Maude L. Campbell

More than two-thirds of U.S. adults and one-third of children and adolescents are overweight or obese, according to the National Center for Health Statistics. This epidemic has given rise to unprecedented numbers of Americans suffering from dyslipidemias, hypertension, and impaired glucose functioning-and an estimated 47 million people have three or more of these interrelated cardiometabolic risk factors. That group has double the risk of developing heart disease and is five times more likely to develop type 2 diabetes, says the National Heart, Lung, and Blood Institute. 

Medical centers throughout the country offer excellent preventive cardiology departments, diabetes and endocrine divisions, specialized obesity centers, and in some cases, dedicated metabolic syndrome programs. This month, we feature four Clinical Centers of Excellence that have developed comprehensive, integrative care approaches to improve management of these cardiometabolic disorders.  

The profiled institutions were selected by the editors of 

 because of the unique programs they offer; each profile provides a snapshot of how a team approach can foster successful management of these disorders.  

One difficulty noted by experts at all four centers is shared by most primary care physicians as well: emphasizing the importance of lifestyle modification. Radical dietary changes and exercise for many of these patients must be started slowly. Some of the tactics used daily by those at our Clinical Centers of Excellence may help you create new ways to motivate patients in your practice. 

				
			Are health plans changing their views on patient education for cardiometabolic disorders? Learn more at 

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			Find up-to-date handouts on cardiometabolic disorders and more at 

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More than two-thirds of U.S. adults and one-third of children and adolescents are overweight or obese, according to the National Center for Health Statistics.

Clinical Centers of Excellence: Cardiometabolic Disorders & Weight

 Each patient with a cardiometabolic disorder is likely to have an additional related disorder. The patient may be seeing one or more specialists for diabetes, heart disease, obesity, or hypertension, although many have yet to be referred for specialty care. Regardless of specialty intervention, individuals with cardiometabolic disorders will continue to be a daily presence for primary care physicians. 

 Patients taking multiple medications are commonly encountered, and the likelihood of nonadherence or an inability to tolerate an agent is greater. Some patients may require substantially more office visit time in order to learn self-monitoring and testing procedures, while others might present with other medical conditions that make managing their cardiometabolic disorders even more challenging. 

 "Patients are getting younger and younger as well. That's one particular hurdle we've had to cross over," says Honey East, MD, associate professor of medicine and a cardiometabolic clinic physician at the University of Mississippi Medical Center in Jackson. 

has gathered management tips from the cardiometabolic experts interviewed for this series. 

Keep a copy of the specialists' report on the patient's chart, says Sharlene Emerson, CRNP, BC-ADM, an advanced practice nurse at the University of Pittsburgh Diabetes Institute. "Many times patients tell me they have seen a specialist, but there is no report."  She suggests having patients carry your business card with instructions to share your contact information with the specialty center staff. 

"Well-prepared office staff can flag or pull any specialists' reports that have been received since the last primary care visit," she says. "This way the specialty reports are not lost, and primary care practitioners and patients can follow through with recommendations." 

Patients with multiple cardiometabolic disorders often take multiple medications, and primary care physicians need to devise ways to keep track of regimen changes. "There must be a continually updated medication flow sheet on the patient's medical record so that there is clarity about what the patient is actually taking," says Emerson. Best practice is to have a patient medication flow sheet and determine at each visit the patient's adherence to the regimen, she adds. "I have gotten in the habit of asking, for example, 'Out of the seven times a week that insulin is scheduled-how many times of those seven do you take it? When do you take it?' " 

A medication flow sheet is easily found on an electronic health record and must be updated at each patient visit and when changes are made between visits. "A paper chart is a different animal," says Emerson. "When the medication sheet is hard to find, it is often not updated, forgotten, or ignored," she says. "This is a dangerous practice. It should be front and center on the chart." 

Primary care physicians should accomplish several things at each office visit: 

Each patient with a cardiometabolic disorder is likely to have an additional related disorder.

CCE: Cardiometabolic disorders management strategies

An estimated 47 million Americans have double the average risk of heart disease because they are affected by a complex constellation of interrelated conditions, including obesity, impaired glucose metabolism, hypertension, and lipid disorders.

  These patients also are five times more likely to develop diabetes, according to the National Heart, Lung, and Blood Institute.

This constellation of conditions-cardiometabolic disorders and weight-has become one of the most pressing public health issues today, affecting approximately a quarter of the U.S. population, accounting for a substantial proportion of healthcare and prescription drug spending, and threatening the vitality of an aging population.

http://www.modernmedicine.com/cardiodisorders 

, for a comprehensive overview.) Following is an examination of the key conditions. 

Abdominal obesity is not only closely associated with the development of diabetes and hypertension, but is now thought to independently lead to cardiovascular disease. Recent research indicates that excess visceral adipose tissue releases metabolites, cytokines, chemokines, and hormones that influence inflammation and other factors to directly affect atherogenesis and the vessel wall.

Experts agree that successful intervention requires more comprehensive patient education with interdisciplinary coordination among healthcare providers. Interventions are also taking place at an earlier age. In an effort to slow the obesity epidemic, 19 states have set stricter nutritional standards for school meals, 27 states have nutritional standards for foods sold in schools, and 20 now require body mass index screening or other weight assessment of schoolchildren.

In the United States, 17.9 million patients have diagnosed diabetes; an estimated 5.7 million remain undiagnosed, and an additional 57 million people have prediabetes, according to the American Diabetes Association.

  The incidence of diabetes among those aged 60 years or older is 23.1 percent. An estimated 16.5 percent of the adult American Indian and Alaska native population are affected by diabetes.

  After adjusting for age differences, the prevalence of diabetes is 11.8 percent among non-Hispanic blacks, 10.4 percent among Hispanic Americans, 7.5 percent in Asian Americans, and 6.6 percent among non-Hispanic whites.

National prevalence data for type 2 diabetes among children and adolescents are not available. Overall, approximately 210,000 Americans aged <20 years have diabetes, an incidence of 0.26 percent, but the data do not differentiate between diabetes types.

  However, type 2 diabetes is being diagnosed more frequently in children, especially among Native Americans, African  Americans, and Hispanic Americans. In addition, one in six overweight adolescents-approximately 2 million-have prediabetes.

According to National Health Expenditure Account data, annual medical costs for patients with diabetes are $190.5 billion.

A complex constellation of interrelated conditions

"If you don't have a good handle on epilepsy, it can be frightening. It still startles me when I see a seizure," says David M. Treiman, MD, director of the Epilepsy Center at Barrow Neurological Institute in Phoenix, Arizona.

"Epilepsy is barely taught in medical schools," he says. Furthermore, there is still a stigma attached to the disorder. Although there has been much improvement during the past two decades in terms of educating neurologists and primary care physicians in the use of antiseizure medications and as to when a referral to a neurosurgeon is warranted, primary care physicians should not hesitate to call an epileptologist for advice. "A few simple questions answered in a couple of minutes would greatly enhance the care for a patient," says Treiman. "It doesn't require the PCP to become an expert."

The goal of seizure disorder management is to render the patient seizure-free without side effects. This usually requires referral to specialists but all the experts at our Clinical Centers of Excellence agree that there are many things primary care physicians can keep in mind when seeing patients who are struggling to reach a seizure-free state.

The first thing to consider when medication is not controlling seizures in a recently diagnosed patient is a misdiagnosis. "Many patients with epilepsy are misdiagnosed," says Orrin Devinsky, MD, director of the New York University Comprehensive Epilepsy Center. "Some do not have epilepsy. Others have a different epilepsy syndrome than the one diagnosed, which has important therapeutic implications."

When the diagnosis is accurate and the medication has previously worked, breakthrough seizures can occur. According to Devinsky the most common reasons for breakthrough seizures are missed medication, sleep deprivation, excessive alcohol consumption, and illness. 

In general, if seizures are chronically uncontrolled or if medication side effects are persistent, patients should be referred to a specialty center for evaluation or in some cases, reevaluation. Tim Powell, MD, an epileptologist at Rockwood Clinic, Spokane, Washington, agrees. He recommends referral after the failure of a second antiseizure drug so that a correct diagnosis and more aggressive therapy options or surgery can be considered.

Overall, primary care physicians should keep in mind that the older medications, such as phenytoin, phenobarbital, and carbamazepine are associated with significant drug-drug interactions and cause more chronic side effects, including bone loss. Devinsky says that newer antiepileptic agents should be considered whenever possible. 

"Primary care physicians should never discontinue an epileptic patient's medication without working with a neurologist no matter how long it has been since the patient had a seizure," advises Judd Jensen, MD, a neurologist who refers patients to the Massachusetts General Hospital Epilepsy Service. He says it happens frequently. 

Powell offers the following medication management tips.

Pay attention to dosing and medication details pertaining to different patient populations including children, adolescents, women, and the elderly.

Female patients may continue taking antiepileptic medications during pregnancy and may also breastfeed while taking these drugs with some caveats. New guidelines developed by the American Academy of Neurology and American Epilepsy Society recommend women with epilepsy avoid taking valproate during pregnancy as evidence shows that valproate is linked to increased risk for fetal malformations and decreased cognitive skills in children.  The guidelines also recommend that women with epilepsy avoid taking more than one epileptic drug at a time during pregnancy since taking more than one antiseizure drug has also been found to increase birth defects compared to taking just one drug.  The guidelines further state that pregnant women with epilepsy avoid taking phenytoin or phenobarbital to reduce the possibility of decreased cognitive skills in their children.

Drug interactions are particularly common among elderly patients 

Seizures are disabling and may prevent patients and their families from engaging in normal activities. It is particularly important to watch for red flags indicating depression or increased risk of suicide in these patients, Powell says. 

He also advises primary care physicians to inquire about and become aware of any specific unmet needs or issues families or caregivers may have because often, these will affect their ability to adequately care for patients with seizures. 

Finally, it is important to involve patients in the decision-making process when developing a therapeutic plan. "Otherwise, they will not follow your recommendations," Powell says.

The goal of seizure disorder management is to render the patient seizure-free without side effects.

Author | Maude L. Campbell

Articles

Clinical Centers of Excellence: Cardiometabolic Disorders & Weight

CCE: Cardiometabolic disorders management strategies

A complex constellation of interrelated conditions

CCE: Seizure Disorders Management Strategies