Pacific Northwest doctors use team-based approach to support patients with metabolic syndrome

This story has been edited to add information about awards won by CHANGE.

In fall 2017, the Pacific Northwest division launched a year-long pilot of a diet and exercise program to help patients with metabolic syndrome, a health disorder that leads to chronic diseases such as diabetes and heart disease. Called CHANGE (Canadian Health Advanced by Nutrition and Graded Exercise) BC, the initiative supports patients through a team-based care model that includes GPs, a dietician, and a kinesiologist. After assessing each patient, the team creates a plan to meet their distinct needs, taking lifestyle, income, physical abilities, and exercise preferences into account, and participants’ family doctors oversee the program and monitor their patients’ progress.

Now underway in Smithers, Houston, and Haida Gwaii, the local initiative is based on Metabolic Syndrome Canada’s CHANGE program and marks the first time the program has been offered in BC.

Representatives from the Pacific Northwest division, including Drs Brenda Huff, Wouter Morkel, and Onoura Odoh, presented an update on the initiative at the recent GPSC Spring Summit, during the Team-Based Care Buffet session.

“Metabolic syndrome impacts one-in-five Canadians, so the potential benefit of the CHANGE BC program is huge,” said Dr Morkel, who is leading the initiative in Smithers. “We are thrilled to introduce this program to British Columbia as pilots in other provinces showed such strong benefits for patients.”

An article by Metabolic Syndrome Canada published in the Canadian Medical Association Journal on the results from Alberta and Ontario CHANGE programs showed 19 per cent of participants saw complete reversal of one or more metabolic syndrome conditions over 12 months. An additional 42 per cent had a decrease in the number of metabolic syndrome criteria within the study period, and the 10-year risk of heart attack was reduced by 17 per cent on average.  

“As family doctors, we are always looking for new and better ways to support our patients’ health,” said Dr Morkel. “We hope this pilot will become a lasting program that can serve as a model for other BC communities.”

In May 2018, the CHANGE BC program was awarded the Innovations in Primary Care award by the BC College of Family Physicians, and the BC Rural Healthcare Award for Effective Healthcare Partnerships, which recognizes five family physicians from the Pacific Northwest Division who are leaders in CHANGE BC: Drs Jaclyn Black, Brenda Huff, Greg Linton, Matthew Menard, Wouter Morkel, and Onuora Odoh.