An incremental approach to improving outcomes.
Heart disease and cardiometabolic syndrome, a combination of metabolic dysfunctions characterized by insulin resistance, impaired glucose tolerance, dyslipidemia, hypertension, and central adiposity have become global epidemics. An estimated 47 million people in the U.S. live with these disorders, which place a huge financial burden on the U.S. healthcare system and on the practices of physicians trying to manage these patients. A 2015 study in the Journal of Diabetes and Metabolism found that in 2014, national medical expenditures attributable to cardiometabolic risk factor clusters in the U.S. totaled $80 billion, with $27 billion of that spent on prescription drugs.
“The impact [of cardiometabolic syndrome] on the healthcare system is massive because it branches out in every direction. Inability to work, immobility. It has an impact on the workforce, on insurance costs, on hospitalizations. I think we need to really act quickly if we want to stop it,” says Jennifer Haythe, MD, a cardiologist with the Center for Advanced Cardiac Care at Columbia University Medical Center in N.Y.
While many patients manage cardiometabolic syndrome and heart disease with medications, physicians find that a combination of lifestyle changes, including dietary and behavioral changes, are key to keeping these patients healthy.
Get to know your patients
It’s important for physicians to get to know these patients’ unique needs in order to personalize a treatment approach that will work, says Mark Menolascino, MD, medical director of the Meno Clinic in Jackson Hole, Wyo.
“You need to know what’s important to people. Do they want to live a long life, or an optimal life?” he says. “Take a few minutes to understand their goals and health wishes and then try to come up with strategies of lifestyle that fit those goals,” he says. For example, there’s no use suggesting a patient take up bicycling if they live in a place with no safe bike trails or lanes, he says.
In addition, it’s important for physicians to inspire change through positive reinforcement and avoid shaming or blaming the patient, says Lucienne Ide, MD, Ph.D., founder of Atlanta-based Rimidi, a cloud-based software that supports clinical workflows around cardiometabolic disease management.
“Patients should feel that the physician is here to support them on their journey and to see that they are making progress, be that a blood glucose goal, a lipid goal, or a weight loss goal,” Ide says.
Patients with cardiometablic syndrome usually are starting out at a deficit of health, nutrition and physical activity. Big changes are just not realistic, Ide says.
“I’m a big fan of the tiny changes movement,” Ide says. “Just [tell patients to] start with something small that is attainable that they can feel good about.”
Menolascino encourages patients to add more activity incrementally to their existing routines. This can include such steps as parking farther from the store and doing several laps around the parking lot before going in or walking up and down stairs at work several times on a break.
“As doctors we have to pick one thing that fits [patients] belief systems that they can be successful at,” he says.
For patients who are motivated by wanting to take fewer medications, Haythe reinforces that lifestyle changes can enable reductions in, and even stopping, some medications altogether.
For those patients who opt for medication over lifestyle changes, she tries to empathize but still encourage change. “I’ll say things like, ‘It’s very hard to get to middle age. Everybody’s body changes. But you could become much healthier and feel much better if you make real changes to your life.’”
She also offers patients a success story about someone who has made these changes and feels better. “I try to empower them to have confidence that it can be done and it’s not hopeless,” she says.
Though lifestyle changes should take priority, for some patients medication and even surgery (gastric bypass or gastric sleeves) may be the necessary starting point, Ide says, and shouldn’t be seen as a sign of failure. “If a patient is just not in a place where they can make a substantial change, a medical intervention may be what they need to move down that pathway and get stability,” she says.
The necessity of exercise
Physical activity is one of the most important steps a person with CMS and heart disease can take for their health, says Chetan Khamare, MD, FACC, a cardiologist at the Premier Heart and Vascular Center in Tampa, Fla. He says the American College of Cardiology (ACC) used to recommend 30 minutes of continuous cardiovascular exercise five days a week, but now they’ve found that just adding an extra ten minutes daily, up to 40 minutes per day, leads to a 25 to 30 percent additional reduction in cardiovascular events.
He also points his patients to an online risk calculator provided by the ACC, which helps establish a baseline of risk for such conditions as heart attack and stroke, and offers physicians a starting point for interventions. He finds that when patients take the agency to use the calculator they’re more likely to commit to healthy behaviors, especially since it’s scientifically validated.
Peer support is also useful in getting patients to be more active, Haythe says. “Tell patients to find a friend to go walking with. Start with just ten minutes outside every day.”
“If your friends aren’t healthy, there’s data to show you probably aren’t either,” Menolascino points out, so he encourages patients to find a group that can help them make healthy choices. He cites the example of a church group that added nutritional lessons to Bible study classes and motivated its members to eat healthier.
Most patients with cardiometablic syndrome and heart disease need to make fairly drastic dietary changes, says Pilar Stevens-Haynes, MD, director of non-invasive imaging at South Nassau Community Hospital in Oceanside, N.Y. But few patients will make all the changes overnight, she says, and physicians need to be encouraging but patient.
Stevens-Haynes sends patients home with a food diary to help them pay attention to what and how they’re eating. Then she’ll encourage them to start with cutting or lowering one thing: canned or boxed food, for example, which is high in salt, or replacing juice or soda with water, or avoiding bread. She then sets a follow-up appointment in three months to see if there have been improvements, such as losing a few pounds, or lower blood pressure, which might enable them to reduce a medication.
Khamare puts eating into a simple set of parameters: “I tell patients if you can grow it in your garden or if you can kill it-within certain parameters-you can eat it. Don’t unwrap it, don’t unbox it. Don’t order it at a drive through.”
However, he recognizes that patients will not follow his recommendations immediately, saying that many patients are in a state of denial about their habits. “I’ll give patients one simple goal so that it’s achievable, realistically, and tell them to have a cheat day once a week.”
If the patient can meet that one goal, then at the follow up appointment he sets another goal, and so on.
Stevens-Haynes says her patients have more success when they use apps and tracking devices like Fitbits and smartwatches. Her patients rave about an app called My Fitness Pal, which allows patients to track calories and macronutrients, and can even scan products in the store and easily input nutritional data.
These devices and apps can also reveal just how active or inactive a person really is. “The perception in general is that we’re much more active than what we really are,” Stevens-Haynes says.
Haythe has learned that the patients who really commit to these changes feel better, reduce or come off medications more quickly, and see increased self-esteem.
Use other professionals
Getting patients to make lifestyle changes doesn’t have to be solely the job of the physician, says Menolascino. “A lot of doctors don’t really know about the psychology of eating and the psychology of behavioral change,” he says. “That’s what health coaches are for.” He thinks physicians should either have an in-house nutritionist/dietician or health coach or develop a strong referral base for them.
Haythe adds that nurses and nurse practitioners can also be helpful. “A diabetes nurse practitioner can do education and prescribe medication, for example. I recommend having those people in [physician] practices.”
Analytics & remote monitoring
Tracking key health indicators is an important part of helping patients stay healthy, Khamare says. He recommends that every practice track such indicators as hypertension, uncontrolled cholesterol, and weight. While every EHR is different, there are ways to set up analytics to track this data.
Ide also promotes the idea of remote patient monitoring from home, via a Fitbit, electronic scale, or a Wi-Fi-enabled blood pressure cuff that sends real time data directly to a physician’s EHR. This allows the physician to stay abreast of health changes between office visits. “Physicians might see a patient four times per year, but [patients] are living with their disease every day of the year,” she says.
With remote patient monitoring, not only does the physician gain valuable data, they can communicate support via electronic messages. “Then maybe I could message a patient after a month and say ‘hey, I see you’ve lost two pounds, great job.’” She says that creates a positive feedback loop that might otherwise be missing, and helps patients feel that their doctors care.
Even better, Medicare now reimburses for some remote patient monitoring and for time physicians spend reviewing data under chronic care management codes.
“It’s important for physicians to know there’s a lot happening in tech that is designed to support them,” Ide says.