1. Exercise and Mental Health Counseling Services Exercise and Mental Health Counseling Services Resources and Expectations for Affiliated Programs

2. October 2009 Joslin Care = Team Care Endocrinologist Nurse educator, CDE Dietitian educator, CDE Exercise physiologist (or related degree) Mental health provider –Social worker –Psychologist –Psychiatrist Orientation policy: Policy AO-20 Come to Boston for training Use Psychosocial Manual (Tab A)

3. October 2009 Our Findings…. Affiliates are not all engaging and/or using the team to its full potential. –Results from conference call polls –Results from Survey Monkey assessment Joslin/Boston may not have provided enough support to mental health and exercise providers –Expanding services with Clinic departments

4. October 2009 Introducing… John ZrebiecJacqueline Shahar

5. October 2009 Minimum Standards All clinic staff will meet basic qualifications, receive appropriate orientation, and maintain CE as per the requirements of their positions and Joslin policies. Each outpatient receives team care, including a complete initial assessment and treatment plan by a diabetologist and a diabetes educator.

6. October 2009 Orientation – Policy AO-20 All psychosocial and exercise counselors are to come to Boston for training –Exceptions made by Director AP –1-2 day orientation in Boston –Review Exercise and Psychosocial manuals

7. October 2009 How is behavioral medicine integrated at Joslin? People –Large staff (social worker, psychologist, psychiatrist) Materials –Assessment tools –Handouts (stress management, emotions) Classes / Support groups –Usually begin with discussions related to feelings, common misunderstandings –You Did It – a specific class on goal setting –Blood Glucose Awareness Training (BGAT) –Support groups Counseling Approaches –A focus on behavioral goal setting –Understanding barriers –Patient directed action steps Participate in team meetings – discuss cases

8. October 2009 Assessment  Gather clinical and exercise history  Perform exercise capacity tests  Stress test, 6-Minute Walk Test, billing code: 94620  Pulmonary function test  Waist and hip measurements, body composition  Questionnaire – barriers to exercise  Provide an individualized exercise plan  Follow up appointment to evaluate results and progression  Do you have an exercise facility and/or exercise specialist your work with?

9. October 2009 Expectations for Affiliates Identify, orient and use your Mental Health Provider and Exercise Physiologist/Physical Therapist Clarify roles and responsibilities: –Attend periodic staff meetings –Attend annual Affiliate Site Visit –Conduct classes for patients/training for Joslin staff –Participate in team clinical case conferences –Conduct support groups and/or other classes –See patients individually by appointment Identify someone on the Affiliate staff who will be the primary link to these providers (to forward Joslin related materials, updates, etc)

10. October 2009 Depression and Anxiety Disorders Depression is common –2-3 times more common than in general population –19% met criteria for major depressive disorder Twice as likely to miss medication doses –About 70% type 2 report some depression symptoms Linked with poorer adherence to diet, exercise, meds and higher A1C levels

11. October 2009 Eating and Related Disorders Eating disorders more common in type 1 women –2.4 times higher risk for developing eating disorder than age matched women without diabetes Insulin restriction common in type 1 –30% insulin restrictors at baseline –Higher rates morbidity and mortality –Screening question: I take less insulin than I should (often – sometimes – never) Goebel-Fabbri, D.Care March 31(3):415-9, 2008

12. October 2009 Exercise Helps Preserve Muscle Mass During Weight Loss Diet Only Loss of Muscle Mass (% Total Weight Loss) Diet Plus Exercise Men Women *P<0.05 Ballor et al., 1994; Garrow et al., 1995;

13. October 2009 Flexibility Exercise  Stretching:  Helps avoid stiff, sore, tired muscles  Helps performing daily activities easier  Helps avoid injuries  Options: static or dynamic stretching, yoga  Perform stretching exercises when muscles are warm  Hold a stretch for 30-60 seconds and repeat twice  Stretch to a point of tightness, without inducing discomfort * ACSM’s Guidelines for Exercise testing and Prescription, 2006.

14. October 2009 Facts about Exercise Behavior  Exercise is voluntary & time consuming  Exercise compete with other valued interests & responsibilities of daily life  Dropout rate is high in the first 3 months, increasing to 50% within 1 year

15. October 2009  Lack of time  Social influence/support  Lack of energy  Lack of motivation Barriers to Being or Staying Active  Fear of injury  Lack of skill  Lack of resources  Weather

16. October 2009 Strategies to Overcome Exercise  Address and overcoming barriers  Use the Barriers to Being Active Questionnaire  Time management  Social support  SMART goals  Teach exercise skills

17. October 2009 Effect of Long vs Short Bouts of Exercise on Adherence and Weight Loss Long bout = one 40-min session. Short bout = four 10-min sessions. Activity (min/wk) Long Bouts Short Bouts Long Bouts Short Bouts 10 8 6 4 2 0 Weight Loss (kg) P=0.08P=0.07 Jakicic et al., 1995

18. October 2009 Summary  Assess patients and incorporate tests to identify current exercise capacity and progression  Address barriers and solution to being active  Discuss blood glucose management, insulin and meds adjustments on days of exercise  Connect with exercise experts to provide individualized exercise program