Table of Contents:

Section 1:
Definition of Adherence......................................................................................................................... 4

Section 2:
Barriers to Medication Adherence...................................................................................................... 6

Section 3:
Barriers to Lifestyle Adherence............................................................................................................. 8

Section 4:
Identifying Non-Adherence................................................................................................................... 9

Section 5:
Role of Health Care Professionals......................................................................................................11

Section 6:
Interventions to Improve Adherence...............................................................................................12

Section 7:
Resources for Health Care Professionals.........................................................................................14

The goals of this toolkit are to:

 Define adherence and the various types of non-adherence

 Identify common barriers to adherence and predictors of non-adherence

 Describe the role of all health care professionals in the identification and management of
non-adherence

 Summarize current methods used to assess adherence

 Review evidence-based, innovative strategies to improve adherence

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Supplement to the Lipid Spin
 Clinician’s Toolkit:
A Guide to Medication and Lifestyle Adherence

Why Adherence?
Adherence is more than merely asking our patients to comply with our prescription to take their medications
and adopt a healthy lifestyle. Adhere simply means “to give support or maintain loyalty.” Health care professionals
should take note of two key words in this definition, support and loyalty. This implies that we have a responsibility
to help our patients navigate the complexity of their disease and treatment, so they may better adhere to the
medications and lifestyle changes we prescribe.

Adherence to Lipid-Lowering Therapies

Despite a declining death rate from cardiovascular disease (CVD) in the United States, one in three Americans
will die from heart disease.1 Furthermore, the American Heart Association estimates 32 million adults have total
cholesterol levels >240 mg/dL, 77 million have hypertension, one in five adults continues to smoke cigarettes,
and one-third of US adults are obese.2, 3 Consequently, the significant burden of CVD in this country is expected to
exceed 40% by 2030.4

Statins are one of the most significant interventions to reduce the burden of CVD because of their ability to lower
low-density lipoprotein cholesterol (LDL-C). Despite a plethora of data demonstrating the ability of statins to
reduce mortality and morbidity in primary and secondary prevention of CVD, they remain underutilized. Previous
studies have found that 50% of statin users discontinue therapy by the end of the first year.5 Furthermore, the
Understanding Statin in America and Gaps in Education (USAGE) Survey found that 62% of former statin users
discontinued therapy because of side effects. Other reasons for statin discontinuation included cost (17%) and lack
of efficacy (12%).5,6 The take-home message from this is that we can likely improve adherence merely by better
educating our patients regarding the risks and benefit of statin therapy.

Therapeutic Lifestyle Change (TLC) approach is another important strategy to aid cholesterol reduction and prevent
cardiovascular disease. Reducing intake of saturated fat and cholesterol, weight reduction if overweight and
increasing intake of soluble fiber and plant-based foods containing sterols and stanols has been shown to reduce
LDL-C by 20-30%.7,8 Additional lifestyle measures to reduce CVD burden include: eating foods high in omega-3 fatty
acids; increasing physical activity; and smoking cessation.

Despite the overwhelming benefit of current treatment modalities, non-adherence persists in a manner that poses
a major threat to the health care system and our patients.

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Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence
Consequences of Non-Adherence
 125,000 deaths per year in the US are linked to non-adherence9

 Non-adherence to cardiovascular medications is associated with increased risk of mortality and morbidity10

 It is estimated that between 33 and 69% of medication-related hospital admissions in the US are due to
poor adherence9

 Cost of non-adherence in the US is estimated at $100-300 billion annually9

 National Health and Nutrition Examination Survey (1988-2006)11

 Obesity é from 28% to 36%

 Regular physical activity ê from 53% to 43%

 Eating ≥5 fruits and vegetables a day ê from 42% to 26%

 Adherence to healthy habits was no more likely in people with cardiovascular disease, diabetes,
hypertension, or high cholesterol

As health care professionals, what can we do?

Despite three decades of work by the World Health Organization (WHO) and Institute of Medicine (IOM), adherence
remains a major concern. Non-adherence is a multi-faceted problem that will require a multi-faceted approach. The
WHO has called for a multi-disciplinary approach from health care professionals, researchers, and policymakers.12
With this in mind, we have developed this toolkit to provide health care professionals with a concise, practical
guide to adherence with useful tips that can be easily integrated into practice and shared with colleagues.

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Supplement to the Lipid Spin
 Section 1. Definition of Adherence
In 2001, The World Health Organization (WHO) held a meeting on adherence to develop a definition suitable not
just for medication-related adherence, but also healthy behaviors.

WHO defines adherence as “the extent to which a person’s

behavior – taking medications, following a diet and/or
executing lifestyle changes, corresponds with agreed
recommendations from a health care provider.”

Adherence and compliance are often used interchangeably but it is important to understand there are notable
differences between these two terms and adherence is the preferred terminology.

Adherence Compliance

Incorporates the patient-provider Viewed as paternalistic and does not

relationship emphasize a “therapeutic relationship”

Requires competence and motivation Represents actual adoption of

on behalf of the patient medication-taking and lifestyle change
behaviors

Allows for open dialogue and Focuses on what the patient is “told to do”
addresses underlying reasons and whether they comply or not
contributing to non-adherence

Continued follow-up is an essential Does not emphasize follow-up to

component of the plan assess patient progress

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Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence
It is equally important to recognize the different types of non-adherence. In the literature, non-adherence is usually
classified as primary or secondary. Of note, secondary non-adherence is also commonly referred to as persistence.
Understanding the types of non-adherence can help providers better recognize non-adherence and make
interventions specifically related to the underlying cause.

Types of Non-Adherence Examples

Primary
 Never filling a prescription
 Medication is purposefully never
filled or taken  Makes no attempt to exercise or eat healthy

Secondary (or Persistence)  Unintentional

 Forgetfulness

 Medication is not taken properly or  Do not understand directions due to poor

continued as prescribed health literacy
 Medication side effects
 Un(or under)-insured

 Intentional
 Patient decides to stop taking the medication
on their own
 Lack of information regarding medication
risks and benefit

 Lack of motivation to follow recommended

treatment plan

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Supplement to the Lipid Spin
 Section 2. Barriers to Medication Adherence
Patients face a multitude of barriers to taking their medication. Poor medication adherence is often viewed as the
patient’s problem but it is also important to recognize the role we, as health care professionals, play in supporting
poor medication-taking behaviors. Poor medication adherence can be frustrating for both the health care
professional, and the patient. Furthermore, evidence supports the notion that adherence decreases as the number
of barriers for the patient and provider increases.13

Patient-related Barriers
 Complexity of medication regimen
 High out-of-pocket cost
 Concern or risk of side effects
 Receives contradictory infomation from
healthcare providers
 Belief system that is inconsistent with
contemporary medicine

Prescriber-related Barriers Pharmacist-related Barriers

 Limited time with the patient  Difficulties communicating with

prescriber
 Uncomfortable speaking to patients  Limited time to review medication
about adherence refill histories
 Lack of incentive to spend additional  Inability to access refill history across
time counseling on adherence multiple pharmacies
 Unaware of lower-cost medications  Limited access to patient’s medical
records in the ambulatory setting

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Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence
The consequence of not recognizing and addressing these barriers is too great to ignore. The breakdown of
medication adherence begins in the prescriber’s office and the likelihood of adherence diminishes as the patient
proceeds to the pharmacy to fill the prescription and once the patient takes the medication home.

NOT FILLED
100% -12%
NOT STARTED
88% -12%
NOT FINISHED
76% -29%

47%
Common Barriers Common Barriers Common Barriers
• Understanding • Perceived SE • Forgetfulness
benefits of therapy • Not understanding • Side effects
• Denial benefits and risks • Financial
• Financial • Polypharmacy • Polypharmacy
• Health Literacy • Denial • Ongoing reinforcement

Medication Medication
Medication
Prescription Process Taking Process
Dispensing Process
in the Prescriber’s in the Patient’s
in the Pharmacy
office home

Reference: Adapted from Medication-taking Behavior over the Medication Use Continuum. American Heart Association 20019
Reference: Adapted from Oyekan E. The B-SMART Medication Adherence Checklist. A Tool to make it easier for Physicians and Providers to do
Statistics You Should Know. Available at: http://dmhc.ca.gov/library/reports/news/rci/oyekan.pdf
the right thing when addressing America’s other drug problem – Medication Non Adherence. Website: Department of Managed Health Care.
http://dmhc.ca.gov/library/reports/news/rci/oyekan.pdf. Accessed August 20, 2013.

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Supplement to the Lipid Spin
 Section 3. Barriers to Lifestyle Adherence
Patients routinely encounter barriers to adherence to lifestyle recommendations intended to manage CVD risk factors.

Patient-specific Barriers to Lifestyle Modification Adherence

 Lack of self-efficacy

 Setting unrealistic goals

 Perceived lack of time

 No motivation to initiate lifestyle changes

 Inability to prevent and manage relapse

 Lack of a support system (e.g., family, friends)

 Unable to handle stress and anxiety

 Limited understanding of how to implement lifestyle change and confront barriers

 Undervalue the role of lifestyle change in the management of chronic disease

Clinician-specific barriers to educating patients about lifestyle behavior changes include lack of adequate time
for education, lack of knowledge about effective counseling strategies and evidence-based nutrition education
approaches and resources.14,15 In addition, clinicians lack knowledge about contemporary nutrition and physical
activity recommendations for the treatment of dyslipidemia.16 Included in Section 7 of this toolkit is a tear sheet
that provides some useful resources to help clinicians encourage patients to implement lifestyle modifications and
offer guidance on how to use motivational interviewing techniques to help patients make lifestyle changes.

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Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence
Section 4. Identifying Non-Adherence
One of the initial steps in identifying non-adherence is to understand which patients are at highest risk of non-
adherence. There are five well-established predictors of poor medication adherence, including cost of medications,
dosing frequency and timing, side effects, being elderly, and self-efficacy.

Predictors of Adherence17
 Medication costs
 Dosing frequency and timing
 Side effects
 Elderly patients
 Self-efficacy

Medication Costs
A recent study found that 46% of patients stopped taking their statin or did not fill the prescription because of cost
and 23% reported skipping doses of their statin to save money.15 Provider knowledge of the patient’s prescription
insurance coverage may alter a treatment plan to include a more affordable medication and subsequently have a
positive impact on adherence. Patient assistance programs, provided by many pharmaceutical companies, should
also be considered for those who qualify.

Dosing Frequency and Timing

It is well documented that adherence diminishes proportionately with an increase in dosing frequency. This can be
one of the easiest predictors to adjust and is often not an issue with once-daily statin therapy. However, the typical
nighttime dosing of statins to coincide with evening endogenous cholesterol production during the fasting state
can be problematic for some patients’ lifestyles. It is often worth sacrificing the small additional LDL-C lowering to
ensure adherence, or the patient can be switched to a statin with a long half-life (e.g., rosuvastatin). If a medication
must be taken multiple times a day, text message or cell phone alarm reminders can be effective.

Side Effects
The USAGE survey found that six in ten respondents discontinued their statin due to side effects. Furthermore, one-
third of the respondents who stopped taking their statin did not inform their provider. One study, however, found
that half of patients who stopped their statin due to an adverse effect were successfully restarted within a year.18 It
is imperative that we educate patients up front regarding the potential side effects and reinforce the need to speak
with their provider before discontinuing any medication.

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Supplement to the Lipid Spin
 Elderly Patients19
Non-adherence is problematic in the elderly population for several notable reasons. The elderly frequently
develop physical (poor eyesight, arthritis) and mental limitations (dementia) that may limit their ability to read and
understand prescription bottle directions, or even open the packaging. Elderly patients also take more medications
than their younger counterparts and are more susceptible to drug side effects. Consequently, elderly patients are at
risk of primary non-adherence and may also lack persistence with taking their medication as prescribed.

Self-efficacy
Self-efficacy is the belief that one can tackle a task without any assistance.20 Social-cognitive models of behavior
show self-efficacy as a predictor of health behavior change. Self-efficacy predicts the formation of behavioral
intentions and the development and implementation of an action plan.21 One way to determine a patient’s self-
efficacy is to ask questions pertaining to their level of confidence to perform a specfic task, such as “How confident
are you that you can take your medications on a daily basis?” If the patient does not believe they are capable of
following a plan of care because they have not reached a level of self-efficacy, they will most likely not adhere.

Regardless of whether these predictors of adherence exist, there are additional “risk factors” that could explain
why your patient may be non-adherent. Once suspicion is raised, it is important to take the next step and attempt
to measure medication adherence. Although multiple objective and subjective tools exist, there is no single, gold
standard.

Characteristics of Patients at HIGH Risk of Non-Adherence

 Not refilling an Rx  Multiple co-morbidities
 Forgetfulness  Lack of trust in their provider
 Poor eyesight  No prescription drug coverage
 Depression  Inadequate response to therapy or lack of
appropriate follow-up
 Language barrier
 Does not understand their condition
 Cultural gaps
 Medical condition without symptoms
 Poor coping skills
 Missing appointments

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Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence
Section 5. Role of Health Care Professionals
A multidisciplinary, health care team is essential for delivering patient-centered, coordinated, and effective health
care.22 Given the complexity of clinical practice and the rapid emergence of new scientific information it is essential
that a team-based approach to patient care be embraced. Interprofessional, team-based care is an effective
strategy for achieving optimal patient care.

Adherence is a complex issue that requires an “all hands on deck” approach. The health care team often begins
with the physician, who plays an integral role in establishing a trusting relationship with a patient. This patient-
physician trust has been shown in several studies to be more important than treatment satisfaction in predicting
adherence and overall satisfaction with care. Equally important are the other members of the health care team:
pharmacists, nurses, nurse practitioners, and registered dietitian nutritionists. Several studies have demonstrated
the effectiveness of pharmacist and nurse-led interventions. Furthermore, medical nutrition therapy provided by
a registered dietitian nutritionist has been shown to improve health and well being, and decrease doctor visits,
hospitalizations and reduce prescription drug use. The significant demand on physicians’ time requires a physician
to collaborate with these health care professionals to help prevent, identify, and manage non-adherence.

Role of Health Care Professionals in Preventing, Identifying and Managing Non-Adherence

Physician
 Extensively trained to prevent, diagnose, and treat disease
 Often viewed as the leader of the health care team
 Likely to have a close relationship with the patient and comprehensive understanding of their medical history
Pharmacist
 Doctorate-level training in pharmacology and pharmacotherapy, and patient counseling and motivational interviewing
 Skilled in identifying and solving complex medication-related problems
 Can enter into collaborative practice with prescribers (in most states) to initiate or modify drug therapy and provide
medication management
Physician Assistant
 Advanced training to prevent, diagnose and treat disease
 A close relationship with the patient and comprehensive understanding of their medical history
 Emphasis on patient education to improve adherence and health status
Nurse and Nurse Practitioner
 Develops a therapeutic relationship with the patient
 Emphasizes needs of the patient and encourages an open dialogue
 May pursue advanced training at the Master’s or Doctorate level to diagnose and treat disease (Advanced Practice
Registered Nurse)
Registered Dietitian/Nutrition Professional
 Food and nutrition experts, who translate the science of nutrition into practical solutions for healthy living
 Perform Medical Nutrition Therapy (MNT) including nutrition assessment, diagnosis and nutrition intervention, education,
counseling, monitoring of progress and evaluation.
 Reinforce patient’s behavior regarding adherence to lifestyle and medication-taking using motivational interviewing
techniques.

Supplement to the Lipid Spin

 Section 6. Interventions to Improve Adherence
According to several studies, interventions to improve medication adherence should be simple. The mnemonic,
“SIMPLE”, categorizes efforts to improve adherence.23,24

Simplify the regimen  Adjust timing, frequency, and dosage

 Utilize once-daily medications whenever possible

S 


Encourage the use of adherence aids (e.g., pillboxes, cell phone
alarms)
Consider each patient’s activities of daily living (e.g., swing shift
workers)

Impart knowledge  Patient-provider shared decision making

 Provide clear instructions and expectations for all prescriptions

I 

Involve relatives or caregivers when discussing medications
Recommend electronic education formats (e.g., video,
websites)

Modify patient beliefs and  Ask patient about their needs and what might help them
human behavior adhere to therapy
M 

Ensure patient understands consequences of non-adherence
Addressed perceived barriers of taking the medication
 Provide rewards for adherence (e.g., praise, coupons, fewer
clinic visits)

Provide communication  Practice to improve interviewing skills

and trust Embrace active listening and provide emotional support
P

 Elicit patient’s input when discussing treatment options
 Allow adequate time for the interaction and encourage patient
to ask questions

Leave the bias  Foster a greater understanding of health literacy and how it

L
affects patients
 Ensure communication style is patient-centered
 Take extra time to understand and overcome cultural barriers
 Tailor education to the patient’s level of understanding

Evaluating adherence  Ask patients simply and directly about adherence

E
 Engage patients about adherence at every encounter
 Measure drug levels or efficacy parameters, when applicable
 Review medication containers, noting last fill date and
remaining medicine

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Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence
Evidence-Based Interventions Shown to Improve Adherence to Medication
A personalized, patient-focused program involving frequent contact with health care professionals, or a
combination of interventions, has been shown most effective.25-29

 Telephone reminders  Case management by pharmacists

 Self monitoring (e.g., medication diary)  Automated refill reminders from the pharmacy
 Fixed-dose combination drugs  Waiving or reducing medication co-payments
 Unit-dose packaging  Rewards (e.g., money, gift cards)
 Education counseling  Pharmacist or nurse-operated disease management clinics

Evidence-Based Interventions Shown to Improve Adherence to Lifestyle Modifications

The most successful interventions are those that include multiple components, include individual and group activities,
and are sustained over time.30-35
 Follow-up telephone call with a health care
professional
 Use video and written educational tools
 Use written contract between the patient and
health care professional
 Use nutritional tools (e.g., portion size
examples, food exchange lists)
 Include one or more individual counseling
sessions; or group sessions
 Invite family members or friends
 Establish and monitor progress toward specific goals
 Use motivational interviewing: express empathy,
support self-efficacy, roll with resistance, develop
discrepancy
 Use relapse prevention/coping and planning
techniques
 Encourage self-monitoring, self-observation, self-
recording, and feedback
 Use pedometers to increase activity level
 Tailor dietary advice to the patient’s ethnicity

Conclusion
Non-adherence with medications and lifestyle recommendations is a significant problem that directly, and
indirectly, affects our patients and overall health care system. The complexity of factors that contribute to
non-adherence cannot be understated. It is important to understand the role patients, and we as health care
professionals, play in addressing this issue. It is equally important to have realistic expectations. One study found
only a 3% gain in adherence when generic co-payments were waived for patients participating in a value-based
insurance program.36 Consequently, the return on investment remains unclear with such approaches as most
patients received waived co-payments without improving their adherence. There is clearly no “quick fix” but
current evidence suggests we are more likely to make progress if we adopt strategies that are simple, targeted,
multidisciplinary, and cost-effective.

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Supplement to the Lipid Spin
 Section 7. Resources for Health Care Professionals
Tools Used to Measure Patient Adherence and Medication-Taking Behavior
Method Pros Cons
Objective
Patient manipulation
Easy
Pill Count
Physical counting of pills in the dispensed packaging Actual medication taking
Inexpensive
not recorded
Limited to patients who use
Non-invasive one pharmacy
Prescription Claims Data
Provides refill frequency over a specified period
Inexpensive Actual medication taking
not recorded
Expensive
Noninvasive
Not practical for most
Electronic Pill Bottle
patients
Records occurrence and time bottle was opened Provides information on
patterns of medication taking
Does not ensure medication
was taken
Subjective

Brief Medication Questionnaire Accurate

Self-reporting tool used to identify patients at risk of non-adherence37 Patient provides false
Validated in wide range of information
disease states

Brief Illness Perception Questionnaire Time consuming

Good test-retest reliability
Assesses cognitive and emotional representations of illness
Patient provides false
Inexpensive
Available at: http://www.uib.no/ipq/ information

Medication Adherence Rating Scale Brief, easy to use Only identifies one barrier
Determines patient willingness and ability to take oral medications daily (forgetfulness)
Inexpensive
Available at: http://www.virtualmedicalcentre.com/tools Patient provides false
Also available on iTunes More sensitive information

Morisky Medication Adherence Scale

Brief, easy to use
Measures medication-taking behavior Patient provides false
information
Inexpensive
Available at: http://www.acpinternist.org/archives/2009/02/adherence.pdf

Medication Adherence Individual Review Screening Tool –

MedAdhIR-ST Brief, easy to use
Only validated in the elderly
Tool to identify and assess adherence among elderly patients38
population
Free
Available on iTunes

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Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence
 Clinician’s Quick Guide to Medication and Lifestyle Adherence
For Health Care Professionals

1. How do I identify which patients are at risk of non-adherence?

!

Characteristics of HIGH-risk patients:

 Misses appointments  Lack of appropriate follow-up
 Refills medications inconsistently  Poor health literacy
 Patients with financial constraints  Elderly (poor eyesight, dementia)
 Inadequate response to therapy  Patients with limited coping skills

2. How can I start a dialogue with my patients about adherence?

Ask open-ended questions vs. close-ended questions to invite patients to share and avoid simple “yes” or “no” responses.

 “How often do you miss taking your medication?”  “Tell me about your current exercise regimen.”

Use motivational interviewing techniques, which are patient-centered and aimed at empowering the patient to work
through the identified problem.

 “How can I help you better adhere to your  “What do you need to know about this medicine to
medications and lifestyle changes?” make you feel comfortable taking it?”

3. What are some methods I can use to measure my patients’ adherence or assess their medication-taking behavior?
 Physical pill count
 Prescription refill history
 Electronic pill bottle/device
 Brief Medication Questionnaire
Patient Educ Couns. 1999;37(2):113-124.
 Brief Illness Perception Questionnaire
Available at: http://www.uib.no/ipq/
 Medication Adherence Rating Scale
www.virtualmedicalcentre.com/tools
Also available at www.apple.com/itunes
 Morisky Medication Adherence Scale
www.acpinternist.org/archives/2009/02/adherence.pdf
 Medication Adherence Individual Review Screening Tool
Consult Pharm. 2012;27:771-81.
Also available at www.apple.com/itunes

4. What are some interventions that have demonstrated the ability to improve adherence?
 Telephone/text reminders  Case management by pharmacists
 Self-monitoring (e.g., diary)  Automated refill reminders from the pharmacy
 Unit-dose (or blister) packaging  Waiving or reducing medication co-payments
 Education counseling  Rewards (e.g., money, gift cards)
 Establishing and monitoring progress toward  Pharmacist or nurse-operated disease
specific goals management clinics
 Including family members or friends
Clinician Resources for Talking to Patients About Lifestyle Changes

“Navigating the Hurdles: Helping Your Patients Overcome Barriers to a Healthier Lifestyle.”

Preventive Cardiovascular Nurses Association (PCNA).

Available at: http://pcna.net/clinical-tools/tools-for-healthcare-providers/heart-healthy-toolbox

“Talking About Weight With Your Patients.”

American Medical Association (AMA).

Available at: http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-

lifestyles/obesity/obesity-physician-resources.page?

“Talking With Patients About Weight Loss.”

Weight-control Information Network: An information service of the National Institute of

Diabetes and Digestive and Kidney Diseases (NIDDK).

Available at: http://win.niddk.nih.gov/publications/talking.htm

“Brief Guide to Motivational Interviewing: Tips for the Coach.“

Preventive Cardiovascular Nurses Association (PCNA).

Available at: http://pcna.net/clinical-tools/tools-for-healthcare-providers/heart-healthy-toolbox

Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence

Contributing Authors:
This toolkit was created by the Patient Adherence subcommittee of the National Lipid Association.

Dave L. Dixon, PharmD, BCPS, CDE, CLS

Assistant Professor, Ambulatory Care
Department of Pharmacotherapy and Outcomes Science
Virginia Commonwealth University School of Pharmacy
Richmond, VA

Dave Dixon, PharmD, is an Assistant Professor at Virginia Commonwealth University School of Pharmacy
where he teaches cardiovascular pharmacotherapy and precepts pharmacy students and residents. Dr.
Dixon has practiced collaboratively with physicians, and other clinicians, in the management of patients
with cardiovascular disease and diabetes. Dr. Dixon is a Board Certified Pharmacotherapy Specialist
(BCPS), a Certified Diabetes Educator (CDE), and Clinical Lipid Specialist (CLS).

Julia P. Bolick, RDN, MS, FNLA, CD, CLS

Cardiovascular Genetics Research Center
University of Utah
Salt Lake City, UT 

Julia P. Bolick, RDN, is a Clinical Dietitian Nutritionist II and Clinical Lipid Specialist employed with
University of Utah’s, Cardiovascular Disease Prevention Clinic for the past 13 years. She is also employed
with Intermountain Health Care’s, LiVe Well Center for the past 6 years in their Executive Comprehensive
Health and Fitness programs as well as the Weigh to Health, Weight Management and Heart4Life
chronic disease management programs. She has been credentialed with the University of Utah since
2006. She is a Nutrition Educator with Precision Health, Pulmonary Rehabilitation Services since 2002.
She has been a private consultant to various companies for wellness counseling and education.

Laxmana M. Godishala, MD, FNLA, FACP, FASH

Medical Director, Parkside International Travel Clinic
Faculty, Department of Medicine, Hennepin County Medical Center
Assistant Professor, University of Minnesota Medical School
Minneapolis, MN

Laxmana Godishala, MD, graduated from the Kakatiya Medical College, Warangal, India. After an
Internship at Mahatma Gandhi Memorial Hospital in India, he completed Transitional Residency at
Medical College Pennsylvania affiliated Frankford Hospital in Philadelphia, then followed by Internal
Medicine Residency at Hennepin County Medical center(HCMC) Minneapolis, Minnesota. Dr. Godishala
is currently Medical Director of International Travel Clinic at Parkside, HCMC in Minneapolis, Minnesota
and an Assistant Professor (clinical Scholar Track) at the University of Minnesota Medical School.

17
Supplement to the Lipid Spin
 Penny M. Kris-Etherton, PhD, RD, FNLA, FAHA, CLS
Distinguished Professor of Nutrition
Department of Nutritional Sciences
Penn State University
University Park, PA

Penny Kris-Etherton, RD, is a Distinguished Professor in the Department of Nutritional Sciences at The
Pennsylvania State University. Dr. Kris-Etherton’s expertise is cardiovascular nutrition. She conducts
controlled clinical nutrition studies designed to evaluate the role of diet on risk factors for cardiovascular
disease (CVD). She served as the President of the National Lipid Association, and Chair of the American
Society for Nutrition Medical Nutrition Council and currently serves as Vice-Chair of the American Heart
Association Nutrition Committee. She has received numerous meritorious awards and is author/co-author
of over 270 scientific publications.

David T. Nash, MD, FNLA

Clinical Professor of Medicine
Upstate Medical Center
Syracuse, NY

David T. Nash, MD, earned his medical degree from New York University. He most recently served as
Clinical Professor of Medicine at Upstate Medical Center in Syracuse, New York. Dr. Nash has served as a
manuscript reviewer for the Journal of the Medical Association, Annals of Internal Medicine, American Journal
of Cardiology, and the Journal of the American College of Cardiology, Postgraduate Medicine, and Geriatrics.
He is a Diplomate of the American Board of Clinical Lipidology and certified by American Board of Internal
Medicine. Dr. Nash is a Fellow of the American College of Physicians, American College of Cardiology,
American College of Nutrition, the Council on Arteriosclerosis (American Heart Association), and the
Council on Epidemiology (American Heart Association).

Lori Neri, CRNP, FNLA, CLS, FPCNA

Cardiac Home Solutions
Allentown, PA

Lori Neri, CRNP, is currently working for Cardiac Home Solutions, providing cardiac care in the outpatient
setting. Prior to that, Lori was the director for The Center for Cardiac Risk Prevention at The Heart Care
Group. She is active in the NLA working on patient adherence and was recently appointed to the NLA
Communications Committee.

Wayne S. Warren, MD, FNLA

Assistant Clinical Professor
Yale University
New Haven, CT

Wayne S. Warren, MD, is a graduate of the Massachusetts Institute of Technology and the Columbia
University College of Physicians and Surgeons. He completed his Internal Medicine residency at the
University of Massachusetts Medical Center and has been part of Chapel Medical Group in New Haven,
CT since that time. He is Board Certified in Internal Medicine and Clinical Lipidology and designated
as a Specialist in Clinical Hypertension by the American Society of Hypertension. Dr. Warren is an
Assistant Clinical Professor at the Yale University School of Medicine and an attending physician at both Yale
New Haven Hospital and the Hospital of St. Raphael.

18
Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence
Toolkit Reviewers:

Jerome D. Cohen, MD, FNLA, FACC, FACP, FAHA

Emeritus Professor of Internal Medicine
Division of Cardiology
St. Louis University
St. Louis, MO

Jerome D. Cohen, MD, is Professor Emeritus at St. Louis University School of Medicine. He has been active
in cardiovascular research for more than 3 decades and has authored more than 170 scientific articles and
book chapters on heart disease with a primary focus on preventive cardiology including issues relating
to hypertension, dyslipidemias, obesity and the metabolic syndrome. He has served on many national
committees for the AHA, ACC and the NLA and is a reviewer for several medical journals and an associate
editor of the Journal of Clinical Lipidology. He continues his research in these areas and is active in teaching
and CME programs. Dr. Cohen is a graduate of The Johns Hopkins University and Washington University
School of Medicine.

Terry A. Jacobson MD, FNLA, FACP, FAHA

Professor of Medicine
Director, Office of Health Promotion and Disease Prevention
Emory University
Atlanta, GA

Terry A. Jacobson, MD, is currently the Director of the Office of Health Promotion and Disease Prevention at
Emory University in Atlanta, GA. His specific expertise is in hyperlipidemia, nutrition and drug management
of hypercholesterolemia, coronary heart disease (CHD) risk reduction strategies, and translating
cardiovascular prevention into practice. He has spent a large part of his career translating prevention into
practice, improving patient outcomes through adherence and behavioral counseling, and implementing
CHD risk reduction strategies for clinicians and health care systems.

Don Lamprecht, PharmD, BCPS, CLS

Clinical Pharmacy Specialist, Clinical Pharmacy Cardiac Risk Service (CPCRS)
Kaiser Permanente of Colorado
Clinical Assistant Professor
University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
Aurora, CO

Don Lamprecht, PharmD, is a board certified pharmacotherapy specialist who has practiced at Kaiser
Permanente Colorado’s Clinical Pharmacy Cardiac Risk Service since 2005. By working closely with
physicians and nurses, his team helps to ensure that more than 14,500 patients with cardiovascular disease
receive evidence-based therapies to achieve secondary prevention goals. He is a clinical assistant professor
at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences.

19
Supplement
Supplement to the
to the Lipid
Lipid Spin
Spin
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Clinician’s Toolkit:AAGuide
Clinician’sToolkit: GuidetotoMedication
Medicationand
andLifestyle
LifestyleAdherence
Adherence