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John Buse, M.D., Ph.D, C.D.E., FACE, University of North Carolina School of Medicine C. Noel Bairey Merz, M.D., FAAC Cedars-Sinai Medical Center

Of the 17 million Americans who have diabetes, a solid majority-at least 65 percent-will die from a heart attack or stroke.

Physicians rank diabetes as the greatest risk factor for heart disease, placing it higher than smoking, obesity or even high blood pressure, according to a recent survey by the American Diabetes Association (ADA) and the American College of Cardiology (ACC). Studies show that people with diabetes are two to four times more likely to suffer heart attacks than people without diabetes. Once they have a heart attack, they are more likely to die as a result of it than people without diabetes who have had a heart attack.

Diabetes and heart disease. They are undeniably, inextricably, mortally linked. And people with diabetes don't know it.

Another ADA/ACC survey earlier this year found that people with diabetes are far more concerned about losing a toe or going blind than they are about having a heart attack. A stunning 68 percent don't even believe that heart disease is a serious consequence of their disease.

But the sober truth is, it is.

In fact, while the risk of dying from cardiovascular disease has been steadily dropping for the general population since the 1970s, it has been climbing for people with diabetes. So concerned are the nation's health-care organizations that they've devoted considerable resources into campaigns to educate the public about the deadly link between diabetes and heart disease, hoping that, armed with enough information, people will begin taking steps to save their own lives.

The ADA and ACC joined forces in a public-awareness initiative entitled "Make the Link! Diabetes, Heart Disease and Stroke," which encourages health-care professionals to improve monitoring and treatment of people with diabetes for symptoms of heart disease. The Make the Link! initiative is made possible by generous support from Aventis Pharmaceuticals; AstraZeneca LP; Bristol-Myers Squibb Co.; Eli Lilly and Co.; GlaxoSmithKline; Merck & Co. and Merck/Schering-Plough Pharmaceuticals; Monarch Pharmaceuticals and Wyeth Pharmaceuticals; Novartis Pharmaceuticals Corp., and Pfizer Inc. This campaign also supports the Department of Health and Human Services' National Diabetes Education Program (NDEP), which has been promoting specific steps people can take to reduce their risk of developing heart disease.

"Be Smart About Your Heart," the NDEP campaign, stresses learning the ABC's of diabetes: "A" stands for the A1C test, a measure of average blood-glucose levels over the last two to three months; "B" stands for blood pressure, and "C" stands for cholesterol. Studies have shown that these three measures are critical indicators of diabetic and cardiovascular health. While many people know that cholesterol and blood-pressure levels should be kept in check to ward off heart disease, what they don't know is that people with diabetes must keep their levels much lower than those of the general population (see box). This is the kind of information the ADA and ACC are encouraging physicians to emphasize with their patients. While their joint survey, which interviewed more than 900 physicians, found that health-care providers reported speaking to people with diabetes about the dangers of heart disease, it's obvious the message is not getting through.

In the end, education can only go so far. People have known for years, for example, that smoking can kill them. People with diabetes who smoke are 11 times more likely to die prematurely than people without diabetes who smoke. Lowering cholesterol, managing blood pressure, taking certain blood-pressure medications (e.g., ACE inhibitors and ARBs) and taking a daily aspirin are a few of the things that have been shown to reduce the risk of heart disease in people with diabetes by 20 to 40 percent each.

These are startling facts. But will they motivate people to take action? Let's hope so. Millions of lives depend upon it.

Breaking the Link: Reduce Your Risk for Heart Disease
People who have diabetes are two to four times more likely to suffer a heart attack or stroke than people who don't have diabetes. Here's what to do to lower those odds:

· If you smoke, get help to quit.
· Lower your A1C, or average blood-glucose level, to 7 or less. Get tested at least twice a year.
· Lower your blood pressure to 130/80 or below. Keep it there.
· Lower your cholesterol (LDL) to 100 or below. Get tested once a year.
· Be active for at least 30 minutes each day-take a walk or rake leaves.
· If you are obese or overweight, consult your health-care provider about a weight- loss plan.
· Eat low-fat meals that are high in fruits and vegetables, and whole grain foods.
· Consult your health-care provider about aspirin therapy and other appropriate medicines that can help reduce the chances of having a heart attack or stroke.

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