Ep 16 – Nurses Helping NASH Patients

How passionate providers (nurses, dieticians, and physicians) can motivate patient lifestyle changes.
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The Surfers focus on steps Allied Health Professionals and passionate physicians can take to improve lifestyle compliance with NASH and NAFLD therapies. The group explores whether the healthcare system can be as effective as companies like Noom and WeightWatchers. This week’s Music from the Liver Community: beautiful Oud music from Dr. Naim Alkhouri.


 
Roger Green : For everyone with an interest in NASH or more broadly fatty liver disease, Surf’s up. Episode 16 of Surfing the NASH Tsunami starts now. We continue our tour of the teenage years. Last week, it was quincenera, two weeks ago was the age when your kids know the most they’re ever going to know relative to you. This week is Sweet 16, 16 being a volatile year in people’s lives and a great party year for young women.

Roger Green : For us though, boy, what a week., As we announced on social media after last week, we have changed distributors. We are now going with Buzzsprout. We’ve changed engineers, we have Magic MiC Wilson, a renowned audio engineer who records blues musicians among other things, is our engineer now. In the process of all that, we’ve learned that we had lost access to our subscriber lists, so we now need your help in building our contact back through all those people we talked about last week, the 2,300 people, 47 countries, India, South Korea. We need your help getting back to those folks.

Roger Green : At the same time, we implemented a new weekly production schedule that will make it smoother and more streamlined for us to get through the week and signed off on two exciting initiatives I’ll talk about next week. And once more, it’ll be a fun one that happens this week as well.

Roger Green : Oh, in the middle of all that I had time for a birthday. No singing, Peter, no singing, Louise, no singing, anybody. I spent two socially distanced evenings, a birthday party with friends and I got two completely appropriate presents, a fantastic rocking chair and superb bottle of rum. Good times for all.

Roger Green : This week, Louise’s back from holiday, off the barge. Maybe even done celebrating Liverpool having now actually won the cup as the season finished in the Premier League. Suneil is unavailable.

Roger Green : Before we go to our normal program, I want to talk a little bit about what’s happened with the subscribership issues. As I mentioned, we’ve lost access to our lists. It also means that if the link that you have to the program takes you through New Pod City, that link will not work anymore, and what we were unable to do is transfer anywhere. So this means if you’re getting notes from your podcaster every time an episode comes up, you’re not getting them right now. It should be back next week or we have another solution, but you’re not getting them right now.

Roger Green : Number two, you will need to create a new link to hear the program regularly. Okay. So here are some things you can do to help. First of all, pick up the podcast, if you haven’t done so already this week at the Buzzsprout address you can find on all our social media postings and letters. At the beginning, it asks you if you’d like to leave your address to get an early notification, you should do that. We will send you early notifications every week.

Roger Green : We will also send you links to all the major sites, Apple, Google, Spotify, Stitcher, TuneIn, Alexa, other things we haven’t had before that we will have now that you can use or you can send to your friends. Also tell any friend you’ve discussed this podcast with that they may need to do the same thing. If we all do that, we should get ourselves back to force in no time at all, and I’m excited to see how it all goes because I’ve never done anything quite like this before.

Roger Green : We do have one addition this week stemming from two things that happened in last week’s podcast. First of all, people really liked Mick Kolassa’s music. The two minutes of his song that we got to play, Recycle Me, which he felt was appropriate for a liver transplant hepatologist being the guest on the show. Then as we learned last week, Naim Alkhouri is quite a talented musician playing the oud.

Roger Green : So we have a recording of Naim playing, and we’re now going to spend the next couple of minutes listening to that before we get started.

Roger Green : Okay. One more tease before we get started, I mentioned two big stories next week. We will introduce you to our new fifth Surfing regular. Suneil will step into a role of diagnostics expert and we will have a fifth regular to join Steve and Peter, Louise and me on a regular basis. We will introduce you to that person next week, you will be delighted, we are.

Roger Green : And second we’ll talk in detail next week about our plans for EASL. We teased that a little bit last week, spoke about some of the articles we might discuss. We’ll let you know exactly what our plans are for that next week as well.

Roger Green : Okay. And onto our podcast. A lot’s happened in the world of liver this week. Got some good, some not so good, some sad, some happy. So what I’d like to do is I’d like to make the week about personal comments, not necessarily personal highlights. Louise, you want to kick us off?

Louise Campbell : Yeah, I’d like to kick off and it’s a sad note, I suppose. One of the greats of liver disease died this weekend, Professor Roger Williams. I did the majority of my liver training at Kings’. Worked through the unit with Roger as the head of that liver unit and was a board Sister within the unit for a number of years. And I think it’s a great loss to everybody.

Louise Campbell : He was a mentor to many. He was, certainly, when I saw him just before we went into lockdown, he was a great source of wanting to drive allied healthcare professionals forward, nursing and still very, very active within the liver community, and I think that’s worldwide. So it’s a great loss and a personal loss for somebody I knew quite well, and my condolences go out to his family and friends.

Peter Traber : Louise, thanks for that. It’s really wonderful to hear from somebody who trained with him, and worked with him, and had a personal relationship with him. Of course, I only knew him from afar and a couple of handshakes. But I think it’s quite appropriate that we’re going to be doing the EASL meeting coming up, and Roger was one of the founders of EASL, very first meetings that were put together.

Peter Traber : I think he was the first British citizen to win the Distinguished Achievement Award from the American Association of Liver Diseases. I hope somebody will be able to pull up that presentation to honor his memory.

Peter Traber : The other thing I wanted to say from a personal standpoint, kicking off, Roger, is that the music of Michissippi Mick and our clips that we’re presenting of music inspired me to dust off my guitars. So I brought one of my strats down that I have sitting next to me in my office, and when I’m tired of working, I pick it up and I play some. So this podcast has inspired me to do that.

Roger Green : Peter, the initiative we’re going to be announcing is Music of the Liver Community, the idea being that people in the liver community have diverse interests and many have interest in music. So we’re going to be asking people on the community, listeners and people who are your friends or yourself in this case, Peter, to send us a two, three minute clip of your playing.

Roger Green : And we will put one of them on every week and we will ask people to tell a little bit of the story of their passion for music and what exactly it is about that clip that made them bring it on. You now have something to practice for.

Peter Traber : Well, I’m not sure that I’ll be that confident to do that, but I did choose to learn a song yesterday that is appropriate for the times we’re living in. It’s Crazy Train by Ozzy Osbourne. [Laughter]

Roger Green : Yeah, that’s true. That’s true. Stephen, A) anything you want to say about Roger Williams, and then B) your week?

Stephen Harrison : Sure. Sure. I personally never met Roger, although I know of his work very well. In fact, he was one of the senior editors for a book on fatty liver that was published in 2016. He certainly was prolific in his authorship of papers. I seem to recall that at one point in his career, he was the most cited researcher in his specialty. And when you look him up, he has over 3,000 papers, chapters and reviews.

Stephen Harrison : I thought I had a decent number, I’m nowhere, I’ll never achieve a third of that number. So that is just really, really impressive. It’s a sad note, but I think he lived an incredible life and I’m glad that I got to learn at least from some of the work that he helped lead, and I know also he was a founding father of EASL as Peter mentioned. For me, it’s hard to top what Peter did with getting out the guitar.

Stephen Harrison : When I was in Iraq in 2009, I actually learned how to play guitar, but I’m sad to say that in the 12 years since then I have forgotten it again. So Peter, you’re going to have to reteach me how to play. I guess, for personal story of the week is we’re gearing up to, send my oldest back to Texas A&M. They have not shut down. They’re going to do a little bit of online, a little bit of in-person, but they’re gearing back up to head back to college here in Texas.

Roger Green : Okay. First of all, the category of true confessions, I was a very successful high school musician. I was in some All-Star bands and stuff like that, but my instrument was the tuba and sousaphone. I doubt I’m going to be doing any two minute tuba solos for this podcast, and sousaphone isn’t worth listening to if you can’t watch somebody dance with it over their shoulder. So I think I’m going to pass on all this, at least until we go to video.

Roger Green : My story of the week, I mentioned this briefly is our son, our daughter-in-law, and our granddaughter moved down to Texas this week. My wife and I, all of our kids are adopted and he has a sister in Corpus Christi who is very close and who is probably the best person for him to be living next door to in his life. But for those of you who have grandkids and those of you who don’t, watching your two-and-half-year old granddaughter toddle away knowing you’re not going to see her for however long is a wrench.

Roger Green : So I’m thrilled for them. I’m a little ticked off they kidnapped my granddaughter, but then she’s their kid, so they have the right to do that. And I wish Ryan, and Kathleen, and Angel really a good life in Texas because they’ve been working really hard to get to the point they can have one.

Roger Green : We got no letters this week, not surprisingly because we had no links, but someone who heard the podcast who I bumped into yesterday did make a comment about EASL, which I thought was really interesting. High volume prescriber, nonacademic said, “It’s always been a hard meeting for people in the U.S. to access if they couldn’t travel.” So this year he heard it was going online and he got really excited and he looked at how much stuff was going on during the day and realized that it was a normal business day and said, “Boy, this is going to be even worse in some ways.”

Roger Green : So, delighted at the idea that we might be taking some of EASL and delivering it to a global audience who might not have made it to London in the first place, but will probably be working their day jobs on August 27, 28, 29. And again, we’ll tell you more about that next week.

Roger Green : All right. Now, to shift to today’s topic. Today’s topic really, we’re going to take a look at the pivotal role that nurses, dieticians, physician assistants, other allied health professionals play in treating patients. This really comes from two things, we’ve been talking about some recently. One is an entire idea of wellness and illness, and that they are two very different paradigms in terms of how you look at patients and what you’re trying to do for them and with them, and that they might produce results.

Roger Green : And the second, which I guess is out of that paradigm question is Stephen’s comment about the smile curve, that you can get people to do really well for three months, but by six months they bounce back up. I’ve always believed that that’s an issue of how much behavioral training and what kind of psychological support goes in, what psychological teaching goes in to getting people through their events. That’s why companies like Noom, for example could be so successful because that’s the platform on which they’re founded.

Roger Green : When you look at organized healthcare, the role of being the intermediary, the person who teaches wellness, and wellness styles, and tries to coach patients to look differently at how they live their lives tend to be nurses, dieticians, physician assistants. We happen to be blessed to have a renowned one on our panel, Louise. And what I’d like to do right now for starts is just take a look at a few different questions, okay, and I’ve got four really.

Roger Green : How much focus in what you do and that part of the job is on maintaining wellness versus preventing or self-treating illness? Number one. Number two: how are the two concepts different in terms of what’s presented to the patient and in the mind of the professional? Number three: what are the keys in supporting and empowering patients to take better charge of their own wellness and to be more efficacious, not just for the three months before the other lip turns up, but in the longterm in terms of taking care of their own wellness?

Roger Green : Let’s stop there. We’ll go through those for each of us, then I’ll come back and ask the fourth question to the group. Louise, you want to kick us off?

Louise Campbell : I’m certainly happy to do that. I think if I look at how much focus is on maintaining wellness versus preventing and self treating illness in what I do, obviously, I’ve moved out of the NHS to take out diagnostics, to front-load early diagnosis of liver disease. So I’m moving more into trying to maintain wellness and locate at a time point when we can try and prevent liver disease, because we have a long time to prevent it.

Louise Campbell : Although I did within the NHS and within my previous roles, it was always about trying to maintain wellness and giving advice. It was usually at a far later stage where it is very difficult to change behavior.

Louise Campbell : It is very difficult to engage if you only use blood markers. Utilizing things that engage patients helps change behavior. But I think very few people don’t want to engage. There is this misnomer that people sometimes are hard to engage or hard to change behavior. It’s about getting access to the level of information, I suppose. And a lot of patients with liver disease don’t get it until they’ve been found. And as I’ve been an advocate for, we only find a few, we don’t find the many.

Louise Campbell : So I now have moved into trying to prevent and get better access. And a lot of patients can self-treat, particularly fatty liver disease, minor tweaks, minor changes. And I think the UK government today announced an obesity strategy, which I’d argue is now the first government internationally to announce a NAFLD and NASH strategy, because what they’re targeting is high-sugar drinks, advertising.

Louise Campbell : And I think, although there’ll be a lot of people for it, there’ll be a lot of people against it. Actually, reducing any and improving people’s diet and exercise, we know are the key factors to trying to change most of the outcomes of fatty liver disease. So it will make massive change even if we only implemented through marginal areas, we will watch cardiovascular risk of drop. We will also watch an improvement in Type 2 diabetes.

Louise Campbell : And that one announcement by the British government today can trigger absolute tsunami of research in all areas where diet and liver disease can crossover. And I think, longterm, we will see it prevent deaths. And I think that’s the advantage whether people agree with it or disagree with it. The government has taken a stance as a result of COVID-19 and obesity. So I applaud that, but we’ve got a long way and it’s going to be delivered largely by allied health professionals and GP practices.

Louise Campbell : So that answers question A, the first one for you.

Roger Green : Why don’t you go on to questions B and C, how are the two concepts different and what do you think are the keys to empowering patients to actually do that well?

Louise Campbell : I think patients, once they’re engaged, do do it very well, and it’s speaking to them in their own language. I’ve spent a long time trying to educate people on cirrhosis, who’ve had cirrhosis for 15 or 20 years. But because they didn’t drink, they didn’t think it was “that type” of cirrhosis. They see it written in letters, they don’t engage with that term. And I think bringing it back to the basic concepts, using an analogy that somebody can visualize and understand really works.

Louise Campbell : And it’s how you present it, and every patient is different, how you present it. And in the terms and the minds of professionals, I think we have to take that nurses come from a completely different angle. We are here to be the patient’s advocate, and therefore we can disagree with our medical colleagues because actually we are there to protect the patient. And sometimes people think that nurses or allied professionals will just say no or put barriers in the way.

Louise Campbell : But it is about a patient and it’s protecting that right of the patient, and sometimes that trumps all. So there is a way that you can say it to the patients that absolutely engages them, but engages them in clinical trials, engages them in their care. And actually it engages them in their family’s care. And I think that’s an importance because what we discuss with NASH Tsunami is not just about the individual. It’s about everybody around that individual being able to help each other.

Louise Campbell : Because one of the biggest reasons that weight loss is difficult is people aren’t overly supportive. And it’s very difficult if you’re on your own. So it’s not just obesity because that’s a highly stigmatized area and people eat for different reasons. So it is really important that we make the differences in the concept, but we that absolutely engage the patient and empower them.

Louise Campbell : An empowered patient can move earth and heaven to achieve what they want, but they just need a guide sometimes and the right information at the right time. And that’s usually with the patient in the room at the time of your intervention. And I think they want to know what happens and what they can do right now to make that change. So hopefully that covers those additional points.

Peter Traber : Louise, I think that the things that you’ve said are right on point and I’d like to make just a couple of observations from my practice of medicine and seeing how people are practicing medicine today. First of all, there are lots of people today involved in the care of patients. Wasn’t like when I first came up through medicine where might’ve been me and one nurse, and the nurse was spread very thin as was I. But now we have many different ancillary healthcare professionals in nutrition, in behavioral modification, in nursing, lots of different areas.

Peter Traber : One of the things that I think is critical for these systems to work is that they actually act as a team. And it means acknowledgement that each team member has certain skills and areas of expertise that are best for the team and best for the patient. And I still don’t see as much teamwork in medicine as I think we need. For something like changes in lifestyle and behavior, it would be very nice to have individual team members being experts in different areas.

Peter Traber : Obviously, dietary behavior modification, and ensure that the team takes all that into accounts so that everybody is giving people the same message, but there’s an individual there that is helping to guide the team. Because I think patients do get different messages from different allied healthcare professionals. I think that can be confusing to the patient and I’m just wondering what you think about that.

Peter Traber : Then I have one other question for you. We talk about liver health, but there are so many other things that these teams of health professionals are dealing with from hypertension, dyslipidemia, cardiovascular disease, osteoarthritis, obesity, et cetera. A lot of them are interrelated, but how do teams accomplish the kind of things we think they should for patients when there are so many different things that the team may have to do for different patients?

Louise Campbell : Your third point is absolutely excellent. I don’t think we can at any stage care for patients and people, unless we do act as a team. And I think what we’re used to, and certainly within our liver practice when I was back in the NHS, but then our Hepatitis C would do that. We would have a massive multidisciplinary team every week, every fortnight discussing the needs of those patients. And I think it was that coordination of care.

Louise Campbell : But I’d like to see it a lot earlier in the healthcare timeline because as we know, a lot of these conditions are diagnosed late. They should be at a GP and a primary care level. Every patient with obesity or the associated comorbid conditions, it would be great to have that multidisciplinary meeting about those patients now. We’ve got a strategy that’s been published today that may well help that because a lot of it is going to be delivered by GP practices.

Louise Campbell : And I think having access to dieticians, we never had access to dieticians. It was a funding issue within the Trust that the whole of the liver unit never had a dietician, yet we know that financially, getting patients out of hospital, that is great. When you’ve got a dietician involved, it turns around patient care, it improves their outcomes, gets them out of hospital quicker. But it was a financial decision from the Trust that we couldn’t afford a liver dietician, so we had to share one.

Louise Campbell : So I think it is going to be very difficult in the way the healthcare system is set up within the UK to get dietitians at a community level for early-stage obesity when a GP has to turn around and say, “You just need to lose weight.” We know that it’s difficult for those patients to lose weight. So that entire coordination has to come up a little bit earlier, and I think that would lead on to the second point where we’d get coordinated.

Louise Campbell : We work as endocrinologists and diabetes specialists. We work within cardiovascular services. We’re quite fragmented in the UK. Predominantly, liver disease is seen as a liver condition for liver physicians. It is not as coordinated as has been described on this program before where endocrinologists are consulted at the beginning in cardiac. So I’d like to see that move, because if that happens, GPs may well see this as more of a coordinated condition.

Louise Campbell : And I think the new strategy driven by COVID and the mortality rate linked with obesity has driven us to now face that a lot of these conditions are connected. So hopefully, we can get more care, but care can only be delivered at the best way through coordination and accepting that somebody else has those specialist skills, or even a theory, or a suggestion that might actually help that patient. So hopefully that answers both of your questions, Peter.

Peter Traber : I just think that healthcare systems in different countries need some advice on this from external sources. And maybe liver societies and fatty liver groups and so forth can help to provide some of the advice and impetus to push some of this forward. Because I’ve heard, having been around for a while, I’ve heard lots of the same kind of discussions going on, but less and less movement, I think to the best system for handling patients and bringing particularly behavior modification types of regimens forward.

Roger Green : The most important thing Louise said, to me, in some ways was supporting research. Because one of the things that I believe is under research within the medical profession per se, is the most effective ways to identify patients and treat different patients in ways that are consistent with their own needs.

Roger Green : If the opportunity now exists for the UK to do significant research on care coordination and the best way to get patients to respond at a wellness perspective, it’s not going to happen tomorrow morning at 9:00. But I would think that will start to move the focus in a different and much more constructive direction. I find that really helpful.

Stephen Harrison : Well, I find the comments that Louise and Peter made to be very accurate. I guess, what I want to take is a slightly different point of view, and that is the value of a passionate provider. I’ll start off with two clinical scenarios that happened to me this week. The first one was a lady I’ve been following for a long time. She has autoimmune hepatitis and fatty liver overlap.

Stephen Harrison : She’s been in remission for years now on low dose CellCept. So really the struggle has been her fatty liver. And with COVID, I was unable to see her in person for about six months.

Stephen Harrison : She was going to her Weight Watchers support group until COVID shut that down. For her, she’s 70 years old, single widowed, that was her outreach, that was her social time as well. So she really went into a funk after that and literally just told me, said, “Doc, I just watched all the Breaking Bad episodes on Netflix and munched out on everything I could get my hands on.” And she gained 16 pounds in that six month period.

Stephen Harrison : She admitted did that part of it was just not being able to be seen and have that continued encouragement that always kept her going. For me, when I have discussions with patients for the very first time, I tell them often that if they don’t work on their lifestyle and begin to reverse this, that bad things are going to happen, potentially.

Stephen Harrison : And I use the quote that, “Sometimes later becomes never.” “I’ll just put it off and do it later,” and ultimately they never get around to it. The other thing I tell them is the harder they work for something the greater they’ll feel when they achieve that accomplishment. And I’ve seen that over and over again, these patients who come in and they’re losing weight. They lose 10 or 15 pounds.

Stephen Harrison : They’re lighter on their feet. They’re not as achy. Their joints don’t hurt. The right upper quadrant pain is gone. They want to keep doing it. People are giving them positive comments, their clothes are fitting better and they come back and now they’ve lost 30 pounds, and 40, pounds, and 50. And I’ve got people that are now losing 70, 80 pounds of weight. It’s not overnight, it’s over a year or two.

Stephen Harrison : Then the other patient was a brand new patient I saw who was referred to me for elevated liver enzymes. And that’s all I had. I had no records. I had no labs. I said, “Why are you here?” She goes, “I don’t know. The doc told me my liver was inflamed and needed to see you.” So what do I do? I order a FibroScan. Literally I stopped seeing clinic and I send her down the hall. She gets her FibroScan, she comes back and she has a CAP of 357, a KPA of 5.7.

Stephen Harrison : The first thing I told her was, “Good news of great joy for you because while you have fatty liver and that’s likely the explanation for your elevated liver enzymes, there’s no significant fibrosis, at least on the scan I have today in front of me and we’re going to go with that. We’re going to complete your biochemical and serological workup, make sure you don’t have viral hepatitis, autoimmune and other things. But the good news is that you can reverse this.”

Stephen Harrison : And she said, “How doc? Tell me how to reverse this.” I said, “You need to modify your lifestyle.” “Tell me how.” And we went through what I tell them. I think at the end of the day, she walked out of there with this quote, “Doctor, all I needed was you or somebody to get me motivated to get off my butt and do what I need to do.” Now, not every patient’s like that, but in that situation we’re hopeful that there will be positive results.

Stephen Harrison : And what I tell them is, “persistent and consistent.” They need to persistently pursue their lifestyle modification and they need to do it consistently. There’s some data that I want to share with you. There are two papers I found that I thought were apropos for this topic today. Number one is a “Needs Assessment for Weight Management.” And this was a paper published in the Mayo Clinic proceedings back in 2018 and they did about 20,000 surveys in five health care systems and 11 States. They had about 2,400 responders, so it’s actually a pretty good ratio.

Stephen Harrison : What they found is that being younger, female, non-white and single, and having some college education or less were all significantly associated with a higher BMI. And the biggest weight loss barriers were food cravings and having a medical condition and limited physical activity. What’s not on here? What’s not on here is having somebody tell me I need to lose weight and exercise, right?

Stephen Harrison : So for me, it’s a simple message, but we have to take the time to deliver the message. And when we deliver the message, it needs to be very, very simple. Again, retired army colonel, “Keep it simple, stupid” has always been my mantra. And so we have to deliver the message in a way that can easily be taken home and relayed to the husband, or the children, or whoever to say, “Look, I’ve got to modify my life. I’ve got to start walking every evening. I’ve got to start carrying some hand weights. I’ve got to start doing some exercises and I’ve got to limit processed carbs.”

Stephen Harrison : I tell people, “No bread, rice, pasta, pizza, potatoes, or tortillas.” That’s simple, it’s easy. Cut out the sodas, cut out the sugar-containing beverages and let’s see how you do. And when they come back, I reiterate that. There’s some other data that’s out there that says, “The more frequent visits we have with our patients, the greater the likelihood they’re going to achieve weight loss success, or if not weight loss success, changing their lifestyle so that it actually effects a positive outcome.”

Stephen Harrison : Here’s a little sidebar. Maybe that’s why the placebo response rates are higher or as high as they are in addition to the heterogeneity of the biopsy read and that sort of thing. I suspect lifestyle modification is playing a role. So just to summarize, the other paper I wanted to highlight that I think is important is our patients often say, “Doc, give me some proof that all this is working. That what I’m doing is going to lead to something positive.”

Stephen Harrison : And there’s another recent paper, I happen to be a part of this one on physical activity measured objectively being associated with lower mortality in patients with fatty liver. And this was just published about a month ago in the Clinical Gastroenterology and Hepatology. And here we looked at a longitudinal analysis of the NHANES database from 03 to 06 and collected mortality data through December of 2015.

Stephen Harrison : And what we found is over a period of about 10-and-a-half years, increased duration of total physical activity was associated with reduced risk of death from any cause. And in a multi-variant model specifically among patients with fatty liver, an increased duration of moderate activity was associated with a lower risk of death from any cause in patients with fatty liver.

Stephen Harrison : So ultimately longer total physical activity and even moderate physical activity are associated with lower all-cause and cardiovascular mortality in patients with fatty liver. So I share that with them. So I give them positive reinforcement on their weight loss, I tell them that this is going to affect a positive outcome relative to these end points that I just mentioned. And I tell them the same message over and over again. And I do it with passion, I do it with compassion, and I’m persistent and I’m consistent in that delivery.

Stephen Harrison : And I think if you’re in a situation where you don’t have access to all these ancillaries, a nutritionist, an exercise physiologist or other healthcare professionals that can help you frame a care plan for these patients, that hope’s not lost. You can still achieve that if you’re in an austere environment or you’re on an island and you’re by yourself and you have to manage these patients.

Louise Campbell : I just absolutely echo what Stephen says throughout that. It’s about getting the right message to the right patient at the right time. And keeping it simple does work because the more we complicate things, the more they get mixed messages. And I think we all have case histories where patients turn that ’round, and I think just keeping it simple, quick wins. Doesn’t have to be complicated, and using as much allied resources as we have is vital.

Louise Campbell : Some patients will need way more than others, but it’s having access to those, and sometimes the simple steps, the easy wins, just start the ball rolling and patients get such reassurance and motivation from that. And going back to Stephen’s smile curve, if you can keep them engaged, see them regularly enough, and I think telehealth will now make such a difference to that, is that these patients can be motivated extremely well and get great outcomes.

Roger Green : Louise, how often is often enough, do you think? You said, “If you see them often enough.” Stephen made the same point. I wonder for both of you, how often do you think is often enough.

Louise Campbell : I think Stephen said it a while back, about three months, I think was his definition of the smile curve, and I think I’d reiterate that. I think anybody who I have seen with fatty liver disease where you can make that change, if you see them within three months of doing that change, it works very well. I saw an 18-year old who was a rugby player, front row. Came in, had FibroScan. Kilopascal’s 13.9, fat cap was 339.

Louise Campbell : And he went away. Often they don’t at that age because they’re immortal, wanted to keep his place in rugby. And what we did was… He was going to university, eating your typical high-carb diet, student diet, pizzas, crisps, beers. And what he did, he turned healthy for the five days a week. And what he did was keep it to the weekends.

Louise Campbell : But he came back eight weeks later having lost seven kilos. He had a cap score of 229. And what was most reassuring was that his kilopascals fell back into the normal. So what we were seeing was probably purely inflamed liver as a result of the fat. So it can be done, and you don’t have to give up everything all of the time, and you can take a step back. For every two steps forward, you might take a step backwards, but getting that positive momentum helps people maintain it in some ways.

Louise Campbell : So, for me, I’d like to see them at the beginning 3 monthly, and then probably 6 monthly because you pick up the ones who do change and it really motivates, you pick up the ones who don’t and they start to take notice.

Stephen Harrison : I think Louise is spot on. Three months is a good time to get these people back and just say, “Hey, what are your challenges? What are your concerns? What are your wins?” And reiterate what you told them before. They always have questions, three months. “Hey, what about this?” I had a lady one time said, “I did what you said. I quit eating French fries and potato chips and I switched to sweet potatoes.”

Stephen Harrison : And I said, “Whoa, okay. You did good there, but you switched to another potato.” “Yeah, but I heard sweet potatoes have lots of vitamins and they’re good for me.” I’m like, “Yep, yeah. That’s true, but it’s still a carb and we need to maybe not eat as many sweet potatoes either.” And it was a little tweak like that that really put her back on the point that she needed and continued to drive weight loss into the six-month point.

Stephen Harrison : So it’s always something little and it’s usually interestingly enough, something little that derails these patients too. It’s not that they don’t want to do it, but something in life gets in the way or they get confused about something and they don’t have a way to follow up, and so they just bag it.

Peter Traber : I believe we really need to take advantage of what we’ve seen during this COVID crisis, and that is video chat appointments for patients. Because it is expensive to go into the office each time and I think we can do a lot more with video visits. I would encourage people to look into that and utilize it.

Roger Green : Thanks, Peter. Let me come from a different perspective as a guy who’s lost 100 pounds over the course of his life, 50 once and probably 25 twice. The second 25 was a year-and-a-half ago, and that will stick because I’m getting too darn old to have to deal with trying to lose it again. I’m at an age where it wouldn’t help me to have it. A couple of observations.

Roger Green : First of all, patients frequently in those moments, one of the things they wrestle with is negative records or playbacks in their head; can’t do this, can’t do that, whatever. The negativity is the thing you’re trying to overcome. The challenge to overcoming it is what happens after the day you blow it? If you understand that it’s just a day, you can get back the next day, that’s very different than the message you say to yourself, “Oh, I blew my diet.”

Roger Green : Because then people just go hog wild and I’ve done this both ways. I’ve gone hog wild earlier in my life, which is why I had to do it again, and then I figured out that it’s just a day. Number two, and I’m intrigued by the three-month comment, because it’s not clear to me that on a three month pulse, that’s enough to know… Some people, all you need to do is give them a steer once every three months, and they’re still motivated through the right thing. Are so fearful of how sick they are that they’ll do it.

Roger Green : But if you have no conditions, per se, you’re just 50 pounds overweight, which is where I was. The motivation isn’t about fear, the motivation is about knowing it’s the right thing to do. And there are things like self doubt, negative self talk, and all that stuff comes more into play. During the time I was losing all that weight, I was actually talking to my doctor at that point who was my friend, every other week.

Roger Green : And I think if I’d been talking to him every three months I wouldn’t have made it. As it was, I gained half of it back eventually. So I wonder whether A; the people that you lose or the people that aren’t as… Louise, you said you get the ones who are really sick. The ones who aren’t really sick yet, who could be dealt with before they ever get to that kind of urgency. There, I wonder whether it isn’t more about frequent small adjustments, and people who can help you hear the head voice.

Roger Green : I know because I have friends who’ve really been successful with Weight Watchers. I know because as I mentioned, my wife works for Noom, and if she touches in, she tracks it with people once a week. Are little things, but usually once a week. I wonder, should healthcare be taking advantage of the services that are organized around weekly or biweekly?

Roger Green : Is that one of the things we should look to do with allied health professionals in telehealth? Or do we really think that’s not something we need to do unless patients ask for it? Or is there a fourth option?

Louise Campbell : I think absolutely, we should be taking use of it. These are very, very well established apps and networks for some of them. I think everywhere that we can look that can support a patient in any disease, that makes a change, that makes a difference to their outcome. And yes, patients getting diagnosed with liver disease are the minor and getting through the healthcare system is actually quite difficult.

Louise Campbell : But I think, and that’s obviously one of the reasons that we deliver FibroScans, trying to get them into primary care. But this becomes part of a great cost-saving initiative. If you can prevent fatty liver disease, if you can prevent the obesity area where that causes fatty liver disease, you can reduce diabetes. With diabetes, you reduce bariatric surgery, with diabetes, you can reduce a vascular surgery and amputations.

Louise Campbell : You can go on and on about what can be reduced, so the ability to cost-save downstream by using any mechanism that patients find useful, and it has to be about the patient and what works for them. Noom is a very good example of a highly-developed app and group, but there are lots of little ones out there that can be just as helpful. And some people like groups, some people don’t, so everybody’s an individual.

Louise Campbell : And I think to be able to use that strength to make cost-savings to healthcare throughout by changing people’s lifestyles and empowering them to do so is absolutely vital. So I’d say yes, use everything.

Roger Green : Well, actually, I want to go to a pre-question, but I want everyone’s answer to be no more than a sentence. Okay? And Peter, I’ll start with you. One sentence answer. Is the healthcare system as constituted in the country you live in, different than Louise, able to deliver the level of wellness support that people need so they never get that sick in the first place? Is it able to deliver the level of wellness for people needed when they are sick? Two part question, one sentence.

Peter Traber : I think that the experience that I’ve had with this is leading two large healthcare systems at different times, University of Pennsylvania and Baylor College of Medicine. And so I’ve seen it from the inside and from a leadership level, and I’ve also seen it from my own healthcare and my own family’s healthcare. I don’t believe that our health system is structured or incented for wellness evaluation and training.

Peter Traber : In fact, it’s why we see a proliferation of behavioral sites and so forth like Noom that Louise just mentioned that are outside of health systems, because health systems are not providing the kind of support people need. That was a lot more than one sentence, Roger. I’m sorry.

Roger Green : Not a problem, Peter. It was quite precise and very good. Thank you. Okay, Stephen, can you do it in one sentence?

Stephen Harrison : I agree with what Peter said.

Roger Green : That’s funny. I was going to do it in three words and they were, “what he said.” So I think we’re all in the same place on this. Louise, different perspective? UK, different country, different role.

Louise Campbell : Irrespective of coming from a different country, I absolutely agree with Peter. I don’t think we can. We’re a national health service, but we react to illness, we do not go out and prevent illness. So I agree with Peter. I don’t think it matters about the countries at the moment.

Roger Green : Okay, great. At some point in time in the future, not next week, we will bring on some people who represent the wellness companies and the wellness perspective, and maybe have a dialogue about what could we learn from them that we actually could bring in as a treatment of patients in the world we live in. Or how could we work with them better.

Roger Green : With that, let me go to final question. The one thing that surprised you most of what you heard today.

Roger Green : I’ll be the brave one. Louise’s story about the rugby player really struck me, I’m the only nonmedical professional on the panel, but I don’t tend to think of people as going back quickly from a bad place to a good place because the problem is that simple. I’m also terribly impressed that an 18-year old kid who didn’t feel immortal and was able to do all that, and I suspect that you and the folks you’re working gave him some exceptional coaching. That’s a story that’s going to stick with me long after this podcast ends.

Peter Traber : Peter. I would agree with that story, but it doesn’t surprise me that much because personally, I found that because of a family history and because of being overweight that my doctor told me, “Hey, Peter, you have diabetes now.” The shock of that had me lose 40 pounds a number of years ago and I didn’t have diabetes anymore. The problem is that without behavioral modification changes that were essential, I was motivated for a period of time, and then the weight creeped back over five years.

Peter Traber : So what we really need is a sustained effort and behavioral changes that I don’t think we think about that much in the healthcare system. My comment to Louise was, follow that young man for a long period of time and see what happens.

Stephen Harrison : I’ll just echo that, and maybe say that we can talk to our patients about lifestyle change. We can put a whole team in place that addresses the needs of the patient. But there’s a joke about a psychiatrist that I’ll use to end, and that is, how many psychiatrists does it take to change a light bulb? One, but the light bulb has to want to change. I may have used that analogy before, but I think it’s apropos.

Stephen Harrison : Sometimes the hardest part for our patients is the six inches between their ears and they have to want to change. It doesn’t matter what we put in front of them. So I think that’s important to remember also.

Louise Campbell : I think the thing that surprised me most is that not one of us thinks that we have a healthcare system that’s suitable to do the wellness side. And I think that’s a shame, but these are big bulky systems that do need to change, and we do need to use other avenues.

Roger Green : I’m going to make one comment and then we’re going to close, which is that I think one of the differences between the wellness systems and the illness systems is that you have to spend your own money to get into the wellness system. And I think when people put their own money down, two things happen, it’s statement of commitment and a statement of investment.

Roger Green : I’m not always a big fan of the idea that goes, “If you don’t have skin in the game, you’re going to treat it less seriously.” But in this case, I absolutely am. If it matters to you, you’re going to pay for it. Not enough that it hurts, but enough that you know you’re spending your own money to solve the problem. I think that actually helps people a lot better. That’s my belief. Coming from my capitalist side, Peter.

Roger Green : That ends today’s episode. I want to thank Stephen. I want to thank Peter. I want to thank particularly Louise who had so much experience to share today, and that was great. As I say, come back next week, we’re going to be talking about our EASL coverage. We’re going to be introducing you, or spoiler alert, reintroducing you to our new permanent Surfer. And please go to the site, and if you’re asked to give an email address, give it to us.

Roger Green : We will send you links you can send to all your friends about how they can find their way to the show again. I think this is an episode people are going to want to hear. We’ve just got to make sure that we notify them.

Roger Green : All right. Special thanks to our new engineer, Mike Wilson who is the guy who’s going to make music and integral part of our show, maybe even Peter’s if we can coax him out of his caution over this. The distribution folks at Buzzsprout who took 15 episodes and moved them over in a span of 15 minutes and have been a delight to work with ever since. Social media, master Eric Rounds is overseeing this entire transition. Our editor, Ellyn Charap, our new administrator, Politea Lea whose job is to make this whole thing run on time every week.

Roger Green : And an extra thanks to you, particularly the subscribers who found your way here this week and could help us get back in touch with the people who weren’t with us next week. We will be back next week with episode 17. It will be really good. We’re going to talk about EASL, we’re going to introduce a Surfer, and we’re going to try to find music.

Roger Green : So one last thought, if any of you who are listening in the liver community are musicians and you’d like us to pick up your music on the program, send a note and somewhere between two and five minutes of your stuff, surfingnash.com, and I’ll get back to you and we’ll talk about it.

Roger Green : Until then, everybody have a great week, stay safe, Surf on, we’re done for today. Thanks. Bye-bye.

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