For people with diabetes, blood sugar isn’t the only important measurement. New cholesterol guidelines suggest the more than 110 million U.S. adults with diabetes or prediabetes also should manage their cholesterol.

The guidelines released earlier this month during the American Heart Association’s Scientific Sessions conference suggest doctors consider prescribing cholesterol-lowering drugs called statins to people with diabetes who are age 40 to 75. The guidelines also give a raft of other specific recommendations for people with diabetes based on age and other risk factors.

The reality has been scientifically clear for a while, but many people are not aware of the connection: Middle-age adults with diabetes are usually considered at moderate to high risk for cardiovascular disease.

“It’s not new but it’s important. If you have diabetes, you have to work to get your cholesterol under control,” said Dr. Scott Grundy, chair of the guidelines writing committee and professor of internal medicine at the University of Texas Southwestern Medical Center and Veterans Affairs Medical Center in Dallas.

Shaun Rivers and Kim Ketter preach much the same thing to their clients.

Their company in Petersburg, Virginia, provides diabetes counseling and educational training. The women, who are twins, believe managing chronic conditions such as diabetes need a “holistic approach.”

For them, that means keeping tabs on the bigger picture, like exercise, blood pressure and cholesterol.

“We liken it to a three-legged stool,” said Ketter, a nurse practitioner. “All things are connected, and you have to learn to manage them all. If you fix one, you might help fix the other ones, and if you fail to manage one, the stool might fall over.”

More than 30 million people in the United States have diabetes, although one in four doesn’t know it, according to Centers for Disease Control and Prevention statistics. Another 80 million have prediabetes, a serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as Type 2 diabetes.

Over the past 20 years, the number of adults diagnosed with diabetes has more than tripled as the population has aged and become more overweight or obese.

There are well-established risk factors for heart disease, such as smoking, high blood pressure and high blood sugar. There also are what the new cholesterol guidelines call “risk-enhancing factors” such as family history, chronic kidney disease and metabolic syndrome. Metabolic syndrome is a cluster of at least three diagnosed conditions, including high blood pressure, high blood sugar, excess body fat around the waist and abnormal cholesterol levels.

Rivers and Ketter use everyday items such as garden hoses to explain what the waxy-like, fatty buildup of cholesterol can do to the body.

“Folks don’t understand how it can affect the body overall,” Ketter said. “It’s like a garden hose, and you have gunk and stuff inside of it accumulated over the years. You are going to have to turn up the pressure to get the same water through that hose. If all that mess is clogging the arteries, you have to turn up the pressure, and that means your heart is pumping harder.”

While the new cholesterol guidelines suggest doctors talk to patients with diabetes about risk, lifestyle, and the possible need for statins, Ketter said she also wants to make sure her patients “on the cusp” of needing medicine are willing to work on good nutrition, exercise and any “bad habits.”

“It’s going to be a lifestyle change for a lot of them,” said Rivers, an advanced diabetes clinical nurse specialist.

She and her sister should know about that. Although “perfectly healthy otherwise,” the two were diagnosed about a decade ago with congestive heart failure, possibly from a genetic cause.

“In our own personal lives, we deal with (cholesterol),” Ketter said. “Our patients respect us for being honest. Life is a series of hills and valleys. Sometimes you are in the valley and can’t get it right and sometimes you are on the hill and looking out. Either way, you make corrections and move on.”

Find more news from Scientific Sessions.