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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Diabetes patients who smoke are also treated differently
Giving Smoking the Attention It Deserves
Tailoring individual risk in diabetes
Toward more creative and consistent doctors
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Petra Denig, Groningen, The Netherlands Department of Clinical Pharmacology
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Solberg et al. conclude that diabetes patients who smoke are different in terms of self-management and compliance, and that aggressive methods may be needed to manage their cardiovascular risk factors. Smoking cessation is clearly important but there is also a need for putting more effort into the treatment of other risk factors, especially in this patient group. Recently, we observed that diabetes patients that smoke are less adequately treated for their hypertension than non-smokers (Schaars et al., 2004). This may be linked to the finding of Solberg et al. that these patients tend to be less compliant in taking their medication, and clinicians may become hesitant to prescribe additional preventive medication. In daily practice it is sometimes necessary to set priorities. Intensified hypertension control, however, can be rewarding since it may improve health outcomes at reduced costs, and appears to be more cost- effective than intensive glycemic control or reduction in cholesterol level (CDC Diabetes Cost-effectiveness Group, 2002). Besides close follow-up of patients to improve the management of cardiovascular risk factors, it seems important to involve the patient in setting priorities and making agreements on achievable goals. For some, this may result in an (assisted) effort to quit smoking; for others, this may be the start of more adequate treatment of their hypertension. Schaars CF, Denig P, Kasje WN, Stewart RE, Wolffenbuttel BHR, Haaijer -Ruskamp FM. Physician, organizational, and patient factors associated with suboptimal blood pressure management in type 2 diabetic patients in primary care. Diabetes Care 2004;27:123-128. CDC Diabetes Cost-effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA 2002;287;2542-2551. Competing interests: None declared |
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Russell E. Glasgow, Denver, CO USA Behavioral Scientist
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The Solberg et al. article on diabetic smokers is important for both its public health, and its clinical implications. Given the health consequences, smoking should be considered as a priority comorbid condition, and it is refreshing to see smoking get the attention that it deserves in diabetes. For too long, the focus, at least in the diabetes management research literature, has been almost exclusively on glycemic control. There has of course been a recent focus on CVD risk factors among diabetes patients, especially hypertension, and this article extends this focus to behavioral risk factors. This paper also raises a challenge that faces clinicians who treat diabetes and other complex chronic illnesses: namely prioritizing intervention goal setting when the patient has many competing risk factors and areas in need of attention (e.g., the article convincingly documents that diabetic smokers have higher rates of depressed mood, lower levels of diabetes self-management, and physical activity). They propose a ‘stage- matched intervention’ approach to help smokers. I would agree that use of a patient-centered, evidence-based approach that involves collaborative goal setting is helpful for both smoking and diabetes self-management issues. However, I would place greater emphasis on the USPSTF (Whitlock et al,. 2002) and AHRQ recommended multi-level “5 A’s approach” noted by the authors, than a stages of change orientation. My experience is that greatest attention should be focused on rearranging the office environment, involving all staff in supporting patient self- management and smoking modification efforts, and providing follow-up support. Such a social ecological approach is likely to be more feasible to implement and integrate into practice than a full blown Transtheoretical Model intervention, and also should work across other self-management areas and for other chronic illnesses (Glasgow et al., 2003). Russ Glasgow, Ph.D. Senior Scientist Kaiser Permanente Colorado Glasgow RE, Davis CL, Funnell MM, Beck A. (2003). Implementing practical interventions to support chronic illness self-management in health care settings: Lessons learned and recommendations. Joint Commission Journal on Quality and Safety, 29, 563-574. Whitlock EP, Orleans CT, Pender N, Allan J. (2002). Evaluating primary care behavioral counseling interventions: An evidence-based approach. American Journal of Preventive Medicine, 22, 267-284. Competing interests: None declared |
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Kevin A Peterson, St. Paul, Minnesota Physician, University of Minnesota
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I would like to thank Dr. Solberg, et. al. for re-emphasizing the importance of smoking cessation in the overall therapeutic approach for diabetes in their recent article “Diabetic Patients Who Smoke: Are They Different?” Too often in clinical practice the treatment of diabetes becomes a synonym for the treatment of hyperglycemia, and important risk factors such as smoking are easily overlooked. A simple chase for progressively lower A1Cs, or more frequent A1CS, undermines the importance of tailoring therapy for the individual. In practice, risk factors are clustered. The best approach to an individual is not easily determined by evaluating performance on a set of diabetes quality improvement measures. Although it may be easier to persist in lowering blood sugars to continually lower levels than to intervene in smoking as a behavior, it is not necessarily the most appropriate treatment for the individual. Dr. Solberg’s article further reminds us that our effectiveness as physicians is compromised by our lack of knowledge and our lack of infrastructure to support and motivate our patients to live healthier lifestyles. Competing interests: None declared |
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John B. Standridge, MD, Chattanooga, TN, USA associate professor of family medicine, University of Tennessee college of medicine
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The issues addressed in the manuscript, "Diabetic Patients Who Smoke: Are They Different?" by Solberg et al are of vital concern to American health care providers. To conclude that "it is time to take smoking more seriously" may be restating the obvious, but if so, it is an obvious statement that needs repeating. The authors have done just that while presenting useful information that supports linkage between diabetic patients who smoke, depression, and problematic behaviors with regard to diabetes care. It is difficult to place depression in proper perspective with smoking and diabetes, both in terms of hierarchy and causation. The authors are to be commended for their effort. While the focus of the manuscript was to describe and delineate the extent of the challenge facing family physicians, the authors nonetheless venture smoothly into solid recommendations that emphasize appropriate stage-matched interventions. More aggressive, “creative and consistent” clinical interventions and support are indicated for this more challenging population. This latter issue was addressed this month in the American Family Physician in a practical article by Koenigberg, et al,[1] titled, “Facilitating Treatment Adherence with Lifestyle Changes in Diabetes.” These two manuscripts complement each other nicely. Together the articles speak clearly to the efforts and expertise of family medicine. 1. Koenigberg MR, Bartlett D, Cramer JS. Facilitating Treatment Adherence with Lifestyle Changes in Diabetes. Am Fam Physician 2004;69:309 -16,319-20,323-4. Competing interests: None declared |
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