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Healthy Habits to Reverse Cardiovascular Risk

      To the Editor:
      As a retired internist who has been managing her own type 2 diabetes for well over 2 decades now, I found the commentary “Stop stenting; start reversing atherosclerosis” by Schade et al, in the March 2021 issue of the Green Journal, of much personal and professional interest.
      • Schade DS
      • Gonzales K
      • Eaton RP
      Stop stenting; start reversing atherosclerosis.
      The authors recommend that primary care physicians discuss the role of medical treatments with patients who have stable angina. They also recommend that LDL cholesterol be brought below 50 mg/dL through a low cholesterol diet, along with the medications rosuvastatin (10 mg/d) and ezetimibe (10 mg/d). This letter is to raise awareness among patients and clinicians about the crucial role of timing of meals and exercise in cardiovascular health.
      Healthy lifestyle habits have been shown to be better than medication in preventing diabetes.
      • Knowler WC
      • Barrett-Connor E
      • Fowler SE
      • et al.
      Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
      Unfortunately, very few adults practice healthy habits for diabetes risk reduction.
      • Siegel KR
      • Bullard KM
      • Imperatore G
      • et al.
      Prevalence of major behavioral risk factors for type 2 diabetes.
      What is in a heathy meal is well known: fiber, lean protein, non-starchy vegetables, healthy fat, and, of course, carbohydrates in moderation.
      American Diabetes Association
      Lifestyle management: standards of medical care in diabetes-2019.
      The American Diabetes Association recommends the Mediterranean diet, DASH (dietary approaches to stop hypertension) diet, low-carb diet, and the plate method. People, however, are not aware that there is a time for everything including eating and exercising.
      As for timing, eating most of the carbohydrates in the early part of the day offers improvements in
      • Jakubowicz D
      • Landau Z
      • Tsameret S
      • et al.
      Reduction in glycated hemoglobin and daily insulin dose alongside circadian clock upregulation in patients with type 2 diabetes consuming a three-meal diet: a randomized clinical trial.
      ,
      • Kahleova H
      • Belinova L
      • Malinska H
      • et al.
      Eating two larger meals a day (breakfast and lunch) is more effective than six smaller meals in a reduced-energy regimen for patients with type 2 diabetes: a randomised crossover study.
      weight, glycated hemoglobin level, fasting glucose level, cravings, insulin dose, C-peptide level, glucagon level, liver fat, and upregulation of clock genes. This is because metabolism is optimal when we eat this way; glucose tolerance is poor in the evening for most people.
      Make use of the second meal effect by eating a morning snack that would offer lower glucose levels after breakfast. This is because glucose tolerance is also worse in the morning for people with insulin resistance.
      • Chen MJ
      • Jovanovic A
      • Taylor R
      Utilizing the second-meal effect in type 2 diabetes: practical use of a soya-yogurt snack.
      Very few people know about this century-old second-meal phenomenon.
      • Jovanovic A
      • Gerrard J
      • Taylor R
      The second-meal phenomenon in type 2 diabetes.
      A 30- to 60-minute morning walk every other day offers many benefits: no hypoglycemia during the activity, glucose tolerance improves for 24 hours and beyond, and fasting glucose normalizes.
      • Chacko E
      • Signore C
      Five evidence-based lifestyle habits people with diabetes can use.
      ,
      • Borer KT
      • Wuorinen EC
      • Lukos JR
      • Denver JW
      • Porges SW
      • Burant CF
      Two bouts of exercise before meals, but not after meals, lower fasting blood glucose.
      A 20- to 25-minute brisk walk or yard work 30 minutes after the start of lunch will blunt the glucose surge in real time.
      • Chacko E
      • Signore C
      Five evidence-based lifestyle habits people with diabetes can use.
      Post-meal walks can be alternated with pre-meal walks.
      According to the evidence, those who practice these simple habits will likely enter a virtuous cycle and enjoy many metabolic benefits, including control of glucose, lipids, blood pressure, and weight.

      Acknowledgments

      I thank my endocrinologist, Dr. Christine Signore, for her continued efforts to protect me from hypoglycemia by ordering continuous glucose monitoring and adjusting medications as needed.

      References

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        • Gonzales K
        • Eaton RP
        Stop stenting; start reversing atherosclerosis.
        The Am J Med. 2021; 134: 301-303
        • Knowler WC
        • Barrett-Connor E
        • Fowler SE
        • et al.
        Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
        N Engl J Med. 2002; 346: 393-403
        • Siegel KR
        • Bullard KM
        • Imperatore G
        • et al.
        Prevalence of major behavioral risk factors for type 2 diabetes.
        Diabetes Care. 2018; 41: 1032-1039
        • American Diabetes Association
        Lifestyle management: standards of medical care in diabetes-2019.
        Diabetes Care. 2019; 42: S46-S60
        • Jakubowicz D
        • Landau Z
        • Tsameret S
        • et al.
        Reduction in glycated hemoglobin and daily insulin dose alongside circadian clock upregulation in patients with type 2 diabetes consuming a three-meal diet: a randomized clinical trial.
        Diabetes Care. 2019; 42: 2171-2180
        • Kahleova H
        • Belinova L
        • Malinska H
        • et al.
        Eating two larger meals a day (breakfast and lunch) is more effective than six smaller meals in a reduced-energy regimen for patients with type 2 diabetes: a randomised crossover study.
        Diabetologia. 2014; 57: 1552-1560
        • Chen MJ
        • Jovanovic A
        • Taylor R
        Utilizing the second-meal effect in type 2 diabetes: practical use of a soya-yogurt snack.
        Diabetes Care. 2010; 33: 2552-2554
        • Jovanovic A
        • Gerrard J
        • Taylor R
        The second-meal phenomenon in type 2 diabetes.
        Diabetes Care. 2009; 32: 1199-1201
        • Chacko E
        • Signore C
        Five evidence-based lifestyle habits people with diabetes can use.
        Clin Diabetes. 2020; 38: 273-284
        • Borer KT
        • Wuorinen EC
        • Lukos JR
        • Denver JW
        • Porges SW
        • Burant CF
        Two bouts of exercise before meals, but not after meals, lower fasting blood glucose.
        Med Sci Sports Exerc. 2009; 41: 1606-1614