Diabetes and heart disease link underemphasized

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[The New York Times] September 2, 2003New Message Emerges in Treating DiabetesBy LINDA VILLAROSA[E] ldridge Lee, a real estate broker and adjunct college professor in Fairburn, Ga., found out that he had Type 2 diabetes more than a decade ago. But he did not take the disease seriously until two years ago, when sky-high blood pressure - a complication of diabetes - led to heart disease."After coming out of heart surgery, I was sitting with a ventilator down my throat and had a moment of realization that the diabetes, which I had pretty much been ignoring, had led to this problem with my heart," said Mr. Lee, 53, who now controls his blood pressure, cholesterol and blood sugar with diet, exercise and six drugs.Like Mr. Lee, many of the nation's 17 million diabetics - and even their doctors - miss the connection between high blood pressure and diabetes. Studies show that cardiovascular disease, set off mainly by hypertension, is the leading cause of death among people with diabetes, and two of every three diabetes-related deaths are caused by heart disease or stroke.Research in the last decade has found that lowering blood pressure in patients with Type 2 diabetes leads to sizable reductions in death rates. Many experts believe that lowering blood pressure may be the most important step - even more important than reducing blood sugar - that people with diabetes can take.Yet, the public has largely missed this message, which is particularly troublesome given the near-epidemic increases in the incidence of diabetes over the past decade. A survey last year by the American Diabetes Association, a nonprofit organization in andria, Va., found that 68 percent of diabetes patients were not aware of their increased risk of heart disease and stroke."Most diabetic patients are more concerned about glycemic control," said Dr. Nesto, chairman of the department of cardiovascular medicine at the Lahey Clinic in Burlington, Mass., and associate professor of medicine at Harvard Medical School. "Hypertension has become the forgotten risk factor."Some in the field blame doctors. "We have the clearest evidence-based data proving that if you lower blood pressure, people with diabetes live longer," said Dr. F. Shaughnessy, director of medical education at PinnacleHealth System in burg, Pa. "But health care providers continue to focus on blood glucose control. Although lowering both is important, blood pressure has been proven to be the bigger deal. But this information remains a well-kept secret."In a study last month in BMJ, a British medical journal, Dr. Shaughnessy examined two years of medical review articles on the treatment of Type 2 diabetes and found that most played down the importance of controlling hypertension."Most practicing doctors are short on time, so they rely on review articles," he said. "It's disturbing that the results of the most important research in diabetes in the past 25 years were incompletely and often inaccurately transmitted to readers. Imagine how many lives could have been saved if their doctors had explained the benefits of lowering blood pressure?"In April, the American College of Physicians published new guidelines for treating hypertension in Type 2 diabetes in the journal ls of Internal Medicine. "We published the guidelines, because our experience had been that when providers and patients think about diabetes, the focus is on treating glucose, since that is how diabetes is defined," said Dr. Sandeep Vijan, a physician-scientist with the Department of Veterans Affairs in Ann Arbor, Mich., and the author of the guidelines."I have to admit that before I started doing this research, I was guilty of that, too," Dr. Vijan said. "Our goal was to get physicians to realize that lowering blood pressure should be the primary area of focus in treating diabetes."The diabetes association estimates that 60 percent of people with diabetes also have hypertension, defined as blood pressure greater than 130/80. Both diabetes and high blood pressure raise the risk of heart attack and stroke, and the combination of the two problems can be particularly lethal."If you add up risk factors, the sum of diabetes plus hypertension is greater than either one alone," Dr. Nesto said. "The same blood pressure in a diabetic leads to a higher risk of cardiovascular disease than a similar blood pressure in a nondiabetic."Officials of the major health organizations say they have done their best to get the word out. Three years ago, the National Institutes of Health issued an advisory urging doctors and nurses to treat blood pressure more aggressively in people with diabetes. For several years, the American Diabetes Association has sponsored an educational initiative called Make the Link: Diabetes, Heart Disease and Stroke, aimed at both professionals and patients. Other associations have done the same.Dr. Eugene Barrett, a professor of internal medicine at the University of Virginia and the president of the American Diabetes Association, acknowledged that even with a good deal of information, the connection between diabetes and heart ailments had not been made. "The message of the A.D.A. and others has been consistent that to prevent cardiovascular disease in diabetics, the goal is to lower blood pressure, cholesterol and blood sugar," Dr. Barrett said.Getting patients to take steps to lower their blood pressure readings may be a bigger problem than lack of information. Most diabetes patients require more than diet and exercise to get their blood pressure under control."It's not uncommon for a patient to require two or three medications to control blood pressure, two or three to control glucose and then if they need to lower cholesterol, that might mean eight different medications," Dr. Barrett said. "Along with the cost, the side effects of the various medications can create problems. And then there's the issue of patients' managing the numbers of pills and remembering to take them."Dr. R. Gavin III, chairman of the National Diabetes Education Program and president of Morehouse School of Medicine, says his organization and others will continue to drive home the point about the benefits of lowering blood pressure."We have a body of evidence and the consensus of concern that we need to reduce cardiovascular disease - the No. 1 killer of diabetics and everyone," Dr. Gavin said. "We know we can't just push glucocentric messages, but we don't delude ourselves that we are swimming upstream as we try to change an established culture of treatment."Copyright 2003 The New York Times Company | Home | Privacy Policy | Search | Corrections | Help | Back to Top Lighthall, Ph.D.Research DirectorRelational Culture Institute ( Office)1408 Colgate Dr., CA 95616530 304-0038530 757-6056 faxdavid@...