Sections 1-10 Flashcards
Assessments
Subjective:
-Sleep diary, Epworth sleepiness scale, Pittsburgh, STOP-BANG
Objective:
-Actigraphy
-Polysomnography (PSG) - gold standard for sleep staging
INTERHEART
Top 5 factors accounted for 80% MI risk: tobacco, lipids, HTN, DM, OB
WORLDWIDE
Examined psychosocial factors & established that they were comparable to the effect of HTN & abd OB
STOP_BANG
Snoring
Tiredness (daytime sleepiness)
Observed apnea
Pressure (HTN)
BMI > 30
Age > 50
Neck circ >16 (men), >14 (women)
Gender (male)
Depression & coronary disease
-Depression is an INDEPENDENT risk factor for coronary disease
-Abnormal platelet adherence, endothelial dysfunction
-Lower HR variability
-Dep precedes coronary disease by several years
-2x cardiac events
Highest sources of sodium in diet
~70% added outside the home
~14% inherent to food
~10% added in home food prep or at table
Ultra-processed
Commercially-prepared
Mixed dishes (burgers, sandwiches, tacos, rice/pasta/grain dishes; pizza; meat/poultry/seafood dishes; soup)
Types of food:
Sandwiches
Pizza
Soups
Chips/crackers/savory snacks
Heartrate variability
Time between each heartbeat
when sympathetic & parasympathetic are balanced, there is variability in time between beats
If sympathetic is high, then have low variability (more equal time between beats)
If parasympathetic is high, then have high variability
The greater the variability, the more resilient and greater cardiovasuclar fitness
Harvard Study of Adult Development
Single most important predictor of happiness and longevity was having social connections
Positive psychology
Strengths-focused approach (what is working well) vs. disordered-focused approach (what went wrong)
When positive emotions outweigh negative emotions, improved well-being occurs
Goal to increase well-being, flourishing through focus on PERMA
Use during all stages of change - examine strengths & motivations, explore & celebrate past sucesses, reconnect to purpsose/meaning, leverage challenges as learning opps
Health Belief Model
Perceived threat to health + perceived severity of this threat vs. perceived benefit of change + perceived barriers to change
Cues to action (internal symptoms, role models, environmental factors) that prompt change adoption
Self-efficacy
PERMA
Positive emotions - focus on these improves well-being; inspiration, hope, love, awe, gratitude, joy
Engagement - using strengths & talents to overcome challenges; have sense of control, clear goals, and fully able to concentrate; high challenge + high skills
Relationships - social connections are critical; strong relationships have greates impact on life satisfaction; focus on growth-focused, authentic relationships
Meaning/purpose - identifying values and pursuing activities aligned with them
Achievement/accomplishment - result of working toward and reaching goals with sucess; results in mastery, self-efficacy
Chronic Care Model
Promotes collaborative care, connection with community resources, increases access to care, increases patient engagement
Emphasizes self-management support & central role of patient in health care
Community resources + self-mgmt + health system intentionally organized (decision support, CIS)
Self-monitoring, self-management
Improved coping, expertise, overall sense of well-being
Emphasizes patient’s central role in their helaht care
Autonomy & self-efficacy are keys to sustainable self-management
Sources Vitamin A
Vision, growth, reproduction, skin
Requires conversion to retinol in plant foods (is preformed in animal foods)
Sweet potato
Mango
Carrots
Cantaloiupe
Butternut squash
Plant milks
5 As behavior change (and specific for smoking)
Assess health risks
Advise change (personalized)
Agree on counseling focus, willingness for change
Assist w/ setting goals, resources
Arrange follow-up & support
Tobacco-specific:
Ask about tobacco use on every patient
Advise quitting
Assess readiness to quit
Assist w/ counseling, Rx
Arrange follow-up (1 week prior, 3 days following quit date, first month ater)
Sourcres Vitamin D
Calcium absorption (bone health), muscle health, glucose metabolism
Salmon
Fortified milk
Sunlight
Supplement
PREDIMED
Pt w/ high CVD risk (had T2DM or mult risk factors)
Mediterranean (nuts vs. olive oil) vs. SAD showed 30% risk reduction of major CV event over 5 years
Chol norms
Total < 150
LDL < 100 (<70 in high risk)
HDL >40 (male), >50 (female)
Trig <150
If total chol is 90-140, plaque progression ceases and other risk factors (e.g., smoking, ob, inactivity) don’t produce plaques
ApoB is a stronger indicator of artherogenicity
Lp(a) independent risk factor for CVD - highly heritable
PPIs (Positive psychology interventions)
-Gratitude journal
-Volunteer work
-Reflecting on how want to be remembered
-practicing acts of kindness
-Counting blessings
-Connecting with others in person
-Thinking of happiest days
Intensive Therapeutic Lifestyle Change (ITLC): phases, key information
Induction: dramatic changes; typically indiv & group visits, multidisciplinary, not require motivation & self-efficacy
Maintenance:
Support:
Suprachiasmatic nucleus
Master circadian clock; located in the hypothalamus
Oscillators in all peripheral cells - mini clocks
Dysregulation comes when internal clock does not jive with social clock
Depression & mortality
-Depresesion is INDEPENDENT marker for all cause mortality
-As strong a marker as smoking
-Increased risk for CA and CVA
PHQ-2, GAD2, PHQ4
PHQ-2:
In the past 2 weeks, how often:
-Feeling down, depressed, hopeless
-Little interest or pleasure in normal things
GAD2
-Feeling nervous, anxious, on edge
-Can’t stop or control worrying
PHQ4 combines the two
For all 3, any score >/3 needs further evaluation
When to screen for TAPS
Smoking: Regularly
Alcohol:
-Ages 18+
-Annually + problem-focused visits when may be alcohol-related
-High risk groups more often
Lapse/relapse prevention & mangement
When might it occur, under what circumstances, with whom
How notice a lapse before becomes relapse?
Who to turn to during a lapse/relapse?
Lapse/relapse are normal parts of change process
Depression & diabetes
-T2DM & depression have BIDIRECTIONAL association
-Insulin indifrectly influences serotonin, norepi, dopamine synthesis
-Depression alters HPA axis & symp NS
-Perceived lack of ctrl over DM can increase dep & anx
Health Professionals Follow-Up Study
2 or more SSB/day (vs. <1/mo) incresased overall mortality by 21% and CVD death by 31%
Higher intake red meat = 11-15% increased risk CHD
Sub plant-protein for red meat decreased risk by 14-17%
Olive oil better than most animal fats & margarine at reducing CHD risk
Vitamin D binding protein decrease mob/mort CRCA
Sleep and health
Shortened sleep lead to:
-Higher nighttime cortisol, glucose, and reduced insulin sensitivity
-Lower daytime leptin -> highger intake carbs
-Reduced testosterone, growth hormone
-Increased AGEs
-Dyslipidemia
-Endothelial dysfunction
-Elevated BP
-Reduced peripheral perfusion
-Increased MI, CVD death risk
-Impaired learning, memory
-Emotional distress, impaired judgment
-Decresaesd alertness, cognitive processing
-Aberrant DNA methylation
-Immune supression
-Gene transcription dysfunction
-OB, T2DM, CV risk, depression, bipolar, seasonal affective, PMS, worsened PTSD, worsened TBI, cancer
Therapeutic alliance
Trust, empathy, inclusive
Working collaboratively towards goals
Depression Tx
-1st line is pharm alone, CBT alone (for mild), or combo; pharm is SOC for mod to severe
-CBT + pharm are more effective than meds alone for dep, panic d/o, OCD
-LM can be adjunct to pharm and CBT
—–Exercise is as effective as pharm for mild to moderate
—-Decreasing fast food, healthier diet
—–F/V have some evidence for increased eudamonia, fewer negative emotions, decreased symp of anx, dep; more + attitude
Transtheoretical Model
Precontemplation: not planning to change or > 6 months out; use MI; listneing, open-ended ?s; anticipate sustain talk; ask how would know ready to change; provide general info health risks
Contemplation: thinking about change in next 6 months; use MI; anticipate ambivalence b/c pros not yet outweighing cons; needs certainty & assurance; ask how would know ready to change; provide general info health risks
Preparation: Decided to make change in next month; CBT; assess confidence; co-create action plan - goals need to be specific & clear; excited & nervous; schedule follow-up
Action: Actively making changes for < 6 months; not yet met goals; CBT; challenge distorted thoughts; celebrate sucesses; very vulnerable to relapse; lapse prevention plan; estab social supportive resources; estab system of accountability & self-monitoring
Maintenance: Making changes for >6 months but still have some desire to return to old habits; CBT; reconnect w/ purpose for change (build autonomous motivation) & continue setting specific & clear goals
Termination: No longer tempted to return to old habits; has adequate self-efficacy & for skills
Diabetes Prevention Program
diet (low-fat, low-cal) + PA (150 MVPA) + lose/maintain 7% vs. metformin vs. placebo
Progression from preDM to T2DM:
lifestyle vs. placebo was ~60% lower incidence
metformin vs. placebo was ~30% lower incidence
lifestyle vs. metformin was ~39% lower incidence
Saw results even without full adherence (7% wt loss)
How to progress exercise (aerobic & resistance)
Aerobic:
-start at 15 min, moderate intensity, 3-4x week
-Increase by 20% until reach 30 minutes
-Increase duration first, then frequency, then intensity
-Slowly increase from mod to vig and from interval to continuous
Resistance:
-Start w/ single set of 8-12 reps (10-15 for older adults w/ lighter weight) of each major muscle group @ 40-50% 1RM, 2 days week
-Gradually increase resistance (weight), repetition (reps), frequency (#sets, days)
-Goal to get to 2-4 sets of each major muscle group
Goals:
-More reps, lighter load = muscle endurance
-Fewer reps, heavier load = muscle strength
INTERSTROKE
Examined top factors for stroke risk; top 10 lifestyle factors were associated a/ 90% of the stroke risk
NHANES
Ultraprocessed foods represented >50% caloric intake
Undiagnosed DM significant problem
Determinants of health
ACE, SDOH & disparities, genetics/epigenetics, SES, health literacy, environmental conditions
CBT
Cognitive behavioral therapy
Gold standard psychotherapy for many d/o
Best for stages of change Preparation/Action/Maintenance
Recognizes distorted (non-productive) thinking and reframing through self-talk
Distorted thoughts such as all-or-nothing, overgeneralizations, mind-reading, fortune telling, mental filters, magnificantion/minimization, personalization & blame, emotional reasoning, labeling/mislabeling, disqualifying the positive
Utilizes ABCDE method of behavioral change
Pre DM vs DM, other measures & when to screen
Pre DM
A1C 5.7-6.4
FBG 100-125
OGTT 150-199
DM >/= 6.5
FBG >125
OGT > 200
Random BG + symptoms
HOMA-IR - measure of insulin resistance
C-peptide is by product of insulin production - will be decreased in T1 and long term T2
Screen in all OW/OB adults w/ 1 other risk factor and all patients starting at age 45
DASH
Low fat, lots f/v, adequate mag, K+, ca2+, fewer snacks/sweets (vs. isocaloric SAD)
Pt w/ & w/o HTN, not on antihypertensives
Lower SBP & DBP after 2 weeks (-5/-3)
Those w/ HTN baseline had more pronounced improvements (-11/-5.5); age <50 did better
Results were comparable to reductions seen in monotherapy
Orig study kept Na+ stable at 3000 but everything else says low sodium (1500-2300)
Good sources of potassium
Bananas
Potato
Avocado
Beans
Beet greens
Apricots
Dates
Nuts
Green vegetables
Goals for max sodium, fat, added sugar
Max sodium 2300 (goal 1500 in HTN)
WHO goal <10% added sugar (<5% ideal); AHA 6-9 tsp (female/male)
AHA <5-6% total calories sat fat
top source in us diet is cheese
Ornish/Lifestyle Heart Trial
3% regression in coronary stenosis maintained over 5 years
Regression overall (lifestyle only, no meds) vs. progression on meds and tons of progression on no meds
Reduced LDL
CHIP
Diabetic cohort, workplace setting, Vanderbilt
ITLC
Less health care utilization, nearly 25% were able to cut one medication
Labels
Low source = </= 5% DV
Good source = 10-19% RDI or DV (regulated term)
High or excellent source = >20% (regulated term)
Gluten-free (regulated term)
Organic (regulated term)
Low sugar not allowed but lightly/slightly/less sweet is used
Natural is not regulated
Light sodium = 50% less
Reduced sodium = 25% less
No salt added = natural sodium still present
Social media impact on mental health
-Problematic social media use (high frequency) is strongly and independently associated w/ depression
-Assoc w/ poor sleep (esp nighttime use), low self-esteem, anx, dep
Triacylglycerol
Severe caloric restriction (~600kcal) resulted in normalization of beta cell function, reduced hepatic & pancreatic triacylglycerol within weeks
Resilience, self-care, burnout prevention - clinician
primordial: decrease risk factors before burnout onset; building social support networks, advocacy
primary: ID and reduce source of burnout; reduce burdens, normalize struggles, decrease isolation, provide support
secondary: reduce severity of burnout; stress management, mindfulness
tertiary: minimize adverse consequences of burnout; referrals to mental health, EAP
% GDP on health care spending
~20%
Sources Vitamin E
Antioxidant, immune fx, endothelial health
Sunflower seeds
Almonds
Sun/safflower oils
Peanut, olive, corn oils
Peanut butter
Serotonin, melatonin, adenosine
Serotonin highest in daytime
Melatonin (a derivative of serotonin) starts; melatonin starts several hours before bedtime and peaks 30 min before bedtime, then stabilizes until rapidly decreasing closre to subjective day. First light exposure (or bright light at any time) causes melatonin cessation
Adenosine accumilates in brain throughtout day - once sufficient, sleep onset is triggered
Caffeine counteracts adenosine accumulation
GEMINAL
ITLC showed reduction in prostate cancer tumor
Lifestyle Medicine core competencies
Leadership, knowledge, assessment skills, management skills, office/community support
Self-motivation & Self-confidence (Self-efficacy) and how can it be increased/influenced
Self-motivation (autonomous or internal motivation); increased by connecting to meaning, purpose, values
Self-confidence: trust in their own capabilities; can be increased through eliciting positive emotions, change talk, leveraging strengths, robust support system, education to increase knowledge, skills
Self-efficacy: self-motivation + self-confidence = confidence they can successfully perform a behavior
Influenced by behavioral capability & environmental factors; CORE of successful health behavior change
Types of fatty acids
Saturated - solid at room temp
-highest is coconut oil (90%)
-palm oil @ 50%
-lard ~40%
-olive oil ~15%
Trans - naturally found in red & processed meats, butter (so also in baked goods, refined grain products); now “unsafe for human consumption” due to high increase in CVD risk
Poly-unsaturated - omega 6 &3 are essential fatty acids
-Get plenty of omega 6 (corn oil, nuts, seeds)
Omega 3 (ALA, EPA, DHA - ALA can be converted into EPA & DHA; ALA source is algae; also in nuts, oils, fish
Mono-unsaturated
Canola, olive, vegetable oils
NOVA
Unprocessed
Minimally processed (culinary ingredients)
Processed
Ultraprocessed
MET definitions, examples
Metabolic equivalent of a tsk
1.0 = sitting comfortably; standard resting metabolic rate
0.9 = sleeping
<1.5 = sedentary
3 = walking 3mph
5 = walking 4mph
18 = running 10.9 mph (
1= 3.5mL O2/kg/min
amnt of O2/kg consumed in 1 min
Goal ~10-20 MET hr/week comes from figure re: mortality risk (HR 0.6 - 0.7); ~70% of benefit is reached by 8.25 MET hr/week (=150 MET min moderate)
MET hour = MET intensity * duration (hours)
Greatest gain (HR1.0 to 0.8) is with going from completely sedentary to minimally physically active
No evidence of increased risk to health at high end, but benefits plateau after ~20 MET hours/400 minutes MVPA
Iron
Heme vs non-heme iron:
heme iron in animal foods is more easily absorbed; excess ion leads to inncreased risk of CVD, BRCA, stomach & esophageal CA
Non-heme iron in animal & plant foods; may be safer
Pair with Vitamin C increase absorption
Avoid Ca2+ supplements w/ meals, tea/coffee (tannins), or high-oxalate greens
Coach vs. expert
Expert is assessing, diagnosing, creating treatment plan, educating
Coach is building self-confidence, self-efficacy, self-management; patients are leaders
Portfolio
Impact of diet (low fat fiber, soy, plant sterols) on LDL
Showed equivalent to statin
Low-dose CT
Age 50-80, 20-pack year h/o, current smoker or quit <15 years ago
Adventist
Reduced all cause mortality in veg versus non-vegetarian diet
Vegan lower BMI, risk of DM, HTN, met synd
EPIC Oxford
Vegetarian & vegan had 37% lower T2DM risk, 12% lower risk of cancer, 22% lower rate ischemic heart dz
SMART & Action plans & LM prescriptions
Specific, measurable, achievable, relevant, time-bound
Action plans have more specific details
Personalized for patient’s skills, abilities, readiness, & confidence
Body fat %
Normal
male <25%
female <30%
Obese
male >/=30%
female >/=35%
Sleep restriction therapy
Goal to re-entrain circadian rhythms
-Take average sleep duration and shorten it, working backwards from needed waking time
-Slowly extend by 15-20 min/week until sleep need is met
Light vs. Moderate vs. Vigorous
Talk test:
Sing - Light
Talk full sentences, not sing - Mod
Few words - Vig
MET
<3 = light
3-5.9 = mod
>/= 6 = vigorous
1 Rep Max (1RM)
Mod 50-69%
Vig 70+
AUDIT-C
3 screening questions:
1) How many days past year consume alcohol?
2) How many drinks on average day when drinking?
3) How often do you consume >/= 6 drinks on a single occasion?
BMI calculation, categories
weight (kg)/[height (meters)2]
18.5-24.9 normal
25-29 Ow
30-34 OB class 1
35-39 OB class 2
>/=40 OB class 3
Guidelines for weight loss (%, calorie deficit, total calories)
Losing 5-10% body weight initially
Calorie deficit at least 500-750/day for slow, consistent
Need minimum 1200 calories
Women 1200-1500
Men 1500-1800
Lose 1 pound/week
Difficult to accomplish by exercise alone
OW/OB need to exercise closer to 250-300 min (vs. 150)
Offer/refer anyone BMI >/= 30 (OB class I) (or >/=25 w/ CV risk factors) for intensive, multi-modal bheavioral interventions
Insomnia strategies; advancing/delaying sleep onset
-Typically has behavioral component
-Stimulus control: bed for sleep & sex only - this is single most important intervention
-In children, often lack of limit setting and attachment issues (can’t go to sleep w/out person/object)
-Cool, dark, quiet (but not silent)
-Warm bath (vasodilation, helps with cooling)
-Avoid strenuous exercise
-Avoid bright lights, devices
-Deep breathing, progressive muscle contraction
-Shifting wakeup time earlier: eating breakfast shortly after awakening
-Eating dinner too early may lead to falling asleep too early
-If falling asleep too late, shift carbs to earlier meals; avoid snacking and carb-rich dinners; eat an earlier dinner
-Eating more carbs at dinner (2-3 hours before ideal sleep time); good for jet lag travelling west
-Carbs earlier = asleep earlier; carbs later = delaying sleep onset
Measuring fitness
Functional - 6 min walk test - no standard but anticpate 400-700 feet; distance is primary goal
Muscular endurance - situps, pushups, squats
Strength - dynamometer grip strength predicts early mortality, funcitonal status, proxy for overall strength
Flexibility - V-sit
CV - step test
Specific effects of PA on diseases
Exercise = meds for secondary prevention of coronray heart disease and prediabetes
Exercise better than antiplatelets, anticoagulants in reducing mortality following stroke
Exercise not better than meds for CHF mortality reduction
Exercise can reduce SBP but not as much as medications
Exercise improved mobility, balance, gait speed, neuroplasticiy post stroke
Resistance exercise can reduce HgbA1c by 0.5% or more in T2DM - sim to meds
Social Cognitive Theory
Recipricoal determinism: personal factors & human behavior & environment
Observational learning (modeling) - imitation of observed behaviors
Self-efficacy is influenced by behavioral capacity & environmental facilitators/inhibitors
Mastery experiences are key to self-efficacy
Bandura
Definitions for problem drinking
At-risk: bingeing monthly; exceeds levels any day or week; increases risk of future problems even if no current symptoms
Binge drinking:
-4 drinks (female), 5 drinks (male) in 2 hours
Heavy use:
->/=5 drinks on >/=5 days/month
Alcohol use disorder: meet 2 of 11 criteria showing a pattern of impairment or distress
-Consequences, compulsion, craving, loss of control (as opposed to tolerance/withdrawal which indicate dependence)
ABCDE approach
Method of behavioral change (CBT)
Action or event that occurred
Beliefs & thoughts about what happened
Consequences of action/event (emotional response)
Dispute unhealthy or distorted beliefs
Effect of reframing on how you feel; next steps
Based on premise that thoughts & beliefs about thoughts drive emotions which drive behavior
Percutaneous angioplasty vs. exercise in stable CHD
Exercise (vs. PCI w/ stenting) showed higher EFS, less likely to experience angina, signif increased HDL, 1/2 cost, increased exercise tolerance
Sources Vitamin C
Antioxidant, iron absorption, tissue growth/repair
Bok choy,
Parsley
Daikon radish
Cruciferous: Broccoli, Cauliflower, Cabbage, Brussels sprouts
Cantaloupe
Pineapple
Oranges
Mango
Kiwi
Spinach, other leafy greens
Pears
Peaches
Cherries
Stress & Chronic Dz MOA
-Impaired immune function
-Inflammation
-Metabolic disease, increased appetite, weight gain, abdominal fat deposition
-Increased glucose, triglycerides
-Decreased bone density
-Increased clotting
-Decreased wound healing
-Pain, fatigue, low mood
-Telomere shortening
Framingham
2 or more risk factors (vs 0) led to 69% (male) & 50% (female) lifetime arhteroslcerotic CVD risk and ~10 year less life expectancy
Systolic BP imp for CVA risk
Pre-HTN increases CVD risk
Changes in happiness level reached 3 degrees of separation
Light types
-Blue wavelengths are the greatest suppressors of melatonin (monochromatic blue light such as blue appliance lights); shorter wavelengths
-Cool white light: halogen, fluorescent, LED back-lit screens (phone, TV, computer) is less suppressive
-Then warm white light (incandescent, candlelight); longer wavelengths
-Red light actually enhances mealtonin
PAVS
Only validated PA vital sign (vs. assessment tool)
1) How many days a week do you engage in moderate to vigorous physical activity?
2) How many minutes per day?
Can add how many days did resistance training
Leading US causes of death
CVD, cancer, accidents, stroke, COPD/pneumonia, Alzheimers, DM, chronic liver, renal dz
60% US adults have a chronic disease: % of types disease
Approximately: 12% T2DM, 38% pre-diabetes; 40% OW/OB; 47% HTN; 12% hyperlipidemia; 7% CVD
Waist circumfrence, waist:hip ratio
Considered “increased”
men >/=40”
women >/=35”
No standardized place to measure
horizontal plane level w/ iliac crests
WHO says between lowest rib & iliac crests
“Increased” waist:hip ratio
men >0.9
women >0.85
Increased waist and/or waist:hip ratios are associated w/ incresed risk of metabolic complications & other chronic disease
Cortisol awakening response (CAR)
-Necessary for alertness at waking; transition from sleep to waking
-Enhanced by consuming a significant proportion of total daily carbs at breakfast and doing so within first hour of awakening
4 principles of MI
Express empathy (show an understanding, listening, body language)
Support self-efficacy (you guide, they decide; highlight their confidence, change talk)
Roll with resistance (non-judmental, listen, ask open-ended)
Hold up discrepancy (highlight through reflections, non-judgmental, allow them to draw own conculsions)
Theory of Planned Behavior
Based on motivation (intention) and ability (behavioral control)
Attitude
Behavioral intention: motivational factors are most important in predicting behavior
Subjective norms
Social norms
Perceived power
Perceived behavioral control
LM vital signs
smoking status
BMI
sleep quality/duration
perceived stress
alcohol use
dietary pattern
exercise
Patient Activation Measure (PAM)
Patient abilities that lead to improved health outcomes
to self-manage illness or problems
to engage in activities that maintain functionhng & freduce health declines
to be involved in treatment & diagnositic choices
to collaborate w/ providers
to select providers/orgs based on performance or quality
to navigate the healthcare system
PSG, referral indications
PSG warranted:
-sleep apnea suspected
-narcolepsy
-REM sleep behavior disorder
-periodic limb movement d/o
No PSG:
-restless lets
-circadian rhythm d/o (advanced/delayed/shift work)
-insomnia
-non-REM parasomnias (sleep walking, talking, terrors)
Refer to sleep med specialist:
OSA (unless trained to treat, order cpap)
Narcolepsy
Periodic limb movement
non-iron deficient restless legs
Refer to sleep med behavioral specialist:
-CBTi
-Sleep restriction therapy
-Relaxation training
2 key elements for improving health behaviors
- trusting therapeutic relationship
- patient support from multi-disciplinary team, friends/family/community
Medical clearance
Risk of exercise is far greater than risk of continuing to be sedentary!
Greatest risk is going from nothing to high intensity
If walked into office without symptoms - cleared for light activity
Clearance needed if symptomatic CV, renal, metabolic dz
Pulmonary disease usually not need clearance but may need accommodations
PARQ+
Clearance may involve PE, labs, echo, EKG, stress test
Potsdam study
4 healthy lifestyle facotrs: BMI <30, healthy diet, never smoker, PA >/= 3.5 hr/week
all 4 (vs. 0):
93% decreased risk DM, 81% MI, 50% stroke, 36% cancer, 78% chornic disease overall
BMI <30 exerted the largest reduction on risk of any chronic disease
Never smoking exerted largest risk reduction on MI & cancer
Disease-specific exercise recommendations
Pregnancy
DM -
-Sustained cardiorespiratory fitness is one of the strongest independent risk predictors of mortality
-Focus especially on reducing sedentary time (multiple bouts activity aids glycemic ctrl)
-insulin, sulfonyureas; check blood glucose +/- ketones
OB - need >/=250 min mod for weight maintenance and even more for weight loss; may prefer non-weight-bearing or more resistance when starting out becuase of joint stress
Regardless of weight, meeting guidelines conferred same increased life expectancy
CV issues - consider cardiac rehab
Atrial fib - weight loss & improved aerobic fitness will decrease recurrence rates
Common elements behavior change theories
Beliefs about risks/benefits
Internal/autonomous motivation
Self-efficacy
Enviornmental influence (social norms, community, supports)
Health behavior influenced by:
Intrapersonal
Interpersonal
Institutional
Community
Public policy
SDOH
Good sources of magnesium
Nuts
Spinach
Edamame
Dark chocolate
Whole-grain bread
Brown rice
Tofiu
Potato
Black-eyed peas
Lima beans
Stress & the brain
Mindfulness programs resulted in radiographic changes to the brain:
-Increased gray matter density in prefrontal cortex (processing, executive functioning, decision making, memory)
-Increased gray matter density in hippocampus (memory, emotion)
-Decreased gray matter density in amygdala (trauma response, emotion)
-Increased neuroplasticity (sulci show younger than stated age)
Advocacy vs. activism
Activism is typically more extreme, vocal, rigid, upfront
Advocacy - coordinate efforts to defend, promote, or protect something or someone by influencing public policy debate and interacting with influencers. Individual, local, state, federal.
Non-adherence
Medications for chronic illness ~50-80% nonadherence
Ask what led to behavior choices & explore other influences
Good sources of soluble vs. insoluble fiber, goals, MOA
Goal 25g (female), 38 (male) - ideal more like 40/50
Only found in plants!!
Soluble: slowly absorbed, so slows down digestion & absorption of glucose; binds to and removes cholesterol; increases insulin sensitivity
Oats
Peas
Beans
Barley
Apples
Citrus
Carrots
Insoluble: not absorbed, so moves through gut more quickly, stool bulk - reduces CRCA risk, promotes laxation; food for bacteria -> SCFA
Whole wheat
Beans
Nuts
Potatoes
Some vegetables
Nurses Health Study
Not smoking, healthy BMI, healthy diet, exercie, low alcohol resulted in 82% lower risk CHD
Refined carbs & trans fats increased CHD risk
Impact of alcohol on breast & colon cancer risk
Vitamin D on colon cancer/polyps
As little as 1-1.9 hr MVPA/week had risk reduction 82% all cause mortality
Combined w/ Health Professionals Follow-up study:
Health plant-based: 34% less risk T2DM; 25% less CHD
Unhealthy plant-based: 16% more risk T2DM; 32% more risk CHD
Increased risk T2Dm=M w/ meat, processed meat, >/= 5 eggs/week
Lyon
H/o acute MI
Med diet (w/ high alpha lineoleic acid-omega3) prevented second MI and other cardiac risks (50-70% reduction in cardiac mobiditiy/mortality), significant cost reduction
Study stopped early after 4 years b/c of sig effects
Lifestyle & Mental Health - Protection & Tx
Sleep, PA, healthy diet, and not smoking can be protective and/or tx for ADHD, depression, anxiety, bipolar, psychotic disorders
Glycemic index vs. glycemic load
GI is a reflection of the potential to raise blood glucose
-more fiber, lower score; more processed, higher score
GL considers portion size + GI and reflects how quickly food enters bloodstream and how much gloucose per serviing it delivers
Short-term fluctuations in blood glucose are not as important as long-term trends
Provider’s personal health practices - how impact patient
Physically active -> increased counseling
Healthy practices -> increased counseling (e.g., smoking, alcohol, exercise)
Those attempting to improve poor habits -> increased counseling (vs. those not making changes)
Non-smoking -> emphasize risks of smoking
weight patient > provider -> record OB dx & initiate convo
Ate less fat -> counsel on cholesterol
Ate f/v -> counsel on nutrition
Vegetarian diet -> counsel on weight loss
Normal BMI -> more confident counsel about PA
Nutrients of concern, underconsumed, overconsumed
Underconsumed:
Vitamins A, C, D, E, K
Fiber
Potassium
Calcium
Magnesium
Choline
Of concern (public health implications):
Vitamin D
Fiber
Potassium
Calcium
Overconsumed:
Sodium
Saturated fat
[trans fats]
Sugar
[cholesterol]
Group 1 carcinogens (processed meats, alcohol)
MBSR
-paying attention to the space around you, surroundings
-awareness of thoughts, feelings - but not judging them
-increased curiosity, connection, calm
-fully present in the moment
-increased tolerance, resilience, empathy, compassion
Medications for quitting
Tobacco:
-Rx combos are more effective than monotherapy
-Rx + therapy results in highest quit rate
-CBT is first line in adolescents; best for pregnant
-5 types nicotine replacement (patch, lozenge, gum; inhaler & nasal spray require Rx); most effective patch + short-acting; stimulate dopamine release by binding to nicotinic receptors
-Virinocline (most effective monotherapy)
-Buproprion
2nd line:
-Clonidine
-Nortriptilyine
Alcohol:
-Naltrexone**
-Acamprosate (non-adherance due to tid dosing)
-Disulfuram (aversion agent; high non-adherenace)
Off-label: gabapentin, topiramate (for w/d, cravings)
Opioids:
-Naltrexone (opioid antagonist)
-Methadone (full opioid agonist)
-Bupronorphine (parital opioid agonist)
Clonidine can help w/ w/d symp
GAD Tx
Ist line is CBT, SSRI, or physical activity
Adjunct - LM, especially diet
~40% premature deaths can be attributed to the following factors
50% of deaths were related to top 9 facotrs
40% were attrib to tobacco, excess alcohol, poor diet, physical inactivity
really 80% b/c was 40% of the list which was 50%
Impact of MBSR/mediration on stress, mental health
Sys review of 47 studies
-MBSR/meditation showed decreased symptoms of depression and anxiety (moderate evidence)
-Low evidence for stress reduction
-Improved pain (moderate evidence; potential for improved social connection since share pain center)
-No or insuff evidnece for being superior to meds or behavioral therapy, so use as adjunct
Sources Vitamin K
Blood clotting, heart health, bone health
Green leafy vegetables
Broccoli
Cabbage
Asparagus,
Kiwi
Nutrient dense (ranked by most underconsumed w/ least overconsumed)
Vegetables + mushrooms
Herbs & spices
Fruits
Legumes
Whole grains
Nuts
Seeds
Aerobics Center Longitudinal Study
Examined global all cause mortality
Low cardiorespiratory fitness was #1 cause of preventable death
Cardiorespiratory fitness: best reflection of whole-body health & function; inversely associated w/ all cause CVD, CA; often assoc w/ increased visceral adiposity, OB, HTN, hyperlipid, & other chronic dz
Hedonia vs. eudaimonia
Hedonia is pleasure for pleasures sake, maximizing happieness; satisfying desires (e.g. spa, watching TV)
Eudaimonia is doing positive things even though they may be challenging; using strengths; fulfilling personal goals; living up to your potential
Eudaimonia is associated with down-regulation of pro-inflammatory genes, lower inflammatory markers, slower rate cognitive decline
Smoking impact on mortality; benefits of quitting
Smoking is #1 cause of preventable death & disease
-Shortens life expectancy by 10 years
-50% of deaths in smokers will be related to smoking
-1/3 cancer deaths related to smoking
-High co-morbidity with cancer, HTN, T2DM (30-40% higher risk), hyperlipidemia, stroke
Quitting:
-Slow COPD progression
-Immediate benefits in 1st 24 hours
-Immediate decrease risk of MI death by 50%
-At 1 year: decrease CVD risk by 50%
-At 2-5 year: decrease stroke risk to that of non-smoker
-At 10 years: decrease lung cancer risk by 50%
-Quit at 30 -> add 10 years to life
Good sources of calcium
Broccoli
Soybeans
Chia seeds
Collard greens
Kale (low-oxalate)
Almonds
Black beans
High oxalate: spinach, beet greens, swiss chard inhibit ca2+ absorption
