Transcript Exercise for Sam

Panel Discussion
Local Primary Care Collaboratives
Learning Workshop 4
Case Study - SAM
Case Study - SAM
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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
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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
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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?
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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 1015% 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 & folate
Vitamin C
Calcium
• Other issues
High alcohol consumption
Occupation – truck driver therefore reliance on takeaway /
café foods.
Possibly lives alone with little support
Smoking
Low 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. labelreading; how to eat less salt & sugar;
importance of fruit and vegetables.
• More SMART goals will be set.
Podiatrist
Overview
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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
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Pulses
Temperature
Hair
SVPFT
Buergers elevation / dependency test
Neurological
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Vibration
Monofilament
Reflexes
Sharp / blunt
Hot / cold
Two point discrimination
Light touch
Biomechanical
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Any previous problems
Callus
Bunions, hammertoes
Exostoses
Arthritis
Shoes, footwear
Joint ROM
How at risk are we?
• Everyone is different
• Set review dates
TREATMENT
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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 reach
average life expectancy
• Predicted - 1 in 4 suffering by 2051
• Cost to Australia is 600,000 years of
healthy life
• Highest health cost item - $14.2 billion
• Currently 55,000 not in workforce
• Costly 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
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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
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Physiotherapy
Dietetics
Pharmacy
Occupational Therapy
Social Work
Drug & Alcohol
Physiotherapy
Benefits of Regular Exercise
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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)
The Lifestyle
Pyramid
SIT
SPARINGLY
TV/Computer
2-3/ week
Leisure
Activities
Strengthening
•Sit -ups
• Golf
•Push-ups
• Bowling
•Light weights
• Gardening
5-7 / week
Do Aerobic Activities
Enjoy Recreational Sports
• Brisk Walks
• Tennis
• Swimming
• Soccer
• Bike Riding
• Basketball
Everyday
• Walk the dog
• Climb the stairs instead of the lift
• Park car further from destination & walk
• Take extra steps in your day
Dietetics
Healthy Eating, Healthy Heart
• Risks factors for heart disease
• Blood cholesterol
– types and function
– desirable levels
• Blood triglycerides desirable level
Healthy Eating, Healthy Heart
• Dietary fats
– types: saturated, polyunsaturated,
monounsaturated, trans
– sources, effect on blood fats
• Fat display - visual aid
Polyunsaturated
Healthy Eating, Healthy Heart
• Alcohol
– recommendations
• Sodium
– ways to reduce sodium intake
• Dietary Fibre
– sources and benefits
Healthy Eating, Healthy Heart
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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
Summary
– healthy diet pyramid
– healthy balanced diet
– low saturated fat eating
Occupational Therapy
Objectives
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Encourage participants to be aware of stress
Able to identify signs & symptoms of stress
Techniques for managing stress
Education in energy conservation
Occupational Therapy
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Group Sessions
What is stress
How stress affects sleep
Strategies for memory improvement
Energy conservation
Relaxation - practical
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
SAM
PROBLEMS IDENTIFIED:
- Type 2 diabetes
- Obesity
- Hypertension
- Macrovascular disease
- Dyslipidaemia
- ETOH +++
- Smokes +++
SAM
PROBLEMS UNKNOWN:
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Diabetic Complication Status
- retinopathy
- PVD
- neuropathy
- nephropathy
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Other Health Issues
- metabolic syndrome
- sleep apnoea
- osteoarthritis
- lower back pain
- psychological status (depression, low self efficacy)
SAM
FACTORS LIMITING SUCCESS OF TREATMENT:
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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
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Insulin sensitivity
BG control
BP
Dyslipidaemia
Markers of inflammation and catabolism
Other Benefits of PRT
Decreased:
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total and visceral fat (PRT targets visceral fat)
depressive symptoms
symptoms of CAD
symptoms of arthritis
Improved:
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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