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Cardiovascular disease (CVD) is the leading cause of death in people with diabetes. Physician counseling of adult diabetes patients is effective at decreasing unhealthy lifestyles that elevate their risk of CVD. However, several barriers prevent primary care physicians from counseling these patients, concludes Leonard E. Egede, M.D., M.S., of the Medical University of South Carolina. His work was supported by the Agency for Healthcare Research and Quality (K08 HS11418).
Dr. Egede reviewed research studies on modifiable CVD risk factors in people with diabetes, barriers to implementing behavioral counseling in primary care, and practical approaches to such counseling. About 34 trials showed that brief physician advice to quit smoking increased smoking quit rates by 3 percent over no advice. Advice to follow a low cholesterol diet (two studies) led to a 7.7 to 11.6 mg/dL drop in serum cholesterol and a 16 percent decreased risk of CVD events such as stroke or heart attack. Advice to lose weight for blood pressure (BP) control led to a decrease of 4 to 8 percent of body weight and a 3.5 mm Hg decrease in systolic BP without medications (decrease of 8.9 mm Hg with medications). Advice on sodium restriction for BP control led to a 1.9 to 6.3 Hg drop in systolic BP over 9 to 18 months. Finally, advice on diet and exercise for weight loss, with behavior modification counseling, led to a 4.4 to 13.2 pound weight loss sustained for up to 2 years.
Up to 50 percent of adults with diabetes may not be receiving appropriate advice on ways to decrease their risk of CVD, according to two studies. Physician pessimism about the willingness of patients to change negative health habits, doubts about the efficacy of advice or counseling, and skepticism about patient adherence to recommendations play important roles in lack of counseling by primary care physicians. Added barriers include limited time to provide counseling, limited training on effective counseling techniques, and low reimbursement rates for counseling in primary care.
More details are in "Implementing behavioral counseling interventions in primary care to modify cardiovascular disease risk in adults with diabetes," by Dr. Egede, in the June 2003 Cardiovascular Reviews & Reports 24, pp. 306-312.
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