Diabetes Forecast

Helping People Lower Their "Bad" Cholesterol

Sundar Natarajan, MD
Internist, VA New York Harbor Healthcare System
Behavioral Medicine
ADA Research Funding
Clinical Translational Award

Cholesterol is a form of fat found in your blood. It's important for survival: Cholesterol is a vital building block for the body's cells and a necessary component for making things like vitamin D. But if too much of the wrong kind builds up in your arteries, cholesterol can lead to heart disease.

People with diabetes are at particular risk for high levels of bad cholesterol, and the effects of high cholesterol are invisible—until it's too late. "In diabetes, people have so many issues to take care of," says Sundar Natarajan, MD, an internist at the VA New York Harbor Healthcare System and associate professor at the New York University School of Medicine. "An asymptomatic condition like high cholesterol can be below the radar. People with diabetes don't think as much about it. But it's an important issue that is not focused on as much as it should be."

People with diabetes have a double challenge when it comes to getting their cholesterol down to levels doctors consider healthy. First, many of the conditions associated with diabetes are the same conditions that contribute to high levels of low-density lipoprotein cholesterol—or LDL ("bad") cholesterol. On top of that, "the threshold for high cholesterol is lower," Natarajan says. "In general, the [LDL] target for people with no risk factors is 130 [mg/dl]. But because people with diabetes are at such high risk, their targets are usually less than 100."

With funding from the American Diabetes Association, Natarajan has set up a study designed to figure out the best way to help patients lower their LDL cholesterol levels. The key to lower cholesterol, as with many things, is a mix of diet, exercise, and often medication. The ADA's recommendations include straightforward advice like "If you smoke, quit," and "Lose weight if needed." But, of course, that's all easier said than done. Natarajan says many patients have trouble making the lifestyle changes needed to lower their cholesterol and keep it down.

Natarajan's goal is to find a way to intervene and get patients on track. "The target and goal is to improve adherence to treatment—that means adherence to diet, adherence to medication, and adherence to exercise," he says. His theory is that regular chats with trained counselors will help patients change their lifestyles.

To test his idea, Natarajan is working with 246 patients enrolled from two Department of Veterans Affairs (VA) hospitals in New York City. Most of them are men with type 2 diabetes who have struggled—and failed—to get their LDL cholesterol levels down. "We enrolled people who had been seeing a doctor for more than a year and still don't have their cholesterol under control," he says.

Over the course of six months, study participants get monthly phone calls from trained counselors. The people in the study have been randomly assigned to three groups: There's a control group, whose members are getting standard, general advice on improving their health, and then two groups whose interventions each represent a different approach to counseling patients on how to lower their cholesterol.

Patients in the first intervention group talk to a counselor using what's called the "Stages of Change" method, which recognizes that different people are at different stages when it comes to making change in their lives—from "pre-contemplation" to "action" and then finally "maintenance." The counselors give patients individualized advice over the phone once a month for six months, based on how ready they are to make lifestyle changes that will improve their cholesterol and health.

The approach researchers take with the second intervention group is slightly different. Rather than tailor the advice to each patient, the counselors talk to them (again, over the phone once a month) about the potential payoffs of healthier behavior and the disadvantages of continuing behavior that results in high LDL cholesterol. "We try to focus on the gains made from following a particular treatment," Natarajan says.

At the end of the six-month period, participants in all three groups have their cholesterol measured. Once all the data are in, Natarajan will be able to compare the groups to see if the phone calls made a difference. The three-way study lets researchers not only evaluate whether counseling over the phone can be effective in changing unhealthy behavior but also test which approach shows the most promise. "I thought these were two good ideas to improve behavior," Natarajan says, "and this would be an efficient way to test both simultaneously."

Natarajan hopes that phone counseling could be a low-cost, convenient, and effective way to reach a high-risk population. Although his study looks specifically at cholesterol, encouraging a healthier diet and more exercise may have a positive effect on other areas as well. "It's not just high cholesterol—we're using the same methods to improve hypertension and heart failure," Natarajan says. "If it works, it has good potential to provide an additional approach to treat diabetes."

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