Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE:Typically, 90% of patients with diabetes 80% of them are overweight or [have obesity]; [it’s] probably closer to 90%. [With obesity], there are a lot of complications within a few years. There is a discussion about [those with] metabolically healthy [obesity], but eventually, they develop complications. It just takes longer, as you said. I think the issue really started in 1998 when Steve Haffner showed that diabetes is a coronary artery disease equivalent in this East-West study that he had, and that’s a population number. The sad part of it is that cardiologists were [arguing] that not everybody’s [the same]. Not everyone has arteriosclerosis, and therefore it’s not a coronary artery disease equivalent, and I agree. However, everyone with diabetes has an increased risk for cardiovascular disease [but] maybe not to the same extent. That’s why in studies you see 2 times to 8 times; we don’t have 1 number. But we have to say, “If you have diabetes, you have a much higher risk for cardiovascular or kidney disease.” That’s 1 part. The second part has to do with the aspect of insulin resistance and obesity. If we look at a group like the Pima [tribe, they] all [have obesity], dyslipidemia, and high blood pressure [that is] not controlled. Half of them will have diabetes, half of them don’t, but they have as much [incidence of] heart disease, stroke, and liver disease as those with diabetes. So we have the condition that is leading to diabetes. We have a laboratory in Arizona, [and] we can look at them and say, “Why did you get diabetes and [another patient didn’t]?” They make enough insulin, so their high insulin level may cause some damage, and we can talk about that at a different time. The third aspect—Jaime, I’m glad I have a cardiologist here because I’ve got somebody I can call on—is the aspect of “It’s just hyperglycemia; it doesn’t mean anything.” Hyperglycemia never showed in randomized control type 2 show reduction within 2 years of events or the cardiovascular-related event. So I want to borrow from type 1 diabetes. Turns out there were studies on type 1 diabetes by a [researcher] in Glasgow, Scotland [named] Naveed Sattar. He’s done some terrific work, and he’s looking at having diabetes unrelated to lipids or blood pressure, just the time of diabetes. Ten years increases the risk for cardiovascular disease, just 10 years of diabetes, especially [for] younger [patients]. And what we think today is that [patients] with type 1 diabetes get heart disease at a much younger age, and their lipids supposedly are good. So there’s much more to the pie. So we can resolve it and maybe talk about it later. Let’s prove that the [patient] with diabetes does not have coronary disease. There’s a very simple test that most insurance companies are not going to pay for; it’s called calcium score. They don’t want to call it preventive [because] they don’t want to pay. I make my patients pay $100 to see. “Are you at risk, or are you not at risk?” And based on that, [we] decide treatment and not only for diabetes. But it’s a great test to help [many] patients on how to go forward. Have you done things like this?

Eugene E. Wright Jr, MD: I haven’t, but you raise an interesting point. I think that’s where the conversation gets to the patient. Once they have an idea and a better understanding of what is potentially ahead for them, we have a shared discussion: “Here are the kinds of things we can do to one [and] predict risks, and here are the kind of interventions that we can do early on to try to delay the onset of some of these things that may be ahead for you.” So that’s an individual conversation with an individual patient. And you’re right; not all patients can afford that. But I think the first thing they need to have is awareness of this, and what is the potential.

Jennifer B. Green, MD: I wanted to get back to your comment about cardiologists doing catheterizations that didn’t show significant coronary artery disease. We do need to remember that that’s not the whole story with respect to cardiovascular complications in diabetes. We know that many [patients] with diabetes, particularly women, may in fact have microvascular changes or damage in the heart and not much involvement of the large coronary vessels. Of course, we see significantly more structural heart disease in [patients] with diabetes, so they are at risk for heart failure as well. So when we talk about these cardiovascular complications, we need to make sure we’re talking about more than just coronary heart disease.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: And I like that, because about 17 to 18 years ago, at the height of the automated Tritan contract threshold [TCT] test era, there came a very interesting study from Canada to show that [patients] 65 [or older] had much more heart failure than anybody [realized]. And TCTs, although they can induce heart failure, can prevent heart failure, and the question came up. Then TCTs went out into the world, and all the data went out into the world. [There were] some great data about that. Until the past 5 to 6 years, when [suddenly] we start seeing heart failure a lot. And numbers got up to 30% to 40% of [patients] with diabetes having heart failure. And yes, the heart failure is [due to] coronary disease because of ischemic heart disease. A lot of that has to do with other stuff: hypertension, cardiomyopathy, and maybe hyperglycemia cardiomyopathy. By the way, if we look at some early studies, [for] A1C [levels] between 5.5 to 6.5, there is the most trajectory [for] changing heart muscle into making that muscle more amenable to develop heart failure early on. So hyperglycemia is a bad condition because it does the glycation of protein. It changes a protein structure, so it has caused damage in one way or another.

Transcript edited for clarity.