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QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Chapter 14
Lipid Management in Diabetes

Lipid abnormalities are common in persons with diabetes (up to 70% of type 2 have lipid disorders). Some problems can be resolved through blood glucose control. Others will require dietary or pharmacological intervention.

Desirable Lipid Levels (fasting)

Testing (Fasting Lipid Profile)

• Adults: At diagnosis and every year
• Children with type 1 diabetes (over age 12): Screen at diagnosis, but after glycemic control is achieved. If initial screening is normal, repeat screening every 5 years. If levels are abnormal, follow-up in 3 months and again at 6 months to assess effectiveness of treatment.
• Children with type 1 diabetes (under age 12): There is no need to screen in absence of parental history of dyslipidemia or early coronary disease. If levels are abnormal, follow-up in 3 months and again at 6 months to assess effectiveness of treatment.
• Children with type 2 diabetes: Screen at diagnosis, regardless of age, but after glycemic control is achieved. If levels are normal, repeat screening every 2 years.

Type 1

• Blood glucose control will often help correct dyslipidemia. 
• Check thyroid function.

Type 2

• Most common type of dyslipidemia: high triglycerides with low HDL.
• Usually have smaller, denser, more atherogenic LDL-particles
• Obesity exacerbates dyslipidemia.
• If no evidence of macrovascular disease; weight loss, increased activity, limiting alcohol, and controlling glucose can help.

Lifestyle Therapies for Dyslipidemia

1. Improved BG control

• Most beneficial for those with type 1 diabetes
• Will help with hypertriglyceridemia
• May decrease LDL-cholesterol up to 15%

2. Fat restriction

• Saturated fat : < 10% of total calories (may need < 7% or total calories)
• Trans fats : minimal intake
• Dietary cholesterol: < 200 mg/day

3. Increase fiber

• Soluble fiber: 10-25 grams/day
• Plant stanols/sterols: 2 grams/day

4. Modest weight loss

• Will lead to decrease in triglyceride levels, increased HDL-cholesterol levels, and a modest lowering of LDL-cholesterol.

5. Increased physical activity

• Will lead to decrease in triglyceride levels, increased HDL-cholesterol levels, and a modest lowering of LDL-cholesterol.

6. Smoking cessation

• Will lead to improvements in lipid profile.

Treatment of Diabetic Dyslipidemia in Adults (order of priorities)

1. LDL-cholesterol lowering

• 1st Choice: HMG CoA Reductase Inhibitors (statins)
• 2nd Choice: Bile Acid Binding Resins (resins) or Fibric Acid Derivatives (fibrates)

2. HDL-cholesterol raising

• 1st Choice: behavioral interventions (see above)
• 2nd Choice: Nicotinic acid (with caution due to BG raising) or fibrates

3. Triglyceride lowering

• 1st priority: BG control
• 1st Choice: fibrates
• Statins are moderately effective in those with elevated LDL also.

4. Combined hyperlipidemia

• 1st Choice: Lifestyle intervention plus a statin
• 2nd Choice:Lifestyle intervention plus a fibrate
• 3rd Choice: Lifestyle intervention plus a resin and a fibrate OR lifestyle intervention plus a statin and nicotinic acid (must monitor BG carefully)

Treatment of Diabetic Dyslipidemia in Children

1. Lifestyle intervention (see above) for LDL-cholesterol of 100-129 mg/dl

2. Consider pharmacological intervention for LDL cholesterol 130-159 mg/dl

• Maximize lifestyle intervention
• Base decision on complete CVD risk profile, including assessment of blood pressure, family history and smoking status.

3. Pharmacological intervention for LDL cholesterol 160 mg/dl

• Bile acid sequestrants (resins) are often recommended as first choice in this age group.
• Statins can be used with caution. Initiate at lowest available dose and increase based on LDL levels and side effects, and monitor LFTs.
• Statins should be discontinued if there is complaint of significant muscle pain or soreness.

4. Elevated triglycerides

• Maximize lifestyle intervention
• If levels > 1000 mg/dl, treatment is necessary. Consider fibrate.
• Fish oil supplementation with omega-3 fatty acids may help lower triglycerides that are not responding to medication.

Resources:
American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care. Vol 29 (1).

American Diabetes Association (2003). Management of Dyslipidemia in Children and Adolescents with Diabetes. Diabetes Care 26:2194-2197.