Healthy Lifestyle Lowers CV Risk in T2D, Regardless of GLP‑1 Use

In people with type 2 diabetes, healthy behaviors such as a better diet, increased physical activity, smoking cessation and good blood pressure also reduce risk of cardiovascular disease. Research from a large group of patients finds that healthy behaviors are associated with decreased CVD risk whether or not patients are taking Glucagon-Like Peptide-1 (GLP-1) receptor agonists. Providers should counsel patients with type 2 diabetes about the importance of a healthy lifestyle combined with medication to reduce CVD risk.

Why It Matters

For many people with type 2 diabetes, cardiovascular disease is the most common cause of morbidity and mortality. Therefore, when managing medical therapy for type 2 diabetes, a strong emphasis must be placed on reducing cardiovascular risk. New therapies have been developed which not only improve glycemic control, but also reduce the risk of cardiovascular events such as myocardial infarction. While these therapies are not a substitute for healthy behaviors, such as daily physical activity and a healthy diet, other modifiable “drivers” of increased risk should not be overlooked. These may include smoking and poor control of blood pressure.

Beyond the effect of individual modifiable dietary and pharmacological exposures, evidence suggests that a subset of lifestyle habits may also additively predict major adverse cardiovascular events (MACE). Importantly, lifestyle factors predominated. In this cohort study of 38,597 adults, individuals following eight low-risk lifestyle habits had a approximately 60% decreased risk of MACE compared to individuals following one or fewer habits. Those following all eight lifestyle habits had an adjusted hazard ratio for MACE of approximately 0.40.

Although GLP-1 therapy was reported to have reduced risk of cardiovascular events, the effect of reporting healthy lifestyle habits on cardiovascular risk was greater. In a recent cross-sectional study, the same data showed that subjects taking GLP-1 receptor agonists had an adjusted hazard ratio of approximately 0.84 for major adverse cardiovascular events compared with nonusers of GLP-1 receptor agonists. Reporting healthy lifestyle habits provided additional risk reduction, even when patients were taking GLP-1 therapy.

Clinicians can use these findings to guide counseling of patients. Combination therapy appeared to be the most effective approach. Any GLP-1 receptor agonist in addition to six to eight low-risk lifestyle measures was associated with a significantly decreased risk of major adverse cardiovascular events compared with fewer than three low-risk factors and no use of GLP-1 receptor agonists. The effect of any GLP-1 receptor agonist in combination with healthy lifestyle was additive and complementary.

The eight lifestyle habits studied in the review went beyond the typical diet and exercise habit. The eight habits studied encompass multiple lifestyle domains that impact risk of heart disease in individuals with diabetes. These included: higher quality of diet; physical activity habit; not smoking; sleep; no heavy alcohol use; stress management habit; social connection and support; and no opioid use disorder, with most being associated with lower risk of CVD.

We need to consider how health care is going to be delivered and paid for. Lifestyle is not just a counselling topic- it is a measurable risk reduction treatment. Lifestyle modifications that reduce cardiovascular risk regardless of pharmacotherapy support inclusion of structured lifestyle interventions, dietitian services, behavioural counselling and cost-effective digital solutions that support long term maintenance of lifestyle change.

Equity matters in this issue. Those patients for whom these programs would be most beneficial are likely the same patients for whom the biggest barriers to using these programs exist. Therefore, by addressing these gaps, systems can work to reduce the gaps in use of programs that integrate lifestyle therapies into standard diabetes care and ultimately achieve more balanced cardiovascular outcomes for all patients.

Who It Affects

Healthy lifestyle habits are beneficial for everyone with type 2 diabetes, regardless of risk of future events and whether or not they are taking GLP‑1 receptor agonists. Importantly, in this study, the risk of future cardiovascular events decreased with the number of healthy lifestyle habits.

For patients already on GLP-1 medications, incorporating healthy lifestyle habits into their treatment may confer additional benefits as the benefits of the medications do not translate into lifestyle benefits. However, the evidence suggests that healthy lifestyle habits will continue to predict reduced risk of future cardiovascular events in patients treated with GLP-1 medications. This combination of pharmacotherapy with weight-loss properties and helpful behaviour change strategies appears to be the way forward.

For the majority of patients with diabetes, who are unable to use, or do not tolerate, GLP-1 therapies, lifestyle change can reduce cardiovascular risk and has shown to reduce risk to a meaningful degree. Healthy lifestyle characteristics predict lower risk of future cardiovascular events, both in association with GLP-1 use and independently of GLP-1 use, and may remain the primary method to lower risk of cardiovascular events in individuals with diabetes.

Care Teams

Every healthcare provider – from primary care physicians and endocrinologists to cardiologists, nurses, pharmacists, registered dietitians, and behavioral health professionals – must share a common vision: one that recognizes lifestyle factors as vital signs. Similarly, diet quality and physical activity levels should become routine and comparable measurements, tracked side by side with blood pressure, lipid profiles, and A1C levels. Smokers or low risk patients should also have their use of tobacco reported, as well as their quantity and quality of sleep, their levels of stress, and their social support. By measuring these factors, healthcare providers will be able to understand their patients’ full cardiovascular risk.

Future interventions could consider the inclusion of Dietitians and/or behavioural health specialists, as the type of intervention required is of a longer term nature and the patients need ongoing support and guidance. The results of this study support the development of referral pathways into diabetes care where lifestyle interventions could become part of the standard care and monitored accordingly.

Providers (such as pharmacists and nurses) can play a critical role in ensuring patients are adhering to and using these medications safely and effectively. They can also address side effects such as diarrhea and nausea with their patients and set realistic expectations for weight loss. Emphasizing a lifestyle change approach can help patients see the approach as more than “just” a lifestyle change, and less than a “full fledged” medication; by framing the approach as complementary, providers can help patients understand how the two can work together for long-term success.

Health Systems and Payers

When cardiovascular risk reduction programmes are implemented fully, and funded and monitored as if they were other treatments, the largest benefits are delivered through effective lifestyle support. This study shows how multidisciplinary care, digital coaching, and partnerships with community organisations can reduce risk of future cardiovascular events and hospitalisation, meeting the highest priorities of health systems and payers operating in a value-based environment.

Decisions about which components to cover are important because most patients will not have access to GLP-1 medications or lifestyle programs. Observing independent benefit of several lifestyle habits supports reimbursement for dietitian visits (behavioral counseling or weight loss nutrition counseling), and a host of other smoking cessation methods and digital lifestyle tools.

Employers and Community Groups

Employers and community organisations can help support healthy lifestyles by ensuring that work and the community setting in which individuals live promote healthy choices. This could be by providing a safe setting in which to be physically active and to consume healthy foods, as well as facilitate social contact. Many of the healthy lifestyle choices that are often difficult for people with serious mental health problems to adopt (such as getting together with others and managing stress) can be achieved through group work, within community settings that are links to mental health services. Nautical training and support is run on a therapeutic basis within the community.

What Changes

• Practical clinical implication: Integrate structured lifestyle support as a co-equal component of diabetes care, regardless of whether the patient is prescribed a GLP-1 receptor agonist.
• Care delivery takeaway: Create clear referral pathways to accessible interventions—dietitians, exercise programs, smoking cessation, mental health services—and track outcomes the same way you track medication adherence.
• System-level action: Payers and health systems should consider broader coverage for intensive lifestyle programs and digital therapeutics, and measure return on investment in reduced cardiovascular events and admissions.

Lifestyle interventions need to be translated into practice. Therefore, healthcare providers need to assess patients’ lifestyle behaviours on a regular basis and offer structured options for healthy lifestyle alongside general advise. The lifestyle prescription could be an intensive lifestyle treatment programme consisting of several sessions of behavioural counselling or a referral to community resources. Important considerations are patients’ physical mobility, presence of comorbid conditions, culture and social network.

In your discussion with your patient on GLP-1 therapy, be sure to include the realistic expectations regarding this class of medications. Discuss with your patient the expected benefits of weight loss and improvements in glycemic control as well as the potential side effects (both beneficial and iatrogenic- nausea/vomiting) and cost of the medications. Some of these drugs are not covered by all insurance plans so this should also be discussed prior to initiation. Additionally, the clinician should explore ways in which medications can enhance behavior change (decreasing hunger, increasing energy, etc) and how to maintain weight loss promoting behaviors long-term to continue to improve cardiovascular risk.

Despite the existence of effective interventions for improving lifestyle behaviors, there are several barriers to translating these interventions into practice. First, there are limitations to the amount of time available to discuss lifestyle at clinic visits and the paucity of providers trained in counseling patients regarding lifestyle. Many patients have limited access to time-based nutrition or behavioral counseling. In addition to these clinical barriers, social determinants such as food insecurity and unsafe neighborhoods present additional layers of complexity. Meaningful translation of lifestyle interventions into clinical practice will require a combination of clinical redesign and policy change. Specifically, training of the primary care team to integrate interventions into their practice; reimbursement for multidisciplinary delivery of lifestyle interventions; and investment in community programs for alleviating barriers to exercise and healthy eating are required.

A high quality measure for overall disease prevention and health promotion would require documentation of whether or not medications for hyperlipidemia, hypertension or smoking cessation were prescribed as appropriate. However, a high quality measure would also track the delivery of high quality lifestyle interventions and patient-centered outcomes such as blood pressure, lipid levels, smoking status, cardiorespiratory fitness level and functional status. Let’s hope future pay for performance initiatives as well as accountable care organizations will consider tracking some of these very important quality measures.

Clinicians would find helpful guidance to guide these decisions. In the patient with very high cardiovascular risk on a very “bad” diet, adding a GLP-1 agent to an intensive lifestyle program would be an appropriate approach. In the patient who is unable to access or cannot use medication to reduce his/her cardiac risk, the clinician will have to focus on lifestyle measures that have been proven to reduce cardiac risk including sodium restriction, healthy blood pressure, use of a statin if indicated, smoking cessation, and increased physical activity as intense as the patient is able to perform.

Future strategies to address obesity will require a combination of effective pharmacological and behavior change interventions. The most effective digital interventions for obesity will incorporate features such as remote coaching, integration with EHRs and/or telehealth nutrition visits. Community-clinic partnerships and group-based programs will leverage peer support to foster maintenance of weight loss over time. Policy changes will also be necessary to ensure an equitable scale-up of existing interventions and new technologies by expanding insurance coverage.

But there are costs and risks of this approach. Focusing on medication in the absence of strong lifestyle support leaves residual cardiovascular risk unmanaged. Focusing on healthy lifestyle in the absence of social and structural analysis of the factors that create health inequities blames the patient for lack of motivation or non-adherence. The clinician must find a balance between showing compassion and accountability. The clinician needs to set reasonable short-term goals and acknowledge the small wins, while also being able to adjust the plan when the patient is not progressing.

Monitoring and long-term follow-up is required for the patients. Cardiovascular risk reduction is a process, not an event. Patients should be monitored in a long-term basis to evaluate and control their BP, lipid levels, kidney function and physical function as well as effective weight loss programs and fitness programs and monitored to maintain weight loss and promote physical fitness.

These new and refined medicines will be highly effective alongside a good programme or set of policies and environments that encourage patients to lead healthy lifestyles. Clinicians will see ‘whole person’ diabetes treatment enhanced by this raft of new medicines, while systems and policymakers will see growing evidence that investment in accessible, durable support to healthy lifestyle behaviours is a key part of effective diabetes care.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC7864843/ https://www.heart.org/en/health-topics/diabetes/prevention–treatment-of-diabetes/living-healthy-with-diabetes https://pmc.ncbi.nlm.nih.gov/articles/PMC6052788/ https://www.cdc.gov/diabetes/diabetes-complications/diabetes-and-your-heart.html https://www.ncbi.nlm.nih.gov/books/NBK585052/