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Modifiable Cardiovascular Risk Factors in Adults With Diabetes
Prevalence and Missed Opportunities for Physician Counseling
Leonard E. Egede, MD, MS;
Deyi Zheng, MB, PhD
Arch Intern Med. 2002;162:427-433.
ABSTRACT
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Background Cardiovascular disease (CVD) is the leading 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 150 493 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.
Results Diabetes mellitus was more prevalent in adults aged 55 and older and
in blacks and Hispanic or other 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.
INTRODUCTION
DIABETES 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 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.
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
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 state-based, 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,  40.0).
For the analysis, we used 4 weight categories: normal weight (BMI, 18.5-24.9),
overweight (BMI, 25.0-29.9), obesity (BMI, 30.0-39.9), and extreme obesity
(BMI, 40.0).
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 leisure-time 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 55 years) were used for the analysis. Two
categories of income (<$25 000 and $25 000), 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
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 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 $25 000 (58% vs 42%) was higher among
adults with DM compared with adults without DM (both P<.001).
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Table 1. Baseline Characteristics Among Persons With and Without Diabetes*
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Comparing modifiable CVD risk factors between groups with and without
DM, the prevalence of self-reported insufficient physical activity was high
in both 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.
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Table 2. Prevalence of Modifiable Cardiovascular Disease (CVD) Risk
Factors Among Persons With Diabetes* (by Ethnicity, Sex, and Age)
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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 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 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.
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Table 3. Comparison of the Prevalence of Counseling for Modifiable
Cardiovascular Disease Risk Factors Among Persons With and Without Diabetes*
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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 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 definition 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 leisure-time 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 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 in-person or household interviews have shown that the estimates obtained
by both methods are similar for most of the population.
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.
AUTHOR INFORMATION
Accepted for publication June 6, 2001.
This study was supported in part by grants 1K08HS11418-01 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.
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.
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