Much of the work documenting the impact of smoking on health does not discuss results on subsets of subjects with diabetes, suggesting that the identified risks are at least equivalent to those found in the general population. Other studies of individuals with diabetes consistently report a heightened risk of morbidity and premature death associated with the development of macrovascular complications among smokers. Although smokers have repeatedly heard of the pulmonary effects of smoking, the cardiovascular burden of diabetes, especially in combination with smoking, has not been communicated effectively to either people with diabetes or health care providers.
Despite demonstrated efficacy of smoking cessation counseling, only about 50% of patients with diabetes are advised to quit smoking by their health care providers (12). Treatment characteristics that have been identified as critical to -o achieving cessation include counseling by multiple health care providers, use of individual or group counseling strategies, use of interventions including problemsolving skills or skills training with social support, and use of pharmacotherapy such as nicotine replacement therapy. Recommendations regarding smoking and <j diabetes are listed in Table 3. Ja
Exercise is generally regarded as one of the pivotal diabetes management J
tools. Results in several long-term studies (13-15) demonstrate sustained im- a
Table 3 Recommendations Regarding Diabetes and Smoking
Assessment of smoking status and history
Systematic documentation of a history of tobacco use must be obtained from all adolescent and adult individuals with diabetes.
All health care providers should advise individuals with diabetes not to initiate smoking. This advice should be consistently repeated to prevent smoking and other tobacco use among children and adolescents with diabetes under age 21.
Among smokers, cessation counseling must be completed as a routine component of diabetes care.
Every smoker should be urged to quit in a clear, strong, and personalized manner that describes the added risks of smoking for people with diabetes.
Every diabetic smoker should be asked if he or she is willing to quit at this time.
If no, initiate brief and motivational discussion regarding the need to stop using tobacco, the risks of continued use, and encouragement to quit as well as support when ready.
If yes, assess preference for and initiate either minimal, brief, or intensive cessation counseling and offer pharmacological supplements as appropriate.
Effective systems for delivery of smoking cessation
Training of all diabetes health care providers in the Agency for Health Care Policy and Research Guidelines regarding smoking should be implemented.
Follow-up procedures designed to assess and promote quitting status must be arranged for all diabetic smokers.
provement in glucose control while a regular exercise program is maintained. Because of the increased incidence of cardiovascular disease in patients with diabetes, the role of exercise in reducing modifiable risks has primary importance. The potential benefits of exercise for people with diabetes include:
1. Improved strength and physical work capacity.
2. Increase in high-density lipoproteins (HDL), particularly in the presence of weight loss.
3. Reduction in plasma cholesterol, triglycerides, and low-density lipo- -o proteins (LDL). |
4. Increased insulin sensitivity. £
5. Reduced hyperinsulinemia. g
6. Enhanced fibrinolysis. <
7. Favorable changes in body composition (i.e., reduction of body fat and Ja weight and increase in muscle mass).
8. Improved control of hypertension with pharmacological agents. a
9. Improved quality of life and self-esteem, and reduced psychological stress.
The primary side effect of acute exercise is hypoglycemia. Patients require specific guidelines either to increase carbohydrate consumption or to decrease medication based on the intensity of exercise and relationship of the planned exercise to the timing of the next meal. For those attempting to lose weight, medication adjustment is chosen over adding extra calories. For some, exercise after a meal without medication adjustment is preferred. Postexercise, late-onset hypoglycemia (PEL) occurs several hours following an exercise session and is a significant concern for those treated with insulin or insulin secretagogues. Postexercise late-onset hypoglycemia can be the result of acutely increased insulin mobilization and sensitivity, increased glucose utilization, replenishment of gly-cogen stores, and defective counterregulatory mechanisms. Patients need to learn how to prevent PEL by remembering to supplement carbohydrates during the postexercise phase, to reduce the dose of insulin that peaks during the postexercise phase, and to monitor blood glucose frequently.
The American Diabetes Association recommends a graded exercise test for patients at high risk for underlying cardiovascular disease based on the following criteria (16): age >35 years; type 2 diabetes of >10 years duration; type 1 diabetes of >15 years duration; presence of any additional risk factor for coronary artery disease; presence of microvascular disease (including microalbuminuria); peripheral vascular disease; and autonomic neuropathy.
Rhythmic exercises with the use of the lower extremities, such as walking or cycling, are safely recommended. Patients with established cardiovascular disease usually require supervision in a monitored cardiac rehabilitation program. Unfortunately, little is known about how to increase or maintain participation in exercise programs. Relapse is common and all health care providers play a role in supporting patients in their efforts at exercise.
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