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Blood Pressure, Cholesterol Are Problems for Many Diabetics

Doctors need to do a better job of outlining the risks

SATURDAY, June 5, 2004 (HealthDayNews) -- Too many people with diabetes aren't getting the kind of blood pressure and cholesterol control they need to limit their high risk of heart attack, stroke and other cardiovascular problems.

That was the assessment of a succession of experts addressing the American Diabetes Association's annual meeting June 5 in Orlando, Fla.

Four studies that looked at the issue in different ways came to the same conclusion: Many physicians are not aggressive enough in recommending preventive measures, and many patients fail to follow their doctors' orders.

The broadest-based study was reported by Dr. Lawrence Leiter, head of the division of endocrinology at St. Michael's Hospital in Toronto. The survey of more than 2,000 diabetes specialists in 50 countries found only half their patients achieve the desired goal of 100 milligrams or less per deciliter of blood of LDL cholesterol, the "bad" kind that clogs arteries.

"The most common explanation was poor patient compliance," Leiter said. "But despite all the efforts of groups like the American Diabetes Association, physicians were treating patients with diabetes but without heart disease much less aggressively than they should."

Many doctors don't recognize that diabetes in itself puts a patient in the same risk category for heart problems as someone who has already had a heart attack, Leiter added.

The same point was made by researchers at the Henry Ford Health System in Detroit who looked at 9,642 people with diabetes enrolled in that health maintenance organization.

In the five years starting in 1997, the number of patients who reached the desired LDL goal did increase, but not spectacularly -- from 22 percent to 37 percent.

"Once patients have a serious cardiovascular event, they are treated more aggressively," said Jennifer Lafata, director of the organization's Center for Health Services Research. "If the same process was implemented before a cardiovascular event, some of those events could be prevented."

A strikingly similar number came from a study of 8,855 people with diabetes done by Health Core, a health outcomes and research group in Wilmington, Del. Again, just 37 percent of the patients reached the target number for LDL cholesterol control, said Vincent Willey, the organization's vice president for research.

It's hard to tell exactly why the percentage is so low, Willey said. One possible reason is that people with diabetes often have a number of medical problems -- including high blood pressure and high cholesterol -- that require them to take a bewildering variety of drugs. The doctor often will prescribe a cholesterol-lowering statin drug, "but you're lucky if someone is still on it at the end of a year," he said.

"So many things can be going on that sometimes it is overwhelming," Willey said.

A similar story surrounds blood pressure, said Dr. Janet McGill, an associate professor of medicine at Washington University in St. Louis. Her report on more than 10,000 people in a free screening program found that 48.7 percent of those with diabetes but no kidney disease had uncontrolled high blood pressure.

Because more than 90 percent of the people had health insurance and more than 80 percent had personal physicians, "it is shocking that their blood pressure was not controlled," McGill said.

"It's not clear where the problem was," McGill said. It's possible these people don't see their doctors as often as they should, she said. But another factor could be what others have called "physician inertia," a failure of doctors to communicate to diabetes patients the importance of keeping blood pressure under control.

But "we don't want to play a blame game," Lafata said. Besides studying physicians' and patients' behavior, "people are trying to think about systems approaches to what comes into play in such a complex situation," she said, "things like the information that is available to clinicians and to patients."

In a related matter, the American Diabetes Association has issued new guidelines to doctors to help their diabetes patients lower their risk of heart disease.

The guidelines recommend a blood pressure goal of less than 130/80. They also call for lowering blood glucose levels, as measured by the A1C test, to less than 7 percent for most people with diabetes and less than 6 percent for individual patients when appropriate.

Aspirin therapy is also recommended for those with diabetes unless their doctor says otherwise.

The guidelines also state that smoking as a risk factor for cardiovascular disease among diabetics is not being adequately addressed by health-care providers. The new recommendations urge doctors and nurses to determine if their patients are smokers and, if they are, to encourage them to quit.

More information

The Federal Citizen Information Center explains the importance of controlling cholesterol levels in those with diabetes.

SOURCES: Lawrence Leiter, M.D., head, division of endocrinology, St. Michael's Hospital, Toronto, Canada; Jennifer Lafata, Ph.D, director, Center for Health Services Research, Henry Ford Health System, Detroit; Vincent Willey, PharmD, vice president for research, Health Core, Wilmington, Del.; Janet McGill, M.D., associate professor of medicine, Washington University, St. Louis; June 4-5 presentations, American Diabetes Association annual meeting, Orlando, Fla.
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