Prediabetes and Diabetes | Types of Cholesterol | Feet Blood Circulation

leg arteriesThere are many ways in which the increased blood sugar levels and insulin resistance of prediabetes and type 2 diabetes can decrease the circulation to your feet and legs.  One way is by having abnormal levels of the “different types of cholesterol” in your blood.  Having abnormal levels of the different types of cholesterol are usually part of the disease of prediabetes metabolic syndrome and type 2 diabetes.

Most people know that a “bad cholesterol level” can cause blockage in the circulation of the heart, and some also know this can occur in the large blood vessels that carry blood into the feet and legs, but most people do not think about the all-important small tiny blood vessels. This is where all the action is. This is where the rubber meets the road.

When we think about the circulation to the feet and legs, we typically think of the larger blood vessels that are like pipes delivering blood through the thigh, down the leg and into the feet. While blockage of these larger blood vessels can certainly cause problems, many foot and leg problems may come about from decreased blood circulation in the small tiny blood vessels that are actually responsible for releasing oxygen, nutrition, and all the other good stuff in the blood that your body needs to function properly.

street with garbage strikeThese tiny blood vessels also collect waste products and move them out of the area so your body can get rid of them. When I lived in Philadelphia as a student, the city sanitation workers went on strike. Seeing what happens to an area when garbage accumulates is not a pretty site. When your small tiny blood vessels are not healthy, something similar to a garbage-sanitation strike can occur.

Many people do not realize that when their doctor tells them what their cholesterol level is, the doctor is telling them their “total cholesterol.”  In a way, total cholesterol is actually made up of several different types of cholesterol. Smart Nutrientology readers dig deeper, and look beyond the simple total cholesterol number. You want to know the breakdown of your different types of cholesterol.

These different types of cholesterol are important to understand because depending on the breakdown of the different types of cholesterol, you may be at a higher risk for decreased circulation, not only to your heart, but to other important areas of your body including your brain, kidneys, and let’s not forget the all-important feet and legs that keep you moving, functional and independent.

Even smarter Nutrientology readers may want to know how many cholesterol-lipoprotein particles they have carrying around these different types of cholesterol, but that’s a post for another day.

Total cholesterol can be broken down into its different parts:

  • Triglycerides (TG)
  • Low-density lipoprotein cholesterol (LDL-C)
  • High-density lipoprotein cholesterol (HDL-C)
  • Non-high-density lipoprotein cholesterol (non HDL-C). For the sake of simplicity, I am going to exclude Non-HDL-C in this post. I will discuss Non-HDL-C in a future post…stay tuned.

If you have ever looked at your lab report from your doctor you have probably seen this break down. If you haven’t seen it, or your doctor has not discussed this with you, you should ask about it.

From a public health standpoint, the impact of bad cholesterol levels has typically been looked at from the perspective of heart health. And for good reason, the heart is a vital organ, but the feet and legs are also very important. Decreased blood flow and circulation to the feet and legs is known as PAD, which stands for Peripheral Arterial Disease.

In some respects, the feet and legs are like a cardiovascular organ themselves. Your moving feet and legs, in many ways, mimic the function of your heart in their ability to move blood throughout your body by the pumping action of your leg muscles. Just as a blockage resulting in decreased circulation to the heart causes problems with blood circulation, the decreased blood flow to the feet and legs is also a well-known cause of disease negatively affecting their function, and possibly placing them at risk for loss.

Most doctors use “statins” if their patients’ cholesterol levels are abnormal. So if you are on a statin, you probably have some degree of abnormal cholesterol, or “dyslipidemia.” In light of the fact that your cholesterol level is relevant to the feet and legs, you should also ask your foot specialist-podiatrist about the levels of your different types of cholesterol, and what this may mean for the circulation health of your feet and legs.


Improve Bad Foot and Leg Blood Flow Common in Prediabetes and Diabetes

walking feetIf we can really understand what is happening at the level of our tiny blood vessels traveling all the way down to the tips of our toes, we will have the knowledge to prevent a lot of prediabetes and diabetes symptoms and disease in the all-important structures that move us from place to place – our feet and legs.

The good news is that researchers are starting to look at different risk factors that may contribute to damage of these small tiny blood vessels. One risk factor is abnormal levels of the different types of cholesterol.

When we get a handle on how different levels of the different types of cholesterol impact our small blood vessels, I believe it will greatly improve our ability to deal with many of the foot and leg complications seen in prediabetes and type 2 diabetes including ulceration, nerve damage leading to pain and numbness, as well as bone problems.


What Does Medical Research Tell Us About Cholesterol Levels and Blood Circulation

Studies have shown that increased Triglycerides, increased LDL-C, and decreased HDL-C, are strongly associated with increased problems with blood circulation of the large blood vessels in diabetics, but what about the small blood vessels?

In a recent study, researchers looked at the different types of cholesterol, or “lipid fractions,” to see if there was any association between the amounts of different types of cholesterol and decreased circulation to the feet, kidneys and eyes of type 2 diabetics.

You guessed it, the different types of cholesterol they looked at were:

  • HDL-C
  • LDL-C
  • Triglycerides

{And non-HDL-C, but we’re saving that for a future post.}

The researchers looked at these different levels of cholesterol to see if there were any patterns linking certain levels of LDL-C, Triglycerides and HDL-C with:

  1. nerve damage in the feet
  2. kidney damage
  3. eye damage

They concentrated on these three areas because disease in the very tiny blood vessels that go to the nerves of the feet, the kidneys and the eyes are often damaged in people with diabetes, and even prediabetes.  They used these three areas as a gauge for small blood vessel disease.


So, What Did The Researchers in This Most Recent Study Find?

As with other studies on diabetic complications involving different types of cholesterol, the amount of HDL-C and Triglycerides are especially important. (1)(2)

This study found that:

Low HDL-Cholesterol and High Triglycerides were associated with:

Nerve damage in the feet, kidney circulation problems, and brain circulation problems presumably from damage to the small tiny blood vessels supplying these areas in patients with type 2 diabetes.

You should know your personal levels of the different types of cholesterol. Having your levels at the right amount is very important in helping you avoid blood circulation problems.

The LDL-Cholesterol level did not show an association.  Although LDL-C has been labeled “bad cholesterol,” and each of the different types of cholesterol is important, it appears that we especially need to pay attention to our HDL-C and TG as far as circulation health is concerned. They appear to be the “biggies” when it comes to circulation health.

The authors of the study I cited above put it this way,  (my additions in parentheses for clarification)

This study demonstrates significant independent associations among HDL-C, TG and non-HDL-C with risk for microvascular events following the diagnosis of T2DM…(healthy normal) HDL-C, and TG levels were significantly associated with a reduced risk of MVCs (microvascular complications). There was no clear association, however, between the attainment of the ADA (American Diabetes Association) goal for LDL-C and microvascular event risk. These findings suggest that to reduce risk for both macrovascular and microvascular events among patients with T2DM, all components of the lipid profile should be treated.

While this study is far from conclusive, it does provide some guidance for avoiding or slowing disease in the small tiny blood vessels that lead to the many complications of diabetes and prediabetes.


So, What Are Healthy Normal Cholesterol Levels?

The term “bad cholesterol levels” generally refers to:

  • Increased total cholesterol
  • Increased LDL-Cholesterol
  • Increased triglycerides
  • Decreased HDL-Cholesterol


Normal healthy levels of the different types of cholesterol that I mentioned vary depending on the source, but generally are as follows:

  • Total Cholesterol – below 220
  • Low-density lipoprotein cholesterol (LDL-C) – below 100-110
  • High-density lipoprotein cholesterol (HDL-C) – above 60-65
  • Triglycerides (TG) – below 100-125

Here are the Mayo Clinic guidelines for cholesterol levels.  Their desired HDL-Cholesterol number is above 60. You need to do better than that, and you can…Don’t settle.


What is HDL-Cholesterol?

cardiovascular disease in prediabetes

plaque in blood vessel wall

HDL-C is as a carrier or transporter of unused cholesterol back to your liver for re-processing. You do not want cholesterol loitering around in your bloodstream. HDL-Cholesterol scavenges up and removes LDL-Cholesterol and sends it back to your liver for “recycling.” It is part of your cholesterol clean-up crew and keeps the LDL-Cholesterol from damaging the inside walls of your blood vessels where plaque forms.  It is this plaque that causes narrowing of the blood vessels and resultant decreased blood flow circulation.

diabetes feet with ulcers on bottom

Diabetic foot wounds

This is why it is typically a good thing to have a high HDL-Cholesterol level. More HDL generally means a higher potential for unblocked blood vessels that allow for the free flow of blood bringing nutrients – and removing waste products – throughout your body including the feet and legs that I am so concerned with. I see the foot and leg complications of borderline diabetes, prediabetes, metabolic syndrome and diabetes on a daily basis.

While the researchers looked only at people with Type 2 Diabetes, if you have prediabetes, you still have some time to act. Take action now.

Stop prediabetes and avoid eventual full diabetes with all its potential worsening side-effects, including decreased circulation to the feet and legs, loss of sensation in your feet, eye disease, kidney disease, early dementia, etc.


So, Bottom Line – What Should You Do Now?

Discuss your cholesterol levels with your doctor. Know your different types of cholesterol, and what can be done with food, movement and lifestyle to try to improve your levels of the different types of cholesterol. Sometimes medication is needed, but for many prediabetics, lifestyle changes can be as good as medicine.


  • Know your Total Cholesterol to HDL-C ratio – Total Cholesterol/HDL-C

One of the most important cholesterol numbers you can look at is your Total Cholesterol to HDL-C ratio. Recommendations vary somewhat, but you want this to be less than 3.5. For example, if your total cholesterol is 207 and your HDL-C is 68, your ratio is 207/68 = 3.04.

Another important ratio is your TG to HDL-C ratio – TG/HDL-C.

  • Know your  TG/HDL-C

You should know this ratio as well.  Other research as shown that circulation problems in the small blood vessels are more common in type 2 diabetics with an increased TG to HDL-C ratio.  Again, you want this to be less than 3.5, but even better, and ideally, less than 2.5.  If you want to stop prediabetes, and prevent full diabetes, you need to strive – under the guidance of your doctor – to be well below the accepted upper limits.

These ratios can also give you a clue as to whether you have the insulin resistance that is so common among people with prediabetes and type 2 diabetes. An increased TG/HDL-C ratio and TC/HDL-C ratio has been identified as a simple way to check for possible insulin resistance. Even if you do not have full diabetes, if these two ratios are increased, this is a sign of insulin resistance and risk for potential cardiovascular disease in adults.

People with prediabetes-metabolic syndrome tend to develop, or already have, insulin resistance. If your ratios are abnormal, you want to address them ASAP.

In diabetics, these ratios have also been associated with an increased risk of heart failure. If you are a diabetic who also has high triglyceride, low HDL-C, or high total cholesterol/HDL-C ratio, you are at an increased risk for heart problems, including heart attack. Many diabetics will get “silent heart attacks” and will not even know they are having a problem.

If your HDL is low, giving you a high Cholesterol to HDL ratio, you need to take action to increase the amount of HDL-C in your system. As evidenced by the studies I cited above, and many others, there is good reason to believe that this will decrease your risk of decreased circulation blood flow.

  • How you eat (diet) will affect your HDL-C level

food for type 2 diabetes diet prediabetes metabolic syndrome As I mentioned above, an elevated TG and reduced HDL-C is associated with insulin resistance which is part of prediabetes metabolic syndrome and type 2 diabetes, therefore eat food that promotes less glucose intolerance and lower blood sugar levels. If you do not tolerate glucose, you should reduce your intake of complex carbohydrates that are loaded with glucose-sugar. You should get the majority of your carbohydrates from vegetables and fruit, not bread, pasta, cereal and other processed grains. Some whole grains as a side dish appear to be okay for most prediabetics and diabetics, but cook well and don’t overdo it.

A reduced carbohydrate diet (3) or the Mediteranean approach (4) have been shown to increase your HDL level and decrease your Triglyceride level in people with prediabetes-metabolic syndrome.

One study done in China compared 12-week diets of either a low-carbohydrate diet that did not count calories, or a diet that was not low-carb, but low calorie.  Both were acceptable to the Chinese women who took part in the study, and both diets were equally effective in reducing weight and fat mass, but the low-carbohydrate diet showed beneficial effects on the different types of cholesterol in the blood with improvement in both Total Cholesterol/HDL-C and Triglyceride/HDL-C.


  • How you move (exercise) will affect your HDL-C level

pre diabetes exerciseExercise physical activity can increase your HDL-C levels.  Both endurance type activity and resistance exercise (“weightlifting”) has been shown to increase HDL-C. (5)(6)(7).  One analysis of this subject looked at seven exercise trials and found that exercise activity improves many areas of cardiovascular health in people with prediabetes-metabolic syndrome.

And it seems that the benefit is greatest when you combine aerobic endurance-type activities and resistance activies (“weightlifting”).(8)

Even less demanding movement activity like yoga may increase HDL-C levels. (9)

There are many options available to you to introduce some form of movement activity into your life to not only improve HDL-C, but also to stop prediabetes and prevent diabetes.  Just do something.  Start slowly and gradually increase your activity level.  Speak to your doctor first, especially if you have a medical problem that may impact your ability to participate in physical activity.  If this is the case, there are supervised facilities that you can go to that would be more appropriate for you, at least at the outset.


  • Diet supplements can support healthy cholesterol levels

I will also be posting shortly about the different diet supplements that may play a role in supporting a healthy cholesterol level. You may review some of the medical and science research pertaining to the use of supplements to support a healthy cholesterol level in prediabetes-metabolic syndrome and diabetes at the Science Library.

You can also visit the Nutrientology Store to see examples of evidence-based smart supplement products that may support and assist you in your effort to improve your health.  Do not rely on a supplement – It’s called a supplement because it supplements your diet, it does not replace a healthy diet.

You do not want to live a life with diabetes complications – prevent, stop and reverse prediabetes now. Learn how to prevent diabetes by staying in touch with Nutrientology and becoming part of the family.

If you are a member of a healthcare field, or otherwise have a special knowledge in the area of nutritional supplements, movement or food, and you would like to share your knowledge with the Nutrientology family, go here. We’d love to hear from you.

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About Robert Creighton

Dr. Creighton is a podiatrist and foot surgeon with over 26 years in podiatric practice treating thousands of patients afflicted with the physiological, physical, and psychological side effects and complications of diabetes and pre-diabetes metabolic syndrome. He believes these disorders present a pressing public health concern that need to be more actively addressed in a multidisciplinary way. Dr. Creighton graduated from what is now the Temple University School of Podiatric Medicine after receiving his undergraduate degree in Biology. He is certified by the American Board of Foot and Ankle Surgery, a member of the American Public Health Association, an American College of Sports Medicine certified personal trainer and a Member of the American Nutrition Association.

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