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:

Well, essentially that means we deal primarily with cardiology patients, but also primary prevention patients that are interested in lowering their lipids, but also working on other lifestyle issues in regards to metabolic syndrome and diabetes.

DR. LARRY KASKEL:

So it’s another name forTLC?

CINDY CONROY:

That’s correct.

DR. LARRY KASKEL:

And TLC, therapeutic lifestyle change or tender loving care, it probably involves a little of both.

CINDY CONROY:

That’s exactly right, a lot of both.

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:

Well what’s the first thing that you usually address with the patient when they come in and decide that, or someone has decided for them that they some lifestyle changes? What you focus on first that is actually not the easiest, but the most likely to succeed?

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:

So, lets do a real life example. Today or yesterday, what did the patient say they are willing to change in or you are kind of jumped on it with them?

CINDY CONROY:

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:

So, you know for the audience if you have one pop a day I have read that could translate into about 13 pounds in a year, is that true?

CINDY CONROY:

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:

If its extra sugar in the diet, extra calories in the diet, it is packaged to some degree as triglycerides in the liver and that’s how transported then through the body in addition to increasing blood sugar, but for a lot of our people its just a matter of the extra sweets in their diet, whether its baked goods or pop its just extra calorie, its not tat they need it for survival, and so for them just to make small changes like cutting down 1 can a pop a day is going to make a significant difference over time.

DR. LARRY KASKEL:

So are people amazed when they learn that their triglycerides are actually coming from sugar and not fats?

CINDY CONROY:

Yes they are. We have many, many patients, who have been battling triglycerides for years and they have never even heard the word sugar, baked goods, and relationship to it. That part has been missed.

DR. LARRY KASKEL:

I mean the last 30 years people have been harping on a low-fat diets, and even The American Heart Association still encourages a low fat diet and its really carbs that seem to be more dangerous to our health than fats.

CINDY CONROY:

Well, I think what we see with our patients at least is that people eat out fairly steady diet of fats, but their sugar intake is what really varies from day-to-day and in lot of instances you know they may eat a lot of dessert because of birthday and they do not have for few days and then their triglycerides spike. So you know, it's more of a situational issue with the sugar perhaps than it is with the fats, which is kind of day-to-day thing. So, we just kind of refocus with their emphasis is on.

DR. LARRY KASKEL:

So you are in the heart of, literally in the heart of America, in the heart of corn production, and everything I have read lately and seen lately is demonizing corn and high-fructose corn syrup, and that we are, if you analyze the average American’s hair, we are made up of 70% corn. So I am wondering do you talk to your patients about the overwhelming amount of corn in our diets.

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:

So back to therapeutic lifestyle changes in a lipid clinic, what kind of staff do you need? Do you need a dietitian? Can you train a nurse or PA or nurse practitioner to do that?

CINDY CONROY:

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:

If you have just joined us, you are listening to Lipid Luminations on ReachMD XM 160, The Channel for Medical Professionals. I am Dr. Larry Kaskel and I am talking with Cindy Conroy, a Registered Dietitian with the Iowa Heart Center Lipid Clinic and we are talking about practical approaches to implement successful risk factor, education, and management programs.

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:

I would think that the barriers are going to be similar everywhere whether it would be access to care, money issues, you know the job market these days is having a big impact, access to health care in general, prescription coverage, all of those things are pretty much across the board. I don’t know that they are specific to Iowa necessarily. I think one of the things that might be more specific to us is our lifestyle in general, you know we have very cold winters compared to the south, you know Chicago will be the same way, but the upper mid west people don’t get as much exercise through the winter, so we try to accommodate for that or get people to do more in the wintertime, and our diet, you know lot of this come from farm backgrounds, and so that may be a little bit different than the metro areas, but I think overall we probably have the same types of barriers as everyone else.

DR. LARRY KASKEL:

Are you seeing an economic affect in Iowa already?

CINDY CONROY:

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:

If someone listening to the show right now and they have been thinking about starting up a lipid clinic or a lifestyle clinic what would you tell them to definitely do and to definitely not do?

CINDY CONROY:

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:

Well Cindy Conroy thank you very much for coming on the show today.

CINDY CONROY:

Okay, thank you.

DR. LARRY KASKEL:

My guest was Cindy Conroy, a Registered Dietitian with the Iowa Heart Center Lipid Clinic and we were discussing practical approaches that would help implement lifestyle changes with our patients.

Thank you for listening to Lipid Luminations presented by the National Lipid Association. For information visit www.lipid.org.