Type 2 diabetes mellitus or adult-onset diabetes is a chronic disease characterized by high levels of blood sugar, usually >126 mg/dL or a Hb A1c >6.5. This is the result of the body becoming resistant to insulin and cannot use insulin properly. Diabetes mellitus is heavily influenced by dietary patterns, physical activity, and body weight. In 2022, the prevalence of diagnosed diabetes is over 11%. Even more concerning is that a third of the US population has prediabetes and is at risk of developing diabetes. A multifactorial approach to treating risk factors in adults with diabetes can reduce major cardiac events.
A heart-healthy diet, rich in fiber and whole grains is the first step in the treatment of diabetes. The Mediterranean and vegetarian diets have been shown to help with weight loss and blood sugar control for diabetes. Avoiding refined sugar or carbohydrates such as white bread, white flour, pastries, sodas, pasta, or sweets. Very often, a dietician-nutritionist or a diabetes education program is necessary to prescribe an appropriate nutrition plan. Caloric restriction is a key element in weight loss. The choice of a diet should take into account patient preferences since it will facilitate adherence.
Physical activity plays an important role in improving cardiovascular health in patients with prediabetes and diabetes. Physical activity can reduce blood pressure, lipids, and visceral fat which is related to improved glucose tolerance and insulin sensitivity, and glycemic control. The most recent WHO guidelines recommend that adults perform 150-300 minutes of moderate-intensity aerobic exercise, 75-150 mins of vigorous-intensity aerobic exercise, or a combination of the two, each week. Moderate-intensity exercise can include a brisk walk, biking 5-9 miles, ballroom dancing, yoga, or recreational swimming. Muscle strengthening or resistance training can further improve glycemic control and facilitate weight loss. Adherence to exercise has been related to a 25-40% reduction in cardiovascular mortality.
THE BENEFITS OF METFORMIN:
Metformin decreases the production of glucose by the liver and increases the sensitivity of the body to insulin. Metformin is considered the first-line therapy for the treatment of type 2 diabetes because of its beneficial effects on HbA1c, weight loss, and improved cardiovascular outcomes compared with sulfonylureas. It has a small risk of metabolic acidosis and has to be used with caution in patients with chronic kidney disease.
NEWER CLASSES OF MEDICATIONS:
SGLT2 inhibitors act at the level of the kidney and increase the excretion of glucose and sodium, leading to a reduction in HbA1c, weight, and blood pressure. Empagliflozin, Canagliflozin, and Dapagliflozin have shown significant reductions in major cardiac events, including heart failure and renal insufficiency.
GLP-1R agonists increase the production of insulin and glucagon in the liver, increase the glucose uptake of glucose in the muscle and adipose tissue and also decrease the production of glucose by the liver. Liraglutide and semaglutide have been shown to reduce the risk of ASCVD in high-risk adults with type 2 diabetes.
In patients with type 2 diabetes and additional risk factors for heart disease, the ACC/AHA guidelines suggest the initiation of these new classes of medications for the primary prevention of heart disease.