ORIGINAL INVESTIGATION
Modifiable Cardiovascular Risk Factors
in Adults With Diabetes
Prevalence and Missed Opportunities for Physician Counseling
Leonard E. Egede, MD, MS; Deyi Zheng, MB, PhD
Background: Cardiovascular disease (CVD) is the lead-
ing cause of death in adults with diabetes mellitus (DM).
Counseling by physicians is effective in inducing lifestyle modification.
Objective: To determine the prevalence of modifiable
CVD risk factors and counseling by physicians among
adults with DM.
Methods: Data on 9496 adults with DM and 150493
adults without DM from the 1999 Behavioral Risk Factor Surveillance System were analyzed to yield estimates of CVD risk factors and counseling by physicians
during routine visits. Multiple logistic regression was used
to adjust estimates for age, sex, ethnicity, education, and
income. Population estimates were created using software for the statistical analysis of correlated data (SUDAAN)
because of the complex survey design of the Behavioral Risk
Factor Surveillance System.
ethnicities (both P⬍.001). Modifiable CVD risk factors,
such as hypertension (56% vs 22%), high cholesterol (41%
vs 20%), obesity (78% vs 57%), and insufficient physical activity (66% vs 56%), were more prevalent in adults
with DM (all P⬍.001) and differed by ethnicity, sex, and
age. Counseling about weight loss (50% vs 21%, P⬍.001),
smoking cessation (78% vs 67%, P = .01), eating less
fat (78% vs 71%, P⬍.001), and increasing physical activity (67% vs 36%, P⬍.001) was less than ideal in both
groups and did not change after adjusting for age, sex,
ethnicity, education, and income with multiple logistic
regression.
Conclusions: Although adults with DM have a
high prevalence of modifiable CVD risk factors, counseling by physicians about lifestyle modification is
less than optimal. There is a need to improve patient
counseling for lifestyle modification by primary care
physicians.
Results: Diabetes mellitus was more prevalent in adults
aged 55 and older and in blacks and Hispanic or other
D
From the Division of General
Internal Medicine and
Geriatrics, Department of
Medicine (Dr Egede), and
Department of Biometry and
Epidemiology (Dr Zheng),
Medical University of South
Carolina, Charleston.
Arch Intern Med. 2002;162:427-433
IABETES MELLITUS (DM) is
prevalent in the United
States. About 10.5 million persons had a diagnosis of DM in 1999, and
about 800 000 new diagnoses are made
each year.1 Diabetes is associated with significant morbidity and mortality, and the
economic burden of DM to the individual and to society is substantial, including direct costs and indirect costs, such
as disability, work loss, and premature
mortality.1-3
Cardiovascular disease (CVD) is the
leading cause of death in persons with DM.
Persons with DM have a 2- to 4-fold increased risk of death from CVD than adults
in the general population of similar age. In
addition, CVD accounts for 48% of deaths
among persons with DM4,5 and is listed as
the cause of death in about 65% of persons
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427
with DM.6 Once patients with DM develop
CVD, the prognosis worsens, compared
with persons without DM,7-12 and the cost
of care increases dramatically.13,14
Although there are several recognized CVD risk factors, strategies to reduce the risk of CVD focus on controlling
hypertension, high cholesterol, obesity,
smoking, and sedentary lifestyle, because
they are amenable to lifestyle modification. Because more than 70% of adults with
DM receive routine care in primary care
settings,15 primary care physicians are
particularly well suited to provide counseling about lifestyle modification. Consequently, the US Preventive Services Task
Force,16 American Heart Association,17 and
American Diabetes Association18 recommend counseling about modifiable CVD
risk factors during preventive health examinations in primary care.
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RESEARCH METHODS
AND DESIGN
This is a cross-sectional study of data on adults with DM
obtained from the 1999 BRFSS. The BRFSS is a statebased, random-digit dialing telephone survey of the noninstitutionalized, civilian population of the United States
aged 18 and older. Details about the BRFSS survey and methods have been published previously.20-22
Our sample included only individuals who responded
to specific BRFSS questions. “Yes” responses were coded as
one group, while “no,” “not sure,” “don’t know,” or “refused to answer” were combined into another group. Individuals who had no responses coded (“missing” or “skipped”)
were excluded from our analysis. In 1999, there were 9496
adults with diagnosed DM, based on self-report that a physician had told them they had DM. We excluded persons who
reported a diagnosis of DM during pregnancy. We defined
modifiable CVD risk factors as the presence of hypertension, high cholesterol, obesity, smoking, or insufficient physical activity. Our definition of modifiable CVD risk factors is
consistent with that used in previous studies.23-27
Hypertension and high cholesterol groups were each
derived from respondents who reported ever having been
told by a physician that they had high blood pressure or high
cholesterol. The obesity category was derived from the
respondents’ body mass index (BMI) and was defined as
weight in kilograms divided by the square of height in meters. We based our classification of overweight and obesity
on the recommendation by the National Heart, Lung, and
Blood Institute in 1998.28 According to this classification, a
BMI less than 18.5 is classified as underweight, 18.5 to 24.9
as normal weight, and 25.0 to 29.9 as overweight. Further
classifications include obesity 1 (BMI, 30.0-34.9), obesity 2
(BMI, 35.0-39.9), and extreme obesity (BMI, ⱖ40.0). For
the analysis, we used 4 weight categories: normal weight (BMI,
18.5-24.9), overweight (BMI, 25.0-29.9), obesity (BMI, 30.039.9), and extreme obesity (BMI, ⱖ40.0).
Current smoking was defined as individuals who
reported having smoked 100 cigarettes in their lifetime
and who smoked currently. Insufficient physical activity
was defined as individuals who reported having no leisuretime physical activity or physical activity less than 20 minutes 3 or more times per week. Education was defined as
the highest grade or year of school completed, and income was defined as the annual household income from
all sources. The physician checkup group was derived from
respondents who reported seeing a physician for a routine
checkup within the past year (1-12 months previously).
Opportunity for counseling was present if an individual reported having a checkup by a physician within the
previous 12 months. Counseling was said to have occurred if during the previous 12 months an individual reported that a physician or other health care professional
talked to them about weight loss, exercise, eating foods with
less fat or cholesterol, or quitting smoking. Missed opportunity for counseling about modifiable CVD risk factors was
defined as the absence of counseling in an individual with
CVD risk factors who reported having a physician checkup
within the previous 12 months.
Three ethnic groups (white, black, and Hispanic or
other) and 3 age categories (18-34, 35-54, and ⱖ55 years)
were used for the analysis. Two categories of income
(⬍$25000 and ⱖ$25000), based on federal poverty levels, and 2 categories of education (less than high school
and high school education or higher) were determined.
We performed 3 levels of statistical analyses. First,
the prevalence of CVD risk factors was compared between
adults with and without DM. Second, the prevalence of
CVD risk factors was determined among persons with
DM by ethnicity, sex, and age. To determine the prevalence of counseling by physicians for modifiable CVD risk
factors, the denominator consisted of the number of persons with each CVD risk factor seen by a physician in the
previous year.
For example, opportunity for counseling for smoking cessation was determined among smokers who reported having at least one physician checkup in the previous 12 months. Similarly, among persons who had a
checkup, opportunities for counseling about weight loss
were among persons with overweight and obesity, counseling about eating less fat among persons with high cholesterol, and counseling about regular physical activity
among all adults. This resulted in different sample sizes for
the different CVD risk factors.
Third, we compared the prevalence of counseling for
modifiable CVD risk between adults with and without DM.
Multiple logistic regression was used to control for age, sex,
ethnicity, education, and income for counseling by physicians about CVD risk factors to obtain adjusted prevalence. Because of the complex sampling design of the BRFSS,
commercially available software (SAS29 and SUDAAN30) was
used for statistical analyses to obtain variance estimates.
The weighting factor in BRFSS pr oduces national estimates by accounting for differences of sampling in geographic regions, telephone density, number of telephones
in a household, number of adults in a household, selected
cluster size, and distribution of age, sex, and ethnicity in
the selected population of the sampling states.19
To determine the prevalence of modifiable CVD risk
factors among adults with DM and the prevalence of counseling by physicians about such risk factors, we analyzed data from the 1999 Behavioral Risk Factor Surveillance System (BRFSS).19
RESULTS
Table 1 compares the baseline characteristics of adults
with and without DM. Women constituted 52% of both
groups (P=.93). There were higher percentages of blacks
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428
and Hispanic or other ethnicities in the DM group compared with the group without DM, and there were higher
percentages of adults aged 55 and older in the DM group
(both P⬍.001). Likewise, the percentage of persons with
less than a high school education (59% vs 46%) and a
household income less than $25000 (58% vs 42%) was
higher among adults with DM compared with adults without DM (both P⬍.001).
Comparing modifiable CVD risk factors between
groups with and without DM, the prevalence of selfreported insufficient physical activity was high in both
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Table 1. Baseline Characteristics Among Persons With and Without Diabetes*
Characteristic
Sex
Men
Women
Ethnicity
White
Black
Hispanic or other
Age, y
18-34
35-54
ⱖ55
Education
⬍High school
ⱖHigh school
Income
⬍$25 000
ⱖ$25 000
Physician checkup
Cardiovascular disease risk factors
Insufficient physical activity‡
Hypertension
Smoking
High cholesterol
BMI
Normal weight (18.8-24.9)
Overweight (25.0-29.9)
Obese (30.0-39.9)
Extremely obese (ⱖ40.0)
Obesity status (BMI)
Overweight or obese (ⱖ25.0)
Normal weight (18.5-24.9)
With Diabetes
(n = 12 214 135 [9496])†
Without Diabetes
(n = 193 469 510 [150 493])†
48.1 (46.4-49.8)
51.9 (50.2-53.6)
48.0 (47.6-48.4)
52.0 (51.6-52.4)
66.0 (64.2-67.8)
14.4 (13.2-15.6)
19.6 (17.9-21.3)
73.5 (73.1-73.9)
9.4 (9.2-9.6)
17.1 (16.8-17.5)
6.0 (5.0-7.0)
28.2 (26.6-29.8)
65.8 (64.1-67.5)
33.1 (32.7-33.5)
39.3 (38.9-39.7)
27.6 (27.2-28.0)
59.3 (57.6-61.0)
40.7 (39.0-42.4)
45.8 (45.4-46.2)
54.2 (53.8-54.6)
57.9 (57.6-61.0)
42.1 (40.4-43.8)
88.3 (87.0-89.6)
41.7 (41.3-42.1)
58.3 (57.9-58.7)
68.5 (68.1-68.9)
65.5 (61.8-69.2)
56.2 (54.5-57.9)
15.2 (14.0-16.4)
41.1 (39.4-42.8)
56.1 (55.2-57.0)
21.7 (21.4-22.1)
22.9 (22.5-23.3)
20.1 (19.8-20.4)
21.6 (20.1-23.1)
34.0 (32.3-35.7)
33.3 (31.7-34.9)
11.1 (10.0-12.2)
43.4 (43.0-43.8)
35.4 (35.0-35.8)
15.8 (15.5-16.1)
5.5 (5.3-5.7)
78.4 (77.0-80.0)
21.6 (20.1-23.1)
56.6 (56.2-57.0)
43.4 (43.0-43.8)
P Value
.93
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
*Data are given as percentage (95% confidence interval). Body mass index (BMI) is defined as weight in kilograms divided by the square of height in meters.
†Weighted sample size [unweighted sample size].
‡This question was not asked by all states.
groups, but was higher among persons with DM (66%
vs 56%, P⬍.001). Similarly, the prevalence of hypertension (56% vs 22%), high cholesterol (41% vs 20%), and
overweight and obesity (78% vs 57%) was higher among
adults with DM compared with adults without DM (all
P⬍.001). Conversely, the prevalence of smoking was
higher in adults without DM (23% vs 15%, P⬍.001).
Table 2 compares the prevalence of modifiable
CVD risk factors by ethnicity, sex, and age among adults
with DM. Hypertension was more prevalent in blacks,
followed by whites and Hispanic or other ethnicities
(64% vs 56% vs 50%, P⬍.001). Overweight and obesity
were more prevalent in blacks and Hispanic or other
ethnicities and less prevalent in whites (84% vs 78% vs
77%, P=.002). The prevalence of smoking (15% vs 19%
vs 15%, P=.07), high cholesterol (42% vs 42% vs 38%,
P=.26), and insufficient physical activity (66% vs 61%
vs 73%, P=.27) was not significantly different across the
3 ethnic groups.
Comparing risk factors by sex, the prevalence of
hypertension (59% vs 53%, P⬍.001) and high cholesterol (43% vs 39%, P = .01) was higher in women than in
men. Although men and women had similar overweight
and obesity prevalence (79% vs 78%), women were more
likely to have extreme obesity with a BMI of 40 or higher
(16% vs 6%, P⬍.001). The prevalence of insufficient
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429
physical activity and smoking did not differ significantly by sex.
Comparing CVD risk factors across age groups (Table
2), the prevalence of hypertension (27% vs 49% vs 62%)
and high cholesterol (17% vs 40% vs 44%) increased with
increasing age (both P⬍.001). The prevalence of insufficient physical activity did not differ significantly (77%
vs 61% vs 67%, P = .13), while overweight and obesity
(77% vs 83% vs 77%, P⬍.001) differed across the 3 age
groups in an unpredictable manner. In contrast, the prevalence of smoking decreased with increasing age (29% vs
23% vs 11%, P⬍.001).
A comparison of the prevalence of counseling for
modifiable CVD risk factors in adults with and without
DM is shown in Table 3. Among adults with a BMI of
25 or higher who reported having a physician checkup
within the previous year, 50% of adults with DM reported receiving counseling from a health care professional about weight loss, compared with 21% in adults
without DM. Similarly, among adults who reported having a physician checkup who also had modifiable CVD
risk factors, such as smoking, physical inactivity, or high
cholesterol, the prevalence of counseling was less than
optimal. Adults with DM were more likely to receive counseling about increasing physical activity (67% vs 36%,
P⬍.001), smoking cessation (78% vs 67%, P =.01), and
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Table 2. Prevalence of Modifiable Cardiovascular Disease (CVD) Risk Factors
Among Persons With Diabetes* (by Ethnicity, Sex, and Age)
CVD Risk Factor
Insufficient physical activity‡
Hypertension
Smoking
High cholesterol
BMI
Normal weight (18.5-24.9)
Overweight (25.0-29.9)
Obese (30.0-39.9)
Extremely obese (ⱖ40.0)
Overweight or obese (BMI ⱖ25.0)
Insufficient physical activity‡
Hypertension
Smoking
High cholesterol
BMI
Normal weight (18.5-24.9)
Overweight (25.0-29.9)
Obese (30.0-39.9)
Extremely obese (ⱖ40.0)
Overweight or obese (BMI ⱖ25.0)
Insufficient physical activity
Hypertension
Smoking
High cholesterol
BMI
Normal weight (18.5-24.9)
Overweight (25.0-29.9)
Obese (30.0-39.9)
Extremely obese (ⱖ40.0)
Overweight or obese (BMI ⱖ25.0)
White
(n = 8 068 596 [6901])†
Black
(n = 1 755 992 [1165])†
Hispanic or Other
(n = 2 389 547 [1430])†
P
Value
65.50 (61.5-69.9)
56.30 (54.4-58.2)
14.60 (13.3-15.9)
42.10 (40.2-44.0)
61.10 (51.7-70.6)
64.00 (59.6-68.4)
18.80 (15.4-22.2)
41.50 (37.2-45.8)
73.40 (63.5-83.3)
49.80 (44.7-54.9)
14.50 (10.9-18.1)
37.70 (32.9-42.5)
.27
⬍.001
.07
.26
⬍.001
22.70 (21.0-24.4)
33.50 (31.7-35.3)
33.70 (31.9-35.5)
10.10 (8.9-11.3)
77.30 (75.6-79.0)
15.90 (12.5-19.4)
33.30 (29.1-37.5)
38.90 (34.7-43.1)
11.90 (9.3-14.5)
84.30 (80.9-87.7)
22.20 (18.1-26.3)
36.30 (31.3-41.3)
27.90 (23.5-32.3)
13.70 (10.2-17.3)
77.80 (73.7-82.0)
Men
(n = 5 874 797 [3892])†
Women
(n = 6 339 338 [5604])†
63.60 (57.7-69.5)
53.20 (50.5-55.9)
16.40 (14.5-18.3)
38.80 (36.3-41.3)
67.30 (62.6-72.0)
58.90 (56.7-61.2)
14.00 (12.5-15.5)
43.30 (41.1-45.6)
21.30 (19.1-23.5)
39.50 (37.0-42.1)
33.10 (30.6-35.6)
6.10 (4.7-7.6)
78.70 (76.5-80.9)
22.00 (20.1-24.0)
28.90 (26.8-31.0)
33.50 (31.4-35.6)
15.70 (14.0-17.4)
78.00 (76.1-80.0)
Age 18-34 y
(n = 737 045 [485])†
Age 35-54 y
(n = 3 445 827 [2673])†
Age ⱖ55 y
(n = 8 031 263 [6338])†
77.10 (63.6-90.6)
27.20 (20.1-34.3)
28.80 (20.6-37.0)
16.60 (11.3-22.0)
60.50 (53.5-67.5)
49.20 (45.9-52.5)
22.60 (20.0-25.2)
40.20 (37.0-43.5)
66.90 (62.4-71.4)
61.80 (59.7-63.9)
10.70 (9.5-11.9)
43.80 (41.7-45.9)
34.00 (26.7-41.3)
26.60 (19.5-33.7)
24.80 (17.8-31.8)
14.60 (7.0-22.2)
77.00 (69.7-84.3)
16.60 (14.2-19.1)
29.30 (26.1-32.5)
38.90 (35.7-42.2)
15.20 (13.0-17.5)
83.30 (80.9-85.8)
22.60 (20.8-24.4)
36.70 (34.7-38.7)
31.70 (29.8-33.6)
9.00 (7.8-10.2)
77.40 (75.6-79.2)
.002
.33
⬍.001
.05
.01
⬍.001
.65
.13
⬍.001
⬍.001
⬍.001
⬍.001
⬍.001
*Data are given as percentage (95% confidence interval). Body mass index (BMI) is defined as weight in kilograms divided by the square of height in meters.
†Weighted sample size (unweighted sample size).
‡This question was not asked by all states.
eating foods with less fat (78% vs 71%, P<.001) compared with adults without DM. After adjusting for the effects of age, sex, ethnicity, education, and income by multiple logistic regression, the differences observed between
adults with and without DM remained.
COMMENT
Adults with DM were more likely to have modifiable CVD
risk factors compared with adults without DM, and these
risk factors differed by ethnicity, sex, and age. There were
missed opportunities for counseling about lifestyle modification among at-risk patients, which needs improvement in primary care settings. This is the first study, to
our knowledge, that has identified the prevalence of modifiable CVD risk factors and counseling by primary care
providers for these risk factors among adults with DM
in the United States.
The distributions of ethnicity, sex, and age among
adults with DM in this study are consistent with those of
previous studies on DM.1,24,25,31 The finding of a higher
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430
prevalence of modifiable CVD risk factors among persons with DM is not surprising. The clustering in certain
individuals of DM, hypertension, high cholesterol, and obesity, known as the metabolic cardiovascular syndrome32
or the deadly quartet,33 has been described. In fact, a recent article26 put DM alongside other major risk factors
as an important cause of CVD for a similar reason.
In this study, the prevalence of overweight and obesity, insufficient physical activity, cigarette smoking, hypertension, and high cholesterol is similar to the findings reported by the Centers for Disease Control and
Prevention, based on data from the 1997 BRFSS.34 In our
study, the prevalence of overweight and obesity in persons without DM was 57%, compared with 54% in the
general population in the 1997 study. The prevalence of
cigarette smoking (23% vs 23%), hypertension (22% vs
24%), and high cholesterol (20% vs 29%) followed the
same pattern.34
On the contrary, the prevalence of insufficient physical activity (56%) differed from that reported in 1997
(28%).34 A likely explanation for the difference is the defiWWW.ARCHINTERNMED.COM
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Table 3. Comparison of the Prevalence of Counseling for Modifiable Cardiovascular
Disease Risk Factors Among Persons With and Without Diabetes*
With Diabetes
Counseling Topics
Weight loss
Smoking cessation
Increasing physical activity
Eating less fat
Without Diabetes
No.†
% (95% CI)
No.†
% (95% CI)
P Value‡
374 852 (221)
134 272 (156)
886 279 (875)
1 572 274 (1245)
49.8 (40.6-59.0)
77.7 (69.7-85.7)
67.4 (63.2-71.7)
77.9 (73.8-82.0)
3 539 371 (1845)
2 379 184 (2221)
10 814 992 (10 154)
11 564 418 (8537)
20.8 (18.5-23.1)
67.3 (64.4-70.2)
36.0 (34.6-37.4)
70.7 (69.1-72.3)
⬍.001
.01
⬍.001
⬍.001
*CI indicates confidence interval.
†Weighted sample size (unweighted sample size).
‡P value adjusted for age, sex, ethnicity, education, and income.
nition of physical inactivity used in the years of comparison. The calculation for physical inactivity in 1997
was based on the percentage of adults who did not engage in any leisure-time physical activity other than regular job duties.22,34 In contrast, physical inactivity in 1999
was defined as individuals who reported having no leisuretime physical activity or who had physical activity less
than 20 minutes 3 or more times per week.19 The 1999
definition is more likely to increase the percentage of insufficient physical activity among adults in the United
States than the 1997 definition used for the estimates by
Holtzman and colleagues.34
Data reported by the Centers for Disease Control
and Prevention in 199635 on state-specific prevalence
of participation in physical activity were close to our
estimates. The definition of insufficient physical activity used in that study was similar to the definition
in our study, and 64% to 84% (median, 73%) of respondents reported no leisure-time activity or irregular activity. Therefore, our estimate on insufficient
physical activity in the US population appears to be
reliable.
The findings from this study suggest that primary care
physicians are doing a less than optimal job in counseling
patients about lifestyle modification for CVD risk factors,
particularly in those at high risk. Counseling efforts in
primary care were less than ideal in patients with and
without DM. These findings are concerning because they
indicate that, despite the evidence that each modifiable
CVD risk factor is independently associated with heart disease and mortality, physicians are not acting in a consistent manner. The evidence is established for hypertension,36,37 high cholesterol,38-40 cigarette smoking,41-48
physical activity,49-52 and obesity.53,54
There is also evidence to support the efficacy of counseling by physicians in modifying CVD risk behavior, including smoking cessation,55-58 physical activity,59-62 and
healthy diets,63,64 leading to the recommendations published by the US Preventive Services Task Force,16 American Heart Association,17 and American Diabetes Association.18 Consequently, it is unclear why the prevalence
of counseling remains less than optimal in primary care
settings.
This is not the only study that has documented
low levels of counseling by physicians for CVD risk factors. A recent study65 on physician advice about CVD
risk reduction in 7 US states and Puerto Rico showed
(REPRINTED) ARCH INTERN MED/ VOL 162, FEB 25, 2002
431
that only 42% of persons surveyed reported receiving a
physician’s advice to avoid high-fat or high-cholesterol
foods. About the same percentage reported receiving
advice to exercise more. Those with a history of heart
attack, myocardial infarction, angina, coronary heart
disease, or stroke were more likely to report receiving a
physician’s advice to eat less fat and exercise more.
Although estimates of counseling in this study differ
from those in that study, the pattern of increased counseling for patients at higher risk is similar.
Primary care physicians have mentioned several
reasons for the low prevalence of counseling, including
not having adequate time to provide counseling, having
limited training in counseling techniques, and being
doubtful about the effectiveness of their counseling efforts.66-72 These reasons may partly explain the low prevalence of counseling of patients with DM observed in this
study.
There are 3 limitations to this study. First, because
the data were based on self-report, there is the potential
for recall bias, especially regarding counseling about CVD
risk factors by physicians. This is less likely to apply to
this study because previous studies73-76 have shown that
self-reported information on DM, CVD risk factors, and
health promotion habits is reliable.
However, what constitutes adequate counseling remains unclear. The US Preventive Services Task Force16
distinguishes physician counseling from physician advice, and defines physician counseling as a more interactive and in-depth encounter, as opposed to physician
advice, which may involve a brief recommendation to
adopt or modify a behavior. Also, whether patients considered referral to weight loss centers, smoking cessation programs, or counseling during DM education programs as counseling by their physician cannot be
determined in this study.
Second, because the BRFSS is a telephone-based
survey, households without telephones were excluded.
This may bias our estimates to a certain degree. The extent of such bias is likely to be minimal for 2 reasons.
First, telephone coverage for households was high in the
United States in 1999, ranging from 89% to 99%.19 Second, several studies76-79 on the reliability and validity of
the telephone survey in the BRFSS compared with inperson or household interviews have shown that the estimates obtained by both methods are similar for most
of the population.
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Third, because the BRFSS is limited to civilian and
noninstitutionalized adults, generalization can only be
made to that segment of the population covered by the
survey.
There are 2 major implications of our study. First, there
is the need for primary care physicians to recognize the
prevalence of modifiable CVD risk factors among adults
with DM. Recognizing the pattern in which these CVD risk
factors cluster in persons with DM may improve identification of high-risk patients. In addition, physicians can use
data from this study to stratify patients with DM during
routine office visits, as recommended by the American Heart
Association.26,27 Second, although there is evidence to support counseling by physicians—and several guidelines and
recommendations encourage counseling about modifiable CVD risk factors—primary care physicians appear to
be performing at less than optimal levels. This may suggest that strategies to improve counseling techniques in primary care are needed, especially on how to counsel patients to modify high-risk behavior. There may be benefit
in incorporating counseling skills into medical residency
education or as continuing medical education activity for
primary care physicians.
CONCLUSIONS
Although adults with DM have a high prevalence of modifiable CVD risk factors, counseling by physicians about
lifestyle modification is less than optimal. There is a need
to improve patient counseling for lifestyle modification
by primary care physicians.
Accepted for publication June 6, 2001.
Thisstudywassupportedinpartbygrants1K08HS1141801 and 1 P01-HS10871-01 from the Agency for Health Care
Research and Quality, Rockville, Md (Dr Egede), and grant
U50/CCU417281-02 from the Centers for Disease Control
and Prevention, Atlanta, Ga (Drs Egede and Zheng).
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the
official views of the Agency for Healthcare Research and
Quality or the Centers for Disease Control and Prevention.
Corresponding author and reprints: Leonard E. Egede,
MD, Division of General Internal Medicine and Geriatrics,
Department of Medicine, Medical University of South
Carolina, McClennan-Banks Adult Primary Care Clinic,
Fourth Floor, 326 Calhoun St, PO Box 250100, Charleston, SC 29425.
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