PRACTICAL APPROACHES THAT WOULD HELP IMPLEMENT LIFESTYLE CHANGES IN PATIENTS
You are listening to ReachMD, The Channel for Medical Professionals. Hi, this is Dr. Thomas Bersot, President of the National Lipid Association and I would like to welcome you to Lipid Luminations hosted by Dr. Larry Kaskel and presented by the National Lipid Association.
Welcome to Lipid Luminations. I am Dr. Larry Kaskel, your host, and joining me today is Cindy Conroy, a Registered Dietitian with the Iowa Heart Center Lipid Clinic and she is here to discuss practical approaches for the successful implementation of a lifestyle change, education, and risk factor management program.
DR LARRY KASKEL:
Cindy welcome to the show.
CINDY CONROY:
Thank you for having me.
DR. LARRY KASKEL:
It's a quite a mouthful, a lifestyle change education and risk factor management program, what does that mens?
CINDY CONROY:
DR. LARRY KASKEL:
CINDY CONROY:
That’s correct.
DR. LARRY KASKEL:
DR. LARRY KASKEL:
So, why are you Cindy Conroy good at it versus other places that are not?
CINDY CONROY:
Well, I think Iowa Heart Center has an approach that is may be a little different from the lot of facilities. We have always utilized dietitians as our primary line of defense with the patients in terms of lipid clinic and risk factor management. All the behavior modification techniques that are used to modify people’s behaviors were used when we talk to people about their diets and that carries over to their exercise regimen and looking at smoking cessation, etc., so we have always utilized dietitians in the Lipid Clinic just as the front line person and then we go from there if we need other specialists.
DR. LARRY KASKEL:
CINDY CONROY:
Usually we do a pretty in-depth interview with them to see what things they feel they can make changes in. It’s hard to impose your restrictions on people if they are not even willing to make minor changes. So, I usually like to have them choose one or two things that they are willing to work on as starting point and they work from there.
DR. LARRY KASKEL:
Well, for instance I had a individual with very high triglycerides and they were used to drinking six to eight cans of regular pop a day and they are willing to cut that in half, they are not willing to give it up completely or change to diet pop, but to cut it to half is a big step forward for them.
DR. LARRY KASKEL:
That would be correct.
DR. LARRY KASKEL:
So how does that happen? Does the sugar get turn into triglyceride or does it go on to the liver and get packaged to triglyceride? How does that work?
CINDY CONROY:
CINDY CONROY:
Not specifically, but we primarily take issue with reading labels and looking four sources of sugar like the high-fructose corn syrup, honey molasses, you know anything that’s going to add sweetener to the food, that’s where we really focus our efforts, and then looking at the portion control, I do not have a problem with individual’s eating sugary things, but more often it’s the portion or amount that they are eating that’s the issue.
DR. LARRY KASKEL:
Do you have in your clinic or any one there do they have a problem with artificial sweeteners because I have heard that they are not so bad, but what they do is a kind of train you who always want sweets.
CINDY CONROY:
Yeah that’s true. We don’t particularly outlaw them, but we do suggest to get in and gets back to the portion, you know you are choosing the artificially sweetened goodies versus fresh fruits and vegetables. You need to perhaps be making some other choices along the line.
DR. LARRY KASKEL:
Well, in our clinic we use primarily dietitians. We do have nurse practitioner that sees the patient in the clinic and she will get patient started on including in on things like sugars and fats, but the real detailed instruction really needs to come from a dietitian. We have a lot more training as far as what to look for and what suggestions might be out there that they can use as alternative choices, portion control and that type of thing. Having access to exercise physiologist is great, but it’s not always practical in every situation. A lot of our patients have been to the cardiac rehab at sometime over the past. So they have got some idea what they should be doing and the cardiology nurses within the practice can help with those guidelines as well. Pharmacist, we occasionally have a pharmacist or Pharm. D. on staff within the office so we can ask questions and have him sit down with the patients if they have lot of questions to on their medications. So there is a variety of staff that can be utilized.
DR. LARRY KASKEL:
Cindy, what clinical elements should really be implemented that will help patient’s compliance?
CINDY CONROY:
I think one of the main things is to have a personal contact with the patient. There is a lot of staff, as we just talked about that could be utilized whether it be the nurse, the dietitian, the nurse practitioner, the physician provider, but the patients need I think to have a personal contact with someone and have, you might want call the case manager that they can always call and talk with no matter what their question and that person can kind of a coordinate their care within the clinic.
DR. LARRY KASKEL:
So like anything else in medicine the relationship is important and some would say the relationship is really what’s curative.
CINDY CONROY:
I believe so. You know one of our main goals for Lipid Clinic is to engage the patients in long-term risk factor management. We just don’t bring them in once or twice and then send him on their way. Most of these patients are with us for an extended period of time, years in fact, and you know with just that personal contact and knowing that you can always get an answer from someone by calling the clinic, and so I think that contact is important and the education process is continuous.
DR. LARRY KASKEL:
And are there another any factors that play out in the community that are important to in terms of maximizing patient’s followup?
CINDY CONROY:
I think acces is important in especially these days when the cost of transportation and people worry about their jobs, not wanting to take time off, you know access in the clinic is important and whether it be may be having Saturday hours or later in the afternoon hours after work, having satellite clinics. We have a network of clinics within the State of Iowa, not all of them have lipid clinic as part of their function, but those clinics can send those calls on to the lipid clinic and by phone that we can contact the patient. So, I think the networking so that the patient don’t have to travel a long distance makes a big difference.
DR. LARRY KASKEL:
We talked about lipid clinics, but it sounds like you are doing more than just managing their lipids. You are managing their sugars, you are managing their lifestyle, your are managing their exercise?
CINDY CONROY:
Well, we do try and offer suggestions on all of those things. Our primary goal is just to improve their overall lifestyle and to reduce the risk, and so you know if we need to refer them to a diabetologist, we do that. If we need to get them set up with a wellness center in their local community, we do that, but we really truly are more of a case manager along with educators.
DR. LARRY KASKEL:
How have EMRs impacted your management of patients and lipid clinic utilization?
CINDY CONROY:
EMR has dramatically changed our processes in the last couple of years. We reverted back to having more of the lipid managed by the individual cardiologist within the practice. Previously almost all of the lipid profiles that came into the charts or records were sent through lipid clinic for review, and if changes needed to be made, we took care of it. Well, now its going back to the cardiologist’s record, and it gives them more ownership with the patient. Its working well in that respect and then just those patients that are at highest risk or not tolerant of their medications or not doing well with their lifestyle changes are referred specifically back in to the lipid clinic.
DR. LARRY KASKEL:
Cindy are their barriers that exist in Iowa that are unique to Iowa that affect patient compliance or is it pretty much the same as everywhere?
CINDY CONROY:
Are you seeing an economic affect in Iowa already?
I think so. We have of course the medicare D patients pretty much all hit the Donahue, so they cant afford the medication, but also food costs are going up, you know the garden produced fresh markets are available now. We have already gotten into the winter season, so food accessibility is becoming an issue as well for especially the older population.
DR. LARRY KASKEL:
I think definite dos, things that they need to have on line when they get started is a provider, a physician and a nurse practitioner that’s very much in support of your clinic and they can lend assistance whether will be seeing patients, writing prescriptions, going out in the community and promoting the clinic to other health care providers and the public. Without that physician or nurse practitioner backing you up it’s very difficult to get going and keep going, but also you can utilize support staff, whether be dietitian, nurses, whatever. With the clinics about 25 years old, we have tried many, many things over the years. Most things work just because we put a lot of thought into before we try anything new. I think you need to have a lot of cooperation within the community, family physicians like to manage their own lipids, which is great, and you have to be respectful of that. If you have a physician that doesn’t want anything to do with the lipids, and since all of patients do, that’s great. We have a lot of OB/GYN physicians, but you know they draw the lipids once a year when the ladies come in, but they don’t know what to do with it after that. So they send them to us and that’s great, but we have to be respectful within the community that each provider has their own style of doing that.
DR. LARRY KASKEL:
DR. LARRY KASKEL:
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