How to Take Care of Your Heart With Diabetes

Diabetes can put you at risk for cardiovascular problems such as heart attack and stroke. The 2023 ADA Standards of Care recommend these steps to keep your heart and blood vessels healthy.

For years, the focus of diabetes care was on glucose control. Today, especially for people with type 2 or older individuals with type 1, managing cholesterol as well as other blood lipids and blood pressure is equally important.

As early as possible after being diagnosed with diabetes, identify your risk factors for heart and blood vessel problems with a thorough medical exam including relevant lab tests. Work with your healthcare provider to understand the results and establish an appropriate care plan for managing glucose, blood pressure, and cholesterol levels, which may require medications.

What are risk factors for diabetes-related cardiovascular complications?

Risk factors for diabetes-related heart and blood vessel problems include the following:

• Having diabetes
• High glucose levels (hyperglycemia)
• High blood pressure (hypertension)
• High cholesterol and blood lipids
• Abnormal blood lipid levels (dyslipidemia)
• Smoking or tobacco use
• Having a BMI greater than 30, especially with increased weight circumference (weight around the abdomen or belly)
• Insulin resistance that is exacerbated by inactivity, excess caloric intake and other risk factors

​Statistics reveal a bleak reality regarding the numbers of people who reach the desired glucose, blood pressure and lipid targets. In 2018, only 1 in 4 US adults diagnosed with diabetes who were nonsmokers met target goals for A1C, blood pressure, and cholesterol. People who already had cardiovascular disease were even less likely to meet these goals. A number of reasons, from a lack of appropriate treatment by your healthcare provider to challenges with lack of access to health care, affordable medications and food, may explain this.

Common diabetes-related heart and blood vessel problems

Atherosclerotic Cardiovascular Disease (ASCVD) describes several conditions that affect blood circulation in the body, all of which begins with the laying down of deposits (plaque) in the walls of arteries. These deposits include lipoproteins and fats that travel in the blood and harden in the arteries around the heart and blood vessels. In people with diabetes, ASCVD tends to occur at a higher rate and at a younger age.

ASCVD includes the following conditions:

Coronary Heart Disease (CHD)

CHD includes myocardial infarction or heart attack and other conditions of the coronary arteries caused by atherosclerosis. A heart attack occurs when the flow of blood to the heart is blocked because a plaque deposit in an artery has ruptured and has formed a clot. This plaque travels to a coronary (heart) artery and causes a minor or major blockage.

Stroke

A stroke occurs when the flow of blood to the brain is blocked because a plaque deposit in an artery in the brain has ruptured and formed a clot. The clot causes a minor or major blockage of the artery, depriving brain cells of oxygen. A stroke may result in problems with speech, coordination, sight, or cognition, as well as permanent brain damage or even death.

Peripheral artery disease (PAD)

Peripheral artery disease occurs when buildup of plaque on the walls of blood vessels causes them to narrow. Peripheral arteries carry blood away from the heart to the legs or arms. PAD is most often diagnosed when it causes pain with walking, numbness, or tingling in the legs and feet.

Heart failure

Heart failure occurs when the heart (a muscle) cannot adequately pump blood. Fluid can build up in the lungs and blood can back up in veins causing shortness of breath and swelling (edema) in the legs. There are many causes for heart failure including narrowed or blocked heart arteries from atherosclerosis, blocked small arteries from diabetes, high blood pressure, heart valve disease, viral inflammation of the heart muscle (myocarditis), irregular heart rhythms (arrhythmias), and other conditions. Heart failure can leave the heart too weak or too stiff to pump blood properly.

Lifestyle modifications

A healthy lifestyle is at the heart of decreasing your risks of experiencing cardiovascular problems. It is important to continue practicing all these actions over time regardless of medications you’re prescribed.

Lose weight

If you carry excess weight, particularly in the abdominal area, try to lose 10 to 20 pounds and keep them off. This action can help you improve many heart and blood vessel disease risk factors. Weight loss through healthy eating, consuming fewer calories day to day, and more physical activity can lower blood pressure, improve abnormal blood lipids, and more. If possible, you may want to consider seeking assistance from a registered dietitian and/or certified diabetes educator for extra support.

Prioritize a healthy diet

Making changes to your eating habits and food choices to eat fewer calories is hard work. Think about these changes as tweaks to your current eating plan rather than a rigid “diet.” Make doable changes one step at a time and focus on choosing a wide variety of foods that are packed with nutrition (nutrient-rich or nutrient-dense) rather than lots of fat, especially saturated fat, and added sugars. Research shows that two eating patterns are healthy for diabetes and reduce risk factors for heart disease – the Mediterranean eating pattern or DASH – Dietary Approaches to Stop Hypertension diet. These eating plans have a lot in common and are also aligned with the ADA’s nutrition recommendations and the U.S. Dietary Guidelines; they both emphasize consumption of non-starchy vegetables, minimize consumption of added sugars and refined grains, encourage whole grains and other whole and unprocessed foods over highly processed and packaged foods, and suggest replacing sugar-sweetened beverages or juice with water.

Exercise regularly

It’s imperative to fit exercise into your healthy lifestyle to improve heart health. Generally, ADA recommends people with diabetes reduce their sedentary activity by decreasing time spent sitting and getting four types of physical activity:

1. Moderate to vigorous intensity aerobic activity: 150 minutes or more per week, over at least 3 days, preferably more, with no more than 2 consecutive days without activity.
2. Resistance exercise: 2-3 sessions per week of at least 30 minutes on nonconsecutive days.
3. Get up every 30 minutes and at least walk around for a few minutes.
4. Flexibility and balance training: 2 to 3 times per week.

Quit smoking

Smoking increases your risk of cardiovascular diseases and death. In people with type 2 diabetes, smoking worsens lipid levels, increases chronic inflammation, and worsens glucose management. You should be asked whether you use tobacco at every medical visit; consider it a vital sign. You should be encouraged to quit and referred for assistance if needed.

Take your medications as prescribed

If you have trouble taking any of your medications due to their side effects, costs or other factors, discuss this with your healthcare providers; there may be alternatives. If you do not understand why you need a medication that is prescribed or believe the medicine will harm you, ask your healthcare providers.

How to Hit Your Glucose, Blood Pressure and Blood Lipid Targets

To keep your heart and blood vessels healthy, ADA and AHA recommend you achieve and maintain glucose, blood pressure and blood lipid targets. It’s worth discussing your targets with your healthcare provider, as they may vary based on a number of individual factors.

Glucose Management

Diabetes is considered a progressive condition, and most people with type 2 diabetes will need an increasing number of glucose-lowering medications to keep their glucose levels within their target. There are two classes of glucose-lowering medications that can also help lower your risks of cardiovascular and kidney disease. Discuss the use of one or both of these medications with your diabetes care providers based on your individual medical situation and other factors.

One class is incretin-based therapies such as GLP-1s and SGLT-2 inhibitors. GLP-1s reduce appetite, stimulate insulin release and inhibit glucagon release in the pancreas. They also slow the digestion of food in the stomach, delaying glucose absorption and rises in glucose levels. GLP-1s also cause weight loss and reduce the risk of cardiovascular disease. The other class of medication, SGLT-2 inhibitors, lowers glucose levels by reducing the amount of glucose that is reabsorbed by the kidneys and increasing the amount of glucose put out in the urine. SGLT-2 inhibitors improve cardiovascular and renal outcomes including reducing hospitalizations for heart failure and reducing chronic kidney disease.

Blood Pressure Management

People with diabetes are twice as likely to have high blood pressure compared to people without diabetes. Keeping your blood pressure under control reduces cardiovascular events, stroke, and heart failure. Blood pressure readings should be taken at every healthcare visit. If you have high blood pressure, you should also monitor your blood pressure at home.

How you and your healthcare providers manage your blood pressure depends on your individual situation and other cardiovascular disease risk factors.

If your blood pressure is greater than 120/80 mmHg (but lower than 130/80 mmHg), take steps to put lifestyle modifications mentioned above into action. You should also aim to reduce the amount of sodium you consume and increase potassium intake from foods and beverages. Your target blood pressure should be lower than 130/80 mmHg (if it can be safely attained).

If your blood pressure is at or greater than 130/80 mmHg, add to the healthy lifestyle and self-care behaviors (see above), starting a blood pressure medication and working to achieve a target below 130/80 mmHg.

There are several classes of blood pressure lowering medications. Two types of medications, ACE inhibitors (generic names of these medications typically end in “pril”) and ARBs (generic names of these medications typically end in “sartan”), are recommended as the best initial blood pressure medicines for people with diabetes. To adequately manage blood pressure within the desired target noted above, some people will need to add another class or classes of blood pressure medication, such as a calcium channel blocker or diuretic.

Blood Lipid Management

A large percent of people with diabetes have abnormal blood lipid levels. In type 2 diabetes, it is typical to have a lower than desirable HDL cholesterol level. It’s also typical to have a higher than desirable triglyceride and LDL cholesterol levels.

LDL targets to aim for

The target for LDL-C is <70 mg/dL in people ages 40-75 years with diabetes and heart and blood vessel disease risk factors; the target is <55 mg/dL in people with diabetes and heart and blood vessel disease risk factors.

How to improve lipid levels

Make your lifestyle as healthy as you can. To improve your lipid levels, try to incorporate as many of the healthy lifestyle modifications mentioned above as you can.

Keep your blood glucose well managed. Improving glucose management also improves lipid levels.

Ask your doctor if starting a statin could help. People with diabetes often need to take a statin medication (generic names of these medications end in “statin”). Statins aim to lower LDL-C; having low LDL levels protects the heart and blood vessels and decreases your chance of death from cardiovascular events.

Based on ADA guidance, whether statin medication is appropriate depends on your age and other cardiovascular disease risk factors.

• If you are between the ages 20 to 39 with heart and blood vessel disease risk factors, there is research to suggest you should start taking a statin medication.
• If you are between the ages of 40 to 75 and do not have heart and blood vessel disease, use a moderate-intensity statin medication.
• If you are between the ages of 50 to 70 with multiple heart and blood vessel disease risk factors, research suggests you start a high-intensity statin medication. A decrease in LDL-C of 50% or greater (from the start of treatment) should be reached with a high-intensity statin medication to a target of 70 mg/dL or less.
• If you can’t tolerate statin medication or if a statin medication is not sufficient to help you achieve your target lipid level targets (particularly LDL-C), there is now another class of medication to use called PCSK9 inhibitors – though these are more expensive medications.
• Note that statin medication should not be used in pregnancy.

Try to keep triglyceride levels in target.

• If your triglycerides are moderately elevated (175 to 499 mg/dL) initially, focus on the same healthy lifestyle and self-care behaviors detailed above. As part of a healthy eating plan, limit sugar-sweetened beverages, refined sources of carbohydrate, and reduce alcohol consumption. In addition, get your glucose levels to target levels.
• If your LDL is under control by taking a statin medication but your triglycerides are still elevated (135-499 mg/dL), discuss with your healthcare provider the addition of a prescription level of omega 3- fatty acid, such as Vascepa or Lovaza. Research shows they can reduce cardiovascular events.
• If your triglycerides are greater than 500 mg/dL, your healthcare provider needs to evaluate the causes and determine the optimal approach.

When and how often should you get your blood lipid levels checked?

You should get a lipid panel to check your triglyceride and cholesterol levels:

• When you are diagnosed with diabetes and every five years thereafter if you are under 40 years old or more frequently if indicated.
• If you take statin medication: When you start taking a statin or other lipid-improving medication, then again 4 to 12 weeks after starting the medication, when there is a change in dose, and annually thereafter.

Does aspirin help reduce diabetes-related cardiovascular risk?

The guidance on taking a low-dose aspirin each day has changed over the years. Aspirin is used to decrease blood clotting. At this time neither the ADA nor AHA recommendations encourage the use of low-dose aspirin as a prevention strategy against primary events (initial events such as heart attack or stroke). These organizations do state that aspirin use (75-162 mg/day) remains beneficial in reducing cardiovascular disease and death in people with diabetes as secondary prevention (to prevent an additional cardiovascular event).

However, depending on your level of risk for heart disease, the risk of bleeding caused by aspirin may outweigh the benefits of taking the medication. Talk with your healthcare provider to fully evaluate the risks and benefits of taking aspirin.

A final word on taking care of your heart when you have diabetes

With so many targets to keep in mind, and medications to consider, managing cardiovascular health when you have diabetes can be overwhelming; but there are clear actions you can take to reduce your risk.

For example, Anna Norton, who has lived with type 1 diabetes for 29 years. When Norton discovered that she had high blood pressure, she immediately began taking proactive steps to maintain heart and blood vessel health. Those included consistently taking medication, incorporating exercise into her daily routine, getting her blood pressure checked at every medical and dental appointment, checking her lipid levels annually, managing stress by fitting in fun activities, and eating as healthfully as possible.

Norton, who is the former CEO of DiabetesSisters, also encourages others to take a can-do stance with healthcare professionals, asking them for details on risk factors and actionable steps you can take as well as support whenever possible.

“My endocrinologist and I also discuss the relationship between my glucose management, physical activity, lipid and blood pressure measures at nearly every appointment,” Norton said, adding, “Our approach is proactive and preventative. She assures me that when I reach the age of 50, she’ll refer me to a cardiologist as a preventive step. As a woman with diabetes, I know I’m at higher risk of heart disease than women without diabetes, so I appreciate her proactiveness.”

Recommendations in this article are aimed at adults with type 1 and type 2 diabetes and excludes children and adolescents as well as pregnant people with diabetes. While there has been far less research conducted in this area, heart and blood vessel disease does affect people with type 1 diabetes.

About this series

Each year the American Diabetes Association updates its Standards of Medical Care in Diabetes based on current science. We’ve translated key points of the up-to-date Standards into plain English so you know how to stay healthy and minimize diabetes complications.

Other articles in this series:

• Your Guide to the 2023 ADA Standards of Care
• How to Keep Your Kidneys Healthy When You Have Diabetes
• How to Keep Your Eyes Healthy With Diabetes

About the authors

Hope Warshaw

Hope Warshaw, MMSc, RD, CDCES, BC-ADM, is a nationally recognized registered dietitian and certified diabetes care and education specialist. She has spent her career, now spanning more than 40 years,... Read the full bio »