MCQ's from the Chapters based on 4th Edition of Board Review Manual Flashcards

Question 1

Q

In relation to Lifestyle heart Trial for CAD by Ornish which of the following options are incorrect:

A. It was a randomised double blind controlled trial
B. A low carbohydrate diet was compared with the American Heart Association Step 2 diet.
C. LDL reduction in experimental group compared to lipid lowering drugs in ambulatory population was 40% at one year.
D. The treatment group had a 7.9% reduction in coronary stenosis at 5 years while the controls had a progression of 27.7% for a net difference of -35.6%
E. The controls who were not taking lipid lowering medication had a progression of 46.7% for a net difference of -54.6%

Answer

A

A and B are incorrect.
A. it was a randomised parallel design.
B. low fat diet (10% fat) was compared with the AHA step 2 diet

Question 2

Q

The following are components of multifactorial life style intervention in the Lifestyle Heart trial ( Ornish) except
A. Low fat vegetarian diet ( Fat constituted 10% on total calories)
B. Anaerobic exercise
C. Stress management
D. Smoking cessation
E. Group psychosocial support

Answer

A

B Aerobic exercise was included, not anaerobic

Question 3

Q

In relation to Lifestyle Heart Trial (Ornish), which one is incorrect:
A. LDL reduction 40% at 1 year and 20% at 5 years in the experimental group
B. AHA step 2 diet LDL reduction 5% or less
C. Rate of cardiac events almost 2x in control group vs experimental group (45 vs. 25)
D. At 1 year 91% reduction in anginal episodes in experimental group compared to control group where there was165% increase in anginal episodes.
E. 50% lost to follow up.

Answer

A

E: 27% lost to follow up.

No lipid lowering medications were used
5-year RCT

Page 71

Question 4

Q

Diabetes Prevention program Research Group, all of the following are true except:
A. NNT to prevent 1 case of diabetes for Metformin group was 6.9 and for life style group it was 13.9
B. Life style program goal was 14% weight loss and 300 minutes of physical exercise per week.
C. Placebo vs Metformin group: Metformin reduced diabetes incidence by 31%
D. Placebo vs Lifestyle group: Life style group reduced incident of diabetes by 58%.

Answer

A

A and B
A: 13.9 in metformin group and 6.9 in life style group
B: Goal 7% weight loss and 150 minutes/week of physical exercise.

Question 5

Q

DASH diet Dietary approaches to stop HT which one is incorrect
A. previously called combination diet
B. diet low in sodium
C. the greatest reduction in BP with DASH diet which was low in sodium. compared to control diet high in sodium.
D. SBP reduction of 7.1 mmHg in HT patient and SBP 11.5 reduction in non HT patient.

Answer

A

D. SBP reduction of 11.5mmHg in HT patient and SBP 7.1 reduction in non HT patient.
DASH
compared *control diet
*diet rich in fruit and veg
*combination diet rich in fruit, veg, low fat dairy products, reduced in sat fat, total fat and dietary cholesterol
weight and sodium intake were constant between groups.
Fruit and veg diet reduced BP more than control diet.

combination diet had greatest reduction. its was true for both patient with HT or without HT.
Those with HT BP reduction SBP 11.4 mmHg
DBP 5.5mmHg compared with control diet.

Question 6

Q

Portfolio diet for treatment of Hypercholesterolemia. which option is incorrect?
A. Diet very low in saturated fat
B Low in plant sterols, soy protein, viscous fiber and almonds.
C 28.6% reduction in LDL-C with portfolio diet.
D. 30.9% reduction in LDL-C with 20mg Lovastatin

Answer

A

B its high not low

Question 7

Q

Lyons diet heart Study looked at secondary prevention of CHD mediterrnean diet vs AHA step 1 diet

Answer

A

Mediterranean arm had fewer of the composite CVD outcomes. results maintained at 4 years study follow up after each participant’s first MI.

Question 8

Q

Esselstyn plant based diet for CAD.

Answer

A

A very low fat plant based diet was shown to reverse and prevent major cardiac event in 177 adherent patient over 3.7 years, Among 177 adherent patient cardiac event rate was 0.6%. among 21 non adherent patients 13 ( 62%) experienced major cardiac events.

Question 9

Q

The CHIP complete health improvement program and plant based dietary intervention with cost savings.

Answer

A

The program was found to be effective in treating type 2 DM and to have a positive return on investment with in a few months.

Question 10

Q

percutaneous angiography compared with exercise training in patient with stable CAD.

to determine if patients with stable CAD can improve myocardial perfusion and reduce disease progression
to compare the effects of exercise training to standard PCI with stenting on: clinical symptoms, angina free exercise capacity, myocardial perfusion, cost effectiveness, frequency of combined cardiac events
( death of cardiac cause, CABG, angioplasty, Acute MI, worsening of angina resulting in hospitalisation)
duration 12 months
101 male patient <=70 Germany
Ergo spirometry
20 mins of bicycle ergometry
cost effectiveness was calculated on average expanse US dollars needed to improve the Canadian cardiovascular society class by 1 CCS
*
*

Answer

A

Key results: exercise training associated with

high event free survival 88% vs 70% for PCI resulting in 26% low risk in exercise group than PCI group.
increased O2 uptake 16%
increased exercise tolerance to by 20%
increased ischaemic threshold by 30%
significantly increased HDL after 12 months HDL decreased in control. LDL remained unchanged during study period.
in the PCI group only ischaemic threshold showed a significant increase after 12 months.
clinical symptoms improved in both groups
to gain 1ccs class $6956 PCI vs $3429 in training group
in both groups symptoms significantly improved
physical work capacity increased 133w to 159w in exercise group but no change in PCI group
resting heart rate was low in exercise group and the maximal heart rate and Vo2 max higher in exercise group at the end of the study.
exercise training more cost effective due to lower repeat hospitalisations and revascularisation as exercise capacity improved in exercise group.

VO2 max: 22.6 ml/kg to 26.2in exercise group
22.3 to 22.8 in PCI group.

Question 11

Q

Comparison of Atkins ( low carb), Ornish (Low Fat), Weight Watchers ( calorie restriction) , and Zone’s diet (macronutrient balance) for weight loss and heart disease.

Answer

A

RCT one year JAMA 2005 Boston MA USA
Each diet reduced LDL/HDL ratio by 10% and no significant effect on glucose or BP @ one year.
the amount of weight loss was associated with self reported dietary adherence levels but not with diet type.
for each diet weight loss was associated with decreased total cholesterol and HDL ratio, CRP and insulin with no significant difference between diets.
overall adherence rate was low. <25%
160 patients 40 each for each diet.
discontinuation rate 50% for Ornish, 48% for Atkins both extreme diets, 35% for Zone and WW both Moderate diets: reason not yielding enough weight loss and too hard to follow.
Adherence and intensity of intervention is more important than the specific diet for weight loss. Intensity is directly related to adherence.

Question 12

Q

The Geminal Study: Gene expression modulation by intervention with nutrition and lifestyle: Ornish Magbanua USA 2008
Pilot study to determine changes in prostate gene expression in a population of men with low risk prostate cancer undergoing intensive nutrition and life style intervention.
* N; 30
* 3 days intensive residential retreat followed by an outpatient phase of weekly tel contact.
* careful surveillance of tumour progression.
* outcomes significant improvement in weight, abdo obesity, BP, lipid profile,
* biopsy taken before and 3 months post intervention
*pairing in RNA samples
* low fat 10% calories from fat, whole food plant based diet, patients were provided with all their food,
diet was supplemented with Soy ( a daily serving of Tofu, 58gm of fortified soy protein, powdered beverage) fish oil 3gm daily, vit E 100 units daily, selenium 200mg daily, vit C 2gm daily
* stress management: 60 mins of daily yoga based stretching, breathing meditation, imagery, or progressive relaxation.
* moderate aerobic exercise 30 mins walking /day 6 days a week.
* a one hour of group support session per week.
* after 3 months they reported: 11.6% of fat cal/day, exercising 3.6 hours/week, and practising stress management 4.5 hours/week.
*limitations: small group, absence of comparison group: this prevents us from definitely saying that gene expression changes are due to the comprehensive lifestyle modification and not due to normal changes in the gene expression.
Large RCT needed.
* Bonferroni correction: to correct large no: of data points.
* only 30% biopsies had tumour tissue. these results are based on normal tissue for male with prostate cancer. This indicate that lifestyle modifications can affect cancer and normal tissue and benefits of lifestyle modifications not only restricted to gene associated with prostate Ca.
although the results are largely based on normal tissue in male with prostate cancer that doesn’t mean that the results indicate that life style modifications doesn’t apply to prostate cancer.

Answer

A

Questions:
1. The following statements related to Geminal Study are true:
A: late stage prostate cancer was studied in 300 men.
B. It was a RCT.
C. Significant improvement in Weight, Abdo obesity, BP, lipid profile
D. diet was 10% cal from carbohydrates.
F. 60mins of Tai Chi based stretching.
G. after 3 months they reported: 11.6% of fat cal/day, exercising 3.6 hours/week, and practising stress management 4.5 hours/week.
H. large study carried out for a year.

Answer: CG

Question 13

Q

Reversal of Type 2 Diabetes: Normalisation of Beta Cell Function in Association with Decreased Pancreas and Liver Triacylglycerol
Hollingsworth et al, 2011
P347 of manual

Objectives
1) Can both beta cell failure and insulin resistance be reversed by dietary restriction of energy intake?
2) Does acute negative energy balance alone reverse Type 2 Diabetes by normalising both beta cell function and insulin sensitivity?
Study design
Case-control study (intervention study)
Intervention group
N=11
Type 2 Diabetes
Age 35-65 yrs
HBA1c 6.5-9.0% (48-75mmol/L)
Diabetes duration < 4yrs
BMI 25-45kg/m2
Asked to continue their habitual pattern of eating till start of the study.
For the study, restricted 600 calorie/day diet and statin therapy continued
Control group
N=9
Matched for weight, age, sex
Assessments of beta cell function, insulin sensitivity, liver and pancreatic fat content and total body fat at:
Baseline (day -1), after 1, 4 and 8 wks of low-energy diet
Results
After one week of restricted energy intake
- Fasting plasma glucose normalised in diabetic group
- Insulin suppression of hepatic glucose output improved vs control group
- Hepatic triacylgycerol content fell in diabetic group by week 8
- First-phase insulin response increased during study period and approached control values
- Maximal insulin response became supranormal vs controls
- Pancreatic triacylglycerol decreased

Strengths
- Demonstrated for the first time that normal blood glucose levels without medication achievable after 1 week with a very low energy diet and accompanied by reversal of hepatic and pancreatic triacylglycerol in the subsequent 3-4 weeks.
Limitations
- Small sample size (necessary to allow for metabolic investigation and examination by magnetic resonance techniques)
- Pancreatic fat measurements included intraorgan adipocyte fat content because current methodology precludes assessment of the more mechanistically important islet intracellular fatty acid content. Animal data suggests the two variables are linked.
- Participants selected to have a relatively short duration of Type 2 DM (up to 4 years). Further studies must establish the extent of reversibility with longer duration Type 2 DM.
- Observations made after 12 weeks of return to a normal diet limited.
- The G allele of the PNPLA3 gene determines high liver fat levels, but in a form that is not associated with metabolic abnormality. Provides a clear genetic basis for the observed individual variation in susceptibility to insulin resistance despite raised liver fat content, and offers a partial explanation of the overlapping hepatic fat levels in type 2 diabetic and control groups. Likely other genetic factors yet to be defined.
-
Conclusions
- Normalisation of both beta cell function and hepatic insulin sensitivity in Type 2 diabetes achieved by dietary energy restriction alone. Associated with decreased pancreatic and liver triacylglycerol stores.
- Abnormalities underlying Type 2 Diabetes reversible by reducing dietary energy intake.

Answer

A

Questions
1) Which of the following statements about this study is false?
a. The study used a case control design.
b. Participants were selected to have a short duration of Type 2 Diabetes- < 2 years.
c. The primary outcomes were beta cell function and insulin sensitivity.
d. Participants were asked to continue their usual pattern of eating until the start of the study.

2) Which of the following statements is true regarding the intervention group?
a. HBA1c 48-75mmol/L
b. Diabetes duration <8yrs
c. Participants asked to continue their habitual pattern of eating until one week before the start of the study.
d. Age 35-70 years

3) Which of the following statements is true regarding the methodology?
a. N=15 in the intervention group.
b. Participants in the intervention group were asked to discontinue their statin medication.
c. Assessments of beta cell function, insulin sensitivity, liver and pancreatic fat content and total body fat were carried out at baseline immediately prior to dietary intervention (day -1) and after 1,4, and 12 weeks of the very low-energy diet.
d. Participants were on a restricted 600 calorie per day diet during the study.

4) Which statement accurately describes the key conclusions of the study?
a. After one week of restricted energy intake, fasting plasma glucose did not normalise in the diabetic group.
b. The first phase insulin response decreased during the study period.
c. Normalisation of both beta cell function and hepatic insulin sensitivity in Type 2 Diabetes was achieved by dietary restriction alone.
d. Pancreatic triacylglycerol increased.

Answers: 1)b 2)a 3)d 4)c

Question 14

Q

The DIETFITS Randomized Clinical Trial (The Diet Intervention Examining The Factors Interaction with Treatment Success) JAMA 2018
By Gardner, Trepanowski , Del Gobbo
Objective
To determine the effect of a healthy low-fat diet versus a healthy low-carbohydrate diet on weight
change, and to determine whether genotype pattern or insulin secretion are related to the dietary
effects on weight loss.
Study design
12-month randomized clinical trial
Sample population
N = 609 adults (18–50 years old) without diabetes with a body mass index (BMI) of 28–40.
Location/venue
Not specified
Intervention
Health educators delivered the behaviour modification intervention to the healthy low-fat participants, (N = 305) and the healthy low-carbohydrate participants, (N = 304) via 22 diet-specific small group sessions administered over 1 year.
Control group
N/A
Outcome(s) of interest
• Effects of a healthy low-fat diet vs a healthy low-carbohydrate diet on weight change
• Relationship of genotype pattern or insulin secretion to dietary effects on weight loss
Summary of methods and intervention
N = 609 overweight adults. Participants were randomized to the 12-month healthy low-fat (HLF);
(N = 305) or healthy low-carbohydrate (HLC); (N = 304), diet.

Key results
• Among 609 participants, 244 (40%) had a low-fat genotype; 180 (30%) had a low-carbohydrate genotype; mean baseline INS-30, 93 μIU/ml
• For the healthy low-fat versus healthy low-carbohydrate diets, respectively:
•The mean 12-month macronutrient distributions were: 48% vs 30% for carbohydrates; 29% vs 45% for fat; and 21% vs 23% for protein.
•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 (mean between-group difference, 0 .7 kg [95% CI, −0 .2 to 1 .6 kg], or 1 .5 lbs [95% CI, −0 .4 to 3 .5 lbs]). This difference in weight loss was not statistically significant.
•No significant diet-genotype pattern interaction (P = 0 .20) or diet-insulin secretion (INS-30) interaction (P = 0 .47) with 12-month weight loss.
•Eighteen adverse or serious adverse events were evenly distributed across the two diet groups
Limitations
• 481 (79%) completed the trial.
• 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. It is possible there were confounding factors. For instance, it could be that for the range of macronutrients consumed in this study there is no difference in the interaction, or that the study was underpowered and therefore unable to detect a small difference.
• It is impossible to identify the effect of a gene (genotype) without measuring the epigenetic state and knowing if the gene is active or quiescent. The epigenome was not assessed in this study, a major limitation in any genotype association study.
Strengths
Health educators delivered the behaviour modification intervention to both groups via 22 diet-specific small group sessions administered over 1 year. The sessions emphasized diet quality and focused on ways to achieve the lowest fat or carbohydrate intake that could be maintained long-term.
Key conclusions
There is considerable scientific interest in identifying the genetic variants that help explain inter-individual differences in weight loss success in response to diet interventions, particularly diets with varying macronutrient compositions. In this 12-month weight loss diet study, there was no significant difference in weight change between a healthy low-fat diet versus a healthy low-carbohydrate diet. Also, neither genotype pattern nor baseline insulin secretion was associated with the dietary effects on weight loss. In the context of these two common weight loss diet approaches, neither of the two hypothesized predisposing factors was helpful in identifying which diet was better for whom. Significance for lifestyle medicine
Dietary modification remains key for successful weight loss, yet no one dietary strategy is consistently superior to another for the general population. Previous research suggests genotype or insulin-glucose dynamics may modify the effects of diets. This study demonstrates that epigenetics must be part of the measures assessed in lifestyle diet intervention studies. Diet determines the expression of many genes.

Answer

A

Questions
1.Which of the following statements about this study are not true?
A. This study was a meta-analysis of 20 RCTs
B. The intervention sought to reduce caloric intake to 500–600 calories per day.
C. The primary outcome was weight loss at 6 months.
D. Weight loss was not statistically different between the two dietary patterns.
E. This study was comparison of healthy low fat diet Vs Plant based diet.
F. Only 50% subjects completed the trial
2.Which of the following statements most accurately describes the findings of this study?
A. Weight loss was about the same for both dietary patterns, and there was no interaction between dietary pattern and genotype.
B. 22 diet-specific small group sessions were administered over 1 year.
C. There was a slight interaction between genotype and insulin level 30 minutes after glucose ingestion, but it was not statistically significant.
D. Subjects with metabolic syndrome were found to lose more weight on the healthy low-carbohydrate diet.
E. Weight loss was greater for the low-carbohydrate dietary pattern.
F. N = 609 overweight adults. Participants were randomized to the 12-month healthy low-fat (HLF); (N = 305) or healthy low-carbohydrate (HLC); (N = 304), diet.

Answers
1.Answer: A, B, C, E, F
2.Answer: A, B, F

Question 15

Q

DiRECT trial
Population
- adults, NIDDM < 6 yrs w BMI 27-45, not on insulin
- n = 306 from 49 practices.
Design: Open label cluster RCT at 49 1’ care practices in
Scotland & England (statistician blinded)
Intervention
1) Withdraw anti-diabetic and BP drugs
2) Total diet replacement (850 cal/d) with liquid formula x 3-5 months then stepped food reintroduction (2-8 wks) &
structured support for LTM weight loss maintenance
Control: best-practice care by guidelines
Outcome: Wt. loss > 15 kg & Remission of DM (HbA1c <
6.5% after at least 2 months off all diabetic meds

Answer

A

Results: 1) Mean decrease in weight: 10.0 vs 1.0 Kg -
delta 8.8 Kg (P<0.0001)
a) Loss of > 15 kg in 24% v 0%; P<0.0001
2) QOL (EuroQol VAS) improved by 7.2 points vs decrease by 2.9 points. (delta 6.4 points; p=0.0012)
3) DM remission 46% vs 4%, OR 19.7; P<0.0001
4) Primary predictor of remission was weight loss:
- none in those who gained weight.
- 86% in those who lost 15kg or more
Comparison with Lookahead:
Overall Direct had a 46% remission rate for NIDDM vs 11.5% (both at 1 yr) in Lookahead (& 2% on ADA diet)
- due to differences in dosing strength (1,200-1,800 cal/d in Lookahead vs 850 cal/d in Direct).
- used a low energy liquid replacement diet.

Question 16

Q

Fasting Mimicking Diet
Aim: To examine whether cycles of the FMD are able to
promote the generation of insulin-producing B cells
Fasting mimicking diet in mice:
a) FMD induces stepwise expression of Sox17 and Pdx-1
b) followed by Ngn3-driven generation of insulin-producing beta cells resembling that observed during pancreatic development.
c) In mice w NIDDM & IDDM, FMD cycles restore insulin
secretion and glucose homeostasis.
Fasting mimicking diet on humans
a) In human IDDM islet cells, FMD
reduce PKA and mTOR activity and
induce Sox2 and Ngn3 expression and insulin production.
b) The effects of FMD are:
Reversed by IGF-1 treatment
Recapitulated by PKA and mTOR inhibition

Answer

A

Fasting mimicking diet on mice & humans:
1) A FMD reverses IDDM and NIDDM phenotypes
in mouse models
2) A FMD promotes the reprogramming of
pancreatic cells to restore insulin generation in islets from
IDDM patients
FMD for humans:
1a) Calories: day 1 = 1100 cal, day 2-5 = 720 calories
1b) % calories: Protein 10%, fat 45%, CHO 45%
2) The human FMD comprises formulations of vegetable based soups, bars & snacks plus an algal oil capsule.

Question 17

Q

Diabetes Care to Cure
A major reason lifestyle measures (LS) aren’t used in clinical practice is that it’s difficult for patients to sustain the changes due to lack of support and the many counteracting stimuli from environmental pressures.
Multiple changes of the health system need to be made
focusing on patient self-empowerment.
These include:
1) Making a 360’ diagnosis (determine all the relevant
biological, sociological, psychological, contextual
conditions of the patient).
2) Identifying the trajectory toward disease
3) Achieving a sustainable and perceivable
lifestyle change
4) Motivational tools are required in the form of personal
coaching and IT/communications support

Answer

A

NIDDM is a genotype-environment interaction disease.
- environment: wrong diet, inadequate [exercise],
disrupted sleep, too much stress
The articles authors provide evidence for the reversibility of insulin resistance & the remission of NIDDM by diet &
lifestyle.
They assert that complete cure may be achieved if:
1) Beta cell function is still appropriate
2) Complications have not yet occurred

Question 18

Q

Which of the following statements are not true
A. In INTERHEART study five of the risk factors ( smoking, lipids, HT, diabetes, Obesity) identified accounted for 80% on the population attributable risk for acute MI
B. Data in INTERHEART study is from 32 countries.
C. Ten life style risk factors in INTERSTROKE study were associated with90% of the risk of stroke in men and women of all ages.
D. Data in INTERSTROKE study was from 52 countries.

4ed. p10

Answer

A

Answer B&D are reversed
A. In addition to the five risk factors/80% risk, all nine identified RF accounted for more than 90% of the PAR of AMI in men and 94% in women. + diet, physical inactivity, alcohol consumption and psychosocial factors ( stress, Mental health, isolation, addictions PAR 30% comparable to High BP and Abdominal obesity)
B. 52 countries
C. 10 risk factors: HT, Current smoking, abdominal obesity, unhealthy diet, physical inactivity, diabetes, alcohol intake, psychological stress, depression, cardiac causes and abnormal lipids.
D.32

Question 19

Q

In the **Chicago Heart Association Detection Project in Industry **, making six life style changes can reduce heart disease risk by 90-95%.
Which of the following are incorrect:
A. 50% decease in total cholesterol => 50% risk reduction of heart disease.
B. Smoking cessation- 50% risk reduction of sudden cardiac death
C. Maintain ideal body weight and waist size- 60% risk reduction of heart disease.
D. 150 minutes/week or more of moderate exercise- 30% risk reduction of heart disease.
E. more than 5 serving of fruit and veg per day- 20-25% risk reduction of heart disease.
F. 6mm Hg decrease in diastolic BP - 16% risk reduction of heart disease

Answer

A

Answer D and E
D 35-55% not 60%
E 35-55% not 30%

Also showed lower Medicare costs !
6mmHg reduction in DBP had the least contribution (16%) for heart disease - but reduced stroke risk 42%!

Note that the list is ordered from greatest to lowest impact on heart disease

Page 10-11

Question 20

Q

Which of the following statements is not true:
A. In Framingham heart study men with optimal risk had 5% life time risk of atherosclerotic CVD versus men with 2 or more risk factors who had 69% life time risk at 50

B. Multiple risk factors intervention trial ( MRFIT) study outcomes included 6-10 years greater life expectancy.

C. Nurses Heart study: 5 health factors associated with low risk of CHD were absence of smoking, BMI <25, Physically active 30 minutes per day, moderate alcohol consumption (5-30 grams or 0.2-1 ounce per day), healthy diet score.

D. Three large prospective studies
* Nurses health study
* Nurses health study 2
* Health professionals follow up study

found that higher adherence to a healthy plant based diet had positive correlation with coronary heart disease.

Answer

A

ANSWER: D

A.Figures for women were 8% vs. 50%. This adds about 10 years to life expectancy. (11+ years for men and 8+ years for women)

B. Low risk patients had 40-60% lower total mortality and 73-85% lower risk CVD mortality.

C. diet score were based on intake of cereal fiber, marine omega 3 fatty acids and folate.

D Healthy (whole food) PBD had an inverse relationship with CAD [HR 0.92] - while unhealthy PBD had positive relationship

Question 21

Q

Name the biological processes affected by healthy lifestyle:
A) Reduces chronic Systemic inflammation
B) Reduces insulin resistance (the underlying cause of Hyperglycemia & related metabolic dysfunction)
C) Provides Antioxidants
D) Gene expression (epigenetics)
E All of the above

Question 22

Q

Which of the following are incorrect:
A. Adventist Health Study 2: Approx decrease in risks for vegans: Diabetes 50% (OR 0.51), metabolic syndrome 55% (OR 0.44), Hypertension 65% (OR 0.37)

B Lyons Heart Study (Med vs. AHA1) : The protective effects of the Mediterranean diet were not maintained for 4 years following a first heart attack.

C. Portfolio diet - high in plant Sterols, Soy protein, viscous fibers & Berries

D The CHIP program at Vanderbilt University for diabetics : Approximately 24% of study participants were able to eliminate one or more of their medications.

4Ed, p12

Answer

A

ANSWER: B & C

A. NOTE: Pesco-Vegetarian had lowest all-cause mortality!

B Protective effects of Mediterranean diet were maintained for 4 years following a first heart attack.
C Portfolio diet included Almonds not Berries

Question 23

Q

Which ONE is INCORRECT regarding the five competencies for Physicians
prescribing Lifestyle medicine?

A. Leadership such as promoting healthy personal behaviours at school, work and home.
B. Knowledge of the available evidence supporting lifestyle interventions and positive patient engagement
C. Assessment skills including lifestyle
“vital signs” like tobacco use, alcohol
consumption, diet, physical activity, BMI,
stress level, sleep and emotional wellbeing.
D. Prescribe medications for the patient’s
chronic diseases as well as counselling and
psychotherapy.
E. Use of office and community support
F. A, B, and C.

Answer

A

ANSWER: D

Management Skills is the 4th competency

Includes lifestyle prescriptions, establishing effective relationships and referring when needed

Question 24

Q

Field of Lifestyle Medicine refers to all
the following except:
A)Holistic approaches to balance core
functional processes, control oxidative
stresses at a cellular level and promote
detoxification.
B) Evidence-based treatment and
prevention of chronic diseases related to
lifestyle and behaviours.
C) Reversal of certain lifestyle-related
diseases.
D) Assisting the patient in enhancing his diet
with whole foods, incorporating physical
activity and emotional well-being practices
and avoiding risky substances. Medications
are used as an adjunct.

Answer

A

Answer A.

Question 25

Q

Regarding adverse drug reactions, which
one of the following is incorrect?
A) They often occur despite appropriate
use.
B) They are the 3rd leading cause of
death in the US, ranking higher than
pulmonary disease, diabetes, AIDS,
pneumonia, accidents and motor vehicle
accidents.
C) There are more than two million serious
reactions per year.
D) The total cost of adverse drug reactions
is more than that of cardiovascular disease or
diabetes

Answer

A

Answer:
B 4th leading cause

Question 26

Q

which is the following is not true
A. Ideally, a ITLC includes an INDUCTION phase which precedes the MAINTENANCE and SUPPORT phases in lifestyle change
- outpatient programs have visits ~ 60 minutes 1-3x/week for 8-18 weeks
- Residential programs are generally 7-21 days long
- Shorter ITLC immersions can last 3-10 days.

B examples of 3 ITLC programs
1) Pritkin program 1970s
2) Ornish program - 1980s
3) Diehl CHIP program - 1990s

C A whole food plant based diet (WFPB diet):
1) Consists of mostly foods from plants (eg whole grains, vegetables, fruits, beans & legumes)
2) Little or no animal products (eg dairy, meat, eggs)
D LM approach include
Feet, fingers, forks, sleep stress love (Mnemonic)
Feet - REGULAR physical activity
Fingers - avoid risky substances (eg tobacco, drugs)
Forks - PREDOMINANTLY whole food plant-based diet
Sleep - ADEQUATE sleep
Stress - stress MANAGEMENT
Love - non-drug modalities to PROMOTE health & PREVENT disease
E All true

Question 27

Q

With respect to lifestyle medicine and its impact on disease pathophysiology, the following are true except:
A. Change gene expression in men with low risk prostate cancer
B. Beta cell regeneration via fasting mimicking diet.
C. Normalisation of beta cell function.
D. Improved Oxygen uptake at peak exercise.
E. Acute systemic inflammation.
F. Increase in LDL-C
G. Change telomerase activity and telomere length.

Answer

A

Answer
E: its chronic systemic inflammation
F. Decrease in LDL-C

Question 28

Q

Physical inactivity is the ______ leading risk factor for global mortality. It is the cause of 1:______ premature deaths.

Question 29

Q

Which risk factors differed between InterHeart vs InterStroke Study?

Answer

A

9 in IH: psychosocial factors
10 in IS: psychological stress and depression were identified separately

Question 30

Q

Name 3 programs that have demonstrated lower healthcare costs through lifestyle modification?

Answer

A

Chicago Heart Association Detection Project in Industry
(low risk CAD men had less than 2/3 Medicare costs of controls, low risk women less than 1/2)

Diabetes Prevention Program

CHIP Lifestyle program - Vanderbilt

Community Weight-loss program for obese patients

Question 31

Q

What is the prevalence of obesity in children and adolescents?

A. 10%
B. 20%
C. 30%
D. 40%

Answer

A

B. 20% (21% in adolescents)

Question 32

Q

Which countries have the best performance compared to spending?

Answer

A

United Kingdom
New Zealand

(USA is the worst in both - 17% of GDP)

Question 33

Q

As of 2021, what are the leading causes of death is the US?

Answer

A

Heart Disease
Cancer
COVID-19
Accidents
Stroke
Chronic lower respiratory
Alzheimer’s
Diabetes

Question 34

Q

60% of average total annual medical costs of $16750 for DM patients is spent on their diabetes care. What are the top 3 expenses?

Answer

A

Hospitalizations 30%
Prescriptions for DM complications 30%
Prescriptions for DM 15%

Question 35

Q

What percentage of US adults with DM are unaware they have it?

Answer

A

23%

11% of total US population has it
Almost 15% of adult population

Question 36

Q

List the 4 most expensive US health conditions, in order

Answer

A

DM2 - 327 billion
CVD - $216 billion (+ $147b lost productivity )
Cancer (over $200b)
Obesity - $147 billion

Question 37

Q

What 4 lifestyle-related conditions have a prevalence over 40% in US?

Answer

A

CVD (48%)
Pre diabetes
Hypertension
Obesity (41.9%)

Question 38

Q

prompt

List 4 steps to establishing effective provider-patient relationships

Answer

A

1.assess the readiness level for change from TTM
2.offer stage-matched brief intervention
3.empower patients
4.create an inclusive environment in which patient feels comfortable and valued.

Question 39

Q

What are the 4 principles of Motivational Interviewing?

What stages is it most helpful?

Answer

A

Four General principles of MI [ESRD]

Express Empathy
Support self efficacy
Roll with Resistance (stay non-judgmental, supportive, curious)
Discuss discrepancy (between current and desired future state)

Helpful in Precontemplation and contemplation stages

Question 40

Q

What are the 4 core skills of Motivational Interviewing?

Answer

A

Four core skills of MI - OARS
Open ended questions: tell me more
explore patients needs, ideas, concerns expectations, experiences, feelings, priorities

Affirmations: use the word You rather than I. enhance patients self efficacy by recognising their strengths, intentions or efforts

Reflections
Summaries

Question 41

Q

What are 4 steps to prepare a patient for CBT?

Answer

A

HARP
What do you Hear in your internal dialogue?

Analyse your internal dialogue: any cognitive distortions?

Reconstruct your thinking: write factual statements to replace distorted thinking.

Practice: to eliminate distorted thinking.

takes a lot of practice…

Question 42

Q

10 Examples Non productive Thinking or cognitive distortions

Answer

A

All or Nothing Thinking: i have not accomplished anything since i have been in graduate school
Overgeneralisation: he never washes his dishes
Mental Filter: my boss’ review of full of criticism
Mind Reading: i know my partner think i did a terrible job on that presentation
5.Fortune Telling: i will probably just mess up and make a fool of myself.
Magnification/Minimisation: i haven’t accomplished anything since i’ve been in medical school.
7.Personlisation and blame: that jerk just cut me off and made me spill my coffee they just ruined my day.
8.Emotional Reasoning: i feel like an idiot so i really must be one.
Labelling/Mislabelling: i am such a disorganised person.
Disqualifying the positive: giving up caffeine may have benefits but those benefits will be worthless since i might have a headache for a few days.

Question 43

Q

ABCDE Model of Dr Albert Ellis to identify and reframe non productive thinking

Answer

A

A: what Action or Event occurred
B: what Beliefs do you have about what happened
C: What are the Consequences of those beliefs? how does it make you feel?
D: how can you Disrupt those beliefs that seem to be distorted and unhealthy?
E: what Effect does this new way of thinking have on how you feel and how you will move forward?

Question 44

Q

What are the 3 approaches within positive psychology?
What are 4 benefits of this approach?

Answer

A

APPROACH
emphasizes patient’s current skills and abilities, strengths and positive actions (and associated successes)

Values positive emotions, engagement relationships and meaning

healthy ratio of positive to negative

BENEFITS
Builds patient’s confidence
Reinforces autonomy and self efficacy which are keys to sustainable self management.
Enhances resiliency and helps undo negative feelings.
Increases the positivity of the patient-provider interaction.

Question 45

Q

life style prescription vs action plan

Answer

A

lifestyle prescriptions are brief, clear instructions for care or treatment pertaining to an individual patient
prescriptions describe the action or behaviour change in the full extent necessary to treat or prevent.
e:g a prescription for 150 minutes of moderate PA for a week.
action plan: the life style prescription is adjusted and personalized for the patient’s ability, readiness and confidence.
e:g of action plan: start with walking 5 minutes a day for 5 days a week increased as tolerated up to the recommended amount of 150 minutes per week.

Question 46

Q

What are the three components of motivation?

Answer

A

Importance, relevance, readiness

Question 47

Q

Define the 5 components of a SMART goal:

Answer

A

specific: identify the exact behaviour to be addressed
measurable: how one will know when the goal is reached.
Attainable: the goal is achievable and can be accomplished with current resources
Relevant: the goal is in alignment with the specific behaviour change
time-bound: the time frame for achieving that goal.

Question 48

Q

3 questions for maintenance of action plan

Answer

A

what benefits have you gained from the changes you have made
what have you learnt from the challenging areas
how do you feel about your situation.

Question 49

Q

What are 4 common components to the following behavior change models?

Health belief model (HBM)

Theory of planned behaviour

Social cognitive theory

Trans-theoretical model

Self determination theory

Answer

A

common components of these theories:
1. beliefs about risks and benefits
2.motivation
4.self efficacy
5.environmental influence e:g social norms.

Question 50

Q

5 A’s of personal behaviour change.

Answer

A

assess: practice in context of health risks
advice: changing practice with clear, specific and personalised advice for behaviour change
agree: on the focus of counselling and treatment based on patient’s interest and willingness to change and collaboratively set specific goals.
assist: the patient in achieving goals to change practices, address motivational barriers via counselling, if needs additional info or help, refer to dietitian
arrange: regular follow up and support.

Question 51

Q

In relation to the evidence base for effective coaching that promotes health behaviour change and improves health outcomes, which of the following is/are not correct
A. a 2017/2019 systematic review published in AJLM showed the most consistent effects of health and well being coaching were observed in both exercise and nutrition behaviour. Health coaching also improved HbA1c, weight reduction and BMI
B. systematic review of 35 studies results: 73% trials showed that intervention did alter provider/patient interaction. Health outcomes were positively affected in 44% trials and negatively affected in 20% trial
C. Physician’s with high empathy scores from their patient were less likely to achieve good HbA1c control than those with low empathy scores.
D. Ten hours of provider training on empathy skills can achieve similar empathy results as those providers who have had longer training on empathy.
E. Health outcomes for HT, glucose levels and functional status are NOT related to the patient-provider relationship.

Answer

A

Answer C and E
C Physician’s with high empathy scores from their patient were more likely to achieve good HbA1c control than those with low empathy scores ( 56% vs 40%)
E Health outcomes for HT, glucose levels and functional status are related to the patient-provider relationship.

Question 52

Q

All of the following are strategies to foster self motivation and self confidence except:

A. Hold the possibility that the patient can commit to change and master change.
B. clear one mind of ‘noise’ in order to listen to the patient with full attention.
C. Be sympathetic.
D. focus on and affirm the positives as much as possible.
E. Avoid sharing personal or other anonymous examples
F Encourage patient to take charge, decide on and commit to a wellness plan.
G. View obstacles and setbacks as necessary parts of behaviour change and the path to success.
H. Look for teachable moments. Physicians often underestimate the importance and power of these moments and impact they can have on health behaviour change.

Answer

A

Answer C and E
C be empathic
E share where disclosure will be beneficial to the patient.
Self motivation is also known as autonomous or internal motivation.
Self confidence is the trust a person has in their reasoning, capabilities and qualities.

Question 53

Q

The following are reflective strategies in health coaching which help to make connections with the patient. True or False.
A. Simple reflections
B Amplified reflections
C. Double sided reflections
D. Shifting focus
E. Reframing.

Question 54

Q

What are the 6 stages of change in the TTM (TransTheoretical Model)?

Answer

A

PCPAMT

Pre-contemplation
Contemplation (start within 6 months)
Preparation (start within 1 month)
Action (< 6 mo)
Maintenance (6 months without relapse)
Termination (~5 years no desire to relapse?)

Question 55

Q

What are the 4 factors that influence self-efficacy per Bandura?

Answer

A

Mastery experiences (strongest)
Vicarious experiences
Social (verbal) persuasion
Physiological feedback- somatic and emotional states

Question 56

Q

Which of the following is NOT a construct within the Health Belief Model

A. Cues to Action
B. Perceived barriers
C. Perceived susceptibility
D. Personal experience
E. Self-efficacy

Answer

A

ANSWER: D

There are 6 constructs. ABC,E +
Perceived benefit (of intervention)
Perceived severity

There are 4 perceptions!

p28, 4thEd.

Question 57

Q

Theory of Planned Behavior

Which of the following constructs is the most important factor in predicting behavior?

A. Attitude
B. Behavioural intention
C. Subjective norms
D. Social norms
E. Perceived power
F. Perceived behavioural control.

Answer

A

ANSWER: B

subjective norms = what we think others will think

Perceived power = internal locus of control

Question 58

Q

Self-determination theory

What are the 3 psychological needs that influence motivation?

Answer

A

Autonomy
Competency
Relatedness

Question 59

Q

TTM - “Are you considering making a change in …?”

What are the best response types to Pre-Contemplation stage (I can’t, don’t need to...)?

Answer

A

Provide information (brief)
O: “How will you know it’s time to think about making a change?”

Listening
Reflecting

Open ended questions

Question 60

Q

TTM - “Are you considering a change in the next month?”

What are 3 responses to Contemplation stage comments (I am still thinking about change)?

Answer

A

Encourage patient to evaluate benefits and barriers
Provide resources/info
Encourage problem-solving

Question 61

Q

TTM

What is best response to Preparation stage comments (I will change)?

Answer

A

develop or refine action plan (guide goals to be specific and clear)

Question 62

Q

TTM

What are 4 good responses to Action stage comments?

Answer

A

Celebrate successes
Plan for relapses
Reframe unhealthy thought patterns
Establish systems of self-monitoring/accountability

Question 63

Q

TTM

What is best response to Maintenance stage comments (I have been doing this despite challenges…)?

Answer

A

Encourage reconnection to reasons for change, keep guiding specific and clear goals

Question 64

Q

TTM

For which stages of TTM is Cognitive Behavioral Therapy (CBT) most useful?

Answer

A

Preparation
Action
Maintenance

MI good for Pre-con and contemplation

Answer 61

A

Benevolence
Honesty
Openness
Reliability
Competence

Answer 62

A

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

Answer 63

A

TEE= Resting energy expenditure+ PA+ Diet induced Thermogenesis
TEE= 60-75% of TEE+15->30% of TEE+10% of TEE

Answer 64

A

how many days a week do you engage in moderate to strenuous exercise such as brisk walking.

2.on average how many minutes per day do you exercise at this level.

sufficiently active = 150 minutes or more per week

Answer 65

A

training increase resting energy expenditure

improves activities of daily living, reduce the risk of falls especially in elderly.

Answer 66

A

Question to ask: how many serving s of Veg do you have in a day? repeat the question with Fruit, Whole grains, Beans, Legumes, nuts, seeds, herbs and spices then low fat diary products.

Answer 67

A

Vitamin A,D, E, C, folate, calcium, magnesium, Fiber and potassium they are found in veg fruit, whole grains, beans, legumes and low fat diary products.

Answer 68

A

A
1.dietary screener questionnaire in the National health and nutritional examination survey (NHANES)
2.Dietary screener in National Health Interview Survey (NHIS) Cancer control Survey (CCS)
3. Dietary screeners in the California health interview survey (CHIS)
4.Fruit and vegetables intake screeners in Eating at Americas Table Study (EATS)
5. Percentage of energy from fat screener.
6.Multifactor screener in observing protein and energy nutrition (OPEN) study.
B
The Mediterranean DASH diet intervention for neurodegenerative delay (MIND) diet score is a dietary screening tool. A positive score is associated with slower decline in global cognitive score, but findings needs to replicate in an intervention trial.
C.
The SOS free ( Salt/oil/sugar free) diet screener from T Colin Campbell centre for nutrition studies
Food included: vegetables 10-30 + servings per day
fruit 4-10+ servings per day, Whole grains 0-10+ servings per day, Legumes 0-5+ servings per day, Nuts and seeds 1 ounce per day.
food not included: animal products, added sugar, salt and oil, refined grains, other processed foods.
D.
A short form food frequency questionnaire (SFFFQ) for primary care patient but didnt show significant agreement with a 24 hours telephone based diet recall.

Answer 69

A

10 item questionnaire scale 0- never to 4- very often over the last one month
1. upset because of something happened unexpectedly.
2. unable to control the important things in your life.
3.Felt nervous and stressed.
4. Felt confident about your ability to handle your personal problems.
5. felt that things were going your way.
6.could not cope with the things that you had to do.
7.able to control irritations in your life
8.felt that you were on top of things.
9.angered because of things that happened that were outside of your control.
10. felt that difficulties were pilling up so high that you could not overcome them.
Negatively phrased questions: 1,2,3,6,9,10
never =0
almost never=1
sometimes=2
fairly often=3
very often=4
Positively Phrased: 4,5,7,8
Never=4
almost never=3
sometimes =2
fairly often=1
very often=0
higher the score more perceived stress one is under.

Answer 70

A

24 item assessing 3 aspects: task engagement, distress, worry

Answer 71

A

mini sleep assessment ask
1.typical weekend hours of sleep
2.typical weekend hours of sleep
3.perceived sleep quality
Epworth sleepiness scale (ESS) 8 question assessment for daytime sleepiness. high scores consistent with moderate to severe excessive day time sleepiness.

Answer 72

A

ask scale 1= lowest to 5= highest
1.in most ways my life is close to my ideal
2.i am satisfied with my life.
these two questions are from satisfied with life scale (SWLS) total 5 questions.
older age, higher education and higher income associated with greater subjective well being.

lower satisfaction= not being white, black and hispanic, lowest level of education and lower household income.

Answer 73

A

current, past or never used.

cigarettes cigars, chew and e cigarettes amount and years

Answer 74

A

screen at every visit if regular drinker otherwise annually.
AUDIT-C The Alcohol Use disorders Identification Test-Concise 3 items 0= never low number of occurrences to 4=often high number of occurrences.
1. how often do you have drink containing alcohol.
2.how many drinks containing alcohol do you have on a typical day when you’re drinking?
3. how often do you have six or more drinks on one occasion?

Answer 75

A

BMI= weight in Kg/ (height in metres)2

imperial (weight in pounds/ (height in inches)2) x703

Answer 76

A

asians 18.5-22.9= normal
23-24.9= overweight
>=25 =obese

Answer 77

A

1 Screening tools are helpful to start early discussion of lifestyle factors/intervention.
2. CVD
1.life’s simple 7 questionnaire
2.ASCVD ( Atherosclerotic CVD) risk estimator plus by the American college of cardiology.
*the assessment indicates the patient’s risk of MI in the next 10 years.
*20-79 years age without heart disease
* non hispanic white and african americans
underestimate risk = in American indian, some asian american of south asian ancestary and some hispanic ( Puerto ricans)
overestimate risk in = Asian americans of east asian ancestary and some hispanics ( Mexican Americans)
* age, gender, total cholesterol, HDL-C, LDL-C, Smoking status, Diabetes history, Treatment for HT, such as use of aspirin and or statin therapy.
* low risk, borderline risk, intermediate risk and high risk

Answer 78

A

10 year coronary heart disease risk in multiethnic study

39% non hispanic whites, 12% chinese americans, 28% african americans 22% hispanic americans.

Answer 79

A

considers family history and high sensitivity CRP which predicts risk of global CVD.

Answer 80

A

Waist circumference
Waist/Hip ratio
Bioimpedence analysis
pulse
BP
Measure of fitness
Fitness testing options.

Answer 81

A

increased risk of diabetes, HT and CVD relative to increased weight and waist circumference
waist circumference is increase if
>=40 inches or >=102cm in men
>=35 inches or >=88cm in women

Answer 82

A

<=0.90 for men

<=0.85 for women

Answer 83

A

*AHA/ ACC 2017
normal BP <120/80
Elevated BP systolic 120-129/<80
stage 1 - 130-139/80-89
stage 2- >= 140/>=90
*high mortality from heart disease, stroke and other vascular disease.
high morbidity from CVD incidence, angina, MI, Heart failure, stroke, PVD and AAA
* prevalence of HT increases with age 42
more than 50% on adult over 60 have HT
*screen for HT at each periodic visit every 6-12 months.
* 2 mm Hg reduction= stroke 6% coronary heart disease 4% total 3%
3= 8,5,4
5= 14,9,7

Answer 84

A

U&ES LFTs Blood Glucose, Blood proteins, Acid base balance, FBC Fasting lipids ( TC, HDL-C, LDL-C, TG, High sensitivity CRP). HbA1c, OGTT, Fasting serum insulin, possibly c peptide, Homeostatic model assessment for insulin resistance ( HOMA-IR) Vitamin D, TFTs.

Answer 85

A

particle size has been shown to help stratify risk. particle density alone doesnt completely describe the role and function of cholesterol fractions.

TG elevation is often associated with low HDL and increase girth waist circumference.

Answer 86

A

HOMA-IR is an estimate of insulin sensitivity and beta cell function based on the fasting plasma glucose concentration, fasting plasma insulin or c peptide measurements.

Answer 87

A

HbA1c of >6.5% but this diagnose 1/3 fewer cases of undiagnosed diabetes then looking at fasting plasma glucose test
Fasting serum glucose >126mg/dl or 7 mmol/L
2 hours postprandial glucose of >=200mg/dl ( 11.1mmol/L) during in OGTT

Answer 88

A

fasting serum glucose of >= 100 mg/dl (5.6mmol/L)but <126 mg/dl (<7 mmol/L)
2 hours serum glucose in the 75gm OGTT of 140-199mg/dl (7.8-11 mmol/L)
HbA1c 5.7-6.4%

Answer 89

A

if no risk factors begin screen at 45 years and then 3 yearly

Answer 90

A

Healthcare effectiveness data and information set. HEDIS most widely used healthcare improvement tool.
HEDIS rates health plans, programs and providers on their quality and public can review the rating online.
In LM tracking is essential for patient care, treatment analysis and reimbursement and follow up.
EMR electronic medical records. can often helpful in traking metrics and high risk patient. it is improtant to know what EMR is traking and how the info is stored, maintained and if automatic prompts are possible.

Answer 91

A

Acupunctures and oriental medicine 2-4 years training
National certification commission for acupuncture and oriental medicine NCCAOM

chripractice DC- 4 years training
federation of chiropractic licensing boards. FCLB

Midwifery CPM, variable training
North American Registry of midwives

massage therapy, 500-1000 hours training
National certification board for Therapeutic massage and bodywork NCBTMB

naturopathic medicine 4 year training
North American Board of Naturopathic examiners NABNE

Answer 92

A

Academy of nutrition and dietetics
National association of nutrition professionals.
American colleage of sports medicine ( registered clinical exercise physiologist, certified clinical exercise physiologist, certified perosnal trainer)
US registry of exercise professionals.
Certified Medical fitness Facility
personal trainer directory
The Yale Griffin Prevention research centre tips for Chronic disease prevention.

Answer 93

A

positive leaderships and management attributes.
communication strategies and structures.
Personal rewards, training and development.
Appropriate resources and procedures.
appropriate skill mix.
supportive team climate.
individual characterisitics that support interdisciplinary teamwork.
clarity of vision
quality and outcomes of care.
respecting and understanding roles.

Answer 94

A

National diabetes education program
Centre for disease control and prevention National diabetes prevention program.
California smokers helpline.
american heart association
Million heart initiative.
Human services referrals and information
state or area agency on aging
Classes and educational resources offered by local health systems, hospitals and public health departments.
local parks and recreation classes and services.
senior centre services.

Answer 95

A

improved access to care
increased patient adherance, satisfaction, lower hospiltalization rates, higher trust in providers, improved access for complex and elderly patient, better monitoring, received greater education from group discussions and peer support, improved access, gain additional choices in their care treatment options) and
provider satisfaction (more efficient use of time, enhances quality, outocomes patients’ health experiences while containing cost and improving income, something different interesting and fun, reduces repitition allows more time and more frequent contact with patients, Group support and collaborative care is helpful in managing difficult, time consuming and psychologically needy patients)
reduce cost. among uncontrolled type 2DM patients group visits reduce total health care expenditure cost by ~30%
group visits also increases physician’s productivity.
billiable when billing criteria are met.

Answer 96

A

Interdisciplinary team is associated with

hgh level of treatment compliance
improved health outcomes.
enhanced patient engagement and chronic disease self management.
enhanced weight loss after one year compared to standard care when provider or dietitian and dietitian/dietitian bth provided educational interventions

Answer 97

A

Interdisciplinary team is associated with

hgh level of treatment compliance
improved health outcomes.
enhanced patient engagement and chronic disease self management.
enhanced weight loss after one year compared to standard care when provider or dietitian and dietitian/dietitian bth provided educational interventions

Healthy eating activites and lifestlye programs are associated with

weight reduction
improved in BP and PA parameters
Maintained behaviour change at 5 months after the program’s completion.

Training Lay healht educator is associated with improved implentation of lifestlye intervention in rural senour centres.

life style modification in primary care.
acceptance and referral to a collaborative or chronic care program from a primary care practice needs regular communications, follow ups to be easy and make sure doesnt take much of primary care time. Primary care nurse help with that.

Answer 98

A

Ornish spectrum program
2.Medical fitness collaboration
1.Ornish: intensive cardiac rehad program
Team:
registered nurse:education, biometric assessments, continuity of care, follow up of chrnoci conditions.

Exercise physiologist: Physical activity rediness questionnaire assessment, individual and group exercise supervision. biometric assessment, fitness safety and principles presentation.

health coach: consistent source of social support throughout change

stress management specialist: mid body techniques, group facilitation and support, participation in group and individual fitness instriction.

registered dietitian: recipe referral, nutrition counselling individually and group presentation on nutrition guidelines.

chef and food services: training in food selection and prep, removes barriers on healthy eating.

group support specialist.focus on lifestyle impact of intervention, facilitating dyanamic and group growth.

administration and medical assistant.
Marketing director.

2 Medical fitness collaboration.
medically supervised inegrated outcomes and accountability based fitness program: active and regular medical oversight, qualified and crednetial staff. disease management and clinical integration of pragrams. individual exercise prescriptions. help transition from structured clinical treatment setting to community or home based exercise program. helpful for patient who need medical oversight and counselling

Answer 99

A

innovative care for chronic conditions (ICCC). report by the WHO at Micro level: patient and family
meso level: health care organisation and community,
Macro level: policy
2.Collaborative care model by the agency for healthcare research and quality (AHRQ) patient. nurse practitioner/ physician assistant, clinical expert, resident, interdisciplinary care team. they coordinate and facilitate patient care.
Value based care: financial incentives for accountable care organisations.
4.Chronic care model created by MacCall institute and Ed Wagner: helpful in explaining the involvement of the community and health care system in chronic disease care. they must work with local community: local gyms, politicians, community centres, oraganisations and faither systems.
implementing ch care model
6.the US deptt of veterans affairs hospital system comprehensive multisite model of care called ‘whole health model’ of care.

Answer 100

A

implementing the chronic care model into the a local medical practice.
health care delivery support
self management support
delivery system design
decision support
clinical information system.

Answer 101

A

funded by Robert wood Johnson foundation in collaboration with the agency for healthcare research and quality (AHRQ)
22 primary care based research network (PBRNs) that developed, piloted and evaluated 27 evidence based strategies to improve delivery and effectiveness of healthcare behaviour in the field of primary care.
four health risk behaviours: tobacco use, Risky alcohol use, unhealthy diet, lack of PA.
findings- **primary care offices were capable and wanted to address health behaviour when funding and support were available via PBRNs.
**health care delivery model such as patient centre medical home was important.
*substantial practice design needed to occur with the integration of public health and community resources.
- dozens of studies were published
- prescription for health toolkit not accessible now.
*AHRQ developed electronic preventive services selector (ePSS) used by provider at time of visit for decision support with screening, counselling and preventive services. website and app.

Answer 102

A

Physician’s personal health behaviours.
2009 survey of californian physicians: number 763
severe to moderate stress: 53%
no or occasional exercise 35%
6 or few hours of sleep 34%
never or occasionally ate breakfast 27%
sedative/tranquilizer use 13%
depression 7%
Marijuana use 4%
2012 survey 53% of primary care physicians were obese.
in 2013 36% of canadian 4th year medical students surveyed didnt meet PA guidelines
in 2013 article overweight resident physicians under acknowledged their overweight status and their under- acknowledgement increased by training year.
other studies have found physicians are practising healthy behaviours therefore arguing against unhealthy doctors’
in 2000 study in men, mortality outcome suggest that physicians live longer than same race professionals and non professional in the US population.
in 2015 study: physicians and medical students engage in more PA than the general US adult population.

Answer 103

A

A. in Life style medicine 3rd edition 2019 by J Rippe. Erica Franks says
1. providers need to focus on their own health.
2.healthy doctors are more likely to produce healthy patients.
B. meta-analysis of 24 studies high correlation between physician’s PA habits and counselling frequency odds of counselling 1.4-5.7 times higher among the exercising physicians.
C. Cross sectional study on 1349 internists
Male internists: with smoking, alcohol, seat belt use, and PA were positively associated with counselling for each health behaviour except alcohol use.
Female: with PA positively associated with counselling patients about exercise and alcohol use.
D. physician who exercise( aerobic and strength) are more likely to counsel patients on exercise than who dont
E.physician attempting to chase their own poor habits counsel more
F. training primary care physician in behavioural counselling and providing them with tools and resources helps in their practice of weight related care.
G. in 2014 study physician and medical student with normal BMI felt confident about counselling their patients about PA.
H. non smoking physician emphasize the risk of smoking.
I physician more likely to record diagnosis of obesity and initiate a conversation if they perceived patient weight to be more than their own.
J. female physician’s personal health practices, counsel of behaviour change at least once a year= if they ate less fat counsel on cholesterol, if ate five fruit and veg per day they counsel more on nutrition, if consumed veg diet counsel on weight loss and nutrition.
K. poor physician health habits impact counselling they provide to their patients.
L. The American Medical association code of medical ethics’’ physician health and wellness’’ physicians have responsibility to maintain their health and wellness for safety and effectiveness of the medical care they provide.
M. Physicians are high risk of burn out: which is syndrome of high emotional exhaustion, high depersonalization and a low sense of personal accomplishment from work.
2019 consensus study by national medical academy NAM report US 35-45% on nurses and physicians have substantial symptoms of burnout. medical students 45-60%.
suboptimal care for patient may be one of the unintended consequences of physician burnout.
NAM suggests interventions to prevent and reduce burnout need to be both individual based and organisationally focused strategies.

Answer 104

A

PA opportunities inside and outside office: gym on site, local gym discounts.
implement wellness culture in office with breaks for PA and healthy foods.
provide healthy meals inside and outside office dont serve or provide unhealthy food at office events.
install standing workstations or treadmill desks especially for those who primarily work on the computer.
consider using technology to assist in tracking activities such as phone applications or pedometers.
engage colleagues in health challenges and competitions.
involve in local community changes ‘’ walk with Doc’’
supporting and incorporating wellness programs in the office helps promote the practices and set an example for patients.

Answer 105

A

Readiness for personal action plan for providers. similar to patient. stage of change SMART goals confidence scale and importance scale etc.
reassess progress, confidence and importance of making change.
celebrate success, brainstorm ways to overcome barriers and to help specific actions.

Answer 106

A

Mobilising physicians for community level changes.
1. advocacy
2. community advocacy for public health needs.
3. goals of acquiring advocacy skills.
4. provider in advocate role
5. ways one can begin to advocate.
a. be a resource by supplying information and educational material, set an example by being a life style medicine champion in one’s social and medical network, offer expertise to elected officials, local decision makers and community organisations, reach out through one’s network both online and in person.
plan or host an event. speak at a community meeting or with the media.
6. advocacy check list.: a. define the problem and desired solution or policy intervention. ( E;g access to healthy food, walking paths, safe places to be PA, neighbourhood design)
b. understand one’s audience stakeholders, who might help or hinder to achieve goals. ideal time to approach the stakeholders.
c. determine strategy tactics and timeline: decision maker meet individually or in group, legal or regulatory guidelines to consider, develop strategies to overcome resistance who might oppose.
d. evaluate outcomes: metrics need to be tracked to determines whether and when then implemented change has worked, predetermine what a successful intervention will look like.

Answer 107

A

Blue Zone project. its a community led collaboration north America.
blue zone five geographical location in the world where world’s heathiest people live ( oinawa in japan, sardinia italy, Nicoya peninsula costa rica, Ikaria Greece, Loma Linda california
communities with 9 common characteristics:
they move naturally in their day to day life
feel a sense of purpose
3.eat mainly a plant based diet
4.stop eating after becoming 80% full
5.relax
downshift
put family first
8.find the right tribe to engage with
9.belong to something greater than yourself.
Robert Wood Johnson foundation. ‘’ creating a culture of health’’ community leaders and medical providers collaborate in these cities to bring about better health.
3.Dean ornish’s plant based cardica rehab program.
4.Plan4health intiative by the american public health association and american planning association.
5.project for public spaces new york connection between place and health.
6.the urban land institute network community designs and place acitivation.
7.main street america: 4 points economic vitality, design, promotion and organisation.
8.creative placemaking by national endownment of arts: incorporating the art to transform communties.
national complete street coalition : to design and construct streets that are safe and accessible to all members of the community.

Answer 108

A

G.
45-60% medical students
35-45% nurses and physicians

Answer 109

A

B. understanding one’s audience is important.

Answer 110

A

C and G
C: Dean Ornish
G: no such project apart from Blue zone

Answer 111

A

D.
Overall benefits of physical activity include:
a. Higher health-related fitness.
b. Higher control and maintenance of a health body weight.
c. Lower risk of disabling medical conditions.
d. Lower chronic disease rates than inactive people.
e. Most interventions to increase physical activity are cost effective, as health care spending increases as activity levels decrease.

Answer 112

A

C. Meditation is not a form of physical exercise.

The different types of exercise include:

a. Aerobic and endurance (cardiovascular).
b. Strengthening (resistance training).
c. Flexibility (stretching).
d. Static and dynamic exercises (balance).

Answer 113

A

B.
Most health benefits are achieved at 150 minutes a week of moderate-intensity of physical activity, or 75 minutes of vigorous physical activity or an equivalent combination. Beyond 150 minutes there are still benefits, but they are much less in amplitude.

Answer 114

A

A.

Exercise is better than medications for post-stroke patients.

Answer 115

A

E. Poor cardiorespiratory fitness

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.]

Answer 116

A

E. All of the above are true statements.

Answer 117

A

A. Begin walking at a moderate intensity for 45 minutes at least five days per week.

The FITT exercise prescription for cardiovascular exercise includes Frequency, Intensity, Type of exercise, Time (duration). For example, begin a slow jog/race walk (type) at a moderate intensity (intensity) for 45 minutes (time) for at least five days per week (duration).

Answer 118

A

C.
With vigorous exercise, one should be able to carry on a conversation without difficulty. 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 (64% to 77% 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.

Answer 119

A

A. 40-50% 1-RM
B. 60-80% 1-RM
C. 80% 1-RM

Reps usually 8-12 per set. Older adults & endurance training 10-15 reps

Answer 120

A

A. Physical activity.
Fitness is defined as “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.”
Exercise is a subset of physical activity that is formally defined as “physical activity that is planned, structured, repetitive, and purposeful in the sense that the improvement or maintenance of one or more components.”
Isokinetic exercise is a type of strength training that uses special machines or dynamometers to maintain a constant (iso) speed (kinetic) of movement.
PLANS R PURPOSEFUL

[CDC. Glossary of Terms. Physical Activity. June 10, 2015.]

Answer 121

A

E. All of the above
These are all considered components of health-related physical fitness. Flexibility (which is not listed) is also considered a component.

[ACSM. Benefits and Risks Associated with Physical Activity. In: Whaley MH, ed. ACSM’s Guidelines for Exercise Testing and Prescription. 7th Ed. Baltimore: Lippincott Williams & Wilkins; 2006:3.]

Answer 122

A

B. 60 minutes or more per day of moderate- to vigorous-intensity physical activity.

The current Centers for Disease Control and Prevention (CDC) guidelines recommend 60 minutes or more a day of moderate- to vigorous-intensity physical activity for children.
Choice C is the recommended physical activity guidelines for adults, while choice D provides additional health benefits to adults above and beyond choice C.
Thirty minutes per day is generally a good goal for most adults, but that’s not a specifically recommended amount of time by the CDC.

[CDC. 2008 Physical Activity Guidelines. Children. 2008. [2/25/18]; Available from https://health.gov/paguidelines/guidelines/children.aspx]

Answer 123

A

B. 10.
While there is evidence that high-intensity interval training is effective in reaping health benefits and fitness improvements, guidelines still recommend that exercise bouts last at least 10 minutes.
Thirty minutes is generally a good goal for most adults, while 60 minutes is a good daily goal for children.

[CDC. 2008 Physical Activity Guidelines. Active Adults. 2008. [2/25/18]; Available from https://health.gov/ paguidelines/guidelines/chapter4.aspx]

Answer 124

A

C. Type.
A FITT prescription includes the Frequency, Intensity, Time and Type of activity.

[ACSM. Guidelines for exercise testing and prescription. 8. Philadelphia: Lippincott Williams & Wilkins; 2010.]

Answer 125

A

B. 1 and 2.
This 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]

Answer 126

A

D. The correct order is: assess, advise, agree, assist, arrange.

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.

and for tobacco or intervention counseling are Ask, Advise, Assess, Assist, and Arrange.

Answer 127

A

A. 1, 3 and 4.
Referral to a health provider should be made on the basis of current physical activity levels and presence of signs or symptoms and/or known cardiovascular, metabolic or renal disease. While one might modify an exercise prescription for someone with pulmonary disease, pulmonary disease alone does not require medical clearance, as it has not been shown to increase the risk of cardiovascular complications.

[Riebe D, et al. Updating ACSM’s Recommendations for Exercise Preparticipation Health Screening. 2015;47:2473-2479.]

Answer 128

A

D. Barely talk
The Talk Test is an intensity measure that’s easy for patients to perform on their own.
Very light or light activity should allow patients to talk and/or sing without difficulty (HR 63% or less of maximal).
Moderate exercise (64 to 76% of maximal) should allow individuals to talk but not sing (Answer C).
Vigorous to maximal exercise (77 to 100% of maximal) should make it difficult for an individual to talk or hold a conversation.

[Persinger R, et al. Consistency of the talk test for exercise prescription. Med Sci Sports Exerc, 2004. 36(9): p. 1632-6.]

Answer 129

A

C. A 30-year-old female who has known diabetes, does not currently participate in regular exercise and is asymptomatic.

An asymptomatic male with no known cardiovascular, metabolic or renal disease does not require medical clearance before beginning a moderate-intensity or vigorous-intensity exercise program.

An adult with known cardiovascular, metabolic or renal disease who is already participating in regular moderate-intensity exercise and is asymptomatic does not need a referral for moderate-intensity exercise. However, a referral is recommended if they want to pursue vigorous-intensity exercise.

It’s recommended that an adult with known cardiovascular, metabolic (e.g., diabetes), or renal disease who does not currently exercise should be referred for medical clearance, even if they are asymptomatic.

Any symptomatic individual should be referred for medical clearance.

[Riebe D, et al. Updating ACSM’s Recommendations for Exercise Preparticipation Health Screening. 2015;47:2473-2479.]

Answer 130

A

C. Five hours.
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.

[CDC. 2008 Physical Activity Guidelines. Active Adults. 2008. [2/25/18]; Available from https://health.gov/ paguidelines/guidelines/chapter2.aspx.]

Answer 131

A

B. 5 to 10% of initial weight; 15 to 20%.

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.

Answer 132

A

D. Leptin and amylin.
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.

Answer 133

A

C.
Weight loss medications help with adherence to a lower-calorie diet and physical activity.
Medications should be used for the FDA approved duration of time with target weight loss in mind.
Approximately 50% of people who undergo bariatric surgery will experience weight regain within five years.
Patients who are physically active pre- and post-surgery may experience fewer surgical complications.

Answer 134

A

B.
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.

Answer 135

A

D.

The effects of lifestyle change include all the above.

Answer 136

A

D
Children should exercise one hour/day, with ≥ three days/week of vigorous activity with muscle-strengthening or bone-strengthening exercises for one hour/day, ≥ three days/week.

Adults >65 should exercise 150 minutes/week of moderate to vigorous aerobic activity, or as close to guidelines as possible.

Answer 137

A

D
Respiratory diseases are not a significant cause of death associated with exercise and do not need to be evaluate in routine exercise screening.
The three components of exercise screening are:
Current physical activity level
Desired physical activity level
Presence of cardiovascular, renal, or metabolic disease

Answer 138

A

A. A sedentary patient with diabetes who is uncontrolled
True

B. Patient with chest pain with light walking
True

C. Patient with asthma and wheezing during exercise
False

D. A patient with high cholesterol
False

E. Moderately active patient with chronic kidney disease who was cleared six months ago
False

Answer 139

A

E.
36 year old male physician, who has a bottle of wine every evening and six beers once a weekend, AUD 18
AUDIT Scores help guide therapy
5-10: at risk drinker (20% will have alcohol use disorder)
11-15: more at risk (40% have alcohol use disorder)
16+: high probability of moderate + alcohol use disorder (90%)
Higher scores = greater sensitivity
An audit score of 18 is consistent with a 90% chance the patient will have alcohol use disorder.

Answer 140

A

D
Physical activity is a validated vital sign; all others have not been validated by research but rather are markers suggested by expert opinion

Answer 141

A

A
Singleness and being overweight are risk factors for physical inactivity (Answer A).

Currently smoking is still listed as the number one cause of preventable deaths, but physical inactivity is becoming increasingly more important as a public health concern (Answer B).

Weight training incorporation often takes a referral to an exercise specialist (Answer C).

Muscular endurance is easy to test in clinic but muscular strength requires assistance with a machine like a bench or squat press (Answer D).

Answer 142

A

A. 0.9 METs
B. 1.0 METs
C. 3 METs [3 = 3!]
D. 5 METs
E. 18 METs

Biking 12mph = 6 METs
Jumping rope = 9 METs

Answer 143

A

METs are an absolute measure, so the patient would need to increase the number of METs/hour/week over time to continue increasing their fitness

Answer 144

A

A. NO, VEGF: Enhanced endothelial function
B. Adiponectin, catecholamines
C. catecholamines, IL-6, myonectin
D. Adiponectin, myostatin, IL-6, -7,-15, GLUT-4
E. follistatin, IL-6
F. BDNF, BDNF-trophic factor
G. anti-inflammatory cytokines
H. increased SCFA
I. TGF beta 1, sclerostin

Answer 145

A

at 400 minutes of moderate or vigorous exercise a week [this is about 15-22.4 METs]

though benefits still accrue, just diminishing returns (gain another 0.5 year at 500 minutes)

Answer 146

A

Improved diastolic dysfunction
increased cardiac efficiency
improved insultin-mediated glucose control
more energy expended in shorter timeframe

No other verified benefits. Any dislike is due to being above lactate and ventilatory thresholds

Answer 147

A

Average 6MWD = 400-700 meters
(how far do they go in 6 minutes)

6MWD Used to estimate COPD severity

Answer 148

A

p203, 4th Ed.

Answer 149

A

Answer: 1. A D E

B less likely

C suppression of immune system and long-term organ and tissue damage
E women

Answer 150

A

B and D Its decreased heart rate variability and hypercoagulability

Answer 151

A

D 14-26 is moderate stress and 27-40 is high stress

Answer 152

A

ANSWER: D and E

A. Adolescents are included
B; its positive screen
C; 72% sensitivity and 85% specificity
F; Spanish speaking Latinos are more likely to endorse crying vs English speaking Latinos

Answer 153

A

B and E B; no specific recommendation by the USPSTF E: score of 0-2= normal, 3-5= mild, 6-8= moderate, 9-12= severe

Answer 154

A

A and C but Band D are non-modifiable

Answer 155

A

B it is too much Arachidonic acid

Answer 156

A

A and C A; Bidirectional C: Negative perceptions

Answer 157

A

B, D and E. B: modifiable and several years D: decreased heart rate variability E: treatment improves symptoms and quality of life. There are no clear findings regarding survival.

Answer 158

A

A G I A; blue light G: meaningful causes I: outdoor in nature

Answer 159

A

F its emotional intelligence

Answer 160

A

E, F, G, H A: exercise is not more effective B: First line C: risk of depression D: These foods are risk on arachidonic acid leading to inflammation to and increase risk of depression I: C is consequences not complications.

Answer 161

A

B cognitive restructuring is to not to focus on events that can’t be changed. Find another way to look at the situation.

Answer 162

A

A, B, E A: ideal ratio 3:1 B: unlikely people will be able to overcome obstacles E: It’s happiest days

Answer 163

A

E: its 6 days per week.

Answer 164

A

ANSWER: C

Adults can grow 700 neurons a day!

Answer 165

A

A, B, D

C: decreased

Answer 166

A

A: prefrontal

Answer 167

A

E and F E: low octane diet e:g white bread/white pasta/white rice/Bakery items F: too little physical exercise.

Answer 168

A

D.
Multifactorial lifestyle variables contribute to nearly 70% of primary care provider visits and can be successfully diagnosed and treated.
Lifestyle medicine: contributes to 70% of primary care provider visits; is multifactorial both in disease generation and treatment; is less likely to be engaged by over-stressed and overwhelmed individuals; and is more likely to be impactful when people in need of close follow up are identified.

Answer 169

A

D. A prior self-harm episode via ingestion of only three pills without hospitalization was not documented in the patient’s chart.
Depression causes more harm when it’s untreated, unrecognized or undocumented in a patient’s past medical history. It’s diagnosed with DSM-V and a high psychometric assessment score upon screening. Depression can be treated with lifestyle modifications rather than pharmaceuticals based on certain screening protocols

Answer 170

A

A. Cognitive Behavioral Therapy (CBT).
Fitness and exercise is comparable to cognitive behavioral therapy (CBT), but it’s not as directly effective as pharmacotherapies. Increasing omega 3 fatty acids demonstrates a good response with bipolar depression and not mania

Answer 171

A

E. Egocentricity.
Unnecessary suffering is wanting a different outcome than the one that has happened. It begins with egocentricity (wants, likes, dislikes, attachments, cravings and aversions), has anticipatory thinking (imagining the worst), can include repeating stories about the past and trying to resist pain.

Answer 172

A

E.

Pain level.

Answer 173

A

A.
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.

Answer 174

A

B. Cognitive agility and deep focus.
Mindfulness skills enable presence, clarity and curiosity in a clinical encounter. These skills directly affect the pre-frontal cortex, thereby decreasing scattered brain states and allowing for deep focus inside of sequential tasking. This kind of focus is how roughly 95% of the population processes information and performs tasks, as opposed to the less than 5% of the population who are able to perform multitasking.

Answer 175

A

A. In-person coaching and phone coaching.
Phone coaching has a 38% effectiveness rate, while in-person coaching has a 41% effectiveness rate. A placebo has a 19% effectiveness rate.

Answer 176

A

E. Measuring disease alteration and prevalence.
Facilitating health behavior change is a process of altering a behavioral pattern from stimulus, to thought, to action via both internal and external resources. It isn’t a tool to measure an already existing disease pathology, the prevalence of that disease pathology, or the observable change of that disease pathology (regardless of mental or physical symptomatology and disease pathology).

Answer 177

A

2 question screening tool, over the past two weeks have you felt:
1. down depressed or hopeless
2. little interest or pleasure in doing things

0-3 points each, 3 or more = positivie

Answer 178

A

unintended weight loss/anorexia
insomnia/hypersomnia
psychomotor changes
fatigue/loss of energy
feelings of worthlessness/excessive guilt
trouble concentrating/indecisiveness
recurrent thoughts of death/SI

Answer 179

A

Screening tool for anxiety and depression:
* over last two weeks
* 2Q anxiety
* 2Q depression (PHQ-2 questions)

Answer 180

A

Maximum score is 12
1. 6-8
2. 3 or higher

Answer 181

A

D. Taking melatonin (1 mg sublingual) one hour before the new ideal sleep time.
Melatonin may help with entrainment. The other responses would all contribute to a delay of sleep onset at the new ideal time.

Answer 182

A

B. A cortisol spike during the first four hours of sleep.

With healthy sleep, cortisol spikes upon awakening, not during the first four hours of sleep. The remaining answers characterize normal sleep during the initial hours of sleep.

Answer 183

A

C. Obstructive sleep apnea.
The patient profile best fits obstructive sleep apnea

Answer 184

A

E. Watching television in bed while falling asleep each night.

Watching television exposes people to blue light, which contributes to a delay of the onset of sleep.

Answer 185

A

A. Behaviorally Induced Insufficient Sleep Syndrome (BIISS).

The patient profile best fits BIISS: A chronic, voluntary sleep restriction that commonly causes excessive daytime sleepiness and daytime fatigue.

Answer 186

A

B. Shift meals that have a higher concentration of carbohydrates to earlier in the day.
Eliminate daytime caffeine, but eliminate alcohol within three hours of bedtime. Avoid high sodium foods as they restrict vasodilation. Dim lights 30 to 60 minutes prior to bedtime.

Answer 187

A

C. Going outside for a walk in the sunshine in the late afternoon.
Shift breakfast and any caffeine until 45 minutes after her ideal wakeup time. Avoid any bright lights until her ideal wakeup time. Light in the late afternoon increases melatonin production and will help her sleep cycle.
D is true, but patient may be able to change her lifestyle to help improve her sleep.

Answer 188

A

E. All are correct.
A Mini Sleep Assessment includes asking about typical weekday hours of sleep, typical weekend hours of sleep and perceived sleep quality. In addition to the above, other “red flags” include poor sleep quality despite seven or more hours in bed and getting more than nine hours of sleep.

Answer 189

A

D. A and C
Melatonin and peripheral skin temperature are directly related. B is incorrect because as melatonin increases, so does the peripheral skin temperature.

Answer 190

A

D. Leads to delayed phase sleep similar to westward travel.
Blue light creates greater melatonin suppression at higher intensities and higher durations. It increases nighttime heart rate, blood pressure and core body temperature. Blue light decreases sleepiness. It also leads to delayed phase sleep that is similar to westward travel (e.g., it postpones sleep onset by making the body think it’s earlier than it is).

Answer 191

A

C.
Impaired sleep quality leads to decreased fear extinguishing and preserved memory of fearful events.

Answer 192

A

A. impaired
B. increased (lack of production inhibition)
C. increased
D. decreased

Answer 193

A

Cortisol increased
Insulin sensitivity decreased
glucose elevated
leptin decreased
testosterone decreased
growth hormones decreased
AGE deposition increased
dyslipidemia
endothelial dysfunction

Answer 194

A

A. stomach
B. tells brain we are hungry (it “ghrrrrgles”)
C. short-term weight hormone

Answer 195

A

BEP-CA:
breast
endometrial
prostate
colorectal
AML

Answer 196

A

increased risk of CA (skin)
increased risk of infection (pneumonia)
unpredictable response in the short-term
CBT is more effective in the long term

Answer 197

A

STOP-BANG

Snoring (loud)
Tired often
Observed apneic episodes
Pressure is elevated or on HTN meds

BMI > 35
Age >50
Neck size 17” or more for men, 16” or more for women
Gender is male

5-8 is high risk, or 2 STOP questions + 1 non-age BANG risk factor

Answer 198

A

Environment (dark, cool)
Light (increase early light exposure, exercise outdoors, red-light if needed at night)
Diet - increase hydration and avoid diuretics (caffeine/alcohol)
increase exercise
Stress - address nighttime worrying/ruminating

Answer 199

A

A. appliance displays
B.halogen, fluorescent bulbs, electronic LED screens
C. incandescent, warm white bulbs, candles

shorter wavelengths (blue) trigger more alert response & inhib melatonin

Answer 200

A

circadian rhythm disorders
primary insomnia
age-related insomnia
jet lag

remember melatonin is a phase-shifter, not a sleep aid

Answer 201

A

A. Noon - no effect
B. Just after 6pm, 30 minute delay (fall asleep later)
C. Around 8-9pm, 60 minute delay
D. Around 3am, 60 min advance - will wake up too early!
E. On awakening (end of night), advances the clock 30 minutes, but is normal and necessary (because the natural clock lasts 24.1-24.4 hours!)

Answer 202

A

C.
Tobacco use is the leading cause of preventable death in the United States. Physical inactivity is the fourth leading risk factor for global mortality.

Answer 203

A

D. All of the above.
Smoking worsens or leads to erectile dysfunction, diabetes mellitus and infertility.

Answer 204

A

B.
Quitting at age 30 adds 10 years of life expectancy versus quitting at age 60, which adds three years of life expectancy.

Answer 205

A

D. A and B.
The combination of counseling and medication is more effective than either alone, and hypnosis is less effective than either counseling or medication.

Answer 206

A

D.
Clonidine is currently a second-line medication for tobacco cessation as an off-label use. It should be prescribed on a case-by-case basis when the first-line medications are contraindicated or have not been effective.

Answer 207

A

B.
Counseling is the best option for pregnant smokers, as there could be a potential risk of birth defects with NRT. Bipolar patients should not use bupropion but can use the patch. NRT is safe for adolescents. There is no association between nicotine patch use and acute coronary syndrome.

Answer 208

A

D. Accept
The 5 A’s model for tobacco cessation helps to facilitate behavior change. It is comprised of: Ask, Advise, Assess, Assist, Arrange.

The 5 A’s of behavior change counseling are Assess, Advise, Agree, Assist, Arrange.

Answer 209

A

B.
At-risk drinking is drinking that increases the risk for future problems, but with no current symptoms; binge drinking ≥ 1 time a month; or exceeding the low risk drinking guidelines at any time.
Getting a DUI would be considered a sign of alcohol use disorder as it is continued use despite internal consequences.
Drinking to avoid withdrawal symptoms is not part of the definition of at-risk drinking or of alcohol use disorder.
“Alcohol abuse and dependence” was the DSM4 terminology for alcohol use disorder.

Answer 210

A

C.
A male who does not like to go to a party if there is not going to be alcohol there, has developed tolerance to alcohol use, wakes up craving vodka, and has experienced alcohol withdrawal over a 12 month period.

Alcohol abuse disorder is diagnosed by the presence of at least two out of 11 possible signs or symptoms of the DSM5 alcohol use disorder criteria during a 12-month period.

Moderate alcohol use disorder is categorized by the presence of four to five signs or symptoms that occur over a 12-month period.

Answer 211

A

D.
Nortriptyline is not an anti-relapse medication.
Anti-relapse medications include naltrexone, acamprosate, disulfiram, gabapentin and topiramate.

Answer 212

A

10 years

Most of the benefit gained in first 5 years (40%)

Answer 213

A

Ask (screen for use)
Advise (of risks/consequences)
Assess (is patient ready?)
Assist (includes pharmacotherapy, counseling)
Arrange (schedule f/u within a week of quit date and 1 month after)

Answer 214

A

PALS don’t use patches

pregnant women
adolescents
light smokers (<10 per day)
smokeless tobacco users

Answer 215

A

How soon until first cigarette (in minutes)?
<5 (3 pts) >60 (0 points)
How many cigarettes a day?
10 or less (0 points) to 31 or more (3 points)

Answer 216

A

5 levels
2-4-5-7-10 (upper limits)

Answer 217

A

Varenicline

nicotinic receptor partial agonist, renally cleared

Cautions: psych or seizure hx, EtOH use, CVD. no other specific contraindications

Answer 218

A

FDA: Naltrexone, Acamprosate, Disulfiram (= placebo)

off-label: gabapentin increases abstinence rates, topiramate may reduce % days of heavy drinking

Answer 219

A

Answer A, D, E are correct.

A – True p 289
B – False. Tobacco products kill 1 in 2 of those people who use them! P289
C – False.
- Cigarette smoking causes:
– 87% of lung cancer deaths (of which lung adenocarcinoma is the most common) = True,
– 32% of coronary heart disease deaths = True
– 70% of all deaths from COPD = False, it’s actually 80%, p289.
D – True. Cigarette smoking may worsen all of the mentioned conditions pg. 290.
Please regarding AMD risk is from Rotterdam Study doi:10.1001/archopht.1996.01100140393005
E –True p291

Answer 220

A

Answer - E.

A – False p295
B – False p295
C – False p295-296
D – False p 296 advise the patient to quit in a clear, strong and personalised manner e.g. continuing smoking will worsen your asthma
E – True p295

Answer 221

A

Answer: C

Rationale:
a. The AUDIT-C should be done on heavy drinkers/those you suspect of heavy drinking at every visit (BR video)
b. The AUDIT-C is an evidenced based screening tool
c. Correct answer
d. The higher the score the higher the sensitivity that the patient has AUD (p. 303)

Answer 222

A

Answer: C

Rationale:
a. Women - binge drinking is 4 per 2 hours, men is 5 per 2 hours (p. 301)
b. No safe amount for those with breast or liver cancer
c. Correct
d. In the USA, no alcohol recommended for those < 21!

Answer 223

A

Answer: B

Rationale:
a. Smokers died 10 years younger https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298160/
b. Correct
c. Quitting at 60 lead to a 3-year increase (p. 290)
d. Study was conducted over a 50- year time span

Answer 224

A

Answer: C

Rationale:
a. Smoking is more damaging than chewing
b. At 10 years the risk of lung cancer is reduced by 50% (p. 290)
c. Correct
d. Tobacco use is the number one cause of preventable death (p. 289)

Answer 225

A

Answers:
1. c
2. a
3. b
4. c

p. 301

Answer 226

A

A & D are correct

1 in 5 deaths
32% of CHD deaths
(p.289)

Answer 227

A

Answer c.

At risk drinking p301

Option b binge drinking.

Answer 228

A

Correct answer: D

Clonidine and Nortriptyline are second-line medications.

(p.293)

Answer 229

A

Answer d.

(p. 302)

Answer 230

A

Answer C

pg 305-306

Answer 231

A

Answer d

(being the key drug in tobacco, pg 290)

Answer 232

A

ANSWER d and f

a. F p 294
b. F p 291 4 in person sessions seem to be especially effective but minimal interventions (<3mins) still increase abstinence rates
c. Tobacco products kill 1/3 of people who use them
d. T
e. P 295 F (they tend to continue to smoke and use the e cigarettes)
f. T p 289
g. F p 294
h. F p 294 (No assoc between patches and acute CV events but caution recommended for NRT)

Answer 233

A

Answer B.

Standard beer weight is 340g

Answer 234

A

Answer- 3, 5

Pg 290
1 is an immediate effect
2 takes 10 years
4 is within 2 weeks

Answer 235

A

E.
Counseling sessions with behavioral health providers could help with mental and emotional health, but this counseling falls under the category of psychotherapy and not personal lifestyle change.
All others are correct. Other therapeutic lifestyle changes include: nutrition and diet and time in nature.

Answer 236

A

B. An increased rate of depression occurs in a linear dose-response curve with higher trans-fat intake.

Whereas, depression is negatively associated with intake of mono- and poly-unsaturated fats.
Depression was 40% more likely to develop in adults who frequently ate fast food compared to those who avoided it.
Some studies show fish oil may help reduce symptoms of depression. However, other studies show little benefit of treating depression with fatty acids.
Treatment with omega-3 fatty acids does appear beneficial among some populations, such as those with depression or bipolar disease.

Answer 237

A

E.
All the above are correct.

Answer 238

A

B.
Doing activities that feel meaningful, and connecting and interacting with others regularly through social media.
Connecting and interacting with others is important. However, it’s most important to regularly connect and interact with others in person and not solely or mainly through social media. The use of social media has been connected to higher rates of depression.

Answer 239

A

ANSWER: A.
B. Description of *Positive affect *

C. Many of the strengths and virtues studied in positive psychology.

D. Description of Engagement

E. Description of *Positive emotion *

Engagement and positive emotion are two of the pillars of positive psychology, along with relationships, meaning and accomplishments. (=PERMA)

Answer 240

A

D. a, d, e, f
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.
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.
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.

Answer 241

A

E.
The food components that Americans get too much of are:
1. added sugars: candies, desserts and sugar sweetened beverages,
2. processed grains: white flour, white rice and white pasta,
3. cholesterol mostly from animal foods,
4. sodium: processed and packaged foods,
5. saturated fats: meats, dairy, eggs, processed foods and oils and
6. trans fat: hydrogenated plant oils, processed foods (trans fats are banned after 2018).

Answers A through D listed the shortfall nutrients: fiber, potassium, Vitamin C and Vitamin E, which are predominately found in nutrient-dense, whole, plant-based foods. Less than 9% of the US population consumes more than two cups of vegetables daily.

Answer 242

A

E.
The top five sources of saturated fats in the US are: cheese, pizza, refined grain-based desserts, dairy desserts and chicken. Walnuts are high in polyunsaturated fats and low in saturated fats.

Answer 243

A

B.
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.

Answer 244

A

B. Ornish Diet

A. DASH Diet for hypertension: a combination of vegetables, low salt and low-fat dairy, which has been found to be adequate first-line treatment for essential hypertension.

B. The Ornish diet for coronary artery disease (CAD): a low-fat, plant-based diet reversed coronary artery disease stenosis in one year and maintained reversal at the five year follow-up.

C. Mediterranean diet for secondary prevention of coronary artery disease: the Mediterranean diet was found to be superior to a prudent Western diet in preventing recurrence of coronary artery disease events.

D. CHIP program and diet for diabetes: The CHIP multifactorial lifestyle intervention was effective in treating type 2 diabetes.

E. Walnuts for hyperlipidemia and hypertension: adding a daily serving of walnuts to ad libitum diet (as you desire) showed effectiveness in lowering serum cholesterol.

Answer 245

A

E.

Nutrition prescriptions are one of the 15 Physician Competencies for Prescribing Lifestyle Medicine.

Answer 246

A

E. The SMART acronym for nutrition prescriptions includes:
Specific type of foods.
Measurable, meaning how much of the food.
Achievable/attainable goals for who will be doing the cooking and the shopping.
Realistic goals for what food is available, the budget, time commitment and what will the patient actually do.
Time connected, meaning what is the frequency for eating the food, and for what duration of time is the prescription written.

The doctor or health care provider’s roles are not part of the patient’s written prescription.

Answer 247

A

E.
Trans fats are associated with increased risks of heart attacks and strokes. Starting in 2018 in the US, trans fats are no longer allowed to be used by the food industry.

Answer 248

A

A.
The best sources of fiber are legumes, whole grains, vegetables, fruits, nuts and seeds. Meat and dairy products do not contain fiber.

Answer 249

A

D. Cruciferous vegetables.

Anti-inflammatory foods include all of the following:
Cruciferous vegetables (broccoli, cauliflower and Brussels sprouts)
Cabbage and bok choy
Dark berries and fruits
Allium vegetables
Carotenoids
Dark green leafy vegetables

Answer 250

A

D.
Foods that are fried, smoked, grilled, baked or roasted have higher AGEs. Foods that are prepared with moist heat cooking, such as boiling, stewing and broiling, have fewer AGEs.

Answer 251

A

C.
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.

Answer 252

A

E.
Type 2 diabetes is generally a reversible disease with aggressive therapeutic lifestyle changes, such as: reducing dietary saturated fats, trans fats, processed sugars and processed grains; eliminating artificial sweeteners; and increasing daily exercise.

Answer 253

A

D.
The risk of breast, colon and prostate cancer are increased with the consumption of red meat, processed meat, highly processed grains, added sugars, high saturated fats and trans fats.

Answer 254

A

D.
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).

Answer 255

A

ANSWER: D

D. 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. The initial focus of the dietary intervention was on reducing total fat rather than calories. Goal <25% of daily calories.

*Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Knowler et al. N Engl J Med. 2002 Feb 7;346(6):393-403.

Answer 256

A

A.
Insulin resistance begins to occur as inflammatory mediators cause damage to liver and beta cells and as muscle and adipocyte cells begin resisting further fat storage. Adipocytes are key factors in the development of insulin resistance. As weight gain occurs, adipocytes undergo hyperplasia and hypertrophy (that is, they grow in number and in size) and begin accumulating in ectopic tissues, such as the liver and muscle cells. Intramyocellular fat accumulation disrupts insulin receptors via production of lipotoxic mediators, causing insulin resistance. Muscle insulin resistance determines the rate of fatty liver progression. Fatty liver progression and the deposit of fatty acids in pancreas are responsible for the rate of hepatic insulin resistance (failure to appropriately respond to blood glucose levels) and beta cell dysfunction.

Answer 257

A

A.

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

Answer 258

A

E.

Diet, exercise, sleep, obesity and hyperglycemia are able to up-regulate or down-regulate gene expression

Answer 259

A

D.
Although Dean Ornish, MD has found that reversing coronary artery stenosis requires the total daily caloric intake from fat to be less than 10% of the total daily intake, that’s not one of the American College of Cardiology (ACC) / American Heart Association (AHA) guidelines.

Answer 260

A

C.

There’s strong evidence that children who consume sugar-sweetened beverages have higher body weights.

Answer 261

A

B is incorrect

Epigenetic changes can all be induced by diet, exercise, sleep, stress, obesity and many other environmental factors.

Answer 262

A

B is incorrect
Compared with vegetarians, the relative risk of diabetes on the death certificate, adjusted only for age, was 2.2 (1.5, 3.4) for male non-vegetarians and 1.4 (1.0, 1.9) for female non-vegetarians. [1]

During 10 years of follow-up, 918 incident cases of diabetes were documented. Diabetes risk increased with higher total protein (hazard ratio 2.15 [95% CI 1.77 to 2.60] highest versus the lowest quartile) and animal protein (2.18 [1.80 to 2.63]) intake. Adjustment for confounders essentially did not change these results. Further adjustment for adiposity measures attenuated the associations. Vegetable protein was not related to diabetes. Consuming 5% energy from total or animal protein at the expense of 5% energy from carbohydrates or fat increased diabetes risk. Diets high in animal protein are associated with an increased diabetes risk. [2]

Barnard et al., 2014

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942738/
[2] https://diabetesjournals.org/care/article/33/1/43/29676/Dietary-Intake-of-Total-Animal-and-Vegetable

Answer 263

A

C.
Positive food prescriptions can help patients focus on including nutrient-dense, low-calorie foods like fruits, vegetables, whole grains and legumes rather than focus on caloric restriction. Though patients who regularly track food intake on their own show higher rates of weight loss, this is very tedious to complete. Usually, formal tracking of all the patient’s meals and beverages for one month would be too time consuming to complete and review in a provider visit. A three-day food log or 24-hour recall may be options that could be completed within the time of a visit. Most studies show a benefit from eating more than five servings of fruits and vegetables a day, with increasing benefits with more servings. Weight checks can be helpful for weight maintenance, but they may cause patient to focus more on meeting a number instead of forming healthy habits and behaviors.

Answer 264

A

A.
Researchers tested the effect of a low-fat, high-carbohydrate (9% of energy from fat, 70% from carbohydrate) near-vegetarian diet containing 65 grams of fiber and 65 grams of cholesterol per day. Participants were 20 normal-weight men with insulin-treated type 2 diabetes, and it was a 16-day trial. Energy intake was individualized to prevent changes in body weight. By the end of the study period, insulin use was discontinued in 11 participants and, in the rest of the participants, it was reduced from a mean of 26 to 11 units per day (P < 0.001). Despite this reduction in medication use, mean fasting plasma glucose concentration still decreased from an average of 164 mg/dL to 152 mg/dL (amount decreased was not significant).

https://pubmed.ncbi.nlm.nih.gov/495550/

Answer 265

A

B.
For BMI of <18 to >32, there is a linear association with blood pressure, from lowest to highest for both systolic and diastolic. Adjusted for age and gender, significantly lower blood pressure was found in non-treated vegans and lacto-ovo-vegetarians compared to omnivores. Adding alcohol intake to the models studied did not identify an alcohol effect, however alcohol intake was infrequent and small. For vegans, lacto-ovo vegetarians and partial vegetarians, effects were reduced (but not reversed) after adjustment for BMI.

Answer 266

A

C.
The study found women who were obese but had high levels of physical activity (≥ 540 MET-min/wk) and ate high amounts of fruits and vegetables daily (>5 servings per day) had the same mortality rates as women who were not obese but also had high physical activity and high fruit and vegetable intake. [Pierce et. al. Greater survival after breast cancer in physically active

https://pubmed.ncbi.nlm.nih.gov/17557947/

Answer 267

A

D.
Normoglycemia can be achieved as part of the normal physiologic process of a functioning pancreas and liver and of responsive muscle and adipose cells or through medications, exercise or lifestyle changes. Medication use will not reverse the cause of muscle resistance. Although changing to a whole food, plant-based diet can improve insulin resistance, this effect can take several days to several years and is not instantaneous with achievement of normoglycemia.

[Weickert. Impact of Dietary Fiber Consumption on Insulin Resistance and the Prevention of Type 2 Diabetes. J Nutr. 2018;148(1):7-12.]

Answer 268

A

C.
Environment in utero is a significant contributor to epigenetic programming. A substantial component of metabolic disease risk has a prenatal developmental basis with greater methylation of RXRA chr9:136355885+ measured at birth being strongly correlated with greater adiposity in later childhood. Novel research demonstrated that paternal nutrition and lifestyles during the peri-conceptional period also contribute to the offspring’s epigenetic programming and risk of future diseases. “One link between environment and disease is epigenetics influencing gene transcription and subsequently organ function. We have previously shown that epigenetic modifications may accumulate during aging, and that DNA methylation in humans is influenced by diet, birth weight, and exercise, suggesting that epigenetics could be involved in age-related and life style–related diseases such as Type 2 Diabetes. Indeed, studies from our group and others have identified epigenetic modifications in patients with Type 2 Diabetes.”

[Duhl et al. Neomorphic agouti mutations in obese yellow mice. Nat Genet. 1994;8(1):59-65.]

Answer 269

A

B. Trans fats are the most damaging fats and are formed by adding hydrogen to liquid vegetable oils to make them solid. Trans fats also occur naturally in meat and dairy products. They are known to increase LDL cholesterol and lower HDL cholesterol, increasing risk for heart disease. Saturated fats come mainly from meat and dairy products. Plant foods that contain saturated fats include coconut, coconut oil, palm oil and cocoa butter. The American Heart Association recommends keeping the amount of saturated fat in the diet to less than 5 to 6% of total daily calories. The 2015 Dietary Guidelines no longer include a recommendation to limit dietary cholesterol to less than 300 mg a day. But the guidelines acknowledge this does not mean dietary cholesterol should not be limited, as diets lower in dietary cholesterol are associated with lower risk of heart disease and obesity. Of note, foods high in dietary cholesterol are mainly higher in saturated fats, except those egg yolks and shell fish that are high in cholesterol but low in saturated fat. [2015 USDA Guidelines, https://health.gov/dietaryguidelines/2015/guidelines/chapter-1/a-closer-look-inside-healthy-eating-patterns/.]
Poly unsaturated fats may help improve blood cholesterol levels, especially if they are used to replace saturated and trans fats. Egg whites do not contain any fat or dietary cholesterol. Insoluble fiber is a carbohydrate, and that may help lower cholesterol levels by not allowing it to be reabsorbed in the colon.

Answer 270

A

D. Cheese.
Foods that are high in saturated fat (more than 8 grams of saturated fat per serving) include higher fat cuts of beef, pork and lamb, salami, sausages and other processed meats, many fast foods (e.g., cheeseburgers), coconut and coconut oil. Cheese is moderately high in saturated fat with 4 to 7 grams per serving, but it’s consumed in high quantities, making it the number one source of saturated fat in the US

Answer 271

A

B.Only statements b, c and d are true.
Insoluble fiber is mainly found in vegetables, wheat, wheat bran, nuts and seeds. Legumes, fruits and oats are high in soluble fiber (Answer A). Phytochemicals are only produced by plants (Answer B). Foods should be viewed as “packages,” not as sources of individual nutrients. Therefore, in a food “package” the macronutrient profiles of fat, carbohydrate and protein influence the micronutrient density. A food package of steak will be high in protein and saturated fat and low in antioxidants. Leafy green vegetables will be high in carbohydrates, have some protein, be low in fat and contain high amounts of vitamins and minerals. (Answer C). When total serum cholesterol is less than 150, progression of plaque development in blood vessels appears to cease even in the presence of other risk factors like smoking, hypertension, obesity and diabetes (Answer D). Exercise is great for maintenance of weight loss, but caloric restriction must be included weight loss (Answer E).

Answer 272

A

Reduced hypertension
1. Dash diet

Regression of coronary artery disease and atherosclerosis and coronary event rate was 100 times higher over four years in those who did not adhere versus those who did.
2. Esselstyn diet

Regression of coronary artery disease and atherosclerosis, Telomere length increased, and Inhibition of prostate cancer cells
3. Ornish diet (+lifestyle intervention)

As effective in lowering LDL cholesterol as statins
4. Portfolio diet

Answer 273

A

A. All statements are true.

All of these mechanisms have been shown to impact endothelial integrity.

https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.120.14759

Answer 274

A

C. Only statements c, d and e are true.
The World Health Organization (WHO) has not declared red meat a group 1 carcinogen, but it was labeled as group 2A. This means it’s probably carcinogenic to humans, but insufficient evidence exists to rule out chance or bias as the cause. Processed meats have been labeled group 1, meaning they are carcinogenic to humans. Coconut oil has not been shown to reduce Alzheimer’s disease. The other statements are true.

Answer 275

A

Answer C.
Walk ≥ 30 minutes four days a week for three months
“Exercise” and “most days” are not sufficiently specific.
“Prepare for a triathlon” is not realistic or achievable, nor is it specific or achievable.
“Swim or walk on alternating days” is not measurable and not time connected.

Answer C is specific, measurable, achievable, realistic and time connected, and includes frequency,
intensity, type and time.

Answer 276

A

Answer B.
Fats, and especially trans fats and saturated fats, are among the leading over-consumed nutrients.
Added sugars and HFCS (high-fructose corn syrup), are also a leading over-consumed food/nutrient.
Minerals and vitamins are, indeed, among the most under-consumed nutrients.
Sodium is over-consumed but potassium is under-consumed.

Answer 277

A

Answer B.
The clinical assessment should include age, gender, medical and surgical history, activity level, nutritional history, vital signs and physical exam.
The ABCD (anthropometric, biochemical, clinical and dietary) assessment is one technique, but not the only valid method.
The dietary assessment need not be performed by a dietitian, nor does it need to include a 24-hour recall, although both of these can be used.
The assessment should include lab tests to assess nutritional status.

Answer 278

A

Answer C.
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.
The study did not examine diet type (Mediterranean) but daily fruit and vegetable intake.
The study found that fruits and vegetables were protective for men and women, with a 4% reduction per daily serving.
The study was a prospective cohort study and not a randomized trial.

Answer 279

A

Answer C.
Each substitute food reduced risk of type 2 diabetes versus red meat, and whole grains reduced risk most compared to processed red meat by ~35%.
Both processed and unprocessed red meat increased risk compared to substitute foods.
All substitute foods reduced risk.
Whole grains reduced risk more than other substitute foods, and the reduction was greatest for processed red meat.
The risk reductions were consistent across all three cohorts studied.

Answer 280

A

Answer B.
PUFAs, MUFAs and whole grains lowered risk of CHD compared to SFAs, but trans fats and added sugars elevated risk.
Not all fats increased CHD risk compared to SFAs, and not all carbohydrates decreased risk.
Trans fats and refined starches/added sugars elevated CHD risk compared to SFAs.
PUFAs and MUFAs reduced risk more than whole grains; PUFAs reduced risk most by 25%.
The smallest difference was between SFAs and refined starches/added sugars.

Answer 281

A

Correct answer = D

Nuts is also a component of the Portfolio diet.

Answer 282

A

Correct answer = C (p 118-120)

Other shortfall nutrients include fibre, magnesium, vitamin C, vitamin D, vitamin E & vitamin K

Answer 283

A

Correct answer = C

A is for Achievable/Attainable (p127)

Answer 284

A

Correct answer = C

Many plant foods are rich in protein (p127-128)

Answer 285

A

Correct answer = B

Fibre stabilises blood sugar (p132). Also decreases risk of diabetes and colon cancer

Answer 286

A

Correct answer = A
A - p131
B, C & D - p134

Answer 287

A

Correct answer = D
AGEs in food occur more in protein rich foods than fatty foods, and lastly carbohydrate rich foods (p134)
A - When temperatures are higher
B - When heat is applied for a longer period of time
C - When food is dry

Answer 288

A

Correct answer = C

To improve hypertension, reduce intake of sodium, saturated fat, alcohol caffeine and tobacco (p137)

Answer 289

A

Correct answer = C
Type 2 diabetes, hypertension, cataracts, COPD, Crohn’s disease (p141-142)
MS improves with restricted saturated fat (p142)
Some speculate that poultry and eggs may affect mood (p142)

Answer 290

A

Correct answer = C

Gastric bypass surgery (p152)
High protein, low carbohydrate diets (p152)
Mediterranean diet (p152)
Low-fat vegan diet (p153)
Plant-based diet (p154)

Answer 291

A

1 & 2) Bad:

Saturated fats in general raise cholesterol (see here)
Trans fat - increases MI & strokes

Good (should replace above)

polyunsaturated - Omega 3s, omega 6 (bad = arachadonic acid, good = linolenic)
Monounsaturated - help lower LDL - Canola, Olive, Peanut (C.O.P.) Avocado
3) Saturated fats
Lauric - coconuts, palm oil, meat - ^ Chol-T, ^ LDL, ^ HDL
Stearic - cheese, dairy, meat, poultry - may lower LDL
Palmitic - palm oil, dairy, meats - ^ Chol-T, ^LDL, ^ HDL

Answer 292

A

In trans fats, there are two carbons joined by a double bond. If the hydrogens are on OPPOSITE sides, it is called ‘trans’; if they are on the same side, it is called ‘CIS’.

Cis are more flexible and thus liquid at room temp; trans are less flexible, leading to oils which are solida at room temp and have longer shelf life.
natural trans fats occur in the body fat & milk of ruminant animals, mainly cows & sheep - not harmful
commercial trans fats raise LDL-C & lower HDL
a 2% increase in energy intake from bad trans fat (vs carbohydrates) is assoc with riks of CAD of 1.93 (P<0.001)

Answer 293

A

1&2) Lauric acid, a saturated fat, makes up 47% of coconut oil and is the #1 oil in it.

3) Lauric acid increases Chol-T, LDL, and HDL
4) Harvard recommends AGAINST coconut oil.
4) Net effect is to increase heart disease

Answer 294

A

WHO: Max 10% of calories
(goal is max <5%, 6 level tsp=24 grams)

AHA: Max 100 calories (=25g, about 6 tsp)

Answer 295

A

outside the home (70.9%)
Inherent to food (14%)
Added in home prep (5.6%)
Added at the table (4.9%)

Answer 296

A

ranking for most underconsumed nutrients with least overconsumed per kCal:

Vegetables (including mushrooms)
Herbs and spices
Fruits

Answer 297

A

Lauric acid

Answer 298

A

Fiber*
Calcium*
Potassium*
Vitamin D*
Magnesium

The rest is vitamins C-A-K-E

*of public health concern per manual, p132

Answer 299

A

FAST BOCK

fortified plant milks
acorn squash
soybeans
tofu prepared with CaSO4

black-eyed peas
okra
chia seeds
kale

Answer 300

A

baked potato
yams
avocado
white beans
banana
beet greens/spinach
dried apricots/dates

Answer 301

A

orange colored (retinol)
sweet potato
cantaloupe
butternut squash
carrots

Answer 302

A

poor wound healing
DM (type 1 and 2)
atherosclerosis
kidney disease

All due to incrased oxidative stress and inflammation

Answer 303

A

35” or greater for women
40” or greater for men

Answer 304

A

broken down into SCFA by gut bacteria (e.g. butyrate)
increased circulatory SCFA leads to:
* increased insulin sensitivity (decr glucose)
* weight regulation
* reduced inflammation
* prevents ectopic lipid deposition
* increases beta-oxidation of fatty acids (makes acetylene-coA)

Answer 305

A

Unprocessed (in natural form)
Minimally processed (roasting, grilling, grinding, milling)
Processed (added salt, oil or sugar) - includes freshly made bread
Ultra-processed (anything with artificial colors, flavors, emulsifiers, preservatives)

Answer 306

A

EPA: algae, seaweed, spirulina, nori
chlorella
ALA: nuts, flax seed, certain vegetable oils

ALA can be converted into EPA/DHA, but poor yield

Answer 307

A

5 steps - open-ended, fill in blanks, associations, details, what else?

Answer 308

A

calcium, potassium, magnesium

Answer 309

A

decreased BP, serum TG, cholesterol
High adherence = 41% lower risk of CVD mortality 27% lower risk of CVD

limited evidence about reduced CAD events and breast CA

Answer 310

A

Lower CVD incidence, DM/CV mortality
Decreases LDL, BP
May help with weight loss

low sat/trans fat, low sodium, rich in K, Ca, Mg, fiber protein

Answer 311

A

Combo of mediterranean and DASH.
Focused on neuroprotection
In addition to whole food-plant based, emphasizes daily leafy greens, berry intake
fish no more than once per week

Answer 312

A

NHS (Harvard Nurse Health Study)
HPFS (Harvard Health Prof F/U study)
WHI (Women’s Health Initiative)
EPIC (European Prospective Investigation into Cancer and Nutrition
AHS (7th-day Adventist Health Study)
Framingham Heart Study
MESA (Multi-Ethnic Study of Atherosclerosis)
NHANES (Nutritional Health and Nutrition Examination Survey)

Answer 313

A

Lyon Heart Trial
OmniHeart
DASH
PREDIMED

Answer 314

A

CHD risk reduced by moderate alcohol intake, medi diet, nuts/whole grains
Stroke risk reduced by medi diet and fish
INCREASED risk of CHD with refined carbs (by 16%) and trans fats
Breast/Colon CA risk increases with EtOH (1/2 per day pre-menopausal), red meat intake
Folate, B6, Ca and VD are protective for colon CA

Answer 315

A

For White men
* More than 2 sugar-sweetened beverages a day associated with 21% increased risk of all-cause mortality and 31% increased risk of CHD death
* High red meat intake 11-15% higher risk of CHD
* replacing margarine/butter with olive oil reduced CVD and CHD risk by 5-7%
* compared to no olive oil, consumption of at least 1.5 tsp a day had lower risk for CVD (14%) CHD (18%)

Answer 316

A

161K women across 40 centers
* HRT did not decrease CHD
* lowering dietary fat to 24% did not lower CA (breast/colorectal) or CHD risk
* CaD supplementation slightly increased bone density but did not impact other disease processes

Answer 317

A

Comparison of 4 dietary cohorts (meat-eaters, fish-eaters, vegetarians, vegans). Stats compare to rates in meat-eating cohort

5 Outcome Areas: CODIC

CVD
Vegeterians/Vegans had 20% higher risk of stroke (?!?)
Lower risk of heart disease (Fish 13%, veget 22%)
Decreased BP, Total and non=HDL cholesterol

OBESITY
Vegan BMI 22.5 Meat BMI 25

DM/PRE-DM
37% lower risk of DM for veg/vgn = Vegans 47% lower risk of DM

INTAKE
Vgn sat fat intake 5% (meat 2x that)
Vgn lowest retinol, B12, v. D, Ca, Zinc (A-B-C-D-Z)

CANCER
12% lower risk of cancer.

Answer 318

A

Cancer-CHD-T2D-Weight-vD

Vegetarians lower risk for all cancers compared to non-vegetarians

Fruit twice a day (75% cancer risk reduction)
“higher” fiber intake (40% less colon CA)
Legumes twice weekly (42% lower colon CA), thrice weekly (47% lower prostate CA)
Meat eating increased risks for colon cancer (60%), bladder cancer (2x=100%), ovarian cancer

CHD
* Nut intake reduced risk of nonfatal MI (74%), fatal CHD (73%) and risk of CHD 39-54% with greatest effects on pts over 80

T2D
Half the prevalence in veg/vgn
* Trend to lower weight, BP, chol, DM the more vegetarian

Vegetarians NOT more vD deficient (in contrast to EPIC) - done in California!

Answer 319

A

18% increased risk of DM2 with high intake of tomatoes, beans, refined grains, high fat dairy and red meat
15% lower risk with whole grains, fruits ,nuts/seeds, green leafy vegetables, low fat dairy

Answer 320

A

NHANES (National Health and Nutrition Examination Survey)

More than 50% of calories come from UPF
Every 5% increase in calories from UPF is associated with .14 drop in CVH score

Answer 321

A

Less beef, lamb pork (switch to chicken), more fish
Root and leafY green vegetables
Replace butter/cream with high alpha-linolenic Oil
No day without fruit

averaged 30% of calories from fat, 8% saturated

Answer 322

A

To keep study arms isocaloric, the carb-rich study arm was allowed more sweets/desserts, which may have resulted in increased intake of refined carbohydrates.

Answer 323

A

Largest and longest RCT to date showing benefit of Mediterranean dietary pattern over just lower-fat pattern. (extra EVOO, extra nuts vs low fat)

Greater emphasis on plant-derived foods reduced all-cause mortality

Answer 324

A

The formation of glycoconjugates leads to:
1. inflammatory responses
2. viral immune escape
3. spread of cancer cells
4. apoptosis

Answer 325

A

FAB-VP
1. Firmicutes
2. Actinobacteria
3. Bacteroidetes
4. Verrucomicrobia
5. Proteobacteria

90% of total are either Firmicutes or Bacteroidetes

Answer 326

A

Sodium (<2300mg daily, <1500mg per AHA)
Alcohol (or drink just a little - J-curve relationship)
Caffeine

Answer 327

A

calcium
magnesium
potassium
garlic

Answer 328

A

potatoes/sweet potatoes
fruit (cantaloupe, banana, peach)
Vegetables (squash, broccoli, spinach)
Legumes (lentils and beans)

Answer 329

A

low-oxalate greens (collards, kale, turnip, mustard, bok choy… all except beet, chard, spinach)
beans
fortified non-dairy milk
low-fat dairy

Answer 330

A

PA BANQ

potatoes
avocados
beans (black, soy, kidney)
amaranth
Nuts
quinoa

Answer 331

A

brazil nuts
sunflower seeds
fish
mushrooms

Answer 332

A

By 2050
it’s predicted that 100 million will have it

Answer 333

A

LARTTIIC
1. Leptin
2. adiponectin
3. resistin
4. TNF
5. TGF-beta
6. IL-6
7. IL-10
8. CCL19

chemokine ligand 19 - T cell activiation

Answer 334

A

An item that is 5% DV or less is considered low-sodium
20% DV or more is considered high

Answer 335

A

Decreased LDL, cholesterol, other cardiometabolic risks
Decreased BP
Reduced DM/CV mortality

Answer 336

A

About a third
(Effect size 0.19 - 0.51)

Answer 337

A

1) US RDA for fiber = 25 grams (women) & 38g (men)
2) Kelly recommends we take no more than 100% per day of total or saturated fat.

Answer 338

A

1) ‘Saturated fat’ - all carbon chain bonds are filled. There are no double or triple bonds to give the molecule bends or turns in the chain.
2) Result - stiff molecules -> stiff cell walls
3) Unsaturated fats - have at least one double or triple bond to cause the molecule to have a bend in the carbon chain. => more flexible in the cell membrane.

Answer 339

A

1) Structurally:

‘Cis’ fats - H on SAME side - crooked - lower melting point.

‘Trans’ fats - H on OPPOSITE side - more straight - higher melting point

2) Function

Cis - crooked - flexible - low melting point

Trans - straight - stiff - high melting point - stiff in cell membrane.

3) Body doesn’t make trans fats.

Answer 340

A

1) POLYUNSATURATED fats have lots of unsaturated bonds in the carbon chain => multiple bends or turns => lower melting point at room temp => flexible in cell membrane.
2) Animal fats => generally saturated (solid @ room temp)

Plant fats => unsaturated => liquid at room temp.

Answer 341

A

1) Vitamin B9 is folate (is benign)
2) Only source of vitamin B12 is bacteria
3) Folate (B9) is plentiful in dark leafy greens, cruciferous vegetables and peas.
4) Elevated homocysteine assoc w CV disease; doesn’t add much to other biomarkers (eg lipids, CRP)
5) B12 = cobalamin

Answer 342

A

1) Good Tot chol:HDL ratio < 3
2) Soft drinks (ie regular pop) can raise TG

Answer 343

A

Mono-unsaturated fats: (COP)

Avocado

Nuts - almonds, hazelnuts, peanuts, pecans

Olives Seeds - pumpkin, sesame

Soft margarine (also MONO unsat) - liquid, tub

Vegetable oils - Canola, Olive, Peanut, safflower

Answer 344

A

Polyunsaturated fats:

Fish - herring, mackerel, salmon, trout, tuna

Nuts - pine, walnuts

Seeds - sunflower

Soft margarine (also MONO unsat)

Veg oils - corn, cottonseed, soybean, sunflower.

Brainscape's Knowledge GenomeTM

MCQ's from the Chapters based on 4th Edition of Board Review Manual Flashcards

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