Serving To Educate Primary Care Clinicians On Metabolic Issues
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Back: Issues of Adherence: Getting Patients With Metabolic Syndrome to Goal
Carol Mason



Carol M. Mason, ARNP, CLS, FAHA, FNLA




Cardiovascular disease (CVD) is the leading cause of death worldwide in adult men and women and is responsible for as many as 17 million deaths annually in the U.S.  The metabolic syndrome is a disorder comprised of major risk factors that can increase a patient’s risk for CVD.  National guidelines recommend we treat patients who meet the criteria for metabolic syndrome as a potential secondary target of therapy.  The diagnostic characteristics include abdominal obesity, hypertension, low high-density lipoprotein (HDL-C), elevated triglycerides, and insulin resistance, measured by elevated fasting blood glucose levels. Presence of any 3 of the 5 are required to make the diagnosis clinically. Complete diagnostic criteria may be found by clicking the following link to the executive summary of “The Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement; Table 1 lists diagnostic criteria.

It is estimated that the number of adults who meet the criteria for metabolic syndrome today is close to 34.6 million. (AHA Heart & Stroke Statistical Update, Dec. 2008) There is clear evidence that the risk of CVD events can be significantly reduced through reduction and modification of major risk factors. The data supporting national “lipid” guidelines derived from major clinical trials dating back to the mid 1960's set goals for treatment  that target both nutrition and levels of activity. Yet despite the presence of evidence-based guidelines highlighting the importance of lifestyle changes, there remain significant gaps between what is recommended and what actually occurs in clinical practice. Patient adherence to lifestyle guidelines remains a major challenge for all health care providers. (Pasternak, RC, Am. J. Cardiol 2004,94(suppl):9F-15F)

According to a World Health Organization 2003 report, "...improving self-management of chronic diseases would have a far greater impact on the health of the population than any improvement in specific medical treatments."  Successful clinical management that effect lifestyle is a challenging task for most health care providers. There are numerous factors that affect a provider's ability to alter a patient’s behavior.  In addition, patients experience numerous barriers  that appear difficult to overcome.  Michele Heisler, MD, MPA recently published a paper in Circulation (Circulation. 2008;117:1355-1357) outlining 5 factors that influence a patient’s ability to successfully accomplish tasks required to achieve lifestyle changes:  These include: (1) patient-related factors, (2) social/economic factors, (3) condition-related factors, (4) treatment related factors and (5) factors related to the health-care team. 

Studies have shown that there is no single, clear-cut patient characteristic that is predictive of success nor is there one that explains poor adherence.  Likewise, there is not one particular tool or method for educating patients that works universally for all patients.  In reality there are multiple explanations for poor patient adherence as well as multiple tools and methods that providers can use to assist their patients. As a first step, clinicians must assess an individual patient’s ability to make healthy lifestyle changes and to maintain them over time.  To do this, the clinician must gain an awareness of a patient's readiness for change and consequently their ability to accomplish the change and associated tasks. The "health belief model" offers a unique look at the underlying traits that form an individual's concept of health and wellness.  It is important for providers to appreciate that not all patients view “wellness” the same.  Most patients fall within a continuum of health appreciation; from those who are raised in homes where the concept of “wellness” is valued to those who come from homes where illness or lack of good health is the norm.  It is often true that as providers we assume that our patients are willing and able to follow basic nutrition guidelines and are interested in regular exercise, but the sad truth is that many of our patients have not as yet accepted these as personal goals.   Intrapersonal factors (e.g., motivation, skills and knowledge) as well as interpersonal processes (e.g., family and social support) greatly influence a patient’s willingness to accept lifestyle recommendations, such as those that involve reducing dietary intake of salt and calories, walking 30–45 minutes daily, and monitoring weight and blood pressure.  It will take a combination of behavioral, cognitive and educational strategies to assist patients in making change.

It will also require the assistance of local, state and federal governments to support neighborhoods and schools that foster healthy lifestyle habits; that provide safe areas for children and adults to exercise and promote the easy availability of nutritious and affordable foods.  Integrating and supporting individualized behavior change-strategies with those of community- and population-based approaches are required of providers as well.   Local community, state, and national organizations must take a lead in supporting health-care providers in their efforts to care for patients with metabolic syndrome by providing tools that they can use in their every-day clinic practice that will: 1) assist in identifying patients ready to make change and (2) then provide the tools that patients can use to move them in a direction that brings their goals within reach. (Okene, Hayman, JACC, Vol. 40, Nov. 2002). 

"Motivational interviewing" is another useful strategy that can aid the provider when resistance is met or the challenge to change seems burdensome.  Motivational interviewing is a 3-step, therapeutic approach that can assist providers in encouraging behavior change in their patients with metabolic syndrome.  Step 1 is to elicit empathy that allows the provider to appreciate what issues in their patients’ lives are maintaining unwanted behaviors and thus preventing change. An example of an open-ended question would be; “what in your opinion is preventing you from walking 30 minutes a day?”  Asking patients to describe what they had for dinner the evening before or what the last kind of exercise they engaged in are also examples of open-ended questions.  Questions such as this can encourage responses that will help both the patient and provider better appreciate the barriers patients face.   Step 2 requires that the patient describe in their own words the potential benefits of the desired change as they perceive them; patients need to hear themselves say why it is important for them to make a change.  Eliciting ideas for change from the patient increases the likelihood they will accept a change. Step 3 is to allow the patient to become “independent” by setting goals in stages (often small and stepwise), that are realistic from the patient’s perspective.  This step also includes the option of using other “team members”: nurses, medical assistants, pharmacists, dietitians, exercise physiologists who can support the patient during times of change on various levels (e.g., telephone, waiting room time, referrals).

Lifestyle changes are the most important element in helping patients halt the progression of metabolic syndrome to cardiovascular disease; they are often the most difficult for patients to achieve and for health care providers to manage.  Studies have shown that trust between a health care provider and a patient is one of the most important elements contributing to a patient’s success; and yet providers tell us that patients find it difficult to undertake the recommendations we ask of them.  Today we are just embarking on a new area of traditional medicine that must bridge the disciplines, involving multivariate explanatory models that focus on:

  1. the patient needing to take responsibility for their own care,
  2. the providers’ and staffs’ needs for education involving behavior and counseling, and 
  3. the community and nation’s need to prioritize lifestyle issues that offer and support incentives that promote healthy lifestyle habits. 
Metabolic syndrome afflicts as many as 35 million adults in the U.S. today; most health care providers work daily with individuals who meet these criteria.  By gaining skills to help motivate, encourage, and support patients in successfully implementing lifestyle changes to improve their health status, clinicians can directly enhance their patients’ wellness and begin reducing the burden of cardiovascular disease in the U.S.  


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