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