risk perception is affected by the beliefs people have regarding the causes of the event under discussion (eg, what causes a heart attack and is it preventable?) and the consequences of the event (eg, is it potentially fatal?). To illustrate the causes of increased CVD risk, the link between CVD risk and specific behavioral or personal characteristics must be made in clear and easily understandable terms. This approach has been successful in rendering overly optimistic perceptions of CVD risk more accurately (Avis et al 1989; Rothman et al 1999). If a patient has uncontrolled blood glucose and blood pressure and smokes, a statement as simple as “smoking, high blood sugar, and high blood pressure all act together to cause damage to blood vessels that supply the heart, and this can cause a heart attack” describes the patient’s characteristics and associates those characteristics with increased CVD risk. Many patients simply have not heard or have not understood this message. The use of widely recognized images and simple pictures can help to make the disease process easy to understand, regardless of the literacy level of the patient. For example, a plumbing pipe becoming progressively occluded with rust and mineral deposits alongside a diagram of a narrowed blood vessel provides a relevant, familiar, and easily understood analogy to describe the process that leads to heart attack and stroke. These images graphically reinforce the message about the causes of coronary disease and MI, and incorporate graphic and allegorical modes of communication in illustrating how the patient’s personal characteristics increase their CVD risk. To illustrate the consequences of a myocardial infarction, two approaches have been shown to be effective: (1) highlight the similarities between the patient under consideration and persons who have experienced an MI; and (2) graphically illustrate the severity of the consequences associated with the event (Rothman et al 1999). Both of these goals might be accomplished by providing patients with a brief written or audio- or videotaped testimonial from a hypothetical patient with DM from a similar age and ethnic background who has experienced an MI. Testimonials have been shown to be more persuasive than similar information presented as statistics or straight facts, and the quality of exemplars has been shown to have a strong effect on one’s view of the importance of a problem (Rothman et al 1999; Strecher et al 1999). Testimonials should include a description of the experience surrounding the acute event and its long-term effects on the individual’s daily activities. The serious and potentially fatal nature of an MI should be Communicating risk in type 2 diabetes clearly communicated to insure that patients are adequately informed and are appropriately motivated to adopt lifestyle and therapeutic interventions. “What is my risk of having a heart attack?” The most intuitive way to begin the risk discussion is to describe the patient’s statistical risk for CVD, eg, “You have a 30% risk of experiencing a heart attack in the next 10 years”. A variety of risk calculation tools can be accessed via the Internet, downloaded to PCs or PDAs, and used in the clinical setting to quickly generate individualized CVD risk estimates for patients with DM. Although risk calculators based on the Framingham Heart Study are most commonly recommended for CVD risk calculation in the US, diabetes is underrepresented in the Framingham cohort, making the equations imprecise in estimating CVD risk in persons with diabetes (Sheridan et al 2003). The UKPDS Risk Engine (available at www.dtu.ox.ac.uk/index.html? maindoc=/ukpds) is a validated CVD risk calculator that appears to be better suited to risk estimation for individuals with DM (UKPDS Group 2001; Lee et al 2004). The data upon which the calculator is based are derived from long- term follow-up of 4050 patients with DM in patients in the United Kingdom Prospective Diabetes Study (UKPDS), a 20-year trial in which patients of Caucasian, Asian, and Afro- Caribbean descent were studied to determine the effect of tight blood glucose and blood pressure control on the risk of diabetic complications (UKPDS Group 1998). The Risk Engine will estimate the probability that a cardiovascular event (fatal or nonfatal MI or sudden death) will happen to a given patient within a specified time frame, usually 10 years, based on age, gender, race, duration of diabetes, hemoglobin A1c (A1c), systolic blood pressure (SBP), total and high-density lipoprotein (HDL) cholesterol, and smoking status. Although the generalizability of the model to DM populations other than the UKPDS cohort has not yet been tested, the Risk Engine provides reasonable evidence-based CVD risk estimates that can be used to inform risk communication. The UKPDS Risk Engine can also be used to demonstrate the reduction in CVD risk that is possible through reductions in blood glucose, blood pressure, and cholesterol levels and through smoking cessation. In a similar fashion, the Risk Engine can be used to provide updated CVD risk estimates for patients at each office visit to demonstrate the reduction in CVD risk that has been Vascular Health and Risk Management 2005:1(4) 303