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IBLM > Key Clinical Processes In Lifestyle Medicine > Flashcards

Key Clinical Processes In Lifestyle Medicine Flashcards

1
Q

What are the Lifestyle Medicine Vital Signs?

A

Review of lifestyle behaviours as they relate to the six pillars:

Nutrition
Physical activity
Stress management
Relationships and social support
Sleep
Avoidance of risky substances inc tobacco

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2
Q

What are the BMI classifications for Non-Asian?

A

Underweight
<18

Normal weight
18.5-24.9

Overweight
25.0-29.9

Obese Class 1
30.0-34.9

Obese Class 2
35.0- 39.9

Obese Class 3
>= 40

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3
Q

What are the BMI classifications for Asian?

A

Underweight
<18.5

Normal weight
18.5-22.9

Overweight
23.0-24.9

Obese Class 1
>= 25

Obese Class 2
35.0-39.9

Obese Class 3
>=40

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4
Q

When is the Waist Circumference considered increased in men and women?

A

Men
>= 40 inches (102cm)

Women
>= 35 inches (88cm)

Measurement techniques may be less accurate in people with BMI > 35

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5
Q

What are normal waist-hip ratio in men and women

A

Men
<= 0.90

Women
<= 0.85

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6
Q

What are normal and obese ranges for percent body fat in men and women?

A

Normal:

Men <25%
Women <30%

Obese:

Men >= 30%
Women >= 35%

How to measure:

1) skin calipers
- easy, portable, simple to use
- operator dependent, may be diminished when obese pts

2) bioelectric impedance (BIA)
- easy to use, inexpensive, portable, safe
- less accurate than other measures and more difficult to calibrate, accuracy decreases as ratio between body water to body fat changes

3) Densitometry (underwater weighting)
- more accurate than BIA
- difficult to perform as individuals must be submerged in water

4) Air displacement plethysmography (Bod Pod)
- accurate, safe and easier to complete than densitometry
- relatively expensive

5) DEXA, CT and MRI scans can be used and are accurate but relatively expensive and not portable

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7
Q

What can the Pulse show as a physical sign in lifestyle medicine?

A

Increased pulse associated with inc CVS and all cause mortality

Possible lifestyle causes of tachycardia
- physical deconditioning
- dehydration
- alcohol
- caffeine

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8
Q

What are the ACC/AHA 2017 Blood Pressure categories?

A

Normal:
<120/80

Elevated:
120/80-129/80

High BP - Stage 1 hypertension:
130/80-139/89

High BP - Stage 2 hypertension:
140/90 or higher

More than 50% adults over 60 have HTN

Small reductions in BP can substantially reduce illness burden:

INTERSALT study:

Reduction Stroke CHD Total
2 6 4 3
3 8 5 4
5 14 9 7

Almost x3 stroke and x2 CHD

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9
Q

What is the diagnostic criteria for Prediabetes and Diabetes?

A

HbA1c
Diabetes >= 6.5%
Prediabetes 5.7%-6.4%
Normal <= 5.6%

Fasting plasma glucose
Diabetes >= 126mg/dL
Prediabetes 100-125mg/dL
Normal <= 99mg/dL

2hr OGTT
Diabetes >=200mg/dL
Prediabetes 140-199 mg/dL
Normal <=139 mg/dL

Random blood glucose
Diabetes >= 200mg/dL

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10
Q

When should testing for diabetes and prediabetes occur?

A

All adult who are overweight or obese with following risk factors (8):
- 1st degree relative with diabetes
- high risk ethnicity
- hx of CVS disease
- hypertension
- physical inactivity
- HDL <35 mg/dL (0.90 mmol/L) or TG level >250 mg/dL (2.82 mmol/L)
- women with PCOS
- conditions assoc with insulin resistance

If NO risk factors
- begin screening at age 45 and repeat every 3 years

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11
Q

What is the ongoing monitoring requirement for diabetes?

A

Annual measurement:
- basic metabolic panel
- urine microalbumin
- lipids

HbA1c every 90 days

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12
Q

What is the weight loss goal for patients with overweight or obesity?

A

5-10% of initial body weight

Average weight loss in intensive lifestyle intervention is 8kg (17lbs) within 6m

If CVD risk factors are present
- weight loss of 2-5% improves glucose, HbA1c and TGs
- weight loss >5% also improves HTN and HDL cholesterol

Women recommended to reduce calories by 500 per day
Men recommended to reduce calories by 750 a day

Consuming approx 3500 fewer calories per week typically equates to 1lb of weight loss a week

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13
Q

What are improvements in CVS risk factors with different weight loss percentages?

A

If CVS disease risk factors are present:

  • weight loss of 2-5% improves glucose, TGs and HbA1c, and SYSTOLIC BP
  • weight loss >= 5% improves HDL cholesterol and DIASTOLIC BP
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14
Q

What are the optimal values for fasting lipid profile?

A

Total cholesterol
<= 150mg/dL (3.8mmol/L)

LDL
<= 100mg/dL (2.6mmol/L) GOAL
<= 70mg/dL (1.8mmol/L) IDEAL esp in high risk

HDL
Helps to remove cholesterol from the body
<40mg/dL in women and <50mg/dL in men one factor found in metabolic syndrome

Triglycerides
Elevated levels >150mg/dL often associated with increased waist circumference and risk for heart disease

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15
Q

How can you train support staff in enhancing health behaviour interventions?

A

Routinely collect lifestyle medicine vital signs
Provide basic counselling and instruction
Provide tools and resources (handouts, websites, apps) where appropriate
Help patients identify useful community resources

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16
Q

Who are members of the interdisciplinary team in lifestyle medicine?

A

Lifestyle medicine specialist, esp for treatment with intensive therapeutic lifestyle therapy change programmes
Registered dieticians
Pharmacists
PT and OT
Nurses
Certified exercise physiologists
Fitness trainers
Coaches
Health educators
Psychologists

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17
Q

Which practitioners can be collaborated with in lifestyle medicine?

A

Integrative medicine practitioners:
- acupuncturists
- chiropractors
- midwives
- massage therapists
- naturopaths

Be sure practice values are aligned with lifestyle medicine

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18
Q

What are Group Visits and associated benefits?

A

Also called shared medical appointments

Benefits
- improved access to care
- increased pt and provider satisfaction
- reduced costs and increased income (from increased efficiency and leveraging of existing resources)
- increases physician productivity and income

Positive effects in management of cancer, diabetes, HF, lung disease and more

19
Q

What is Telehealth and the associated advantages and disadvantages?

A

Benefits:
- improved access for individuals in remote areas, pts requiring specialist care and handicapped
- cost saving to provider and pts
- more amenable to frequent visits

Drawbacks:
- technology issue s
- limitations to vital signs, physical exam and labs
- may feel less personal

20
Q

How is Tracking used in lifestyle medicine practice?

A

Essential for pt care, treatment analysis, reimbursement and follow up

Helps pts and financial payers see the effectiveness of a lifestyle intervention, improving engagement and commitment

21
Q

How can Electronic Health Records help in lifestyle medicine?

A

Helpful to track metrics and high risk pts

Most systems have built-in capacity for data extraction
When using EHR:
- know when and where lifestyle measures will be collected, stored and maintained
- have effective way to extract info from EHR

22
Q

What is the Collaborative Care Model?

A

CCM by the Agency of Healthcare Research and Quality (AHRQ)

Model showing how pts, clinical experts, residents, nurse practitioners and interdisciplinary teams can collaborate in an academic setting to provide care for chronic conditions

Patient at centre of model and sets goals, develops skills and assumes self care

23
Q

What is the Chronic Care Model?

A

Created by the MacColl Institute and Ed Wagner

Centred on an informed activated and engaged pt + prepared pro-active primary care practice team
Must work with local and national healthcare system
Must work with local community

24
Q

Why use Chronic Care Models?

A

Chronic care models:

Promote collaborative care among providers and allied health providers
Connect pts to be beneficial community resources
Improved access to appropriate providers and allied health professionals
Engage pts more actively in their care

25
Q

What are examples based on the Chronic Care Model?

A

Ornish Lifestyle Medicine Programme

Intensive cardiac rehab programme
Includes RN, exercise physiologist, health coach, stress management specialist, RDN, Chef, Group support specialist, Administration assistant or medical assistant, Marketing director

26
Q

What are the benefits of the Chronic Care Model?

A

Higher levels of treatment compliance
Improved health outcomes
Enhanced pt engagement and chronic disease self-management
Increase weight loss after 1 year compared to standard care

27
Q

What is Value-based care?

A

Provides financial incentives for accountable care organisations, patient-centred medical homes and similar organisations to achieve standard health goals instead of merely having visits for disease treatment
Provides the support system needed to achieve successful lifestyle change

28
Q

What is Prescription for Health?

A

6-year initiative funded by Robert Wood Johnson Foundation in collaboration with AHRQ
Longitudinal study of 22 primary care practices that examined strategies for promoting heath behaviour change in pts

4 health behaviours targeted:
1. tobacco use
2. risky alcohol use
3. unhealthy diet
4. lack of physical activity

Primary care offices could effectively address health behaviour issues when funding and support were available

To implement behaviour change strategies a healthcare delivery models such as pt-centred medical home was important
Typically required substantial practice redesign and integration of community resources

AHRQ developed the Electronic Preventive Services Selector (ePSS) - can be used by providers for decision support with screening, counselling and preventive services

29
Q

What is PDSA?

A

Plan
Do
Study
Act

Focuses on small-scale improvements over short periods of time that typically require several cycles to create desired change

30
Q

What is Root cause analysis?

A

Use tool when something goes wrong or near miss

  1. Ask ‘5 whys’
  2. Ask ‘So what? (Consequence of something not going as planned?)

3.Draw cause and effect diagrams
- define problem and place at head ‘fish’
- write categories leading to problem as ‘bones’

  1. Steps for analysis
    - any repeat causes?
    - research: interview team members, conduct pt surveys, create process maps
    - decide to address a few causes: rv solutions with team and apply PDSA
31
Q

What is Evidence-Based Medicine?

A

Systematic approach to clinical problem solving that integrates the best available evidence with clinical expertise and patient values

32
Q

What is Evidence/based practice?

A

Making a conscientious effort to base clinical decisions on research that is free from bias and using the interventions most likely to improve how long or well patients live

33
Q

What are Patient Activation Measures?

A

Patient activation is an important factor in the push for patient-centred care

Often used to measure pt engagement

100 point scale used to determine pt engagement in healthcare

34
Q

What are Therapeutic alliance measures?

A

Therapeutic alliance:
Measure of partnership and collaboration between a therapist and client with 3 features
- mutually agreed upon treatment goals
- alignment on treatment tasks
- emotional bond between therapist and client

Can be measured using any of a variety of a validated scales:
Working Alliance Inventory (WAI)

35
Q

What were the findings of the Lifestyle Heart Trial?

A

5-year RCT
Determine feasibility of sustaining intensive lifestyle changes for a total of 5 years and effects on CHD without lipid-lowering medications

Intensive lifestyle changes:
- Low fat (10% of calories) vegetarian diet
- Aerobic exercise
- Smoking cessation
- Stress management
- Group psychosocial support
NO lipid lowering meds used

Conclusions:
In ambulatory pts with moderate-severe CHD:
- significant reductions in both LDL cholesterol and anginal episodes after 1 YEAR
- more regression of coronary
atherosclerosis after 5 YEARS
- pts following usual care had MORE progression of coronary atherosclerosis after 5 YEARS than 1 YEAR with MORE THAN TWICE as many cardiac events

36
Q

What were the findings of the DIRECT Trial?

A

12-month RCT
Assess whether intensive weight management within primary care would achieve remission of T2DM and to provide either weight mx programme or best practice care by guidelines

Conclusions:
- At 12 months almost **HALF **of participants (46%) achieved remission to non-diabetic state and off antidiabetic drugs
- Associated with weight loss for entire study population

37
Q

What were the findings of the Diabetes Prevention Programme (DPP) Trial?

A

~2.8 year RCT
Determine if modifying diabetes risk factors inc overweight/obesity and sedentary lifestyle with a lifestyle-intervention programme or with administration of metformin would prevent or delay development of diabetes
Subjects DID NOT have diabetes

Study design:
Subjects with elevated fasting and post-load plasma glucose concentrations were assigned to placebo, metformin twice daily or a lifestyle modification programme

Conclusions:
Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk
Lifestyle intervention MORE EFFECTIVE than metformin - almost twice

38
Q

What were the findings of the Jenkins Portfolio Study?

A

3-month RCT
Determine whether a dietary pattern low in saturated fat and emphasises plant sterols, viscous fibres, soy protein and nuts reduced cholesterol comparable to statins

Conclusions:
- control, statin and dietary portfolio groups had average decreases in LDL cholesterol of 8.0%, 30.9% and 28.6% respectively
- comparable reductions in CRP
- LDL reductions in statin and dietary portfolio groups were all significantly different from changes in control group
- NO SIGNIFICANT DIFFERENCES in EFFICACY between statin and dietary portfolio treatments

39
Q

What were the findings of the Diabetes reversal study by Saraathi et al?

A

Prospective study of 32 patients with newly diagnosed T2DM
Initially treated with intensive lifestyle therapy (low cal diet 1500kcal/day) and brisk walking (1hr per day) over more than 2 years

Conclusions:
- reversal/remission rates at 3m, 1yr and 2yrs were 75%, 75%, and 68.75% respectively
- over half achieved complete reversal
- 21.9% achieved partial reversal
- rates of complete and partial remission at 1 year were 50% and 25%, and at 2 years were 46.9% and 21.9%

40
Q

What were the findings of the study by Sallam et al on Therapeutic lifestyle change intervention and metabolic syndrome criteria?

A

12-month RCT
Examine whether addition of amlodipine 5mg/atorvastatin (10mg) to therapeutic lifestyle change intervention would beneficially modulate metabolic syndrome (MetS) and oxidised LDL levels (Ox-LDL)
Pts with MetS randomised to therapeutic lifestyle change plus placebo or therapeutic lifestyle change plus amlodipine/atorvastatin for 12m

Conclusions:
- addition of amlodipine/atorvastatin has advantage of improving lipid profile and BP
- therapeutic lifestyle change alone comparable to lifestyle change combined with amlodipine/atorvastatin in improving MetS
- weight change determines lifestyle change-associated change in Ox-LDL levels
- adipose tissue metabolic health significant predictor of therapeutic lifestyle change-associated loss of body fat mass

41
Q

What were the findings of the Hambrecht PCI vs exercise training in pts with stable CAD?

A

12-month RCT
Determine if pts with stable CAD can improve myocardial perfusion and reduce disease progression, compare effects of exercise training to standard PCI on clinical sx, angina-free exercise capacity, myocardial perfusion and cost-effectiveness

Conclusions:
- 12m of exercise training - maximal tolerance was increased significantly along with ischaemic threshold
- exercise training associated with 16% increase in maximal oxygen uptake
- expenses for 1 year of exercise training averaged 3708 compared with 6086 per PCI pt
- both groups clinical sx improved significantly during study period

42
Q

What are the 4 validated dietary assessments?

A

Starting the Conversation (8-items)
Mediterranean Diet Adherence (MEDAS)
ASA24 - NCI
DHQ - National Cancer Institute

43
Q

What are the key findings of studies by Ornish and Esselstyn?

A

Very low far plant based diet shown to reverse and prevent major cardiac events
Decreased risk of developing CVD by almost 25%
WFPB diet offers beneficial effects via polyphenols - have positive effect on endothelial layer of vasculature through negation of LDL oxidation and inflammation

44
Q

What were the key findings of the CHIP programme?

A

Effective in treating T2DM and to have positive return on investment within a few months

IBLM (10 decks)

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