As if diabetes doesn’t give us enough to worry about in the day-to-day, we also have to be constantly aware of what could happen to us, down the line. Here at the ‘Mine, we’re big believers that knowledge is power, and it’s better to be prepared for the worst, which is why we’ve been bringing you an in-depth look at various diabetes complications in our “411 Series” since the beginning of the year.
September is National Cholesterol Education Month, so even though we covered heart disease in February, we’re going to take a deep dive into cholesterol, which most of us probably didn’t plan on thinking about until we were old and gray. Well, cholesterol is a big deal for PWDs of all ages, namely because heart disease is the No. 1 complication and killer for us. But thankfully, there are some things we can do about it.
Did you know that cholesterol is actually a necessary component of life? It lives inside a waxy substance found in all of your cells, and has a variety of functions, including helping to build your body’s cells. So not having any cholesterol is definitely not what we’re aiming for…
Cholesterol: Good vs. Bad
There are two kinds of cholesterol: LDL and HDL. LDL is more-or-less the “bad” kind, the kind that you get from one too many trips through the drive-thru. Build-up of LDL in the arteries causes heart attacks. HDL is the good kind. HDL helps to rid the body of the bad kind of LDL cholesterol by shuttling it down to the liver to be disposed of.
And as it happens, people with diabetes naturally have higher LDL and lower HDL. Lucky us, huh? Researchers aren’t entirely sure why, but high levels of insulin in the bloodstream appear to breakdown HDL and raise LDL. Another gift with diabetes is that it tends to raise triglycerides, a different kind of fat roaming around the blood stream.
About 20% of Americans actually have this problem (too low HDL / too high LDL). What should your numbers be?
HDL: At least 40 mg/dl, but preferably 60 mg/dl or higher (the more, the better)
LDL: Under 100 mg/dl, but preferably even lower than that, to around 70 mg/dl because people with diabetes are already at such a high risk for cardiovascular disease
Got Lipids?
Of course, the best way to keep tabs on your cholesterol levels is to get your annual labs done, specifically a blood test called the Lipid Profile. It’s actually a single blood draw that’s sufficient for the lab to measure your LDL, HDL, and triglycerides (three for the price of one!)
The book that Amy co-wrote with Dr. Jackson of Joslin Diabetes Center, called Know Your Numbers, Outlive Your Diabetes, has lots of information about this test (and what you can do about it if your numbers are out of range – see below).
Quoting from that guidebook: “If you have concerns about your triglycerides, the test should be done following overnight fasting. LDL and HDL cholesterol are not much affected by food, however, so you don’t need to be fasting if you’re taking the test especially to monitor these lipids. Nevertheless, it is always bad form to show up for your blood test gripping a fast food takeout sack, even if it was a two-for-one special. Don’t laugh, as we’ve seen this happen! And the smell of French Fries can be disconcerting in the lab.”
So, have you made your annual labs appointment yet?
Fix-It Strategies
In their book, Rich and Amy recommend the following steps to improve your cholesterol numbers:
* Eat foods with low cholesterol and avoid saturated fats. The American Heart Association recommends less than 300 milligrams, but if you already have heart disease, limit your intake of saturated fats to 200 milligrams. Luckily, cholesterol is listed close to carbohydrates on the nutrition label of packaged foods, so it won’t be too hard to find.
* Quit smoking. Smoking lowers HDL (“good”) cholesterol levels. Plus it does a whole host of yucky things to you. So knock it off. Please.
* Exercise. Being overweight leads to an increase in triglycerides and an decrease in HDL cholesterol. Meanwhile, exercise is a “marvel of health improvement” that helps lower your lipids, A1C and blood pressure! Aerobic exercise is king here, i.e. physical activity that elevates your heart rate for a sustained amount of time.
* And then there are meds. The most commonly used and discussed meds for lowering cholesterol are a family called “statins,” including lovastatins (Advicor, Mevacor, and Altocor), atorvastatins (Lipitor), and pravastatins (Pravachol and Pravigard). But statins are pretty controversial, as you may have heard…
The Statin Conundrum
You’ve probably heard about the risk/benefits debate over statins (it’s always in the news). And maybe you’re thinking, Do I really need another drug? Well, that’s debatable…
Last year at the European Association for the Study of Diabetes (EASD) conference, Professor John Betteridge, of University College London Medical School, stated his conviction that all people over the age of 40 with either type of diabetes should be taking statins. Dr. Robert Eckel, an endocrinologist and past president of the American Heart Association, also recommended this advice to us in February because PWDs have such an increased risk of cardiovascular disease.
On the negative side, there’s all the evidence of unsettling side effects, ranging from muscle pain, to liver damage, to mental confusion described as “cognitive dysfunction.” So you might be wondering if you should be jumping on this statin bandwagon.
In July, the Boston Globe reported about a study that’s suggesting a more measured approach, as in the answer may lie in your A1C number. The more elevated it is — and the older you are — the more likely you are to have a heart attack or stroke. In those cases, a statin would prove invaluable. But for those with a “normal” A1C number (7.0 or less) and in folks who are younger, a statin is probably not necessary.
The Boston Globe story quoted Dr. Om Ganda, head of the Lipid Clinic at Joslin Diabetes Center, saying, “I don’t think we should lump all diabetics into the same high-risk category. Clinicians really need to use their judgement and consider other factors like age, family history of heart disease, blood pressure and cholesterol levels, and smoking habits.”
Right, and the same goes for us patients as far as using our judgement. If you think you might need a statin, discuss it with your doctor. But don’t let him/her talk you into anything you’re not comfortable with. Be an active participant in your health and do your homework. And make sure you get your cholesterol screened every year, otherwise you don’t know what you’re up against!
Early in my diabetic career, I believed my doctors and took statins and other cholesterol lowering drugs. What a huge mistake, I survived, but the whole episode put my life in danger. As I read more about the dietary fat, cholesterol and heart disease theory I became dismayed at the situation. There is poor science behind these theories, dietary fat does not just “raise” cholesterol and cholesterol does not “cause” hardening of the arteries. Huge amounts of money have been spent with studies trying to prove these theories and they have failed. Gary Taubes wrote about this in his landmark book “Good Calories, Bad Calories.”
Following the NCEP advice, my triglycerides soared on a high carb diet and my HDL “tanked.” Today, I follow a low carb high fat diet to lower my triglycerides and keep my cholesterol profile healthy (not low). I choose lots of healthy fats and have triglycerides and HDL well within target.
Be a smart patient. Read about this on your own. Ask questions of your doctor. Don’t simply trust all medical advice. As diabetics, we always must take personal responsibility for our own health and that goes for diet and cholesterol.
Thank you for posting this. I have been struggling to understand why my cholesterol is so high yet my lifestyle should prove the exact opposite. So I appreciate the information here that is hard to really nail down by surfing the net. This was really informative.
Dr. Om Ganda has it right, of course. Having all diabetics take statins is one of those generalities that demands questions.
My primary care doctor wanted me to take them simply because I was a diabetic. When I pushed back and he actually looked at my LDL, he frowned and said, “You’re right, your LDL is too low for a statin.”
bsc has it right as well – “Be a smart patient”
Cheers,
Mike
I’ve seen what a difference exercises makes in LDL and cholesterol values. Last year my LDL was 101 and my cholesterol (with Lipitor) was 175. This year I’ve been exercising much more frequently and my LDL is 79 (20% reduction), cholesterol is 157 (10% reduction).
Apart from making me feel and sleep better, exercise is key in helping get these numbers into range. Make time for yourself and exercise.
I second the remark about not putting all people with diabetes into the same category. Insulin resistance, high cholesterol, high blood pressure and heart disease seem to come as a package for many people with Type 2. Type 1 results because of an autoimmune attack on the beta cells. Although heart disease can result from poor control of blood sugars, it is a complication of Type 1 not an integral part of the disease process. Obviously anyone with Type 1 can get high cholesterol just like any other person, but it’s because of genetics, poor diet, lack of exercise, etc. It’s not because one has Type 1.
They need to do more heart studies on patients with Type 1 (especially well-controlled Type 1) rather than grouping us with Type 2 patients. Our diseases are different and our risks are different.
When I was diagnosed with Type-2 diabetes at the end of last year, my total cholesterol was well over 400 and triglycerides over 4000 (yep). The crazy high triglycerides meant they couldn’t determine the levels of the major cholesterol types. A few weeks later, when my triglycerides were low enough to get more detail on the cholesterol, my VLDL was almost 50 and HDL was in the low 20s. The cardiologist (whom I got sent to because of the triglyceride levels and occasional chest pains), had a conversation with me about the direct link between dietary carbohydrate intake and triglyceride levels (in addition to blood glucose). My regular doctor also provided lots of research material (I’m a huge science geek, both professionally and in my non-working life).
After that, I progressively cut out the most sources of carbohydrates from my diet (using pre and post meal blood glucose tests to fine tune what sources caused the largest blood sugar spikes). These days, I consume a diet high in fats (including saturated fats like ghee and coconut oil), moderately high in protein and low in carbohydrates. I also, very gradually, added exercise into the equation, ramping up from a couple of 10 minute walks each day (about the maximum I could sustain) to ~60min/day combined with resistance training 3 x week.
Since the end of spring, I’ve had two lipid profiles done, and am maintaining triglycerides in the 90-100 range, VLDL below 20, LDL 70-90 and HDL is over 40 and rising. I’ve never had lipid numbers this good.
The latest thinking on cholesterol is what matters more than your LDL number is the size of your LDL “bad” particles. Big, fluffy particles are good since they travel through the blood vessels, small particles are bad since they tend to be sticky and stick to each other and build up and form a blockage to the heart. I don’t know if you need a separate test to know the size of your particles but it’s something to find out.
My LDL the past few years is always slightly over 100, like 107. But my HDL is also over 100, like 108. That 1:1 ratio means even tho my LDL is over 100 no statins needed here. Yet, my GP wanted to put me on them for years and I refused. I did my homework. BTW, I’m convinced my high HDL is from eating so many vegetables every day at lunch and dinner, in addition to a healthy diet and regular exercise.
It isn’t the saturated fats that cause high triglycerides and VLDL (which are probably more damaging than LDL itself), it’s the carbs. ALL diabetics, including Type 1′s, have peripheral hyperinsulinemia, either because we produce too much, or we shoot our insulin into the skin, whereas natural insulin goes from the pancreas straight to the liver, which uses up to 90% of it. So, no, there is no difference between the types on this one. Type 1′s die of heart disease and strokes just as much as Type 2′s do.
I attended 2 presentations at AADE, both of which came to the conclusion that it’s fructose and added sugar that cause artery disease. Fructose is immediately converted in the liver to triglycerides and VLDL. That’s certainly part of the picture, because sucrose, as added sugar, is half fructose. Even excess glucose, as in when you’re high, is converted into triglycerides and VLDL. That’s why doctors assume that all diabetics have high cholesterol, because they assume that everyone is as poorly controlled as they were historically.
But the other part, as stated in the column, is hyperinsulinemia. The less insulin you need to take, the less peripheral hyperinsulinemia. Stands to reason. And the best ways to lower your insulin intake are, exercise, as you mentioned AND limiting carbs as much as possible. There are no nutrients in grains, potatoes or fruits that can’t be gotten in vegetables. So there is really no reason to eat them, other than as occasional treats. And you can eat all the vegetables you want!
As far as statins, there is a risk/benefit ratio. If you clearly have problems with triglycerides, VLDL and LDL, and diet and exercise don’t work, then statins might be worth a try. Again, this is not restricted by Type, but by the metabolism you were born with. There are insulin-resistant Type 1′s AND insulin-sensitive, so-called Type 2′s (who are actually NOT classic Type 2, but have other metabolic issues which simply haven’t been described, and no antibodies, so they are thrown into the Type 2 garbage can). Many people do just fine on statins, with no side effects for decades, and for them, why not? If you happen to be the one with side effects, you can always stop. There is simply no black and white answer to this one.
When I went from high to lower carb diet with lots of vegetables, my lipid profile normalized. The last piece of the puzzle for me was triglycerides-those normalized once I lowered my A1c to 5-6% range. I can’t believe I used to have really high cholesterol. Those days are hopefully long gone.
You mention ‘Eat foods with low cholesterol’ but you don’t spell out what good examples of those might be.
To make it easy, all animal products (not just meat, chicken, and fish, but also milk, butter, other dairy, and eggs) contain cholesterol. Further, only animal products contain cholesterol. There’s no cholesterol in fruits, vegetables, whole grains, or anything else that never had a mom.
Individuals’ inherent levels of cholesterol will vary, but instead of looking to drugs with side effects as a solution, why not just cut down on eating animal products? The only side effect is better health.
Our 13 year old T1 son was prescribed a statin 14 months ago due to an LDL level of 119. After much discussion with other medical professionals and much time spent in consideration of the real risks we opted to revisit the idea of a statin in several years rather than expose a child to a dangerous medication with no real knowledge of the long term consequences. Our thinking was that increased risk of heart disease is not the same thing as having heart disease and the long term unknowns of giving statins to a growing child are not worth playing with. Our Endo was pretty pushy about it but we were increasingly convinced that our course was best for our son. So imagine our surprise when we learned that his LDL level is probably not really that high. It turns out that most cholesterol tests use a calculation to estimate your LDL levels because a separate test that really does measure LDL is time consuming and expensive. The Friedewald calculation says LDL = total cholesterol – HDL – (triglycerides/5). However the calculation is thrown off by high or low triglyceride levels. So if your triglycerides are below 40, as our son’s are, or above 400, you would need a specific LDL test to accurately measure your LDL. With that in mind I find it suspicious that statins are so frequently offered as a first line of defense against heart disease and stunned that they would be suggested for children. Whether their known side effects concern you or not, they definitely have not been around long enough for long term results to be determined. So why wouldn’t every patient insist on an accurate testing of their LDL level before embarking on a dangerous drug? My guess is that, like my family, they have no idea their LDL hasn’t really been measured.