Okay, thank you all for coming. We're going to get started. So we're going to learn today about how psychiatry can and should be central to multidisciplinary chronic disease management. But another alternate title could be how to use lifestyle medicine prescriptions to treat your patients via collaborative care. So first we'll do our disclosures. I am and my colleagues are employees of Nudge Health. I'm a co-founder and a shareholder. And now we'll get started by watching a video compilation of four of our patients who are kind enough to share their stories with us as they have been treated using collaborative care and this combination of lifestyle medicine. So you're going to get to know these four patients. My heart rate was 170. Went to the emergency under the care of my endocrinologist and my cardiologist. And ended up with AFib. 2013, I became disabled. I'd go from one surgery to another, you know. I didn't have my mind right. I was still having bouts of depression. I wasn't moving. I wanted to move forward. I wasn't able to move forward on my own. We were having a heck of a time controlling my blood pressure. Everything that we were doing medically was not working. And so that's when Dr. Roth said, let's try Nudge. Deb, the nurse, who was fantastic, called me. And I just immediately felt very at ease. I knew it was going to work because she's very knowledgeable, very supportive. You know, I didn't like it at first, but we took that little Nudge. To get it in that mindset. And finally I seen the light and I'm down 41 pounds every Monday, as of Monday. When I first started in the program, I get on that treadmill, man, I couldn't walk over five minutes. I started paying attention and then my five minutes after a week turned into 10. 10 now, I'm up to 40 minutes without even breaking a sweat. Sometimes a little bit of coaching helps, and that's what I found with Nudge, that you had a coach with you the whole way. You had somebody that listened. Dr. Katie was an incredible force to be able to make lifestyle changes, which were very helpful. She says, now, let's think about that. Let's talk about that. Now, have you looked at it from this perspective, you know, and in a different view? Let's talk about what you're doing every single day. What are you doing to start your day? What are you doing to, you know, get into the right frame of mind? I mean, I can cope with anything now. In fact, friends call me now and with some of their problems and I'm just going, OK, I can, you know, and yeah, it's much, much better. I don't have the anxiety that I did. I mean, I feel very good about my health now. I'm also a type two diabetic, and she's even helped me in that area to make sure that my A1C is correct and my blood sugars are pretty much on track. But the greatest, I guess, the sleeper was Deb calls on one of her case manager inquiries. She just happened to ask, how are you doing? And the tears flowed. And I told her, I said, I'm just being hit hard with the death of my husband, even though it's five years. This is very hard. So she suggested a class they had for bereavement. I signed up for it and we all explained our path in our journey. We were all different stages of grief. But the most amazing thing happened. Both the psychiatrist and the social worker took part and shared their grief, which made it human. I left that class and I never looked back. I have never looked back since I moved forward because of that class. And the program that I'm in, it's just marvelous. I love it. I'm a hundred percent different person than I was three months ago. My medications are now decreasing and my lifestyle management is actually increasing. So it makes for a tremendous package of success that I'm just so grateful for because I didn't know how to how to manage this. You just saved my life. This is how I look at it. You saved my life. To have your life back mentally and physically is a blessing. So I just love watching that video, I feel like kind of it gets to the reasons that I went into medicine and and that's kind of medicine that I want to practice. And so let's let's step back a bit. We're going to talk today about chronic disease. We're going to talk about how collaborative care can help us treat chronic disease using lifestyle medicine. So the real problem is that chronic disease is this huge issue we have. It accounts for more than 90 percent of direct health care costs in the United States. And when you include indirect health care costs, that number balloons even larger. And indirect health care costs includes things like absenteeism, disability, like you heard one patient say, premature death. And it it will likely be treating chronic disease and addressing this. In the 21st century, it will likely be the public health imperative. And if we don't get a hold of it, it is going to be have severe consequences for individuals, for families, for governments. It's so dear. Even the health and security of our country may depend on our ability to have a healthy population. And it's not a problem with a simple solution. It's very multifactorial. It includes things like environment, government policy, tradition, cultural factors and individual choices, lifestyle choices. So the challenge then for us as psychiatrists being in this medical field is to really identify how we can contribute. And my my main kind of contention in this talk today is that our skills, we have a really unique set of skills in medicine where we bridge behavior and medicine and that the combination of these two skills make us really uniquely positioned to help address this. And I really want to redefine how we think about what's possible with with collaborative care and lifestyle medicine and psychiatric care. So let's take a step back and talk about the collaborative care method. This is an evidence based treatment methodology that was developed by the University of Washington AIM Center in the 90s. And the first randomized controlled trial was published in JAMA in 2000. And it treated depression and anxiety in the primary care setting. And what it did was it took a behavioral health care manager who interfaced with the patient. So the provider introduced the patient to the behavioral health care manager. And the behavioral health care manager did most of the face to face contact with the patient. And the psychiatric consultant was behind the scenes making sure that the diagnosis was correct and the treatment plan was accurate. And they found that using this kind of triangle to treat patients was really, really effective. And it since then has been shown to be effective at treating comorbid chronic chronic diseases, too. So just a quick poll of the audience to see where such and where. Where you guys are. Who's heard of collaborative care before? Almost everybody here probably who's done like practice collaborative care that would allow you to build those CPT codes. OK. And has anybody. So we have some psychiatrists who participated as the consulting psychiatrist. It looks like. OK, good. So it's really effective. The trials and almost all the RCTs for collaborative care show that depression and anxiety decrease by 50 percent or more within 12 weeks. And when you compare that to standardized care, both in a typical outpatient mental health setting or within primary care, sometimes it takes as long as 87 weeks. And these Medicare found it to be so effective and the data was so compelling that they created this unique set of codes that we use. That we use to get paid for it. And the APA has made it a national priority to train psychiatrists and really increase nationwide access to collaborative care. There's a number of bills in state legislatures. Giving providing grant money to primary care practices to get that to get this off the ground. There is there are national legislature bills being proposed. There's like a bipartisan one from a congressman in Texas and somewhere else. So really there's this kind of this writing this wave of all of this data showing how effective it is. And I want to emphasize that the psychiatrist in this model has really limited contact with the patient or sometimes no contact with the patient. And we can do this because it's not a fee for service model. So the codes allow the care manager to aggregate minutes of care throughout the month. And then it becomes this consultative process between the psychiatrist and the care manager to make sure the diagnosis is correct. If you would like to ask a question could you go to the microphone because it's being recorded. So the psychiatrist is available for diagnostic clarification to see the patient. Yeah I know. Yes I have a question about the behavioral health care manager. What is the credential. Yes we'll get to that. We'll get to that. So the psychiatrist is available when needed for diagnostic clarification and can see the patient directly but mostly it's not. And and so because there isn't this pressure to come up with the right diagnosis after one visit after you know 45 minutes to an hour visit it allows for a much more rich consideration of the patient. And it was also validated with mostly telephone contact. This was pre synchronous telehealth and it gave the care manager a lot of liberty in contacting the patient wherever the patient could and in much shorter periods than typical outpatient psychotherapy. And part of this requirement is to have a technology registry where you track outcomes. It is measurement based care patients get their symptoms get measured frequently and we track it on a population health basis so the care manager and the psychiatrist can look at the whole panel and really see who's who's making progress who's plateauing and when symptom decreasing decreases plateau then we can dynamically change the treatment to get better outcomes. So like we talked about the financials are also unique. These are the four requirements to build these codes. You must have the three member team. Psychiatrists are actually the only specialty that are not allowed to build these codes because we must be the consultant psychiatrist. So the psychiatrist gets paid from the revenue generated by the primary care physician. You must measure outcomes consistently. You must track outcomes and review them in a technology registry. And then this last part is really significant. The patient must have an F code from ICD 10 so they must have a psychiatric diagnosis. So I want you to remember that because we're going to bring that up again later. And so we found that kind of the first generation of collaborative care studies showed that treating depression and anxiety was great. And then they thought OK we know that there's this bidirectional link between chronic disease and mental health. So we know for example that if you have a heart attack you're more likely to get depressed and if you have depression you're more likely to get a heart attack. And all of your outcomes are worse. And so they went back and they looked and they found that despite treating the depression and anxiety the chronic condition outcomes were no better. So they didn't save any lives. People were still rehospitalized. People still had heart failure acute episodes. People still died at the same rate. So then kind of the second generation of collaborative care research went back and said OK what if we what if we empower the care manager to also monitor and track the symptoms in that and the outcomes of the comorbid chronic disease. So what if the care manager follows up with the patient once a week or every other week about hypertension or blood sugars and diabetes. What happens then. And what we found what they found was that both the depression anxiety as well as the comorbid chronic disease get better. So as a psychiatrist this is kind of all of us probably who that's the wrong way who has kind of dealt with patients who have comorbid chronic conditions physical conditions that are affecting their mental health. And I know I have been remarkably frustrated particularly with chronic pain patients but also with people with out of control blood sugars. You know it's it's it's really hard to get them stable sometimes. And we know that those out of control whole body inflammation and other things make them more susceptible to illness make them more susceptible to physical illness as well as destabilizing mental illness. So and I kind of felt pretty helpless doing this before. Doing this before. And so in some ways co-care isn't really known. I'll call it collaborative care co-care co-care is not really nationally known. There are still a fair number of psychiatrists that I've talked to who haven't heard of it before or if they have heard of it they think of it as general integrated care and they have they don't really understand the nuances of that triangle and the requirements for Medicare to have those billing codes. And it turns out that it's really really complicated to set up. So it's really hard on a systems level to get the permission to hire people without having income yet. It's really expensive to set up the technology registry and then you have to deal with all these competing priorities of the system and then just convincing the compliance folks to sign off on it and your billing team could be you know a project in and of itself. So that's partly why there's all this push in the legislature to get grants and other funding to help this happen it's complicated. So our company Nudge Health is just one of the implementation solutions that are available to help people do this and we really grew out of the cardiology space after several of our co-founders had worked in another company and they saw they witnessed it was within cardiology and they were doing remote implanted device monitoring and they saw that when people with an implantable cardiac device had mental health issues their outcomes were worse. And so when we started we were immediately focused in cardiology and we were immediately focused in comorbid chronic disease management and we really wanted to affect cardiovascular disease outcomes as much as we wanted to affect mental health outcomes. And so as part of that we immediately integrated remote patient monitoring of blood pressure and weight. And then we have since integrated lifestyle medicine to complement the collaborative care measurement based treatment to target principles. And we really use this fundamental idea that all chronic disease has its basis in messed up behavior of some kind. And as behavioral health experts we are uniquely positioned to help treat it. And we really are focused on helping patients create sustainable behavior change that will persist after treatment. So how many of you have heard of lifestyle medicine as a distinct area of medicine. It's relatively new. Yep it's growing rapidly. There is an American Board of Lifestyle Medicine. There's an international board. They offer a board certification now and there's the American College of Lifestyle Medicine that does CMEs and stuff like that. As on a side note there's this book that the APA published called Lifestyle Psychiatry and based on my attendance at this conference there's a lot of interest from psychiatrists around integrating more effectively lifestyle treatments like nutrition and exercise into our care. So I got board certified in December and the knowledge gains are really really excellent. And so this is how we've taken the classic collaborative care triangle and we've included we grew it to a circle to include lifestyle medicine. So we added health coaches who are bachelor's level trained people who have special training in motivational interviewing and behavioral activation and evidence based treatments that don't require licensure. We also added exercise specialists and you're going to hear from Amy Pike today who's with me and we've added registered dietitians and you'll hear from Ashley here today who's with me who's are one of our registered dietitians. We have our remote patient monitoring team and then we changed the following physician. Remember this grew out of the primary care space but we have since integrated in cardiology and we have a breast surgeon who's one of our clients and we have obstetrics and gynecology and so all of them are able to build these codes and all of them have treat chronic conditions where there's really strong evidence that behavior change affects disease outcomes. So we organize our treatments around the six pillars of lifestyle medicine. These are the six pillars stress management is code for depression and anxiety physical activity sleep quality or insomnia social support behavioral risks and that's smoking cessation and alcohol use typically and other drugs and then nutrition. So just curious we all learn a bio psychosocial model of treatment and we all typically are trained to think about the whole person but then treating nutrition and exercise and other things like that. Has anybody tried to get it paid for. Has anybody tried to incorporate that into your practice. Yeah. Has anybody had patients go seek kind of extra outside coaching or treatment to get this paid for. Yeah. And so there's this huge industry of non-medical people kind of growing up stepping up to fill this void because I don't know if you know but for Medicare you Medicare will not cover nutrition a registered dietitian visit unless the patient has a diagnosis of diabetes or kidney failure. So it's been kind of in the news lately with Osempic and we go be Medicare doesn't consider obesity a chronic disease by itself. It has to be obesity plus something else. And even then, they restrict care. And so it's hard to get high-quality, evidence-based nutritional recommendations without going to Facebook or TikTok or Instagram. So today, right now, I'm going to explain our depression, anxiety, and insomnia pathways to you. So we have outcomes based on every pathway that we measure, as collaborative care requires. So we use a PHQ-9 and a GAD-7. And then for insomnia, we use the Insomnia Severity Index. And we use the evidence-based brief behavioral treatment for insomnia. We use motivational interviewing. And we use behavioral activation. And then we have optional psychoeducational group classes. You heard one of the patients refer to our bereavement class. And then the care manager is typically a registered nurse with a psychiatric registered nurse or a social worker. And so Medicare actually does not require specific licensure or training or background on the part of the care manager. They just require that the person have extra training in that area. And they kind of did this because they know that nationally, our behavioral health colleagues are really a diverse group. And different states have different licensure requirements. And in some, I'm from California. I'm in San Diego. We don't have the degree of licensed professional counselor as a recognized degree, whereas in other states, they do. And there's also marriage and family counselors. There's PhD psychologists. There's social workers, masters of social work, licensed clinical social workers. And so it's really heterogeneous. So Medicare did not require a specific degree pathway, which I think was really wise of them. So treatment for these pathways is based on our evidence-based modalities. And in my experience, having significant motivation for change for a moment or even a week or two is typically not enough for people to have sustainable lifestyle change because usually, change is hard. We see this a lot in the dieting community, where people are motivated to make change. They make a change. They start a new diet. And then they struggle. Something happens. They give up. And then they feel shame. And they don't go back until some other huge event happens. They're motivated again. And it's this cycle. We see that also with our depressed patients, that people try and make healthy changes, but it's hard. So when you link motivation with individual coaching that can create an achievable plan, that's really where we're seeing the best results. And because of this, we also use the evidence-based SMART goals, principles, and social psychology research. Now, in typical collaborative care, the consulting psychiatrist is available to help coach the primary care physician on medications when needed. But in our experience, because these behavioral health treatment plans are so acceptable to patients and so effective, that we only make psychopharm recommendations in 4% of cases or less. So yeah, yeah, exactly. Now, keep in mind, we're coming from a cardiology population and a breast surgeon population. And so our average PHQ-9 scores, our mean PHQ-9 scores across all patients are about a 10 or 11. So they have moderate symptoms. But we do have a significant number of patients. At any given time, we have about 100 patients who are in the PHQ-9 of 15 and up. And so we do have a pretty significant population. We also find that about 30% of our patients, like the general population, are already on some kind of psychotropic. And many of them have their own outside psychiatrists or therapists. And so when that happens, we don't duplicate treatment. We just offer them a treatment in another lifestyle pathway. So if they're working on depression with their therapist and they're having insomnia problems, we say, great. We can help you with your insomnia. And insomnia treatment is evidence-based and then possibly can help treat your depression. We even have some patients with severe mental illness. So we turned on our very first patient who had schizoaffective disorder bipolar type and was chronically hypomanic and mildly sexually inappropriate on the phone with the care manager. And he quit smoking. We have another patient right now who is living in a group home. And he has schizophrenia. And he's been able to decrease his smoking from two packs a day to a half a pack a day. And he continues to go down. So I think regardless of the patient that we have, we're really able to make a significant difference. And again, the behavioral treatments with this coaching and focusing on achievable small behavior change really has been quite effective. Out of everybody we've treated, which is around 2,000 in collaborative care, I think I've only referred three patients to IOP. And no one's had been hospitalized psychiatrically that we know of. So it is not a typical outpatient psychiatry setting. But again, this was developed from the primary care setting. And there are a lot of patients in that mild to moderate area where I think they can get extra help. And we also have primary care physicians that we're working with. And so as we move more into the primary care space, I'm sure we'll get a higher acuity population. But again, we're confident that the behavior health treatment works pretty well. So I'll share some outcomes for these pathways from a Medicaid population in Southern California from the Inland Empire. The Inland Empire is the desert area east of Los Angeles where the Concert Coachella is held. And it's really rural. This is from a cardiology clinic in Palm Springs. Something like 40% of the patients were Spanish speaking only. 60% reported food insecurity. So these are true Medicaid patients who are socioeconomically disadvantaged. We had 158 total patients, 64 of whom participated in a lifestyle pathway plus remote patient monitoring. And the rest participated in remote patient monitoring only. And outcomes were tracked from, well, patients started to be enrolled in August of 2022 through November of 2022. And then we looked at this data through December of 2022. So it's a relatively short window. But we found that 43% of patients in that time achieved a 50% reduction in scores for depression. 35% of people with anxiety symptoms achieved a 50% reduction in scores. And 27% of patients with insomnia achieved a 27% reduction in scores. It's really fast. The majority of the, when you look at week over week changes, the majority of the change happens in the first four weeks, four to eight weeks. So a four month time window is sufficient to see pretty significant change. Then when we looked at the blood pressure, we used linear mixed effect modeling to account for the rolling enrollment and the relatively small sample size. And that helped us predict changes over time and the effect that we had. And we found that systolic blood pressure decreased 1.32 millimeters of mercury per month. And diastolic decreased a half a millimeter of mercury per month. So a patient enrolling in August of 2022 and continuing treatment until December would see about a five and a half millimeter mercury systolic decrease and about a two and a half millimeter mercury diastolic decrease by December. And then when we looked at lifestyle compared to lifestyle plus RPM versus lifestyle versus, excuse me, RPM alone, we found that systolic blood pressure decreased by almost seven millimeters of mercury and diastolic decreased by almost three. The P was 0.002 and you can see those confidence intervals. So this suggests that the blood, the lifestyle intervention was helpful and produced a greater change. And you might say, well, Dr. Hill, if a patient comes in with a blood pressure in the high 140s at stage two hypertension, if you decrease by five or six points, that's still stage two hypertension, big deal. But it turns out that lowering blood pressure on a population health basis by even two millimeters of mercury, two to five, is a really substantial improvement and saves a lot of lives. So this is from the InterSalt study from the 1980s actually. And they found that if you can lower the blood pressure by five millimeters of mercury, you can prevent 9% of coronary deaths, you can prevent 14% of stroke deaths and 7% of all-cause mortality. And then potential number of lives saved, this was in 1985, so times many multiples today. So today in a typical primary care doctor's panel of 2,000 patients, if the primary care doctor could achieve that level of blood pressure reduction, they'd save 280 stroke deaths, 180 heart attack deaths, and 140 deaths of any cause. So we're pretty excited about that. And now we're going to transition and discuss the two other evidence-based intervention areas for mental health, nutrition, and fitness. And so when we started this, I was pretty confident in my ability to set up the depression, anxiety, and insomnia pathways. I'd had training in that in residency, but I was less confident in nutrition. And I really feel then, as I do now, that adding multidisciplinary team members allows us to give patients better care. And so we hired a registered dietitian, and we followed the typical co-care script for patients. They interface with a care manager on the regular co-care schedule, but then they got to see a registered dietitian once a month. And we, because the Medicare doesn't have those degree requirements, the registered dietitian acts as a specialized care manager, and we give them extra training in behavioral health interventions, which meets those requirements. And what we found, interestingly enough, is that patients loved meeting with the registered dietitian, but they really struggled to achieve weight loss and other health outcome goals, like reduction in hemoglobin A1C. They were pretty good with the blood pressure, but they just hung out. And when they plateaued, collaborative care principles suggest that you modify the treatment, you increase the treatment, you add some kind of medicine, and we really couldn't do that. So we felt like it wasn't really collaborative care. So we did have some success. I mean, you heard from a couple of the patients who talked about their improved diet, their improved diabetes, but we decided to shut that down in November of 2022 and do a program revamp and try to get it more, try to be more successful. And so we had two goals. We wanted to better identify patients who were motivated to change immediately, and we wanted to separate them out from the patients who just kind of wanted to dip their toes and then change water. They weren't really sure if they wanted to commit. And then we wanted to create a treatment protocol for both groups that would lead to sustainable behavior change and improved metabolic outcome. So now I'd like to introduce you to my colleague, Ashley Nader. She's our lead registered dietitian, and she's the chief architect of this redesigned nutrition program. And she has degrees in biological sciences from the University of Alabama and registered in dietetics, nutrition and dietetics from Ohio University. And she's been advocating on social media for diet and nutrition lifestyle change and the power of plants long before she got to nudge. So I'll let her take it from here. Awesome. Thank you, Katie. I'm very honored to be here. So thank you all for being here. I'd first like to share with you the outcomes from our first pathway that Katie talked about before we shut it down and redid the new pathway. You'll see here the length of treatment time was about five months. And the blood pressure average decreased 9 points systolic and 4.5 points diastolic, which is excellent. Weight decreased by 6 and 1 half pounds, which translates to about a 3% weight reduction. And so this is similar to other nutrition intervention outcomes from the literature. So we're hoping to improve that from that 3% more towards that 5% to 10% with our revamped program. All right. So our revamped program rolled out in January of 2023. So just a few months ago as the Nudge introductory nutrition program. So that was kind of what Katie was talking about when she was talking about dipping your toes into that behavior change of being interested in nutrition. So it's the introductory program. And then we have the Nudge comprehensive nutrition program, which requires a little bit more commitment. And we assess that motivation for behavior change beforehand. So we have health coaches that participate in both of these programs. The patients regularly meet with them in both of the programs. And they use motivational interviewing to identify and highlight personal values and target ambivalence. They use SMART goals, behavior activation, and problem solving as some of the treatment techniques that are used to identify those barriers and to change and create a series of achievable goals. Those achievable goals are very, very smart, very, very tiny, very specific. We use co-care requirements to have frequent validated assessments. We use weekly registry guided treatment teams and collaboration with the partnering physician when needed. One of our methods to identify patients who are motivated for immediate change is to ask patients to complete a set of prerequisites beforehand. So those prerequisites look like a commitment sheet. They commit to showing up to group classes. They commit to doing labs before and after the program. They commit to themselves to give it their all throughout the entire program. So it really kind of sets them up for success, outlines expectations of the program, and gets them rolling in. Another one of those prerequisites includes a nutrition questionnaire. And then the other one is to complete a 24-hour food recall for us beforehand, before that initial intake. Within that food, that nutrition intake, we ask things like, how is your relationship with food? What kind of diets have you participated in in the past? Do you have any prescribed nutrition diet prescriptions from your doctor? Have you worked with a registered dietitian before? As well as things like, how are your bowel movements? How's your gut health? What kind of other nutritional related diseases do you have? So the introductory program involves meeting with a health coach twice a month, like we stated. They use motivational interviewing at every visit. And they have a registered dietitian leading health coaches in the goal setting throughout that program. We have a few principles here that we like to kind of focus on, seven of those. So generally speaking, we have a wellness packet, as well, that we send to them that outlines everything for them to have as a resource at their fingertips. So we focus on increasing fruits and vegetables, increasing whole grains, reducing sugar, sweet, and beverages. I would argue that's one of the most important ones. Decreasing processed foods and sodium, those sneaky ingredients in those processed foods. We have a focus on label reading, and just understanding how to read a label, how to fill your plate. And then finally, we talk about meal prepping with our patients and how to be successful in the kitchen. We do track objective data, including a lipid panel beforehand and every six months. We have them take their weight at least once a week. And that gets sent to us automatically. We measure their BMI. We use blood pressure as a remote patient monitoring device, as well. We use PHQ-9, GAD-7. We measure their weeks in treatment, and also their goals. So we've got some tabs on them, you could say. All right, moving on to that comprehensive nutrition program. It's a bit more comprehensive. So it's a 16-week program that is led by one of our registered dietitians, but it also has those health coaches, as well. So we have multiple people keeping our patients accountable. They have an individual session with one of our registered dietitians from the get-go after they've completed those prereqs, like I described before. They have, every other week, a group class. So they come into that group class. It's a community-like environment. It's really great, if I should say so myself. And then at the end of the program, they receive a final evaluation from one of our registered dietitians. So they have that individual touch point before and after. The group classes are more general education setting. And then in the middle of that are the health coaches, as well. So 16 weeks, someone's talking to you every single week. Also with that program, you get a wellness package from us. You get a nutrition manual that acts as a resource or tool they can have at their fingertips, like I stated before. We give them a tape measure to measure their waist circumference. And we take that measure once a month. We have that weight scale, like I talked about. And then they have a couple other fun things, like a portion control size bowl. We talk about portion sizes. And then they have a snack pack, as well, a cute little purple snack pack that patients love to add their snacks in if they're going to appointments or they have a long day away from the house. It really kind of works as less temptation to stop at that McDonald's on the way home. So we introduce nutrition principles that we call habits. And after introducing and practicing one habit, we teach them how to habit stack. These habits are small enough and achievable enough to stack on top of one another throughout the 16 week program. So at the end of the 16 weeks, we have a really nice, comprehensive, whole person, whole picture view of nutrition. We have a linked Facebook group that the patients have an opportunity to collaborate with one another. They throw up their own recipes, links to Tupperware, you name it. It's a really nice place for them to engage and kind of step outside of that expert, just educating them. They have each other as well to get through the program. The focus is on making really achievable goals, identifying obstacles to those goals, and planning to get around those goals. Like I said, in those group classes, we like to identify the successes of course. What went well for you this week? But most importantly, we talk about what didn't go well. Where did you struggle? All right, Jimmy, maybe Alice can help you figure out what she did to get that green starter successful this week. So that's a really nice environment. Highly recommend. Our habits that you see here up on the screen are the eight habits that we have throughout the 16 weeks. So these are the habits that are stacked on top of one another. That first one is starting your meal with a green starter, getting those vegetables in, and making it a non-negotiable. We have them pick one meal. So we start with one, and then we move on to two. Really small. Next is optimizing breakfast. Our your first meal of the day. So if you don't eat breakfast, that's OK. We want to meet you where you're at, and then we'll focus on enhancing or enriching that first meal. Thirdly is planning for success. That includes meal prep and kitchen basics, things like Tupperware, things like using a blender if you have it on hand, not necessary, but just things that can really kind of help ease the way of getting into the kitchen and cooking things that you've never cooked before. Fourth is diving into desserts and how to enjoy them guilt-free. Fifth is determining the quality of carbohydrates. So complex versus refined, things like that. Discovering the difference between fats, talking about saturated versus unsaturated. There are healthy fats out there. A lot of our population kind of grew up in the all fat is bad, low fat everything, right? So we really help to educate and let them know that not to be afraid of these healthy fats. Smart snacking with mini meals is our next one. And then decreasing animal products while increasing your plant protein. So we like to say plant forward. So we're moving towards being plant-based, but we're meeting the patient where they're at. We initiated our first cohort at the end of January, like I said, our very first cohort, which was exciting and the early data is promising. We know that eating is a behavior wrapped in many other things, right? Well, we're seeing some really great change in behavior. We're seeing patients go from eating the standard American diet to a more flexitarian or pescatarian diet, and then even more towards a whole food plant-based diet. We do this by customizing meal plans for them. We found that the most important thing here is to meet the patient where they're at. Cannot emphasize that enough. If they're at a standard American diet, we're not trying to take them from that to 100% whole food plant-based, no processed ingredients. It's unlikely that that will be sustainable. So we meet them where they're at and we get them one step further in the right direction. We are seeing things like chronic pain patients reporting less symptoms. We're seeing blood pressure decrease. We're seeing waist circumference decrease as it relates to metabolic syndrome. And we're also seeing the ease of habit stacking. Like I said, these habits are really small, really achievable, but at the end of 16 weeks, they're consistent, they're sustainable. The most important thing here as well is that they're meeting those habits week after week. They have somebody coming in and checking in on them every single week. Okay, how did last week go for you? How can we improve this for you? What barriers did you have? Let's make this more smart for you with those smart goals. That's where the care managers and the health coaches really kinda come in and help with that. So by focusing on the behavior of eating instead of dieting like we are so conditioned to follow, we are releasing that sustainable change. So I'll turn the time back over to Katie and I think you guys, she'll be discussing some of the challenges that we have while creating the program. Thank you. Thanks, Ashley. So the main huge challenge is that diet change is hard and we're really not going to significantly affect chronic disease outcomes without improving diet. I think in some ways it's way harder than treating depression. Another challenge is that weight loss can be elusive. We've achieved that 3% weight loss pretty consistently and early results from our new programs suggest that we will improve that with some people but some people aren't getting there. And so we really don't know. Nationally there's a really big discussion about obesity and about weight loss and how we achieve it and all the different things going into it. And so we're kind of in that same space. And then the third challenge is this widespread incidence of disordered beliefs around eating. And people have a lot of history with yo-yo diets. They make a radical change and they fall off the wagon. They feel shame and they do it again. And we really want to emphasize slow and consistent change. If you have a bad day, that doesn't mean it's the end. It just means tomorrow you get to try again. And when you focus on achieving the long-term improvement rather than on a daily basis, we talk a lot about how imperfection is part of life. So probably lots of people have felt this, either themselves or family members or patients struggle with and then fail and then give up. I know I have seen that in lots and lots of patients and family members. And we see it in just depression treatments and we see it in change and failure can be discouraging but really the way we talk to patients about how they're changing and the long-term goals can make a big difference in how successful they are over time. So for those of you in the audience who don't have access to a registered dietician or who don't have a nutrition program like we set up, I'm gonna suggest a way that you can start integrating some of this knowledge immediately. After I became trained in lifestyle medicine, I immediately started changing my non-collaborative care practice, my regular clinical practice. And so every time I start a second generation antipsychotic, I mean every time, I talk about nutrition. I recommend against snacking. I recommend people start with a green starter. We talk about some of those principles and habits that you saw in the prior slides. I talk about increased hunger and weight gain and then I track metabolic outcomes every three months. And then at subsequent visits, that's one of the big things that I follow up on. How is your hunger? How is your snacking? Have you seen any weight gain or change? And then for my young adults, I try to do this for everyone, but I've had the most success. With my young adults, I try to get the person at home who's in charge of cooking on the phone and in the visit. So I usually say, hey, let's call your mom and talk to your mom about this. And we've had a lot of success with that because moms are always interested in trying to get their kids to eat healthier, I have found. Spouses typically are very motivated too. And when you talk about it as a health risk and a worsened risk because of the medicine, people are really willing to listen. So we do SMART goals together about meal prep and changes. I've collaborated with primary care physicians on this before and it's been really effective. So now I'll switch gears and move into describing the physical activity treatment pathway. We're gonna introduce my colleague Amy Pike. Oops, I missed, there should be a quote in here. Here it is, okay. So this is from that lifestyle psychiatry book that the APA published. Lifestyle interventions have been demonstrated to exert neurobiological and epigenetic effects. Physical exercise is the most potent intervention known for stimulating synaptic plasticity. The literature is just full of great studies showing that moderate intensity exercise is as good as pharmacotherapy alone for mild to moderate depression. And it can also be helpful in people with severe symptoms. And we know that increased physical activity across the lifespan is associated with decreased risk of chronic disease and decreased risk of all-cause mortality. And sedentariness, conversely, is associated with pretty much every bad outcome you can think of. So many patients will preferentially choose exercise as their first behavior change of choice. And I've seen this in the inpatient setting, in the IOP, and in the outpatient setting. Everybody says, I feel better when I exercise. I wanna exercise, but I'm just too depressed. I can't be, I'm not motivated. And so we really wanted to provide this evidence-based treatment at Nudge, and we wanted to focus on people helping, focus on helping people get sustainable behavior change. And you got to see two of those patients talk about their experience with the physical activity pathway in the video. So Amy is a physical therapist. She's the chief architect of our physical activity program, and she's also a cancer survivor whose physical fitness she and I both think likely played a role in her survival. Thank you. I am so honored to be here, and I'm glad that you guys are all here. I am a physical therapist. I practiced in the acute inpatient setting for 10 years. In the tail end of which, in 2017, I was diagnosed with stage four colon cancer. I was at peak health. I had a very good diet at the time. I was exercising twice a day, and that was six years ago. My world got flipped upside down. I craved normalcy probably more than anything during that time, and for me, that meant physical activity and the gym. So sometimes that would simply mean getting off the couch, getting into the gym, and sitting in a chair just to be in that environment. But pushing myself physically and mentally was the best medicine for me at the time. So I firmly believe that I am part of the data that supports that increased physical activity, and that corresponds to increased survival. And the data right now shows that that is most supported in the breast cancer and colon cancer populations. From my own personal experience, and from what I saw working in the hospital, was that exercise has a very good correlation in affecting chronic disease. So in terms of my own personal history, when I was asked to be a part of Nudge in designing a fitness pathway that would be delivered to a broad spectrum of adults with various activity levels, fitness backgrounds, and various levels of chronic disease, I was very excited, naturally. Our main goals in our exercise fitness pathway were to empower patients to become independent with their own fitness routine. So basically not just when they would be meeting with me and our health coach, but much longer after the fact. Can we keep them moving, keep them active? We wanted to increase their overall activity through daily steps and also days of the week. And we wanted to increase their strength and balance through strength exercises. So our pathway entailed a fitness specialist who would act as a care manager for our patient. They would perform an initial assessment with the patient and then follow up with the patient once a month after that. And they would also meet with a health coach twice a month. So they were getting three points of contact while they were enrolled in the program. Like in the nutrition program, the health coach would explain the fitness program to them, hone in on motivation and any barriers that the patient might have, working on problem solving, helping the patient with accountability, and the fitness pathway was really the only pathway that synchronous telehealth access was required. Because we wanted for the fitness specialist to be able to assess the patient's movement and be able to reinforce proper technique and safety with some of the strength exercises. Patients would also have the option of attending a virtual group fitness class once a month. During the initial assessment, the fitness specialist would assess the patient to select an appropriate exercise prescription. So they would take into account the patient's abilities, any mobility limitations the patient might have, and also their fitness experience. The program would then be able to progress in volume and complexity based on the patient's response to the exercises. During that initial assessment, we would measure the patient's strength functionally through a timed five-time sit-to-stand test where the patient would sit and stand five times. And this is a test that is evidence-based and validated measure. It's used by physical therapists and the rehab community. And it's able to assess whether or not a patient is within norms for their age demographic. So we can then set goals for strength and be able to measure an outcome through that. We also would ask for a self-report of minutes of sustained physical activity. And we wanted these to be active physical minutes, so not things like gardening or timing yourself as you walk around a grocery store. We wanted it to be minutes of sustained physical activity with the purpose of exercise. And we would take a total of not only their minutes a day, but days of the week so that we could calculate minutes of weekly sustained physical activity. Then we would educate the patient on the Borg scale. The Borg scale is also known as RPE or rate of perceived exertion. And this is important because it teaches the patient to be more aware of their body and how they're going to be responding to the activity or exercise so that they're not overdoing it or underdoing it. If they're overdoing it, then they're only training themselves to get through the exercise. They're not going to learn or adapt to the exercise. Similarly, if the exercise is too easy and it's lower end on the RPE scale, then the patient's also not going to be able to get any stronger or adapt. They're just going to be able to go ahead and do the exercise. So it's teaching the patient to assess, are they having pain? How much are they, has their respiratory rate increased? And then they're able to self-modify how many repetitions of the exercise they're going to do, either increase or decrease based on their response. It also allows for them to report their level of exertion on each exercise so their fitness specialist can know when they're ready to progress in volume or maybe progress to a more complex version of the exercise. In subsequent follow-ups, we measure the patient through that scale. We also measure their report of repetitions of each exercise and their minutes of walking. The patient reports their minutes, repetitions, and BORG through an app that we use, which allows us to go ahead and modify their exercises week over week. However, if the patient doesn't have access to technology or doesn't want to access exercises through email, we can also send them a mailer copy and follow up and make any modifications or progressions in our monthly call. Patients were found to improve strength, activity tolerance. They would report more repetitions of each exercise. They would also report decreased RPE. So I always would tell my patients, take, for example, I ask you to do a bunch of push-ups. You're able to do five. I expect that as you improve in strength, you'll be able to then do six, then seven, then eight. Similarly, as you get stronger, maybe on those five push-ups, you would initially report an RPE of seven. I expect that as you get stronger, you'll be then able to report an RPE of six and then five and so on. So it gives the patient more feedback that they're making progress, not only in the amount that they're able to do, but in the challenge of each exercise. The exercises that we would assign to the patients are all based on functional movements. So they would correspond to tasks that patients do in their daily life. This has more carryover to patient independence, longevity, sustainability. Thank you, Katie. So, here's a dumbbell RDL is one example. And so here you'll see one of our coaches with dumbbells performing a hinge movement. So she's loading her hips and bending forward. This has lots of carryover to things like picking an object up off the floor, reaching down to a bottom shelf in a refrigerator, right? But let's say that the patient has pain or range of motion limitations, or they use their knees too much, or they load their back when they do this. A more simplified version of this exercise would be a broomstick hinge. So taking an object that the patient has in their home and lining it up behind their back, this teaches them to keep their back straight and load their hips. So the exercise is very functional, very simple, mostly body weight, and don't require the patient to have equipment. The other, my favorite exercise that I think is important for all humans in general, but specifically for my patients, the squat pattern, right? So here we have an air squat. This loads the hips, loads the knees, but it's also one of the most functional exercises because it's simply the movement of being able to sit down and then return to a standing position, right? So whenever patients tell me, oh, I'm not allowed to squat, my doctor says I can't squat. I respond, oh, I'm so sorry, your doctor doesn't want you using toilets anymore. That's very unfortunate, right? So, next one. If the patient doesn't have the range of motion to be able to perform a full squat, you will remember that that fitness coach was getting pretty low. Her hips were dropping below the level of her knees. What we do is we introduce the patients to a mini squat. And this is simply just reducing the range of motion of the hips and knees and ankles to kind of accommodate any movement or mobility limitations that the patients might have. Okay, you guys have all been sitting for a very long time. So let's go ahead and have everybody stand up. Let's go ahead and do five squats together. I want everyone to kind of move at their own pace. You can use the chair in front of you. You can come out into the aisles and get a little bit more space. But let's go ahead and reach our hips back, sending your knees out over your toes. Go as low as you are comfortably. If you want to add a challenge, you can go down slower and then pop up a little bit more quickly. Good, and once you've gotten in five, you can go ahead and return to your seat. Well done, well done. So let's go ahead, do a body scan. How's everybody feeling, right? Maybe a little bit of adrenaline. I have a little bit of adrenaline, but that might have more to do with the microphone than the squats. You might notice your heart rate has increased a little bit. Your breathing rate might have increased a little bit, right? Maybe you feel just a little bit silly. Maybe you have a feeling of community since everybody got up and did it together, right? All of these things are positive, rewarding things that will help reinforce this habit of starting to get more movement into our day, right? And this is something that I would also encourage you all to do with your own patients, right? Just kind of able to do a body check, able to feel your heart rate increase is a good thing to be able to connect with your patients on. This slide is an example of our mailer that we send out to patients. You will notice that here we've got, this is the days of the week, right? So Monday, Tuesday, Wednesday, Thursday, Friday, we have a walking program. It's a progressive walking program where the patient is encouraged to increase their minutes of walking each day per their tolerance. And then subsequent exercise each day has three to four exercises, three days a week. So they're walking four days a week, strength exercises three days a week. The repetition prescription is on this page. And then we also include illustrations and written step-by-step instructions of each exercise for the patient to be able to do. We had some really great data initially. In 12 weeks of reported data, the patients reported minutes of their daily walking. This increased 71% up to 30 minutes a day. The average days of a week increased 62%, 4.6 days of the week, which those numbers get the patients closer to the U.S. Preventative Service Task Force recommendation of 200 minutes of exercise in a week. It's subjective data, however, because it is patient-reported. But our objective data of the five-time sit-to-stand test showed that people improved 41%. So basically, I kind of say that this is a pretty fail-safe program. You ask a patient to walk five days a week. Maybe they only do the walk one or two days a week. That's still an improvement from what they were doing at baseline. And then having them do the exercise of sit-to-stand once a week is going to automatically improve the strength and their confidence in that movement, which is going to improve their five-time sit-to-stand test time. So I just encourage you to use just encouraging your patients to walk and performing sit-to-stands. And you're getting them more active, and you're getting them stronger. So I'm going to turn this back over to Katie. Thanks, Amy. So we think it's pretty exciting. And I want to just point out that co-care is really limited to patients with the psychiatric diagnosis. So based on our results and the results in the larger literature, it's really clear that nutrition and exercise programs, from a behavioral perspective, based on these behavioral principles, have a much larger potential to affect many, many more people. And so in the lifestyle medicine community, providers really struggle to get nutrition and exercise paid for, but we can do it with collaborative care. And so I would love to see the F codes in ICD-11 or 12 really reflect the data that suggests that, like, you know, so you could diagnose something like hypertension associated with maladaptive behavior patterns or syndromes. So you don't have to say you have a psychiatric diagnosis. You have a behavioral issue, and we can treat it. And so we want to, like, formalize the evidence that demonstrating all chronic disease has behavioral health involvement. And so for the patients we are able to serve, designating the registered dietitians and exercise coaches as specialized care managers really helps open up the types of evidence-based treatments we can give them. And so we've redefined a little bit about what we can do in collaborative care. And I want to just show you one last thing to help you use this in your practice locations, no matter where they are. This comes from Tiny Habits, which is the work of Dr. B.J. Fogg. He's at Stanford. He wrote this book. I highly recommend it. And he has this fun little equation called behavior equals motivation times ability times a prompt, and then we have a pause and we celebrate. And so we want to get this side of the equation big enough that we get the behavior to happen. So if your motivation is really low, maybe your ability will be high enough or the prompt will be automatic enough that we can still get the behavior to happen. Or the opposite. If you are a 15-year-old boy trying to ask a girl to prom and you want to learn to play the guitar so you can serenade her, your ability is very low. You don't know how to play the guitar, but your motivation is so dang high that you might get it done in the three weeks while you're preparing to ask her to prom, right? Conversely, if you're trying to brush your teeth, your motivation might be low, but your ability is really high. As long as you're not a 2-year-old learning to brush your teeth, most people don't have to think about it, so the behavior still happens. So what Dr. Fogg says is that behavior change is not about willpower alone. It's about making small and sustainable goals. So I write this out, I throw it on a prescription pad with patients, and together we create goals. And I focus on decreasing the ability, making the goal so tiny that your ability is really, really high. So I usually say, and I've treated a lot of active-duty patients in an inpatient and IOP setting, and they always want to exercise as their treatment to feel better. So I say, okay, how many push-ups can you do? Or you pick an exercise, so they pick push-ups. How many push-ups can you do on your worst day? On your very worst day, when you have no motivation, you can barely get out of bed. And invariably they say something like 20. I'm like, no, no, no, your very worst day, when you can't even brush your teeth. If you were going to do push-ups, how many could you do? And so I help bring them down, and we usually land on about two, two push-ups. Could you do push-ups, too, on your worst day? They say yes. And then we pick a prompt. What is happening in your life every day that happens automatically that you can tie this to so you don't forget? Brushing your teeth, using the restroom, putting on your shoes, parking the car. So they pick one. And then after we do the ability, after we reach two push-ups, then we have to celebrate in some way and acknowledge that we did well. So that's a check mark on a calendar. That's a sticker chart. Everybody loves stickers, even grown-ups. That's a little Tiger Woods fist bump or a yes. And that gives you a little bit of a dopamine that's very satisfying, and you're more likely to continue. And then we don't stop ourselves. So if you achieve two push-ups, you're more likely to keep going. It's harder to start something than it is to continue something. So if you get your two push-ups in and you want to do more, that's great. But you will have been successful if you only do two push-ups. And so using these, using this equation, using these principles of tiny habits, using these principles of behavior change, I do this with my nutrition prescriptions with my patients on second-generation antipsychotics. I do it to do lifestyle exercise prescriptions with my patients. And I really invite you to do the same. We really want to focus on small, meaningful changes. And I've also had really significant success with severely depressed patients in the hospital setting, setting these tiny goals. In the hospital setting, it's usually like walk up and down the hallway once. And they're able to do it. And they feel really good. We celebrate that. And then before you know it, they're walking up and down the hallway like 10 or 15 times. They're getting out of bed. So, Ashley, give us a quick example of a nutrition goal that's so tiny it's really hard to fail. Okay. One of my favorite nutrition goals is to have patients have a glass of water as soon as they wake up before brushing their teeth. Okay, great. Staying hydrated. Okay, a glass of water as soon as they wake up. And Amy, what about a tiny fitness goal that's so tiny it's too hard to fail? Stand up and sit down each time you get up off a couch. Great. Okay. So, I really, yeah, come with me on this journey. Include nutrition and fitness prescriptions in your regular everyday life. Use the biopsychosocial model with evidence-based behavioral plans together, no matter what your treatment setting and no matter what you do. And together we can achieve a greater, we can begin to chip away at the chronic disease epidemic. And then, of course, I always encourage people to get trained in and to do collaborative care because I think it's so much fun. Thank you very much for your time. And now we'd like to open it up to questions. Applause This is a great program, it sounds like. Really, you're implementing so many things that are known to be useful but aren't used so often. And that's very satisfying. Thank you. You're a for-profit organization, I understand. We are. We're a privately owned company and we're one implementation solution for people who are looking to implement collaborative care or chronic disease management. I didn't add that I think you're focused on measurement. It's also something that we know we should be doing but we're not doing it mostly. Yes, we are a measurement-based care company. That's a wonderful thing to see. Do you have to charge patients some sort of a concierge fee to be able to provide all these services? Or are you getting by with Medicare money? We're getting by with Medicare money and regular insurance. There is increasing penetration in the private insurance market. More and more insurance plans are covering these codes and we're using the collaborative care codes to pay for everybody. So just like in the regular triangle, the primary care physician would use the collaborative care income to then pay the care manager and the psychiatrist, we just spread it out among more team members. I don't want to be monopolizing things but it occurs to me that as you're working this out in a financial way and in the behavioral aspect, it seems to me you're going to be winding up being consultants for other folks that want to put together such programs and that that surely should be an important part of your role. Yeah, we've thought about that because we have pretty significant training. It turns out that integrating health coaches who don't have master's degrees in behavioral health is actually a little bit tricky. And nationally a lot of people are trying to use health coaches and we're trying to broaden our pool of people who can help patients. We see that in other countries. They use community health workers as well but training them is a little bit hard. So we invest a lot in training and we are considering getting certified as trainers of health coaches. There's going to be a new national board for health coaches in a year or two. And so, yes, that's something we've been considering as well. Thank you. Hello. Hi, Katie. Lovely presentation for everyone here. I'm a fifth year for folks here. I'm a fifth year in the Family Medicine and Psychiatry Program at UC Davis in Sacramento. And so talking about one of the lifestyle interventions through family medicine has been huge and also a way of, I think, building rapport with patients to make them feel like I don't only just care about medications that they're taking, you know, I actually care about the life that they lead. But on the psychiatry side, I'm a part of the Integrated Care Committee for the APA and we recently tried to get through a set of position statements regarding integrated care and the amount of strikethrough that was on that document was remarkable in terms of even getting like our national organization to take a position on these are evidence-based things psychiatrists can and do have a role in intervening on metabolic syndromes, cigarette smoking, routine vaccinations. And so what is your sense of the psychiatric community taking part in or taking some ownership of medical care where it's not necessarily been a part of the culture? Yeah, I mean, that was my original kind of point to this talk is that we have all of this evidence in many of these different areas of medicine and our training really gives us an advantage compared to others. I mean, in lifestyle medicine, I got trained on like, you know, four of the six areas in residency whereas most doctors don't have that advantage. I think there is growing need and I think there's growing recognition among psychiatrists that this needs to be a more formal part of our treatment plan. I went to a bunch of the nutrition lectures and some of them were standing room only. So I think as our recognition as a society and as physicians in general grows about how bad chronic disease has gotten, there's also an increasing desire on everybody's part to try to figure out what we're going to do about it. You know, I would say the exercise data is really strong. It's been there for years, decades even. The nutrition data is showing that increased inflammation and chronic disease and things like that. I think that's emerging and that's not quite as robust but there is really good, interesting kind of smaller studies, smaller scale studies, so I think that's going to come. But I think the trend is growing. I think 10 years from now, it will be very different than it is now. You know, in one of the other talks, someone said that they would be laughed out of the room 15 years ago if they got up and talked about how nutrition was an important part and thing for psychiatrists to think about and prescribe. And we just know there's so much more evidence now that this should be a part of our biopsychosocial model. So I'm hopeful. Hello. Just one more question about the collaborative model. Just in case, I mean the example is always about the primary care practitioners but you have mentioned that you are collaborating with the cardiology service. So the BCP or primary health care, are they also associated with the cardiology service or you are dealing directly as a psychiatrist in the collaborative model with the cardiologist instead? So the cardiologist is the one billing the codes and prescribing the collaborative care treatment. And then we do collaborate with primary care physicians who are usually not related. These are usually not in the same system. We have some clients who are large health systems and then they're all in the same system. But frequently our clients are independent solo cardiology groups or, for example, the breast cancer surgeon that has privileges at the hospital but isn't in a larger group. And so in those cases during treatment team when it comes up, then we interface with primary care physicians. And the psychiatrist will call and talk to the primary care physician if needed. But we are making most of our recommendations to the cardiologists, which kind of adds another layer of complexity since primary care physicians for the last 30 years have accepted that they need to treat depression and anxiety. And even though the literature is really excellent in cardiology and the National Cardiology Association say it behooves you to screen for and treat anxiety and depression in your patients, most of them are not doing that yet. This is my understanding because the family physicians and general practitioners, they have accepted to be part of the collaborative model and they work on themselves. But the cardiology, I'm not sure about it. We have plenty of cardiologists who are willing to let us treat the patients, but they're not as good at having that close collaborative relationship. But that also happens when I'm active in some of these national collaborative care groups, both on the APA website and in a couple other national groups, and lots of people find the same, that some doctors love to learn and want to learn more and some doctors just want you to treat their patients. So the one who's prescribing is the cardiologist or the primary care physician? Cardiologist. Yeah, I mean, the one who's prescribing, let's say, antidepressant anxiolytics will be the cardiologist in this case. Yes, sometimes. Sometimes we get patients who are patients of the cardiologist, but they're being prescribed antidepressants from another physician. And in that case, we're not really associated with that physician, and so we offer treatment in another area where we don't compete and we don't have to try and make changes to medicine that the cardiologist is not prescribing. Thank you very much. Hi, I'm Dr. John from New York. I work in an inpatient state hospital, so I'm wondering how you can implement some of this work into our unmotivated patients. These are difficult patients. They're not motivated. Yes. And I'm impressed by the amount of work and time you put into this, you know. Program development, yes. Yes, program, yes. So I was an inpatient physician until January of this year, and I have done this very successfully with my patients in the hospital. I would say that it's easier to do exercise than it is to do nutrition. We have to collaborate more with the registered dieticians in the hospital, but even then I've had some patients where we've tried to get them to choose the vegetarian option for one meal a day as a way of increasing their plants or starting with a salad and eating a whole plateful of salad first. And when they're not motivated, I fall back on my motivational interviewing training where I really try and link their values and what they want their life to look like to what they are now, and then we just create goals so tiny that they're able to do them. So I've had severely psychotic patients. I've had severely depressed patients who are getting out of bed that we motivate to start moving more with these tiny goals and then some kind of a celebration. It's frequently sticker charts or something like that in the hospital or high fives, congratulations from other staff members. So it's just really it's a matter of getting to know each individual patient and then creating an individualized treatment plan using Dr. Fogg's principles. So I would say if you wanted to implement this on a larger level, on a state hospital level, getting patients or getting the staff members trained in Dr. Fogg, in Dr. Fogg's like BMAP-C equation, giving them examples, doing case-based examples would be a great start. Okay, thank you. Well, thank you so much for coming. I really appreciated it. applause

psychiatry

multidisciplinary approaches

chronic diseases

lifestyle medicine

collaborative care

mental health

patient outcomes

behavior management

nutrition

fitness

public health

holistic care