Roach and Marrero risk (Meigs et al 1997; ADA 2004a, 2004b). Addressing these multiple comorbidities is challenging for providers faced with large caseloads and limited time during the outpatient encounter. In addition, “clinical inertia” among physicians, ie, recognition of a problem but failure to act, is well described (Phillips et al 2001; O’Connor 2003; Grant et al 2004). From the patient’s perspective, many with DM are unaware that diabetes itself is a CVD risk factor. A recent survey found that almost 70% of people with diabetes do not realize that they are at increased risk of CVD and stroke (Bairey-Merz et al 2002), and patients often underestimate their CVD risk (Rothman et al 1999; Strecher et al 1999). Patients often do not receive sufficient information from their physicians to allow them to understand their personal health risk and to participate in their own healthcare (Heisler et al 2002; Kinnersley et al 2004), and most patients remember and understand as little as half of what they are told by their physicians (Rost and Roter 1987; Crane 1997; Roter 2000). Patients are more likely to translate advice from their providers into appropriate behavioral changes if they are made aware of their health status and participate in treatment decisions (Greenfield et al 1988; Anderson 1995; Anderson et al 1995). Even when information is conveyed, many patients have limited ability to understand risk and risk-reducing therapies due to low health literacy, defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. Persons with low health literacy are unable to fully participate in decisions about their own health, adhere poorly to prescribed therapies, and are more likely to have poor glycemic control compared with those with adequate health literacy (Schillinger et al 2002; Nielsen-Bohlman et al 2004). While multifaceted disease management programs have improved the dissemination of health information to patients, most primary care physicians work in practice settings without such programs. Clearly, methods that facilitate patients’ understanding of their risk, regardless of their literacy status, and that increase physicians’ ability to impart health risk information in a busy clinical environment are urgently needed. This effort should in turn lead to shared decision making, a process in which the patient’s preferences and their physician’s knowledge are incorporated into the therapeutic planning process. Shared decision making has been shown to improve glycemic control and quality of life in patients with diabetes (Greenfield et al 1988; Kinnersley et al 2004). The elements of CVD risk communication “What is a heart attack?” Effective individualized CVD risk communication can be constructed around several general principles. Patients want practical, concise information focused on the identification of the problem, what specifically they need to do, why it is in their best interest, and what outcomes they can expect (Davis et al 2001; Davis, Fredrickson, et al 2002; Davis, Williams, et al 2002). With respect to CVD risk, patients want to know: (1) What is CVD? Or what is a heart attack? (2) Am I at risk of having a heart attack? (3) What can I do to lower my risk? (Table 1). Because myocardial infarction (MI) is the most common and potentially fatal cardiovascular event experienced by persons with diabetes, it seems appropriate to structure the discussion of CVD risk around the “risk of having a heart attack”. However, for many patients, the term “heart attack” may have little meaning or may be associated with misperceptions. In order to fully understand the implications of having an MI, patients must be provided with explicit information about what exactly might happen and how it might occur (Avis et al 1989; Gerrard et al 1999; Lipkus and Hollands 1999; Rothman et al 1999). In this context, Table 1 Components of comprehensive cardiovascular disease (CVD) risk communication 1. “What is a heart attack?” Graphic illlustration of the atherosclerotic process using simple language, diagrams, and analogies Graphic description of the consequences of a CVD event, eg, pain, disability, and death as possible consequences of a myocardial infarction Patient testimonials 2. “What is my risk of having a heart attack?” Calculation of individual CVD risk (UKPDS Risk Engine) Assign risk severity: eg,“high” Compare individual risk with “average” risk Compare hemoglobin A1c, blood pressure, and cholesterol with recommended targets 3. “How can I reduce my risk?” Overview of therapeutic options Shared decision making to develop a treatment plan Regular follow-up and feedback regarding the status of CVD risk factors NOTE: UKPDS, United Kingdom Prospective Diabetes Study; UKPDS Risk Engine is available at www.dtu.ox.ac.uk/index.html?maindoc=/ukpds. 302 Vascular Health and Risk Management 2005:1(4 )