Lifestyle Medicine

Question 1

What is ITLC?
Including what they include and how they are delivered.

Give 4 examples of ITLC

What’s the point of them?

Answer 1

It stands for Intensive Therapeutic Lifestyle Change.
They’re intensive lifestyle changes programs which encourage drastic changes in daily routine including habits around
Sleep
Diet
Physical Activity
Stress Management

Usually delivered in groups, always with a multi-modality team.
Typically out-patient appointments of 60 minutes, one to three times a week for 8 to 18 weeks.
Or in-patient of 7 to 21 days.
There are shorter programs

Examples include:

1. ## Pritkin program
2. Ornish pogram
3. CHIP program (Diehl) [Comprehensive Health Improvement Plan]

The ITLC programs produce the essential induction phase that is needed in order for people to make the dramatic lifestyle changes necessary to treat severe disease and help them experience health improvements that promotes changes without requiring significant self-efficacy.

Question 2

What does Lifestyle medicine require compared to conventional medicine.

State the 6 lifestyle medicine elements and intervention modalities

How does a provider act?

Define: reversal vs control of chronic disease

Answer 2

It requires patient engagement and responsibility for treatment outcomes.

Elements & Modalities

1. Whole food, plant-based diet
2. Physical Activity
3. Stress management and emotional wellness
4. Sleep
5. Smoking cessation and avoid risky substance abuse
6. Positive Psychology and connectedness.

Providers act as medical experts and coaches.

Reversal is all lab markers or diagnostic tests for a disease within normal range WITHOUT use of any medications and no signs or symptoms.

Control is improvement in labs and diagnostic tests to acceptable levels but without complete normalization. May be achieved with or without medical intervention e.g. BP below 140/90 with ramipril

Question 3

What is integrative medicine?

Answer 3

Considers the whole person needs, physical, social, emotional, mental, environmental and spiritual.

It aims to address these through conventional, complementary and alternative medicine. - it integrates experienced complementary and alternative medicine methods with EB conventional medicine.

Question 4

What is functional medicine?

Answer 4

This focuses on the physiological and biochemical functions of the body (cells to organs).

Aiming to investigate the balance and processes of cellular metabolism, digestive function, detoxification and control of oxidative stress.

It tends to emphasizing testing of various hormones and metabolites that are not well proven.

Question 5

What is mind-body medicine?

Answer 5

This investigates the interactions between body and mind behaviourally, emotionally, mentally, socially and spiritually. It treats with relaxation, hypnosis, visual imagery, meditation, yoga, biofeedback, spirtually, tai chi etc.

Some have an evidence base.

Question 6

What is preventative medicine?

Answer 6

This includes all aspects of morbidity and mortality for the general public, i.e. public health.
It emphasizes population-based interventions that include vaccinations, screening and protection from bioterrorism.

Question 7

How does conventional contrast to lifestyle medicine?/ what is the main difference.

Answer 7

As in another question: patients are typically the recipients of care in conventional medicine, they comply with the treatment but not required to make significant changes.
Providers are considered responsible for care and outcomes, while the patient is a passive receiver.

Question 8

What did the study “Epigenetic differences arise during the lifetime of monozygotic twins” find with example of numbers.

Answer 8

That DNA sequence (genes) only explained 10% of variance in health status, i.e. 90% was determined by epigenetics and environmental exposure.

Question 9

What was the INTERHEART study?

What did it identify?

Answer 9

It was published in the Lancet in 2004.

It was a standardized case control study about acute myocardial infarction risk factors. With data from 52 countries.

it identified 9 worldwide risk factors for AMI.

1. Smoking
2. Hyperlipidaemia
3. Hypertension
4. Diabetes
5. Obesity
6. Diet
7. Physical Activity
8. Alcohol consumption
9. Psychosocial factors (stress, mental illness, isolation and addiction. They found here that they were comparable to the effects of HTN or abdominal obesity.

Importantly the top 5 accounted for 80% of the risk!

Consistent across gender, race/ethnicity and location.

Question 10

What did the INTERstroke study identify

Answer 10

Published in the Lancet in 2016. The INTERstroke study was a prospective case controlled study to look at risk factors for stroke.

1. Hypertension
2. Current Smoking
3. Abdominal obesity
4. Diet
5. Physical Activity
6. Diabetes
7. Alcohol intake
8. Psychological stress
9. Depression
10. Abnormal lipids.

Attributed to 90% of the risk for men and women.

Question 11

Approximately what proportion of the population are effected by salt in their diet causing hypertension?

Answer 11

~50% of people respond to salt.

Question 12

What is the GEMINAL study?

Answer 12

Delivered by Dean Ornish in 2008.

Pilot study involving 30 men with low risk prostate cancer using lifestyle change, who declined surgery or hormone intervention.

Tumours decreased in size and biomarkers improved.

Gene expression was measured via prostate needle biopsy

intervention
low-fat, whole-foods, plant-based nutrition; stress management techniques; moderate exercise; and participation in a psychosocial group support

Question 13

What is the central oscillator in the brain?

Answer 13

The suprachiasmatic nucleus

Question 14

What actions and sleep environment prescriptions are appropriate?

What about light exposure?

Answer 14

Use bed for sleep and sex only
Establish regular sleep cycle for bedtime and waketime
Increase bedtime peripheral cutaneous vasodilation (limit evening sodium, have a hot drink/shower)
Minimize bedroom noise/light
Powernaps may be helpful if less than 30 minutes [More than this is not productive]
Maybe even 8 - 12 minutes.

Increasing daytime exposure to sunlight
Increasing daytime physical activity
Decrease light at night

Question 15

What are the lifestyle medicine vital signs?

Answer 15

Physical activity 
Diet
Stress
Sleep
Emotional Well-being
Tobacco use
Alcohol consumption
BMI

Question 16

What is the DASH diet?

Answer 16

Dietary Approaches to Stop HTN.

Original study compared low fat, vegetable based diet to standard western diet.
Sys & Diastolic reduced comparable to medication.

Emphasizes vegetables, fruits and low-fat dairy foods — and moderate amounts of whole grains, fish, poultry and nuts.

Standard DASH diet. You can consume up to 2,300 milligrams (mg) of sodium a day.
Lower sodium DASH diet. You can consume up to 1,500 mg of sodium a day.

Question 17

What is the counterpoint study

Answer 17

By Lim in 2011. Diabetologia
Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol

Answered, can beta cell failure and insulin resistance be reversed with caloric restriction?
To 600 Kcal a day!

Only 11 subjects:
Had diabetes for <4 years

• matched non-diabetic controls.

After 8 weeks:
Improved hepatic & pancreatic TAGs (MRI measured)
First phase insulin improved
Maximal insulin production was supranormal.

Average weight loss during the 8 weeks of dietary intervention was 15.3 ± 1.2 kg, equivalent to 15 ± 1% of initial body weight

Question 18

What’s the normal range of BMI?
What are the overweight and obese ranges?

How do calculate it?

Answer 18

Healthy: 18.5 - 24.9
Overweight 25 - 29.9 
Obesity I: 30 - 34.9
Obesity II: 35 - 39.9 
Obesity III: >40

Weight in kilograms divided by height in meters squared.

Question 19

How do you diagnose T2DM according to NICE?

What is classified as high risk?

Answer 19

Suspected with random plasma glucose more than 11 mmol/L

Diagnosed via
HbA1c more than 48 mmol/mol [6.5%]
Or a fasting plasma glucose level of 7.0 mmol/L or greater.`

High risk is defined as a fasting plasma glucose level of 5.5 to 6.9 mmol/l or an HbA1c level of 42 to 47 mmol/mol (6.0 to 6.4%).

or OGTT at 2 hours >7.8 - 11 is pre-diabetes/impaired glucose tolerance.

Question 20

What is the LookAHEAD Study?

What was the primary outcome?

What happened?

What study does it link to?

Answer 20

A four year randomised control trial published in JAMA 2012 by Gregg AW
With 4503 adults with T2DM with BMI >=25

Compared intensive lifestyle intervention ( weekly group and individual counselling for six months then 3 times per month for 6 months then twice monthly and a refresher group series in years 2 to 4.
They also consumed betwen 1200 - 1800 kcals per day with reduced total and saturated fat. With an activity goal of 175 mins per week.

There were Diabetes support education controls. 3 group sessions per year on diet, Physical activity and social support.

Primary outcome was partial or complete remission of T2DM HbA1c <48 mmol/mol / fasting glucose < 7 mmol/L

Greater weight loss
Fitness better
Greater remission rate
Continuous sustained remission.

Question 21

How much time should adults & older adults (18+) be spending exercising per week?

Give examples

Specific benefits?

What is really important?
- what’s the link?

Answer 21

Older adults should aim for AT LEAST 150 minutes (2.5 hours) per week of moderate intensity (I.e. can talk but not sing) or at least 75 minutes (1.25 hours) per week of vigorous (breathing fast and difficulty talking).
Or a combination!

moderate would be brisk walking.

vigorous would be stairs, running or sport.

Reducing T2DM by 40%
CVD by 35%
Falls & depression by 30% 
Joint and backpain by 25% 
Cancers - colorectal and breast by 20%

To break up periods of being sedentary/inactivity.
For older adults regular light activity is emphasized.

Sitting time is associated with all-cause and cardiovascular mortality, and cancer risk and survivorship.

Prolonged sitting is harmful, even in people who achieve the recommended levels of MVPA (moderate-vigorous physical activity)

Question 22

What is the DiRECT study?

Inclusion criteria?

Interventions?

Primary outcome?

Results?

What does this study link to?

Answer 22

An open-label, cluster-randomised study of 49 PCP (primary care practises) in the UK.
Published in the Lancet in 2018 (Lean et al ME)

Assignment of either weight management
or
best-practice according to the standard guidelines

To assess whether intensive weight management within routine primary care would achieve remission of T2DM.

T2DM <6 years
BMI 27-45
Not on insulin
20-65

Interventions

1. Stop antidiabetic & antihypertensives
2. Diet replacement with 825- 853 Kcal per day for 3 -5 months

> =15 Kg weight loss
T2DM remission (HbA1c <48 Mmmol/mol
AFTER >2 months off all antidiabetic medications

QOL by EuroQOL better in intervention, worse in controls.
weight loss 10kg in intervention 1kg in control.

As weight loss goes up remission rates increase

It links to the LookAHEAD intensive lifestyle intervention - where they ate 1200-1800 kcals: where the remission rates were much lower.

Question 23

What is positive psychology?

What are the pillars of positive psychology?

Answer 23

The study of strength and virtues that create/enable thriving, happiness and less misery

The pillars can be remember as PERMA

Positive emotion: ability to optimistic, view timeline in positivity

Engagement: fully absorbed in present moment

Relationships: Positive social connnections emotionally and physically (connectedness)

Meaning: purpose for why one is one the Earth

Accomplishments: having ambition nd accomplishing realistic goals

Question 24

What is the resiliency tipping point?

What tool can you use?

Answer 24

You need 3 positive to 1 negative to have good resiliency

From Fredrickson B, 2009

You can use positive ratio daily for 2 weeks as a tool to track emotions - not validated but can help patients track emotions and awareness.

Question 25

Whats the single most important predictor of happiness and longevity?

Answer 25

Having a social connection

Remember micro-moments of connectivity help activate the parasympathetic nervous system

Question 26

What’s the initial recommended weight loss for health benefit for obesity?

Answer 26

5 - 10 % of body weight.

You need to manage expectation. Most will be disappointed at 10%

Question 27

What is the NICE guidance for obesity and bariatric surgery?

Answer 27

CG189 advises that:

Bariatric surgery is a treatment option for people with obesity if they fulfill ALL of:

1. BMI >=40 or 35-40 WITH other significant disease that would be improved with weight loss (T2DM, HTN).
2. All appropriate non-surgical measures have been exhausted without benefit.
3. A tier 3 service is available
4. The person is generally fit for anaesthesia and surgery
5. The person commits to long-term follow up. `

Question 28

What are the determinants of health?

Answer 28

Adverse childhood events
Genetic and epigenetic predispositions
~10% variance

Epigenetics
~70-90%

Local environmental conditions

Health Literacy

Socioeconomic status

Question 29

What out of 10 does a patient need to have for importance or confidence level to achieve their goal

Answer 29

If it is above 7 /10 they are more likely to achieve that goal

Margaret Moore, 2008
Think transtheoretical model. 
7 is preparation 
8 is action 
10 Maintenance

Question 30

What is a SMART goal?

Answer 30

Specific
.e.g. apple

Measurable
One, every day

Achievable/Attainable
Who will do the shopping?
What barriers are there

Relevant
It works towards to the patients goals, what will or can the patient actually do.
Don’t set goals too high.

Time scale

Question 31

What is the ABCD of nutrition assessment

Answer 31

Anthropometric data
weight etc
Biochemical Data
primary labs
Clinical assessment
Age, gender, medical and surg hx
Dietary Assessment

Question 32

What is the Nurses Health Study?

Answer 32

Harvards Nurses’ Health Study

Followed 84251 nurses for 14 years

Question 33

What is the Health Professionals’s follow up study?

What did Joshipura KJ e al 2001 find?

What did Pan Et Al 2011 find?

Answer 33

The HPFS followed 42148 heath care providers for 8 years for incidence of non fatal MI or fatal CVD.

Joshipura 2001 published in
annual journal of internal medicine, the effect of fruit and vegetable intake on risk for coronary heart disease and found
Each daily serving of fruits and vegetables reduced risk of CHD by 4%
With green leafy vegetables and vitamin C risk fruits and vegetables conferring the most protective effect.

Pan et al 2011, Published in American J Clinical Nutrition looking at red meat consumption and risk of type 2 diabetes between the Nurses Health Study and Health Professionals Follow up Study.

Diet assessed by food frequency questionnaire.

Unprocessed and processed red meat associated with type 2 diabetes.
Substitution with nuts, low fat diary and whole grains reduced risk of diabetes.

Pan A et al Am J Clin Nutr 2011

Question 34

What type of studies are the Nurses Health Study and Health Professionals Follow-up Study?

Answer 34

Prospective Cohort Studys

Question 35

What is HOMA-IR?

Answer 35

HOMA-IR stands for

HomeOstatic Model Assessment - Insulin Resistance

It is a method for estimating beta-cell function and insulin sensitivity from fasting plasma insulin and glucose concentrations

The relationship between glucose and insulin in the basal state reflects the balance between hepatic glucose output and insulin secretion, which is maintained by a feedback loop between the liver and β-cells

The predictions used in the model arise from experimental data in humans and animals
Decreases in β-cell function were modeled by changing the β-cell response to plasma glucose concentrations. Insulin sensitivity was modeled by proportionately decreasing the effect of plasma insulin concentrations at both the liver and the periphery
No distinction is made between hepatic insulin sensitivity and peripheral insulin sensitivity.

It is used appropriately for cohort and epidemiological studies.

Question 36

What should you restricted saturated fat to as a percentage of total calories?

Answer 36

Saturated fat should be less than 10% of total calories

e.g. at 9 kcals per gram.

For a reminder

Protein 4 Kcal per gram
CHO 4 Kcal per gram
Fats 9 Kcal per gram
ETOH 7 Kcal per gram

There for for a 2500 kcal diet

10% = 250 kcals

so less than 28 grams

The lower the better pretty much.

Question 37

What did Lowe, Wu & Rohdin-Bibby et al., 2020 show?

Answer 37

This was a study called

Effects of time-restricted eating on weight loss and other metabolic parameters in women and men with overweight and obesity.

Q: what is the effect of time-restricted eating on weight loss and metabolic health in patients with overweight and obesity.

It was a prospected randomized clinical trial including 116 adults for 12 weeks.

Primary outcome was weight loss. Secondary outcomes were weight, fat mass, lean mass, fasting insulin, fasting glucose, HbA1c, estimated energy intake, total energy expenditure and resting energy expenditure.

There was no significant difference for the primary or secondary outcomes.
(specifically:, there were no significant differences in fat mass, fasting insulin, glucose, HbA1C, or blood lipids between the TRE and CMT groups.)

Importantly though:
The IF group loss significantly MORE lean body mass than the non-if group.
In particular appendicular lean mass (aka arm and leg muscle). In particular they showed 65% of weight loss was lean mass in the TRE group when weight loss typically causes 20-30% of weight loss to be lean mass.

However the eating window here was 12- 8 pm. Not early which Sutton et al., 2018 may have demonstrated it needs to be before 3 pm with a 6 hour eating window.

Question 38

What did Sutton et al., 2018 find regarding IF?

Answer 38

Sutton et al., 2018 published in Cell Metabolism a study
“Early time-restricted feeding improves insulin sensitivity, blood pressure and oxidative stress even without weight loss in men with prediabetes.

Question 39

What does the effect of processing or cooking having on red meat?

Answer 39

It produces N-nitroso compounds (NOC), hererocyclic amines (HCA) and polycyclic aromatic hydrocarbons (PAH) that are potentially carcinogenic.

N.B.

even if something says nitrate free - and they preserve with celery juice - this still has a high nitrate content…

Question 40

What did the 2015 Study by Li Y et al show that was published in Journal American College of Cardiology?

What other paper supports the findings?

Answer 40

This study, titled
“Saturated fat as compared with unsaturated fats and sources of carbohydrates in relation to risk of coronary heart disease: a prospective cohort study.

Again another study that used the Nurses Health Study and Health Professionals Follow-up study

Review picture in file associated with this card
Isocaloric substitution of CHO from refined starches/added sugars in PUFA significantly reduces CVD risk up to 30%

Substituting refined starches/added sugars doesn’t benefit.

Substituting trans fat is worse.

Siri-Tarino SW, et al. 2015 in Annual Review of Nutrition supports these in their paper.

Question 41

What’s the Hawthorn effect?

Answer 41

A type of reactivity in which individuals modify an aspect of their behavior in response to their awareness of being observed.

Question 42

At what activity level is most of the exercise benefit gained?

Where is there additional health benefits?

What is a key finding relating to activity?

Answer 42

At 150 minutes per week is where most of the gains have been made

5 hours or 300 minutes of moderate (maintain talking) or 2.5 hours 150 of vigorous (can’t talk)

However continuing up to 420 minutes a week there is moderate increase

600+ may increase injury risk.

Being sedentary is a distinct class of behaviour, twice as prevalaent

Question 43

What did Ekblom-Bak et al., 2010 show?

Answer 43

That Television viewing had a hazard ratio for all cause mortality of 1.5

sitting is 6.9% of all cause mortality.

There is a dose response to being sedentary.

Question 44

What is a double sided reflecton?

Answer 44

A double sided reflection involves both a pro-change statement and a resistant statement that the patient has made.

.e.g. You say you know you need to exercise more regularly but that you find you have no time to do so.

Question 45

What is the BMI classification for the Asian population for being overweight?

What about black?

What about waist circumference in asians/chinese?

Answer 45

A BMI of 23.0 to 27.5 kg/m2 is considered overweight for Asians. A BMI of ≥ 27.5 is considered obese for South Asian or Chinese Decent.
- According to WHO advice on BMI.

For people of South Asian or Chinese descent, the range is likely to be between 18.5 and 22.9 kg/m2 for health range.

It’s prudent to use these same thresholds amongst black people for prevention of diabetes.

Alberti et al., 2007 International diabetes federation guidance: suggests that men with a waist circumference greater than 90 cm (35 inches) and women with a waist greater than 80 cm (31.5 inches) should be considered overweight.

from NICE PH46
The evidence gathered does confirm that people from these groups are at an equivalent risk of diabetes, other health conditions or mortality at a lower BMI than the white European population.

However, the Committee did not consider the evidence sufficient to make recommendations on the use of new BMI and waist circumference thresholds to classify whether members of these groups are overweight or obese.

Question 46

What are the 4 behavioural change theories found within the board review manual?

Answer 46

1. Health Belief Model
2. Theory of Planned Behaviour
3. Social Learning, cognitive theory
4. Stages of change, transtheoretical model

Question 47

What is the health belief model?

What does one need?

Give a worked example

What doesn’t it take into account?

Answer 47

First developed in the 1950s by Public health, looking at why people didn’t adopt screen tests etc.

Self - efficacy - the confidence in ability to act and succeed in completing the change

Before seeking preventative measures one needs to
1. Believe there is a threat to health (perceived susceptibility, perceived severity

2. Believe that there is a preventative measure that is accessible and low risk
   (perceived benefit outweighs perceived barriers)
3. That the preventative measure will allow him to avoid the health trheat
4. There should normally be a cue to action, driving self-efficacy.

Worked example could be.

Perceived threat is heart disease causing morbidity or death.
Perceived susceptibility might be low as assumes they are fit enough (walking everyday/fitter than their peers, not had any issues so far.
Or perceived severity (even if I have a heart attack it won’t be that bad because other people have them).

Preventative measure could be adopting a Mediterranean/whole food plant based diet.
Perceived barrier could be, doesn’t know how to cook/prepare the foods/what foods it involves. (food islands etc). Could be a financial cost that doesn’t out weigh perceived benefit of reducing risk of heart attack.

Cue to action could be having a heart attack. (or medical reminders).
Self-efficacy is the confidence in adopting in this example the change in diet.

Can be considered under 3 topic headings.

Individual perceptions
Modifying factors
Likelihood of Action

It doesn’t take into account that some behaviours are habitual (like smoking)
Doesn’t account for emotions or social aspects of disease.
E.g. family could be influencing decisions.

Question 48

A. What is the theory of planned behaviour?

B. Whats the most important factor for predicting behaviour change?

Give an example

Answer 48

Personal intention to engage in health behaviour is influenced by:

1. Beliefs (social normals/subjective norms, perceived power)
2. Attitude (evaluation about the risks, benefits, and capability of achieving (perceived behavioural control) the desired health outcome.

So you have

1. Attitude towards the behaviour
2. Subjective norm
3. Perceived behavioural control

Linking into intention and then behaviour

B. Behavioural intent / internal motivation

From Jeni Schul

Attitude to weight lifting (she thought she could be silly,
Subjective/social normals - most females were not weight liftings.
Perceived control - didn’t have access to tools needed.

These all lowered intention and behaviour.
Friendship group changed.
More girls who lifted, attitude towards it changed - important for bone health etc.
Access to better gyms, intention changed. and lifting behaviour achieved.

Published by Ajzens theory of planned behaviour 1988

Question 49

What is the social learning and cognitive theory?

Answer 49

Developed in 1960 - combined theory in 1980s.

Personal factors (influence on thoughts and actions) - ta
Environment (Culture, communication: talking with friends, policies)
Human Behaviour (response to stimuli to achieve goals)

Reciprocal determinism, the person, the behaviour and the environment all influence each other in a dynamic and reciprocal fashion.

Behavioural capability, self-efficacy.

e.g. Observing an act of kindness, we are more likely to do an act of kindness.

Question 50

What is the stages of change transtheoretical model?

Answer 50

Originally develop for smoking cessation.

Describes something as a process rather than something that occurs quickly.

Different interventions can be used at different stages, stages can be skipped, moved through quickly or maintained.

1. Precontemplation
   No awareness of problem behaviour, no plan for change
2. Contemplation
   Considering change in the next six months
3. Planning
   Aware of need to make change, prepare for change in next month
   May be making changes but no achieved goal.
4. Action
   Making change and goal behaviour achieved
   Behavioural change for less than 6 months.
5. Maintenance
   Made behavioural change for at least 6 months or more.
   (6). Relapse
   Goal behaviour change no longer happening.

Patients once they’ve been in the maintenance phase aren’t at risk of relapse as they were before.

Question 51

What are the four main principles of motivational interviewing?

When is motivational interviewing most helpful?

Answer 51

1. Express empathy
   Opened ended questions, reflective listening, normalising feeling and concerns, support autonomy right to choose or reject change.
2. Developing discrepancy
   High discrepancy between patients values, goals, priorities and present behaviour
   Reinforce and support change talk and commitment language
   Build and deepen commit to change.
3. Roll with resistance
   Back off and use reflection when patient expresses resistance
   empathy
   Ask permission to provide information (can I tell you about the benefits of stopping smoking? Can I tell you about the benefits of eating more fruits and vegetables?)
4. Support self-efficacy

Motivational interviewing is most helpful in the pre-contemplation and contemplation stages.

Question 52

What are the different features of self-motivation?

what is self-efficacy?

Answer 52

1. Autonomous or Internal motivation
2. External motivation produced by environment.

Self-motivation and self-confidence are key for self-efficacy

Self-confidence can be increased by eliciting positive emotions, leveraging strengths, developing strong support system and appropriate stage matched education.

Self-efficacy is an individuals belief in his or her capacity to execute behaviour necessary to produce specific performance attainments.

Self-confidence is understanding that you trust your own judgement and abilities

Self-motivation is the drive, internal or external to continue, produce, develop or attempt.

Question 53

What are some examples of non-productive thinking?

How do you deal with these?

Answer 53

All or nothing
Catastrophising
discounting the positive
overgeneralising
mind reading
fortune telling (this will never work)
Should and must statement.

You need to reframe non-productive thinking, examine the evidence for and against nonproductive thoughts.

You can use self-talk - might feel forced at first but it can be helpful (I know this is difficult but I can do this).

Question 54

What are the ABCD of behavioural change?

Answer 54

relates to

A: what ACTION or event occurred

B: What BELIEFs do you have about what occurred

C: What are the CONSEQUENCES of those beliefs, how does that make you feel?

D: How can you DISPUTE those belief that seem to be distorted or unhealthy?

Example:

ACTION; eats package of sweets

BELIEF: still had work to do and thought it would give me a boost

CONSEQUENCES: I felt guilty for eating so much, I wished I’d had, had a good snack instead

DISPUTE: In reality could have had a glass of water, I could have had a walk, I could have picked a high fiber food instead.

Question 55

What are the 5 As for behavioural counselling?

Answer 55

Patient centeredness, encourage internal motivation for change.

It is not advice - not giving information.
Its aiming to put patient at centre.

Assess - health behaviour risk

Advice - to change behaviour with clear, specific personalised advice.

Agree - on the focus of the counselling and treatment based on patients interested and willingness.

Assist - the patient in setting and achieving goals to change practices
- here we can address motivational barriers, determine the need for additional information or help and refer if needed

Arrange follow up and support.

**
The 5A’s begin with assessing patient beliefs, behaviors, and knowledge, then advising by providing information about the health benefits of change, and then agreeing on a collaborative goal. Next, the provider assists the patient in identifying barriers, strategies and problem-solving techniques before finally arranging to follow up on plans.

Question 56

What are the 5 As of tobacco cessation?

what are key time periods here?

Answer 56

Ask - identify tobacco use

Advice - clear strong personalised for quitting

Assess - is the tobacco user ready and willing to make a quit attempt

Assist - provide counselling and or pharmacotherapy for those who are ready

Arrange - schedule follow up and accountability, preferentially one week prior to quit date and three days following quit date.

N.B. NICE advises Initially, follow the person up after:
2 weeks of nicotine replacement therapy (NRT).
3-4 weeks of treatment with varenicline or bupropion.
Measure the carbon monoxide (CO) level 4 weeks after quitting.
A CO level of 10 ppm or less suggests the person is a non-smoker.
Thereafter, use professional judgement about the number, timing and frequency of appointments offered.

Question 57

Which is better 10 hour provider training on empathy or longer training on empathy?

Answer 57

10 hour training achieves similar empathy results as those providers who have had longer training on empathy.

Question 58

What are at least two key constructs for effective, sustainable self-management?

Answer 58

1. CBT techniques - especially when patients are dealing with feeling of outside pressures, failures ore being out of control
2. social support strategies
3. Community and employee programs
4. Support with digital technology

Question 59

What is the definition of a lapse?

How does this compare with a relapse?

What are the features of a relapse prevention plan

Answer 59

A short term period when an action plan is not followed.

A relapse is a sustained period when an action plan is not adhered to. It requires following the same steps as starting a new action plan.
You must address thoughts and emotions arising from a potential feeling of failure.
Here the unhealthy behaviour may have become a habit again.

Relapse prevention involves:

a) when might a lapse occur
b) under what circumstances
c) with whom
d) how to notice a lapse before it becomes a relapse
e) who to turn to during a lapse or a relapse

Question 60

What’s the difference between a lifestyle prescription and an action plan?

Answer 60

Lifestyle prescriptions are actions needed to treat or prevent a condition based on the scientific evidence and the patient’s medical condition
e.g. 150 minutes of moderate physical activity per week.

Action plans are the lifestyle prescription ADJUSTED for the patient’s ability readiness and confidence.
Action plan for achieving prescription: start with walking 5 minutes each day for 5 days a week. Then increase as tolerated up to the 150 minutes.

Question 61

What are some of the withdrawal symptoms of smoking cessation and how long will they last on average?

How much weight on average will someone who quits smoking gain?

Answer 61

Increased appetite lasts the longest at more than 10 weeks and affects 70%

Depression lasts less than 4 weeks and affects 60%

This is similar for restlessness & poor concentration

Nicotine craving lasts more than 2 weeks and affects 70%

Disturbed sleep is less than a week and affects 25%

Light-headedness is less than 48 hours and afffects 10%

Irritability/aggression affects around 50% of people and lasts less than 4 weeks.

on average 5 - 9 kg of weight gain occurs in people not adopting other healthy diet change when stopping smoking.

Question 62

What percentage of the UK population smoke as of 2019?

Answer 62

around 14.1%

There is a continuing trend of decline

Around two-thirds of people who smoke say they would like to stop, and three quarters state that they have attempted to stop in the past

Question 63

What are the major causes of death from smoking?

Answer 63

Three causes account for 70% of these deaths: lung cancer, chronic obstructive pulmonary disease (COPD) and vascular disease.

More than a quarter of all cancer deaths can be attributed to smoking (including lung, oral, throat, bladder, kidney, pancreatic, stomach, liver and cervical cancers)

Question 64

If someone smokes what is the best type of advice?

Answer 64

Very brief advice (VBA)

It is typically less than 30 seconds.

ASK about current and past smoking behaviour
[relate this to 5 As]
- Two most important indicators are
How many cigarettes they smoke per day (0 points for <=10, 1 for 11- 20, 2 for 21-30, 3 for >=31

How soon after waking they smoke their first cigarette
3 points for within 5 minutes, 2 for 6 - 30 mins, 1 for 31 - 60 and 0 for after 60 minutes.

Ask about previous quit attempts if successful and if they tried treatment, whether they had support and the experience of withdrawal symptoms and cravings.

ADVISE with verbal and written information on the risk of smoking and benefits of stopping. Include treatment options, behavioural support, medication and e-cigarettes.

The best way to quit is behavioural support and medication, set and quit date and commit to it. The hardest day are first 48 hours.
Identify lapse and relapse triggers
Stress, seeing other smoking, drinking (intoxication).
Discuss medications.
distraction techniques.
There is a not-a-puff rule: the first lapse, such as a single puff from a cigarette almost always leads to ther person going back to regular smoking.

3/4 of people who relapse do so because of being with others who are smoking.

Discuss barriers (weight gain).

ASSESS is the person ready to quit?
If they are continue
if not think about harm reduction approach*

ASSIST provide the prescription for which suits them best, refer to local stop smoking service

ARRANGE - follow up
Record the smoking status at every opportunity.

Question 65

What are the three components of exercise screening?

Which system does not need to be evaluated on routine screening

Answer 65

1. Current physical activity
2. Desired physical activity
3. Presence of cardiovascular, renal or metabolic disease

Respiratory disease is not a significant cause of death associated with exercise

Question 66

What is AUDIT/AUDIT-C?

Answer 66

AUDIT

Alcohol Use Disorder

5 - 10 % at risk drinking (20% have AUD)
11 - 15: More at risk (40% have AUD)
16+ high probably of moderate AUD 90%

Audit score of 18 or more is 90% chance the person has an AUD

Question 67

Which vital sign has been validated by research?

Answer 67

Physical activity is a validated vital sign - others have not.

Question 68

What should an exercise prescription be?

Answer 68

SMART &
FITT

Having
Frequency
Intensity 
Type 
Time

Question 69

What is the most over consumed macronutrient?

Answer 69

Fat, especially trans and saturated fat

Question 70

What did the study by Joshipura show?

Answer 70

Each daily serving of fruits or vegetables was associated with a 4% reduction in risk of fatal coronary heart disease and non-fatal myocardial infarction.

Question 71

What is most health to make you be aware of behaviors you’re change and the thoughts and emotions surrounding them?

Answer 71

Monitoring is the most helpful skill in long-term lifestyle change.

Question 72

What’s the major controlling factor for chronic disease?

Answer 72

environment and its effect on epigenetics is the controlling factor for 70-90% of chronic disease.

Question 73

The patient is in the precontemplative and contemplative phases what is the best behaviour intervention?

Answer 73

The best intervention is motivational interviewing.

guiding style to engage clients, clarify their strengths and aspirations, evoke their own motivations for change and promote autonomy in decision making

R - resist the urge to change the individual’s course of action through didactic means
U - understand it’s the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour
L - listening is important; the solutions lie within the individual, not the practitioner
E - empower the individual to understand that they have the ability to change their behaviour. (Rollnick et al 2008)

Question 74

What is the best behavioural intervention when someone is in the preparation stage?

Answer 74

Cognitive Behavioural Therapy is the best intervention when someone is in the preparation, action & maintenance steps.

The basic principles: Recognising and reframing non-productive thinking
Being more aware of underlying beliefs and emotions (getting patients to connect their emotions with their actions).
working through the ABCD of behavioural change

A what action or even occurs
B What beliefs do you have about what occurs
C what were the consequences, how does that make you feel
D How can you dispute those beliefs.

In ALL stages use positive psychology (emphasing the postives, silver lining etc).

.

Question 75

What are the four principles of motivational interviewing?

Answer 75

Express empathy
Support Self-efficacy
Roll with resistance
Develop discrepancy between where the patient is and what the patient wants.

Question 76

In terms of nutrition what is depression positive and negatively associated with?

Answer 76

There is a linear dose response curve with trans-fat intake.
Whereas depression is negatively assocaited with mono and poly-unsaturated fat intake.

Depression is 40% more likely to develop in adults who frequently eat fast food compared to those who avoid it.

There MIGHT be some benefit to omega 3 intake in depression or bipolar.

Question 77

What is eudaimonia vs hedonia?

Answer 77

Eudaimonia the perspective that happiness comes from inherent meaning and purpose, and human nature works to discover that meaning, finding what nourishes and what dampens it in order to live life in a full and deeply satisfying manner. Eudaimonia is associated with: less activation of the amygdala; more engagement of higher cortical function with negative stimuli; and sustained activation of the reward circuit with positive stimuli. Eudaimonia appears to aid adaptive and protective functions, and it’s associated with greater insular cortex volume.
Eudaimonia is associated with gene regulation: pro-inflammatory genes are down-regulated while antibody synthesis genes are up-regulated. Hedonia is associated with the opposite pattern.

Hedonia is the perspective that happiness is characterized by the presence of positive emotions and expressions and the absence of negative emotions and expressions, with an overall high amount of life satisfaction. The thought process behind hedonia is that humans are born empty, and they acquire meaning through social and cultural interaction.

Question 78

What is at risk drinking?

Answer 78

Drinking that increases ris for future problems, with no current symptoms.

Question 79

If you quit smoking at age 30 how many years life expectancy do you gain compared to quiting at 60?

Answer 79

10 years gained when quiting at age 30

3 years gained when quiting at 60

Question 80

What is compassion fatigue & compassion burnout?

Answer 80

Compassion fatigue is distress and tension in which the helper is traumatized and preoccupied with suffering. Compassion fatigue can lead to poor coping, poor self-care and self-sacrifice, which is similar to PTSD. Compassion burnout is associated with lack of job satisfaction, to many hours, low pay and stress.

Question 81

physical inactivity is in what position in global mortality?

what did the aerobics center longitudinal study by sui et al show in terms of preventable deaths?

Answer 81

Physical inactivity is the fourth leading risk factor for global mortality.

Low cardiorespiratory fitness was the no. 1 cause of preventable deaths from all-cause mortality in 40,842 men and women who were enrolled in the Aerobics Center Longitudinal Study. [Sui et al. Percentage of Deaths Attributable to Poor Cardiovascular Health Lifestyle Factors: Findings from the Aerobics Center Longitudinal Study. Epidemiology Research International. 2013

Question 82

How does the talk test relate the heart rates and exercise intensity?

Answer 82

The Talk Test is a common measure of exercise intensity.

a. Very light to light exercise (63% or less of maximum HR) and are able to talk and/or sing.
b. Moderate exercise (54% to 74% of maximum HR) and are able to talk but not sing.
c. Vigorous to maximal exercise (77 to 100% of maximal HR) and have difficulty speaking

Question 83

How does ACLM define fitness? (Via CDC)

Answer 83

The ability to carry out daily tasks with vigor and alertness without undue fatigue, with ample energy to enjoy leisure-time pursuits and the ability to respond to emergencies

Question 84

What did the BMJ study by Naci et al., show in relation to exercise and post stroke outcomes?
How did coronary artery disease compare?

Answer 84

meta-epidemiological study included 305 randomized controlled trials (RCTs) and found that exercise decreased mortality more than medications in post-stroke studies. Exercise also had an equivalent effect on mortality to medications for the secondary prevention of coronary artery disease (CAD) and pre-diabetes, but it was inferior to medications with regard to heart failure patients. [Naci et al. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ. 2013]

Question 85

How much exercise does someone who wants to lose more than 5% of body weight and maintain this significant weight loss have to do?

Answer 85

People who want to lose a substantial amount of weight (more than 5% of body weight) and people who are trying to keep a significant amount of weight off once it has been lost need a high amount of physical activity unless they also reduce their caloric intake.

Many people need to do more than 300 minutes of moderate-intensity activity a week to meet weight–control goals. Seventy-five minutes is likely insufficient to meet health recommendations or weight loss goals. Two and a half hours would be appropriate for general health benefits. Seven hours may offer additional health benefits and further assist with weight loss efforts

Question 86

What percentage weight loss achieves most health benefits?

Answer 86

Research has shown that goal weight loss for health benefits is five to 10%, however weight loss of 15 to 20% may be necessary for continued disease improvement in individuals who have a BMI > 35 and comorbidities.

Question 87

What hormones are linked to relapse in weight loss after one year of significant weight loss?

Answer 87

One year after initial weight loss, a change occurs in the circulating hormones of appetite that encourage weight gain, including increased gherlin, GIP, PP, and decreased leptin, peptide YY, CCK and amylin.

Question 88

what grade recommendation is intensive behavioural therapy for obesity according to USPSTF?

Answer 88

Intensive behavioral therapy for obesity is a US Preventative Services Task Force (USPSTF) grade B recommendation and includes screening using BMI, nutritional assessment, intensive behavioral counseling and behavioral therapy.

Question 89

How does the US consider short fall nutrients

Answer 89

If 25% or less of the population get enough of them:

they incluide
Vit C & E
Fiber
Potassium

Question 90

With regard to cholesterol what did the study Effects of a dietary portfolio of cholesterol-lowering foods versus Lovastatin on serum lipids and hypercholesterolemia,” by DA Jenkins et al, in the American Journal of Clinical Nutrition, 2006 find?

Answer 90

Participants who ate the dietary portfolio of cholesterol-lowering foods, (plant sterols, soy protein, nuts and viscous fiber) were able to lower LDL-cholesterol concentrations >20%. This was statistically significantly compared to the control group and almost equal (no significant difference found) to the response to Lovastatin 20 mg, a first-generation statin medication.

Question 91

what are the lifestyle vital signs?

Answer 91

tobacco use, alcohol consumption, diet, physical activity, body
mass index, stress level, sleep, and emotional well-being.

Question 92

How much does sodium restriction change blood pressure?

Answer 92

Sodium restriction typically reduces blood pressure by 2.5 to 7 mmHg. According the American Heart Association, the ideal limit of sodium should be less than 1.5 grams daily, with the upper limit being 2,300 mg daily. The largest sources of sodium in the US are processed foods and canned foods.

Question 93

What did the Baylor University Conference tell us?

Answer 93

Facts learned from 2013 Baylor University Conference: If the serum total cholesterol is 90 to 140 mg/dl (2.327 - 3.620mmol/L), there is no evidence that cigarette smoking, systemic hypertension, diabetes, inactivity or obesity produces atherosclerotic plaques. Hypercholesterolemia is the only direct atherosclerotic risk factor, the others are all indirect. Optimal LDL is 50 to 70 mg/dl (1.293 - 1.810mmol/L). Plaque progression ceases with total cholesterol < 150 mg/dl (3.879mmol/L).

Question 94

The Diabetes Prevention Program (DPP) trial was the first major study to compare lifestyle intervention to medications to prevent diabetes

Answer 94

Participants were not placed on a strict diet. Rather, they were encouraged to gradually achieve the fat and calorie levels through: better choices of meals and snack items; healthier food preparation techniques; and careful selection of restaurants, including fast food and the items offered. The initial focus of the dietary intervention was on reducing total fat rather than calories. This allowed participants to accomplish a reduction in caloric intake while at the same time emphasizing overall healthy eating. It also streamlined the self-monitoring requirements, which was important given the diversity of educational and literacy levels among participants. After several weeks, the concept of calorie balance and the need to restrict calories as well as fat was introduced.

The calorie goals were calculated by estimating the daily calories needed to maintain the participant’s starting weight and subtracting 500 to 1,000 calories per day (depending on initial body weight) to achieve a one to two pound per week of weight loss. The fat goals, given in grams of fat per day, were based on 25% of calories from fat. Four standard calorie levels were used: 1,200 kcal per day (33 grams fat) for participants with an initial weight of 120 to 170 lbs; 1,500 kcal per day (42 grams fat) for participants with a weight of 175 to 215 lbs; 1,800 kcal per day (50 grams fat) for participants with a weight of 220 to 245 lbs; and 2,000 kcal per day (55 grams fat) for participants weighing >250 lbs. The fat and calorie goals were used as a means to achieve the weight loss goal rather than as a goal in and of itself. Therefore, if a participant reported

Question 95

what percentage of the american diet is processed?

Answer 95

63% of US food consumption comes from processed foods with added fats, oils, sugars and refined grains.

Question 96

What did the Ornish et al., JAMA 1998 article show?

Answer 96

This is the lifestyle heart trial.
It randomised 48 adults with coronary artery disease into TWO groups.

Randomized controlled trial conducted from 1986 to 1992 using a randomized invitational design.

Objectives: To determine the feasibility of patients to sustain intensive lifestyle changes for a total of 5 years and the effects of these lifestyle changes (without lipid-lowering drugs) on coronary heart disease.

Main outcome measures: Adherence to intensive lifestyle changes, changes in coronary artery percent diameter stenosis, and cardiac events.

Forty-eight patients with moderate to severe coronary heart disease were randomized to an intensive lifestyle change group or to a usual-care control group, and 35 completed the 5-year follow-up quantitative coronary arteriography.

20 received usual care - including advice about health eating & exercise.

28 received lifestyle intervention. Which was a low fat (10%) vegetarian diet (The diet consists of unlimited consumption of fruit, vegetables, grains, beans, and legumes and restricts all meats (including fish), oils and fats, nuts, avocados, dairy products, and simple carbohydrates)
aerobic exercise,
smoking cessation, stress management and group psychosocial support. 4
No lipid lowering medications

CAD stenosis were assessed with blinded quantitative at baseline

N.B. There was self selection bias as 50% refusal rate amongst people. So not truely randomised.

Outcomes:
Experimental group at 5 years 37.3 % stenosis vs 59.7% for the control not taking a statin.

There for a relative reduction of 7.9% vs 27.7 INCREASE in control group.

The control group had 45 cardiac events (angioplastic, bypass, hosptalisation, MI or death) vs 25 in the experimental group. Risk ratio of 2.47

(more than twice the rate of cardiac events)

There was a dose response to the intervention with 82% showing a regression in the experimental group.

Question 97

What was the 2002 Knowler et al., NEJM study?

Answer 97

Reduction in the Incidence of T2D with lifestyle intervention or metformin.

Randomised control trial of 3234 non-diabetics with impair fasting glucose,

1. Placebo
2. Metformin 850 mg BD
3. Lifestyle modification [7% weight loss and at least 150 minutes of physical activity week)
   It included minority groups. (45%).

The primary outcome was incidence of T2DM.

Mean age 51 mean BMI 24 (so all obese).
68% women

Average follow up of 2.8 years

Incidence of T2DM was
per 100 person-years

11 in placebo

7. 8 in metformin
8. 8 in lifestyle modification.

Compared with placebo

ILM reduced incidence by 58%
metformin reduced it by
31%

To prevent diabetes in 3 years

6. 9 people would have to have the ILM
7. 9 would have to receive metformin

The intervention was nearly twice as effective as metformin.

Question 98

What did the Jenkins et al JAMA 2003 study show?

Answer 98

This was the “effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and c-reactive protein”.

TBC

Question 99

What was the study by Hambrecht et al in 2004 show?

Answer 99

Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial

101 males were recruited after routine angiography and randomized to 12 months of 20 minutes of bicycles ergo per day at 70% of symptom free heart rate or to PCI.

They had stable coronary artery disease. 
Eligible patients had class I to III angina pectoris (classified according to the Canadian Cardiovascular Society [CCS]) with documented myocardial ischemia during stress ECG and/or 99mTc scintigraphy.

Outcomes: clinical symptoms; angina-free exercise capacity; myocardial perfusion; cost-effectiveness; and frequency of a combined clinical end point. (Clinical end points included death from a cardiac cause, stroke, coronary artery bypass graft (CABG), angioplasty, acute myocardial infarction and worsening angina with objective evidence resulting in hospitalization).

Exercise was associated with a higher event free survival 88% vs 70% in the PCI group and increased VO2 Max +16%

£6956 was spent on the PCI vs £3429 dollars in the training group. 
Cost efficiency was the cost to improve the canadian cardiovascular society class by one.

Question 100

What was the point of Dansinger et al., 2005 study in JAMA?

Main take away?

Answer 100

Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial

To assess adherence rates and the effectiveness of 4 popular diets (Atkins, Zone, Weight Watchers, and Ornish) for weight loss and cardiac risk factor reduction.

160 overweight or obese participants between the ages of 22 to 72 years who had diagnosed hypertension, dyslipidemia or fasting hyperglycemia.

After 2 months of maximum effort, participants selected their own levels of dietary adherence.

Many take away:
Eat diet signifiacnt reduced the LDL/HDL cholesterol ratio at 1 year with no real effect on BP or glucose.

Amount of weightloss was associated with self-reported dietary adherence level, but not dietary type.

Over all adherence was <25%

Question 101

What did the 2008, GEMINAL study by Dean Ornish show?

Published in PNAS.
Proceedings of the National Academy of Sciences USA

Answer 101

Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention

Pilot study conducted to determine changes in prostate gene expression in a population of men with low-risk prostate cancer. The study participants all declined immediate surgery, hormonal therapy, or radiation and participated in an intensive nutrition and lifestyle intervention while undergoing careful surveillance for tumor progression. This study is known as the Gene Expression Modulation by Intervention with Nutrition and Lifestyle (GEMINAL) study.

30 men completed the protocol.
3 month lifestyle modification used
3 day residential
outpatient phase where they was weekly telephone contact with a study nurse.

Everyone showed improves in weight, abdominal obesity, BP, lipid profiles.

They also had paired prostate biopsies taken at start and end.
These showed modulated gene expression: (reduction in gene transcription).

Only 30% of these biopsies contained tumour - major limitation.

Question 102

5 years after the GEMINAL study. Dean Ornish published another study in the Lancet, wrhat was this on?

Answer 102

Effect of comprehensive lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study

10 in intervention group, 25 as external controls.

Life style intervention
Low fat (<10%) WFPB
-Supplemented with soy, fish oil, vit E, selenium, Vit C.
Stress management 60 mins
Moderate aerobic exercise (walking 30 minutes for six days per week)
One our group support session per week

Telomere length decreased in control group and increased in the intervention group.

Question 103

Lim et al., Diabetologia 2011 showed what?

Answer 103

Study: Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol

Eleven people with type 2 diabetes (49.5 ± 2.5 years, BMI 33.6 ± 1.2 kg/m(2), nine male and two female) were studied before and after 1, 4 and 8 weeks of a 2.5 MJ (600 kcal)/day diet

8 non-diabetics as matched controls

Fasting plasma glucose normalized in the diabetic group (from 9.2 ± 0.4 mmol/L to 5.9 ± 0.4 mmol/l, or 166 ± 7.22 mg/dL to 106 ± 7.22 mg/dL; p=0.003).
Insulin suppression of hepatic glucose output improved from 43 ± 4% to 74 ± 5% (p=0.003) versus controls 68 ± 5%.
Hepatic triacylglycerol content fell from 12.8 ± 2.4% in the diabetic group to 2.9 ± 0.2% by week eight (p=0.003).
The first-phase insulin response increased during the study period (0.19 ± 0.02 to 0.46 ± 0.07 nmol /min /m2; p<0.001) and approached control values (0.62 ± 0.15 nmol /min /m2; p=0.42).
Maximal insulin response became supranormal at eight weeks (1.37 ± 0.27 versus controls 1.15 ± 0.18 nmol /min /m2).
Pancreatic triacylglycerol decreased from 8.0 ± 1.6% to 6.2 ± 1.1% (p=0.03).

The study showed that reducing dietary energy intake can reverse the abnormalities underlying type 2 diabetes.

Question 104

What is normal fasting blood glucose?

Answer 104

Normal fasting blood glucose is <5.5 (<42 HbA1c)

impaired is 5.5 - 6.9 (42 - 47 HbA1c

Diabetic 7 or more

Question 105

What did the study by Gregg eg al., 2012 in JAMA show?

Answer 105

Association of an intensive lifestyle intervention with remission of type 2 diabetes

This is the LookAHEAD trial.
Many people thought that bariatric surgery was better due to the modest outcomes.

To examine the association of a long-term intensive weight-loss intervention with the frequency of remission from type 2 diabetes to prediabetes or normoglycemia.

observational analysis of a 4-year randomized controlled trial (baseline visit, August 2001-April 2004; last follow-up, April 2008) comparing an intensive lifestyle intervention (ILI) with a diabetes support and education control condition (DSE) among 4503 US adults with body mass index of 25 or higher and type 2 diabetes.

Intervention:
Intensive:weekly group and individual counseling in the first 6 months followed by 3 sessions per month for the second 6 months and twice-monthly contact and regular refresher group series and campaigns in years 2 to 4 (n=2241)
They also followed a 1,200 to 1800 kcal diet. with reductions in total and sat fat
Also aimed for 175 minutes a week of physical activity.

The DSE, which was an offer of 3 group sessions per year on diet, physical activity, and social support (n=2262).

Outcome measures: Partial or complete remission of diabetes, defined as transition from meeting diabetes criteria to a prediabetes or nondiabetic level of glycemia without hypoglycaemics.

ILI weight loss at 1 year <7.9% 4 years 3.9% versus diabetes education
ILI had greater fitness - difference
15.4% at 1 year and 6.4% at 4 years
ILI was more likely to experience remission 11.5% prevalence first year, 7.3% at year 4
Compared to 2% in the education.
in ILI 9.2%, 6.4% and 3.5% had sustained remissions for 2, 3 & 4 years.

Question 106

What is the Gardner DIETFITS randomised clinical trial?

Answer 106

Published in JAMA 2018
To determine the effect of a healthy low-fat (HLF) diet vs a healthy low-carbohydrate (HLC) diet on weight change and if genotype pattern or insulin secretion are related to the dietary effects on weight loss.

609 adults aged 18 to 50 years without diabetes with a body mass index between 28 and 40.

Randomized to the 12-month HLF or HLC diet.

The study also tested whether 3 single-nucleotide polymorphism multilocus genotype responsiveness patterns or insulin secretion (INS-30; blood concentration of insulin 30 minutes after a glucose challenge) were associated with weight loss.

Health educators delivered the behavior modification intervention to HLF (n = 305) and HLC (n = 304) participants via 22 diet-specific small group sessions administered over 12 months. The sessions focused on ways to achieve the lowest fat or carbohydrate intake that could be maintained long-term and emphasized diet quality.

Primary outcome was 12-month weight change and determination of whether there were significant interactions among diet type and genotype pattern, diet and insulin secretion, and diet and weight loss.

participants were not being instructed to follow a specific caloric restriction, the mean reported energy intake reduction relative to baseline was approximately 500 to 600 kcal per day for both groups at each time point after randomization.

Weight change at 12 months was −5.3 kg (-11.7 lbs) for the healthy low-fat diet versus −6.0 kg (-13.2 lbs) for the healthy low-carbohydrate diet

There was no significant diet-genotype pattern interaction (P = .20) or diet-insulin secretion (INS-30) interaction (P = .47) with 12-month weight loss.

Eighteen adverse or serious adverse events were evenly distributed across the two diet groups.

Previous research suggests genotype or insulin-glucose dynamics may modify the effects of diets. Neither of the two hypothesized predisposing factors was helpful in identifying which diet was better for whom.

They comment: These results are inconsistent with similar analyses of other dietary weight loss intervention cohorts, and it seems implausible there is no interaction between genotype and weight loss with different macronutrient dietary patterns.

Question 107

What did the lean ME et al., Lancet 2018 study show?

Answer 107

This was the DiRECT trial:
Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial

In the UK, published in the lancet.

Aimed to assess whether intensive weight management within routine primary care would achieve remission of type 2 diabetes.

Open label, cluster-randomised. at 49 primary care practises in Scotland & Tyneside.

T2DM diagnose within 6 years, BMI 27 - 45, not on insulin and 20 - 65 yrs

Intervention:
(1) withdrawal of antidiabetic and antihypertensive medications, and (2) total diet replacement (825 to 853 kcal per day formula diet for three to five months), and (3) stepped food reintroduction over a period of two to eight weeks, and (4) structured support for long-term weight loss maintenance.

or Standard guidelines

Outcomes were weight loss of 15kg or more
remission of diabetes HbA1c <48 after 2 months off all antidiabetic medications during the 12 month study period.

306 individuals

24% achieved the 15kg loss in the intervention, but non in the control.
Diabetes remission 46% in the intervention, 4% in controls. Odds 19.7
Remission was associated with weight loss.

Remission not achieved in the 76 who gained weight.
The more weight loss the higher the percentage of remission.

Mean body weight fell by 10kg in intervention and 1 kg in the control.

QOL improved in intervention.
Nine serious adverse events by 7 of the intervention group. 2 by the control group.

Importantly this DIRECT trial found that unlike the LookAHEAD which had 11.5% and 6% remssion at year 1 and 4.
Here they had 46% had remission at 12 months.

Question 108

What did the Study by Cheng in 2017 show?

Fasting-Mimicking Diet Promotes Ngn3-Driven β-Cell Regeneration to Reverse Diabetes

Answer 108

Published in cell:

And then promotes some horrendous prolong - which is actually just LITERALLY FASTING.

1100 kcals day one then
day 2 to 5

720 kcals day 2 - 5

AND ITS A SOUP DIET.

WAT.
250 dollars or something.

and only 9% protein. JEEZ.
Talk about ALL THOSE LOST GAINS.

See study..

THE TREAT randomised clinical trial by Lowe et al., published in JAMA internal medicine.

yet we need body mass. and it’s correlated with health.

Question 109

From Diabetes Care to Diabetes Cure-The Integration of Systems Biology, eHealth, and Behavioral Change

Answer 109

he healthcare approach toward lifestyle-related diseases needs to change. Huge health and economic profits could be achieved if everyone would adopt an “optimal” lifestyle. This article presents abundant scientific evidence that lifestyle interventions can lead to major reductions in obesity, type 2 diabetes, and cardiovascular disease. The (economic) benefits of a lifestyle-based therapy for type 2 diabetes have been demonstrated by a 10-year study, yet the introduction of a new healthcare system for preventing and treating lifestyle-related diseases has not materialized for a number of reasons, as discussed in this article.

One of the major reasons lifestyle measures aren’t used in clinical practice is that it’s difficult for patients to sustain the changes. In the short term, or in a setting where the lifestyle choices are rigidly imposed, lifestyle change can be achieved, but in the long term the daily life changes fade away due to a lack of support and the many counteracting stimuli from environmental pressures. Another reason lifestyle as medicine has failed to take hold is the lack of economic benefits within the context of our current healthcare system. And a major reason is the failure to take a systems approach instead of making reductionistic changes. Thus, the theory and practice differ, and we face a multifactorial challenge that requires removing economic, social, psychological and biological barriers.

A reorientation of health research and care is needed, starting with: re-defining health and its underlying mechanisms; realizing that integrated participatory and personalized health optimization strategies are needed; redesigning the methods to quantify health toward the development of a new generation of health biomarkers, lifestyle interventions, support tools and economic values. All of these changes need to be focused on self- empowerment, as listed below.

Refocusing on flexibility as a core characteristic of human physiology, meaning that chronic disease is reversible.
Diagnosis has to quantify much more than the medical condition. A 360° diagnosis is needed to determine all the relevant biological, sociological, psychological and contextual conditions of the patient. The trajectory toward disease needs to be identified and quantified in order to empower the individual to achieve a sustainable and perceivable lifestyle change.
Interventions will need to span all relevant bio-socio-psycho-economic factors and thus change from reductionist to systemic and from generic to fine tuned toward personal goals.
Motivational tools are required in the form of personal coaching as well as Information and Communications Technology (ICT) support.
Health literacy needs to be improved as part of personal health empowerment.
Personal health data handling needs to completely refocus in order to empower the citizen/patient to valorize their health data for personal health and research.
Together, the points above need to lay the foundation of a new approach in lifestyle-related health science and a new health economy.
Type 2 diabetes is a “genotype–environment interaction disease”, meaning the diabetic phenotype is expressed as a result of accumulated environmental pressures (including wrong diet, too little physical exercise, disrupted sleep and too much stress) in concert with genes that render individuals susceptible to the disease. Over the past 50 years our environment has changed in ways that have increased the burden of all four components mentioned. Reversal and cure of type 2 diabetes thus needs to focus on: (1) biological reversal (i.e., using lifestyle as medicine), (2) coping with the environmental pressures (i.e., behavioral change), and (3) reduction of the environmental pressures (i.e., socioeconomic changes).

In this article, the authors provide evidence for the reversibility of insulin resistance and the remission of type 2 diabetes by diet and lifestyle, asserting that complete cure may be achieved if beta-cell function is still appropriate and complications have not yet occurred. They demonstrate that type 2 diabetes is a “systems disease” with multiple organs and processes involved, and assert that the disease deserves to be treated in a personalized manner, and if necessary in a “personalized lifestyle-personalized medicine combination.”
Compliance to lifestyle change has been a major obstacle for implementation in healthcare, but the advancements in behavioral change technologies, eHealth, health literacy, and personal health data valorization may now allow for a switch from a research setting to real-life socioeconomic implementation. There are enough arguments and instruments currently available to (1) implement a lifestyle-based therapy for type 2 diabetes and other food-related lifestyle diseases and (2) extend this to a prevention and optimal health focused healthcare.

Also, they argue that in implementing a lifestyle-based healthcare system there will be an enormous economic gain. This economic gain will in turn finance healthcare system changes and economic changes that support lifestyle-based approaches for optimal health and prevention. Since stakeholders, losses, and profits in this new economy will be substantially different from the current situation, the present healthcare industry will transit slowly toward this new system.

Therefore, creative ways to implement these changes need to be explored. Ultimately, health data cooperatives may become the basis and drivers for this change, but this will take some time to develop into an economic reality. In the meantime, creative new “ecosystems” need to be explored that combine all the necessary instruments for specific type 2 diabetes populations to be really effective. The goal would be to demonstrate its therapeutic efficacy but also—and possibly more important—to demonstrate that a new health economy that provides the necessary support services can become profitable while significantly reducing net healthcare costs. (Those services would including coaching, ICT, foods, diagnostics and medication, all of which should be personalized and integrated).

Such ecosystems should preferably be regional, facilitating the simultaneous change of all relevant components in the “change system” to interact. This will allow community building and involvement of local healthcare centers, the local health and lifestyle-related economy and others.

The Chicago-based South Side diabetics project, Improving Diabetes Care and Outcomes on the South Side of Chicago, is a good example. The key point is that many early adopter activities, programs and movements are already active in this area, and they’re covering parts of what’s needed. A challenge will be to connect and integrate these efforts into functional and flexible programs that can deliver “tailored systems solutions” depending on the personal and subgroup needs. The major challenge will be to fund these programs, at least to the point that they become self-sustainable. Here, sustainability does not necessarily imply a profitable service as such, but rather the identification of new natural funders, those being the entities that profit from the new systems. In addition to the actual service providers, these natural funders can include governments, health insurance, employers and investors.