Disease Management

We cannot stress it enough, many of our chronic diseases are a result of our lifestyles.  The best way to prevent diabetes, high blood pressure, high cholesterol, and obesity is to modify our lifestyle habits.   Lifestyle habits include diet, exercise, smoking, weight management and stress management.

At Upper Valley Family Care we take a patient focused team approach to disease management.  Our team of physicians, nurse practitioners, physician assistants, dietitian, medication specialist, and care coordintors work with you to develop and monitor your treatment plans.  Through care visits focusing specifically on disease management our nurse practitioners, physician assistants, and care coordinators can provide extended time and expertise to provide advice, education, and resources beyond that provided during a normal physician office visit.


Obesity is the presence of too much body fat and is the main culprit in cardiometabolic disorders.  Reducing weight improves insulin response and blood pressure and helps control lipids.  The level of obesity is determined by the Body Mass Index indicating the relation between height and weight.  Achieving a healthy BMI can be challenging.  Reducing calorie intake while increasing calories burned through exercise can help you reach your goal.  BMI goal is less than 25.  A BMI of 25 to 29.9 is considered overweight, 30+ is considered obese.   A BMI calculator can be found on the Centers for Disease Control website http://www.cdc.gov/healthyweight/assessing/bmi/

Metabolic Syndrome

Metabolic disease is 3 or more disorders related to metabolism occurring in an individual at the same time.   This combination increases the risk for developing coronary artery disease, stroke, and diabetes.  These disorders include:

  • Extra weight around your waist
  • Insulin resistance or glucose intolerance
  • Elevated blood pressure
  • Increased triglycerides
  • Decreased HDL

The treatment goal is to reduce weight, blood pressure, LDL cholesterol, and blood sugar through lifestyle modification.  Aggressive lifestyle changes can delay or even prevent the development of serious health problems.


Diabetes is a chronic disease that occurs when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces.  Diabetics are much more likely to have a stroke, heart disease, or heart attack.  Diabetes is also the leading cause for blindness, lower limb amputation, and kidney failure.

UVFC Treatment Plan and Goals

Recommendations for Adults with Diabetes


Blood pressure is the force of blood against the inside of the blood vessels.  When your blood pressure is high, your heart has to work harder.  High blood pressure can lead to heart attack and stroke and can also cause damage to the eyes and kidneys.  The goal is to have blood pressure in the normal range.  If you fall in the prehypertension range, you should initiate lifestyle changes.  If your blood pressure is greater than 140/90, you may require medication.                    


Normal blood pressure Under 120/80

Prehypertension Between 120/80 and 140/90

Hypertention Over 140/90


Cholesterol (lipids) is a waxy, fat-like substance that occurs naturally in your body.  If you have too much cholesterol in your bloodstream, the excess is deposited in your arteries contributing to narrowing and blockages.  This reduces the supply of blood to the heart and can lead to heart disease, chest pain, and heart attack.

Lifestyle modifications to improve your lipids include reducing cholesterol and fats in your diet, especially saturated fats, weight reduction, and regular exercise.  Medication may be needed to help achieve goal.


Total Cholesterol      Under 200

HDL Cholesterol      Over 40

LDL Cholesterol       Under 100

Triglycerides            Under 150


COPD is a serious lung disease that makes it harder and harder to breathe.  Two co-existing diseases of COPD are chronic bronchitis and emphysema.  The airways in the lungs become smaller and smaller causing shortness of breath.  The leading cause of COPD is cigarette smoking.  It can be very difficult to stop smoking.  Nicotine gum, lozenges, and patches can help.  There are also medications that can help.  We have trained staff available to help patients through this process.