Week 4 Flashcards
Behaviour change: Stages of Change Model: Individual
- recognises that individuals can be classified into discrete ‘categories’ of decisional change-stages
- cannot be forced through stages if not ready
- based on pattern of change in individuals trying to quit smoking
- now applied to numerous other behaviours
Stages of Change
- pre-contemplation
- contemplation
- preparation
- action
- maintenance
Downwards
relapse
upwards
pre-contemplation
- These people don’t want to make a change right now
- “I don’t want to exercise”
- not many options at this stage - act as a resource
What can you do for the patient? - provide information and education
- discuss why patient is here - what do they value?
- tie in what they value with area of focus
- establish trust and rapport - empathise and let patient know this is a long-term process
Contemplation
- Thinking about it
- “im thinking about starting to exercise”
- explore patients previous thoughts on change
Contemplation- decisional balance
- minimise cons and focus on pros
Preparation
- planning it
- “im going to be starting to exercise (date)
- what prompted change? (better health, family, knowledge)
Does patient have a plan? - patient may have some idea or started some actions regarding change
- work with patient to develop plan, set out specifics (timeline, goals, barriers, etc.)
action
- “I have been exercising for 2 months now”
- still have work to do
What things need to be considered: - how recent was change? may not be routine yet
- any barriers not accounted for?
- focus on positive aspects of change - be a cheerleader
- recognise that this is just the beginning and need to guard against possible relapse
Review and revise plan if needed (any barriers?)
- how do they feel? problems? complications?
Relapse
- 6th stage of change but in the opposite direction
- relapse is a common process and part of change
- smokers ‘quit’ an average of 3 times before becoming long-term quitters
- can be small relapse (holidays) or large (injury, loss of job)
- need to identify ‘trigger’ of relapse (may have nothing to do with desired behaviour change)
- what is current stage of patient (may skip stages, i.e. maintenance to preparation)
Maintenance
- “I have been exercising for 2 years now”
- interaction may not need to be as intense
- keep patient interested to maintain behaviour (review motivation, revise goal)
- barriers still may arise
- have plans for ‘high-risk’ situations that can be a barrier to maintaining behaviour
diet and nutrition
- diet is a complex behaviour (shopping, food preparation, eating)
- many choices are based on taste, price and convenience, and culture
- a healthy diet does not need to be tasteless
- many of us eat more than we require
- decreasing fats are being replaced by refined carbohydrates
is dietary cholesterol bad?
- dietary cholesterol has little relationship with blood cholesterol
- in most of us, your body will produce the cholesterol it needs
- in Feb 2015, the US Dietary Guidelines Advisory Committee removed a warning of high dietary cholesterol
- In Cada there is no guideline on cholesterol
- when you lower dietary cholesterol you change other things in a person’s diet as well
saturated fats
- mostly from animal products
- solid at room temperature
- no association with mortality, cardiac events
- are they bad? it depends on what you replace them with:
- carbohydrates?
- unsaturated fats?
trans fat
- fats formed through hydrogenation for extended shelf life
- found in processed foods
- up arrow LDL-C and down arrow HDL-C
- positively associated with mortality, cardiac events
sugar taxes
- similar premise to tobacco - tax something you want people to consume less of
- over 50 countries have implemented sugar tax of some kind (not Canada)
Critics: - regressive tax - affects poor more
- won’t solve obesity
- nanny state (telling people what to do)
Mediterranean Diet
Characterised by high intake of:
- vegetables
- legumes
- fruits and nuts
- minimally processed cereals
- moderately high intake of fish
- high intake of monounsaturated lipids coupled with low intake of saturated fat
- low to moderate intake of dairy
- low intake of meat products
- regular but moderate intake of alcohol
Benefits of the Mediterranean Diet - Lyon heart study
- 423 first myocardial infarction patients assigned to Mediterranean diet or Western diet for 46 months
- Mediterranean diet associated with 72% reduction in combination of cardiovascular death/non-fatal myocardial
Benefits of the Mediterranean Diet - European Prospective Investigation into Cancer and Nutrition (EPIC)
- nearly 500,000 men and women
- mediterranean diet associated with a small, but significant, reduction of risk
- 4.7% cancers in men and 2.4% in women could be avoided if all followed med. diet
sodium in the bloodstream
- sodium regulates cell volume, needed for nerve impulses, transport of glucose, amino acids and other nutrients into the cell, muscle contraction, etc.
- in the bloodstream sodium is maintained in constant proportion with water
- the body does not store water-soluble sodium for a long time. The excess sodium is disposed of by the renal (kidney) system in the urine
Sodium and hypertension (individual level)
- increasing your intake of sodium stimulates the body to increase its intake of water-containing foods
- this increase in blood volume raises blood pressure - until we can eliminate the excess sodium (and water)
- about 1/5-1/3 of people are hypersensitive to the effects of sodium on blood pressure
Sodium intake
Health Canada <2300 mg/day (1 teaspoon salt)
- in the past <1500 mg/day
CAN crude average: 2760 mg/day (Health Canada 2017)
- US 3400 mg/day
WHO target <2000 mg/day
Where does your salt come from?
5% added while cooking
6% added while eating
12% from natural sources
77% from processed and prepared foods
Does process foods add sodium?
YES A LOT
What are some of the obstacles to introducing a salt policy?
- no viable alternative
-> microbial food safety, preservation and shelf life
-> control of fermentation in cheese and bread
-> maintenance of colour in meats - taste
- industry opposition
-> salt industry
-> food sellars - Canadian lifestyle facilitates fast-food
- price
- opposition to regulation
Sodium and blood pressure
Review of low vs high sodium diets concluded: sodium reduction resulted in a 1% decrease in blood pressure in normotensive, a 3.5% decrease in hypertensives
Potential benefits of lower salt intake
If the US population reduced its sodium intake to 1200 mg per day, there would be the following reductions:
- coronary heart disease: 60,000 - 120,000
- Stroke: 32,000 - 66,000
- Myocardial infraction: 54,000 - 99,000
- All-cause deaths: 44,000 - 92,000
This is similar in magnitude to tobacco, obesity, and cholesterol
so what does it all mean?
- we need salt to live - not just involved in blood pressure
- studies seem to agree on lowering sodium in people with high blood pressure
- incredibly hard to lower sodium to 2300 mg/day
- high salt foods are usually processed and may be detrimental apart from sodium content
- difficult to have a low sodium diet without a high potassium one
Challenge with Nutrition Science
Nutrition research is messy:
- relies on recall
- substitution
- few randomised trials
- still don’t know what ‘ideal’ diet is
- most fad/health diets promote whole, natural foods and limit sugar and processed foods
Assisting Canadians with their diet
- influence the consumer- marketing
- influence the choice at point of purchase
- influence the production and composition
Influencing the production and composition
Two main options:
- voluntary - incentives needed
- involuntary - government intervention needed
- use of guidelines/protocols
- working with the industry
- consumer demands/expectations
Example: trans fatty acids
Point of purchase education
Front of package symbols - e.g. check mark
- what does it mean - healthy, healthier, healthiest
- who places the symbol (motivations)
Challenges
- nutrient criteria
- use of words, “lite”, “fat free”, etc
Nutrition labels
- complexity - message requires a certain level of literacy and comprehension
- clarity - does the information permit a healthy choice
Health Canada changes to food package labelling
changes to:
- nutrition facts table
- list of ingredients
- serving size
- sugars
Physical Activity
- any bodily movement produced by skeletal muscles that requires energy expenditure
-> exercise is a planned, formal subset of activity for the purpose of improving fitness/health - many of us do not get the recommended amount
- misconception of all or none
- increasing your current activity by any amount is beneficial
- low intensity activity is beneficial
- one of the most cost-effective prevention strategies
Physical Inactivity: Effects
associated with:
- obesity
- diabetes
- cardiovascular disease
- some cancers (colon cancer, breast cancer)
WHO calls physical inactivity the 4th leading modifiable risk factor for early death
WHO Current Recommendations - don’t need to memorise but good to know
- 150 mins of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate - and vigorous-intensity activity
- adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate-and vigorous-intentisty activity
- muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week
AHA Scientific Statement - Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease
- health professionals to engage in an active lifestyle
- encourage schools and communities to promote and facilitate physical activity
- be educated about exercise as a therapeutic modality
- prescribe exercise and physical activity
- perform stress testing prior to vigorous exercise in selected patients at high risk, with symptoms or cardiovascular diseases
