Panel Discussion Local Primary Care Collaboratives Learning Workshop 4 Case Study - SAM.
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Transcript of Panel Discussion Local Primary Care Collaboratives Learning Workshop 4 Case Study - SAM.
Panel Discussion
Local Primary Care CollaborativesLearning Workshop 4
Case Study - SAM
Case Study - SAM
• Gender: Male• Age: 50• Weight: 107 kg• Height: 170 cm• BMI: 37.0• Diagnosis
• Type 2 Diabetes (3 years ago)• Myocardial Infarct (6 months ago)
Medical History
• HbA1c: 7.5• BP: 160/100• Total Cholesterol: 6.6 mmol/l
– Triglycerides: 2.4 mmol/l– HDL: 0.9 mmol/l– LDL: 3.1 mmol/l
• Cigarette Consumption: 30 per day• Alcohol - Binge drinking Fri, Sat, Sun (10 drinks)• Weekday: 2-3 drinks per night
Medical History
• Exercise: none
• Occupation: Long distance truck driver
• Diet: Truck stop food – pies, sausage rolls, chips
• Teeth: Extensive decay and has difficulty chewing
Medications
• 1 Aspirin tablet daily
• Beta Blocker - Metoprolol 50 mg, 2x daily
• Ace Inhibitor- Ramipril 10mg daily
• Statin – Simvastatin 40mg daily
• Metformin 850mg 2 x daily
• Gliclazide 60mg daily
People Involved
• General Practitioner
• Cardiologist
• Cardiac Rehab
• Diabetic Educator
• Exercise Physiologist
• Dentist
• Physiotherapist
• Social Worker
• Podiatrist
• Ophthalmologist
• Quit Program
• Dietitian
Diabetes Educator
Sam
• Sam is not eating healthy food and does no exercise.
• He has poor teeth, smokes and drinks excessively.
• All this and he had an AMI recently.
• It is a good bet he was seen by dietitians, cardiac rehab staff and even a diabetes educator following the recent AMI. • His GP and Cardiologist would certainly have spoken with him.
• But he still continues with poor self - care.
• My first question is “why?”
Process and Priorities
I would like to see Sam myself initially to try to understand his situation
He has had diabetes for three years. Has he seen a diabetes educator before - what has he already been told? Make some judgement about the sort of information he needs
Find out his social situation- look for positives/negatives - ? kids. We can build on this information later
It is likely he is depressed. Even at this stage I would be considering if it is appropriate for him to see the psychologist at RNSH diabetes service.
How would we do this? The angle I might use is stress management - the life of a long distance truck driver is stressful.
We wont get him to change any lifestyle practices without understanding the barriers to change.
Initially
I would ask Sam what he wants from the consultation and in life generally.
I would build on this to provide a frank explanation about how diabetes develops and the risks of not getting control
of his situation.
My Priorities
Informed choice - our responsibility - important to maintain communication with GP and other members of the care team.
Teeth - Dental Services
Cigarette Consumption / Alcohol - Quit line Drug and Alcohol Services
Exercise - GP, Healthy Lifestyles, Physiotherapy, Exercise Physiologist
Diet/Obesity - Dietary Dept
Complication Screening including Feet - Podiatry Sydney Diabetes Health Assessment Unit
HbA1c: 7.5% - Explain implications and discuss the option of self blood glucose monitoring
Blood Pressure, Lipids etc
Sam’s Priorites?
Set some goals together
He may not be ready to make changes yet
Likely small steps at first. Probably one thing at a time
May have nothing to do with diabetes
Establish some reasonable time frames
Be prepared for set backs along the way
Try to be present at other consultations for support
Offer group programs and Diabetes Australia-NSW Hornsby Branch
At all times mind your language - non judgemental
Provide a free blood glucose meter
Some suggested strategies
• Describe BGLs as either high or low, not good or bad
• Help customers view BGLs as providing positive feedback, regardless of the number will help reduce guilt and anxiety
• Refer to checking BGL’s rather than testing
• Develop realistic expectations early on
Avoid the tyranny of numbers
Dietitian
What other information would be helpful in the referral?
• Current BSLs• Is Sam doing SBGM? If so how often?• Target BSLs and HbA1c• Renal function• Any visual impairment• Family history of NIDDM & CVD• Literacy level• Other relevant medical history e.g. depression,
mental illness.
What information will I gather from Sam?
• Waist circumference and weight history• Psychosocial information – living arrangements;
cooking facilities and skills; financial status; cultural issues; family & social support.
• Current knowledge re diet and his conditions (has he seen a dietitian before?)
• Attitude towards his own health and nutrition and readiness to make changes.
• On a scale of 1-10 how important is it to him to improve his health?
More information from Sam
• Full nutrition history – usual food intake to include a typical day with usual options for main meals and snacks; beverages; frequency and timing of meals; weekends.
• Food frequency for common items not already discussed.
• Restaurant / takeaway choices.• Type of alcohol.• Salt? Supplements?• Eating behaviours; digestive problems.
My assessment of Sam
• Anthropometry
BMI 37 = Class 2 obese;
IBW (BMI 20-25) 58-72kg
(35kg overweight).
Most probable sustainable weight loss 10-15% body weight = 11-16kg.
Assessment (cont)
• Biochemistry:
HbA1c 7.5% (acceptable control 7.1-8.0%)
TC 6.6mmol/L (<4.0mmol/L)
LDL 3.1mmol/L (<2.0mmol/L)
HDL 0.9mmol/L (>1.0mmol/L)
TGs 2.4mmol/L (<1.5mmol/L)
BP 160/100 (120/80)
Assessment (cont)
• Clinical Data:
N.B. Some of Sam’s medications interact with alcohol i.e.
Metformin (contraindicated as may cause lactic acidosis with Xs alcohol)
Gliclazide (risk of hypoglycemia with alcohol)
Metoprolol interacts with alcohol
Dietary Assessment
• Dietary Data (much assumed):• Excess energy (Calories / kilojoules)• EER = 11,140kJ (2650 Calories) at current
weight• High fat especially saturated fat – fat should =
20-35% energy with sat & trans fats <10%energy (AMDRs 2006)
• High salt/sodium (1600mg; UL 2300mg SDTs 2006)
• Low fibre(38g/day SDT recc to reduce CVD risk)• Low n-3 FA’s (610mg/day SDTs 2006)
Dietary Assessment (cont)
• Other nutrients at risk:B Vitamins & folateVitamin CCalcium• Other issuesHigh alcohol consumptionOccupation – truck driver therefore reliance on takeaway /
café foods.Possibly lives alone with little supportSmokingLow physical activity
Aims of MNT for Sam
• Secondary CVD prevention through reduction of risk factors.
• Reduce risk of NIDDM complications.
• Improve QOL through lifestyle interventions.
Goals for Sam
• Long term goals:
Achieve target BGL and HbA1c
Reduce weight by 10-15%
Reduce waist circumference to < 102cm then < 94cm
Achieve target lipid levels
Reduce BP ideally to 120/80 (taking age into account)
Nutrition Education for Sam
• Outline at an appropriate level the relationship between diet and both CVD and NIDDM.
• Probe for basic understanding of above and use suitable resources to illustrate.
• Discuss the interaction of alcohol with 3 of his medications and the very real risk of hypos.
• Go through his current eating plan with him and address the issues previously mentioned in the dietary assessment (slides 14 & 15)
Goal-setting with Sam
• Ask Sam where he feels he can make some changes to his lifestyle.
• Help Sam set 3-4 SMART behavioural goals that he should be able to achieve before the review consultation.
• Advise Sam on how to achieve these goals given his occupation and current habits e.g discuss and give resources on healthier fast food / café choices; tips on cutting back on alcohol; simple recipe ideas and healthier snack suggestions.
Possible goals Sam might set
• Prepare a home-cooked meal using recipe ideas given on 2 evenings per week.
• Eat breakfast on work days (5/7). (Healthy breakfast options now available at some outlets e.g. McDonalds)
• Choose a healthy sandwich or salad from café menu at least 4/7
• Alternate alcoholic drinks with diet soft drinks on weekend sessions.
Next consultation with Sam
• Sam should return for review within 2-4 weeks.
• Goal attainment will be assessed.
• Further education will be given e.g. label-reading; how to eat less salt & sugar; importance of fruit and vegetables.
• More SMART goals will be set.
Podiatrist
Overview
Overweight Type 2 Diabetes Smoker Excessive alcohol consumption No exercise
How can a podiatrist help?
1) Screening - how at risk are we?
2) Keep our patients pain free
Diabetes Assessment
• Hx / medication etc.
• Vascular
• Neurological
• Biomechanical
Vascular
• Pulses
• Temperature
• Hair
• SVPFT
• Buergers elevation / dependency test
Neurological
• Vibration• Monofilament• Reflexes• Sharp / blunt• Hot / cold• Two point discrimination• Light touch
Biomechanical
• Any previous problems• Callus• Bunions, hammertoes• Exostoses• Arthritis• Shoes, footwear• Joint ROM
How at risk are we?
• Everyone is different
• Set review dates
TREATMENT
• Education• Debridement of callus & corns• Nail care• Orthotics• Footwear• Manipulations / mobilisations• Stretching / exercises etc
Conclusion
• Our aim is to keep feet healthy
• Keep people walking
• Talk to your podiatrist
Cardiac Rehabilitation Coordinator
Coronary Artery Disease
Coronary Artery Disease still remains the leading cause of death in Australia today for both men
and women
Cardiovascular Disease Today
• In 2004 - 50,292 deaths - 60% did not In 2004 - 50,292 deaths - 60% did not reachreach average life expectancyaverage life expectancy• Predicted - 1 in 4 suffering by 2051Predicted - 1 in 4 suffering by 2051• Cost to Australia is 600,000 years of Cost to Australia is 600,000 years of healthy lifehealthy life• Highest health cost item - $14.2 billionHighest health cost item - $14.2 billion• Currently 55,000 not in workforceCurrently 55,000 not in workforce• Costly in quality of lifeCostly in quality of life
Cardiac Rehabilitation• Phases - 1, 2 and 3 • Patients - AMI, CHD +/- Stents, CMO,
CABG, Valve Surgery. • Maximise physical, psychological and
social functioning• Introduce and encourage behaviours
that may prevent or minimise possible recurrence of cardiac events
Cardiac Rehabilitation
Phase 2 - Initial Assessment• Medical/social history• ECG• Observations• 6 minute walk test pre and post • Exercise Stress Test
How the Heart Works • Normal anatomy, physiology &
electrical conduction• Coronary artery disease - risk
factors• Angina - myocardial infarction• Tests & investigations - angiograms
Involvement of Allied Health
• Physiotherapy • Dietetics • Pharmacy• Occupational Therapy• Social Work• Drug & Alcohol
PhysiotherapyBenefits of Regular Exercise
• improves blood supply to the heart• heart pumps more efficiently• overall oxygen transfer improves• increased muscle tone (heart & skeletal)
• altered porky:perky ratio (burning fat & increasing muscle)
Everyday
SIT SPARINGLY
TV/Computer
2-3/ week
5-7 / week
Leisure Activities
• Golf
• Bowling
• Gardening
Strengthening
•Sit -ups
•Push-ups
•Light weights
Do Aerobic Activities
• Brisk Walks
• Swimming
• Bike Riding
Enjoy Recreational Sports
• Tennis
• Soccer
• Basketball
• Walk the dog
• Climb the stairs instead of the lift
• Park car further from destination & walk
• Take extra steps in your day
The Lifestyle The Lifestyle PyramidPyramid
DieteticsHealthy Eating, Healthy
Heart • Risks factors for heart disease• Blood cholesterol
– types and function– desirable levels
• Blood triglycerides desirable level
• Dietary fats– types: saturated, polyunsaturated,
monounsaturated, trans – sources, effect on blood fats
• Fat display - visual aid
Healthy Eating, Healthy Heart
Polyunsaturated
• Alcohol– recommendations
• Sodium– ways to reduce sodium intake
• Dietary Fibre– sources and benefits
Healthy Eating, Healthy Heart
• Hypertension Dietary guidelines• Label reading• Nutrition Claims• Heart Foundation Tick
Healthy Eating, Healthy Heart
• Plant sterol margarines– sources & benefits on chol.
• Antioxidants– sources & benefits
• Phytoestrogens & soy protein– sources & benefits
Healthy Eating, Healthy Heart
Summary
– healthy diet pyramid– healthy balanced diet– low saturated fat eating
Occupational Therapy
Objectives• Encourage participants to be aware of stress
• Able to identify signs & symptoms of stress
• Techniques for managing stress
• Education in energy conservation
Group Sessions• What is stress• How stress affects sleep• Strategies for memory
improvement• Energy conservation• Relaxation - practical
Occupational Therapy
Medications
• Medicines used to treat heart disease• Groups - ACE, beta blockers, calcium
channel blockers, cholesterol lowering, nitrates & diuretics
• Actions, uses, instructions & side effects
• Mediterranean diet - anti oxidants
Social Work• Psychological reactions associated
life style changes • Communicate within group to
normalise these feelings/reactions • Stress management techniques• Foster positive attitude -
toward making lifestyle changes and assume responsibility for continuing health care
Smoking - Quit for Life• Identify smoking status & treatment
required• Manage patient nicotine dependence• Prescribe nicotine therapy• Education & Persuasion• Monitor patient withdrawal• Follow-up next 3 months
Conclusion
Cardiac rehabilitation is a safe and effective launching pad for ongoing prevention
following diagnosis of cardiac disease.
Exercise Physiologist
SAMPROBLEMS IDENTIFIED:
- Type 2 diabetes
- Obesity
- Hypertension
- Macrovascular disease
- Dyslipidaemia
- ETOH +++
- Smokes +++
SAM
PROBLEMS UNKNOWN:
• Diabetic Complication Status- retinopathy- PVD- neuropathy- nephropathy
• Other Health Issues- metabolic syndrome- sleep apnoea - osteoarthritis- lower back pain - psychological status (depression, low self efficacy)
SAM
FACTORS LIMITING SUCCESS OF TREATMENT:
• Multiple medical problems• Polypharmacy• Obesity• Poor diet (malnutrition)• Smoking• Time• Motivation to change his behaviour• Cost• Previous negative experience with exercise• Unrealistic expectations
Problems with Current DiabetesTreatment
• `Glucocentric’ – target BG control rather than underlying insulin resistance
• Most medications treat outcomes (BG, BP, lipids etc) rather than cause (physical inactivity, visceral obesity)
• Weight loss diets can lead to loss of lean tissue including muscle and bone mass
• Aerobic exercise advice difficult for many patients due to multiple comorbidities
Problems with Current Diabetes Treatment
Role of PRT in Diabetes Treatment
• PRT or Weight Lifting- induces structural, functional and metabolic change- improves HbA1c (similar effect to OHAs)- effects better than aerobic activity
• Shown to improve all components of metabolic syndrome- Insulin sensitivity- BG control- BP- Dyslipidaemia- Markers of inflammation and catabolism
Other Benefits of PRT
Decreased:- total and visceral fat (PRT targets visceral fat)- depressive symptoms- symptoms of CAD- symptoms of arthritis
Improved:- capacity for aerobic work- muscle mass, strength & endurance- range of motion & joint function- self-efficacy- gait velocity & balance- sleep quality & morale
Exercise for Sam
• Supervised, High Intensity PRT - tailored program; performed and progressed with supervision
• Gentle Aerobic Activity - increase incidental exercise where possible- care with monitoring – ß blockers will mask HR change - PRT or circuit training preferable to intense aerobic activity
initially- very gradual warm-up and cool-down essential
• Pilates- posture and postural awareness- core strength to prevent LBP
Risks of PRT
Musculoskeletal Injury
Almost entirely preventable with:- adherence to proper form- isolation of the targeted muscle group- slow velocity of lifting- limitation of ROM to pain-free arc of movement- no use of momentum and ballistic movements to complete a lift- use of machines or chairs with good back support- observation of rest periods between sets and rest days between sessions.
Risks of PRT
Cardiovascular Response• Lower HR but higher systolic & diastolic BP than walking up an
incline
• Systolic BP response less than climbing 3-4 flights of stairs
• Double product lower than for aerobic exercise • PRT in older adults - no more stress than a few minutes of
inclined walking, and much less than climbing stairs. • 26000 subjects tested – NO cardiovascular events
Exercise & Chronic Diabetic Complications
Peripheral Vascular Disease & Neuropathy• Risk of foot injury greater with repetitive aerobic activity than
with supervised PRT
• Routine pre-and post-exercise foot examination essential to reduce injury risk
• PRT a viable option for those with lower extremity amputation or active foot ulcers
• PRT optimises strength and functional independence in those recovering from surgery, on bed-rest or confined to a wheel chair
Exercise & Chronic Diabetic Complications
Nephropathy• No evidence that exercise worsens kidney disease
• Avoid activities that increase systolic BP more than 200 mmHg
• Aerobic activity precluded in those with anaemia; may increase proteinuria
• PRT helps prevent wasting syndrome of end-stage kidney disease
Exercise & Chronic Diabetic Complications
Retinopathy• No evidence that exercise worsens eye disease
• Eye problems worsened by changes in IOP rather than changes in systemic BP
• Avoid activities that increase systolic BP more than 200 mmHg
• PDR: avoid activities that may IOP (Valsalva, head down positions, Squash, high intensity PRT)
Take Home Message• Use combination of aerobic and strength training for type 2
diabetes where possible
• Aerobic activity may be precluded in those with complications including macrovascular disease, neuropathy, arthritis, obesity etc. but not PRT
• All exercise targets insulin resistance directly. This is independent of weight and body composition change.
Exercise does you good metabolically, even if you don’t lose weight