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Logo of AMEN 2016-Radical Practice: Healing in the 11th Hour

Metabolic Syndrome: Addressing Root Causes

Neeta Hillman Aysha Inankur

Description

Objectives:

At the conclusion of this CME activity, the learner will be able to:

1. Optimize strategies for screening and monitoring metabolic syndrome to promote lifestyle change.

2. Communicate to patients, in practical terms, the benefits of lifestyle choices on metabolic syndrome.

3. Construct an evidence-based plan to educate and motivate patients to combat metabolic syndrome while addressing common barriers. 

Recorded

  • October 28, 2016
    3:15 PM
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Well it's my privilege to talk with you about metabolic syndrome this afternoon and before we begin I'd like first of our heads for a word of prayer. Dear Heavenly Father think keep for this opportunity to think about your simple methods for preserving and recovering metabolic health. I pray for wisdom for myself and Dr Coleman to share information that would be most useful to those in this room. And I pray for your Holy Spirit to empower each of us as we go home to use the tools you've given us to address the metabolic concerns of those around us. Thank you. In Jesus' name in the end so that theme of our conference this year is radical practice and I understand one of the definitions of radical is roots. So Dr Relman and I wanted to talk about addressing root causes of metabolic syndrome and information is going to be rooted in the Add to this tough message so I'm going to present sound coach from Alan White and well as in scientific evidence which we'll discuss also. So first I'm going to briefly define metabolic syndrome. I will describe it's important and then talk about treating root causes through nutrition sleep and trust in guy. And then Dr Hellman is also going to talk about treating root causes to exercise sunlight and we both felt that trust in God was important enough that we should each share how we incorporate it into our practice. So first of all metabolic syndrome is a cluster of breast factors for atherosclerotic cardiovascular disease in type two diabetes and a person has it when they have three out of five eight criteria. The first being central obesity defined as an ethnicity specific waist circumference for persons of European origin that cutoff is forty inches or greater in men and thirty five inches or greater in women who are not under the. The National Diabetes Federation has other ethnicity specific Cup points now good for you to their website. Second criterion is elevated. At least one hundred fifty milligrams per deciliter or medication treatment for that condition reduced H.D.L. cholesterol. Less than forty milligrams for Duff we don't men or fifty milligrams per deciliter in women ordered drug treatment for low H.D.L. elevated blood pressure defined as the colic at least one hundred thirty or diastolic of eighty five or about or drug treatment for hypertension and then finally elevated fasting blood glucose of at least one hundred milligrams for deciliter or history of the condition and treatment with drugs for AIDS. So metabolic syndrome matters because it does have a very costly potential consequences it doubles the risk of after Florida cardiovascular disease over the next fight to ten years. And today faces the rest of type two diabetes by five colds. So we wanted to talk about root causes. Which have been defined as the overweight or obese condition. There's a call in activity and insulin resistance in recent literature has found insulin resistance to be a connecting factor kind of a central factor that links all the high components of metabolic syndrome. And so for addressing over weight status and insulin resistance Our goal is to shift the energy balance so that energy expenditure XTI of energy intake. I say published this month looked at dietary patterns they were trying to find out which dietary pattern was most associated with metabolic syndrome. So they looked at over eight thousand Chinese persons in a case control study they divided them into three dietary patterns. First was the high protein cholesterol group. Characterized by high intake of animal ople or animal internal organs animal blood and stockades the second group consumed a high carbohydrate diet consisting of a lot of processed carbohydrates has just been all sugars. And canned and fruit cakes ice cream juice third group was a balanced pattern characterized by vegetables of my shrooms and core cereals in the diet. And the consumption of the high animal foods was associated with the highest prevalence of metabolic syndrome and some of the potential mechanisms they listed are that nice spoon are high in saturated fats and cholesterol they're also high in energy intake energy dense food and the blight. In the product and can contribute to iron overload which husband associated with insulin resistance so consumption of bad shovels and crosstabs carbohydrate was associated with the lowest President problem of metabolic syndrome. Another study published this month looked at thirty four women who are obese they did not have diabetes. They were put into three groups. So the control group was told to maintain their current weight and then there were two groups on low calorie diets in their daily calories were restricted so they would lose ten percent of their starting weight. And they were actually successful at losing that ten percent. The first group ones are saving the recommended daily allowance of protein. And the second group received about one hundred fifty percent of the recommended daily allowance in that although both groups lost about the same amount of weight those on be recommended daily allowance of protein improve their insulin sensitivity by up to thirty percent whereas those. On B. high protein diet did not improve their on time to T.V. and there was also known prove men's and oxidative stress which did improve on be recommended daily allowance of protein. So high protein diet can work for weight loss. Bites or reverting insulin said to insulin resistance which I mentioned as a court Beach area metabolic syndrome a high protein diet does not seem ideal want to treat a couple quotes from councils on diets in fields and dietary recommendations on Wright said great spirits next and vegetables constitute the diet chosen for us fire creator these foods prepared simple and natural and manners possible are the most healthful and heating one and then she said on pages ninety four ninety five. That which is most conducive to health can be secured in almost every Land's End she added to the whole grains beans peas and lentils so she included lagoons in an optimal diet. So when Rakeysh want to lose weight. I tell them about this study from Harvard. What's being at over one hundred thousand persons from the nurses' health studies one in two in the health professionals followed study. They looked at people over decades and they were able to isolate a difference component in their diet and measure which components for most associated with weight gain or weight loss over time and the foods that were associated with weight loss are represented by the bars to the left vegetables nuts whole grains fruits and yogurt. Now I reckon the first four in this list the vegetables not whole grains and fruits because they have antioxidants. They are high in fiber and they are cholesterol green. Fish here. The American College of endocrinology. Published their consensus guidelines for treatment of insulin resistant type two diabetes and they recommend a mostly plant based diet for this group of people the American Diabetes Association in their annual Standards of Care published earlier this year recommended diet high in fiber foods a high fiber which the plant food. Am known glycaemic load and the person with diabetes is overweight or obese. They should also restrict their calories with the goal of losing Pike to ten percent of their weight. So in patients in my clinic want to know what they can eat to lose weight. I suggest eat food that are high in fiber and high in water. Neither of those components canteens calories and they both will add volume to their food so that their stomach will be full before they have exceeded their calorie allotment for the Neil. So green we can have actual As you can see the group especially the out above the ground vegetables are some of the richest foods in water and then for fiber. I recommend that people look at the Coke plate Living dot org website where there is a cream biker guy with steam the foods high in fiber and various categories it's just a sample of their hand out for their web page for net and see. So it shows the serving size. Number of calories per serving. And then the number grams of fiber per serving. And they have a similar guide bar vegetables fruits whole grains and the girl says Hall make ation with diabetes about this study on the boom. Adults with type two diabetes were given a three month trial and they were told to add one cup of cookbook looms to their diet every day. So two half cup serving. And at the end of the three months they have bought on average five point seven pounds. They dropped their. He won by point by and they're trying to came down by twenty one points. Now number the medicines we use for type two diabetes lower A one C. by close to point five so I talking with whom are in fact in natural treatment for type two diabetes. The question arises how often shit patients with insulin resistant diabetes who are wanting to lose weight eat this study looked at adults with type two diabetes but then Montreal today with three snacks. Which they agreed as six meals a day or and in another group they had the same types of patients consuming two meals per day. The first meal was eaten in the early morning by ten am the second meal was eaten in the afternoon at least by four P.M. anywhere between and four P.M.. And both groups had their calories restricted by five hundred per day. And what they count as those on the two meals a day had reduced their waist circumference by the end of the study nearly four times as much as those on the six meals a day those on the two meals a day of the case their body mass index significantly more than those on fixed meals a day baffling blood sugar on two meals a day down by fourteen million grams protest leader. Whereas six meals a day came down by just eight point four six milligrams per deciliter and insulin pumps are to be improved over twice as much until today versus six meals a day counted one diet concludes page one seventy six said the practice of eating but two meals a day is generally found a benefit to health yet under some circumstances persons may require a third meal while the health professionals follow up study wants us to ask what frequency of meals would be most beneficial militant over twenty nine thousand men who are eating anywhere from once a day to eight times a day and they defy. And snacking is eating more than three meals per day. So the men who were eating more than three times a day increased had an increased risk of Type two diabetes which was mediated by a higher body mass index in those men who were snacking so if a person could eat a third in Iraq. How large is that meal be back in the House today compared to breakfast. The study of adults with insulin resistant diabetes were called on to patterns in the first case on the breakfast diet so they ate nearly half their calories for breakfast and supper she wondered five calories or they just the opposite a very small breakfast a large supper. And then they looked at glucose levels. Sorry it's difficult to see their glucose for those odd heavy breakfast day it had dropped twenty percent one to two hours after the meal in compared to those who were eating the large dinner and insulin levels were actually twenty percent higher for those on the heavy breakfast diet and the patients were not taking in for induction. So the elevated employer models suggested improved pancreatic function close minded of a quote from councils one day to page one seventy three says at breakfast time the stomach is in a better condition to take care of more food than at the second or third meal of the day make your breakfast correspond more nearly to the hardest meal of the day so I advice patient completes you eat breakfast like a king lunch like a queen and supper like a commoner to make some calls for make ations and I guess to give them a practical example of what this could look like I typed out a sample meal plan I don't tell patients that they should follow this. Exactly. And it's not a diet it's really more of an exchange system to give them. Ideas of Healthy Start Chiz healthy proteins healthy fat bad you tell them they could try to start eating breakfast for example. According to this plan and I also warned them that if they were to overnight start eating this kind of a diet. If they aren't used to eating much fiber they might have gastrointestinal disturbances. So for breakfast. I ate given the recipe for making whole grain cereal in a crockpot overnight and then have fruit options healthy fat protein for lunch recommend a large salad and some starch options as well as fat and then after is definitely the lightest meal other tools in my office are paying file folder in which I have a number and out one of which is a recipe file patient start eating their big salad for lunch. They likely will wants a salad dressing to put on it so I have cholesterol free salad dressing recipes in there and then I recommend that they use different free apps calorie King makes an out that has appeal large database of foods including restaurant foods where through which they can quickly. Look up the nutritional information they can also see the nutrition information for bulk hoons and then the super Tracker dot U.S.D.A.. Has a free diet and now it's just software that they can plug in what they eat in a day and it will give them the breakdown of their macro and micro nutrient intake also free biker guy you have a hand out with a list of the fiber content of different food. And then use some of the major themes on a counter patients like to ask if they can take them home because they often will see a recipe that you want to try. How many can you use an electronic health record. Probably most of us in this room. Yes. I found and probably you have found you think Dave findings are macro can save a lot of time. So like to put my lifestyle recommendations in as Dave findings that I can insert into the plan that they take home can refer to later. So moving on to sleep. One should read a couple of quote on the writings of Ellen White. The importance of regularity in the time for eating and sleeping should not be overlooked. Since the work of building up the body takes place during the hours of rest. It is essential. Especially knew that leap. Should be regular and a buy that is not from child. Page three sixty three. And then in seven manuscript releases page she twenty four. She says. Sleep is worth far more before than after midnight two hours to go to sleep before twelve o'clock is worth more than four hours after twelve o'clock. So the three things that we see are that sleep should be regular abundance and sleep before midnight is worth more than afterwards so studies have looked at the duration of sleep and it wink with metabolic syndrome and seven to eight hours of sleep per night minutes so stated with a lower prevalence of metabolic syndrome and honest survey when patients free when people reported sleeping less than five hours a night they had a fifty percent increased risk of having metabolic syndrome. So that from the previous page by the end of sleep. We see a certainly imparted for metabolic help. And then a second thing that I read about in those quotes was that we should be regular social jetlag is now being studied in relation to metabolic halt and it's really the difference between a person's naturally preferred versus socially imposed sleep schedule. So if I went to bat and got up one. Hour later on weekends than they did on a weeknight I would have a social jetlag of one Al or. Researchers won and colleagues from University of Pittsburgh looked at social jetlag and found that those who had a social set like a greater than sixty minutes. Had a higher risk of having a low H.D.L. cholesterol high trait with their every insulin resistance greater waist circumference and higher body mass index and these individuals in the study actually were middle age healthy adults who had day shift so these were not like Swing Shift workers they work to during the day during the week and then had a different sleep schedule social imposed on them. More units an evening then cut off to me accounts relate to metabolic syndrome morning Miss or a morning kroner time I represent people who go to bed early and get up early people with evening this are the evening type go to bed late get up late. So the study Korea by human colleagues looked at over six hundred person that they grouped into either the morning type the evening type or neither. And they found the morning types that went to bad as on average around ten fifty at night. And they got out. People are laughing Does that sound like a late bedtime. They awakened around five thirty eight in the morning on average those with the evening tight went to bed closer to one A.M. and awakened around seven thirty A.M.. And both groups and up sleeping at the same length of time. Overall there was no significant difference. But what they found was that even tie. Was associated with a one point seven fold increased risk of diabetes and metabolic syndrome and there was also. Increased risk of low muscle mass and so we see that those three things we just read about from the quotes from Ellen White regularity instantly abundantly and sleep before midnight don't have an impact on mythology health. So I can give cation evidence based recommendations for improving their lifestyle and clinic and I think to make it really practical for them it's helpful to use Mark Boal Has anyone used particle. Yeah. Number of people are not in their heads and so their specific measurable it's a ball results focused and timely education presenting clinic recently to refer me to optimize for and one regimen. And I asked her I said I told her insulin works best when it's accompanied by a healthful lifestyle so I said Is there anything you can do you think through a healthy eating or through physical activity to also lower your blood sugars and she thought for a while and then she said well I snack on fleet cranberries during the mornings. So I asked her if she liked fresh fruits and she did she said she really liked great. So after dialoging with her for a little while she decided to add one serving of grapes and we talked about counting those out to make sure she was getting exactly serving as dessert with her lunch through place the cranberry she was snacking on during the morning. So that's with the physical she was going to continue that for a few months until she found me I go and get in clinic and then even if I help my patients make smart goals as a Christian physician I feel like those patients are going to be most successful in achieving the goal when they have faith in God trust in God. A patient came to my clinic earlier this month to mention she could live eight pounds over six month period. And. And I said to her what I usually say when people are successful with weight laugh they asked how did you do it. And she said I was in a church space program she said I really wasn't on any particular diets the focus was just controlling portion sizes. And she said it was a very spiritual program in which we claimed Bible promises. Whenever we were confronted with temptation to over eat. So I was reminded of this quote from town Sunday contents page twenty eight in order to rightly understand the subject of temperance we must consider from a buyable standpoint and certainly Bible promises are powerful motivators for lifestyle change. One research group that implementing a Boucle philosophy in a way that must approach. The collaborators for the word. This is a church based Whitesell intervention program that really following the guidelines of the Diabetes Prevention Program lifestyle intervention for diet and exercise but they're also getting spiritual message each session and see these are some of the spiritual messages that there are brain you can look up their study on line this is just the study design that I had with Stan the results are not out yet. I believe the study is ongoing. But I think although the principles are certainly applicable for a group intervention. They could also be useful in clinic and some of my favorite text here quotes were the difference between a righteous man and what good is that the righteous fault seven times and get up. Proverbs twenty four seventeen and then the race is not this way or the strongest Ecclesiastes is nine eleven but to those who endure and lean on the Lord at patients came to my clinic a few months ago with type two diabetes. He was concerned because his A one C. had most recently been twelve point two which corresponds to an average blood sugar around three hundred and he did not work outside the home and so he was exposed to the temptation to eat the food that was easily accessible in his refrigerator throughout the day I talked with him about lifestyle intervention and at the end of the visit. I said I offer to stay upright with my patients would you like me to say a prayer with you. He did when he came back a few months later he is average blood sugar on the glucometer for the last two weeks was in one fifty nine. So I said How did you do it and he said. God has strengthened me God is really getting the willpower to resist eating those foods that I would normally overindulgent and think for the prayer and I'm sure he'd been praying on his own as well. So in summary it's really a privilege to share the simple lifestyle strategies. With patients and clinic on how they can improve their metabolic health. It's a privilege to help them set smart goals and to pray with them and then watch guide empower healthy lifestyle choices. Thank you for your attention and I will give the microphone over to Dr Coleman. That was that was very hopeful those of it really encouraging practical information that Dr non-chord gave and I hope you are able to apply those I seen those same recommendations work. When it working at both Wiemar over three and a half years and boy and that wild with patients or that period of time they're extremely extremely successful and in very short period of time patients see the results and they feel so much better when they do. All right I'm going to talk to you a little bit about exercise and then actually looking at the the evidence. Behind some light and fresh air. One of the difficulties for me is you know we have a lot of times. As for a prophecy concerning getting out or exercise and sunlight. But I want to know what that one of the data there's that. Part of me that have a difficult time sharing with patients. What I don't know if I don't know why it works and so I do want to share with you a little bit of the data that comes with that I cause I share the information with them but it's so much more powerful and I can share with them especially how how it works. This is one of the statements again they're coliseums and sort of frosty but this is one of the most powerful tying in each of the principles that I'm going to talk about if those who are sick. So again we're not talking just about well people but those are not feeling well already what exercise their muscles the daily women and men women as well as men in outdoor work using brain bone and muscle proportionately weakness and langar with this appear healthy take the place of disease and strength the place of feebleness rising above there and pains. So again people with AIDS and pains rising above their aches and pains let them in gauge in useful employment suited to their strengths. So that the other Another key component by such employment and the free use of air and sunlight many an amazing it invalid might recover health and strength I'm going to talk about why some of these things are likely important with metabolic syndrome exercises very critical looking at a study that looked at women mainly elderly women over the age of sixty five over twelve months. What they found is that exercise that they didn't specify the different types of exercises that people would use it was aerobic but they didn't specify the exact amount. What they noticed is that trunk go body fat to decrease so the fact that it's more dangerous because the part about. Apple shaped the versus pear shaped great pear shaped being specifically fat under the skin and then being fat. That's around the organs that's the more dangerous metabolic like the active the one that is more prone to give a person insulin resistance because different hormones that are increase and decrease when there's a bunch of increased around the org. Or when it's larger and then hip circumference also has decreased by glitter eyes and H.D.L. us recognize these because after an in-car mention those as those factors that are involved in metabolic syndrome. So we notice that exercise significantly improve this. And again this is over a year in these studies they didn't show as much change in glucose high sensitivity or P.. Again we're looking at metabolic syndrome and its effect on heart disease or in blood pressure but understand that in the study they didn't even look at the duration and we'll talk about why duration matters and exercise and just a little bit. This is a logical blunder that you've done looking at people over sixteen eighteen over his eighteen years. These are men ages thirty to fifty nine. And they are what I love about this study is that they looked at people in all different levels of activity to help us understand. OK how much like to be in what amounts matters sedentary versus moderate activity versus high heavy and the specifically when you talk about high activity you know we're not talking about people running marathons not talking about them you know doing doing what is it P.X. ninety or anything like that. What is the big leagues talking about is training with expenditures we look over a week. How many calories are they expanding with exercise specifically not just the amount of calories they're expanding from sitting and lying down but exercising specifically and what that comes out to is roughly you're talking about exercise as burning about three hundred till a calorie is a date. OK What giving you an idea of what that means if you take one hundred sixty lb male walking through a half miles an hour. They're burning about three hundred fourteen calories if they walk for about an hour. OK So just to give you kind of a picture. Again what they found is that if people exercise in that range of bring about two thousand calorie kilocalories a week or let's say roughly three hundred calories a day for seven days there and the activity that they're doing this one supposedly found that the activity they were doing or helping to maintain. Good aerobic activity of exercise and fitness OK aerobic is the key to take out from this from these studies they were able to this is going to be a very protective factor for them when it came to metabolic syndrome especially in middle aged men H.D.L. we take help patients often times to increase their H.D.L. would be usually tell them to do to increase H.D.L. exercise regular but what type of exercise that was one thing that was key for me is though if a person has one milligram protest leader decrease in their age deal that's two to three percent increase in their risk of heart disease and you imagine you know for males you remember what the goal was for males where there are good cholesterol needed to be around forty forty for a male and then fifty for a female and many of our patients are sitting around twenty twenty five thirty at the most so imagine then what their increased risk of heart disease is two thousand and seven Japanese men and also study actually found that duration. The duration of the exercise had more to do with increasing the age the album the intensity or the frequency of the exercise. But and many times when I used to mention to patients or what does this mean as far as the duration of exercise they thought Oh great. That means that the go out to you know all day long and every day to be able to increase my cholesterol what they found was a little as twenty minutes was beneficial. OK so that's another encouraging to see that the six of twenty minutes continuously with added benefit for every ten minutes I was added beyond an hour effect was plateaued. So going for two hours three hours didn't necessarily get an added benefit. One thing though that I do encourage you to understand is when they were looking at the exercise they're talking about maintaining the heart rate for that twenty minute period for some patients that means they can walk that walk or sit and during that period of time of sitting their heart rate is still up. If they're not very fit so for your old these patients that twenty minutes of exercise just means that they're. Keeping their heart rate up as that makes them doesn't necessarily mean that they have to be moving the entire time. So important for those who have aches and pains also. What type of exercise by far and away study after study has shown again aerobic exercise. What does that mean specifically getting their target heart rate into the sixty to sixty percent eighty five percent and beyond that there are some detriments But again even up to the seventy seventy five percent range reduce that that fat that create decreases levels of adiponectin increasing levels of resist and that will increase for insulin resistance and also to help improve weight loss. Karim study actually looked at patients over a period of time and this makes very good sense but it was just mice that they looked at in the study that out. Irrespective of how much weight that a person had whether they were lean or obese the ratio. OK The ratio of their muscle to their fats made a pretty big difference than would have been venting metabolic syndrome so if they had more muscle rather than fat they had less the likelihood of developing metabolic syndrome later on. Even if they were maybe a little bit heavier side so one of the things I just encourage patients especially if you're talking the younger patients making sure that they engage in doing resistance training at a time there are multiple benefits for that including Auster proses other things like that understand people with metabolic syndrome a type two diabetes have a significant increase and in osteoporosis the resistance training helps them in multiple in many many ways. Another med analysis and two thousand two hundred this one specifically took patients that had already had impaired glucose tolerance what people term as pre-diabetes and then type two diabetes and these are looking at at studies that are all the studies included were randomized controlled trials and they were looking at resistance training and they looked at the amount of resistance training also in all of these. When a person included or is a tree. It was just resistance training no aerobic exercise changes in these patients just resistance training that a reduction in their IT Once the use of their blood glucose all were all blood glucose over a three month period their fat mass and their systolic blood pressure and. I was just looking at the studies and the the physician who composed the study actually looked took the study and then went a little bit further to find out how much time that it actually takes for this to happen so by the same all this is looking at the duration of resistance training and had patients just doing one bout So one time they are doing some resistance training thirty minutes and then looked at them at three months and then looked at him then at four months. What I take away from this is that a lot of the markers did not change until that poor month close for that four month period. What does this mean for our patients. You know we want to make sure that we help patients understand that it's going to take time to see some of the changes. One of the good things that they will feel better. Sometimes before their markers fully change but in gauging them and telling them ahead of time looking give me a six month we're going to implement some of these changes we're going to slowly do them over six months and then these are some of the things that we can expect to see happen and I comes to resistance training especially for many of these markers that may take. And this is low level resistance training again for thirty minutes three days a week is roughly the average that they have for these patients. It may take about four months for them to see significant changes and in many of these markers. By far and away the study after study has shown when you compare when you combine aerobic training with resistance training that patients do better and all markers can concerned with metabolic syndrome. The other question is sort of how much when looking at these studies by the way. P.D.F. I can also send to you. I'll give you my email address at the end so that you can. All of these studies but this is the article by the author by the name of straws or she doesn't really really great job in being able to summarize all of the exercise studies to date. I think it was up to those a bit to the thirteen that she had she had looked at some of these studies she's a really good does a really really good summary of the evidence behind many of these so I recommend that you look at that for a little bit more detail but the best results again you'll see many studies are saying that a person needs moderate intensity exercise. What we're basically took to give you an idea if all of the studies are talking about those that expend at least three hundred kilo calories a day at a minimum of five up to six days a week. OK that's what we're looking for. That's a direction so irrespective whether they say it's moderate or high intensity or whatever three hundred to look calories a day that there is spending specifically in exercise and then ideally sixty minutes a day. Those who had greater than three hundred minutes per week of exercise were able to maintain their weight loss rate we don't want to just get the weight off of my keep it off. What does that mean roughly you're talking about forty five minutes over seven days or you're talking about one hour five days a week just to give your patients an idea but here's the really encouraging thing. The activity spread throughout the day also made a difference. OK so some of my patients. I've got patients that have that have either five or milder or patients who have really severe osteoporosis and they cannot walk for an hour. OK but they can do ten minutes multiple times a day five or six times a day or they can do twenty minutes three times a day and those patients can perceive the same benefits so encourage your patients if you give them that hope all of a sudden it doesn't seem as daunting and also remind them that we're working towards a goal or not starting out at the end goal when we do this other benefits of exercise on metabolic syndrome as I look at my time really quickly if I might. Come back to the slide other benefits of metabolic syndrome under verge of exercise metabolic syndrome barriers to exercise one of the common things that your patients will tell you when they say that they cannot exercise great pain. I have pain made a lot of low back pain. I actually will refer you to if you weren't here for the previous lecture that Dr Drew. Kim had on pain he actually gave some good tips concerning pain and if you will talk to if you will listen if you're on audio versed listen to that lecture it can help you with helping getting some ideas concerning how to be able to combat that. But understand American or mythological Association has mentioned this and so has the Americans as vision as are the American Board of infill medicine and some of the consensus that they've come says a statement that they've made those who have chronic pain who are not active have more days and greater intensity of pain than those who are less active or sedentary and encourager patients especially those that are that have pain that actually they will do better over time if they if they can continue to stay moving. One thing I want to also mention the benefit of resistance training one thing that I find with my patients over and over again when they start exercising injury and pain is what will keep them from continuing to exercise those that incorporate resistance training have less injury less balls and are better able to maintain the exercise long term. I have family members who are concerned about their their family their elderly patients walking because a fall. If they have corporate resistance training balance I actually improves and and so does the risk of in reducing or reduction of the risk of injury and pain falls other things with practical tips that I fell into one of the benefits that I had when I words of Wiemar for the three and a half years and. And I'm over it a while because I got to call patients daily OK so I get to hear their complaints day and night day and night and that's a good thing though because then we've got to address what really works and what doesn't work because when a patient goes home. I don't always know what is necessarily working and I'll tell you with my patients especially that Auster upright is one of the most critical things that help is if they are used for twenty minutes. They go out and they exercise that they will ice the joints that typically hurt for twenty minutes after they exercised the delayed pain and stiffness the next morning the next day they'll prevent them from exercising is significantly decreased and more able to function the next day and it's a very practical simple thing to do and one that one other little quick tip by a third of people gel packs is that you know you may be working with patients who are who are not who don't have a lot of money heifer. Or type of those start corn syrup. Carol syrup or light corn syrup if you put that into a Ziploc bag and put it in the freezer it's a cheap fact that they can use and especially those that have you know large joints where you know I spoke in their back is going to cause pain. These are things that significantly helped and kept my patients walking. If you've ever been in the pathways to health. It's the same thing that we've actually found ice Mossad's really works to help people with with pain. If patients are having trouble exercising for a long period of time as a mother the benefit of working both that we are in the wild if they are D. hydrated in Durham's is going to decrease. If they have high protein diets their endurance is going to decrease the high carbohydrate diet complex carbohydrates. Well actually help them with glycogen stores to be able to maintain duration of exercise also really quickly and i Pod as my timer never started do you do when can you just give me a good time really quick a time. That's OK Are let me just tell you really quickly sunlight This is actually one of my amazing. You know what does sunlight actually do for us. One of the things you view radiation actually increase the circulating nitric oxide if you guys are here there last night we understood that Microsoft's I was one of the mechanisms one of the very potent and factors when it came to as far as antioxidants were concerned or eight or a free radical that was actually beneficial helps to visit I lesion and lower blood pressure that was looking at human subjects and what the direct effect was of U.V. radiation but what this study is that we've found so many different benefits from exercise. This is a study that is often quoted Swedish study looking over twelve years. Those with the greatest exposure of sunlight had a thirty percent risk reduction when it came to low risk of actually having diabetes later on. That's pretty profound I mean very few things reduce your risk by thirty percent getting out of the sunlight is one of those things that I fully helped. One of the things they postulated also was they were looking at different mechanisms. Was there an effect also of glucose metabolism in two thousand and fourteen. This is a study that has gotten a lot of excitement the challenge as it was done in mice these are high fat Fed diet mice the study was really profound as it is you expose these mice of a fat diet to U.V. radiation. I mean factor after factor after factor involved and metabolic syndrome decreased weight gain glucose intolerance insulin resistance nonalcoholic fatty liver disease and serum fasting levels of insulin glucose and cholesterol. OK this is U.V. radiation. What was fantastic about the study is that it they found that it was independent of the vitamin D. because one of the things my patients say is Well can I just take a vitamin D. supplements is that going outside what we're finding is that there are benefits that are outside of the vitamin D. when getting out with women when you get out into the exercise and exercise in the sunlight this. Study has sponsored level human studies that are now going on. So I continue to look for data in the future concerning this knob that sparked a thought back to a quote I read before this from your view in the Herald June twentieth eight hundred ninety nine article be those who eat freely of pork cannot but the disease. Those who have much outdoor exercise do not realize the bad effects of pork eating as those who do those whose life is mostly indoors and whose habits are sedentary and labors mental I'm not promoting eating pork what I or what I want you to understand is many of our patients are engaged in eating and diets that promote metabolic syndrome when they get outside us and exercise their benefits that are confirmed God gave wisdom such as a right to mention that outer exercise in the exploitive self helps and has a protective factor in that and encouraging our patients to make sure they engage in that the other really cold thing a lot of these studies that have come out and recently as in two thousand and one U.V. radiation. When we get exposure of the sun on our skin the hair follicles and the pigment cells of us can actually produce beta endorphins what our beta endorphins are the natural opioids of our body help actually with pain reduction so patients with pain when they get outside an exercise one of the benefits actually is getting them out there and also to feel good hormones a feeling of well being improves. I'll come back to that quote if I have a little bit of time. This is a systematic review looking at eleven trials total of eight hundred thirty three participants over all of these trials looking at outdoor versus in directivity those who exercise outdoors had a greater feeling of just feeling overall wellbeing increased energy and positive engagement decrease tension confusion and depression and understand many of these things are things that prevent our patients from getting exercise to begin with you add those benefits taking them outside it's improved but here's what's neat they had a greater enjoyment and satisfaction with our. Directivity how many of my patients repeatedly mention I just hate exercise. And getting them out. They're more likely to engage and we found this over and over again both when I was that we mar and that while that if we could get patients outside rather than on the machines there in a wall. They were more likely to actually engage in exercise this the study the patients that they were more likely to engage effectively later but they didn't measure the next study though Canadian study actually looked at it. Here's the exercise. There are other benefits that were mentioned before but what they found is and post-menopausal women out over the indoor exercise when they followed them long term they were more likely to stay engaged with exercise right because we're not just concerned about short term results but long term results with our patients. As far as sustainability is concerned we like OK so just to give you a couple of really quick tips there are practical tips that I found helping our patients succeed. I'll tell you over and over again no matter what. How many times you tell your patients that they want them to exercise the keep coming back and they have an exercise they have an exercise. What are the some of the things that we can do practically that have helped our patients succeed want to talk to them and find out what their off Stickles are OK is it pain. You know with many of my patients low back pain over and over again especially in patients that have put on weight low back pain is the limiting factor. We use and in our own sort of profits used to teach people actually think a lot about posture. And and talking to them about what we now talk about us for strength Ravan many exercise when they talk about core strength but we don't talk about that very much anymore with our patients when we teach them how to be able to do very simple exercises for core strength pelvic tilt and doing things like me to chest exercises and develop. In their poor strength. What ends up happening is these patients are then able to engage with less back pain. OK I have my patients it takes two minutes two minutes every day to do ten let me know what the pelvic tilt of it is essentially you're lying on your back and you are pushing your knees are bent and then you're pushing your stomach down into the down into the floor. OK you're essentially tightening and strengthening your core it's a physical therapist says that it's not as easy as you think even for people who are quiet who are aerobically or aerobically fit may not necessarily actually have good core strength. But if you can help them do these exercises. They're less likely to be in pain over and over again patients that told me if they do those exercises and do the need to test again two minutes in the morning to minutes in the evening takes of the most five to ten minutes in a day bending are slow or fast but they do it. They have lost back pain when they are engaging in exercise. Let me let me other one of the things many of your just mad because to me the practicality is very important. I am not the most efficient patient person and seeing patients and so when I take extra time to do all of this is very challenging and one principle that I all learned this president actually brought to me. I remember my husband and I saw stars they both had talked to me about the first things twelve tells us that we have varying depths or a god has given us different gifts know the gifts of your staff members when you're selecting and they may be you working for a company. It's not your own practice but they're slightly made specifically for an enemy who likes to engage and talk with patients have the most a wonderful experience. I decided I need to go and get a primary care physician myself recently and I it was a it was a P.A. who was working in the city close by. She had the most wonderful and they have. And took the information that many a times physicians end up sitting in spending poring over and over hours in doing this. One of the things that you can do you can have your M.A.R. your C.M.E. fill out standardized questionnaires ahead of time and when you go into the office they're going to ask you anyway. About you know whether you're smoking or you're drinking alcohol or you're doing whatever else have them also talk to the patient how much are you exercising paid. How much are you exercising but then also asking that you make a standardized motion or what are your barriers to exercise not understand that your I may or C.N.A. may not know what to ask but give them. You know to put on the questionnaire specifically is it back pain that's keeping you from doing it. Do you just not like the exercise or the taking too much time are you busy or whatever it may be have them fill those full of that information ahead of time so that you can quickly look at it and then address those issues with your patients. For some patients that at the hospital. I have even less time with everything else all the paperwork that I have to do one of the things that I found is nurse educators every single hospital has to meet or measures. And many of these nurse educators are flagged you know first smoking education their flag for coronary disease patients chest pain patients P.T. patients your nurse educators are oftentimes doing it because they love to educate patients. I simply handed to one of my nurse educators. I think I said look if I find patients who come in for you know there are twenty chest pains are quick there twenty four hours in and out of the hospital. I handed to them. These are patients I've identified as having metabolic syndrome going to fly them as a nurse education. Can you take that with questionnaire and can you address of these things with these issues with the patients and she was very willing to do it and then she would flag the note back to me when I went to discharge the patient. I quickly mentioned to her. Hey you talk to the nurse educator about these things are you are there any particular point that you want to implement the patient would tell them which factor they're going to implement and then I put that. My discharge summary for the primary care physicians of the primary care physician knows that the patients made this commitment and I have asked the and I've let the patients know that you will be asking can them concerning the follow up on this. So even as a hospital as you have opportunities. Let me also mention one last things I know my time is up. One other way. If you're a sub specialist you know I learned so much from my colleagues who in particular we have an amazing oncologist and a couple of medical center non-college us and. An orthopedic surgeon were both well loved in the community and they use their Ph very very well you know nurses and N.P.'s that are oftentimes working for some specialist will mention that they don't feel like they feel like they're just doing paperwork all the time they don't have time to actually engage with the patient one of the best ways to get them to engage so when a patient actually came into the hospital the cancer patients were actually or the orthopedic patients they would actually spend their Ph not only to just do the quick note and follow up for how they're doing in the hospital but what they would actually do is to do this. The patients a captive audience in the hospital during that we have our period and they would give them a quick little questionnaire to find out and look at some of the barriers that they were having to is implementing some of the exercises or order regimens or nutrition arguments that they had recommended to the patient vision would fill out that information and then the the physician would actually just touch base with them so you use your resources that you have in effect of ways we have primary care physicians who will spend their Ph to get them more engaged. They will spend their Ph to the hospital for five or ten minutes just to do this it is and the pay is again life so they love it. They feel like they're actually talking to the patient and not just doing paperwork for the physician so. So again these are just a couple of things that I just encourage you. The the last thing I guess that I would. I'd mention to you to two other verses that have just made a profound impact in my practice Revelation twelve eleven they overcame by the blood of the Lamb of the word of their testimony. No matter where I have been in practice whether it's been at we were three and a half years whether it was at Wildwood whether it was in the hospital patients when patients share testimonies it in to other patients they engage and they want to make the changes themselves. If you're holding dinner with the doctors in your community. If you are if you have group sessions in your clinic have patients specific we pick up patients who have had improved and even if they're not coming to the group. Tell your patients would you find us coming and sharing five minutes what happened at the beginning of the or whatever. What happened when you engage these things when patients hear the stories from other patients are more likely to engage and they are when you and I sometimes mention of them our stories unless we're sharing our own personal stories with them. So don't forget the power that that comes with that and I will end with that level and then we'll take questions. This media was brought to you by audio first a website dedicated to spreading God's word through free sermon audio and much more if you would like to know more about audio verse or if you would like to listen to more service leave to visit W W W audio verse or.

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