Remember the nurse who teared up as she told me she’d just been diagnosed with diabetes, and that her doctor said being told she was diabetic was the same as being told she had just had her first heart attack? That story reveals the elephant in the room for most diabetics—although they aren’t ignoring it as much as they aren’t realizing it’s even there. They don’t know the strong correlation of diabetes to heart failure or a heart attack. This is the one significant finding in medical literature everyone who is prediabetic or diabetic needs to understand.
An article in the Journal of the American Medical Association reported a study that pointed out the close association of insulin resistance and the risk of heart failure. Researchers emphasized how diabetes and obesity are a double whammy against us. They estimated the morbidity caused by heart failure in a diabetic is four to eight times that of the general population.
Obesity is a prime risk factor for heart failure. Diabetes is also a risk factor for heart failure. Insulin resistance is a precursor of both diabetes and heart failure even before diabetes is evident.
One quote from this report is especially important to absorb: “Abdominal obesity is closely associated with insulin resistance.” Losing the excess weight there is especially crucial to defeating diabetes.
The good news is that the same lifestyle changes you can make to defeat diabetes will also protect the arteries of your heart. I call that a win-win.
How Your Heart Figures In
When we moved into our new home years ago, a friend of mine gave me a housewarming gift. I didn’t own a gun, not even a pistol, but he thought I should have some sort of protection since I was living out in the country. I opened the box and was surprised to find a small double-barreled shotgun neatly packed with wrapping paper. I took it outside and shot it a few times—until my shoulder hurt, and then I put it away, thinking I would never need it.
Then one night at about three o’clock our burglar alarm went off. My heart started racing. I jumped out of bed, found the shotgun, and my son and I began going from room to room. He opened closet doors as I wondered if someone was hiding behind each one. It wasn’t too long before I heard the back doorbell ring. I went to the door and saw the county sheriff standing there. When he saw me and my shotgun, he started laughing—loudly.
“Doc.” He pointed toward the gun. “Let me give you some advice. If you ever catch someone in your house, march them out to your backyard, shoot them, and then drag them back into the house.” He kept laughing as he looked at my firearm. “If you shoot that gun indoors, your ears will ring for two weeks.”
I knew he was kidding about shooting someone, but I was glad to know how loud a shot inside would be.
I had known someone seemed to be in my house in the middle of the night, but I hadn’t known two other things. One was that when the alarm went off, it also notified the sheriff’s office. The other was that one of the sensors was connected to a door in the garage that had blown open.
I tell you that story to remind you that diabetes is not just a single-barrel problem; it’s a triple one. Most everyone thinks of diabetes as simply a sugar issue. That’s part of the problem, but not all of it. Defeating diabetes has a triple target: diabetes prevention, heart disease prevention, and Alzheimer’s prevention. Diabetes must be shot at with three barrels of lifestyle changes—exercise, diet, and weight. If you don’t do what will protect against the heart- and brain-related problems of diabetes, you’re not fighting the whole fight.
Protecting the arteries in your heart and brain are of paramount importance in association with diabetes. If I could get only one idea across to diabetics, it would be that diabetes has a huge impact on the health of arteries. The three lifestyle barrels you need to work on in defeating diabetes are all associated with the health of your arteries.
In this chapter we’ll focus on the arteries in your heart, and in the next chapter on the arteries in your brain.
An article in the Annals of Internal Medicine points out the importance of the arteries in your heart the best. Researchers followed participants who had abnormal glucose levels but did not yet have diabetes. They were divided into a group that lost 7 percent of their weight and exercised thirty minutes a day at least five days a week. The other group was given a common medication to control their glucose. After 3.2 years, they were evaluated to see which group had protected their heart better by having controlled their blood pressure, their cholesterol level, and insulin resistance.
The exercise weight-loss group had over twice the improvement the medicine-alone group did, with a reduction of 41 percent in the lifestyle change group versus a decrease of only 17 percent in the medication alone group.
The message of the study is that diabetics need to go beyond relying on medication to control diabetes. They also need to focus on preventing the associated heart risks that go along with diabetes. Defeating diabetes is more than glucose control. It means also addressing the problems that are so commonly associated with diabetes, and that involves weight, cholesterol, blood pressure, and activity.
An article from the American Medical Association compared two groups of people—one that ate a significant amount of fiber and one that ate very little fiber. The odds of developing insulin resistance were sevenfold greater in the group that ate the least amount of fiber.
One point in this study is extremely important: diabetes affects the small arteries as well as the large arteries of the body, and this arterial involvement accounts for most of the increased morbidity and mortality associated with type 2 diabetes.
If I could make that statement above flash in red, I would. Here’s why: if a diabetic loses weight and exercises, their fasting plasma glucose will go down, their fasting serum insulin will improve, their “hero” HDL cholesterol will increase, their “lethal” LDL cholesterol will decrease, and both their systolic and diastolic blood pressure will improve. Weight loss and exercise address the glucose and improve heart health.
Diabetes = Heart Attack
An article published in Acta Diabetologica includes this eye-catching statement: “Diabetes is now considered a heart attack equivalent and, therefore, an aggressive, multifactorial, long-term intervention in patients with diabetes is critical.” What the authors of this study are saying is exactly what this book is emphasizing, and what that diabetic nurse’s doctor told her. You can’t look at diabetes as only a sugar problem; you must look at where that diabetic path leads. The clear majority of diabetics die from heart disease.
Coronary heart disease (CHD) refers to disease of the arteries of your heart. As LDL cholesterol builds up in the walls of the arteries, bleeding and clots or plaque formation build up. This leads to a decreased flow of blood through that artery and subsequently less blood to the area that artery is supplying. The medical reports center on heart disease because that’s the organ most commonly affected by a decrease in blood flow.
It’s important, however, to understand that the problem occurring in the arteries in the heart also occurs in arteries throughout the body. When you read about heart attacks causing the most deaths of diabetics, a little further you will see an additional percentage of deaths and disabilities because of blockage of arteries in the brain, which results in strokes. (Again, we’ll talk more about the arteries of the brain in the next chapter.) The same process occurs in the arteries of the legs. The number one cause of amputations of lower extremities is blockage of arteries in the legs of diabetics. So keep all the risk factors of diabetes in mind as you choose an eating plan.
This article makes some dietary suggestions for heart health:
There are good carbohydrates linked to fiber and bad refined carbohydrates that allow more glucose into your blood. And remember, there are good fats and bad fats. Stop eating bad fats and replace them with good ones. Your choice makes all the difference, as the article cited above puts it clearly: “Replacement of saturated fat with monounsaturated fat is associated with a 3-fold greater reduction in coronary heart disease than that obtained by replacement of saturated fats with carbohydrates.” The good fats are found in fish, olive oil, and nuts. The bad fats are in red meat, cheese, egg yolks, cream, butter, and most fried foods.
When you finish reading this book and get started, you will have developed an eating plan that will not only control the glucose in your system but also protect your arteries. I want you to understand the connection of having diabetes and ending up with a heart attack or stroke. To do so, you need to not only know how carbohydrates affect your body but also the importance of your cholesterol numbers.
Let’s look briefly at the most common cholesterol particles reported on your blood work—the LDL cholesterol and the HDL cholesterol particles—and how they impact your arteries.
Getting a splinter in your finger is the best illustration of what happens when LDL cholesterol gets into the walls of your arteries. I call the reactive process that takes place the “splinter syndrome.” The spot where the splinter is embedded begins to swell and turn red. The surrounding tissue considers that splinter a “foreign body,” and if the splinter doesn’t come out, your body’s natural response is to develop a wall of scarring tissue around it. The initial swelling around the splinter is the result of the body pouring fluid into the area. The fluid is filled with soldier-type cells, called macrophages, that attack the splinter. Many times there is even bleeding into this swollen battlefield, and the finger turns red and more swollen.
Finally, one of two things happens. The resulting inflammation can be so fierce that it swells and the fluid breaks through the skin and drains out. An example of this is a boil that ruptures and drains from the battleground tissue to the outside. Or after the battle against the foreign body splinter reaches its height, healing begins to take place. The body sends cells called fibroblasts that begin to lay down fibers that join to form a healing scar throughout the battlefield.
This scar tissue is not the normal kind of tissue once there. Scar tissue is firmer and harder and isn’t pliable. You can palpate the thickened, hardened area of scar tissue forming just under the skin’s surface, and that scar remains—fixed, thickened, firm, hard, and swollen. If another splinter enters the skin in that same area, another battle takes place, and the resulting scar area gets larger and larger. After repeated battles, calcium can become a part of the healing, and the plaque buildup is even firmer and harder.
A similar process happens in the walls of your arteries. I like to think of sugar as the beginning cause of inflammation. Once again using sandpaper as an illustration, I visualize sugar as a piece of sandpaper that rubs the walls of arteries raw, which allows for easier access into the wall of the arteries of the LDL cholesterol splinters. The initial step is that of inflammation. LDL cholesterol is the splinter that gets through the lining of the artery and into the media, the middle portion of the arterial wall. However, there’s a difference between getting a splinter stuck in your finger and getting an LDL cholesterol splinter stuck in the wall of your artery.
If you stick your hand into the middle of a thornbush and get stuck, you won’t stick your hand in again because you felt the pain of the prick. The problem with the LDL cholesterol splinter syndrome is that you don’t feel the splinters going into your arteries. These splinters get through the lining wall of your arteries and cause the battle to begin, and the wall of your artery reacts much like your finger does to a splinter. The area can become so inflamed that there is bleeding with the inflammatory reaction, and it can rupture through the lining into the lumen of the artery. A clot forms and plugs the entire artery at that point.
Or the arterial wall can stay intact and the splinter battleground ends in a healing process. But the scars of battle remain. The enlarged scar formation protrudes into the lumen of the artery, and the result is a partial blockage of the flow of blood through that area (like crimping a straw). This is what is commonly referred to as plaque buildup. The next time an LDL cholesterol splinter gets stuck in the same area, the process repeats itself. The secondary battleground either pops open and causes a clot to form inside the artery, or it heals again and bulges even more into the inside of the artery. The result is more plaque buildup. This secondary plaque protrudes even farther into the lumen of the artery, causing the flow of blood to be even less to the heart muscle downstream.
It’s imperative to keep your LDL cholesterol low. But how you get there is more important than just getting the numbers down. You can be fooled if you’re only looking at the numbers. Taking medication alone, without lifestyle changes, isn’t a guarantee that you’re doing all you can to protect your arteries. You should work on your LDL score as you would a golf score—the lower the better. Think of saturated fat in food being the main cause of your LDL cholesterol becoming elevated. Think of it every time you want to eat red meat, cheese, egg yolk, cream, butter, or any fried foods.
The other side of the coin from the lethal LDL cholesterol is HDL cholesterol. HDL stands for high-density lipoprotein cholesterol. Think of the H as standing for “hero” or “healthy.” This is the good cholesterol number you’ll be attempting to get as high as possible. HDL cholesterol protects you by battling the LDL cholesterol. Here’s an easy way to visualize how this works:
Think of an HDL cholesterol particle as a patrol car that floats through the bloodstream, looking for LDL cholesterol criminals. Imagine the HDL cholesterol patrol car pulling up to an area where LDL cholesterol “splinters” are getting into the wall of an artery. The HDL cholesterol patrol car picks up several splinters, carries them to the liver, and then deposits them there to be disposed of. The liver takes the LDL cholesterol particles and passes them out of the body in the bile. While the liver is working to place this excess LDL cholesterol into the process of forming bile, the HDL cholesterol “patrol car” particle is on its way back to the arteries, where it picks up some more LDL cholesterol to transport back to the liver.
You want as few LDL splinters as possible and as many HDL patrol cars as possible.
How do you do this? Think of the saturated-fat foods as raising your LDL cholesterol. Think of exercise and losing weight as raising your HDL cholesterol. Eat right. Exercise. Get to your ideal weight.
As you can now begin to understand, diabetes is a much larger concern than just trying to control your blood sugar. The foods you eat, the exercise you do, and the weight you carry all affect your cholesterol, which harms your arteries if it’s too out of balance.
The same lifestyle risk factors that contribute to diabetes also put your arteries at risk, which affects your heart and brain. All these systems are intertwined. When you make changes to defeat diabetes, those changes will protect your heart and brain health as well.
Now let’s turn to your brain.