The use of hospital pharmacy The use of hospital pharmacy profiles to identify patients with profiles to identify patients with metabolic syndrome and their metabolic syndrome and their

history of nutrition intervention history of nutrition intervention from a registered dietitianfrom a registered dietitian

Presented by: Presented by:

Simon Leung, Dietetic InternSimon Leung, Dietetic Intern

July 17, 2008July 17, 2008

OutlineOutline Metabolic Syndrome OverviewMetabolic Syndrome Overview Problem/Research QuestionsProblem/Research Questions MethodsMethods ResultsResults ChallengesChallenges Future ResearchFuture Research ConclusionsConclusions AcknowledgementsAcknowledgements

Metabolic Syndrome Metabolic Syndrome OverviewOverview

A cluster of metabolic risk factors that: ↑↑ risk of CVD ~2-foldrisk of CVD ~2-fold ↑ ↑ risk of Type-2

diabetes development ~5-fold

Prevalence in North Prevalence in North America: America: Approximately ~25%Approximately ~25%

Abdominal obesity

Glucose intolerance/ Insulin resistance

Hypertension

Atherogenic dyslipidemia

DiabetesDiabetesDiabetesDiabetes CVDCVDCVDCVD

Adapted from National Cholesterol Educational Program (NCEP), Adult Treatment Panel (ATP) III; 2001.

Characteristics of the Characteristics of the Metabolic SyndromeMetabolic Syndrome

Slide source: www.obesityonline.org

International Diabetes International Diabetes Federation (IDF) Definition of Federation (IDF) Definition of

Metabolic SyndromeMetabolic SyndromePre-requisitePre-requisite::

Central (abdominal) obesity:Central (abdominal) obesity: American: male, ≥≥ 102 cm; female, ≥≥ 88

cm

Plus 2 of any of the following factorsPlus 2 of any of the following factors:: Raised fasting blood glucose:Raised fasting blood glucose:

≥ ≥ 5.6 mmol/L or previously diagnosed type 2 5.6 mmol/L or previously diagnosed type 2 diabetesdiabetes

Raised triglycerides:Raised triglycerides: ≥ ≥ 1.7 mmol/L or specific treatment for this 1.7 mmol/L or specific treatment for this

lipid abnormalitylipid abnormality Reduced HDL cholesterol:Reduced HDL cholesterol:

Males < 1.03 mmol/L; females, < 1.29 mmol/LMales < 1.03 mmol/L; females, < 1.29 mmol/L Or, specific treatment for this lipid Or, specific treatment for this lipid

abnormalityabnormality Hypertension:Hypertension:

Systolic BP ≥ 130, or diastolic BP ≥ 85 mm HgSystolic BP ≥ 130, or diastolic BP ≥ 85 mm Hg Treatment of previously diagnosed Treatment of previously diagnosed

hypertensionhypertension

Age-Specific Prevalence of Age-Specific Prevalence of the Metabolic Syndromethe Metabolic Syndrome

Ford ES. Prevalence of the metabolic syndrome among US adults. JAMA (2002) 287(3):356-9

Nutrition & Metabolic Nutrition & Metabolic SyndromeSyndrome

Western dietary pattern, Western dietary pattern, meat and fried foods meat and fried foods associated with metabolic associated with metabolic syndromesyndromeLutsey et al Circulation (2008) 117 Lutsey et al Circulation (2008) 117 (6), pp 754-761.(6), pp 754-761.

Eating patterns consistent Eating patterns consistent with 2005 Dietary with 2005 Dietary Guidelines for Americans Guidelines for Americans associated with ↓ associated with ↓ metabolic syndrome metabolic syndrome prevalenceprevalenceFogli-Cawley et al AJCN (2007) 86, Fogli-Cawley et al AJCN (2007) 86, pp 1193-1201.pp 1193-1201.

Confusion over Confusion over definition of definition of metabolic syndrome metabolic syndrome criteriacriteria

Metabolic syndrome Metabolic syndrome diagnosis “Rarer diagnosis “Rarer than a blue moon”than a blue moon”Ford ES Diabetes Care (2005) Ford ES Diabetes Care (2005) 28(7), pp. 1808-1809.28(7), pp. 1808-1809.

Problems/Research Problems/Research QuestionsQuestions

The prevalence of metabolic The prevalence of metabolic syndrome within the community syndrome within the community hospital is unknownhospital is unknown

If metabolic syndrome does exist the If metabolic syndrome does exist the dietitian is not receiving referralsdietitian is not receiving referrals

Therefore, metabolic syndrome Therefore, metabolic syndrome inpatients not receiving nutrition inpatients not receiving nutrition interventionintervention

Problems/Research Problems/Research QuestionsQuestions1.1. Is there a new Is there a new

multidisciplinary approach multidisciplinary approach for a dietitian to identify for a dietitian to identify Metabolic Syndrome?Metabolic Syndrome?

2.2. Have Metabolic Syndrome Have Metabolic Syndrome patients ever seen a patients ever seen a dietitian?dietitian?

MethodsMethods

Cross-sectional prospective studyCross-sectional prospective study 22-bed acute care community 22-bed acute care community

hospitalhospital Three month collection periodThree month collection period Informed verbal consent obtainedInformed verbal consent obtained Anonymity of patient maintainedAnonymity of patient maintained

1.1. List of medications for metabolic syndromeList of medications for metabolic syndrome

2.2. Created data collection toolCreated data collection tool

3.3. Screened pharmacy profiles – PharmacistScreened pharmacy profiles – Pharmacist

4.4. Reviewed charts for dataReviewed charts for data

5.5. Visited patients with NursingVisited patients with Nursing Waist circumferenceWaist circumference InterviewInterview

Waist CircumferenceWaist Circumference

Obtained verbal Obtained verbal consentconsent

Physically located Physically located markersmarkers

Measurement Measurement read on read on exhalationexhalation

Two readingsTwo readings

Adapted from the Metabolic Syndrome Institute website http://metabolicsyndromeinstitute.org

6.6. Identified those with metabolic syndromeIdentified those with metabolic syndrome

ResultsResults100 patient

pharmacy profiles reviewed

46 patients EXCLUDED from

studyN = 54

patients on ≥ 1 MEDICATIONS for metabolic syndrome

YESn = 26 (48.1%)

had metabolic syndrome

NOn = 28 (51.9%) did not have metabolic

syndrome

CharacteristicsCharacteristics

Metabolic Syndrome GroupMetabolic Syndrome Group Prevalence:Prevalence:

48%48% 42% - Ford et al JAMA (2002) 287, 356-35942% - Ford et al JAMA (2002) 287, 356-359 47% - Curtis et al Diabetes Care (2007) 30, 47% - Curtis et al Diabetes Care (2007) 30,

2553-582553-58 By gender:By gender:

Men – 38.5%Men – 38.5% Women – 61.5%Women – 61.5%

Average age:Average age: 73 +/- 9.0 (mean +/- SD)73 +/- 9.0 (mean +/- SD)

Metabolic syndrome not diagnosedMetabolic syndrome not diagnosed Top 5: CHF, Sepsis, MI, NSTEMI, SBOTop 5: CHF, Sepsis, MI, NSTEMI, SBO

Number of Medications for Metabolic Syndrome in Patients with and without Metabolic Syndrome

39

28

18

7

4

0

44

15

46

12

15

0

8

0

5

10

15

20

25

30

35

40

45

50

1 2 3 4 5 6 7

Number of Medications Used for Metabolic Syndrome

% o

f P

atie

nts

No MetS

MetS

R=+0.477, p<0.05R=+0.477, p<0.05

Number of Years Patients with Metabolic Syndrome Last Consulted with a Dieitian

30.8%

34.6% 34.6%

28.0%

29.0%

30.0%

31.0%

32.0%

33.0%

34.0%

35.0%

Never >5 years ≤5 years

Time Frame

% o

f P

atie

nts

Reasons Why Patients with Metabolic Syndrome Consulted with a Dietitian

31%

38%

12% 12%

4% 4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Has not seen RD Diabetes Diet WeightManagement

General Nutrition WeightManagement &

Heart Healthy Diet

Diabetes &Weight

Management

Reasons

% o

f P

atie

nts

ImplicationsImplications

Metabolic syndrome medications:Metabolic syndrome medications: Identification of metabolic syndromeIdentification of metabolic syndrome Identification of central obesityIdentification of central obesity

Multidisciplinary approach to Multidisciplinary approach to dietitian referraldietitian referral PharmacyPharmacy NursingNursing

Expedites referral to dietitianExpedites referral to dietitian Patient receives nutrition intervention for Patient receives nutrition intervention for

metabolic syndrome soonermetabolic syndrome sooner

ChallengesChallenges

Time limitationsTime limitations

Small sample sizeSmall sample size

Missing dataMissing data

Data collection Data collection Time consuming Time consuming

Future ResearchFuture Research

Further study needed in larger Further study needed in larger institutions (e.g. long-term care, institutions (e.g. long-term care, urban hospitals, community health urban hospitals, community health centres)centres)

Similar results in younger age Similar results in younger age groups?groups?

Determine if nutrition intervention Determine if nutrition intervention would benefit metabolic syndrome would benefit metabolic syndrome patientspatients

ConclusionsConclusions Metabolic syndrome was Metabolic syndrome was

prevalentprevalent Pharmacist can be Pharmacist can be

included in healthcare included in healthcare team to refer patients team to refer patients with metabolic syndrome with metabolic syndrome to dietitianto dietitian

There is a gap in the There is a gap in the dietary management of dietary management of metabolic syndrome in metabolic syndrome in inpatients with metabolic inpatients with metabolic syndromesyndrome

AcknowledgementsAcknowledgements

Deborah Quintal RD CDEDeborah Quintal RD CDE

Alan Gervais, PharmacistAlan Gervais, Pharmacist

Adam Telner MDAdam Telner MD

Joseph Murphy RDJoseph Murphy RD

Louise Gariepy PhD CandidateLouise Gariepy PhD Candidate

Shelley Graham RD CDEShelley Graham RD CDE