An article written by Dr Edward Leatham, Consultant Cardiologist. Author of The Naked Heart. The views expressed here are my own and not necessarily a consensus view.
Tags: Glucose, Coronary heart disease, CGM, NH1 search website using Tags to find related stories.
Recent scientific discoveries have aligned much like planets, leading to an inescapable conclusion among many physicians that disordered glucose metabolism may be as important as LDL cholesterol in the genesis of heart disease, as well as many other modern afflictions. This recognition stems from the connection between glucose ‘dysregulation’, diabetes, and inflammation, and the understanding that numerous adult diseases affecting people over 60 have an inflammatory root cause.
Insulin resistance, obesity, and diabetes are increasingly prevalent, fueled by lifestyle changes and the widespread availability of low-cost, ultra processed food. An estimated 537 million adults aged 20–79 years are currently living with diabetes globally. It represents 10.5% of the world’s population in this age group.
Insights gained from the use of continuous glucose monitors (CGM) have revealed that many non-diabetic individuals exhibit transient elevation in blood glucose after consuming high-carbohydrate foods to levels normally only seen in insulin resistant or deficient diabetics. This observation has sparked significant interest in whether ‘glucose dysregulation’, characterised by both high variability (a known cardiovascular risk factor) and excursions (‘spikes’) above normal levels (e.g., 7.8 mmol/L or 140 mg/dL), could be an important contributor to many long-term diseases.
Despite the lack of long-term clinical trials to test this hypothesis adequately, the urgency of the matter, especially for those at high risk of heart disease, heart failure, and coronary artery atherosclerosis, cannot be overstated. However, while we await robust clinical trials, we can speculate, as there are already strong indicators of the importance of ‘the glucose axis’. For example it was established decades ago that diabetes and raised HbA1c are major risk factors for cardiovascular diseases and poor glucose control has long been associated with poor outcomes in patients with acute coronary syndromes. Recently, various landmark trials have grabbed the attention of cardiologists and put ‘glucose’ right back under the spotlight because it seems when present in excess, glucose is shaping up to be a really important ‘baddie’ . Several different classes of glucose-lowering drugs, initially developed for diabetics, have shown immense promise by lowering major cardiovascular endpoints (including all cause mortality ) in non diabetic patients, as evidenced by the SELECT trial with semaglutide and numerous studies on SGLT2 inhibitors in heart failure patients.
Fuelled by an interest in coronary inflammation In our medical practice, we have observed that many high-risk patients with atherosclerosis equipped with continuous glucose monitors exhibit high glucose responses to food, often reaching values seen in diabetic patients , despite being ‘non-diabetic’ or ‘pre-diabetic’ based on conventional criteria like HbA1c.
Given that it is relatively straightforward to improve glucose profiles with dietary and lifestyle changes, it seems a good time for cardiologists to become more proactive in treating glucose variability/dysregulation in their non diabetic patients who have coronary heart disease or heart failure.
In practice the implication is that where high risk patients with dysregulated glucose profiles are also overweight, potent drugs like SGLT2 inhibitors and GLP-1 agonists should be considered to both lower body weight and improve glucose profiles, with the potential for even better outcomes in these specific groups. There is enough ‘smoke’ present in these cases to diagnose a ‘smouldering fire’. Perhaps it is time to try to put the fire out before it turns into a fatal blaze?
For other non diabetic patients at intermediate risk that have moderate dysregulated glucose, lifestyle and dietary interventions are reasonably well evidenced, along with consideration of glucose lowering medications such as Metformin, with its long established safety record and efficacy in weight reduction and improved glycaemic control.
This approach not only opens new avenues for treating heart disease but also highlights the interconnectedness of metabolic health and cardiovascular well-being, urging a holistic view in medical practices focussed on preventing, as well as treating, modern diseases.
For those that are interested, a review of the reading list and podcast material below is recommended.
Conclusion
- There is increasing evidence that high blood and tissue glucose levels may be an important risk factor for many non communicable diseases.
- CGM monitoring should be considered in all patients affected by heart disease, in order to define glucotype and current glucose profile- bioth easily treated if ‘unhealthy’ .
Key messages
- Glucose excursions or ‘spikes’ over 7.8 mmol/L (140 mg/dL) are extremely common in non diabetics with heart disease. This may have a role in driving inflammation that contributes to an underlying inflammatory cause.
- Preliminary research indicates that many people develop a high blood and tissue glucose level in response to carbohydrates consumed in their diet, including supposedly ‘healthy’ fruit and starches.
- It is possible, that due to genetic and gut biome factors there may be a previously unrecognised, widespread intolerance to ultra processed foods and high glycaemic foods in apparently ‘healthy’ people, may be contributing to long term inflammatory disease.
For other stories related to glucose, coronary heart disease, and heart failure, explore our archives by entering a tag under the search function above.
Naked Heart Podcasts
Other related articles
- Effects of long-term glycemic variability on incident cardiovascular disease and mortality in subjects without diabetes 2019
- https://www.ncbi.nlm.nih.gov/ :facts about Diabetes
- Glucotypes reveal new patterns of glucose dysregulation 2018
- Nutrigenomics in the context of evolution 2023
- The Role of SGLT2 Inhibitors on Heart Failure Outcomes in Nondiabetic Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
- Cardiovascular Protective Properties of GLP-1 Receptor Agonists: More than Just Diabetic and Weight Loss Drugs
- Semaglutide Effects on Cardiovascular Outcomes in People With Overweight or Obesity – SELECT
- Cardiovascular Protection by Metformin: Latest Advances in Basic and Clinical Research
- Protective effects of metformin in various cardiovascular diseases: Clinical evidence and AMPK‐dependent mechanisms
- Glycemic Markers and Heart Failure Subtypes: The Multi-Ethnic Study of Atherosclerosis (MESA)
About
The Naked Heart is an educational project owned and operated by Dr Edward Leatham. It comprises a series of blog articles, videos and reels distributed on Tiktok, Youtube and Instagram aimed to help educate both patients and healthcare professionals about cardiology related issues.
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