Non-modifiable Risk Factors
There are a variety of risk factors and lifestyle choices that can contribute to type 2 diabetes and heart disease, which is the leading cause of death among American men and women. Some of these factors are modifiable , meaning they can be changed, and include things like diet, exercise and smoking. Other factors are non-modifiable and cannot be controlled, such as age, gender, race and ethnicity and family history. Although these traits cannot be changed, knowing about them and their associated risks will help in assessing your overall health.
Age: As your age increases, so does your risk for developing cardiovascular disease and diabetes:
i. 85 percent of Americans 65 and older die from heart attacks
ii. Anyone of any age is capable of developing type 2 diabetes, however;
iii. 10.5 percent of men over the age of 20 have diabetes, and
iv. 8.8 percent of all women over the age of 20 have diabetes
Race & Ethnicity: The risk of cardiovascular disease and diabetes is higher in certain ethnic groups:
i. African Americans, Mexican Americans, American Indians, native Hawaiians and some Asian Americans have an increased risk of diabetes and heart disease. This is partly due to higher rates of high blood pressure, obesity and diabetes in these populations.
ii. African Americans are also more likely than other ethnic groups to develop type 2 diabetes.
Gender: Gender influences your likelihood of developing heart disease:
i. Men are more likely to develop heart disease.
ii. Once a woman reaches menopause, her risk increases as well, but the prevalence is still not as high as a man’s.
Family History: If a member of your immediate and/or extended family has heart disease or diabetes, your chances of developing those conditions increase as well.
It is essential to share non-modifiable risk factors with a doctor, but the best way to prevent heart disease and type 2 diabetes is to manage the modifiable risk factors.
Accumulating research shows there are a number of factors that contribute to a person’s overall likelihood of developing type 2 Diabetes and heart disease.
Modifiable risk factors include:
Two out of three Americans are now overweight or obese, which poses a threat to their cardiometabolic health. But for many patients, weight loss can be a struggle because it means substantial changes in eating and exercising habits. These can be some of the hardest habits to change, and there is no “one size fits all” or quick fix. Have a frank, open discussion with your patient about their risk for diabetes and CVD. Explain how even just a small weight loss could have a big impact on their health, quality of life, and on the length of their life. If they have other cardiometabolic risk factors, they should know that losing weight can help manage blood pressure and cholesterol, among others.
i. Measure BMI routinely at each regular check-up.
BMI 18.5-24.9 = normal
BMI 25-29.9 = overweight
BMI of 30 or greater = obesity
ii. Recommend & counsel for lifestyle modification
iii. Reduce calorie intake
iv. Increase physical activity
v. Remind patients that even a small calorie deficit will lead to weight loss. A deficit of 100 calories per day leads to a 10lb weight loss over a year.
vi. Consider pharmacologic treatment
High Blood Glucose
Insulin resistance and high blood glucose are substantial risk factors for diabetes and in the long run, heart disease and stroke. ADA uses the fasting plasma glucose (FPG) test to determine if patients’ glucose levels are too high.
Healthy blood glucose – FPG under 100
Pre-diabetes – FPG 100 – 125
Diabetes – FPG more than 125
Hypertension leads to elevated risk for myocardial infarction, stroke, eye problems and kidney disease. Often a silent disease, many patients won’t know they have high blood pressure until informed by their health care provider.
For patients without diabetes:
i. Blood Pressure should be measured at each regular visit or at least once every 2 years if it is less than 120/80 mmHg
ii. Blood Pressure should be measured while seated after 5 min rest in office
For patients with diabetes:
i. Blood Pressure should be measured at each regular visit
ii. Blood Pressure should be measured while seated after 5 minutes rest in office
iii. Patients with 130/80 mm Hg should have Blood Pressure confirmed on a separate day
i. DASH (Dietary Approaches to Stop Hypertension) diet
ii. High in whole grains, fruits, vegetables, and low-fat dairy
iii. Low in saturated and trans fat, cholesterol
iv. Physical Activity
v. Weight loss, if applicable
If Blood Pressure is 140/90 mm Hg, drug therapy is indicated
i. Combination therapy often necessary
ii. Treatment should include ACE or ARB
iii. Thiazide diuretic may be added to reach goals
iv. Monitor renal function and serum potassium
Abnormal Lipid Metabolism
Inform patients of the health risks of both high LDL cholesterol and low HDL cholesterol, as well as triglycerides. Patients should also be aware that modest weight loss and increased physical activity can have a beneficial effect on lipid management.
In adults (> 19 years) without diabetes, test at least every 5 years, including adults with low-risk values. Low-risk values are:
i. LDL <100 mgdL
ii. LDL <100 mgdL
iii. HDL >40 mgdL for men
iv. >50 mgdL for women
v. Triglycerides <150 mgdL)
Inflammation & Hypercoagulation
Proinflammatory/prothrombotic factors are known to underlie cardiometabolic risk. Inflammation is a major component of atherogenesis and other cardiometabolic problems. Creactive protein (CRP), an emerging marker of inflammation, may provide useful information to assess CVD risk, but trials documenting its clinical utility have not been completed. This may give a more complete picture of risk.
Relative risk categories for hs-CRP levels:
Low risk <1 mg/L
Average risk 1-3 mg/L
High risk> 3 mg/L
Patients with hs-CRP levels in the high end of the normal range have 1.5 to 4 times the risk of having MI than those with CRP values at the low end of the normal range. Weight loss, aspirin and statins have been shown to reduce CRP levels, however, at this point, no controlled prospective trials have shown the benefit of CRP lowering.
More research is needed to establish hypercoagulation as a solid indicator of risk, to determine the positive predictive value of the test, and to standardize assays.
35% of coronary heart disease deaths can be attributed to an inactive lifestyle, and consistent exercise can reduce CVD risk.
Staying active can:
i. Increase insulin sensitivity
ii. Improve lipid levels
iii. Lower blood pressure
iv. Aid weight management
v. Improve blood glucose management in type 2 diabetes / Lower risk of CVD
i. Encourage your patients to find ways to fit activity into their daily routine. Examples include taking the stairs, parking further away, taking the stairs instead of elevator, or walking to another bus stop.
ii. Encourage patients to aim for at least 150 minutes/week of moderate aerobic exercise. This can be broken down into multiple spurts of activity each day. If they are just starting out, encourage them to start with just 5 or 10 minutes, 3x per day and build from there.
iii. Many patients are motivated by wearing a pedometer and tracking their steps. Encourage them to join a walking group and challenge each other to more and more steps. A good online group exists at diabetes.org/ClubPed
Most patients know smoking is bad for their health, but quitting is often easier said than done. If you have patients who smoke, be sure to emphasize not only the grave dangers of continuing smoking, but also the tremendous benefits of quitting.
i. Obtain documentation of history of tobacco use
ii. Ask whether smoker is willing to quit
iii. If no, initiate brief, motivational discussion regarding:
iv. The need to stop using tobacco
v. Risks of continued use
vi. Encouragement to quit, as well as support when ready
vii. If yes, assess preference for and initiate either minimal, brief, or intensive cessation counseling.