Multidisciplinary Perspectives on Reducing Cardiometabolic Risk - Episode 3
Peter L. Salgo, MD: Let’s talk about our goals in treatment. We’ve established the need to have goals, and then there’s the question of, how do we get patients there without overwhelming them? But we do need to decide what we want them to do, right? Let’s talk about lifestyle modification in type 2 diabetics, in particular. How do you discuss that with somebody? I mean, if you say, “You’re overweight and you need to lose weight,” they walk out of your office and say, “Huh.”
Stephen A. Brunton, MD, FAAFP: The issue, once again, is not overwhelming them during their first visit. And one of the benefits we have in primary care is that we do have a continuity with the patients. I think if one explains to them what diabetes is, most of them recognize that lifestyle has a lot to do with it. Putting a person on “an ADA [American Diabetes Association] diet,” which doesn’t even exist—you know, basically saying, “You need to lose weight”—we say that without giving them exact methods of how to do that. So, I think it’s about creating realistic goals. Weight loss doesn’t mean you go from 300 to 120 pounds. But it also means the benefits of a small amount of weight (a 5% weight loss) will change a lot of the cardiovascular parameters.
Peter L. Salgo, MD: But people are making fortunes on diet books because they know that, after a few weeks, they’ll go off the diet and buy a new book.
Stephen A. Brunton, MD, FAAFP: The results of the Diabetes Prevention Program really showed us that you can actually get a lot of benefit just by some weight control and exercise—and this is actually more effective than the millions of medications we use. So, particularly in the prediabetic patient or the patient with diabetes, we can change their whole parameter and the whole way diabetes will end up by lifestyle. I try to explain that to patients and say, “We can change the way this disease is going to be,” giving them a sense of optimism and hope.
Peter L. Salgo, MD: You were going to say something?
Karol E. Watson, MD, PhD, FACC: I completely agree. I am one of the investigators of the Diabetes Prevention Program, and I’ve got to tell you, it’s fabulous what you can do with blood cells. I also have to tell you, it’s really hard. But what we’ve seen over time is that if you stop the intent intervention, people gain weight. So, it requires everyone to keep being …
Peter L. Salgo, MD: That’s what you were alluding to, right?
Stephen A. Brunton, MD, FAAFP: Right. The thing about weight is that if you lose weight, all the physiological processes go to regain it and gain beyond that. Once again, it’s modest weight loss, and it’s really, as you mentioned Karol, incorporating into their regular lifestyle. It needs to be something that they’re willing to do.
Peter L. Salgo, MD: Let’s say we have the perfect physician—that would be you.
Stephen A. Brunton, MD, FAAFP: Thank you.
Peter L. Salgo, MD: And you have a motivated patient and you have this conversation. How does that conversation go?
Stephen A. Brunton, MD, FAAFP: It’s important to explain to them what diabetes is and explain to them what they can do to control it. Because sometimes you give the patient a diagnosis of diabetes and they start to fall into themselves and feel like they’re out of control. You have some cultural issues, there, as well. I deal with a large Hispanic population and have seen situations where people feel that they’re being punished. So, it’s about getting an understanding of what they think diabetes is and then figuring out what they are willing to work on—explaining that if they can lose some weight, can change their diet, and can do some exercise, they can make a difference. Work with them in a manner of one thing at a time and then progress them.
Rosemarie Lajara, MD, FACE: To put it into the right perspective, I think the sustainability of the effort is the more challenging part. The buy-in, if a patient is recently diagnosed, is that you have that opportunity. But it’s the sustainability of the effort.
Karol E. Watson, MD, PhD, FACC: I totally agree.
Christian T. Ruff, MD, MPH: I also think it’s modest goals, too. And I think an important part of what you mention is, ideally, many of these patients are significantly overweight and are inactive. But even with a 5%, 7% weight loss, or even with 30 minutes of brisk walking several times a week, you get a lot of bang for your buck with very modest reductions in weight and modest physical activity. And so, I think if you have this dramatic transformation of a person’s life in middle age, that’s hard to do. That’s certainly not sustainable for most patients. But if you can get them to buy in, at least a little bit goes a long way. It’s still hard, and I still think, in many patients, the sustainability is tough. But you don’t have to do too much to have really long-lasting benefits.
Peter L. Salgo, MD: What percent of the folks that you’ve seen with newly diagnosed type 2 diabetes mellitus, in whom you suggest lifestyle changes and who start to make them and actually continue to make the changes and follow up, in the long-term, succeed?
Stephen A. Brunton, MD, FAAFP: Part of the problem is that we often don’t acknowledge their small successes. I had a situation where a patient kept a diet diary. They came in and they’d lost a pound. But we don’t even look at the diary or even say, “Wow, you’ve lost a pound.” So, we need to sort of acknowledge that and allow the patient to self-acknowledge. The other thing, I think, is that in the word diet, there is a 4-letter word, and d-i-e is the first part of it. I don’t punish patients with a diet. I say, “Let’s see what we can work in. Can you cut out the tortillas, as part of the day?” I suggest something that they’re willing to change, on a small basis, and let them cheat once-a-week.
Peter L. Salgo, MD: That being said, what percent stick with it?
Rosemarie Lajara, MD, FACE: A very low percentage.
Peter L. Salgo, MD: Very low.
Christian T. Ruff, MD, MPH: What’s very low?
Peter L. Salgo, MD: This is, typically, a difficult problem, isn’t it?
Stephen A. Brunton, MD, FAAFP: But it doesn’t mean you don’t try it. You recognize that any lifestyle change is going to correspond with people sort of dropping out. So, you reassure them and say, “Well, a lot of people have trouble with this. Let’s try it again.” But some people feel, if they’ve failed once, that it’s out for them.
Karol E. Watson, MD, PhD, FACC: And, Stephen, sometimes I will just infer maintenance. The average American gains 2 to 3 pounds a year.
Rosemarie Lajara, MD, FACE: Right.
Karol E. Watson, MD, PhD, FACC: And sometimes, if I’ve seen them gaining every year, I’ll say, “Please, the next time I see you, let’s make sure you haven’t gained anything. Keep walking, keep following your diet, and let’s...”
Christian T. Ruff, MD, MPH: Even if you don’t gain or lose weight, just being more active is still beneficial. So, I encourage people (even if their weight loss has stagnated) that the fact that they’re still trying to exercise 3 or 4 times a week is still going to provide a lot of long-lasting benefit and they should be very proud of that and not focus, necessarily, on the fact that they didn’t meet their weight loss targets.
Peter L. Salgo, MD: Is American pop culture, to some degree, at fault? You hear all these ads for diet plans—“You’re going to lose 40 pounds in the first month.” I had a patient say to me, “If I do this, how much will I lose?” And I said, “A pound a week.” And the person said, “That’s not enough.”
Karol E. Watson, MD, PhD, FACC: “This ad tells me I could do 10 pounds a week.”
Peter L. Salgo, MD: I ask, “How about 52 pounds a year?” “Oh, that would be great.”
Stephen A. Brunton, MD, FAAFP: There are tricks. I’m from Australia, and our plates, in Australia, are half the size of American plates. And so, psychologically, you fill up your plate (particularly at the buffet, which I do that a lot). Part of the thing is giving people, you know, tricks. “Eat half your meal on a small plate, and wait 20 minutes.” These kind of strategies can help our patients, and we can suggest that. They try it and they go, “I am full after 20 minutes. I don’t need to keep on eating.”
Transcript edited for clarity.