fat or fat free milk, low fat yogurt and cheese. Low fat cheese should be limited to 3 servings per week, but choose your cheese carefully!

Can Jellyfish Ward off Dementia?

Hearing the word dementia has a devastating effect on those who have had a family member suffer with it. What is dementia and can it be prevented? Dementia isn’t a specific disease, but an umbrella term for a set of symptoms that affects memory, thinking, personality, and activities of daily living.  In addition, there is confusion, disorientation, and difficulty in finding words and problem solving.  Alzheimer’s disease is the most common cause of dementia, occurring in two thirds of all cases.  Vascular dementia is the second most common type, occurring as a result of damage to the blood supply to the brain. This damage may be from a stroke, diabetes or high blood pressure, putting heart patients at risk.  While dementia is not a normal part of aging, the older we get, the higher the risk for dementia.  Genetics play a big part; those with a family history of dementia are at higher risk. Other risk factors include, heavy alcohol use, smoking, high blood pressure, depression and diabetes. 

Mild cognitive impairment is an intermediate stage, where there are changes in thinking that exceed normal aging (benign forgetfulness), but not as severe as full-blown dementia (malignant forgetfulness).  One passes through the mild cognitive impairment stage on the way to dementia. 

Neither mild cognitive impairment nor dementia can be cured. There are many medications which help with the symptoms, but they don’t alter the course of the disease. Can dementia be prevented?  There are many over the counter products being sold that claim to prevent dementia. These include supplements, vitamins, ginkgo biloba, jellyfish proteins, green tea extract, St John’s wort and others. However, when rigorously tested, none of these compounds have been shown to slow the progression to dementia, despite their advertising claims. In February 2019, the Food and Drug Administration cracked down on the sale of unapproved products claiming to prevent, treat or cure Alzheimer’s disease sending warning letters to 17 companies selling these supplements.  Since this approach doesn’t work, what can prevent dementia? In 2017, a National Academy of Sciences panel reviewed all of the published prevention studies and suggested three interventions to slow cognitive decline: increased physical activity, blood pressure control and being mentally active. 

Controlling high blood pressure as a measure to prevent dementia is an appealing concept.  The brain seems to be very vulnerable to sustained high blood pressure. Hypertension changes the structure of the small blood vessels of the brain, leading to vascular dementia. In addition, hypertension is a well-known risk factor for stroke. Can lowering blood pressure reduce the stress on the blood vessels and delay the progression of dementia? This hypothesis was tested in two large trials. In the HOPE trial, lowering blood pressure did not delay cognitive decline. This trial only included patients older than 70 years old. The SPRINT trial enrolled 9000 hypertensive patients with an average age of 68 and followed them for 5 years.  The risk for dementia was not reduced by intense blood pressure lowering (a blood pressure goal less than120) compared to a blood pressure goal less than 140.  However, the intense treatment group had a lower risk for mild cognitive impairment.  Unfortunately neither trial was able to prove that lowering blood pressure prevented dementia, but there are signals that we may be on the right path.  Both trials may be limited as the patients were older and followed for only a few years. Perhaps patients have to be followed for many years to see an effect and perhaps blood pressure control should start at an earlier age (for example, starting medications when patients are in their 40’s). 

Thousands of studies have been conducted looking at exercise and brain function. In general, exercise is felt to be beneficial.  Exercise may be helpful in a variety of ways including lowering blood pressure and promoting neurogenesis (the generation of new brain cells).  A large recent study evaluated all of the clinical trials on exercise and brain function and concluded the following. Exercise significantly improved cognitive function in adults over 50 years old, even if mild cognitive impairment or dementia were already present. Since some patients may begin to show signs of dementia as early as 45 years old, it is never too early or too late to start exercising.  Aerobic exercise and resistance training were similarly effective. To achieve improvement in cognitive function, exercising for a minimum of 45 minutes at moderate to vigorous intensity, on as many days of the week as possible is recommended.

There is a lot we don’t know about preventing dementia. We do know that taking brain supplements and substances found in jellyfish do not work. Lowering blood pressure may be helpful but even if it isn’t, there is no downside. Controlling blood pressure is always beneficial for overall health and there is little risk. Similarly, exercise may or may not help prevent dementia but it is good for overall health and there are no side effects. So skip the supplements and walk away from dementia. 

A Spoonful of Medicine Helps the Sugar Go Down

Diabetes mellitus is one of the most common chronic conditions in the world and a significant risk factor for heart disease.  It is a major contributor to global morbidity and mortality. What is diabetes and how can it be controlled to reduce the burden of heart disease and cardiac death? Diabetes is a disease characterized by high blood sugar.  Type I diabetes starts at an early age and occurs because the body does not produce enough insulin (insulin is a hormone secreted by the pancreas and is responsible for regulating the sugar in the body). Type II diabetes occurs in adults, accounts for 90% of the cases of diabetes, and is the result of the body resisting the effects of insulin.  The prevalence of Type II diabetes keeps rising, paralleling the obesity epidemic. It has been estimated that 13% of all U.S. adults have diabetes.  Diabetes is diagnosed by a single blood draw, looking at two tests, glucose (blood sugar) and hemoglobin A1C (a three-month average of the blood sugar). Diabetes is present if hemoglobin A1C is greater than 6.5% or the fasting blood sugar is greater than 126 mg/dl or the nonfasting blood sugar is greater than 200 mg/dl.

Heart disease is the main cause of death among patients with diabetes. Diabetics have a twofold to fourfold increased risk for blockage in the heart arteries, a heart attack or cardiac death and a twofold to fivefold increased risk for congestive heart failure (fluid in the lungs). In addition, diabetic patients are at increased risk for stroke and blockage in the leg arteries.   Therefore the treatment goals for the diabetic patient include lowering the blood sugar, reducing the risk for complications of diabetes (for example kidney disease and blindness) and especially reducing the risk for heart disease.

Cardiovascular risk factor management in Type II diabetes starts with diet.  Patients are often referred to specialized dieticians to help with monitoring caloric intake and carbohydrate consumption. A Mediterranean-style diet can greatly reduce blood sugar.  The goal is to lower the hemoglobin A1C to < 7%. Overweight and obese patients are counseled about weight loss; even a modest reduction in weight of 3-5% can make a big difference.  For severely obese patients, weight loss surgery (for example, gastric sleeve) is often recommended. With significant weight loss, diabetic medications can be weaned down and in many cases stopped.  Diabetic patients with elevated blood pressure should be placed on medication, with a blood pressure goal between 120 and 140.  Diabetics whose LDL cholesterol is high should be prescribed a statin, with an LDL goal < 70 mg/dl. Achieving these aims is not easy.  In a large recent study of 73,000 diabetic patients, 73% met the hemoglobin A1C target, 69% met the blood pressure goal and 48% hit the LDL number. Unfortunately, however, only 21% met all three goals.

Recently, the medical management of the patient with Type II diabetes underwent a revolution.  There are twelve classes of medications (including insulin) and at least 36 individual drugs approved for the treatment of diabetes.  Picking the right drug or the right combination of drugs can be difficult. It is generally agreed that treatment start with metformin, which has been shown to lower hemoglobin A1C and reduce cardiac events.  Picking the right target for treatment is just as difficult. For the past 20 years, the medical therapy of diabetes focused on intensive control of blood sugar. However, this approach did not reduce cardiovascular events and may have increased them.  Then in 2008 the Food and Drug Administration mandated that any new diabetes drug must prove its cardiovascular safety before being approved for use.  This resulted in the discovery of new drugs which did just that; they were shown to lower the risk for major heart events and reduce cardiac deaths. This has led to a fundamental shift in diabetes management, away from lowering blood sugar and toward reducing cardiac risk.  In fact, for the first time ever, the American Diabetes Association and the American College of Cardiology have aligned their medication recommendations for treating Type II diabetes.  

The new agents fall into two classes of diabetes medications: sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists.  Both classes of agents substantially reduce the risk for heart attack, stroke and cardiac death. Both reduce blood pressure and promote weight loss. The best-studied SGLT2 inhibitor is empagliflozin (Jardiance), a once a day oral medication. The classic GLP-1 agonist is liraglutide (Victoza), a once weekly injection. It is felt that SGLT2 inhibitors are better for CHF patients while the GLP-1 agonists are better at reducing heart attack and stroke. 

The bottom line, according to both diabetes doctors and cardiologists, is that patients with Type II diabetes and established heart disease start treatment with lifestyle management (especially diet and weight loss).  If medication is needed, then metformin is the first line agent.  If a second line agent is necessary, then either an SGLT2 inhibitor or a GLP-1 agonist should be used, depending on patient characteristics.