Lifestyle Assessment & Health Promotion Interventions

Lifestyle See Ch 24 in Buttaro Overweight/obesity Physical activity Tobacco use/addiction Domestic Violence And… Accidents/injuries, alcohol use/abuse, eating disorders, substance use/abuse Lots of overlap! – This is a wrap-up of non-CA screening and health promotion items

Why does this matter? Morbidity and mortality linked to “lifestyle factors” like overweight/obesity, tobacco use, physical inactivity Connection is through incidence and prevalence of diabetes, cardiovascular disease, stroke, cancer Review of screening for lipid disorders, cardiovascular disease and diabetes will be considered separately.

Life Style Assessment – Obesity Assessment Obesity is epidemic – 22-37% of adults are obese (variation within sex and racial groups). Rates are rising fast. >50% of adults are considered overweight Classification BMI kg/m2 Underweight <18.5 Normal weight 18.5/24.9 Overweight 25-29.9 Obesity (Class 1) 30-34.9 Obesity (Class 2) 35-39.9 Extreme Obesity (Class 3) >40 Note – BMI may overestimate fat of very muscular individuals; use clinical judgment

Other Obesity Assessments Waist circumference – measure at top of iliac crest, at end of normal expiration It is an independent risk factor for mortality High risk is >40 inches for men, > 35 inches for women Assessments that are not meaningful: Waist to hip ratio Waist measure if BMI> 35 Bioelectric impedance Height/weight tables

Obesity: CVD Risk reduction Factors other than obesity status play a role in assessment of risk…but reductions in obesity are associated with reduced severity in these risk factor High absolute risk of mortality comes from Established CVD or other atherosclerotic diseases Type 2 DM Sleep apnea. Three or more of Hypertension, cigarette smoking, elevated LDL-C, low HDL-C, impaired fasting glucose, family hx of early CVD, patient age (male>45, female >55)

Weight management targets CVD Low risk or not at risk and normal weight Maintain healthy life style For CVD low risk or not at risk but overweight minimum goal is prevent further weight gain via lifestyle changes Preferred goal for all others overweight/obese is 10% body weight loss Slow rate of loss: 1-2 pounds per week Loss accomplished over six months Maintenance period before further weight loss attempted Use combo diet modification, increased physical activity and behavior therapy

Dietary Therapy Reduce caloric intake by 500-1,000 kcal/day. Do not go below 800 kcal/day Select 1,000-1,200 kcal/day for women & 1,200-1,600 kcal/day for men & women who weigh >165lbs or who exercise. Rework diet to be both lower calorie and lower fat. Must accommodate cultural needs. No fad diets! Make plan healthful, sustainable, appealing Encourage pt to think in terms of permanent changes in habits, not a temporary “diet” Need frequent contact with practitioner, lots of reinforcement.

Recent Research Meta-analysis of low-fat vs. Mediterranean style diets Mediterranean style diets were statistically more likely to lead to weight reduction But only by 2kg over a 2 year period in people to stuck to the program and were BMI > 29 to start with Not sure there is any clinical significance to this difference Article on D2L Not clear that there are low or moderate intensity interventions that are broadly effective.

USPSTF “B” recommendation in favor of high intensity counseling for obese (BMI > 30) individuals BMI is a good way to screen/assess for obesity High intensity counseling for diet and exercise is effective in achieving modest (3-5kg) weight reduction Reductions in intermediate outcomes (DM, lipids, BP) were sufficient to justify intervention. Plus, no harms identified. “I” recommendation for low or moderate intensity interventions, or for high intensity interventions for those who are merely overweight (BMI 25-29.9) Other organizations have a more aggressive stance.

High Intensity Interventions USPSTF: “The most effective interventions combine nutrition education and diet and exercise counseling with behavioral strategies to help patients acquire the skills and supports needed to change eating patterns and to become physically active.” 5 A’s can be used “high intensity” is face-to-face counseling (individual or group) more than once a month for at least 3 months. “moderate intensity” is once a month, face to face. “low” is < once a month. Pharmaceutical intervention should be offered only as part of a high intensity program Surgical procedures (lap banding, etc) should be reserved for those with Class III obesity or Class II with at least one obesity related illness. Mortality runs 0.2%. No evidence that interventions are effective in overweight individuals in reducing intermediate outcomes. No evidence that behavior management interventions (in contrast to diet/nutrition counseling and increased exercise intensity) are effective.

Teaching needs Set specific but achievable goals Motivation matters (Consider using MI techniques) Food composition, calorie content How to read food labels Serving sizes Wise food purchasing Low cal cooking Adequate water intake

Pharmacotherapy for weight loss Limited to those with BMI > 30 or BMI > 27 plus concomitant obesity related risk factors or diseases. Not all benefit from all drugs. If wt loss not at least 4.4 lbs after 4 weeks, drug is not likely to be helpful. Meridia (sibutramine) – appetite suppressant. Withdrawn from U.S. market in 2010. Next generation of drugs has been consistently rejected by FDA. For more info: NYTimes: FDA declines to approve new diet drug. http://www.nytimes.com/2011/02/02/business/02drug.html

Pharmacology for obesity Xenical (orlistat) – OTC as Alli. Inhibits gastric and pancreatic lipases, reducing fat absorption. Pregnancy category B, unknown safety in nursing. Must strictly adhere to low fat diet else many, many GI side effects (oily spotting, flatus, fecal urgency, fatty stools) Fat-soluble vitamin deficiency possible 120mg PO TID. Take with meal or within 1 hour after. Omit if no meal or no-fat meal. Use supplementation for fat soluble vitamins Keep dietary fat at <30% of calories Rx: 90 pills = $486 Alli otc – 60mg x 170 pills = $70. OK for diabetics and ages > 12. Caution in elders. Not of users of cyclosporin

Surgical Interventions (Updated since USPSTF) Now approved for those with BMI of 30 and comorbid conditions or BMI of 35 without comorbid conditions 20-26 million people are potential candidates by only 200,ooo have the surgery each year Costs $12-30,000, often not covered by insurance. Multiple associated follow on costs (also not covered) Non-trivial risks of morbidity & mortality Very effective short-term but results often not sustained long term.

Other interventions Latest fad: injection of hCG with 500 kcal/day diet Injectable hCG available only by RX. Off-label use. Anecdotal support, no research Expensive ($1,000 per month) See recent NYTimes article if interested http://www.nytimes.com/2011/03/08/nyregion/08hcg.html?ref=weight In terms of actual effectiveness, calorie reduction is required. No data supporting strategy on macronutrient composition. Many herbal/alternative therapies available on internet. Caution patients – many contain adulterants or are dangerous.

Healthy Eating New USDA food recommendations: My Plate www.choosemyplate.gov/

www.choosemyplate.gov/

DASH eating plan Free plan booklet from HHS Focused on diet to reduce BP but very suitable as guide to shifting to healthier eating habits and portion control Benefits are especially large for African-Americans & elderly Booklet on d2L

Weight Watchers Recent article in The Lancet indicated free access to Weight Watchers was more effective than family practice physician guidance in achieving weight loss. WW group lost 3.4 kg more over 12 months Stuck with it in higher percentages (~80% vs ~50%) Study paid for by WW…. Copy on D2L

Conclusion - Obesity Imperative to address overweight and obesity Find path/process that works in your practice Make recommendations consistent with client’s cultural needs Establish follow up pathways with pts Model good health behaviors!

Physical Activity Significant positive effects Across ages, conditions, moods, stress Very limited contraindications How much is enough? Minimum aim: 30 minutes, moderate intensity, most days of the week (think: 5) Strength training, balance training Relationship between gains is positive and linear Write an actual prescription

Gauer, R.L.,& O’Connor, F.G. (2000). How to write an exercise prescription. Retrieved 9/12/11 from www.hooah4health.com/toolbox/exrx/default.htm Note assessment of stage of change, evaluation of prior health status.

Gauer, R.L.,& O’Connor, F.G. (2000). How to write an exercise prescription. Retrieved 9/12/11 from www.hooah4health.com/toolbox/exrx/default.htm GXT – graded exercise testing

An Exercise Prescription Activity Selection Duration Frequency Intensity Progression Resistance training Flexibility training

Screening prior to ↑ activity For most asymptomatic individuals – no testing No personal history of CVD or complaints of chest pain No family hx of sudden cardiac death or MI before age 60 No cardiac abnormalities on physical exam No unaddressed co-morbidities For men over 40 and women over 50 who have been sedentary and plan to start a vigorous program, may need stress test Moderate activity (vigorous walking) is OK

Pre-exercise exercise stress test Diabetes present (ACC/AHA guideline 2002, level of evidence C – expert opinion) Multiple risk factors (not much evidence) Hypercholesterolemia (TC>240mg/dL) HTN (SBP > 140or DBP>90) Smoking, diabetes, family hx or MI or sudden cardiac death before age 60 Framingham risk score of moderate or greater risk within 5 years Asymptomatic males over 40 (& women over 50), especially if previously sedentary

Community Based Interventions Community based interventions do have evidence of effectiveness. Community wide campaigns School-based phys ed programs Improved access to places for physical activity Individually adapted behavior change programs

Eating Disorders Anorexa and bulimia – excessive concern with body shape and weight with impaired psychosocial functioning. Affect 1% to 4.6% of young adult women Typically during adolescence Women 10x rate of men Significant coincident diagnoses of anxiety, depression, alcohol & substance use/abuse Shame, secrecy, denial are common

Screening See new guidelines from Academy for Eating Disorders’ Medical Care Standards Task Force. Endorsed by Society for Adolescent Health and Medicine. Key points: Eating disorders affect boys/men as well as females Look beyond low body weight/BMI Look for precipitous weight loss and substantial fluctuations Look for amenorrhea or menstrual irregularities or unexplained infertility Look for constipation without dietary cause Look for excessive exercising or extreme physical training Serious medical consequences can result from undiagnosed disease, so screen carefully!

Physical Exam Comprehensive psych, medical history plus PE Typically BMI <17.5 but not all are cachectic. May see depressed body core temp, bradycardia, hypotension, dry skin, thinning hair. May see poor dentition – enamel erosion on inner surfaces of molars from repeated emesis Cardiac rhythm abnormalities Slow motor responses, muscle weakness Those who binge/purge may have enlarged parotid glands Look for evidence of cutting & self-harm behaviors too!

Differential & Diagnosis Differential dx – consider both psych & medical AIDs, cancer, hyperthyroidism, Klein-Levin syndrome, peptic ulcer disease, adrenocortical insufficiency Body dysmorphic disorder, drug abuse, major depression, schizophrenia Diagnosis per DSM IV (see p 1400 in Buttaro)

Management Very time/attention intensive Consider referral to in-patient in serious cases May need medical stabilization first (cardiac disturbances, fluid & electrolyte imbalances, anemia) Definitely need team approach with psych, family counseling, dental, possibly endocrine as part of team Eating disorders and underlying psych issues are usually chronic conditions

Tobacco & Nicotine Single largest preventable cause of death in U.S. Nicotine one of 4,000 components of smoke Long term exposure associated with cancer, HTN, CVD, GI and reproductive disorders Nicotine is HIGHLY addictive 35 million smokers in U.S. Only 7% quit each year. Affects pathways in brain producing feelings of cognitive arousal, alertness, improved memory and energy. Addictive pathways & receptor laid down in 3-6 weeks.

Addiction By definition: Compulsive drug seeking and use, even in the face of negative health consequences.* 10% of adults lack genes for nicotine sensitivity Withdrawal sx: dysphoria, difficulty thinking (within 1-2 days) All pts should be asked about smoking/nicotine use and advised to quit. Assess for ‘stages of change’ Pre-contemplation, contemplation, etc National Institute on Drug Abuse

Help your patient quit! Assess stage of change Offer support, strategies for cessation (p134) Use MI techniques Offer pharmacological support, but always in conjunction with behavior modification strategies Offer referrals to local support groups

Nicotine Replacement (NRT) Gum, patches, inhalers, nasal spray Nicotine can affect CV system via vasoconstriction. Can precipitate arrhythmias Must refrain from smoking while using NRT Assess current nicotine intake – need to replace at basal rate plus extra for ‘breakthrough’ sx

Gum 2 mg and 4mg pieces If >25 cigarette/day habit then 4mg PO q 1-2 h x 6 weeks. Then q2-4h x 3 wk, then q 4-8h x 3wk. Max 24 pieces per day. Available OTC. If <25 cig/day habit then 2mg pieces, same schedule MUST stop cigarettes concurrently Contraindications: arrhythmias, TMJ, pregnancy Watch for mouth/gum/tooth pain, HA, nausea, hiccups, rash, diarrhea, flatulence

Gum No food/drink for 15 minutes before hand Place gum in mouth, chew til tingling sensation felt Park gum in buccal pocket Chew several times every few minutes for additional nicotine release May chew same piece until no tingling sensation on chewing May cause hyperglycemia in diabetics. Monitor. May cause HTN if concurrent buproprion. Check for other interactions on drug by drug basis

Patch Comes in 7mg, 14mg, and 21mg per 24h transdermal systems (patches) 6-10 cigarettes/day: one 14mg patch daily x 6 weeks, then one 7mg patch daily x 2 weeks. >10 cig/day: one 21mg patch daily x 6 weeks, then one 14 mg patch daily x 2 weeks, then one 7mg patch daily x 2 weeks. Must stop smoking at onse. Apply patches to clean, relatively hairless skin. Remove old patch daily. Local rashes/irritation likely. Use 1% OTC hydrocortisone creams. Same cautions/precautions as gums.

Inhalers, nasal sprays Consult your mobile clinical reference. Same principles apply.

Buproprion HCl Same as Wellbutrin. Brand name Zyban. Not the same as buproprion HBR (Aplenzin) for major depression. Pharmacology = other antidepressant, mechanism unknown, inhibits uptake of norepinephrine and dopamine Black Box warning about suicidality, esp in teens and children Assess for current and past history of depressive sx and suicidal ideation. Chart carefully. Be sure follow up is in place. Other contraindications: current seizure disorders, eating disorders, other current use of buproprion.

Buproprion HCl Use 12 hour ER formulation 150mg ER PO bid x 7-12 weeks. Start with 15omg ER qday x 3 days, then go to BID. Max 300mg/day. Separate doses by at least 8 hours, last dose no later than 6pm. Stop smoking on day 6 or 7 of treatment Avoid, minimize alcohol use Do not crush or chew.

Varenicline (Chantix) Works on nicotine receptors Black Box warning – suicidality, worsen psychiatric sx if underlying mental illnesses Start with 0.5g PO qday x 3d then 0.5 mg BID x 4 days. Continue at total daily dose of 1-2mg/day, divided for total of 12 weeks. May extend to 24 weeks. Take with food. Stop smoking on day #7 or between days 8-35 (taper) Comes in starter pack and regular dose pack.

Smoking Cessation Reassure pts – it may take more than one or two attempts to stay quit but it is possible. If relapse occurs, be very encouraging about success on subsequent attempts. Pharm. Interventions double or triple likelihood of success vs no supportive therapies. “Cutting back” – doesn’t get much in the way of health benefits, prolongs periods of withdrawal SE. Better to go cold turkey. For < 10 cig/day, can pretty easily get by w/o meds. Plan for a stress relieving substitute behavior!

Alcohol Abuse Using when the pt knows it is harmful (medical, work, financial, family, hazardous activities, social) and has been advised to stop. 3rd leading cause of preventable death in U.S. (after smoking and obesity) Half the deaths are attributed to alcohol related injury Of men 18-25, 60% binge drink (5+ drinks in a row) Significantly increases risk for injury, risk taking in unprotected sex. ¾ of all foster children are children of alcohol or drug dependent parents. Half of all violent crime is alcohol or drug related. Overall morbidity/mortality linked to smoking.

Abuse crosses all demographic, SES groups Lower SES have higher rates of both abstinence and alcoholism Prevalence of alcoholism: Native Americans > Hispanics > Whites > Asians > Af-Americans Men have twice the prevalence of women Abuse include binge drinking (>5 drinks/day) at least once in a 30 day period Dependence occurs when physiological changes occur, requiring continued intake of alcohol to maintain homeostasis.

Alcohol Depressant Absorbed in stomach and small intestine Absorption delayed in presence of food Metabolized in liver Adverse effects of L-T use – fatty liver, elevated triglycerides, hypoglycemia In dependent states, alcohol is metabolized more quickly (i.e. greater tolerance before toxicity shows) Blood alcohol concentration (BAC) of 0.08 is threshhold for intoxication in IL

Definitions One drink 12 ounces of beer (1 can) 360 mL @6%= 21.6mL 5 ounces of wine 150 mL @ 14%=21 mL 1.5 oz distilled spirits (100 proof) 45 mL@50%= 22mL Adults oxidize 7.5-10mL/hours The difference between intake and what is oxidized goes to the blood stream where it can be measured as BAC.

Withdrawal When BAC falls below level to which individual has adapted, see sx Mild: Anxiety, HA, nausea, hypervigilance, tachycardia, mild tremors Severe: Diaphoresis, worsening tachycardia, elevated BP, auditory/visual/tactile hallucinations, fever. Even seizures, DTs, status epilepticus. DTs: delirium tremens. Deterioration of mental status and instability of autonomic nervous system. Shows up in 24-72 hours of last drink in serious chronic alcoholism. Urgent!

Identifying alcohol abuse Fewer than half of cases of alcohol abuse are identified as such. Rarely is it the presenting complaint. Harder to identify in low incidence populations Harder to identify in binge drinkers (but not daily users) Safe levels of alcohol Women & men over 65: 1 drink per day, max 3 per day and 7 per week Men under 65: 1 or 2 drinks per day, max 4 in one day and 13 in one week.

CAGE Have you ever felt you ought CUT down on your drinking? Have people ANNOYED you by criticizing your drinking? Have you ever felt bad or GUILTY about your drinking? Have you ever had an EYE-OPENER drink first thing in the morning? Yes to two or more suggests alcohol use disorder. Focus on use patterns and consequences of use rather than absolute amounts consumed

Physical Exam See p 1373 – Always sniff! Labs – none specific but look at MCV – may be elevated in a folate deficiency situation GGT, AST, ALT – elevated GGT will return to normal first (about 3 weeks of sobriety) AST>ALT in alcohol abuse (vs hepatitis where ALT>AST) See multiple levels of dysfunction across the physical exam depending on length of alcohol dependency

Differential Dx Hypertension Cardiac arrhythmias Liver disease Pancreatitis Endocrine disorder Anxiety Substance abuse

Management Do 5 A’s at a minimum Assess readiness for change and go from there May want a follow up appt May want to include family May refer to AA or Rational Recovery Family will need some degree of support/referral Al-anon or Al-ateen If imminent harm to self or others, consider referral/admission to acute care

Pharmacological Support Address metabolic deficiencies Supplements for thiamine, multivitamin, folic acid Emotional support Depression often present. SSRIs typically helpful. Anxiety may be present. SSRIs helpful there too. If significant withdrawal sx are anticipated, either refer to addiction specialist or to acute care for detox

Consequences Trauma, alcohol poisoning, MVI, violence, suicide Longer term – functional impairments, homelessness Metabolic – vitamin deficiencies (B1, folic acid, B6, niacin, A), pancreatitis, chronic gastritis, liver disease. Hyperuricemia, blood sugar dysregulation, hypogonadism. Neurologic Read pp 1375-76. Neuro signs are late in the progression of disease

Consequences Cardiovascular Contributes to HTN 3 or more drinks/day doubles the risk of refractory HTN. Binge drinking can cause wide swings in BP But low steady levels of consumption are thought to contribute positively to lower lipid profiles and reduced platelet aggregation. “Holiday Heart” Heavy drinking around the holidays leads to runs of tachyarrhythmias including aFib. Dilated cardiomyopathies are the end state

Consequences GI Reflux esophagitis Frequent vomiting –> Mallory Weiss syndrome Portal HTN causes esophageal varices ETOH + nicotine -> esophageal adenocarcinoma Chronic pancreatitis Colon adenomas -> colorectal cancer Fatty liver, alcoholic hepatitis and cirrhosis None of this ends well with continued drinking…

Fetal Alcohol Syndrome No safe level of drinking during pregnancy Fetal Alcohol Syndrome (FAS): 2,000 cases/year Leading cause of mental retardation Intellectual impairment Developmental delays Growth retardation Characteristic abnormal facial features

References Buttaro See Medscape tutorial on alcohol use and abuse at http://emedicine.medscape.com/article/285913-overview#a0101 Very thorough Recommended over Buttaro for in depth study (optional)

Safety – Domestic Violence USPSTF has “I” insufficient evidence recommendation on screening for Family and Intimate Partner Violence Nevertheless, assess universally for current and history of DV DV affects all ages & classes & racial groups

Basics of Domestic Abuse Protect privacy during screening Note – it is common for pts to deny abuse. Have to screen every visit as pt may not share info until provider relationship is more developed Know reporting requirements, esp. related to minors and dependent adults Call security/police if imminent danger.

Safety – Domestic Violence Ask directly: Have you ever been hit, slapped, kicked, or otherwise physically hurt by someone? If yes, by whom? Have you ever been threatened, controlled, or forced to do things you did not want to do? If yes, by whom? Are you afraid of your partner or anyone else? Have hotline cards in the women’s rest room.