For years, you’ve told patients to eat well and exercise.
The warning signs of metabolic syndrome will be all too familiar: high blood glucose levels, high blood pressure, high triglycerides, low HDL, and a large waist circumference. One in five Canadians has three or more of these conditions, and can be diagnosed with metabolic syndrome.
Metabolic syndrome is a predictable, preventable condition.The latest research demonstrates its links to specific genetic traits, and the significantly increased risk patients face of developing chronic diseases including hypertension, cardiovascular disease, strokes, diabetes and their complications.
The Progression of MetS
- Genetic trait
- Accumulated body fat
- Develop MetS
- Progression to disease (ex. diabetes, CVD, hypertension, etc.)
“A growing body of medical evidence shows that the progression of metabolic syndrome is the best predictor of pervasive, chronic conditions, including diabetes, cardiovascular disease and hypertension. Family medicine clinics are the optimal means to address metabolic syndrome early, through implementing a closely monitored and manageable diet-exercise lifestyle intervention program for patients.”
— Dr. Khursheed Jeejeebhoy, Emeritus Professor of Medicine at the University of Toronto, and Director of Nutrition Support for St. Michael's Hospital in Toronto
The three sections below provide the most recent details on the Pathophysiology of Metabolic Syndrome, how the CHANGE Program works, and how the team approach makes lifestyle intervention manageable in your busy family practice.
Source: Increased glucose transport-phosphorylation and muscle glycogen synthesis after exercise training in insulin-resistant subjects. Perseghin G, et al. N Engl J Med. 1996 Oct 31;335(18):1357-62. Reprinted with permission.
Metabolic syndrome (MetS) is the result of insulin resistance. MetS presents with impaired glucose tolerance, compensatory hyperinsulinemia, raised triglycerides, reduced HDL and increased abdominal adiposity, which are phenotypic features caused by resistance to the action of insulin in muscle and adipose tissue.
The most important site of insulin resistance is muscle. In muscle, insulin resistance reduces the insertion of the glucose transporter into the membrane and thus reduces entry of glucose into muscle. Insulin resistance has two additional effects:
- It alters the phosphorylation of glucose in muscle necessary for its use
- It reduces glycogen formation necessary for energy storage in muscle
The inability of muscle to take up insulin results in reduced glucose disposal (hyperglycemia), which causes hyperinsulinemia.
Insulin resistance also has effects on adipose tissue. Under normal conditions, insulin suppresses Hormone Sensitive Lipase (HSL) and promotes triglyceride accumulation. In the insulin resistant person, insulin does not bind to the receptors found in the membrane and HSL activity is not suppressed, resulting in an increased hydrolysis of triglycerides, which in turn leads to increased release of glycerol and fatty acids in the blood.
After being released into the blood, the high free fatty acids flux to the liver, increasing the production of Triglycerides which are incorporated into VLDL (very low density lipoproteins) which are then secreted into the bloodstream. Once there, the VLDL is broken down into triglycerides and LDL cholesterol.
During insulin resistance, the high levels of free fatty acids in the blood also cause the liver to increase triglyceride synthesis, resulting in hypertriglyceridemia. If hypertriglyceridemia is present, triglycerides replace the lipoprotein core of cholesterol, causing a reduction in HDL.
Hyperinsulinemia causes sodium retention and hypertension, and if energy intake exceeds expenditure, promotes triglyceride synthesis in adipose tissue. In turn, adiposity especially of abdominal fat increases TNF production and increases insulin resistance.
In short, the genetic trait of insulin resistance is the underlying cause of metabolic syndrome, which left unchecked results in diabetes, myocardial infarction and strokes.
The CHANGE Program has selected the Mediterranean diet as one of the building blocks for a personalized and gradually introduced diet. The diet is combined with exercise to create an effective lifestyle intervention program to combat MetS.
The Mediterranean diet has shown to be quite effective in the prevention of MetS, and has been shown in randomized, controlled clinical trials to prevent major cardiovascular events in high risk patients.
The Mediterranean diet is characterized by consuming foods:
- High in monounsaturated fat, mainly from olive oil
- High in complex carbohydrates from legumes and grains
- High in fiber, mostly from vegetables and fruits
- High in fish
- Foods with refined carbohydrates
- Processed foods / Fast food
- Red meat and animal fat
The high content of vegetables, fresh fruits, cereals and olive oil guarantees a high intake of beta-carotene, vitamins C and E, polyphenols and various important minerals that are suggested to have a beneficial effect. Several researchers have associated the Mediterranean diet with improvements in the blood lipid profile (in particular HDL cholesterol and oxidized LDL), decreased risk of thrombosis (i.e., fibrinogen levels), improvements in endothelial function and insulin resistance, reduction in plasma homocysteine concentrations, and a decrease in body fat.
In a carefully controlled and detailed study (Perseghin G, et al. N Engl J Med. 1996 Oct 31;335(18):1357-62), researchers examined the mechanism and degree to which exercise training improves insulin sensitivity in insulin-resistant offspring of parents with diabetes.
Ten adult children of parents with diabetes were matched with a control group of the same age, sex and body build. Both groups were subjected to aerobic exercise performed three times a week for six weeks. The study demonstrated that exercise reverses the metabolic abnormalities of insulin resistance and increases insulin sensitivity. Hence, aerobic exercise gradually introduced and increased will be very important in altering the fundamental abnormality of the MetS.
Exercise provides additional benefits. Physical exercise has a direct positive action on the heart itself, leading to:
- Increased myocardial oxygen supply
- Decreased myocardial oxygen demands
- Formation of collateral coronary circulation improved myocardial contraction
- Electrical stability of the heart
Medical studies have also demonstrated the beneficial effect of physical activity on blood pressure levels. Moderate levels of exercise can significantly decrease blood pressure in patients with mild to moderate essential hypertension.
The CHANGE Program is unique evidence-based lifestyle intervention developed using medical research. Its team approach draws upon the expertise of family doctors, nurses, dietitians and kinesiologists, and makes efficient use of each professional’s time. The family doctor plays a central role in identifying eligible patients and encouraging participation, while the dietitian and kinesiologist actively guide the lifestyle intervention with frequent one-on-one or group sessions.
5 Keys to Success
What makes the CHANGE Program more effective at reversing MetS than other diets or workout plans? The difference can be summarized in five key ways:
The central role of the patient’s family doctor — MetS is often first detected by the family doctor. Effective lifestyle intervention to manage MetS requires the active support by the family doctor, as an individual’s primary advisor and most trusted expert on overall health. The family doctor has the established relationship to encourage participation, closely monitor progress by ordering relevant tests and offer a voice of reason that cuts through the gimmicks, fads and mixed messages of non-medical programs.
Team approach — Family doctors are important, but they can’t do everything. By engaging specialized expertise from dietitians and kinesiologists, the CHANGE Program ensures participants receive targeted support. At the same time, the team of health professionals actively collaborates to get a holistic view on the progress of patients, so they can identify and correct any issues that may inhibit success.
Personalization — Research demonstrates that cookie-cutter programs don’t work. To achieve the best health outcomes for as many participants as possible, the CHANGE Program relies on the expertise of family doctors, dietitians and kinesiologists to tailor the program for individuals’ lifestyle, income, physical abilities and diet and exercise preferences, offering the best opportunity for lasting change.
Gradual intervention — Bad habits die hard. Permanently altering patient lifestyles is only achievable through a carefully designed plan of incremental steps. The CHANGE Program enables participants to experience frequent positive feedback.
Close and repeated follow-up over 12 months — Change takes time. Reversing the effects of years of detrimental diet and exercise habits requires frequent ongoing, consistent support and feedback for more than just a minute every few months to see the long-term benefits take root. Setbacks will naturally occur, and the CHANGE Program is designed to be flexible enough to respond, so participants learn how to get back on track.
How the CHANGE Program works in a family medicine clinic
Here is an overview of the process a clinic puts in place to guide patients through the CHANGE Program.
Screening Visit — At an initial visit, or as part of a regular check-up, family doctors order initial blood work, including blood pressure measurement, cholesterol profile, fasting blood sugar and HgA1C. Waist circumference is also measured.
Baseline Visit — At the follow-up appointment, the family doctor reviews the blood work results to determine whether the patient is eligible for the CHANGE Program, as well as apply their own knowledge of the patient to assess his or her readiness to begin an extended and intensive diet-exercise program. The doctor “nudges” the patient toward adopting the CHANGE Program, while discussing the alternatives available.
Dietitian and Kinesiologist — Patients meet separately with the dietitian and kinesiologist for assessment, goal setting and individualized plans. For the first three months, patients follow up weekly with these health professionals for close monitoring and motivational support, meeting privately or in a group setting. Over the final nine months of the CHANGE Program, patients meet with the dietitian and kinesiologist separately once a month.
Follow-up Visits — At three, six, nine and 12 months, the family doctor often has follow-up appointments with the patient. Each time, they record blood pressure and order the same course of blood work to assess changes and communicate results to the team. Where necessary, the family doctor can also modify pharmacotherapy, encouraging patient compliance and help remove any barriers the patient may face.
Throughout the program, the family doctor regularly interacts with the dietitian and kinesiologist to discuss the patient’s progress and adjust the intervention if necessary.
By working as a team, the family doctor, nurses, dietitian and kinesiologist are able to effectively and efficiently support the patient through their lifestyle change. Read more about how the team approach makes implementation of the CHANGE Program practical and manageable in a busy family clinic.
CHANGE in practice
Beginning in 2012, three large family medicine clinics in Edmonton, Quebec City and Toronto were the first to implement the CHANGE Program.
As part of the feasibility study, staff at each clinic underwent training in CHANGE processes and applied standardized screening to their patient populations. Prior to the start of the study at each participating clinic, the local ethics committee reviewed the study protocol and consent forms. Family doctors evaluated each qualifying patient for eligibility and readiness before offering him or her the opportunity to participate in a customized diet and exercise lifestyle intervention. The study included baseline data collection and blood work at frequent regular intervals to monitor patient progress and program efficacy.
Results for the preliminary tranche of 101 patients as of December 2014:
- 75% program completion (4% drop out, 4% withdrawn and 17% lost to follow-up)
- 51% patients demonstrated improvement at 12 months, i.e. VO2 max, Mediterranean diet scores and healthy eating indices
- 25% patients demonstrated reversal of MetS at 12 months, i.e. blood glucose levels back to normal without pharmacotherapy
- Most participants successfully reduced their 10-year risk of cardiovascular disease
Final results from this initial phase of more than 300 patients will be published in early 2016.
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The CHANGE Program is designed for family medicine clinics to provide medically supervised lifestyle intervention for patients with metabolic syndrome (MetS). It succeeds where other interventions in the past have failed, by helping family doctors, nurses, dietitians and kinesiologists in primary care settings work together to improve the overall health of patients with lasting benefits.
The CHANGE Program uses a coordinated team approach first and foremost because it supports better patient outcomes. Preliminary results from the CHANGE Project feasibility study at three clinics show that patients’ risk of an acute coronary event in 10 years was significantly reduced after 12 months of the lifestyle intervention.
Developed for busy clinics
But the only way time-strapped family doctors can offer this kind of personalized health care is to rely on a team that's able to provide the intensive diet and exercise coaching most patients need. Dietitians and kinesiologist are able to apply specialized expertise in personalized one-on-one sessions, and nurses or other clinic staff can help coordinate their findings with a family doctor to help patients improve over time
With the CHANGE Program, family medicine clinics offer patients access to better health care:
- Medical expertise and supervision of the doctor
- Personalized nutritional expertise of the dietitian
- Customized exercise expertise of a kinesiologist
The team approach ensures patients get a diet-exercise plan that’s right for them, with specialists who take into consideration any physical, economic or lifestyle restrictions and preferences they have.
The role of kinesiologists
Building up a sustainable fitness regimen for patients is critical to reversing metabolic syndrome that has partially deteriorated and prevent the onset of more severe illness.
In the CHANGE Program, kinesiologists work to establish a long-term relationship with patients and actively monitor and coach their progress, beginning with weekly sessions for the first three months, followed by monthly check-in appointments over the final nine months of the program.
Kinesiologists collaborate with patients to set personalized goals that take into consideration any barriers and determine an effective strategy for gradually increase exercise intensity.
Within the CHANGE Program framework, kinesiologists provide individualized tests recommended by the Canadian Society of Exercise Physiology (CSEP) and collect data on patients’ exercise and fitness abilities over time to assess progress. Fitness assessments include:
- Aerobic Fitness Score
- Health Benefit Zone
- Muscular tests
- Flexibility tests
Kinesiologists tailor an exercise program consisting of aerobic intervention (i.e. treadmill / ergocycle / elliptic / stair / rowing machine workouts of 20-30 minutes performed at 50% of maximal heart rate 3 times a week), muscular and flexibility exercises, and resistance training.
The role of dietitians
Nutrition is an essential component of combating metabolic syndrome. Within the CHANGE Program — which meets the 2015 Canadian Task Force obesity practice guidelines — a Registered Dietitian is responsible for providing individualized dietary intervention, including counselling, education and support.
With each patient, dietitians complete an initial nutrition assessment, including a food intake history, and conduct a joint goal setting exercise to discuss and prioritize risk factors and identify barriers. After reviewing some potential broad action steps for dealing with the priority identified (e.g. controlling weight, controlling blood sugars, lowering blood pressure, increasing HDL cholesterol, lowering LDL cholesterol, or lowering triglycerides), the dietitian creates an individualized dietary intervention.
Follow-up sessions — weekly for the first three months; monthly for the following nine months — can be conducted in person, within a group, or via phone or email. At each session, the dietitian collects data on the patient’s diet changes over time to assess progress (such as decreased added sugars, balanced meals, increase in plant sterols), counsels on further dietary modifications, and establishes dietary goals for the next visit.
CHANGE provides dietitians with many resources, including a Dietary Management Care Map as well as worksheets and fact sheets to share with patients. A substantive dietary guidance package for each component of the intervention includes the principles, key advice, strategies, and client resources that can be used to help patients achieve dietary behaviour change.
In addition, dietitians can participate in a national mentoring support program lead by academics from The Applied Human Nutrition Program at the University of Guelph.