Table 5.

Current Recommendations for CVD Risk Factor Management in Type 2 Diabetes Mellitus

Risk Factor	Relevant Statement or Guideline	Specific Recommendation and Level of Evidence
Nutrition	“Nutrition Therapy Recommendations for the Management of Adults With Diabetes”43	Reduction of energy intake for overweight or obese patients (ADA Level of Evidence A). Individualized medical nutrition therapy for all patients with diabetes mellitus (ADA Level of Evidence A). Carbohydrate monitoring as an important strategy for glycemic control (ADA Level of Evidence B). Consumption of fruits, legumes, vegetables, whole grains, and dairy products in place of other carbohydrate sources (ADA Level of Evidence B). Mediterranean-style dietary pattern may improve glycemic control and CVD risk factors (ADA Level of Evidence B). Limit of sodium to <2300 mg/d, similar to recommendations for the general population (ADA Level of Evidence B; note that the AHA differs and recommends sodium <1500 mg/d).
Obesity	“2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society”58	Overweight and obese patients should be counseled that lifestyle changes can produce a 3%−5% rate of weight loss that can be sustained over time and that this can be associated with clinically meaningful health benefits (ACC/AHA Class I; Level of Evidence A). For patients with BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with an obesity-related comorbidity who want to lose weight but have not responded to behavioral treatment with or without pharmacological treatment, bariatric surgery may improve health (ACC/AHA Class IIa; Level of Evidence A).
Blood glucose	“Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)”59 “Standards of Medical Care in Diabetes-2015”4	Lower A1c to ≤7.0% in most patients to reduce the incidence of microvascular disease (ADA Level of Evidence B); this can be achieved with a mean plasma glucose of ≈8.3–8.9 mmol/L (≈150–160 mg/dL); ideally, fasting and premeal glucose should be maintained at <7.2 mmol/L (<130 mg/dL) and postprandial glucose at <10 mmol/L (<180 mg/dL). More stringent A1c targets (eg, <6.5%) might be considered in selected patients (with short disease duration, long life expectancy, no significant CVD) if this can be achieved without significant hypoglycemia or other adverse effects of treatment (ADA Level of Evidence C). Less stringent A1c goals (eg, <8.0% or even slightly higher) are appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced complications, cognitive impairment, and extensive comorbid conditions and those in whom the target is difficult to attain despite intensive self-management education, repeated counseling, and effective doses of multiple glucose-lowering agents, including insulin (ADA Level of Evidence B).
Blood pressure	“An Effective Approach to High Blood Pressure Control: A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention”60 “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)”61 “Standards of Medical Care in Diabetes-2015”4	For most individuals with diabetes mellitus, achieve a goal of <140/90 mm Hg; lower targets may be appropriate for some individuals, although the guidelines have not yet been formally updated to incorporate this new information (Expert Opinion, Grade E).60,61 Pharmacological therapy should include a regimen with either an ACEI or an ARB (ADA Level of Evidence B); if 1 class is not tolerated, the other should be substituted (ADA Level of Evidence C).4 For patients with CKD, antihypertension treatment should include an ACEI or ARB (Expert Opinion, Grade E). Hypertension/blood pressure control has been revised to suggest that the systolic blood pressure goal for many people with diabetes mellitus and hypertension should be <140 mm Hg (ADA Level of Evidence A) but that lower systolic targets (eg, <130 mm Hg) may be appropriate for certain individuals such as younger patients if it can be achieved without undue treatment burden (ADA Level of Evidence C).4
Cholesterol	“2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines”62 “Standards of Medical Care in Diabetes-2015”4	Patients with diabetes mellitus between 40 and 75 y of age with LDL-C between 70 and 189 mg/dL should be treated with a moderate-intensity statin*† (ACC/AHA Class I; Level of Evidence A) (ADA Level of Evidence A). Statin therapy of high intensity‡ should be given to individuals with diabetes mellitus between 40 and 75 y of age with a ≥7.5% estimated risk of ASCVD (ACC/AHA Class IIa; Level of Evidence B) Among individuals with diabetes mellitus who are <40 or >75 y of age, practitioners should evaluate the benefit of statin treatment (ACC/AHA Class IIa; Level of Evidence C) Evaluate and treat patients with fasting triglycerides >500 mg/dL

ACC indicates American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; ADA, American Diabetes Association; AHA, American Heart Association; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; A_1c, glycated hemoglobin; BMI, body mass index; CKD, chronic kidney disease; CVD, cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; and TOS, The Obesity Society.

^*Moderate-intensity statin therapy lowers LDL-C on average by 30% to 50%.

^†We note that these recommendations do not replace clinical judgment, including consideration of potential risks, benefits, drug interactions, and adverse events.

^‡High-intensity statin lowers LDL-C on average by >50%.