Half of people with diabetes have uncontrolled hypertension.
People with diabetes and their doctors are failing to give cholesterol and blood pressure control the attention needed to reduce the high risk for heart attacks and strokes in diabetes, according to four reports at the American Diabetes Association's 64th Annual Scientific Sessions.
“Diabetes management requires equal attention to control of blood glucose, cholesterol, blood pressure and other cardiovascular risk factors — but it’s not happening, as today’s research reports show,” said Eugene J. Barrett, MD, PhD, president of the American Diabetes Association. “Physicians around the world and their patients are failing to make the link science has long since proven — that two out of three people with diabetes die from heart disease and stroke.”
Two reports show that only 37 percent of people with diabetes — in two different, very large and geographically separated HMO groups — achieved LDL cholesterol levels of <100 mg/dL, as recommended by the American Diabetes Association. (LDL-C is the “bad” fraction of cholesterol closely associated with cardiovascular disease – CVD).
A third report showed that, despite the efforts of the American Diabetes Association and other organizations, most diabetes specialists around the world still do not consider diabetes a “coronary equivalent” and still do not have low enough LDL-C goals for their diabetes patients.
A fourth report showed that almost half of people with diabetes have uncontrolled hypertension and that up to 75 percent of those in the study who also had kidney disease had uncontrolled hypertension.
New Lipid Reports:
The first study retrospectively reviewed a group of 9,642 enrollees with diabetes in a major HMO in Michigan, according to Manel Pladevall, MD, MS, Clinical Epidemiologist at the Center for Health Services Research, Henry Ford Health System in Detroit. Researchers assessed what percentage of those people were tested for LDL-C, what percentage were treated and what percentage achieved the goal of <100 mg/dL — at five time points — over the course of five years starting in 1997.
“The percentage of patients who reached LDL-C levels of <100 mg/dL improved from 22 percent to only 37 percent over five years through 2001, despite an increase in the percentage of patients tested for LDL-C from 37 percent to 67 percent and an increase in the percentage actually treated from 19 percent to 41 percent,” said Dr. Pladevall.
A second retrospective study reviewed the database of a 1.1 million member managed care group in the southeastern United States. Researchers at Health Core, a health outcomes and clinical research group, identified 8,855 people with diabetes who were tested for cholesterol levels between October 1, 1999 and September 30, 2000. They determined who received prescriptions for cholesterol control and assessed LDL-C levels over time. Their findings were startlingly similar: only 37 percent of these people were at the LDL-C cholesterol goal of <100 mg/dL three years later.
“Any clinician would agree that getting to lower LDL-C goals is important in people known to be at significantly higher risk for cardiovascular disease,” said Vincent Willey, PharmD, Vice President of Research for Health Core, Wilmington, Delaware.
“That two surveys of major populations in very different areas of the country have come up with identical numbers — only 37 percent had achieved the American Diabetes Association recommended LDL cholesterol goal of <100 mg/dL — supports the evidence that much needs to be done to educate physicians and people with diabetes to reduce cardiovascular disease risks,” said Dr. Barrett. “While the data presented in these reports provide assessments as of at least two years ago, and we trust that rates have continued to improve, further work clearly still needs to be done.”
The AUDIT Study:
The AUDIT Study was a worldwide survey of physician attitudes comparing practice patterns related to lipid levels in people in with type 2 diabetes.
“AUDIT was designed to help discern a paradox: while mounting evidence from clinical trials has proven that people with diabetes benefit from lipid-lowering therapy, which reduces their risk of heart attacks and strokes, only a minority of patients actually achieve healthy lipid goals,” said Lawrence Leiter, MD, Head of the Division of Endocrinology, St. Michael’s Hospital, and a professor at the University of Toronto, Canada.
“Despite the recommendations of the American Diabetes Association and other organizations around the world that people with diabetes have their cholesterol managed as aggressively as people with heart disease, our survey of diabetes specialists in 50 countries showed this is not happening,” said Dr. Leiter:
Where is the disconnect? He made four key, sequential points.
1. The survey showed that the targets that diabetes specialists set for their patients are frequently not as low as their professional organizations recommend.
2. In their daily clinical practice, many diabetes specialists still do not recognize that diabetes is a “coronary equivalent.” Indeed, 45 percent of physicians have a different LDL-C goal for people with cardiovascular disease (CVD) vs. those without CVD; 85 percent of physicians have an LDL-C goal of <100 mg/dL for those with CVD vs. 59 percent for people with diabetes but without CVD.
3. Diabetes specialists estimate that only about half of their patients with type 2 diabetes achieve the cholesterol goals set for them — goals that may not be low enough to begin with.
4. The physicians surveyed perceive the primary barrier to goal-achievement to be patient compliance, i.e., the traditional tendency to blame the patient.
“These results demonstrate the need for further educational efforts to ensure that all people with diabetes receive appropriate lipid-lowering therapy to reduce the global burden of cardiovascular disease,” said Dr. Leiter.
The fourth report focused on uncontrolled blood pressure found in a free screening program offered to individuals 18 years or older who had a personal or family history of diabetes, hypertension or kidney disease — and 10,043 participants with complete data were reviewed.
“Almost half — 48.7 percent — of those who had diabetes, but no kidney disease, were found to have uncontrolled hypertension,” reported Janet McGill, MD, associate professor of medicine in the Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis. Among those who had kidney disease, uncontrolled hypertension increased with each stage of the disease and ranged from 55 percent to 75 percent. Further, the prevalence of uncontrolled hypertension was significantly higher in people with diabetes, compared to those without, across the spectrum of kidney function, from normal to severely impaired.
“We know that blood pressure is the single most important factor in preserving kidney function, and can also be critical in reducing the risk of cardiovascular disease,” said Dr. McGill. “Doctors and patients can work together to control blood pressure effectively through medication and lifestyle changes, but constant vigilance and monitoring is necessary.”
Make the Link! Diabetes, Heart Disease and Stroke
Make the Link! Diabetes, Heart Disease and Stroke is a joint initiative of the American Diabetes Association and American College of Cardiology that works to increase awareness of the link between diabetes and heart disease and help educate physicians and people with diabetes about how to reduce those risks.
Consumer research conducted as part of the Make the Link! Initiative showed that 68 percent of people with diabetes do not consider cardiovascular disease to be a serious complication of diabetes. Furthermore, 60 percent of people with diabetes surveyed reported that they do not feel at risk for either high blood pressure or cholesterol problems.
While the management of blood glucose has always been and remains a cornerstone of diabetes care, diabetes requires a comprehensive program that includes management of blood glucose, management of blood pressure, and management of cholesterol.
“The American Diabetes Association calls these key components of care the ABCs of diabetes – A is for A1C, a long-term measurement of blood glucose control, B is for blood pressure, and C is for cholesterol,” said Dr. Barrett. “We urge physicians to help people with diabetes make the link by talking to them about managing the ABCs of diabetes, and other ways to reduce their risk for heart disease and stroke.”