Panel Discussion Local Primary Care Collaboratives Learning Workshop 4

1. Panel DiscussionLocal Primary Care CollaborativesLearning Workshop 4 Case Study - SAM

2. 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)

3. 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

4. Medical History • Exercise: none • Occupation: Long distance truck driver • Diet: Truck stop food – pies, sausage rolls, chips • Teeth: Extensive decay and has difficulty chewing

5. 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

6. People Involved • General Practitioner • Cardiologist • Cardiac Rehab • Diabetic Educator • Exercise Physiologist • Dentist • Physiotherapist • Social Worker • Podiatrist • Ophthalmologist • Quit Program • Dietitian

7. Diabetes Educator

8. 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?”

9. 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.

10. 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.

11. 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?

12. 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

13. 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

14. Avoid the tyranny of numbers

15. Dietitian

16. 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.

17. 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?

18. 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.

19. 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.

20. 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)

21. 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

22. 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)

23. 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

24. Aims of MNT for Sam • Secondary CVD prevention through reduction of risk factors. • Reduce risk of NIDDM complications. • Improve QOL through lifestyle interventions.

25. 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)

26. 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)

27. 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.

28. 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.

29. 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.

30. Podiatrist

31. Overview • Overweight • Type 2 Diabetes • Smoker • Excessive alcohol consumption • No exercise

32. How can a podiatrist help? • Screening - how at risk are we? • Keep our patients pain free

33. Diabetes Assessment • Hx / medication etc. • Vascular • Neurological • Biomechanical

34. Vascular • Pulses • Temperature • Hair • SVPFT • Buergers elevation / dependency test

35. Neurological • Vibration • Monofilament • Reflexes • Sharp / blunt • Hot / cold • Two point discrimination • Light touch

36. Biomechanical • Any previous problems • Callus • Bunions, hammertoes • Exostoses • Arthritis • Shoes, footwear • Joint ROM

37. How at risk are we? • Everyone is different • Set review dates

38. TREATMENT • Education • Debridement of callus & corns • Nail care • Orthotics • Footwear • Manipulations / mobilisations • Stretching / exercises etc

39. Conclusion • Our aim is to keep feet healthy • Keep people walking • Talk to your podiatrist

40. Cardiac RehabilitationCoordinator

41. Coronary Artery Disease Coronary Artery Disease still remains the leading cause of death in Australia today for both men and women

42. 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

43. 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

44. Cardiac Rehabilitation Phase 2 - Initial Assessment • Medical/social history • ECG • Observations • 6 minute walk test pre and post • Exercise Stress Test

45. How the Heart Works • Normal anatomy, physiology & electrical conduction • Coronary artery disease - risk factors • Angina - myocardial infarction • Tests & investigations - angiograms

46. Involvement of Allied Health • Physiotherapy • Dietetics • Pharmacy • Occupational Therapy • Social Work • Drug & Alcohol

47. Physiotherapy Benefits 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)

48. 2-3/ week SIT SPARINGLY TV/Computer The Lifestyle Pyramid Everyday • Leisure Activities • Golf • Bowling • Gardening • Strengthening • Sit -ups • Push-ups • Light weights 5-7 / week • 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

49. DieteticsHealthy Eating, Healthy Heart • Risks factors for heart disease • Blood cholesterol • types and function • desirable levels • Blood triglycerides desirable level

50. Healthy Eating, Healthy Heart • Dietary fats • types: saturated, polyunsaturated, monounsaturated, trans • sources, effect on blood fats • Fat display - visual aid Polyunsaturated