If you have diabetes, you probably already know about your increased risk for heart disease and stroke. But did you know that the risk of atherosclerosis (narrowing of the arteries) and its associated risks - heart disease, stroke, and peripheral artery disease - appear earlier in people with diabetes?

You should care about this because heart attacks and strokes are responsible for about 75 percent of deaths in people with diabetes. Significant heart disease is already present in about one-half of patients when they are first diagnosed with type 2 diabetes.

People with either type 2 diabetes or pre-diabetes are more likely to have risk factors for atherosclerosis than those with normal blood glucose levels, but they are also more prone to atherosclerotic complications like heart attack and stroke, even if they have no other risk factors.

And even though women have a lower risk of heart attack before menopause, premenopausal women with diabetes have heart attacks as often as men with diabetes of the same age.

At what age do men and women with diabetes develop a high risk for heart disease? About 15 years earlier than people without diabetes, according to a recent Canadian study that compared nearly 400,000 adults who have diabetes with more than 9 million adults who don't have diabetes.

An earlier study showed that people with type 2 diabetes who'd never had a heart attack were at the same risk for heart attack and death from heart disease as people without diabetes who did have a prior heart attack.

For these reasons, the U.S. National Cholesterol Education Program (NCEP) considers the presence of diabetes as a risk factor equivalent to already having heart disease. NCEP guidelines recommend aggressive treatment of risk factors such as harmful LDL cholesterol and high blood pressure in people with diabetes.

I agree with the growing practice of striving for LDL cholesterol levels around 70 mg/dL in patients with type 2 diabetes. People with type 1 diabetes are at even greater risk for heart disease than those with type 2. However, because many people with type 1 diabetes are quite young, it is not yet clear when they should start aggressive LDL cholesterol-lowering efforts.