After spending nearly two decades trying to manage her Type 2 diabetes, Agnes Czuchlewski landed in the emergency room in 2015, with news that she’d just experienced a heart attack. She also learned that she had metabolic syndrome, a cluster of conditions that includes diabetes but also brings higher risk of heart disease and stroke.
“Because I needed to lose quite a bit of weight when I was first diagnosed, I was focused on the number I saw on the scale, and then on my blood-sugar numbers,” recalls Czuchlewski, 68, who lives in New York City. “I didn’t realize other numbers came into play, like blood pressure and cholesterol. That came as a shock. It made me realize that there was more I needed to get under control than I thought.”
According to the American Heart Association (AHA), people with diabetes have double the risk of stroke compared to those without diabetes. They also tend to develop heart disease or have a stroke at an earlier age, and the AHA estimates that an American adult with diabetes is hospitalized for stroke every two minutes.
The connection is related to how the body handles blood glucose to make energy, says Dr. Deepak Gulati, a neurologist at The Ohio State University Wexner Medical Center’s Comprehensive Stroke Center. When food is broken down into glucose, it uses the hormone insulin to enter cells, but those with Type 1 diabetes lack the insulin needed for this process. With Type 2 diabetes, too little insulin is produced. In both cases, that can cause too much glucose to remain in the blood, which can result in increased fatty deposits in the blood vessels.
“These blood vessels are in the brain, heart, and other organs,” says Gulati. “The deposits can weaken the walls of the blood vessels and also cause blockages, which significantly increases risk for heart attacks and stroke.”
That doesn’t mean cardiovascular problems are inevitable for those with diabetes. Although there are some factors you can’t change, like family history or your age—stroke risk increases as you get older—the good news is that there are ways to make stroke prevention more robust when you have diabetes.
Be aware of your risk level
The first step for prevention is simply to be aware of the link. Like Czuchlewski discovered, managing diabetes is crucial for health, but without knowing about stroke risk, you could be ignoring other essential variables like blood pressure and cholesterol.
“Often, we see patients who have their blood sugar at a good level, and their diabetes controlled, but they have no idea they need to focus more on cardiovascular health than someone without their condition,” says Dr. Caroline Messer, an endocrinologist and medical director of the neuroendocrine center at Lenox Hill Hospital in New York.
Awareness needs to go in both directions, she adds. That means not only should people with diabetes understand stroke risk, but those with cardiovascular issues may want to investigate the possibility they have diabetes. Sometimes, Messer says, someone in the emergency department who’s had a stroke or heart attack will be told they also have diabetes, and that can be alarming.
You don’t need to wait until a dramatic health event, either. If you have other risk factors for heart disease like high blood pressure, sedentary habits, poor nutrition, and high cholesterol, Messer suggests it’s beneficial to get a complete checkup—one that looks at the possibility you have diabetes as well as heart issues, since they go hand in hand.
“Risk for one can raise risk for the other,” she says. “So, if you already know you have heart-health challenges, it’s a good idea to get checked for diabetes as well. That will help you manage everything that might be going on.”
Know your numbers
With diabetes, the numbers that get the most attention are daily blood-sugar levels as well as the A1C—a test that measures blood-sugar levels over three months as a way to spot trends. But it’s also important to understand where you are in terms of cholesterol and blood pressure.
“High blood pressure, or hypertension, on its own doesn’t have any symptoms, so people may not know it’s a problem for them until they have an event like a stroke or heart attack,” says Gulati. “As someone with diabetes, you should be very aware of what your blood-pressure reading is, given your higher stroke risk.”
According to the U.S. Centers for Disease Control and Prevention (CDC), a normal blood pressure is 120/80 mmHg. You’re considered to have hypertension with a reading of 140/90 or above, Gulati says. High blood pressure damages arteries throughout the body, which can cause them to burst or get blocked more easily. If that happens, it can limit or stop oxygen from getting to the brain, resulting in a stroke.
It’s also useful to learn how to decipher your cholesterol numbers. A high amount of low-density lipoprotein (LDL) cholesterol can indicate fatty deposits in the blood vessels, while high-density lipoprotein (HDL) cholesterol is often called the good kind. It absorbs cholesterol, and higher HDL levels can lower your risk for heart disease and stroke.
Much like blood pressure, there are usually no symptoms of high cholesterol, says Gulati, so you could have sky-high LDL levels without realizing it. Plus, hypertension and high cholesterol are connected when it comes to stroke risk. Plaque deposits from cholesterol can narrow your arteries, causing your heart to pump harder to get blood through your body. That can increase blood pressure.
Getting your numbers checked and understanding what they mean—as well as having a conversation with your doctor or diabetes educator about how to address them—is a vital step toward preventing stroke, says Gulati.
Expand your care team
Because of the high risk of stroke for those with diabetes, Messer suggests adding a cardiologist to your care team, in addition to an endocrinologist.
“Everyone with diabetes should see a cardiologist at least once a year, especially if you have additional risk factors like hypertension or family history of stroke,” she says.
You may also want to consider other health professionals who have the knowledge and insight to address both heart health and diabetes. For example, this list might include a diabetes educator, registered dietitian, physical therapist, and smoking-cessation counselor.
That last one could play a key role if you’re struggling to give up tobacco. A 2018 study in the journal BMJ Open found that people with diabetes who smoke are 3.5 times more likely to experience a stroke than those who don’t smoke. Another study, in a 2009 edition of Diabetes Care, noted that smoking amplifies cardiovascular risk in those with diabetes, in part because it raises blood pressure. It can also damage blood vessels and increase insulin resistance.
Read More: The Truth About Fasting and Type 2 Diabetes
Consider medication if recommended
If you have high cholesterol or hypertension, your doctor may suggest going on medication that addresses those issues, such as calcium channel blockers or statins, says Gulati. Although a medication regimen will depend on your specific situation, he adds that options like these are not only safe to take with diabetes medication, but that it’s fairly common for them to be paired together.
Even if your numbers are in a good range, another option you and your doctor might consider, adds Messer, is a diabetes drug class called GLP-1 agonists. This class of medication has been shown to help with blood-sugar control and potential weight loss, and research indicates it’s promising for decreasing risk of stroke in people with diabetes.
Whatever medication you and your doctor decide to try, another essential strategy is to adhere to your medication schedule. That might sound obvious, but a 2014 study in JAMA found that medication nonadherence—when people don’t take their meds as recommended—is a common problem, and up to half of adults in the U.S. who take prescriptions may struggle with it. Another study, about diabetes medications specifically, found that non-adherence is associated with poor glycemic control and higher risk of diabetes complications.
Focus on heart-healthy lifestyle changes
If you have diabetes, it’s likely you’re already careful about what you eat in terms of carbohydrate and fat content as a way to control blood sugar. It’s also helpful to look at heart-healthy diets for inspiration, suggests Dr. Jason Tarpley, a stroke neurologist and director of the Stroke and Neurovascular Center for Pacific Neuroscience Institute at Providence Saint John’s Health Center in Santa Monica, Calif.
“When it comes to the best way to prevent stroke, food is pretty darn good as a starting point,” he says. “An approach like the Mediterranean diet can help with both your diabetes and your cardiovascular health, particularly with its emphasis on seafood, beans, and nuts.”
Other heart-boosting lifestyle habits are also key. For example, getting regular physical activity, focusing on quality sleep, lowering stress, quitting smoking, and maintaining meaningful social connections have been shown to help with factors like blood pressure regulation, Tarpley says.
Mayo Clinic notes that, over time, getting fewer than six hours of sleep per night can contribute to the development of high blood pressure because of negative changes in regulation of hormones like cortisol and melatonin. People with diabetes already face hormone challenges, and these can worsen with sleep problems. According to the CDC, too little sleep can increase insulin resistance, for instance.
Physical activity is another boon to stroke prevention and diabetes management. The American Diabetes Association noted in the journal Diabetes Care in 2016 that exercise improves blood-sugar control, reduces cardiovascular risk factors, contributes to weight loss, and even helps with emotional wellbeing.
“There are many factors you can’t change when it comes to stroke risk as someone with diabetes,” Tarpley adds. “You can’t change your genes or your age, most notably. But there are modifiable factors that can make a huge difference. It’s actually exciting to see how much better you can feel with habits like these, and you’ll be lowering your risk of stroke at the same time.” •