Lifestyle Medicine

Multiple Risk Factor Intervention Trial (MRFIT)

low risk fx's -->: -73-85% lower CVD mortality risk -40-60% lower total mortality rate -6-10 yrs more life expectanccy

Lyon diet Heart Study Diet

mediterranean diet > AHA step 1 diet

EBM exercise benefits

meta-analysis showed exercise>meds for: post-stroke trx -exercise=meds for secondary prevention of CAD and prediabetes -diuretics<meds in HF

Short sleep misperception

mismatch b/w sleep duration and interpretation (think you're not sleeping well but you are)

Self-motivation, self-confidence, self-efficacy

motivation: internal drive; connect pt's personal drivers to behavioral changes confidence: pt's trust in their own reasoning, capabilities and qualities efficacy: built from motivation and confidence; the level of a person's confidence to successfully perform a behavior (influenced by own behavioral capability and environment)

Chronic Care Model

Partnering with community resources, encouraging self-management, and practicing care w/in healthy systems organizations

Mini Sleep Assessment

- typical weekday hrs/sleep -weekend hrs/sleep -perceived sleep quality -look for < 7 hrs/sleep, >1-2 hr weekday/weekend difference, poor quality, > 9 hrs, daytime fatigue, sleep disturbances, sleep onset >20 min

Muscle Endurance Assessment

-# correctly performed reps during one minute: squats, push ups, sit ups -have established norms for age/sex

Flexibility exercise guidelines (from Am college of sports med)

-10 min 2-3 d/wk (better if daily) -each major muscle group x 10-30 sec each x 2-4 reps (total 60 sec for each group) -older adults: hold stretches longer (30-60 sec) total 60 sec -no pain, best when muscles are warm, no bouncing

PA recommendations to reduce T2DM

-150 min/week moderate intensity -best glucose control if combined with dietary advice

Ornish Lifestyle Heart Trial

-1990 with 5 yr results in 1998 -blinded RCT; n=48 adults with CAD -control; usual care with info about healthy eating and exercise -intervention: lifestyle program (low fat veg diet, aerobic exercise, smoking cessation, stress mgmt, group support) with no lipid lowering meds -f/u: 1 and 5 years -outcome: CAD stenosis via angiography -results: 7.9% reduction in stenosis (exp) vs 27.7% increase in stenosis (control); 47% increase in stenosis in controls not taking lipid lowering meds; 25 cardiac events (exp) vs 45 (control)-RR: 2.47 -CAD regression lasted x 5 yrs in exp group but control had continued progression -dose-response relationship for adherence and stenosis regression -82% exp group had regression

Positivity Ratio

-2-minute online test -measures positive emotions over past 24 hours -recommend to use x 2 weeks to track change in emotions -good measurement of resiliency -not standardized test

Red meat consumption and T2DM risk study

-2011 -n=from other studies: 37000 M, 80000+87000 women -f/u 4 million person-years -assessed diet by FFQ q 4 yrs -outcome: incidence T2DM -eating unprocessed red meat was associated w/ T2DM risk after adjusting for age, BMI, other lifestyle fxs -pooled HR for 1 serving red meat: unprocessed: 1.12 processed: 1.32 total: 1.14 -RR's: 100g unprocessed red meat/day 1.19 50 g processed red meat/day 1.51 -substitue 1 serving nuts, low-fat dairy or whole grains for one serving red meat/day decreases risk of T2DM x 16-35% -conc: processed red meats increase risk of T2DM

Fats and Carbs for CHD risk study

-2015 -n=43000 M, 85000 F w/o T2DM, CVD, or CA -diet assessed by FFQ q 4 yrs -f/u: 24-30 yr -outcome: CHD -polyunsat fat vs lowest=20% lower risk -whole grains vs lowest=10% reduction -intake of refined starches/added sugars=10% increased risk -replacing 5% calories from sat fat with PUFAs, MUFAs, or whole grains decreased risk x: 25, 15, 9% lower risk -replacing sat fatty acids with refined starches/added sugars had no change in CHD risk (not significant) -conc: PUFAs and whole grains lower CHD risk vs SFAs; trans fats and refined starches/added sugars raise risk of CHD vs SFAs (not significant)

Aerobic exercise activity guidelines

-3-5 yo: physically active throughout the day -6-17yo: 1 hr/day moderate: include vigorous >=3/wk, bone strengthening >=3x/wk and muscle strengthening >=3x/wk -18-64: 150 min mod/wk or 75 min vig per wk or combo; better health benefits=double the recs; any breakdown of minutes=ok ->65 yo: adult guidelines if capable, otherwise as much as they can -pregnant F: 150 min mod/wk or same as prior to pregnancy if vig -chronic dz pts: 150-300 min mod/wk or 75-150 vig/wk or combo or as much as possible additional health benefits: 300 min/wk mod or 150min/wk vig or combo (double regular recs) lose weight=90 min/day maintain weight=60 min/day general health benefits=30 min/day

Physical Inactivity stats

-4th leading RF for global mortality -Aerobics center longitudinal study: low cardio fitness was the #1 cause of preventable deaths from all cause (over smoking and obesity) -other study showed 6.9% all-cause mortality d/t sitting (independent of PA) -causes 1/10 premature deaths -% burden of dz attributable to physical inactivity: 6% CHD, 7% T2DM, 10% br CA, 10% colon CA -RR mortality decreases stepwise: 20% w/ 1.5 hr exercise, 30% with 3 hrs, 40% with 6 hr/week)--150 min mod PA reduces mortality x 19% (7 hrs/wk=24%) -only 50% adults meeting guidelines for PA

6 Lifestyle changes to reduce HD x 90-95%

-50% decrease in total cholesterol (decrease HD x 50%) -6mmHg dec in SBP (dec HD x 16%, 42% for stroke) -stop smoking (dec AMI x 50%) -maintain ideal body weight and waist size (dec HD x 35-55%) ->=150min mod exercise/week (dec HD x 35-55%) ->-5 fruit/veg servings/day (dec HD x 20-25%) -all of the above=90-95% decrease in AMI risk -smoking 1-5 cigarettes/day increases AMI risk x 40%

Assessing Functional Capacity

-6 min walk test: walk as far as possible in 6 min (may stop and rest); mimics daily life; useful to compare pre and post on same patient (no standard rating)

Prescription for Health Model

-6 yr initiative by Robert Wood Johnson Foundation -22 PCP cites to develop 27 evidence based strategies to improve delivery and efficacy of health behavior change in PCP -4 risk behaviors: tobacco use, risky alcohol use, unhealthy diet, lack of PA -results: feasible for PCPs; practice re-design was needed to integrate public health and community resources; ePSS development based on USPSTF recs for screening, counseling and prevention

Strength training/resistance exercise guidelines

-6-17 yo: 1 hr x 3/wk -18-64: 2-3/wk (48 hrs apart) healthy adults: 1 set 8-12 reps per muscle group older adults: 1 set 10-15 reps muscle groups=chest, back, shoulders, biceps, triceps, abs, quads, hams ->65: same as adults but with lighter weights -chronic dz: strength 2/wk or as much as possible 1-3 sets of 10 exercises increases resting energy expenditure 5% (100 cal/day) for 3 days after workout

Assessing Cardio fitness

-6-minute walk test -max VO2 -Step testing -submaximal talk test for ventilary threshold (approximates highest level of activity sustained for 1-2 hrs; measure lactate in blood--lungs must blow of CO2 to compensate) -rockport walking test: estimates VO2 -Fitness registry and the importance of exercise national database (FRIEND): has reference ranges for max VO2 for age/gender

Stress vital sign

-70% PCP visits are related to stress -use perceived stress scale assessment (10 ?'s, ranked 1-5); higher score=more stressed

Stress and disease

-70% PCP visits d/t stress and lifestyle -stressed people are less likely to do healthy behaviors -stress affects organs, neuroendocrine balance, and immune system -chronic stress can be dx and prevented/trx

Eggs

-? increased risk for DM if >3 eggs/week -no relationship with CVD risk -1 egg=140-340mg cholesterol (<300 mg chol/day rec by 2010 dietary guidelines, no current recommendation other than minimize)

USPSTF Guidelines

-AAA screening x 1 w/ US M 65-75 w/ smoking hx (any amt) -HTN: >=18 yo q 1 yr -obesity: all adults -DM: 40-70 yo BMI>25 -tobacco screening: all adults+pregnant women (I in adolescents)

Diabetes Risk Assessment Tools

-ADA risk assessment for developing T2DM -Finnish Diabetes Ass'n: 10 yr risk of developing T2DM -Austrailian T2DM assessment tool:

LM Prescription for Sleep

-Actions/environment: (bed=sleep and sex only), regular sleep wake cycle, increase pm peripheral cutaneous vasodilation (bath/shower, socks, heating pad, no caffeine), no bluelights or noise, power naps = <30 min, increase daytime light exposure, PA -Dietary: no caffeine after noon, no alcohol w/in 3 hrs of bed, no late night snacking, avoid high Na foods (vasoconstrict), hydrate -stress: turn off 1 hr before bed, wind-down routine, MBSR/meditation

Lab test for LM

-CMP (kidney, liver, blood sugar, proteins, electrolyte, acid/base) -CBC -fasting lipids TC=HDL+TG <150=good LDL=TC-HDL-(TG/5) or LDL=TC-HDL-TG/2.17)-->only if TG<400 HDL TG: elevated norm ass'd with low HDL and increased waist circ -hsCRP: chronic inflamm marker for CVD risk assessment -fasting serum glucose, a1c, oral glucose toleranct, fasting serum insulin, c-peptide, HOMA-IR c-peptide: measures endogenous insulin production/B-cell fx HOMA-IR: homeostatic model assessment for insulin resistance=estimate of insulin sensitivity and B-cell fx from fasting plasma glucose/insulin/c-peptide measurements -Vita D (25-hydroxychalecalciferol) -TSH and T4

Integrative Medicine

-COMBINES alternative medicine with conventional medicine -patient centered -addresses all aspects of health (very comprehensive) -includes meds and supplements in addition to lifestyle medicine techniques

Hyperlipidemia Nutrition Prescription

-Decrease fat intake (transfats, sat fats (cheese, pizza, dessert, chx) & omega 6 FA's) -reduce animal product intake -increase fiber (40-45 g/day), omega 3, plant sterols -eat vegetable rich diet -increase nut intake (1 handful/day each almonds, walnuts, +/- pecans)

Dietary Guidelines for Americans

-Dept of Agriculture and Dep't of HHS -updated q 5 yrs -based on recs from Dietary Guidelines Advisory Committee (experts)

Trans Fats

-FDA: unsafe for human consumption and removed from food 2018 -high: solidified plant oils, processed foods, meats, dairy -top sources in US: grain based processed foods>animal>margarine>french fries>potato/corn chips and microwave popcorn -Trans (trans orientation must be made in lab setting; higher melting point; stiffens cell membrane) -partially hydrogenated vegetable oils -H's on opp side-->straighter C-C chain -increase CVD and stroke

CVD Risk Fx Measurement tools

-Framingham risk assessment (risk of MI in 10 yrs; used for >20 yo w/o HD or DM; assesses: TC, HCL, smoking, BP, HTN meds; underestimates risk for pt w/ DM) -2008 Framingham: includes DM so applies to stroke, TIA, claudication, HF -2013 ACC/AHA: 10 yr risk for athersclerotic CVD; used for M/F, 40-79 yo, AA, non-hispanic caucasiian only; rec's statin initiation for CVD risk prevention -2015 MESA: multi-ethnic; coronary Ca score; measures 10 yr HD risk; M/F; -Reynold's risk score for Women: fx's include FH, hsCRP; predicts risk of global CVD

T2DM Reversal, beta cell function normalization-Lim, Diabetologia, 2011

-H: dietary caloric restriction can reverse beta cell failure and insulin resistance -n=11 T2DM (2 F)+ 8 matched controls -pre and post quasiexperimental -f/u: 1, 4, 8 wks -intervention: 600kcal/day -outcomes: beta cell function, hepatic and peripheral insulin sensitivity and basal hepatic glucose output -results: fasting plasma glucose normalized (9.2-->5.9;166-->106); insulin suppression of hepatic glucose output improved; hepatic triacylglycerol content fell; insulin response increased; max insulin response became supranormal; pancreatic triacylglycerol decreased -conc: dietary energy restriction normalized beta cell fx and hepatic insulin sensitivity in T2DM with decreased pancreatic and liver triacylglycerol stores *CALORIC RESTRICTION CAN REVERSE T2DM*

Relapse Prevention

-Identify high risk situations -plan ahead for potential lapses (skills to get back on track) -cognitive restructuring (don't abandon goals if have a lapse, identify unhelpful though patterns)

Mindfulness Based Stress Reduction (MBSR)

-Jon Kabat-Zinn -9 classes/8 weeks (45 min practice, workbook and group activities) + continued practice 6d/wk -formal: meditation -informal: attention -gives ppl time bw stimulus and response to analyze -STOP (stop, take a breath, observe, proceed)

ACC/AHA lipid trx recs

-LDL>190 -DM 40-75 LDL 70-189 w/o CVD -DM 40-75 w/ 10 yr CVD >7.5% lifestyle recs for all: DASH diet (-LDL -11), mod-vig aerobic exercise 40 min x 3-4/wk (-LDL -3-6)

Diabetes care to cure-Lausanne, Front Endocrinology, 2018

-LM hasn't taken hold bc hard to maintain behavioral change and no payment in current healthcare system -T2DM is combo of genes and environment -T2DM can be reversed w/ lifestyle change -focus of T2DM: LM, behavioral change, socioeconomic/environmental changes

Core Competencies for Prescribing Lifestyle Medicine

-Leadership: -healthy behaviors=foundation of medical care -personally practice healthy lifestyle -advocate for and create healthy environments -knowledge: -know evidence on smoking, exercise, plant-based diet -pt-provider relationship -assessment skills: -full LM assessment (social, psychological, biological) -behavior change stage of pt and family -LM "vital signs" -mgmt skills: -practice national guidelines -evidence based action plan/lifestyle prescription w/ pt and family -evidence based counseling methods -referral if needed -office and community support: -interdisciplinary team approach -office systems to support LM -QI, community referral

LM depression trx

-Lifestyle: (exercise, mindfulness (intentional distraction and relaxation), bibliotherapy, light therapy, computerized interventions, sleep mgmt, positive relationships and support, address lifestyle related risk fx's (poor sleep, poor diet, loneliness) -psychological: use if not responding to lifestyle (CBT, Behavioral therapy, interpesonal therapy, psychotherapy) -pharm: SSRIs, SNRIs=1st line (NNT: 1/8, 2/3 w/ SE's) TCAs: if SSRI/SNRI not tolerated; NNT: 1/16, 1/4 w/ SE's MAOs: more SE's and food interactions, 3rd line trx -combo therapy:

LM trx for T2DM & Metabolic syndrome

-Low fat vegan diet -exercise to decrease insulin resistance -Ornish lifestyle program -reduce stress -minimize refined carbs (processed carbs, pastas, sugars) and free fats -carbs + insulin resistance injures beta cells, elevates glucose

Insurance and tobacco cessation

-Medicaid: 41 states for individual counseling, less for group and phone -Medicare: anyone who smokes (w/ or w/out illness) -private: most coer

Lyon Diet Heart Study

-Mediterranean diet vs AHA Step 1 diet for secondary CVD prevention -med diet had protective effects x 4 yrs after AMI (helps decrease morbidity and mortality)

Mono-unsaturated fats

-Monounsaturated -liquid oils at room temp -olive oil/olives -avocado oil/avocados -healthy

Policy supporting LM

-National prevention strategy of ACA -Healthy People 2020 -National Strategy for Quality Improvement in Health Care (congressional report 2011) by HHS recommending to promote effective prevention, whole team effort, community improvements

low fat vs low carb diet for weight loss+insulin secretion genotype influence (DEITFITS)-Gardner, JAMA, 2018

-RCT -n=609 non-DM -intervention: 12 mo x healthy low-fat or low-carb diet (education in 22 sessions) & SNP genotype patterns and insulin secretion -outcome: weight loss -f/u: 1 yr -results: weight change was similar in both grps (6 kg); no significant diet-genotype pattern or diet-insulin secretion pattern

National Diabetes Prevention Program (DPP)-Knowler NEJM 2002

-RCT -n=>3000 pre-diabetics -placebo vs metformin (500mg bid) vs lifestyle (>150 min PA/wk to get 5-7% weight loss w/ less fat, decreased calories + my plate) x 12 mo -outcome: incidence of T2DM -table 1: 51 yo, 68% F, 45% minority, BMI 34 -f/u: 2.8 years (shortened bc ethics issue--do lifestyle or metformin) -results: DM incidence: 11 placebo, 7.8 metformin, 4.8 lifestyle DM incidence reduction: lifestyle-58%; metformin 31% -NNT in 3 yrs w/ lifestyle intervention: 6.9 -NNT in 3 yrs w/ metformin: 13.9 -earliest RCT for lifestyle intervention vs meds in PREVENTING chronic dz -reduced risk of T2DM x 58% and 71% in >=60yo (all ethnicities and genders) -decreased CVD risk also with decreased BP and cholesterol -further questions: sustainability of changes and any long-term vascular benefits/mortality benefits (10 yrs after, participants 1/3 less likely to get T2DM)

Hambrecht Study-Circulation 2004

-RCT to compare PCI with stenting to exercise for stable CAD -f/u: 1 yr -n=101 males -outcomes: angina free exercise capacity, myocardial perfusion, cost-effectiveness (avg $ to improve canadian CVD score x 1), freq of clinical end point (death, stroke, CABG, angioplasty, worsening angina-->hopsitalization, AMI) -intervention: 12 mo x exercise x 20 min/day at 70% symptom free HR or PCI w/ stent -results: higher event free survival (88% to 70%); increased VO2 max (both statistically significant) -$7000 vs $3500

Atkins, Ornish, WW and Zone diets for weight loss and HD RR-Dansinger, JAMA

-RCT-single center -n=160 overweight/obese 22-72 yo's w/ HTN, DLP, or pre-diabetes -intervention: atkins (low carb), zone (macronutrient balance), WW (calorie restriction) or Ornish (low fat) -f/u 1 yr -outcomes: weight loss and HD RR -results: weight loss: atkins-4.6 lbs, zone-7.1 lbs, WW-6.6 lbs, Ornish-7.2 (weight loss amt ass'd with diet adherence but not type) -DLP: all reduced LDL/HDL ration x 10% -HTN: no change -pre-DM: no change -adherence ~ 25% -weight loss ass'd with decrease total/HDL ratio, CRP, insulin (no diff bw diets)

Portfolio Diet Study-Jenkens JAMA 2003

-RCT; n=55 -intervention: portfolio diet with cholesterol lowing food (plant-sterols, soy protein, viscous fibers (eggplant/okra), and almonds) or lovastatin 20mg qd + usual diet (below) -control: usual trx diet (low fat, whole wheat cereal) -f/u: 1 month -outcome: LDL reductions -results: controls 8%, statin 30%, portfolio diet 28% -outcome: CRP reductions control 10%, statin 33%, portfolio 28% -results: no significant difference bw results of statin group and portfolio diet -reduction in HDL was reported as an adverse event -FDA now supports foods with high plant sterols as CHD reducing process

Obesity Guidelines

-USPSTF: all adults (>18 yo) should be screened for obesity; if obese (BMI>30)-->offered intensive lifestyle intervention (grade B) -ACA/AHA 2013: BMI>27 + CVD risk fx's or BMI>30=comprehensive lifestyle intervention + pharmacotherapy

Lifestyle prescription for weight loss

-WFPD -emphasize nutrient density=high fiber (non starchy veg/legumes) -high protein (plant based) -healthy fats (Med diet) -low glycemic load (complex carbs and no added sugar) -+/- intermittent fasting -60-90 min/day PA -caloric restriction 500/day=running 35 miles/week for 1 lb weight loss per week

Added sugar/high fructose corn syrup Foods

-WHO rec <10% calories from sugar with <5% (6 tsp) added sugar/day; American average=13% calories and 13 tsps added -AHA: max 100 calories (6 tsp sugar or 24 g per day for women, children, teens; 150 calories (9 tsps, 36 g) for men -top 5 sources of sugar in US diet: beverages>snacks/sweets>grain based desserts>other desserts>dairy desserts -LIQUID SUGAR CALORIES=MOST

Entrainment

-ability to be brought into rhythm (synchronization based on external inputs) -ex: wake/sleep cycle entrained by day/night -awakening cortisol entrained by am food

Keys for positive patient-provider relationship

-acknowledge and reflect pt views of self care and QOL -support pt's autonomy -promote pt self-efficacy

Overconsumed foods in the SAD diet

-added sugar/high fructose corn syrup (beverages) -cholesterol (animal products +/- fungi) -sat fat -sodium -trans fats -processed grains (white flour, rice, pastas) -high calorie foods (desserts, chx, sweetened bevs, pizza)

Lifestyle medicine approach

-addresses lifestyle related causes of morbidity and mortality -trx=lifestyle changes; other adjuvants as needed -requires effort and commitment from patients -long term treatment -patient is active partner in trx -evidence-based; avoid fads

Balance/Neuromotor exercise guidelines

-adults: motor and proprioception skill 20-30 min/day (balance, yoga, etc); total: 1 hr/wk ->65 yo: balance training >=3/wk (helps reduce risk of falls)

Circadian rhythm modifiers

-change the amt of input that gets to SCN -pupillary reflex (alters amt of light into RGC) -sunglasses, bluelights, sunlamps (changes intensity of light) -SNPs: PER and CRY proteins -cutaneous fat stores: affect temperature -vascular tone (affects temp)

Saturated Fats

-all carbon bonds filled, no turns/bends -higher melting point -solid at room temp -thickens cell membrane and interferes with signaling and transport of mlcs; lots in animals -lauric (coconuts): neutral -stearic (cheese?, dark chocolate): neutral -palmitic (palm oil, milk, meat): most common sat fat): harmful -myristic (dairy, coconut oil, butter): harmful -increase TC, LDL, HDL, CVD risk and colorectal cancer -highest sources in US: cheese, pizza, grain based desserts, dairy desserts, chicken

Nutrient Packages

-all natural sources of food provide a nutrient package -only manufactured foods have a single nutrient content (vita C, co-Q10, Ca) -whole foods=favorable nutrient packages -plants>animals for nutrient mix EXCEPT in some metabolic deficiencies -we don't know all the nutrients we are getting from food or all the nutrients we need yet so best way to get proper nutrition=whole foods from the earth

Conventional Medicine

-allopathic medicine -dz=secondary to exposure to pathogens or environmental fxs or genetic predisposition -trx: acute and target pathogens or long-term to target risk fx's -dz-focused approach -patients are passive recipients of care, not participants -physician centric -symptom-targeted treatment -pt not required to make major changes

Nurses' Health Study and Health Professionals' f/u study

-annals of IM 2001 -n=84000 nurses x 14 yrs; 45000 physicians x 8 yrs -outcome: nonfatal or fatal MI -diet assessed by food frequency questionnaire -1 daily serving of fruits/vegs >3 per day reduced risk of CHD x 4% -RR 0.96 p<0.01 -processed meat > 5x/wk increases r/o DM

Plant-based diet and depression

-arachidonic acid (chx and eggs): ass'd with increase r/o depression and SI -vita C= co-factor of dopamine production

Therapeutic Lifestyle Change

-as effective as psycho or pharmaco therapy -trx and control mental disorders -elements: PA, diet, time in nature, relationships, stress mgmt, spiritual involvement, service to others

Tobacco Use Vital Sign

-ask re: tobacco use (all forms, current, past, etc) -document type of tobacco, length of time using, and frequency (pack years)

Alcohol and mortality

-ass'd w/ 10% all CA's, 20% intentional injuries, 7% deaths

Sleep Stats

-avg US adult sleeps 6 hr 57 min (20% sleep < 6 hrs) -37% YA's sleep < 7 hr/night (doubled stat since 1960) -1/3 life spent sleeping -no objective test for how much sleep someone needs

Theory of Planned Behavior/Reasoned action

-behavioral change is based on motivation (intention) and ability (behavioral control); based on behavioral intention (motivation behind making a change=biggest driver of change) -6 constructs represent one's actual control over behavior 1. attitude (re: risks/benefits/control) 2. behavioral intention (motivation) 3. subjective norms (perception of other's opinion re: behavior) 4. social norms (actual behavior of a group/customs of a group) 5. perceived power 6. perceived behavioral control

circadian rhythm outputs

-behavioral/physiological consequences of operators -sleep -performance: alertness, kinetic activity, motor skills (precision), strength/stamina -food seeking behaviors (quantity and quality)

Cognitive Behavioral Theory

-best for preparation, action, maintenance stages -helps with problem solving basic principles: -recognize and reframe non-productive thinking (all or nothing, catastrophizing, discounting the positive, overgeneralizing, mind reading, fortune telling, "should" or "must" statements) -be aware of underlying beliefs/emotions -reframe self talk by working through ABCD of behavioral change A: what Action or event occurred? B: what Beliefs do you have about what occurred? C: what are the emotional Consequences of those beliefs? D: how can you Dispute the beliefs that are unhealthy or Distorted?

Omega 6 Fatty Acids

-biggest source=chicken>grain based dessert>salad dressing>chips>nuts/seeds>pizza>breads>pasta>mexican>mayo>quickbreads>eggs>popcorn>sausage/bacon/ribs -soybean oil=54% omega 6 -pecans=high in omega 6 (walnuts=high in omega 3) -olive oil=monounsaturated (omegas=polyunsat) -dark leafy greens=1:1 omega 6:omega 3

Circadian rhythm operators

-body's rxn/response to modified inputs -core body temp -melatonin secretion -cortisol secretion and timing of spike -cutaneous blood flow

Mindfulness Research

-brain can grown 700 new neurons/day -brain restructures based on thoughts, attitudes, emotions -conscious thought can re-train brain through activating self awareness (extended and momentary separately) -8 wks mindfulness = increase L prefrontal cortex (planning, personality, happiness); increase gray matter in hippocampus, reduce gray matter amygdala (emotion/stress/depression) -strengthen pre-frontal cortex-->amygdala connection (problem solve and modulate emotions)

Food and sleep

-breakfast: none, late, low-carb=decreased cortisol spike; early breakfast helps shift wake-up time earlier -dinner: increased carbs (or late diinner) delays sleep

Stress Screening

-brief discussion re: stress recommended for all pts -stress mgmt plans help prevent/trx stress -work stress + HD, T2DM -perceived stress scale (cohen, 1983)-10 ?'s

Macrocitic Anemia and Plant Sources

-caused by B12, B9/folate or homocysteine deficiency (rare in WFPD) -CBC w/ diff -vita B12 (cobalamin)--only made by bacteria; fix=fortified foods (milk) or supplements (water soluble, no OD concern) -B9/folate: plants ~ dark leafy greens, cruciferous vegetables, peas -elevated homocysteine is ass'd with CVD but adds little to other biomarkers (lipids, CRP); no added value to get homocysteine levels for CVD risk profiling

Smoking death stats

-causes 1/5 deaths in US -tobacco products kill 1/2 people who use them -smoking=87% lung CA deaths, 32% CVD deaths, 80% COPD deaths -ARR for CA=30%

Circadian Rhythm

-central + peripheral oscillators -central = suprachiasmic nucleus -peripheral =all major organs to allow synchronization w/ centrsl -sleep propensity: ability to transition to sleep or stay asleep

Suprachiasmic Nucleus (SCN)

-central clock -part of hypothalamus -regulates melatonin -nerves from SCN directly innervate other tissues -input nerves=from retina to entrain central oscillators -output nerves=to pineal gland for melatonin secretion -output splanchnic nerves=to ANS/adrenal glands-->NE/epi/glucocorticoids/aldosterone to regulate blood flow, T, food intake

Micronutrients

-chemical elements essential in small amounts for growth and health (vitamins/minterals) -beneficial non-nutrients: good but not essential for life (antioxidants (decrease inflam), anti-inflam, phytochemicals, support immune system, etc) -supplements not required to get micronutrient balance, better from whole food -normally: antioxidant, improve cell health, anti-inflam -balance is key: too much or too little is bad -prescription: specific foods that tend to contain specific micronutrients; don't prescribe specific micronutrients

Nutrient deficiency and mood

-child-bearing age F: folate, B12, Ca, Fe, selenium, zinc, omega 3's ass'd w/ depression; folate deficiency decreased med. efficacy -fish oil and folic acid (+/- omega 3's in pregnant women and bipolar) supplements for depression trx -fried foods, refined grains, sugar associated w/ depression/anxiety -fast food frequently = 40% increased risk for depression -dose-response relationship bw fat type and depression (trans-fats + depression, mono-poly unsat fats - depression)

DiRECT trial-Lean, Lancet, 2018

-cluster RCT; 49 PCP practices in Scotland and England -n=306 w/ T2DM in last 6 yts not on insulin -H: PCP led dietary intervention can lead to remission in T2DM -intervention: weight mgmt program (no DM or HTN meds, ~800kcal/day x 3-5 mo)+food reintegration -control: best practice -outcome: weight loss of >33 lbs (15kg) and remission of DM after 2 mo no DM meds -results: weight loss in 1/3 intervention grp, no control grp; 46% remission in intervention grp (4% in control group); remission ass'd with weight loss in all people; majority of remission in ppl who lost >15 kg; QOL increased in intervention grp, decreased in control;

Providers and advocacy

-contribute to public health (provide info to organizations) -provide credibility -lend a powerful voice -not much mass appeal, but can serve as champions for special causes and talk to the media (not like a celebrity) -should not leverage network of providers d/t contracts

High Micronutrient Food Families

-cruciferous vegetables (broccoli, cauliflower, cabbage): 1c/day -dark green leafies (spinach, chard, kale, arugula, loose leafy lettuce): 2 c/day -alliaceous veggies (onions, garlic, leeks): 1/2 c/day -carotenoid veggies (carrots, beets, yams): 1/2 c/day -other vegetables (tomato, celery, squash, peppers, cucumbers, eggplant): 1 c/day -dark berries (cherries, pom, blue, etc): 1/2 c/day -other fruit (apples, pears, melons, citrus, stone, tropical): 3 c/day

Circadian rhythm on sleep physiology

-darkenss + melatonin -->vasodilation-->warm extremities/cool core body-->sleep -continued patter x 4 hrs sleep (slow wave)-->decresed BP/sympathetic tone -during sleep=DNA repair, leptin secretion (controls appetite), increased cortisol, FA metabolism -late sleep: decreased melatonin-->cooling extremities and increased core temp-->longer REM-->increased BP, sympathetic tone/baroreceptor sensitivity -awakening: cortisol spike

Physical activity as a vital sign

-days per week * min per day = minutes per week -incorporate PA guidelines (cardio and strength) + balance/flexibility

Health effects of poor sleep

-decreased attention, mood, melatonin, leptin (increased appetite), decreased caloric burn and body T, time w/ lower BP, memory, cognitive fx, anxiety/fear extinguishment, DNA repair and apoptosis, immunity -increased insulin resistance, glucose levels, cortisol (abd fat), sympathetic tone=higher BP, CA + IL-10 cytokines, aberrant DNA methylation -increased risk for breast, endometrial, prostate, colorectal, AML CA; MI/CVD/vasospastic disorders

Delayed phase shift

-delays SCN clock--> longer than 24 hr rhythm -d/t westward travel or 100-1000K home lighting (100% melatonin suppression) -majority of people have delayed phase clock (24 hr 8 min) -reset x <=20 min/day

Cognitive Theory (social learning)

-demonstrates social nature of behavior -focuses on maintenance of behavior -behavior is influenced by personal factors, environment, human behavior, role models, etc -reciprocal determinism: dynamic interrelated influence bw environment, person and behavior -foundational aspects: behavioral capability and self-efficacy -limitations: relationships are not quantified bw these aspects, disregards some biological predispositions and past experiences -ex: kindness or vaccines

Depression and CAD

-depression precedes CAD -increases 2-yr risk of cardiac events and death -doubles cardiac events (controlling for EF and # blocked arteries) -increases risk of events in pt's w/ CAD x 15-30% -unknown mechanism: abnormal platelet adherence; poor lifestyle; endothelial dysfx; lowered HR variability

Diffusion of Innovation Theory

-describes adoption of a new idea amongst a population 1. innovators 2. early adopters 3. early majority 4. late majority 5. laggards

Lifestyle changes on telomerase actviity in prostate CA-Ornish, Lancet 2013

-descriptive study of long term results of RCT -n=35 men w/ low grade prostate CA -f/u: 5 yrs -intervention: lifestyle changes (diet, activity, stress mgmt, social support) -outcome: telomere length -results: increased in LM, decreased in control; 5 yrs: LM telomerase activity and less decrease in control (not ass'd to adherence to LM) -conc: LM intervention ass'd with increased telomere length in 5 yrs and adherence to LM was ass'd with telomere length

Nutrition and epigenetics

-diet has the biggest impact on epigenetics -yeast ox-redox cycles are controlled by epigenome -arterial atherosclerosis involved -cell aging is reversible -cell type is determined by the epigenome (fibroblasts, cardiomyocytes)

Insomnia

-difficulty initiating or maintaining sleep --->daytime consequences -adequate sleep opportunity -duration >=3 mo >=3/week -ass'd w/: fatigue, poor memory and motivation, irritabiity, accidents, HA/GI issues, persistent worry about sleep

Alcohol Use Disorder Symptoms (DSM-V)

-drinking more than wanted to -wanted to cut down -lots of time finding or recovering from alcohol -lots of time drinking -drinking or aftereffects interferes w/ life -continued drinking despite social problems -reduced pleasurable activities to drink -drinking increases risk of getting hurt (unsafe sex, driving, walking in dangerous area) -drink despite health issues (+ anxiety, depression, BP) -drink more to get same effect -withdrawal symptoms 0-1=no AUD 2-3=mild 4-5: mod 6+=severe

Periodic Limb Mvmt

-limb mvmt ocur ~30 sec intervals while sleeping -increased incidence after 50 yo -ass'd w/ RLS

Fluid status and sleep

-during sleep: warm extremities and cool core (slows HR, etc) -dehydration can decrease blood flow to ext --> increased core T and difficulty sleeping -poor sleep + cortisol-->mineralocorticoid action and worsening of dehydration -yoga, benzos, and non-sleep meditation + blood flow to extremities and decreases SNS (decreases HR~ sleep)

Depression Referral to Mental Health Provider

-dx is unclear -pt wants psychotherapy +/- meds -initial trx does not lead to improvement -sx's relapse after initial improvement -physician believes it is the best setting for pt trx -high screening tool score -meets DSM criteria -SI -previous SI attempts -hx substance abuse -co-morbid mood disorders (panic attacks)

Depression

-dx predicts dx of T2DM -alters hypothalamic-pituitary-adrenal cortex axis, SNS, and subclinical inflamm -dx associated w/ increased risk of CVD (x 15-20%, 2x events), stroke, CA -~strength for mortality indicator as smoking -don't use TCAs for depression trx + CVD risk (prolongs QT)

Anti-relapse meds

-efficacy for mod AUD: 1/4; severe: improves long-term recovery chances -use if therapy alone has failed -min 6 mo trx Naltrexone: 50 mg po qd/bid/prn; injectable -blocks mu receptor -reduces risk of heavy drinking x 83% and drinking days x 4% Acamprosate: modulates glutamine neurotransmission -RR: 0.86, NNT=9, increased abstinance x 11 days; no effect on heavy drinking 2nd line: Disulfiram 250 mg po qd: - aldehyde DH-->buildup of acetaldehyde-->N/V/D/sweating/HA -high rates non-compliance gabapentin 300-600 mg po bid/tid -~8% more effective than placebo in 12 wks (11% abstinant) -possible abuse potential Topiramate: 100-150mg po bid -off-label use -~8% reduction of heavy drinking days x 14 wks

Dairy

-essential component of "My Plate" -comprise ~10% standard American diet's calories (1/2=mild, 1/2=cheese) -no or weak relationship with CVD reduction, stroke, DM -replacing with plant-based would decrease CVD risk by decreasing sat fat and Na -dairy may improve HTN/DM -moderate evidence to improve children's bone health (1 c mild=5% decrease fx risk in white and asian women and fortified dairy improves BMD x 0.7-1.8% in 2 yrs -yogurt may decrease inflammation but cheese increases inflammation

LM prescription for acute depression

-evaluate for: precipitating causes, SI, psychotic sx's; if none then refer -mild-moderate sx's: prescribe CBT, support groups, PA before meds -increase dose or change meds if not improvement in 3-4 wks -no improvement in 6-8 wks=refer to professional -build relapse plan and emotional well-being action plan components to prescribe: PA increase fruit/veg intake sleep mgmt mindfulness/relaxation therapy bibliotherapy light therapy digital programs (CBT apps) positive relationships/social support

EPIC study

-every 5% of calories from animal protein=30% increased r/o DM

Mental Health and nutrition

-evidence suggests improved mental health with decreased BMI

Pathogenesis of T2DM

-excess calories-->overload cells-->resist uptake-->elevated glucose and TG (esp post-prandial)-->increased adipose tissue, leptin production-->weight gain-->inflammation -poor diet-->poor microbiome-->decrease short chain fatty acids-->poor glucose mgmt -fatty liver-->poor glucose stasis (+gluconeogenesis) -inflamm damage liver and B-cells-->insulin resistance from excess insulin release -pancreas releases more insulin to combat resistance-->increases appetite -B-cell burnout/damage from inflammation-->decreased insulin-->increased glucose levels in blood

Mental health and exercise

-exercise trx/prevention for depression=CBT

Circadian clock inputs

-external fx's that can entrain circadian rhythm -light intensity -light wavelength -food (carbs) -fluid (blood osms) -ambient temp

Chicago Heart Association Detection Project

-fewer risk fx's at 50 yo predicted better QOL in older age (per Medicare costs) and longer life expectancy

Mind-Body Medicine

-focuses on interactions bw mind and body -treats dz with methods targeted to the mind (relaxation, hypnosis, imagery, etc) -major focus on emotional, spiritual, etc -ex: hypnosis, visual imagery, yoga, etc

2018 Physical Activity Guidelines

-from HHS; complement dietary guidelines (USDA and HHS) -first PA guidelines: 2008; updated 2018 -improves sleep quality, brain fx, depression, anxiety, QOL, physical fx for old and young -immediate results seen from 1 episode of exercise; risk of dz dec w/in days-wks -make PA safe -150 min mod/wk or 75 min vigorous/wk

Genetics/Epigenetics in health

-genes det'm 10% health -epigenetics (gene switches from environment)=90% -2005 twin study showed nurture>nature

Cancer Nutrition Prescription

-goal: support immune system (anti-ox, fiber (40-45 g/day), beta carotene, lycopene, resveratrol, selenium, vita C, vita E, NOT SUPPLEMENTS) AND -decrease inflammation (avoid AGEs from thermal processing, sat fat/processed foods, reduce IGF-1 through decreasing animal protein intake and exercise) Breast: BMI<30, less meats, more soy, less alcohol, more exercise, more fruit Prostate: increase vegetables; high lycopene (tomatoes, watermelon) and selenium (brazil nuts) and whole food soy colon: less red and processed meat; more fiber, Ca, folate Gastric: less processed meat/salt, more fruits/vegs

AUDIT-10

-gold standard for alcohol screening -use if screen + on AUDIT-C -0-7=low risk; provide feedback/education -8-10=at risk/hazardous use; provide brief intervention -16-19=harmful use; intervention, monitoring, outpt trx ->20=dependent use; referral for intensive trx -CANNOT be used to dx AUD, only provides correlation

6 primary components of LM trx

-healthful eating: whole, plant based diet -increase physical activity -manage stress -form and maintain relationships -improve sleep -tobacco cessation -

OmniHeart

-healthy diet -partial substitution of carb with protein or monounsat fat-->decreased BP, improved lipids and reduced CVD risk

Type of plant based diet for DM

-healthy plant based foods = 34% lower risk of DM -processed plant foods=16% increased r/o DM

Emotional Well-Being Vital Sign

-healthy ways of coping with emotions and stressors -tied closely to mental health -influenced by LM components and positive psychology 2 questions, rated 1-5: 1. In most ways, my life is close to my ideal. 2. I am satisfied with my life OR: 12-item short form or 36-item short form for overall well-being

Anxiety screening

-helpful to r/o anxiety before concluding stress as cause for issues -USPSTF: no recs for anxiety screening -GAD-2-->HAM-A, GAD-7 or DSM-5 -DSM-5 GAD anxiety: all sx's for >50% days x 6mo (excessive anxiety, uncontrollable worry, >=3: restless, easily fatigued, concentration issues, irritability, muscle tension, sleep change, w/ life impairement -PHQ-4: assesses depression/anxiety together

Depression screens

-helpful to screen to differentiate from stress -USPSTF (grade B) rec to screen >12 yo q year (if support is in place) -PHQ-2-->PHQ-9 -PHQ-4: assesses depression/anxiety together (>2= + screen-->SI ?'s) -Major depressive disorder (MDD) dx based on DSM-5 (>=5 sx's every day x 2 weeks and interferes w/ fx): depressed mood, anhedonia + weight change, sleep chane, psychomotor change, fatigue, guilt, concentration change, SI (w/ or w/o plan)

T2DM nutrition prescription

-high fiber/plant based -reduce fat and simple sugar intake -eliminate artificial sweeteners -reduce processed grains -reduce high glycemic index food (~ ingesting glucose) -reduce sat and trans fats -reduce total caloric intake (increased calories-->TG-->weight gain)

Cholesterol in American Diets

-high levels: mainly animal foods and fungi -eggs>chx>beef>cheese>pork -goal LDL=50-70 -goal TC<150 (achievable through WFPD) TC<150 and LDL<70=no atherosclerosis (even from obesity, smoking, etc)

High Caloric food in American Diets

-high: fats, oils, snack food, processed meats -lowest: whole veggies, whole grains, whole fruits, legumes, herbs/spices, mushrooms, low-fat dairy -top sources in US: refined grain based desserts>non-whole grain bread>chx>sweetened bevs>pizza

Saturate Fat in American diets

-highest: meats, dairy, eggs, processed, oils (coconut and palm) ->8g/serving: processed meets, fast food, coconut and coconut oil (1 Tbs) -4-7 g/serving: whole mild, leaner meats, cheese -1-3g/serving: nuts/seeds, avocado, oils, 1 eggs, fish -top sources in US: cheese>pizza>bakery products>ice cream>chx

Glycemic Index

-how much and how quickly an ingested food affects glucose blood levels (high GI=quick BS high) -scale=0-100 -low<=55 -glycemic load=GI*gram carbs/100 -low<=10, high>=20

When to test for DM?

-if normal weight and no RF's: 45 yo q3y -all adults w/ BMI>25 + >=1 risk fx's: physical inactivity 1st degree relative with T2DM high risk race (Asian Am, Black, Latino, Native Am, Pacific Islander) F w/ baby >9lbs or dx with GDM HTN >=140/90 or on meds F w/ PCOS preDM signs of insulin resistance (acanthus nigricans) hx CVD

Timeline of smoking cessation benefits

-immediate: reduce MI risk x 50% (decrease HR and BP) -3 weeks: improve lung fx and circulation -1 month: decrease coughing and wheezing -1 yr: reduce CVD risk x 50% -2-5 yrs: stroke risk = that of non-smoker -10 yr: reduce lung CA risk x 50% -quit at 30 yo, gain 10 yrs life -quit at 60 yo, gain 3 yrs life

Most effective comprehensive lifestyle interventions for obesity

-in-person, highly intense (>14 sessions/6 mo) -individual or group -trained interventionists/nutritionists -components: caloric restriction, increased PA, behavioral strategies,

Behaviorally Induced Insufficient Sleep Syndrome (BIISS)

-inadequate sleep for functional performance -voluntary sleep restriction w/ longer sleep on weekends -prevalence: 7-20# gen pop -risk fx's: 30's, alcohol abuse, >40 hr work week, stress, depression

Connectedness

-includes micro-moments of connectivity (brief but authentic social interactions) -positive resonance (positive social interactions) -stimulates parasympathetic nervous system-->physiological benefits (decreased HR) -single most important predictor of happiness and longevity

Behavior contracts

-inconclusive evidence but can be good for accountability -clear terminology (not a contract, but aid for behavior change) -clarify goals -use to help set and meet goals -offer resources w/ contract

Alcohol health effects

-increased BP -increased r/o stroke -increases unintentional injuries -increases r/o CA

HTN Prevalence

-increases w/ age ->60 yo=>50% w/ HTN -screen q 6-12 mo -decrease in mmHg-->% decrease in mortality (stroke, CVD, total) 2-->6-->4-->3 3-->8-->5-->4 5-->14-->9-->7 -accounts for 45% HD deaths and 51% stroke deaths -rural>urban

Common obesity

-influenced by a lot of genes -genetic factors only contribute some to risk, mainly lifestyle -FTO gene=chrom 16; people have have this gene = 20-30% higher risk for obesity than those who don't BUT PA can offset this

Disease's Unique to Western World

-ischemic heart disease -gallbladder dz -appendicitis -diverticular disease -colon CA -hemorrhoids -varicose veins -hiatal hernia -obesity

Western Diet pitfalls

-lack of antioxidants -lack of fiber (specifically through complex carbs) -emphasis on animal protein/saturated fat -emphasis on low-fiber simple carbs -after industrial revolultion-->decrease in fiber, increase in animal fats, salt, sugar -63% diet=processed -25%=animal based foods -6%=processed plant based foods =6%=unprocessed plant based foods -sugar=13% of calories (13 tsp or 52g) per day

Physician Competencies for Prescribing Lifestyle Medicine-JAMA 2010

-landmark article for ACLM -described 15 competencies needed for physician to prescribe LM -authors: blue ribbon panel of LM experts -defined lifestyle medicine

Relapse Prevention Planning

-lapse: short period where unhealthy action isn't a habit yet -relapse: sustained period where action is not adhered -address relapses with new action plans; address thoughts/emotions from failure -plans assess potential triggers: who, what, where, noticing a lapse to prevent relapse, support during lapse -est relapse reminder and back-up plan (check-ins, build in support, avoidance, etc)

plant sources of iron

-lentils -chickpeas -beans -tofu -nuts -chia seeds (and other seeds) -SPINACH

Blue light and sleep

-light = greatest entrainer of circadian rhythm -blue light = greatest melatonin suppression (even at low intensity or short duration) -increases cortisol, HR, BP, core body T, decreases sleepiness -shifts sleep cycle into later phase -blue light exposure increases sensitivity of SCN to light --> cyclical decrease in melatonin secretion

Nutrition Facts Label

-look at serving size -calories per gram: carbs/sugars and protein: 4 fiber=0 calories!! alcohol: 7 fat: 9 -if amt of a nutrient per serving size < 1/2 g it is shown as 0g

Functional Medicine

-looking to balance core functional processes (metabolism, hormones, etc) -fixes physiological and biochemical functions -may use supplements and meds

Ornish diet for newly dx low-mod grade prostate CA or CAD

-low fat, plant-based diet

Endothelial Lining Integrity influenced by:

-lower NO -lower TMAO (tri methyl amines oxides) -endothelial progenitor cells for replacement of senescent injured cells -absence of intestinal bacteria in vegans thus unable to make pro-atherogenic TMAO -presence of intestinal bacteria in gut of omnivores to turn lectin and carnitine (red meat, chx, fish)-->proatherogenic TMAO

Promoting behavior change in patients

-match goals to their stage of change -early stages: MI (pre- and contemplation) -later stages: CBT -always: positive psychology -enlist social/environmental support (use support analysis tool) -make a written action plan based on prescription (adjusted for appropriate stage of change)--intermediate goal: move to next stage of change

Melatonin suppression and disease

-melatonin suppression ass'd w/ bipolar, SAD, MDD -melatonin suppression increases w/ age (2/2 cataracts and retinal luminance)

Fasting mimicking diet on B-cell regeneration; Cheng, Cell, 2017

-mice -intervention: 4 day fasting diet -outcome: generation of insulin-producing B-cells -results: restored insulin secretion in T1DM and T2DM mice -conc: fasting mimicking diet promotes restoration of B-cells in T1DM and reverse both types of DM -human study: proprietary diet foods x 4 days

Fe-Deficiency Anemia and Plant Sources

-microcytic anemia: caused by Fe deficiency (rare in whole food plant diet) or destruction of RBCs (NSAIDS-->GI bleed) -CBC w/ diff (RBC, MCV, MCHC, RDW) -serum Fe, ferritin, TIBC labs -Vita C aids absorption of Fe -body adjusts absorption for Fe levels (absorbs more when needed) Plant sources for Fe: legumes, seeds/nuts, kale, dried fruit, quinoa 100g spinach=1.1 x Fe than 100g red meat =2.2 x Fe than 100g salmon =3 x Fe than 100g boiled eggs =3.6 x Fe than 100g chx

Sleep Vital Sign

-mini sleep assessment: 1. typical weekday hrs sleep 2. weekend hrs sleep 3. quality of sleep

LM trx for CVD

-minimize free fats -oils, margarine, mayo, salad dressing, oily foods -paralyzes endothelium (can't make circulation promoting cytokines) -elevates LDL -calorie dense foods -portfolio diet or Ornish progra

ITLC: Intensive Therapeutic Lifestyle Change

-most intense lifestyle changes (max dose for induction phase) -normally used in immersion programs or residential programs -needed in reversal of advanced/severe conditions (prevention only requires TLC) -strongest LM evidence come from ITLC studies; efficacy of TLC presumed from these studies -multi-factorial (not just focused on one aspect of LM)

Blue Zones

-move naturally -plant heavy (beans) -faith (4x/mo) -purpose -moderate wine consumption -80% rule (80% full, nothing after 5pm) -loved ones first -right tribe/community -regular down time

Interheart study

-multi-center (52 countries) case-control looking at AMI risk fx's -results: -5 factors accounted for 80% risk (smoking, lipids, HTN, DM, obesity) -+diet, physical inactivity, alcohol consumption, psychosocial fx's= 90% AMI in men and 94% in women -risk fx's are the same in all geographic nations and races/ethnicities and genders -strongest predictors: apoA1, apoB ratio, current smoking (66%) -abd obesity>BMI

DASH diet for HTN

-n=459 adults w/ SBP<160 and DBP 80-95 -icontrol period: typical US diet x 3 wks -8 wk intervention: control diet fruits/veggies DASH=fruits/vegs, low-fat dairy, low sat and total fat -Na intake and body weight held constant -results: reduced SBP x 5.5 and DBP x 3 mmHg more than control -fruits and veggies reduced x 3 and 1 more than control -DASH diet had greater impact on pts with higher HTN levels -conc: DASH diet is comparable to medication starting dose for essential HTN

Sleep Hygiene Assessment

-naps >30 min/day -daytime hydration -variations in sleep/wake pattern -prolonged non-sleep periods in bed -going to bed upset -activities in bed (eating, TV, etc) -uncomfortable bed/room -worry in bed -caffeine/alcohol w/in 3 hrs bed

National Weight Control Registry (NWCR)

-national database for people who have lost ~66 lbs and kept it off x 5.5 years -recommendations from study: most people need >150 min mod activity/wk to maintain weight loss (~1 hr/day)

Obesity stats

-no state has less than 20% obesity -prevalence in kids=stable x 10 yrs at 17% -blacks>hispanics>whites -rural/underserved at higher risk -middle age>young adults

Retinal Ganglion Cells (RGC)

-non-visual -sense light -retinal neurons -send info to SCN -contains melanopsin (photopigment) to train SCN clock and melatonin secretion

Stages of Change (Transtheoretical model)

-not a continuum, can skip, revert, etc bw stages 1. precontemplation (no awareness of the problem, not changing in next 6 mo); 0-3 confidence and importance scale 2. contemplation (considering change, plan to change w/in 6 mo); 4-6 confidence and importance scale 3. preparation (preparing to change in next 1 mo); 7 confidence and importance scale 4. action (made a change but not at target goal; change lasting < 6 mo so far); 8-9 confidence and importance scale 5. maintenance (goal behavior achieved x >=6 mo); 10 confidence and importance scale 6. relapse (not from original model)-goal behavior no longer happening; occurs in action or maintenance phase but can re-enter into any phase

Pierce JP study (obesity and breast CA survival)

-obese women w/ high PA and high fruit/veg intake = mortality to skinny women with high PA and fruit/veg intake -survival=physical activity related

HTN Nutrition Prescription

-reduce Na (restriction decreases x 2.5-7 mmHg); <1.5 g/day (highest sources: pre-prepared food in restaurants/breads, rolls, pizza, sandwiches--grain based ingredients>canned goods/soups/cold cuts> savory snacks) -reduce sat fat (cheese, high fat dairy, processed and animal fats) -increase K, Ca, Mg (dark green leafy, legumes, berries) -moderate alcohol/caffeine intake -+/- water only fasting under medical supervision -flax seed, celery, hibiscus tea, garlic=8mmHg decrease

LookAHEAD study: Intensive LM and remission of T2DM-Gregg, JAMA, 2012

-observational analysis of 4 yr RCT (8 years long) -intervention: intensive lifestyle intervention + DM support and education (weekly counseling x 6 mo + 3 sessions/mo x 6 mo + bimonthly contact x 2-4 yr; caloric intake 1200-1800/day low sat fat+ increased PA 175 min/wk)-adapted from DPP -control: 3 group sessions/yr on diet, PA, social support -n=4000 overweight, T2DM -outcome: frequency of partial or complete remission of T2DM to pre-diabetes or normoglycemia -results: intervention lost 7.9% more weight @ 1 yr; 15.4% better fitness; 11.5% remission in yr 1 and 7.3% in yr 4 (2% at yr 1 and 4 in control); 9.2% sustained remission x 2 yrs, 3.5% x 4 yrs (<2% at all time points in control) -conc: *comprehensive, long-term lifestyle intervention produced >=5% weight loss at 8 yrs in 50% participants*; intense LM can help remission in T2DM but rates were low; consider bariatric surgery to treat T2DM--this ILI may not be intensive enough

Sodium in American Diets

-often in processed foods or mixed dishes -sources in US: mixed dishes>protein>grains>veggies>sweets/snacks -goal: <2000mg/day (Na/serving<calories/serving=good!)

Poly-unsaturated fats

-omega 3: anti-inflammatory (flax seed, chia seed, fish) -omega 6: pro-inflammatory (corn oil, sunflower oil) -lots of bends/turns; make membrane flexible; lots in plants; lower melting point

Framingham Heart Study

-outcome: lifetime risk for atherosclerotic HD -n=men w/o HD at age 50 -results: no risk fx=5% lifetime risk of CVD >=2 risk fx's=69% lifetime risk Women no risk fx's: 8% lifetime risk Women >=2 risk fx's: 50% risk M/F no risk fx's: life expectancy 10 yrs longer than those with >=2 risk fx's

Sedentary Behavior

-own class of activity level -2x prevalence of smoking, HTN, HLP -even PA people who are otherwise sedentary, have dose response increase for dz (independent risk fx for dz) -sitting=6.9% all cause mortality -risk lowered if move 1-5 min/hr -TV viewing=HR 1.5 all cause mortality (despite PA)

Advanced Glycation End Products (AGE's)

-oxidative stress inducers secondary to food preparation -can + DM -found in protein>fat>carbs; high temps, longer cooked, dry, extreme pH -increase with grilling, broiling, roasting, searing, frying -increase over time (body detoxes them slowly) -promote long-life cell damage (nerve, brain, collagen, eye) -correlated with DM, athersclerosis, kidney dz, slow wound healing -less if boiled, stewed or broiled

National Prevention Strategy

-part of ACA passed in 2011 -strategy to change healthcare from sick care to wellness and dz prevention -coverage for providers to do lifestyle modification: physical activity assessments/counseling; obesity screening and nutrition; screening and counseling for alcohol use; tobacco cessation

Positive Emotions

-pillar of positive psychology -typically occur in non-life-threatening situations -protective against distressing thoughts w/ chronic illness -ideal resiliency ratio=3:1::positive:negative thoughts (more likely for people to overcome obstacles) -promote positive emotions through finding strengths and virtues -ex: hope, joy, pride, love, content, gratitude, hope)

Interventions based on stage of change

-precontemplation: educate and discuss risks of unhealthy behavior -contemplation: personalize health risks, highlight benefits of change -preparation: assist with commitment, plan specific changes, discuss how to modify the environment; make plan -action: set up frequent f/u, identify social support, CBT, obstacle solving, reframe unhealthy though patterns -maintenance: CBT reinforcement; relapse prevention plan (discuss potential triggers) -relapse: problem solve

Advanced phase shift

-premature circadian rhythm (SCN < 24 hrs) -d/t early light exposure or eastward travel -reset x <=10 min/day

Diet Vital Sign

-presence of whole foods -typical shortfalls=Vita A, D, E, C, folate, Ca, Mg, fiber, K -best replaced with vegs, fruits, whole grains, beans/legumes, low-fat dairy -assess servings/day for: veg, fruit, whole grains, beans/legumes, nuts/seeds, herbs/spices, low-fat dairy -assess over-consumption of unhealthy products if time (added sugars, high fructose corn syrup, cholesterol, refined grains, Na, sat fats, trans fats, high caloric foods, processed grains) -servings/day for: sugary bevs, processed/pckgd food, fried food, high-fat dairy, meat, eggs -suggest Michael Greger's Daily Dozen phone app

Physician-Patient Relationship

-promotes adherence -compassion (RAIN: Recognition of what's happening, acceptance to make room for the experience, investigate w/ curiosity, non-identification of experience)

InterSTROKE study

-prospective case-control to look at stroke risk fx's -10 risk fx's found: HTN, current smoking, abd obesity, unhealthy diet, physical inactivity, DM, alcohol intake, psychological stress, depression, cardiac causes, abnormal lipids -accoung for 90% strokes

Prostate GEMINAL study-Ornish, 2008

-prospective cohort; n=30 men w/ low risk prostate CA -outcome: gene expression -intervention: 3 mo comprehensive lifestyle program (<10% calories from fat, whole food plant diet + 60 min/day stress mgmt+ 30 min/day x 60 days mod aerobic exercise+1hr group support/wk+soy, fish oil, vita E, selenium, vita C supplements) -results: improved weight, abd fat, BP, lipids (ss); gene expression was altered in 500 changes: 450 down-regulated and 50 were turned on (not all had known fx's) -limitations: 30% biopsy samples had tumor tissue

Nurses' Health Study

-prospective study -f/u: 14 yrs -n=84,000 women conc: 5 health factors ass'd with lower CVD risk: 1. no smoking 2. BMI<25 3. >=30 min PA /day 4. moderate alcohol (<1 oz/day) 5. healthy diet score (inc fiber, omega 3s, folate) -results: 82% dec risk CVD if all 5 fx's present

5 elements of well-being

-purpose -social -financial -community -physicial -2/3 of healthcare workers are thriving on 2 or less of these 5 elements

Obstructive Sleep Apnea (OSA)

-recurrent apnea or hypopnea during sleep 10s-1min -score=apnea-hypopnea index (AHI) based on polysonmography AHI: 5-15: mild, 15-30=moderate, >30=severe -prevalence: 26% gen pop (80% undx) -ass'd w/: overweight/obese, metabolic syndrome, HTN, increased neck circ (>17in), loud snoring

Adventist Health Study

-reduced mortality in vegan (no meat, eggs, or dairy), no alcohol or tobacco (all-causes, ischemic HD, CVD, CA, other) -linear relationship bw veggie diet and lower BMI, lower odds of getting T2DM, HTN, or metabolic syndrome -meat eaters vs non meat eaters: 97% increased r/o DM in M and 93% increased risk in W

Alcohol consumption vital sign

-regular drinker=screen every visit; otherwise once/year -AUDIT-C (3 ?'s): rated 0-4, 12 total; <3=normal 1. how often do you have an alcoholic drink? 2. how many drinks/day? 3. How often >6 in one setting? + screen-->full AUDIT-10 (5-10=20% AUD, 11-15=40% AUD, >16=90% AUD) AUDIT 10: mod-high risk=referral; low risk=brief intervention AUDIT=gold standard screening tool F: no more than 3 drinks a day and 7 in a week M: no more than 4 drinks a day and 14 in a week

ACC/AHA A recommendations

-sat fat calories <5-6% daily -no trans fats -emphasize unprocessed fruit/veg/whole grains

USPSTF Lifestyle Guideline Recs

-screen all adults for: obesity, tobacco, alcohol (B, I < 18 yo) -offer: smoking cessation for smokers intensive lifestyle counseling for: -weight loss if obese -diet changes for CVD risk fx's -alcohol decrease if excessive users

2015 Exercise Screening Guidelines from Am. College of Sports Med

-screen to identify people who need medical clearance before exercise; goal=reduce exercise related CV events, not to limit exercise 1. clinical dz who need medically supervised exercise (cardiac rehab) 2. uncontrolled conditions that need to be controlled prior to exercise -based on 3 RF: current PA level, sign/sx's of CVD, metabolic or renal dz, desired level of PA -pulm dz does not require clearance (no increase in CV related deaths/complications) -USPSTF grade D for stress test in asx pts before exercise (insufficient beneficial evidence)

Patient responsibilities for emotional wellness

-self mgmt: connect w/ others, get involved in activities, work on relaxation, + creativity, journal for stress and gratefulness, spiritual needs -cognitive restructuring: re-frame, look from different angles, ABCD, focus on positive

Resources for sustained behavior change

-self-monitoring -problem solve and learn from barriers using ABC chart Antecedent (what happened before event), Behavior, Consequence (what happened after) -Develop potential solutions: MI to have pt think of ideas -Act and assist: practice potential solution w/ pt and evaluate how it worked

Restless Leg Syndrome (RLS)

-sensation of urge to move legs -worse in evenings -movement helps w/ symptoms -sx's not d/t other medical issue -prevalence: 5-15% gen po

American Nutrition Shortfalls

-shortfall nutrient=one under-consumed by 25% of US population -Calcium (dairy, seeds, tofu, almonds, beans, dark greens) -Fiber (only in plant foods, supports microbiome) -Mg (brazil nuts, edamame, dark chocolate) -K (potatoes, avocados, soybeans, plantains) -Vita A (sw potatoes, liver, spinach, canteloup, black eyed peas) -Vita C (bok choy, broccoli, brussels, citrus) -Vita D (high fat fish, dairy; SUNLIGHT>DIET for Vita D) -Vita E (sunflower seeds, almonds, hazelnuts) -Vita K (oils, dark leafy greens, brussels)

Fat

-should be 15-30% total calorie intake -Polyunsaturated -monounsaturated -saturated -trans -prescription: don't count fat grams, instead prescribe types of food ex: cheese/pizza -normally a negative prescription

Flexibility Assessment Tests

-sit and reach (hamstrings and low back); don't use w/ low back pain pts -hamstring flexibility may be related to decreased risk of falls and/or decreased low back pain -can compare to age/peers/gender

Body Composition Assessment Tests

-skin fold caliper testing: subq fat is proportional to the total mt of body fat (~1/3 of the body); w/in 3.5% accuracy; test abdomen, tricep, bicep, chest/pectoral, medial calf, midaxillary, subscapular, spurailiac, thigh; normal ranges: M-10-22% and F-20-32% -Densitometry: estimates body fat % based on body mass:volume ratio (underwater weighing, DEXA, mulitcompartment) -bioimpedence test is related to hydration status and often incorrect; not recommended

Exercise Intensity Assessment Tools

-talk test: able to talk and sing=light; able to talk, not sing=mod; neither=vigorous -respiratory rate: breaths per minute (best indicator of perceived exertion) -Perceived exertion (Borg scale): 1-10 (<3=light, 3-4=mod, >=5=hard) -Heart rate reserve (HRR)=ACSM recomendations (40-85% HRR) -max HR: <64%=low intensity, 64-76=moderate, >76=vigorous -METs: <3=light, 3-6=mod, >6=vigorous

Short Physical Performance Battery (SPPB)

-test for disability to predict mobility -includes: gait speed test, balance test, chair rise test -structured exercise can improve this score, prevent physicial decline, allow people to remain independent for longer (18% reduction in physical disability)

Physical Activity Vital Sign

-the aspect of total daily energy expenditure which pt's have the most control (others: rest, thermic effect from food) -2-item vital sign: 1. days/wk for mod-strenuous exercise (brisk walk) 2. min/day at this level? -Strength training must be asked separately (days/week)

T2DM

-the dz most influenced by body weight -BMI > 30=7x risk of T2DM in men and 12x risk in women -fat cells (esp abdominal) secrete inflammatory hormones-->cell dysfx and insulin resistance; alter carb/fat metabolism-->high BS

Action Plan

-the lifestyle prescription adjusted for the patient's ability, readiness and confidence -ex: start walking 5 min/day and increase to 150 min/wk (the original prescription) -should be written down and reviewed w/ patient -create during preparation phase of change

Positive Psychology

-the scientific study of strengths and virtues that enable individuals and communities to thrive (focus on happiness, but not lessen misery) -components: (PERMA) positive emotions (optimisitic), engagement (mindfulness), relationships (emotional and physicial connections), meaning (purpose in life), accomplishments (ambition) -not a trx -ex: count blessings, find and improve strengths, gratitude, kindness, etc)

Lifestyle Medicine Definition

-the use of lifestyle interventions in the treatment and management of dz -aim: replace medication with lifestyle changes -elements: whole food, plant-based, physical activity, adequate sleep, stress mgmt, avoidance of risky substances -collaborative model with patient -evidenced based -applies to every patient, every practice

Preventive Medicine

-traditional medical approach to prevent health conditions -immunizations, mammography, etc -focus in pubic health and population health

Muscle Strength Assessment Tests

-use weights (bench or squat press) -find their max load (lbs for 1 rep only) -refer to gym

Complementary and Alternative Medicine (CAM)

-used in addition or instead of standard trx -practices are not currently considered part of conventional medicine (not evidenced-based) -may use supplements, spiritual healing -typically not strong in science

Root Cause Analysis

-used to see what went wrong, or what caused a near miss -use 5 why's -cause and effect/fishbone dx -analyze -implement PDSA cycles

Bioelectrical Impedance Analysis

-uses small electrical signal to measure water w/in someone's body to determine body composition (fat:muscle) -more accurate for body fat% than BMI (better assumption of nutritional status) -recs: M <25%, F<32%

Tobacco Cessation Med Combos

-varenicline + bupropion=71% smoke free at 12 wks, 58% at 6 mo -bupropion + NRT=54% at 8 wks (50% w/ lozenge only)

Supplemental Melatonin

-varies individually -good for jetlag and circadian rhythm disorders -1-6mg=typical dose (possible cyp-450 interactions) -no endogenous suppression evidence now -SL=better bioavailability -sustained formulas=good for westward jetlag (increases morning drowsiness)

LM H&P

-vital signs (PA, diet, stress, sleep, emotional well-being, tobacco use, alcohol, BMI)-not standards, just a check-in -risk fx assessment (CVD, pre-DM, T2DM) -physical exam (waist, WHR, BIA, pulse, BP) -lab work and interpretation (CMP14, CBC, lipids, hsCRP, FSG, A1c, insulin, c-peptide, vita D, B12, TSH) -dx and mgmt -collaborative care and referrals

LM PE

-waist circumference (increased=increased risk for T2DM, HTN, CVD); M>=40" F>=35" -waist:hip ratio: normal M<=0.90 F<=0.85 -Bio-impedance analysis (BIA): body fat chart comparisons -pulse (may be elevated 2/2 physical deconditioning, alcohol, caffeine) -BP: normal <120/<80, elevated 120-129/<80, stage 1: 130-139/80-89, stage 2: >140/>90 (increases morbidity/mortality 2/2 HD, stroke, MI, AAA, etc)

Weight and lifestyle choice relationship

-weight is ass'd with: shorter sleep duration, increased stress, smoking cessation (< 10lbs, more in women; lose weight after quit smoking complete)

Best LM interventions for HTN

-weight loss (1mmHg decrease/1kg lost) -diet (DASH: fruits/vegs, whole grains, low fat dairy, reduced sat and total fat)=-11 mmHg -decrease dietary Na: <1500mg/d=-5mmHg -increase dietary K: 3500-5000mg/d=-5mmHg -exercise: aerobic=-7mmHg, dynamic resistance=-4mmHg, isometric resistance=-5mmHg -alcohol moderation=<2/d M <1/d F=-4mmHg

PA guidelines for weight control

-weight maintenance: >250 min/we mod; 60-90 min/day mod; strength/resistance 2/wk (less helpful than cardio) -weight loss: using PA alone for weight loss improves DBP, TG, fasting glucose, and CVD risk but little reduction in weight-requires caloric control as well -diet=weight loss; PA=weight maintenance

Planning advocacy

1-observe community of interest to determine needs 2-define advocacy goals and how you can best contribute 3. consider: -can an individual/group make a request to the decision makers? -are there other guidelines to consider? -is there an opportunity for public comment?

Levels of Processed Food

1-slightly (smashed or cut but nothing removed) 2-moderate (some content removed and/or added ingredients available in typical kitchen) 3-ultra (added ingredients not found in normal kitchen; chemicals) 80% whole or slightly processed <5% ultra

LM elements

1-whole food, plant based diet 2-physical actvity 3-stress mgmt/emotional wellness 4-sleep 5-smoking cessation/avoid risky substance abuse 6-positive psychology and connectedness

Mindful Weight Loss Approach

1. Am I physically hungry? (do you need a meal?) 2. How do I feel about my dietary choices so far today? (occasional treats are important) 3. Is it worth it? (no=use strategies to address what is triggering the craving and write in craving diary) If yes to the above... 4. How much of do I need to feel satisfied? -- savor without distractions or judgement Mindful Eating=listening to your body over intellectual decisions (good vs bad foods, etc)

ACSM 3 stages of exercise:

1. Initial (1-6 wks): mod intensity aerobic at 40-60% HRR in intervals; 15 min progress to 30 min 3-4/wk; goal: minimize soreness, injury and prepare for more exercise 2. Improvement (4-8 mo): duration increased <=20% weekly until 20-30 min vigorous; intensity max=5% increase in HRR q 6 session HRR=max HR - resting HR 3. Maintenance (forever): starts when pt reaches fitness goals (50th % for all fitness parameters)

10 steps to organize mind for patient assistance

1. ability to cross 3 dimensions: Focus, awareness, content 2. Agility to transition from one brain state to others (awareness, imagining, evaluating, collaboration, etc) 3. brain energy (+ through emotional and physical energy) 4. no frenzy before pt encounter (name it, non-judgementally acknowledge it, elicit + emotions) 5. prepare (clear mind) 6. connect (+ vagal tone) 7. focus attention (improve sleep) 8. no distractions 9. brain breaks (not possible with media exposure) 10. be creative (non-linear, divergent thinking) 11. be strategic

Exercise Pre-participation screening algorithm

1. asx and currently does or does not exercise: no clearance, progress slowly 2. asx w/ known CV, metabolic or renal dz: if currently exercising, no clearance for mod or slow progression to vig if cleared in past 12mo; not currently exercising=med clearance, start light 3. symptomatic: d/c exercise and get clearance; progress slowly

Motivational Interviewing

1. express empathy (normalize feelings, open ended ?'s; support autonomy) 2. develop discrepancy (highlight inconsistencies, support change talk) 3. roll with resistance (back off and reflect, empathy, ask permission to provide info) 4. support self-efficacy (identify successes, offer options for small changes) best in pre- and contemplation stages supports self-efficacy, self-motivation, self-confidence

LM Coaching process

1. help pt develop awareness of issue through reflections (simple, amplified, double-sided, or shifted-focus) 2. finding stage-matched intervention (educated for precont, action plan for prep, problem solve in action, reinforce + behavior in maintenance, problem solve and refarme in relapse)

Mindfulness Attitudes

1. non-judging 2. non-striving (relaxing) 3. acknowledge > acceptance 4. patience 5. self-reliance 6. beginners mind (open and unafraid)

Evidence for pt-physician interventions to influence health outcomes

1. physician elicits and encourages input from pt (activating the pt) 2. provider more emotionally engaged; matching pt's personality, give more info ahead of time 3. combo of activating pt and enhancing provider approach (1 and 2) -health outcomes were + affected in 44% of encounters where these were employed; improved collaboration

Maintenance of an action plan

1. reiterate provider's role 2. review dx and lifestyle recommendations 3. review action plan from last visit (successes and challenges) 4. summarize pt experience 5. positive psych to compliment any progress 6. ask: benefits gained, lessons learned, overall feeling about situation? 7. set new goal 8. summarize new goals with new action plans

Daily Total Energy Expenditure

1. resting energy: 60-75% total (mainly muscle protein breakdown/synthesis)=burns 5-6 calories/lb muscle/day in untrained muscle; if trained muscle=9 calories/lb/day 2. PA: 15->30% (only controllable caloric burning area) 3. Thermic effect from food: 10% -10% weight loss-->20-25% total energy expenditure decrease (non-resting decreases 30%, skeletal work increases 20%, 24 hr expenditure decreases 20%)

Responsibilities of LM Physicians

1. screen for lifestyle risk fx's and dz's 2. trx chronic dz with prescription of lifestyle changes 3. work w/ multidisciplinary team (refer out when needed) 4. ensure pt understanding of lifestyle influences 5. coach behavior change based on readiness to change

80% all premature deaths are attributable to:

1. tobacco use 2. poor diet 3. lack of physical activity

LM trx intensity

2 components: 1. intensity of contact hours 2. extent of lifestyle changes made ITLC maximizes both of these

Secondary insomnia

2/2: meds, peripheral hypoperfusion/vasospasm, visual impairment (opacification, retinal degeneration), RAAS issue (fluid imbalance)

Dr. Ludwig Johns Hopkins 2005 NEJM study

2000=first generation to have decreased life expectancy than prior generation

Red Meat Consumption and Mortality Study

2012 substituting nuts, legumes, whole grains, poultry, fish for 1 serving red meat (processed>unprocessed>total) decreased HR of mortality (~20% max)

Metabolic Syndrome

3 out of 5: -abd obesity (waist circum >40 or >35)-->TNF alpha, IL-6, PAI-1 (inflammatory adipokines) -hyperTG (>150) -low HDL (<40 M, <50 W) -HTN (>=130/85) -high fasting glucose (>=100)

Tobacco Cessation Meds

5 NRT: directly stimulate nicotinic receptors in ventral tegmental brain-->dopamine release -patch alone=15% more effective than placebo at 8 wks (45% tobacco free) -lozenge alone=10% more effective (40% at 8 wks) -<10 cig/day = no NRT benefit 2 non-nicotine meds: -Varenicline (chantix): partial nicotine receptor agonist (prevents w/drawals and reduces nicotine highs) -most effective monotherapy (30% more effective than placebo, 51% smoke-free at 12 wks, 35% at 6 mo) -pregnancy: C -12 weeks (+ 12 weeks=6 mo max) -Bupropion SR (Zyban): NE and dopa reuptake inhibitor - 10% more effective (40% at 8 wks) -? less weight gain -CI bipolar -pregnancy: C -6 mo max Off-label: clonidine, nortriptyline

METs

=metabolic equivalents (ratio of metabolic rate exercise: resting) -metabolic rate=amt O2 consumed -rest=1 MET sleeping: 0.9 walking=3 climbing stairs=5 running=18 -MET hrs/wk=MET/hr * hrs/wk -max benefit=10-20 MET hours/wk but min of standing x 2 hrs/day reduces mortality -no max recommendation-any increase = benefits, but benefit size decreases the higher you go

Nutrition Assessment

A: anthropometric data (weight, height, WHR, BMI, waist circumference, BIA-bioimpedance-helps est fat) B: biochemical data (lab work: Na, K, Hgb, Hct, glucose, a1c, albumin, TC, LDL, HDL, TG; vita D, B12, Fe, Ferritin) C: clinical assessment (age, gender, med hx, surg hx, activity level, nutritional hx (weight loss hx), absorption issues, vitals, PE) D: dietary assessment (current intake: solids/liquids; 24 hr recall and 3 day food record, mini nutritional assessment for the elderly >65 yo, behavioral motivators) -include religious, financial, emotional assessment as well -utilize RDs

Protein

Animal: -most concentrated (chx>beef>fish) -readily digestible -more sulfur-containing amino acids-->require buffering and can deplete Ca Plant: -soy, tofu, lentils, pinto beans, hempseed, whole wheat bagel, pumpkin seeds -less digestible -contain all essential amino acids, just not ideal proportion (combine them) --Legumes= best source of whole food, plant based protein (1.5cups = 22 grams of protein daily & recommended as a routine dietary goal for healthy adults) -rarely require prescription except elderly (poor absorption so require 25% more protein >70 yo), children, athletes -should be 15% calorie intake -broccoli>hamburger -soybeans=chx -weight loss=1.2-1.5g/kg (90-120g/day) -maintenance=0.7-1g/kg -higher protein intake increases thermogenesis and satiety

ABCD's of nutrition assessment

Anthropometric (height/weight, BMI, waist circ) Biochemical (labs) Clinical (vitals, PMH, PE-hair, nails, muscles) Dietary Intake (24 hr recall, 3-day record, food frequency questionnaire)

Tobacco Cessation 5 A's

Ask about smoking at each visit Advise patients regularly to stop smoking using a clear, strong, personalized message Assess patient readiness to quit Assist patients to set stop dates, meds, and provide educational materials for self-help Arrange for follow-up visits to monitor and support patient progress. Time constraint: Ask, advise, refer

5 A's

Assess: health risks Advise: changes (clear and specific) Agree: focus and pt's interest in change Assist: setting and achieving goals Arrange: regular f/u and support -5 A's are proven to improve motivation; patient centered instead of expert centered -goal: brief health behavior counseling using COLLABORATIVE approach to improve internal motivation -counseling /=advice 5 A's of Tobacco Cessation: Ask (about tobacco use), Advise (strong advice to quit), Assess (stage of change), Assist (through counseling, meds, etc if ready to quit), Arrange (f/u)

5 A's for physical activity

Assess: is the pt exercising; how do you feel about exercise? Advise: specific info about health benefits matched to stage of change; tailor advice to pt's problems and comorbidities Agree: goals and a prescription Assist: goal setting, social support, self monitoring, brainstorming ideas to fit exercise into daily life; relapse prevention Arrange: f/u session and interim support, and referrals if necessary

BMI Vital Sign

BMI=kg/m^2 OR lbs/in^2*703 underweight <18.5 normal 18.5-24.9 (lowest risk 19-22) overweight 25-29.9 obese 30-34.9 (class 1), 35-39.9 (class 2), >=40 (extreme, morbid, class 3) Asian-Americans: overweight=23-27.9 obese=>28 -32% of healthcare workers are obese

Weight loss meds (Obesity guidelines of ACA/AHA)

BMI>27+ comorbidity BMI>30

Bariatric Referral (obesity guidelines of ACA/AHA)

BMI>40 or BMI>35 + obesity ass'd comorbidity -T2DM, HTN, OSA, fatty liver, OA, DLP, GI disorders, HD -must be motivated

Insomnia trx

CBT > meds

Techniques for weight loss

CBT: -self monitoring (diet and exercise) -goal setting (SMART) -assess obstacles and determine good time to start -normalize a healthy diet -problem solve stimulus control change serving container size slow eating rate +/- behavioral contract social support (family, friendly competition, etc) focus on skill over willpower (develop guidelines to follow until behavior becomes habit)

5 components of fitness

Cardiorespiratory Muscle Strength Muscle Endurance Flexibility Body Composition

Overview of diets (DASH, Ornish, Mediterranean, CHIP,)

DASH (HTN) vegetables, low salt, low fat dairy diet Ornish (CAD): low fat, plant based for CAD stenosis reversal (1 and 5 year f/u) Mediterranean (2/2 prevention of CAD) CHIP (DM) walnuts are good for HLP

Epigenetic Influencers

Diet, exercise, sleep, obesity Good influencers: polyphenols, B-vitamins, exercise, stress reduction, maternal/paternal diet Bad influencers: sugar, alcohol, sat fat, processed food

Steps to making an action plan

Find a behavioral change pt feels >7 on confidence and importance: 1. explain role as expert and coach 2. share dx and potential outcomes if no lifestyle/medical changes are made 3. describe lifestyle prescription and potential positive outcomes 4. identify progress using positive psychology 5. identify new areas for action 6. identify pt's confidence and importance level for each change (>7 likely to succeed) 7. have pt summarize goals (SMART) and resources needed 8. plan for obstacles/barriers/support 9. refer if necessary 10. confirm pt commitment (positive psychology)

JNC 8 HTN guidelines

JNC 8 recommends 4 drug classes for therapy ACE, ARB, CCB & Diuretics JNC 8 raises the systolic threshold level at age 60 (<150/90 over 60, <140/90 < 60 or DM or kidney dz) Treatment is recommended when the blood pressure is >150/90 mmHg There controversy concerning this recommendation-can produce syncope if treat too aggressively JNC 8 recommends a blood pressure <140/90 for those with CKD and/or diabetes Treat with an ACE or ARB

Health Belief Model

Looks at why people DON'T do a preventive strategy/behavior change 1. perceived susceptibility (individual fx) 2. perceived severity (individual fx) 3. perceived benefit 4. perceived barriers 5. cues to action (stimuli or triggers)-modifying fx 6. SELF-EFFICACY (confidence in ability for behavior change) ex: Zika virus - sexually active 24 yo woman in Miami would use prevention, but 80 yo man in KY maybe wouldn't -doesn't include habitual behaviors or emotional/social aspect of dz

Alcohol recommendations

M: < 4 drinks/day; < 14 drinks/wk binge=>5 drinks/2 hrs F: <3 drinks/day; < 7 drinks/wk binge=>4 drinks/2hrs heavy alcohol use: > 5 days binge drinking/1 mo at risk drinking: exceeds recs 1/wk; binge drink >=1/mo 1 drink=12 oz beer, 8 oz malt liquor, 5 oz wine, 1.5 oz liquor

Alcohol options for change

MENUS Manage drinking Eliminate drinking Never drink/drive continue Usual patterns Seek help

PDSA

PLAN: desired improvement, change, testing, desired outcome DO: map process flow, do changes, collect data STUDY: review data, interview people about the process, determine modifications ACT: repeat on larger scale, adapt to changes needed, try something new?

Pillars of positive psychology (PERMA)

Positive emotion (optimism) Engagement (blissful immersion in present moment) Relationships Meaning: purpose for life Accomplishments: sense of satisfaction

Macronutrients

Protein Fat Carbohydrates

AUDIT feedback

RANGE Range: AUDIT scores 0-40 AUDIT: helpful correlating screening tool Normal scores=0-7 Give score=pt's score and explanation Elicit pt rxn=what do you make of that?

5 R's of MI for tobacco cessation

Relevance (negative consequences of smoking) Risks (health risks) Rewards of quitting Roadblocks to quitting Repetition

STOP: Brief OSA assessment

Snoring Tired often Observed apnea episodes Pressure (elevated BP) <2=low risk >=2: sleep study

SI and T2DM

ass'd with: -insulin therapy -duration of diabetes -unsatisfactory glycemic control

Carbohydrates

Whole-Food Carbs: -healthy -veggies, fruits, legumes, tubers, whole grains Processed: -harmful -sugar, flours Carb prescription components: -fiber (F: 25 g/day, best >40g/day; M: 38 g/day, best >45 g/day) -decrease refined sugar and flour -stay steady on starch (neutral or protective if whole food, harmful if processed) -prescribed as a specific food

T2DM Dx labs

a1c>=6.5 fasting serum glucose >-126 (7 mmol/L) OGTT: 2 hr post prandial glucose>=200 (11.1 mmol/L)

Lifestyle Prescriptions

actions needed to trx or prevent a condition based on scientific evidence + pt's medical condition ex: prescribe 150 min mod PA/wk

Stress reaction

an internal event leading to an *external reaction* of alarm, activation of SNS, overstimulation, or internalization of the situation which -->maladaptive coping and breakdown of emotions

Physical activity

any mvmt of the body using energy beyond baseline and utilizing skeletal muscle contraction

Measures of Fitness

cardio: step testing muscular endurance: squats, push ups, sit ups flexibility: sit and reach body composition: skin calipers

Exercise Prescription

cardio=FITT: Frequency, Intensity, Type, Time strength=FIRS: frequency, intensity (weight), repetitions, sets resistance: intensity=5-6/10 x 8-12 reps beofre fatiguing flexibility: 2-4 reps, duration 10-30 sec x 2-3 for all muscle groups balance: start w/ hand hold support and eventually remove support, stand on uneven surface

stress response

external event leads to *internal conscious processing* that allows a person to be mindful of the situation, recognize influences and chain of event reactions and make a deliberate choice -allows for better emotional control, greater sense of calm/balance, mental equillibrium

Prediabetes lab dx

fasting serum glucose >=100 (5.6 mmol/L) and <126 2h OGTT serum glucose 140-199 a1c 5.7-6.4%

Hedonia

happiness is characterized by presence of positive emotions and absence of negative emotions humans are born empty and acquire meanting through social and cultural interaction ass'd with upregulation of pro-inflammatory genes

Eudaimonia

humans are born full of meaning and purpose and they discover (not acquire) it throughout their lives belief in this may help mitigate dz risk and promote longevity -ass'd with downregulation of pro-inflammatory genes, less amygdala activation, increased cortical fx, and improved reward circuit

Foods that + Inflammation

processed grains/sugar (<1 serving/day) processed meat/red meat (class 1 carcinogen for colon, stomach, pancreatic, prostate ca) harmful fats (trans, oxidized, solid)

exercise

purposeful, organized PA to improve or maintain one's health

Behavioral Determinants of Positive health outcomes

required: 1. trusting relationship bw pt and PCP 2. pt support from multidisciplinary team, family, community

Suffering

state of pain, distress, loss, damage, disability, hardship or death 2 kinds: 1. necessary (experienced by all humans): illness, old age, separation from loved ones, death 2. unnecessary (stems from egocentricity: our wants, likes, dislikes, attachments, etc): wanting a different outcome than the one that has happened, anticipatory thinking (imagining the worst), repeating stories about the past, trying to resist pain -judging w/out mercy + suffering -minimizing suffering: recognize poor thought patterns, attention>inattention, intentionally connect, order/regulation>disorder, ease>disease

Top food groups to avoid (minimum nutrients/calorie)

sugar sweetened beverages processed meats fried foods processed snack foods with added fat, sugar, salt confections high fat dairy red meats poultry eggs fish added fats/oils reduced fat dairy refined grains

fitness

the ability to perform one's activities of daily living, respond to emergencies, and enjoy leisure time activities without excess fatigue -the outcome of exercise -components= cardiorespiratory endurance muscle strength muscle endurance body composition flexibility

Personalized Medicine

the interactions of lifestyle medicine, genetics, and pharmacotherapy

Nutrition Prescription

use SMART goals format: name, date, provider's signature core prescription components (TAF) 1. Type of food 2. Amount of food 3. frequency of eating Positive prescriptions (eat more of something good) Negative prescriptions (eat less of something bad)

vegetarian and vegan diet for DM (NIH study)

vegan>ADA diet x 22 wks -a1c decreased 3x more, LDL 2x more, lost more weight and reduced meds more

Top foods to consume (max nutrients/calorie)

vegetables herbs/spices fruits legumes whole grains nuts seeds

Portfolio Diet for Hypercholesterolemia

very low saturated fats high: plant sterols, soy protein, viscous fibers, almonds

Esselstyn plant based diet for CAD

very low-fat plant based prevents major cardiac events x 4 yrs

Precaution Adoption model

~ transtheoretical stages of change -7 stages (unawareness to maintenance) -linear model, not cyclical (cannot move backwards)

Physical activity recommendations to reduce CA risk

~3-4 hours/week -17-30% decrease for colon -25% decrease for breast CA -prevents recurrence and primary onset for breast CA -PA during treatment improves QOL and survival