Dr. Ahmad Shahzad
Founder | Lyallpur Diabetes Foundation
Consultant Diabetologist | Educator | Advocate for Preventive Care
Effective lipid management in diabetes is essential for reducing the risk of cardiovascular disease, one of the leading complications among people with diabetes. Dyslipidemia, which is also called abnormal lipid levels, is a primary cause of heart attacks and strokes. With the help of lifestyle modifications and the right medication, diabetics can significantly enhance their health outcomes in the long-term. Knowledge of lipid management is one of the major steps to complete management of diabetes.
Understanding Diabetic Dyslipidemia
Diabetic dyslipidemia is a typical and serious metabolic disorder which is hyper triglycerides, low HDL (good) cholesterol and excessive power of small, dense LDL (bad) cholesterol. This coexistence mainly because of insulin resistance poses a great risk of cardiovascular disease (CVD) in both types 1 and 2 diabetes.
Pathophysiology
The distinct lipid profile in diabetic dyslipidemia arises from insulin’s reduced effectiveness and availability.
- Higher Triglycerides: The resistance of insulin in fat tissue causes the greater lipolysis (fat breakdown), which results in the release of more free fatty acids into the blood. These fatty acids are then converted into triglyceride-rich very-low-density lipoproteins (VLDL) by the liver to a greater level. Also, the body cannot clear the VLDL because of the decreased activity of lipoprotein lipase in the blood.
- Reduced HDL cholesterol: Because of the surplus triglycerides in VLDL particles, they are shifted to the HDL with the help of cholesteryl ester transfer protein (CETP). This fatty HDL is then quickly degraded by hepatic lipase resulting in reduced HDL levels in the blood.
- Small, dense LDL: This is the same process which exchanges triglycerides in VLDL and LDL. This triglyceride-enriched LDL is broken down making it smaller and denser. Their size and density make them atherogenic especially since they can easily get their way into arterial walls, are poorly eliminated in the blood and more easily oxidized.
Symptoms and screening
Diabetic dyslipidemia is not usually symptomatic. The main mechanism of detection is lab testing and the symptoms usually manifest only in cases of complications. The screening of dyslipidemia is done by using a fasting lipid panel.
The signs and symptoms of severe dyslipidemia or its complications are:
- Cardiovascular symptoms: Angina (pain in the chest), dyspnea, palpitations, and weakness of the body, because of constricted arteries.
- Neurological symptoms: Slurred speech, visual disturbances and sudden weakness (transient ischemic attacks symptoms or stroke symptoms).
- Xanthomas: Yellowish, waxy, or fatty blisters on the skin, particularly around the eyes (xanthelasma), palm, and tendons.
- Lipemia retinalis: This is a rare disease where the extremely high levels of triglycerides make the retinal blood vessels look creamy white.
Why Lipid Management Matters in Diabetes
Lipid control is of central importance in the management of diabetes due to its leading role in prevention and delay of the cardiovascular catastrophes of this condition. Dyslipidemia (abnormal lipid levels) is a major predisposing factor to atherosclerosis, the pathophysiology behind heart attacks and strokes.
Diabetes drastically increases cardiovascular disease risk
Diabetics face two to four times the risk of heart diseases and stroke as compared to non-diabetics. The etiology of this augmented danger is a complicated mixture of metabolic deviations including:
- High triglycerides: High fat levels in blood are linked to high risk of atherosclerotic cardiovascular disease (ASCVD) and pancreatitis.
- Low good cholesterol (HDL-C): It is commonly low levels of high-density lipoprotein (HDL) that carry bad cholesterol off the arteries caused by diabetes.
- B. big bad cholesterol (small, dense LDL-C): Due to the probable high level of total LDL cholesterol in diabetics, the particles are smaller and denser, which leaves them with more chances to harm the walls of blood vessels and create plaques.
Aggressive lipid management reduces risk
Diabetics face two to four times the risk of heart diseases and stroke as compared to non-diabetics. The etiology of this augmented danger is a complicated mixture of metabolic deviations including:
- High triglycerides: High fat levels in blood are linked to high risk of atherosclerotic cardiovascular disease (ASCVD) and pancreatitis.
- Low good cholesterol (HDL-C): It is commonly low levels of high-density lipoprotein (HDL) that carry bad cholesterol off the arteries caused by diabetes.
- B. big bad cholesterol (small, dense LDL-C): Due to the probable high level of total LDL cholesterol in diabetics, the particles are smaller and denser, which leaves them with more chances to harm the walls of blood vessels and create plaques.
The benefits extend beyond blood sugar control
Although managing blood sugar is a primary part of diabetes management, lipid control can be even more effective in the prevention of cardiovascular complications. Indicatively, in one study, the reduction in LDL cholesterol by 35 percent and the increase in HDL by 8 percent may potentially save much more life years in diabetic patients than in non-diabetic patients with established heart disease.
What effective management looks like
Effective lipid management plan consists of lifestyle modification and in most cases, medications:
- Modifications in lifestyle: A low saturated and trans-fat diet, exercise and weight loss can all serve to improve the lipid profile of a person.
- Pharmacotherapy: Most individuals with diabetes should start with statins to lower the LDL-C level and decrease cardiovascular risk. In case additional reduction is required or statin cannot be tolerated, additional drugs such as PCSK9 inhibitor, ezetimibe may be used.
- Holistic Approach: The American Diabetes Association (ADA) suggests routine screening and holistic treatment of all cardiovascular risk factors such as blood pressure and smoking cessation to supplement lipid control.
Target Lipid Levels for People with Diabetes
Based on the
American Diabetes Association (ADA) 2024 Standards of Care, target lipid levels for people with diabetes depend on their individual cardiovascular risk. The recommendations have become more aggressive in recent years to reflect the high risk of heart disease in diabetic patients.
Target levels for people with diabetes
| Lipid Type | Target Level | Notes |
| LDL-C (“bad” cholesterol) | Primary prevention: <70 mg/dL is recommended for most adults aged 40–75. For those with additional ASCVD risk factors (such as being aged 20–39), it is also reasonable to treat toward this goal. | The ADA considers people with diabetes to have a high risk of atherosclerotic cardiovascular disease (ASCVD), a condition that includes heart attack and stroke. |
| LDL-C (“bad” cholesterol) | Secondary prevention: A target of <55 mg/dL is recommended for those with established cardiovascular disease. | This more aggressive goal is based on strong evidence that lower LDL levels reduce the risk of future cardiovascular events. |
| Triglycerides | <150 mg/dL. | High triglycerides increase the risk of both heart problems and pancreatitis. If triglycerides are very high (>500mg/dL), lowering them is the first priority. |
| Non-HDL-C | Secondary target: The non-HDL-C goal is usually 30 mg/dL higher than the target LDL-C. | For patients with triglycerides between 200–499 mg/dL, non-HDL-C is considered a key secondary target. |
| HDL-C (“good” cholesterol) | Men: >40 mg/dL. Women: >50 mg/dL. | Low HDL is associated with higher cardiovascular risk, but raising HDL with medication has not been shown to reduce cardiovascular events. Raising HDL is best achieved through lifestyle changes. |
How these targets are achieved
Lifestyle modification is the main approach to lipid management, then pharmacotherapy, mainly using statins.
- Lifestyle changes: This is the initial one and involves weight management, more exercise and a balanced diet that is heart friendly.
- Statin therapy: It is the initial medication of LDL cholesterol reduction. Statin therapy is dependent on age and ASCVD risk.
- Combination therapy: In case of failure of the LDL target utilizing the highest dose of statin, ezetimibe or PCSK9 blockers can be introduced.
- Targeting triglycerides: In patients with extremely high triglycerides, fibrates or high dose icosapent ethyl can be added to statins.
You may also like to read: Managing Cardiovascular Risk in Diabetes
Pharmacologic Management
Managing diabetic dyslipidemia is a critical part of diabetes care and focuses on both lifestyle modifications and medication.
Lifestyle changes
- Diet: Low consumption of saturated and trans fats, increased consumption of fiber, fruits, and vegetables.
- Weight control: Reduced weight can help to dramatically change lipid profiles, lowering the triglycerides and raising the HDL.
- Exercise: Frequent aerobic exercising is beneficial in increasing insulin sensitivity and lipid profile.
- Glycemic control: Glycemic control is important, because inadequate glycemic control aggravates lipid abnormalities.
Pharmacological treatment
- Statins: These are the initial treatments of most individuals with diabetes, independent of baseline LDL concentrations, as they greatly minimize cardiovascular occasions.
- Ezetimibe: This is a cholesterol absorption blocker which is frequently combined with statin treatment in high-risk patients that cannot maintain their LDL targets on statin only.
- PCSK9 inhibitors: Very high-risk patients who continue to have high LDL despite statin and ezetimibe can be administered these injectable drugs.
- Fibrates: The medications are mainly prescribed to reduce triglyceride levels that are considerably high, especially when the risk of pancreatitis is high.
- Icosapent ethyl: An omega-3 fatty acid which is purified and can be used to reduce triglycerides in individuals with high levels of triglyceride in their blood and confirmed cardiovascular disease.
Final Thoughts
In conclusion, lipid management in diabetes plays a crucial role in preventing cardiovascular complications and improving overall health. Monitoring, proper lifestyle, and proper medical treatment can be used to keep the good lipid level and minimize risks in the long run. Through putting lipids management at the forefront of diabetes management, one can attain improved heart health and quality of life.
FAQs
What is the primary target in lipid management for patients with diabetes?
The control of LDL-C is the primary treatment objective of dyslipidemia in diabetic patients when the LDL-C is at target level and the hypertriglyceridemia remains, or when the blood sample is not taken in a non-fasting state.
Does metformin reduce lipids?
Other studies support the fact that metformin lowers lipid profile, and have found a decrease, and the rest have provided conflicting values and results.
Can statins and metformin be taken together?
Metformin and statin used together showed favorable results in nondiabetic mellitus and dyslipidemia.
What drug cannot be taken with metformin?
Steroid tablets, e.g. prednisolone. pills that cause you to pass urine (diuretics), e.g. furosemide. heart and high blood pressure (hypertension) medicine, e.g. testosterone, estrogen or progesterone.