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Every Practice a Lifestyle Center

Tim Howe

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Tim Howe

Medical Director of Wellness and Diabetes Education at Parkview Adventist Medical Center

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  • October 28, 2011
    9:30 AM
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I thought I'd start out with some case studies we could title this lecture out around the surgeon this misleads their vascular surgeon but I didn't do the two studies in lifestyle medicine these are cases from my own practice I don't have a lifestyle center you could go to we marring get similar results or to Eugene Pines or any of those but you can do this in your own practice and that's really the take-home message of this first part these are people that just walked into my practice and unfortunately not all of them listen the first time but you know that happens with me at home I don't always listen to my wife the first time I learned though they suffered from not listening to me and I suffer from not listening to her case studies JB and eighty three -year-old woman with hypertension coronary artery disease hyperlipidemia she had an anomaly or aneurysm repair in nineteen seventy four vessel coronary artery bypass grafting in nineteen eighty and aorta femoral bypass in nineteen ninety eight you might say that she has vascular disease to develop type two diabetes in two thousand and four complicated by stage three chronic renal insufficiency in two thousand seven and two thousand eight she presented with severe intermittent claudication maximum tolerable walking distance before rest less than one hundred that's trouble for pulses were traced to absent her meds were swallows in the proper while fifty b.i.d. eight four percent and eighty rather major dose there aspirin eighty one isosorbide 's two milligrams vague with design five milligrams daily nitro and is still having chest pain when she walked if she could tolerate it like pain I said well we can do no surgery again maybe by your kidneys wouldn't stand it very well it might kill you would you like to try something else he so I'd rather do anything and have surgery I've had enough of that I said all right will do a reversal diet now reversal diet is the same thing that acyl spine and oration those guys used only mine I do allow a few knots it's not really mine began reading ministry of healing she says be careful with those diet and health that's the chapter if you want to look it up so she'd shrug chose to try reversal diet September two months later she was walking three miles a day without chest pain no less I didn't take that long it took to week she came in back in two weeks and she said I want you know I walked for two miles today that's the longest she had walked in years and so she is not needed any nitro October this suggests our before he came down she fell off her diet this summer I had a quarterback on more blood pressure medicine as you can see there is a result of that but eventually got the idea that maybe she should get back on it where leg started a and now she's doing better she still on no diabetic meds look at her serum creatinine one one yes she still has renal insufficiency but it's better than it was in two thousand eight next case this guy is a mass as you can see you got the previous one was a mess look at this one GH seventy six -year-old man with coronary disease can just superb preorders already had several MRIs diabetes mellitus type two athletes type to be used on insulin stage three chronic renal insufficiency coronary artery bypass grafting in nineteen ninety two court are right coronary artery endarterectomy in nineteen ninety eight that right Carteret carotid was actually done twice a clotted the first time they'd repeated it and then it occluded again trouble you know it has severe peripheral vascular disease was right subclavian bilateral for mold right renal artery stenosis in the carotid artery had completely occluded on the right in two thousand but in two thousand ten I did another duplex scan which showed greater than seventy percent stenosis alone left carotid and again total collusion or occlusion of the right he was admitted in July to the ICU with non- QA them my after evaluation by cardiology he was told his coronary artery disease a small vessel diffuse disease for which there was no therapeutic options other than Matt 's so nurses discharge meds and by the way he did have chest pain on the day of discharge with minimal activity like walking out the door this discharge meds were swallows in the proper all hundred B ID losartan hundred milligrams daily simvastatin eighty milligrams feeling now you'll notice that I wouldn't use simvastatin at this dose today and amlodipine but we didn't know better than chlorthalidone twenty five milligrams and Lasix why chlorthalidone and Lasix because I needed to use both in order to keep his potassium within normal limits I mean this guy 's a mess aspirin eighty one milligrams daily Plavix seventy five milligrams daily Lasix eighty milligrams daily isosorbide sixty milligrams daily amlodipine ten milligrams daily plus is on the outlook NovoLog and one rear sixty five units a day on a mission a serum creatinine was two six this potassium ex three experience chest pain with mild exertion on the day of discharge it was to try reversal diet why because even want to die I mean it's pretty simple as backs of the wall what you do so in a wide work with this guy for years they've been through our lifestyle choices program it said yeah yeah give me meds well now meds won't work surgery won't work so October a little more than a year later on a reversal diet he walks regularly he still has congestive heart failure with a low ejection fraction has to be careful with the salt and potassium intake that's from the height or rent any mechanical aldosterone is but he has had no chest pain is not required nitro for the last ten months as medication is as follows in the top twelve fifty by the ID amlodipine daily atorvastatin down to twenty milligrams daily aspirin eighty one Lasix twenty eleven meters and twenty four units he does not require NovoLog anymore look at his serum creatinine one seven potassium normal LDL sixty and look at this September that's this year two thousand eleven carotid artery duplex showed less than fifty percent narrowing of the left carotid artery this was confirmed I didn't believe it so I confirmed it with an MRA right still included surgery done do that surgery corrects a mechanical problem that is just not as address the disease process next one this guy and I'm going to be interviewing now when I go home on November three from Maine Public radio on their speaking in Maine interesting guy he came to me in referral from the surgeon he had a facial leaves emanated to be resected but he had mentioned the surgeon know by the way I get chest discomfort when I walk surgeon setting for free the treadmill stress test because of that prior to seeing the surgeon the week before you'd not seen a physician for fifty years on September seventeen the letter forget this two thousand ten is pre- test blood pressure was one sixty over ninety the exercise for two minutes twenty seconds on the Bruce protocol developed chest discomfort actually do develop chest discomfort before you get two minutes if four millimeters ST depression with the peak pressure of two twenty over one ten the refuse nitro I stopped the treadmill said would you like some Nitro should know I don't think so it's not too bad yet thirty minutes later and all this time I'm trying to talk him into going in the hospital thirty minutes later his ST segments were still down there depressed a millimeter but his pain had eased out and saved on awaited knees I'm sure strokes bumped but we did check those his blood pressure a drop in that nice two hundred and eighty over one hundred he refused ICU admission despite strong urging he was given scripts from top pro-life pro- simvastatin lisinopril urged to take aspirin he requested information on time and he and his wife are counseled on diet by my nurse practitioner Mary Penner who's here today and if you want some help on what to say talk to her not me for two hours and on the foolishness of trying diet alone by me why because this guy was a great I mean this chance of sun death was high I mean let's face it sometimes if you break your leg you need to cast and that's what meditation is it's not to be used when the legs heal medicine doesn't fix anything but sometimes it's needed but even sell his medication at all I gave it to them but even filling it was seen in the office three days later on a careful diet his blood pressure was one thirty over seventy B was eating very carefully three weeks later he was seen in the office and he noted that he walked the three mile on Yonkers served trail on Westport Island I went and walked because I want to see what it done I couldn't believe it without chest discomfort though he did admit to fatigue and leg soreness the next day as it was the longest walk two taken in several years the next week he had the clan surgery much to the distress of the anesthesiologists of Skype call me up and said you know this guy could drop dead on the table I suggest we just walked three miles in Europe can do that to them so going there October eleven he reported no just a lot October two thousand eleven he's reported no chest discomfort with exertions and see one on the sky be still following the diet strictly walking regularly feels great on no medication and all of the interviewing him next week okay now here's this case here at I wouldn't even try this in fact here's the truth I usually talk to diabetics that are type two I don't mess around with type one and I was working with this girl and you Wilson in the story where this happens but she said how come you won't help me I said what we can reverse your diabetes she situated on waste trying to do something so we did DGS fifty five -year-old woman asked my age she was born just a few months made she always reminds me choose my elder and I have to do what she says she has a forty seven year history of type one diabetes she's on an insulin pump her diabetes is complicated by retinopathy with unilateral blindness neuropathy with peripheral and autonomic neuropathy she has gastroparesis she has nephropathy status post renal failure dialysis and renal transplant or husband gave her a kidney before they were married that's real love in nineteen ninety six and two thousand because the gradually increasing engine cap was done which showed small vessel diffuse coronary artery disease and they said well we can't help you in two thousand eight because of superior peripheral vascular disease she developed recurrent foot ulcerations and digit amputation was discussed once you start that you go to the digits and you do the four foot venue BKA and when you're up to and a.k.a. but she didn't want to do that she was losing vision in her left thigh despite laser treatments every three months and could no longer read in December two thousand and eight her serum creatinine was two six yet absent pedal pulses and lower extremity segmental pressures and waveform showed incompressible lower extremity vessels bilaterally and moderate distal ischemia on the right and left secondary to iliac and warfare world artery occlusive disease and also distal disease she's in trouble somewhat desperation and because she said to me aren't you going to do anything and her husband said I don't have another kidney to give you in January two thousand nine offer to coach her and her supportive husband you know why he was supportive on a reversal diet and she has followed the diet strictly cents in August two thousand eleven listen closely segmental lower extremity pressure and waveform studies were repeated and showed how much evidence of ischemia no evidence of this was steamy on the right or left her beautiful pulses are now palpable in her sensation to a ten gram nylon monofilament that was absent in two thousand eight is normalized except on the right distal great toe where it remains diminished in two thousand eleven or serum creatinine was one six that's an improvement notice that right doesn't happen with medicine or cholesterol HDL ratio was three one she just four to six times a day and has few if any sugars below eighty since changing her diet where's before this was a common occurrence now her hemoglobin A-1 C was six one is six one you're not supposed to run on that well okay you're supposed to run it at seven why because you can't get someone below seven and not have them experience hypoglycemia which is definitely to the heart and the brain unless they're on a very careful diet which she is I have never seen control like hers because I never had another type one diabetic on the skin therefore the birth she runs her sugars essentially normal without hypoglycemia she reports there is much easier to control her blood sugar than before she is not had any angina or required nitro for more than a year or visualized her vision stabilize you can read again after the dietary changes not needed any further laser treatment or ophthalmologist has reduced her visits to yearly the natural biosis you know what that is on the legs and you know it's not her biosis diabetics looked metallica diabetic or or something like that anyway it's gone and her nephrologists ophthalmologists and vascular surgeon are non- plus at some point it may become malpractice not to offer lifestyle she probably wouldn't be alive today and I have a question how many of you in this room are doctors doctors of medicine her doctors and dentist dentistry will you stand up right you can also do how many of you know what it means to be a doctor it means to be well the word doctor comes from the Latin word dosage or it means to teach you should be a teacher and Ellen White knew that she said the truth physician is an educator he recognizes his responsibility not only to the patients that are under his the record here but also to the community in which he lives we stands as a guardian of both physical and moral but that it gets sticky the physician 's example no less than his teaching should be a positive power on the right side the cause of reform calls for men and women whose practical life practice is an illustration of self-control it is our practice of the principles we inculcate the Gibson weight do you have trouble changing your patient's lifestyle what your own look like the world needs a practical demonstration of what the grace of God can do in restoring the human beings their lost kingship giving a mastery of themselves there is nothing the world needs so much as the knowledge of the gospel saving power revealed in Christlike lives did we switch here it we go from physical or spiritual not yet she's talking about the physical there is nothing the world needs so much as the knowledge of the gospel saving power the Gospels ability to change your health habits in mind remember what Paul said I'm not ashamed of the gospel for it is the power of God and salvation Ellen White desire data says the very essence of the gospel is restoration restoration is not just emotional and spiritual it's physical to these aren't in your handout as I told John Chung I can't stop adding staff so this morning I added some more this is from the college and medical D'Angelo seven three the union of Christ like were are for the body and Christlike work from the soul is the true interpretation of the Gospel no right there between for the Bonnie and for the sole genuine medical missionary work that's what were supposed to be doing genuine medical missionary work is the gospel practice volume made of testimony one sixty eight will make sense you know were medical missionaries and were practicing the gospel right now but listen let's go on this is from councils on health the Ministry needs a medical missionary work to demonstrate the practical working of the gospel and then from page five twenty four the medical missionary work is the gospel in illustration show me how the gospel works it works in the spiritual just like it works in the physical let me say one thing and get it clear with you don't be teaching salvation or signaling by works feeling comes by faith in a power the power of God that's the gospel the reason that health the medical missionary work is the opening wedge is not because we do this bait and switch thing it's because medical missionary work is the gospel in illustration remember what the Bible says Psalm one oh three verse three who forgiven all of mine iniquities who heal with all thy diseases remember the Hebrew parallelism here is saying the same thing in both lines it's the the same gospel and if you want to change patients lives you have to introduce trust in divine power at the beginning because were not being Ornish were not also sign were not Campbell we don't tell you how how to live longer for twenty years to lengthen your life by ten or twenty were talking about eternity that was just an aside is but I want to listen closely this next quotes from ministry of healing the auto memorized the chapter the physician and educator the physician is continually brought into contact with those who need the strength and encouragement of right example many are weak and moral power they lack self-control and are easily overcome by temptation the physician can help the souls only has he reveals in his own life a strength of principal that enables him to triumph over most injurious habits every injurious habit and defiling life I lost in his life must be seeing the working of a power that is divine if he fails here however forceful or persuasive his words may be his influence will tell for evil look at your own life look at your heart not your waistline is your influence telling for evil is it better find that out no matter how persuasive or forcible your words is a power of God work in your life and I was tasked to review the literature on this incursions change while I did I read about fifty or sixty articles and I included one here because I think it's a lot straighter from the writings but just read through this with me you'll get my drift this is family practice actually British Journal unchanged on the spelling so you'll be able to read it conclusion the relative importance of specific behaviors varies across preventive interventions this points to a need for tailored practice interventions targeting the specific barriers that impede a given preventive service the negative influence of the physicians own behaviors indicates a need for associated population -based interventions that reduce the prevalence of high risk behaviors in the population as a whole and clear all what if a fine they found a specified position drinks and tells patients to stop if he doesn't exercise he doesn't tell his patients to start and if he doesn't know his own plot blood pressure he does a really lousy job at controlling his patients blood pressures the bottom line is this if you don't stock it you can't sell now I talked about malpractice earlier not all offering lifestyle medicine may one day be malpractice but I want you to read this and think about another kind malpractice in their work of dealing with disease and death positions too often lose sight of the solemn realities of the future life in their earnest effort to avert the Carol of the body they forget the parable of the soul the one to whom they are ministering maybe losing this whole long life this last opportunities are slipping from his grasp this sold the position must meet where at the judgment seat of Christ I don't know if they hand you have the unfortunate opportunity to be involved in malpractice I have another physician made a mistake and sucked me into on more than one occasion I have been perfect but I'll tell you what I'd rather stand before any judge of the circuit before the judge with the blood soul long way well you know I practiced medicine for twenty two years in the same town Brunswick Maine and I see about twenty patients a day used to see more about what the benefits of computerized medicine and meaningful use which is entirely on meaningful to me I can't go as fast as I did dating and I can't tell you how many days I've been in my office someone comes in they need lifestyle counseling am already an hour behind my nurse can tell you how many times I can she's worked with me for twenty two years bless her heart all or other vital organs and I she's only missed a half-day work and she came and that David to get bombings Center home will I have ideas and have a good opportunity to work with the position and training you told me once anybody can be a doctor if they have good enough nurse will I do she did tell you and I can't tell you how many times I've gotten home late on a cold water night and we got a lot of those in Maine we do have a beautiful summer rain it's gorgeous it's beautiful last year was on Wednesday him to lead you get home you get home at a scold you know in and my wife's and dad and and that you not use feel the warmth emanating from that bed and I'm without the crawl in you know the beeper goes off at CERN so you go back in your dog card and think how can you well I'm here to tell you you can't attend can be what you doing without help my favorite prayers God be merciful to us Paul said in my murder of my strength my weaknesses made perfect in history no less one thing is one thing I'm not short on his weakness never found that out when you neglect of prayer you deprive your patients and blessings medical ministry one ninety five when you neglect to offer prayer for the sick he deprived them of great blessings for angels of God are waiting to minister to souls in response to your petitions when the last time you left the Angels hang of standing around your office fail I hope that brother praise elsewhere anything to do here I hope that Sister Graves stand there twiddling their thumbs so what you want them to do well changing your patient's diets in the office practice you better begin every day with prayer I was a little bit afraid to do this in our office because not everyone in the office is an ancestry of the lady that's not enough who is the most insistent where prayer shoes one who always says thank you after worksheet for Prairie Luke five seventeen and it came to pass on a certain day as he was teaching the power of the Lord was present to heal is a powerful Lord present to heal in your office if it isn't you know I didn't want to reasons in your life so what are you having prayed one of the two nearly where you get your life back to the start friend all right so while I do what I do for these five people for people well I'm front rough in years week one and you might not like it you might have another one this is what I hand them as is what you need the first week same thing every breakfast everyone to never supper and don't complain to me you're the one that got yourself into this mess and and and I tell them one thing I said you will not be hungry that's all I would guarantee you won't be hungry so you can read through what I give him and then I say I want you to read two oh one should read one of these books to read prevent and reverse heart disease by hassle sign a reversing diabetes by Neal Barnard of China studies and got cancer or forks over nine cents out the book as well as moving they can't read they can look at the movie or you can even try ministry of healing diet house it works works really well in week two they return and everyone will say well I feel better but then I have some melts the and then I have see Mary Penner is sitting right here and they think they've done gone to heaven but if she's gone her before she was working for me of late had put up with me and if any of you are interested in some of the menus we use or the other recipes Mary has a cookbook she has said some things whether you can contact where we stand up this is very better and she can help you anybody here that has coronary disease talk to her and now is essence nine cents coronary artery disease is a toothless paper tiger if you eat right it will goal was ninety nine percent of the time there is one percent of people that have terrible genetic problem but that's only one percent those are the ones reliever Brian Swartz for referring the rest and come to Weimar or more and was in way to reduce around one hour diet counseling and were there desperate with me and they've got to have recipes and cookbooks and then using whereby all the new ingredients and how to season things week three they return for lab testing follow-up and encouragement in connecting with venues outside of the office for further teaching and we tried all kinds of and we have a two week lifestyle choices program or they commonly have a lecturer and exercise every evening and then we provide them all their food they get supper on site and a take-home breakfast and lunch you know it's not ideal it's a lot better to send them away someplace in the country sanitarium style but this works in its affordable and insurance covers it and we got great numbers we been doing it for sixteen years and works good or another thing I really like a supper and a group visit when you're not doing lifestyle choices we do that Mary cooked supper I never miss a supper in America suffer at all had a patient come and know his bellies out to hear this and I has diabetes and coronary disease is after suppers are never eaten as good as you can tell I've eaten a lot I did try to take Mary home to be as good but Mary's husband right with allowing this that works cooking schools work like a man but remember if you don't introduce some of the power that sustains change that enables change will just be reset introduce them to the power of God in closing I like to say the biggest impediment to lifestyle change in the patient is the unchanged life of the doctor got there and think about any questions question from a bad way give them handouts with recipes and menus we have a three week menu and recipes Mary has a cookbook for sales she has a copy of a fair neighbor engine bracket have a wonderful cookbook seven secrets of one of my patients had been on the vessel signs prevent and reverse heart disease diet and stuff that's in his book and she got that one and she said I thought I'd gone to the promise land we are very careful with diets one were working with people this sick time for a note these people are not easy these are sick puppies I mean the guy with the four millimeter ST depression he was really the easy one the only thing I was really worried about was that first two weeks asked why would you know that when women were scores Brian Brian what would you have done with that guy cast him right that is exactly and asked what I thought to run me put some in this guy make sure he makes it the next two weeks of being a minute and a half on a treadmill drive and and and and normalize even when he left in a half an hour later I was chewing my nails to the stone Martin is actually I think this guy had either severe triple vessel disease or left main disease and I tried to getting the go the ICU and he says no I don't think I will and I said all right but you may drop dead walking down the hall but even three three weeks later you know what happens here is your body gets the ability to make its own nitric oxide again flow mediated dilation normalizes within two weeks on a very careful diet and I the Lord Neil the diet that you and refund interview one character questions yes when you introduce land-based deceit that diet to use did you tell his patients also develop that the gospel or tell me that changed the diet because well what won't I don't tell him about the gospel in the sense of sitting down with the writings of Paul I tell them look God will help you make the change that simple I believe I say I believe that the God who designed your body to heal itself will help you make the changes needed to help you and I and were it to be praying for you that's the gospel italics I mean really what is the gospel the gospel is God 's will has has forgiven your sense as all the stuff you just didn't get yourself into this mess is forgiven then he'll help you start new and he will help you obey these laws and he'll bring it because you can't do it on your own that's what the gospel in residence but the essence of the gospel is restoration physical spiritual and so we start we start with the physical that the opening wedge wires in the opening words they say on this works it works for my body may will work for my screwed up family and that everything else in some studies find them hope to these alleged possible right questioned in all arranges insurance well it's pretty easy after you develop a track record dropping that in the lifestyle choices program we do but was two things on insurance one group visits work fine for the supper of her lifestyle choices that's the base of Darwin Hospital of the way it works is really simple on to in two weeks the average cholesterol drops fifty points the average blood pressure drops ten points average pulse drops ten points and the average weight drops forty five pounds and you show the insurance companies this may sickly or we could do that by now we had to go to each one of them yeah but I mainly been doing at sixteen years I still have another minute right else feel for what suggestions do you have that those who worked with egg and now a public setting for a public hospital or government hostile something like that how can you share your faith or pray with patient and not getting to roll what you know what I think it's just fine to get in trouble doing the right thing bring it on a raised down Lori is the Lord and I think you know my exam on your immigrant guide in this media was using my audio verse four amen at the Pentagon and was never him I learned more about me then please visit www. nine and I will like there was more free online service please visit www. online 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