In this episode we talk with Ryan Garbalosa, DO, FACC, a cardiologist practicing in the Carolina East Health System in New Bern, North Carolina.

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Interview transcript below:

Steve Legault: Hello and welcome to the ACOFP.DO FM Clinical Podcast. I'm, Steve Legault, the Director of Knowledge, Learning and Assessment and host for this episode. Today, we're going to be talking about cardiovascular disease and type 2 diabetes. We're welcoming Ryan Garbalosa, DO, FACC to the podcast. He practices as a cardiologist in the Carolina East Health System in New Bern, North Carolina. He's an alum of Nova Southeastern University College of Osteopathic Medicine, completed his residency at Palmetto General Hospital, followed by a Fellowship at the Deborah Heart and Lung Center in New Jersey. Welcome to the Podcast Dr. Garbalosa.

Ryan Garbalosa: Thank you for having me.

Steve Legault: Excellent, well for today's conversation. I thought it would be great to discuss type 2 diabetes and cardiovascular disease in a few different sections, beginning with risk and prevention. So what are the most important cardiovascular risk factors to monitor in patients with diabetes.

Ryan Garbalosa: A large portion of our knowledge of cardiovascular risk comes from the Framingham Heart Study something that's been going on for 70 years, and the risk factors for diabetics are just about the same as the risk factors for all the rest of us things like smoking, high blood pressure, high cholesterol, you know, our old favorites things that we're all familiar with.

Steve Legault: How aggressively should blood pressure be managed in patients with diabetes to reduce cardiovascular events.

Ryan Garbalosa: Blood pressure is pretty important, and it's a modifiable risk factor. The most recent Acc Aha guidelines came out in about 2017. They changed the definition of blood pressure as well as stage one hypertension to anything over 130 over 80. It's a class, one recommendation to start pharmacologic therapy, and any diabetic with stage one hypertension. In addition to your usual lifestyle modifications, diet exercise, particularly the dash diet. Our goal is to keep blood pressures under 130 over 80, which will in turn reduce their cardiovascular risk, reduce, stroke, reduce heart attack, and that's kind of based off what we saw in the Sprint Trial. Blood pressure is pretty important. They recently changed the guidelines. In 2017 we had an Acc. Aha update to hypertension, and they changed the definition of stage one hypertension to anything that was over 130 over 80, and this made a lot more people hypertensive, including diabetics and diabetics being that they are a. They have a specific, they have a risk factor themselves for being diabetic, for hypertension. They recommend that you aggressively treat their blood pressure with a goal of less than 130 over 80. It's a class, one recommendation, in addition to lifestyle, modification, like the dash, diet and exercise, and the more aggressive you are with treating their blood pressure, the more heart attacks and strokes you prevent, and that comes from data from the sprint trial.

Steve Legault: Excellent. Well, thank you, and kind of getting into medication management for this. How do the newer diabetes, medications, the SGLT2 inhibitors and GLP-1 receptor agonists. How do they impact cardiovascular risk?

Ryan Garbalosa: They're all pretty favorable. Ever since the black box labeling of TZD medications for heart failure several years back there's been a lot of scrutiny over the development of new diabetic...

This episode we welcome Shirin Doshi, DO to the Clinical Podcast to talk about nutrition and how it relates to diabetes technology. We cover providing advice on eating habits and eating patterns, team-based approaches to nutrition, and how CGMs can influence eating and behavior.

• CGM and Nutrition
• Continuous Glucose Monitoring and Diabetes Distress

This transcript was created with the aid of automatic speech recognition technology.

Stephen Legault: Hello and welcome to the ACOFP DO.FM Clinical podcast. I'm Steve Legault, the director of Knowledge, learning and assessment and host for this episode. Today we're going to talk about the important intersection of nutrition and diabetes technology. For people with diabetes, food nutrition choices carry even more significance. With advances in technology, patients can see the impact of those choices almost immediately. Today we welcome Shirin Doshi DO. She's the lead physician advisor for Sparrow Hospital, where she supplies provider education, reviews hospital cases for medical necessity, assists with insurance denials, and continues to assist the medical staff with coding and documentation requirements, who's also part of the planning faculty for the American Diabetes Association supporting healthy eating habits through CGM program. Welcome to the podcast, Doctor Doshi.

Shirin Doshi, DO: Hi, Steve, nice to be here.

Stephen Legault: Well, thank you so much again for participating, and let's jump right in. But before we get into diabetes specific technology, let's talk about nutrition. I imagine that giving advice on eating habits and food selection can be a tricky area in some cases. How do you go about discussing those food choices that support overall health goals and targets with patients?

Shirin Doshi, DO: Well, every patient is different in the way that you speak with them because it depends on their level of understanding and their primary language, etcetera. So, it just depends on what they come to the table with, with their understanding. But one of the key points is that many of our patients do not have significant financial resources, and so it can be really difficult for them to buy, you know, the healthiest foods, the organic food, you know, the, the convenience of major fast-food chains. And some of those types of things are definite barriers. So, what I do is I discuss with them just a healthy balance. Foods, you know, including the good fats, protein, complex carbs, foods that are really dense and fiber and vitamins and minerals. And I explained to them that, you know, you don't have to go to a fancy, expensive organic food store, that you can go to your regular local market. And even frozen options of fruit and vegetables can be quite healthy, and they tend to be quite cheap compared to some of the fresher options. The other thing is that we talk about avoiding, you know, significant amounts of simple sugars, which are in, like, highly processed foods, like candy, you know, cakes, cookies, ice cream, stuff like that. And a lot of the white things such as white pasta, white rice and white bread, you know, trying to steer patients towards more the complex carbs. Fresh food, even though it still has sugar in it, it's, it's still balanced with fiber and, you know, vitamins and minerals, et cetera, and so it is a better option than food that is liquidities, that you just slurp up, that your body doesn't have to work super hard to actually absorb all those nutrients. And if we can get them to just even start making small choices, little baby steps in their nutrition, we can get them to a...

This month we welcome Robert Agnello, DO, FACOFP to the Clinical Podcast to talk about pain management and opioid use disorder. We cover integrating opioid analgesics into treatment plans along with patient education, handling patient opioid use outside of prescribed use and how to talk to patients about incorporating OMT into their treatment plan.

This transcript was created with the aid of automatic speech recognition technology.

Steve Legault: Welcome to the ACOFP DO.FM Clinical Podcast, I'm your host, Stephen Legault, the Director of Knowledge, Learning and Assessment at ACOFP.

Steve Legault: On today's episode. We're going to be talking about pain management with a specific focus on opioids. Opioid use disorder affects about 2.1 million people in the United States.

Steve Legault: We're glad to be joined for this episode by Robert Agnello, DO, FACOFP.

Steve Legault: He's an Assistant Professor of Family Medicine and Pain Medicine at Campbell University.

Steve Legault: He also serves as the Faculty Senate chair at QSOM for the University and is the NBOME Clinical Family Chair.

Steve Legault: Dr. Agnello serves on the Board of the American Academy of Osteopathy, and on a number of education focused committees here at ACOFP, including the Substance Use Disorder Task Force.

Steve Legault: welcome the Podcast Dr. Nolan. Anything I missed in your background that'd be helpful.

Robert Agnello: Oh, that sounds great, Steve, I think you covered it completely.

Steve Legault: Excellent. Well, thank you. And again, glad to have you here.

Steve Legault: you know you were one of the subject matter experts who created our de-stress pain management, rethinking opioid non opioid therapy, and we cover a lot in that course, and I encourage anyone listening to go and take a look at it and complete it. It will satisfy your DEA requirements, and it's also just a great in-depth resource for anyone looking to learn more about pain management.

Steve Legault: And it's also free. So any anybody who is in healthcare is welcome to do that regardless of ACOFP membership. So we encourage everyone to participate. But I wanted to ask your thoughts on a few specific aspects we cover in the course.

Steve Legault: When looking to safely integrate opioid analgesics into treatment plans, what considerations need to be made around patient education?

Robert Agnello: Oh, thank you so much, Steve, for that question. I think it's very important that all clinicians, physicians all provider types that are involved in chronic pain management. Consider the opportunities for opioid medications, you know, regarding analgesic management.

Robert Agnello: They are an option, you know. We are recovering from some very significant limiting recommendations that were out in the round 2016, and finally was recognized and loosened up upon in 2022 by the CDC.

Robert Agnello: There are patients that benefit from analgesic medications, including opioids. And there are tools that we have to help us select. You know the correct patients that could do well on opioid medications. First, we always want to make sure we have a wonderful history physical exam, and then come up with a complete his treatment plan.

Robert Agnello: And in that treatment plan we should be very integrative about our approach, very osteopathic about our approach, considering optimizing non-pharmacologic strategies, interventional procedures, and different adjunctive pain medications. There's a whole host to choose from.

Robert Agnello: But every now and then I like to give this example. You're going to get that patient. I won't say any specific age, but they have very extensive degenerative change, maybe in their spine, their hips, their knees, their quality of life is impacted, their functional status impacted and their pain levels are high and maybe they have a little bit of renal...