WASHINGTON, DC—“The whole idea is to look at diabetes as the enemy. Instead of just attacking the enemy from one end, you want to attack the enemy from all sides. Surround the enemy.”
That is the message that Peter Kokkinos, PhD, director of the Exercise Research and Testing Lab at the DC VA Medical Center, gives to patients signing up to take part in the center’s Lifestyle Interventions for Veterans (LIVe) program. “I explain that to my patients, and when they hear it in that way, they understand it perfectly.”
If controlling a patient’s diabetes is a battle, then medication is the traditional, and sometimes only, weapon brought to bear. While medication can be effective, it can only go so far, Kokkinos explained. “Medication and drugs do part of it. But we know that diabetes responds to diet and exercise. With LIVe, we’re basically taking diabetics and implementing a lifestyle modification.”
A holistic program that includes exercise, nutrition counseling, spiritual support, stress management, as well as music and art therapy, LIVe is designed to be flexible enough to adapt to each patient’s unique needs, while intensive enough to dramatically impact the patient’s health.
Even though the program is only in its infancy, the preliminary results have VA physicians sending patients in a steady stream to sign up, and program leaders looking for ways to expand LIVe outside of the DCVAMC.
The Holistic Approach
LIVe is the brainchild of Kokkinos and Dr Raya Elfadel Kheirbek, DCVAMC associate chief of staff, who was recently appointed acting chief medical officer for VISN 5, which includes the DCVAMC, as well as medical centers in Baltimore and Martinsburg, VA. They applied for a grant from the VA’s Office of Transformation Initiatives in December 2009 and were awarded $2.3 million to implement a pilot program.
“They were looking for something outside the box that improves outcomes, but was really patient-centered,” Kheirbek explained. “We give medications. We do a lot of disease-modifying treatment. But we’re moving towards what it is our patients would like to see. And we want something that is individualized.”
Doctor Kokkinos and I are developing a program that is really holistic. We’re not only giving the medicine, but all aspects of care. There’s the diet and exercise, the medication, but also music therapy and spirituality. We have incorporated these into the program. They’re not therapy, but rather mechanisms to improve outcomes of care.”
Currently the program includes three exercise physiologists, two dieticians, a program manager, as well as Kokkinos. The team is highly integrated, and functions differently according to each patient. The leadership of the team changes depending upon whether a patient’s biggest concern is weight, or diabetes, or maybe hypertension, Kheirbek explained. While the end goal might be to improve a patient’s health, the team starts by focusing on the patient.
Kokkinos explained that the LIVe program takes the term “lifestyle intervention” very literally. The goal of the program is not just to throw all possible treatment modalities at the problem in the hope that something will stick. If a patient is just given medication, they take that medication and believe that is all they can do to affect the disease. But if they are given tools that make them an active participant in controlling their diabetes, then that not only improves outcomes, but also changes the entire dynamic between the patient and their disease.
“We tell the patient, ‘Look, your primary care doctors give you your medication. We’re going to give you something else. We’re going to control your diet. We’re going to control your stress level. We’re going to make you see the world from a different perspective. We want to empower you and make you capable of taking control of your life and your condition,’” Kokkinos said.
Positive Preliminary Data
While the program is still in its early stages, it already has hard data supporting its methods. For patients entering the program, baseline weight after four to eight weeks of regular exercise and diet dropped by five pounds. Blood glucose levels of patients prior to starting their daily exercise routine startedat an average 172. After 30 minutes of exercise, glucose levels dropped to 107.
Patients are seeing a steady, cumulative improvement in blood pressure. The average patient starting the program has a BP of 180 mm Hg. That veteran might be prescribed 30 minutes on a treadmill at 1.4 mph two to three times a week. By the second week, the patient’s BP has dropped to 146. During the third week, the treadmill is accelerated to 2.2 mph. As expected, the patient’s BP rise to 178. However, by the fourth week, the patient’s BP has dropped to 160.
“We increase deliberately, because we want to challenge the body,” Kokkinos declared. “The body gets better and better. It adjusts.”
Right now, the program is limited by time and space and patients’ schedules to getting veterans in two to three times a week to exercise. However, those in the program are prescribed exercises to do at home.
“We tell them, ‘When you leave here, we want you to do something. Replicate what you do here, or do some home exercises.’ And we give them home exercises to do,” Kokkinos stated.
Most patients keep with the regimen at home. Soon the program team will be able to prove that. Kokkinos’ office is filled with boxes containing monitors that will soon be distributed to patients in the program. While exercising, patients will wear the monitors, which will track their BP and heart rate. When they return to the hospital, that data will be downloaded and added into their health record to give a better view of how the patients’ health is changing.
“Medication lasts a day. You have to take it every day to get the effects. Exercise is the same way. You have to do it every day, though the effects of exercise last up to three days,” Kokkinos said. “Exercise has a longer affect, but we don’t want any diabetic to go beyond the third day without doing something.”
Building on Success
Listening to Kokkinos and Kheirbek speak about the program, there is the sense of still-stunned delight that LIVe has had such success. “It’s quite astounding,” Kokkinos exclaimed. “What I see looking at the cardiovascular data—it’s shocking. How can just a little bit of exercise do so much?”
“I think why veterans are so happy in this program is that we’re looking at the overall assessment of the person. And we’re tailoring the plan to their individual needs,” Kheirbek said. “It’s not like hypertension management, where everybody who has hypertension [gets a similar therapy]. It’s not population based, but an assessment-based approach.”
The program is looking to reach 300 patients by the end of the year—a figure they will have no problem reaching, Kokkinos said. They are nearly halfway there through word-of-mouth just within the DC facility. Later in the fall, the hospital will begin a larger marketing push, distributing brochures to veterans and creating short media broadcasts covering different health aspects of the program.
Although the program is still in its pilot stage, Kokkinos and Kheirbek are already looking to expand it within the DCVMC and then move it to the rest of VISN 5. The DCVAMC has just signed a contract with George Washington University Medical School to have medical students in need of patient contact hours come in and assist in the program. New space is being created for exercise equipment, and new equipment is being purchased. Kokkinos hopes to expand the program’s focus to include hypertension management.
“What we see are such wonderful results—probably beyond my expectations,” Kokkinos declared. “I believe with Dr Kheirbek’s help in the VISN, we can do so many good things with this program.”
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