1. The use of hospital pharmacy profiles to identify patients with metabolic syndrome and their history of nutrition intervention from a registered dietitian Presented by: Simon Leung, Dietetic Intern July 17, 2008

2. Outline Metabolic Syndrome Overview Metabolic Syndrome Overview Problem/Research Questions Problem/Research Questions Methods Methods Results Results Challenges Challenges Future Research Future Research Conclusions Conclusions Acknowledgements Acknowledgements

3. Metabolic Syndrome Overview A cluster of metabolic risk factors that: ↑ risk of CVD ~2-fold ↑ risk of CVD ~2-fold ↑ ↑ risk of Type-2 diabetes development ~5-fold Prevalence in North America: Prevalence in North America: Approximately ~25% Approximately ~25%

4. Abdominal obesity Glucose intolerance/ Insulin resistance Hypertension Atherogenic dyslipidemia DiabetesDiabetes CVDCVD Adapted from National Cholesterol Educational Program (NCEP), Adult Treatment Panel (ATP) III; 2001. Characteristics of the Metabolic Syndrome Slide source: www.obesityonline.org

5. International Diabetes Federation (IDF) Definition of Metabolic Syndrome Pre-requisite: Central (abdominal) obesity: Central (abdominal) obesity: ≥≥ American: male, ≥ 102 cm; female, ≥ 88 cm Plus 2 of any of the following factors: Raised fasting blood glucose: Raised fasting blood glucose: ≥ 5.6 mmol/L or previously diagnosed type 2 diabetes ≥ 5.6 mmol/L or previously diagnosed type 2 diabetes Raised triglycerides: Raised triglycerides: ≥ 1.7 mmol/L or specific treatment for this lipid abnormality ≥ 1.7 mmol/L or specific treatment for this lipid abnormality Reduced HDL cholesterol: Reduced HDL cholesterol: Males < 1.03 mmol/L; females, < 1.29 mmol/L Males < 1.03 mmol/L; females, < 1.29 mmol/L Or, specific treatment for this lipid abnormality Or, specific treatment for this lipid abnormality Hypertension: Hypertension: Systolic BP ≥ 130, or diastolic BP ≥ 85 mm Hg Systolic BP ≥ 130, or diastolic BP ≥ 85 mm Hg Treatment of previously diagnosed hypertension Treatment of previously diagnosed hypertension

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

7. Nutrition & Metabolic Syndrome Western dietary pattern, meat and fried foods associated with metabolic syndrome Western dietary pattern, meat and fried foods associated with metabolic syndrome Lutsey et al Circulation (2008) 117 (6), pp 754-761. Eating patterns consistent with 2005 Dietary Guidelines for Americans associated with ↓ metabolic syndrome prevalence Eating patterns consistent with 2005 Dietary Guidelines for Americans associated with ↓ metabolic syndrome prevalence Fogli-Cawley et al AJCN (2007) 86, pp 1193-1201.

8. Confusion over definition of metabolic syndrome criteria Confusion over definition of metabolic syndrome criteria Metabolic syndrome diagnosis “Rarer than a blue moon” Metabolic syndrome diagnosis “Rarer than a blue moon” Ford ES Diabetes Care (2005) 28(7), pp. 1808-1809.

9. Problems/Research Questions The prevalence of metabolic syndrome within the community hospital is unknown The prevalence of metabolic syndrome within the community hospital is unknown If metabolic syndrome does exist the dietitian is not receiving referrals If metabolic syndrome does exist the dietitian is not receiving referrals Therefore, metabolic syndrome inpatients not receiving nutrition intervention Therefore, metabolic syndrome inpatients not receiving nutrition intervention

10. Problems/Research Questions 1. Is there a new multidisciplinary approach for a dietitian to identify Metabolic Syndrome? 2. Have Metabolic Syndrome patients ever seen a dietitian?

11. Methods Cross-sectional prospective study Cross-sectional prospective study 22-bed acute care community hospital 22-bed acute care community hospital Three month collection period Three month collection period Informed verbal consent obtained Informed verbal consent obtained Anonymity of patient maintained Anonymity of patient maintained

12. 1. List of medications for metabolic syndrome

13. 2. Created data collection tool 3. Screened pharmacy profiles – Pharmacist 4. Reviewed charts for data

14. 5. Visited patients with Nursing Waist circumference Waist circumference Interview Interview

15. Waist Circumference Obtained verbal consent Obtained verbal consent Physically located markers Physically located markers Measurement read on exhalation Measurement read on exhalation Two readings Two readings Adapted from the Metabolic Syndrome Institute website http://metabolicsyndromeinstitute.org

16. 6. Identified those with metabolic syndrome

17. Results 100 patient pharmacy profiles reviewed 46 patients EXCLUDED from study N = 54 patients on ≥ 1 MEDICATIONS for metabolic syndrome YES n = 26 ( 48.1% ) had metabolic syndrome NO n = 28 (51.9%) did not have metabolic syndrome

18. Characteristics Metabolic Syndrome Group Prevalence: Prevalence: 48% 48% 42% - Ford et al JAMA (2002) 287, 356-359 42% - Ford et al JAMA (2002) 287, 356-359 47% - Curtis et al Diabetes Care (2007) 30, 2553-58 47% - Curtis et al Diabetes Care (2007) 30, 2553-58 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 diagnosed Metabolic syndrome not diagnosed Top 5: CHF, Sepsis, MI, NSTEMI, SBO Top 5: CHF, Sepsis, MI, NSTEMI, SBO

20. R=+0.477, p<0.05

23. Implications Metabolic syndrome medications: Metabolic syndrome medications: Identification of metabolic syndrome Identification of metabolic syndrome Identification of central obesity Identification of central obesity Multidisciplinary approach to dietitian referral Multidisciplinary approach to dietitian referral Pharmacy Pharmacy Nursing Nursing Expedites referral to dietitian Expedites referral to dietitian Patient receives nutrition intervention for metabolic syndrome sooner Patient receives nutrition intervention for metabolic syndrome sooner

24. Challenges Time limitations Time limitations Small sample size Small sample size Missing data Missing data Data collection  Time consuming Data collection  Time consuming

25. Future Research Further study needed in larger institutions (e.g. long-term care, urban hospitals, community health centres) Further study needed in larger institutions (e.g. long-term care, urban hospitals, community health centres) Similar results in younger age groups? Similar results in younger age groups? Determine if nutrition intervention would benefit metabolic syndrome patients Determine if nutrition intervention would benefit metabolic syndrome patients

26. Conclusions Metabolic syndrome was prevalent Metabolic syndrome was prevalent Pharmacist can be included in healthcare team to refer patients with metabolic syndrome to dietitian Pharmacist can be included in healthcare team to refer patients with metabolic syndrome to dietitian There is a gap in the dietary management of metabolic syndrome in inpatients with metabolic syndrome There is a gap in the dietary management of metabolic syndrome in inpatients with metabolic syndrome

27. Acknowledgements Deborah Quintal RD CDE Alan Gervais, Pharmacist Adam Telner MD Joseph Murphy RD Louise Gariepy PhD Candidate Shelley Graham RD CDE