Lifestyle Medicine 2015: Tools for Promoting Healthy Change Agenda

Saturday, June 27, 2015

7:00–7:45 Registration/Continental Breakfast

7:15–7:45 Meet and Greet

7:45–8:45 Lifestyle Medicine: True Healthcare Reform

David L. Katz, MD, MPH

8:45–10:15 The Lifestyle Medicine Dream Team

Physician Social Worker

Exercise Physiologist Health Coach

Dietitian

Elizabeth P. Frates, MD, Moderator Kriston Kent, MD, MPH Karen Lane, LICSW Cedric Bryant, PhD Heidi Duskey, MA Debra Wein, MS, RDN, LDN, NSCA-CPT*D, CWPD

10:15–10:30 Invigoration Break

10:30–11:45 Practitioner-to-Practitioner: Lessons Learned and Successes Earned by Early Adopters

Elizabeth P. Frates, MD, Moderator Amira Aly, MD Reza Antoszewska, NP-C Karyn Bender, RPh, CHHC Barbara Brown, MD and Lynn Kossow, MD Rebecca Brown, MD and Larry Schmidt, MD Lilach Malatskey, MD, MHA Krutika Parasar, SciB Karen M. Sherritt, MD

11:45–12:45 Lunch (on your own)

12:00–12:45

Optional Lunch-and-Learn Forum: Billing and Coding for Lifestyle Medicine

Nancy M. Enos, FACMPE, CPMA,CPC-I, CEMC

12:45–1:45 Motivational Interviewing: The Evidence-Based Strategies that Produce the Best Results

Joji Suzuki, MD

1:45–2:45 Sleep Sat Bir Singh Khalsa, PhD

2:45–3:00 Meditation break (optional) Sat Bir Singh Khalsa, PhD

3:00–4:00 Obesity and Sleep Fatima Cody Stanford, MD, MPH

4:00–5:00 What Really Gets Patients (Even Reluctant Ones) to Effect Healthy Change

Cheri Blauwet, MD

David L. Katz, MD, MPH

Lifestyle Medicine:

True Healthcare Reform

Lifestyle as Medicine: a GLiMMER of hope?

David L. Katz, MD, MPH, FACPM, FACP

Director, Prevention Research Center

Yale University / Griffin Hospital

President, American College of Lifestyle Medicine

Editor-in-Chief, Childhood Obesity

Author, Disease Proof

Harvard

6-15

The Blind Men and the Elephant

-John Godfrey Saxe

Out of the Woods-

The Elephant in the Room

The Peril, Promise, & Problem

…and the other problem

A Fork in the Road

The Right Metaphor

Sandbagging

Not Just Waitin’ on the World to Change

The Big Spoon

The Fork in the Road, Revisited

The Forest through the Trees

Death, in the dark wood…

McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-12

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the

United States, 2000. JAMA. 2004;291:1238-45

The People in Potsdam-

Ford ES, Bergmann MM, Kröger J, Schienkiewitz A,

Weikert C, Boeing H. Healthy living is the best revenge:

findings from the European Prospective Investigation

Into Cancer and Nutrition-Potsdam study. Arch Intern

Med. 2009 Aug 10;169(15):1355-62

Or the UK: Kvaavik E, Batty GD, Ursin G, Huxley R, Gale CR. Influence of individual and combined

health behaviors on total and cause-specific mortality in men and women: the United

Kingdom health and lifestyle survey. Arch Intern Med. 2010;170:711-8

Or the US McCullough ML, Patel AV, Kushi LH, Patel R, Willett WC, Doyle C, Thun MJ, Gapstur SM.

Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and

all-cause mortality. Cancer Epidemiol Biomarkers Prev. 2011;20:1089-97

Fresher still-

Akesson A, Larsson SC, Discacciati A, Wolk A. Low-

Risk Diet and Lifestyle Habits in the Primary

Prevention of Myocardial Infarction in Men: A

Population-Based Prospective Cohort Study. J Am

Coll Cardiol. 2014 Sep 30;64(13):1299-306

Fresher-er…

Aleksandrova K, et al. Combined impact of healthy

lifestyle factors on colorectal cancer: a large

European cohort study. BMC Med. 2014 Oct

10;12(1):168. [Epub ahead of print]

Fresher-er-er…

Chomistek AK, Chiuve SE, Eliassen AH, Mukamal KJ,

Willett WC, Rimm EB. Healthy lifestyle in the

primordial prevention of cardiovascular disease

among young women. J Am Coll Cardiol. 2015 Jan

6;65(1):43-51

rePercussions…

…to our pith and marrow; the case for nurturing nature:

Ornish D, Magbanua MJ, Weidner G, Weinberg V, Kemp C, Green C, Mattie MD,

Marlin R, Simko J, Shinohara K, Haqq CM, Carroll PR. Changes in prostate gene

expression in men undergoing an intensive nutrition and lifestyle intervention.

Proc Natl Acad Sci U S A. 2008 Jun 17;105(24):8369-74

Hietaniemi M, Jokela M, Rantala M, Ukkola O, Vuoristo JT, Ilves M, Rysä J, Kesäniemi Y. The effect

of a short-term hypocaloric diet on liver gene expression and metabolic risk factors in obese

women. Nutr Metab Cardiovasc Dis. 2009 Mar;19(3):177-83

Freedland SJ, Aronson WJ. Dietary intervention strategies to modulate prostate cancer risk and

prognosis. Curr Opin Urol. 2009 May;19(3):263-7

Ujvari U, Hulchiy M, Calaby A, Nybacka Å, Byström B, Hirschberg AL. Lifestyle intervention up-

regulates gene and protein levels of molecules involved in insulin signaling in the endometrium of

overweight/obese women with polycystic ovary syndrome. Hum Reprod. 2014 Jul;29(7):1526-35

The Master Levers of Destiny-

Feet

Forks

Fingers

But….

Lost in translation…

Knowledge, alas, isn’t power…

Katz DL. Life and death, knowledge and power:

why knowing what matters isn’t what's the

matter. Arch Intern Med. 2009 Aug 10;169(15):1362-3

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1995

(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 2010

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

15%–<20 20%–<25% 25%–<30% 30%–<35% ≥ 35%

Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

CA

MT

ID

NV

UT

AZNM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

ILOH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

NH

MA

RI

CTNJ

DE

MD

DC

PRGUAM

Age-adjusted Percentage of U.S. Adults Who Had

Diagnosed Diabetes

<4.5%Missing data

4.5 - 5.9% 6.0 - 7.4%

7.5 - 8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics

1994

Age-adjusted Percentage of U.S. Adults Who Had

Diagnosed Diabetes

<4.5%Missing data

4.5 - 5.9% 6.0 - 7.4%

7.5 - 8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics

2010

From the frying pan…

http://www.pophealthmetrics.com/content/8/1/29

Projection of the year 2050 burden of diabetes in the US

adult population: dynamic modeling of incidence,

mortality, and prediabetes prevalence

One-Third of U.S. Adults Could Have Diabetes by 2050:

CDC 'Alarming numbers' point to importance of healthier lifestyles in reversing the

trend, experts say

HealthDay News, October 22, 2010

By 2050, between one-fifth and one-third of all adults could have diabetes -- with virtually all the

increase attributed to type 2 diabetes, which is largely preventable.

U.S. Diabetes Rates Soaring: CDC

Numbers have doubled over 15 years across

18 states, and all states now have rates of 6

percent or more

By Steven Reinberg

HealthDay ReporterLast Updated: Nov. 15, 2012

Masters RK, Reither EN, Powers DA, Yang YC,

Burger AE, Link BG. The Impact of Obesity

on US Mortality Levels: The Importance of

Age and Cohort Factors in Population

Estimates. Am J Public Health. 2013 Aug 15.

[Epub ahead of print]

Dabelea D, Mayer-Davis EJ, Saydah S, Imperatore G, Linder B, Divers J, Bell

R, Badaru A, Talton JW, Crume T, Liese AD, Merchant AT, Lawrence JM,

Reynolds K, Dolan L, Liu LL, Hamman RF; SEARCH for Diabetes in Youth

Study. Prevalence of type 1 and type 2 diabetes among children and

adolescents from 2001 to 2009. JAMA. 2014 May 7;311(17):1778-86

Diabetes in young people up 30% to 35% in past decade

By Steven Ross Johnson

May 6, 2014

Cooked?

40 Percent of Americans Will Develop

Diabetes, CDC Projects

Rates for black women and Hispanics even higher

at 50 percent

By Dennis Thompson

HealthDay Reporter

TUESDAY, Aug. 12, 2014 (HealthDay News) –

Aug. 13, 2014, The Lancet Diabetes & Endocrinology, online

The Writing is on the Wall-

November 12, 2008

Child Obesity Seen as Warning of Heart Disease By PAM BELLUCK

February 10, 2011, 2:27 pm

Stroke Rising Among Young People By TARA PARKER-POPE

The Promise of Public Health,

in Private Parts-

What lifestyle can do…

80% reduction in heart disease

90% reduction in diabetes

60% reduction in cancer

and so on…

4 Healthy lifestyle factors help ward off chronic disease. Diet, exercise, low body mass index and not smoking

can reduce the incidence of heart disease, diabetes, stroke and cancer. Duke Med Health News. 2009;15:4-5

Knoops KT, de Groot LC, Kromhout D, Perrin AE, Moreiras-Varela O, Menotti A, van Staveren WA.

Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE

project. JAMA. 2004;292:1433-9

The Public-

in private parts…

Katz DL. Facing the facelessness of public health:

what’s the public got to do with it? Am J Health

Promotion. 2011 Jul-Aug;25(6):361-2

The Problem-

When clear where “there” is-

(Can We Say What Diet Is "Best"? David L. Katz; Huffington Post, 9/7/11: http://www.huffingtonpost.com/david-katz-md/best-diets_b_950672.html)

-it may still seem…

you can’t get there from here:

…& the other problem:

Is it clear where “there” is?

Fingers…Feet…Forks...

Health Diet/Nutrition

Low-Carb Diet Beats Low-Fat for Weight Loss

•Mandy Oaklander @mandyoaklander

Sept. 1, 2014

Bird’s (Katz’?) eye view-

Katz DL et al. Can we say what diet is best for

health? Annu Rev Public Health. 2014 Mar 18; 35:83-

103

Science Compared Every Diet, and the Winner Is Real Food

Researchers asked if one diet could be crowned best in terms of health outcomes.

If diet is a set of rigid principles, the answer is a decisive no. In terms of broader

guidelines, it's a decisive yes.

James Hamblin Mar 24 2014, 1:14 PM ET

Katz DL et al. Nutrition in Clinical Practice, 3rd Edition. Wolters

Kluwer/Lippincott Williams & Wilkins. September, 2014

Other eyes, on the same prize -

Mann J et al. Low carbohydrate diets: going against the

grain. Lancet. 2014 Oct 25:384;1479-80

Ley SH, Hamdy O, Mohan V, Hu FB. Prevention and

management of type 2 diabetes: dietary components and

nutritional strategies. Lancet. 2014 Jun 7;383:1999-2007

Katz DL, Hu F. Knowing what to eat, refusing to swallow it. Huffington

Post. 7/2/14

Macronutrients, Misrepresentations, &

Mayhem-

Chowdhury R et al. Association of Dietary,

Circulating, and Supplement Fatty Acids With

Coronary Risk: A Systematic Review and Meta-

analysis. Ann Intern Med. 2014;160:398-406

Bazzano LA et al. Effects of low-carbohydrate

and low-fat diets: a randomized trial. Ann Intern

Med. 2014;161:309-318

Low fat vegan

Low GL

DASH

DPP Paleo

Low Carb Mediterranean

“Eat food, not too much, mostly plants.”

-Michael Pollan

Much the same, in 572 pages…

Scientific Report of the 2015 Dietary

Guidelines Advisory Committee

http://www.health.gov/dietaryguidelines/2015-

scientific-report/

Mostly plants? Fuggedaboudit!...

Blanck HM, Gillespie C, Kimmons JE, Seymour JD, Serdula MK. Trends in

fruit and vegetable consumption among U.S. men and women, 1994-2005.

Prev Chronic Dis. 2008 Apr;5(2):A35. Epub 2008 Mar 15

Kimmons J, Gillespie C, Seymour J, Serdula M, Blanck HM. Fruit and

vegetablei ntake among adolescents and adults in the United States:

percentage meeting individualized recommendations. Medscape J Med.

2009;11(1):26. Epub 2009 Jan 26

Katz DL. Plant foods in the American diet? As we

sow... Medscape J Med.2009;11(1):25. Epub 2009

Jan 26

EVEN when clear where “there” is-

(Can We Say What Diet Is "Best"? David L. Katz; Huffington Post, 9/7/11: http://www.huffingtonpost.com/david-katz-md/best-diets_b_950672.html)

-it may seem…

you can’t get there from here:

A sandbagger…

and proud of it!

No Child Left (on their) Behind-Square Peg, Round Hole?

As easy as “ABC” for Fitness-

Activity Bursts in the Classroom

Katz DL, Cushman D, Reynolds J, Njike V, Treu JA, Walker J,

Smith E, Katz C. Putting physical activity where it fits in the

school day: preliminary results of the ABC (Activity Bursts in the

Classroom) for fitness program. Prev Chronic Dis. 2010

Jul;7(4):A82. Epub 2010 Jun 15

A Katz & Katz Production

2002 David & Catherine Katz

Katz DL, Katz CS, Treu JA, Reynolds J, Njike V, Walker J,

Smith E, Michael J. Teaching healthful food choices to

elementary school students and their parents: the Nutrition

Detectives™ program. J Sch Health. 2011 Jan;81(1):21-8

The ONQI Algorithm-

Numerator Denominator

FiberFolateVitamin AVitamin CVitamin DVitamin EVitamin B12Vitamin B6PotassiumCalciumZincOmega-3 fatty acidsTotal bioflavanoidsTotal carotenoidsMagnesiumIron

Saturated fatTrans fatSodiumSugarCholesterol

•Macronutrient Adjustors

Fat quality

Protein quality

Glycemic load

Energy density

•Trajectory Scores

•Weighting Coefficients

Categorical stipulations

• Pure foods vs.

processed

• Intrinsic vs. added

sugars

• Artificial

sweeteners

• Etc.

Katz DL, Ayoob KT, Decker EA, Frank GC, Jenkins DA, Reeves RS, Charmel P. The

ONQI Is Not a Black Box. Am J Prev Med. 2011 Sep;41(3):e15-6

Chiuve S, Sampson L, Willett WC. The association between a nutritional quality

index and risk of chronic disease. Am J Prev Med. 2011;40(5):505-13

Katz DL, Njike VY, Rhee LQ, Reingold A, Ayoob KT. Performance characteristics

of NuVal and the Overall Nutritional Quality Index (ONQI). Am J Clin Nutr.

2010;91:1102S-1108S

Katz DL, Njike VY, Faridi Z, Rhee LQ, Reeves RS, Jenkins DJ, Ayoob KT. The

stratification of foods on the basis of overall nutritional quality: the overall nutritional

quality index. Am J Health Promot. 2009;24:133-43

Jacobson MF. An important new way to rate the nutritional quality of foods. Am J Health

Promot. 2009;24:144-5

Measuring what matters…

RR of all-cause mortality, top vs. bottom quintile of

NuVal scores

NHS: RR = 0.88; p<0.001 (n ~ = 70,000)

HPFS: RR = 0.87; p = 0.001 (n ~ = 40,000)

Chiuve S, Willett WC et al. Harvard School of Public Health

Abstract presented: Experimental Biology 2010; Anaheim, CA

Am J Prev Med 2011 May;40(5):505-13

NuVal Mom of the Month for January, 2012:

Sally Galvin of Olathe, KS

NuVal con tempo >100,000 foods scored and audited

In >2000 supermarkets in 33 states, coast to coast

Reaching ~40 million shoppers every week

Sandbags…

on the assembly line:

http://www.yalegriffinprc.org/

www.turnthetidefoundation.org

Not just waitin’ on the world to change…

OWCH: On-line Weight Management Counseling

for Healthcare Professionals

http://www.turnthetidefoundation.org/OWCH/index.htm

Katz DL, Shuval K, Comerford BP, Faridi Z, Njike VY. Impact of an educational

intervention on internal medicine residents' physical activity counselling: the

Pressure System Model. J Eval Clin Pract. 2008 Apr;14(2):294-9

Katz DL. Behavior modification in primary care: the pressure system model.

Prev Med. 2001 Jan;32(1):66-72

O'Connell M, Comerford BP, Wall HK, Yanchou-Njike V, Faridi Z, Katz DL.

Impediment profiling for smoking cessation: application in the worksite. Am J

Health Promot. 2006 Nov-Dec;21(2):97-100

Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC. Impediment profiling

for smoking cessation. Preliminary experience. Behav Modif. 2003

Sep;27(4):524-37

O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan W, Katz DL.

Impediment profiling for smoking cessation: results of a pilot study. Am J Health

Promot. 2003 May-Jun;17(5):300-3

Medicine Lifestyle

The big spoon…

is culture.

Katz DL. Is obesity cultural? US News & World Report,

Eat + Run Blog; 10/4/12;

http://health.usnews.com/health-news/blogs/eat-

run/2012/10/04/is-obesity-cultural

Lifestyle Medicine

is

CULTURAL Medicine

GLiMMER

Global Lifestyle Medicine Movement to Effect Revolution

http://glimmerinitiative.org/

Lighting the World’s Way to Health

GLiMMER: Vision

The Earth is both a beautiful Blue Planet, and a

universal Blue Zone

LiM

Global coalition of lifestyle medicine organizations;

ACLM as convener

Development, Refinement, Dissemination of best

practice models

Contributions to medical education (all levels)

Engagement of payers and policy makers to

advance reimbursement models

Participant in the True Health Coalition (aid, out)

Able to leverage cultural supports (aid, in)

LaM

The True Health Coalition

Designed to advance the #UseWhatWeKnow

principle

Ship & Sail, Wind & Wave

Project components are “ship & sail,” specific to a

given destination

The True Health Coalition generates a wind to fill

all sails by establishing consensus, repudiating

distractions and discord

Join us -

True Health Coalition

One Voice, United

A global voice devoted to disseminating and applying

what we know for sure about health promotion and

disease prevention.

Sign up today to become a member of the True Health

Coalition. Your voice matters!

sign me up!

http://glimmerinitiative.org/#coalition

The Road Not Taken

-Robert Frost

Thank you!

David L. Katz, MD, MPH, FACPM, FACPDirector, Yale Prevention Research Center

President, Turn the Tide Foundation, Inc.

130 Division St.

Derby, CT 06418

(203) 732-1265

David.katz@yale.edu

www.davidkatzmd.com

The Lifestyle Medicine Dream Team

Physician

Kriston Kent, MD, MPH Social Worker

Karen Lane, LICSW Exercise Physiologist

Cedric Bryant, PhD Health Coach

Heidi Duskey, MA Dietitian

Debra Wein, MS, RDN, LDN, NSCA-CPT*D, CWPD

Lifestyle Medicine in the Real

World

Kriston Kent MD MPH

The Kent Center for LIFE

Naples, FL

The Lifestyle Medicine Dream Team:

Physician, Nurse, Exercise Physiologist,

Health Coach, Dietician

Kriston Kent MD MPH

The Kent Center for LIFE

Naples, FL

No Disclosures

Kriston Kent MD MPH

The Kent Center for LIFE

Naples, FL

Objectives

• Describe how I arrived at Lifestyle Medicine

practice

• Essential components of a Lifestyle

Medicine practice

• Additional components/Adjuncts to a

Lifestyle Medicine practice

• Challenges of a Lifestyle Medicine practice

Introduction to:

The Kent Center for LIFE

My background:

• Raised on a cattle farm by 2 college

professors in the deep South

• Grew most of our fruits and vegetables (and

fried most of the vegetables)

• In late 1970s: read “the aerobics way” by

Kenneth Cooper MD MPH

Introduction to:

The Kent Center for LIFE

My background:

• Aging well and extending “health span”

became a passion by age 20

• 10 years of medical school and surgical

residency(little time for health habits)

• 1990:Started solo Facial Plastic Surgery

practice in Naples Florida with wife, 3 young

children, and lots of debt

Introduction to:

The Kent Center for LIFE

My background:

• Grew a successful practice helping people

“Age well on the outside” for 20+ years

• Empty nest and renewed passion for healthy

aging led to major personal/professional

lifestyle change

• Obtained MPH in Lifestyle Medicine from

Loma Linda University

Introduction to:

The Kent Center for LIFE

My Additional background:

• Attended: Active Lives: Transforming

Ourselves and Our Patients

• Attended: Healthy Kitchens, Healthy Lives

• Completed externship with the Institute of

Lifestyle Medicine – Harvard Medical School

• Completed externship with St. Helena

Center for Health

Introduction to:

The Kent Center for LIFE

KCL program development:

• Chose key team members

• Nutritionist/licensed clinical dietitian

• Fitness professionals/physical therapists

• Behavior professionals/LMHC

• Certified health and wellness coaches

• Developed protocols for each area with the

specific team member

Introduction to:

The Kent Center for LIFE

KCL program development:

• Taught entire team curriculum for each

critical area

• Lifestyle medicine evaluation

• Advanced nutrition evaluation

• Advanced fitness evaluation

• Advanced health behavior evaluation

• Advanced health and wellness coaching

protocols

Introduction to:

The Kent Center for LIFE

KCL program development:

• Chose patients for beta testing/focus

group

• Performed overall Lifestyle Medicine

Advanced Assessment for each beta

group patient

• Started beta group on one year “journey to

improved health and chronic disease

treatment/prevention”

Squaring Off the CurveThe Kent Center for LIFE

"Health Span"

• Dr. Kenneth Cooper's concept of:

• "Squaring off the Curve"

Squaring Off the Curve?

• More Life

• Better Life - "Health Span"

–Happier

–Healthier

–Freedom

– Independence

Increased Health SpanExamples:

• Reduced doctors visits for sickness

• Greatly reduced/remove need for medications, surgery, medical procedures

• Greatly increased time of feeling well/enjoyed life

• Greatly increased time of independent living

• Greatly reduced chance of assisted/nursing home living

"Health Span"• i.e. increase quality of life

• Jack Lelane :

–“People thought I was a charlatan and a nut. The doctors were against me – they said that working out with weights would give people heart attacks and they would lose their sex drive”

"Health Span"

LIFE• L- Living

• I- Inspiration

• F- Food

• E- Exercise

L- Living

LIFE• L- Living

– a physician supervises, guides, and inspires the individual towards Optimal health :• Reducing medications

• Improving health values

• Improving the quality and quantity of life

-- by helping them change their lifestyle habits!

Lifestyle Medicine MD Advanced Assessment

• Targeted health history

• Biometric evaluation

– Bio impedance

– Vital signs

– Basal metabolic rate eval

• Targeted lab evaluation

– Advanced cardiovascular lipid/lipoprotein eval

– Advanced cardiovascular inflammatory eval

– Advanced metabolic eval

– Intracellular micronutrients testing

– Screening for major organ/endocrine function

Lifestyle Medicine MD Advanced Assessment

• Key health habits evaluation – baseline score

• Diet score – establish baseline score

• Health Risk Appraisal(HRA)

• Nutrition screening form

• Physical activity screening form

• Framingham risk score

• Development/presentation of key health successes and challenges

Lifestyle Medicine MD : Ongoing Care

• Basic plan: Individualized 6 month or 12 month package with lifestyle medicine physician

• Upgraded plans include:

– Predetermined visits with health and wellness coach

– Predetermined package of advanced nutrition visits

– Predetermined package of advanced fitness visits

– Predetermined package of health behavior visits

• Regardless of plan, 6 month and 1 year programs involve:

– Follow-up Biometric and lab evaluations

– Follow-up health habits evaluation, diet score evaluation…

I- Inspiration

LIFE

• I- Inspiration– a behavior specialist/professional

counselor helps the individual with the stages of change and guiding the person towards their goals

– while the lifestyle coach keeps them on track, motivates, and inspires them to continue with change

LIFE

• I- Inspiration– Advanced Health behavior module includes:

• Advanced health behavior assessment by LMHC

• Recommendations regarding challenges identified during assessment

• At least 3 sessions with a certified health and wellness coach

LIFE

• F- Food– Advanced Nutrition module includes:

• Nutrition assessment by our licensed clinical dietitian

• Individualized Nutrition plan formulated by the dietitian and lifestyle medicine physician using challenges identified during assessment

• At least 2 follow-up visits with the nutritionist

• These visits are customized according to patient desire and needs

LIFE• F- Food

– the nutritionist individualizes and personalizes their food plan, increasing functional foods in the diet, to improve the health from the inside out

– helping to reverse disease and improve quality of life through the foods that they choose

– Pantry “clean out”, grocery shopping field trips, food prep assistance, eating out field trips

LIFE

• F- Food– our-base diet is a Mediterranean diet

emphasizing plant-based, whole food choices

– Full Plate Diet

– For patients with moderate/high cardiovascular risk• Esselstyn diet

• Ornish diet

E- Exercise

LIFE• E- Exercise

– Advanced Fitness module includes:• In depth assessment by a physical therapist

• Includes evaluation of gait, posture, balance, muscular strength, muscular endurance, aerobic capacity, and flexibility

• Fitness recommendations and plan are developed by physical therapist and lifestyle medicine physician based on the evaluation and patient desires

• At least 2 follow-up visits with physical therapist or personal trainer

LIFE

• E- Exercise

– the physical therapists and personal trainers help guide the individual towards physical activity and exercises to help correct alignment & balance, increase strength and flexibility, increase aerobic capacity and design a program that is fun, challenging, and sustainable for life

“The Real Cause” - Example:

• US soldiers atherosclerosis

• Middle aged atherosclerosis

• Mother-in-law example

• Don’t wait for symptoms and then only treat the symptoms

• TREAT THE CAUSE!

The Real Solution

• Bob

– Cardiac risk: TC dropped from 375 to 148 (227 points)

• Triglycerides dropped from 3721 to 202

• Weight dropped from 222 to 202(20 lbs.)

– Stroke risk: BP dropped from 138/88 to 110/72

– Diabetes risk: Blood sugar dropped from 186 to 95 (91 pt. drop)

• HA1c dropped from 7.6 to 5.3

– MD reduced/stopped 4 of his medications!

– All in a matter of 12 weeks!!

Same Patient – 115 # lighter

The Real Solution• Kathy

– Cardiac risk: TC dropped from 205 to 120( 85 points)

• LDL Cholesterol dropped from 92 to 47

• Weight dropped from 200 to 180 (20 lbs.)

– Stroke risk: BP dropped from 154/82(on BP meds) to107/74( off BP meds) (47 pt. sys BP drop!)

– Diabetes risk: Blood sugar dropped from 102 to 90( 12 pt. drop)

• HA1c dropped from 5.8 to 5.5

– All in a matter of 16 weeks!!

The Real Solution

• Others

– C/V & DM risk:

• Weight dropped 19 lbs., 16 lbs.

– Stroke risk: • BP dropped from 154/82 to 124/75 (30 pt. sys BP drop!)

• Another patient experienced 17 Pt. drop in Sys BP

– Diabetes risk:

• Blood sugar dropped 27 pts. (126 to 97)

• HA1c dropped from 6.0 to 5.8

– All in a matter of 12 weeks!!

Thomas Edison once said:

"The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease"

Value of Investment

• What is feeling better worth?

• What is more energy worth?

• What is looking better worth?

• What’s an additional year of Health worth?

Kent Center for LIFE: Plans available

• Basic plans:

– Silver: Major lifestyle medicine evaluation and 6 months working with lifestyle medicine physician and staff

– Gold: Major lifestyle medicine evaluation and 12 months working with lifestyle medicine physician and staff

• Advanced plans:

– Platinum: Major lifestyle medicine evaluation and 12 months working with lifestyle medicine physician and staff plus: Advanced nutrition module/Advanced fitness module/advanced health behavior module (2 of 3)

– Diamond: Major lifestyle medicine evaluation and 12 months working with lifestyle medicine physician and staff plus: Advanced nutrition module/Advanced fitness module/advanced health behavior module with health and wellness coaching(all 3)

Kent Center for LIFE: Plans available

• All plans are fee-for-service

• Global fee i.e. not charged per visit with physician

• Patients on basic plan purchase additional modules as desired and indicated

• Most lab test are covered by insurance

The Lifestyle Medicine Dream Team: Social Worker

Healthy Cooking Classes

Self-Compassion Yoga Community Acupuncture

www.lifeideals.net

Online Trainings•Health Coaching •Motivational Interviewing •Non-Violent Communication

Webinars•Guest Speakers •Blog

1

The Lifestyle Medicine Dream Team

The Health Coach

Heidi Duskey, MA, MS, PCC

2

Disclosures

Atrius Health

o Health Coach

Innosight

o Consultant

Objectives

o Outline the opportunities and considerations of

adding a health coach to your care team.

o Provide a brief sampling of the literature supporting

the effectiveness of health coaching across a

variety of behaviors and morbidities.

o Broaden this sampling with practical tips from my

own experience and practice.

o Enroll you in the possibility of hiring a health coach

for your team.

o Offer one tool for empowering behavior change

conversations with your patients.

3

4

Atrius Health

© 2014 Atrius Health, Inc. All rights reserved. Not for distribution.

The Northeast’s largest nonprofit independent multi-

specialty medical group. A national leader in delivering

high-quality, patient-centered coordinated care.

Dedham Medical Associates

Granite Medical Group

Harvard Vanguard Medical Associates

VNA Care Network

Providing care for ~ 675,000 adult and pediatric

patients with 750 physicians across more than 35

specialties

Atrius Health Core Competencies

5

Corporate Data Warehouse integrates single platform, electronic health record data with multi-payer claims data

Widespread extensive Population Health Management including disease-based and risk-based rosters, population managers

Long history with and majority of revenue under Global Payment across commercial and public payers

Sophisticated development and reporting of Quality and Performance Measures leading to high achievement

Patient-Centered Medical Home foundation, achieving level 3 NCQA across all primary care practices

© 2014 Atrius Health, Inc. All rights reserved. Not for distribution.

WHYadd a health

coach to my

team?

6

Current State: how daily choices impact health

+

=+

=+

=+

+

+ +

=

=

+

Health coaches . . .

o Provide expertise as behavior change specialists

o Behavior is the leading determinant of health,

resulting in 40% of premature deaths. Leading

causes of death are tobacco use, poor diet, and

physical inactivity (Mokdad et al., 2004) .

o Preserve capacity of other team members, permitting

them to serve patients at the top of their licenses

o Improve patient outcomes in diabetes mgmt (McGloin et

al., 2015), smoking cessation (Sforzo et al., 2014), the health

of cancer survivors (Galatino et al., 2009), obesity (Schwarz,

2013) and other chronic diseases (Margolius et al., 2012)

8

Health coaches . . .

o Improve provider satisfaction

“I would estimate that at least ¾ of the medical issues I address at

each patient visit are heavily influenced by lifestyle. Having an

available health coach is a potent resource to help patients make

important lifestyle changes.”

“A health coach has become an enormous asset to the care delivery

team . . . We would be the poorer in our practice without this

complementary component and skill.”

“Health coaching provides a forum for the patient to really explore

their personal concerns, fears, and worries – as well as their

motivations.”

9

Health coaches . . .

o Increases patient satisfaction

“I am no longer overwhelmed with life. I make choices! Plus, my

cholesterol is normal.” (LDL decrease: 152 to 94)

“I’ve learned that smaller incremental changes make a big difference.

Also, I can still eat what I’ve always eaten, just smaller portions.”

(Weight loss: 25 lbs)

“Coaching has helped me take responsibility for my own health with

no guilt.” (Weight loss: 13 lbs, A1C decrease: 7.5 to 7.1)

“[I’m most proud of ] my attitude adjustment: Learning to take on

what's mine and let go of what isn't. No longer judging myself.“ Weight

loss: 21 lbs, career change, improved mgmt of Barret’s esophagus

10

WHICHbehaviors can

the coach help

my patients

change?

11

A health coach can help your patients . . .

o Stop smoking

o Modify their diet

o Increase their level of physical activity and exercise

o Improve their sleep hygiene

o Manage stress more effectively

o Take their medication as prescribed

These changes inform

o Improved self esteem and self awareness

o Increased energy and well-being

12

WHOdo I choose

to be the

health coach

on my team?

13

Professional Health Coaches . . .

o Are credentialed through a recognized coach training

organization

o Wellcoaches, Wisdom of the Whole Coaching

Academy, Duke Integrative Medicine, MentorCoach,

California Institute of Integral Studies

o National Consortium for the Credentialing of Health

and Wellness Coaches

o International Coaches Federation

o Have an additional expertise in an area useful to the

clinical team (e.g., nursing, nutrition, exercise physiology,

behavioral health, health psychology)

14

Professional Health Coaches . . .

o Can also provide training to other team members

o Medical Assistants (Willard-Grace et al., 2015)

o Nurses (Margolis et al., 2012)

o Patients who serve as peer coaches (Thorn et al.,

2013)

o Can work with individuals or groups as facilitators with

or without other team members

o Can serve as behaviorists at Shared Medical

Appointments

15

HOWdoes the

health coach

collaborate

with my team?

16

Collaboration . . .

o Describes the coach’s relationship to the primary care

physician or clinical team lead

o Referral-based relationships are coordinated.

The patient has two care plans.

o Consultative relationships are integrated. The

patient receives a unified care plan.

o In addition, the coach can be co-located within the

practice, the department, or the lead clinician’s office

to facilitate warm hand-offs and informal

communication.

Source: Blount, 200317

WHATother logistics

do I need to

consider?

18

Logistic considerations include . . .

o Template structure

o Frequency and length of service

o Choosing panel size and patient cohort

o Charting responsibilities

o Accessing the organization’s electronic medical

record and sharing of chart notes with other team

members

o Referral protocols to the coach and from the coach

to other team members

o Providing patients with the option of telephonic

appointments in addition to face-to-face encounters

19

HOWcan I improve

my ability to

promote healthy

lifestyles for my

patients today?

20

Change the question. Change the conversation.

o Some behavior change conversations are not informed

by lack of knowledge.

“Doctor, I know what to do.”

“I feel stuck.”

“Why do I do this?”

o What are the questions your patient is not asking?

What perspectives do they never question?

Change “Why?” questions to “What?” or “How?”

How do they know their thinking is accurate?

What shifts when the question shifts?

21

Thank you!

22

References

Blount, A. (2003). Integrated primary care: Organizing the evidence.

Families, Systems, & Health, 21(2), 121-133. doi: 10.1037/1091-

7527.21.2.121

Galatino, M. L., Schmid, P., Milos, A., Leonard, S., Botis, S., Dagan, C.,

Albert, W., Teixeira, J., & Mao, J. (2009). Longitudinal benefits of wellness

coaching: Interventions for cancer survivors. International Journal of

Interdisciplinary Social Sciences; 4(10).

Margolius, D., Bodenheimer, T., Bennett, H., Wong, J., Ngo, V., Padilla, G.,

& Thom, D. H. (2012). Health Coaching to Improve Hypertension Treatment

in a Low-Income, Minority Population. Annals Of Family Medicine, 10(3),

199-205. doi:10.1370/afm.1369

23

References

McGloin, H., Timmins, F., Coates, V. and Boore, J. (2015). A case study

approach to the examination of a telephone-based health coaching

intervention in facilitating behaviour change for adults with Type 2 diabetes.

Journal of Clinical Nursing, 24, 1246–1257. doi: 10.1111/jocn.12692

Mokdad, A. H., Marks, J. S., Stroup, D. F.,Gerberding, J. L. (2004). Actual

causes of death in the United States, 2000. The Journal of the American

Medical Association, 291(10), 1238-1245. doi: 10.1001/jama.291.10.1238

Schwartz, J. (2013). Wellness coaching for obesity: A case report. Global

Advances in Health and Medicine, 2(4). doi: 10.7453/gahmj.2013.029

Sforzo, G. A., Kaye, M., Ayers, G. D., Talbert, B., & Hill, M. (2014). Effective

tobacco cessation via health coaching: An institutional case report. Global

Advances in Health and Med, 3(5), 37 -44.

24

References

Thorn, D. H., Ghorob, A., Hessler, D., De Vore, D., Chen, E., &

Bodenheimer, T. A. (2013). Impact of peer health coaching on glycemic

control in low-income patients with diabetes: A randomized controlled trial.

Annals Of Family Medicine, 11(2), 137-144. doi:10.1370/afm.1443

Willard-Grace, R., Chen, E. H., Hessler, D., DeVore, D., Prado, C.,

Bodenheimer, T., & Thom, D. H. (2015). Health coaching by medical

assistants to improve control of diabetes, hypertension, and hyperlipidemia

in low-income patients: A randomized controlled trial. Annals Of Family

Medicine, 13(2), 130-138. doi:10.1370/afm.1768

25

+

The Lifestyle Medicine Dream Team:

Dietitian

Debra Wein, MS, RDN, LDN, NSCA-CPT, CWPD

+

No disclosures

+Who is a Dietitian?

■ Common credentials

■ RD: Registered Dietitian

■ RDN: Registered Dietitian Nutritionist

■ LDN: Licensed Dietitian Nutritionist

■ The food and nutrition experts. Dietitians translate the science of

nutrition into practical solutions for healthy living.

Academy of Nutrition and Dietetics. What is an RDN? http://www.eatright.org/Public/landing.aspx?TaxID=6442452104. Accessed on August 22, 2014.

+Education and Training

■ Dietitians must hold a BS, MS (2017), or PhD

■ Didactic Program of Dietetics

■ ACEND-Accredited Dietetic Internship

■ National Dietetic Examination

■ Continuing Education (75 credits over 5 years)

+ Board Certified RDN SpecialistsCertified professionals complete at least 4,000 hours of practice

experience and pass the Board Certification as a Specialist in Dietetics

Examination.

Examples

■ Board Certified Specialist in Renal Nutrition (CSR)

■ Board Certified Specialist in Sports Nutrition (CSSD)

■ Board Certified Specialist in Oncology Nutrition (CSO)

■ Board Certified Specialist in Pediatric Nutrition (CSP)

■ Board Certified Specialist in Gerontological Nutrition (CSG)

+Certificate of Training

■ Certified Eating Disorders Registered Dietitian (CEDRD)

■ Certified Diabetes Educator (CDE)

■ Adult Weight Management

■ Childhood Weight Management

■ National Board of Nutrition Support Certification (NBNSC)

+Using Evidence-Based Research

in the Nutrition Care Practice

+Nutritional Counseling, Typical Session

60-75 minutes

■ Detailed subjective and objective questions to gather specific information on patient.

■ Discuss/clarify: chief concerns, medical history, social history, anthropometrics, typical food intake, allergies / intolerances, medications, OTC, vitamin/mineral supplements, herbs, physical activity, lifestyle –stress, alcohol, smoking, cravings, past history with diets, barriers to change, etc.

20-45 minutes

■ Follow up questions assessing

the patient’s change

■ Review successes, barriers, goals,

further education

■ Weave education throughout

session

■ Goal setting

■ Don’t forget maintenance!

Initial Session Follow-Up

+Partnering with an RDN

■ People may be more inclined to see you as the expert, if you lead

a healthy lifestyle.

■ Understand a wide variety of situations

■ Shop in a different grocery stores to know what is/is not available

■ Know local resources: food banks, food assistance programs

■ Consider different cultures, ethnicities, and socioeconomic status

++

+

+

+

Why see an RDN?

+10 Reasons to Visit an RDN

1. You have diabetes, cardiovascular problems or high blood pressure.

2. You are thinking of having or have had gastric bypass surgery. Since your stomach can only manage small servings, it's a challenge to get the right amount of nutrients in your body.

3. You have digestive problems. A registered dietitian nutritionist will work with your physician to help fine-tune your diet so you are not aggravating your condition with fried foods, too much caffeine or carbonation.

4. You're pregnant or trying to get pregnant.

5. You need guidance and confidence for breast-feeding your baby. A registered dietitian nutritionist can help make sure you're getting enough iron, vitamin D, fluoride and B vitamins for you and your little one.

6. Your teenager has issues with food and eating healthfully.

7. You need to gain or lose weight.

8. You're caring for an aging parent.

9. You want to eat smarter. A registered dietitian nutritionist can help you sort through misinformation; learn how to read labels at the supermarket; discover that healthy cooking is inexpensive, learn how to eat out without ruining your eating plan and how to resist workplace temptations.

10. You want to improve your performance in sports.

Source: http://www.eatright.org/resource/food/resources/learn-more-about-rdns/10-reasons-to-visit-an-rdn,

last accessed, June 11, 2015.

+

Conclusion

Dietitians are…

■ The experts on nutrition

■ A member of the patient’s lifestyle medicine dream team

■ Able to offer exclusive time talking about diet and ways to

achieve nutrition goals

+

+

+Questions?

debra@wellnessworkdays.com

781-741-5483

@wllnswrkdys

Practitioner to Practitioner Lessons Learned and Successes Earned by

Early Adopters

Amira Aly, MD Reza Antoszewska, NP-C Karyn Bender, RPh, CHHC

Barbara Brown, MD and Lynn Kossow, MD

Rebecca Brown, MD and Larry Schmidt, MD

Lilach Malatskey, MD, MHA Krutika Parasar, SciB Karen M. Sherritt, MD

Amira Aly, MD

Coming Back to our Bodies:how the Body’s Wisdom can Guide Lifestyle

Transformation

• No relevant financial relationships.

No relevant financial relationships.

Lifestyle Medicine can bridge the gap between caring for the

physical and psychological:- Practitioner as the ultimate tool: change agent.

-Patient as capable captain of their own ship.

-Strengths-based approach.

-Experiential learning.

References:1.KABAT-ZINN, J. (1991). Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York,

N.Y., Pub. by Dell Pub., a division of Bantam Doubleday Dell Pub. Group.

2.FRANKL, V. E. (1984). Man's search for meaning: an introduction to logotherapy. New York, Simon & Schuster.

3. HEFFERON, K. (2013). Positive psychology and the body: the somatopsychic side to flourishing.

4. Edward Phillips, MD. CME ONLINE: Lifestyle Medicine Competencies Case Study. Available from

<http://cmeonline.med.harvard.edu/course_descriptions.asp?Course_id=156> [14 May 2015]

Lifestyle Medicine Prescription:

Co-creating Self-Care Routine with Patients• Physical self-care:(habit-based nutrition, exercise prescription).

• Emotional self-care: (mindfulness practice, mind-body integration

skills).

• Social self-care (plan based on filling out a social support form

inspired by the one provided in HMS CME—Lifestyle Medicine

competencies +/- joining mind-body skills groups.)

Lifestyle Medicine In OncologyReza Antoszewska MS ANP-C

Legacy Cancer Institute

Portland OR

1

I have nothing to disclose

Disclosure

2

Describe Lifestyle Medicine’s Role at Legacy cancer Institute

Provide information on lifestyle Medicine Resources used in the clinic

Objectives

3

Diet

Exercise

Restorative sleep

Emotional resilience

Sense of connection

Environment

Lifestyle Medicine in Oncology

4

Symptom management

Prevention of sx

Cancer Risk Reduction

Plan for menopausal sx:

Hot flashes and Night Sweats

Sm protein meal before bed time

Mind/Body type exercise such as Tai Chi or Chi Gong

Daily ½ hour exercise or more

Trigger reduction: sugars, caffeine, ETOH spicy foods

Mindful activity during hot flashes

Stressors identified and managed

Fish oil and flax seed

Lifestyle Medicine in Oncology

5

Anticancer: A New Way of life, by David Servan-Schreiber

www.aicr.org Lifestyle medicine for cancer risk reduction- great patient resources

The Cancer Fighting Kitchen, by Rebecca Katz

www.lumosity.com web site offers games and activities to strengthen memory. It is a brain gym.

Selected Resources

6

Move a Little, Lose a Lot by James A. Levine MD.

www.strongwomen.com/fitness/fitness-eprograms

www.strongwomen.com/fitness/fitness-eprograms/strong-bones-overview/

http://www.mayoclinic.com/health/mediterranean-diet/CL00011

www.ewg.org – environmental considerations

Marc.ucla.edu/body.cfm?id=22 UCLA Mindfulness podcasts. Free podcasts to help with relaxation and sleep

http://www.huffingtonpost.com/2014/01/21/meditation-apps-stress-positive-thinking-mood_n_4639232.html

Selected Resources

7

https://www.functionalmedicine.org/

http://www.cityofhope.org/center-for-cancer-survivorship

http://www.harvardhealthbooks.org/book/mind-over-menopause-the-complete-mindbody-approach-to-coping-with-menopause/

http://www.legacyhealth.org/health-services-and-information/health-services/for-adults-a-z/cancer/all-cancer-services/survivorship-services.aspx

References

8

The Healing

Power of

SimplicityKaryn Bender RPh CHHC CMI

Integrative Pharmacist, Holistic Health & Nutrition Coach, Medical Intuitive,

Herbalist

Dislcosures

None

Objectives

Start from where you are

Know your own first step in healthy

change

Help your patients discover their first step

Trust in the power of one step at a time

Personal story We all have our life and health stories

Healing life with Lupus, thyroid disease, cancer

Lupus: Stress reduction and self esteem

Thyroid: Diet, exercise, stress reduction, sleep

Cancer: Value every moment of life

Easy diet changes came first, other lifestyle changes followed. Fueling for success & healing

Noticeable results

Grateful for my body and life every step of the way

Simple Powerful Steps

Menagerie of information – keep it simple

Witness results

Create your healthy life tool kit: make it

personal, simple, do-able, familiar, fun

Reach out, inspire others

Karyn Bender RPh CHHC CMI

References McCarty. It Works: Doing One Thing at a Time. Life Saving

Philosophy Blog [Internet]. January 7, 2012. URL: https://www.psychologytoday.com/blog/life-saving-philosophy/201201/it-works-doing-one-thing-time. Accessed: May 01, 2015

O’Connell A. The Pros and Cons of Doing One Thing at a Time. Harvard Business Review. January 20, 2015. URL: https://hbr.org/2015/01/the-pros-and-cons-of-doing-one-thing-at-a-time. Accessed: May 01, 2015

Lipman F, Claro D. The New Health Rules: Simple Changes to Achieve Whole-Body Wellness. New York, NY: Artisan; 2015

LowDog T. Life is Your Best Medicine: A Woman’s Guide to Health, Healing and Wholness at Every Age. Washington,DC: National Geographic Society; 2012

Dr. Lynne B. Kossow

Dr. Barbara A. Brown

1.0 hour initial consultation to begin the process of developing your own customized Lifestyle Medicine program for which you will be receiving on going lifestyle coaching throughout the year.

Direct doctor/patient e-mail communication for non-urgent issues.

Doctor phone time 7-9am and 5-6pm Monday-Friday when you can call in and speak directly to your doctor.

A private phone line connecting you directly to our administrative assistant so that your calls can be answered promptly and efficiently throughout the day.

Priority appointment times to accommodate your schedule

Added time to all follow-up office visits to discuss your Lifestyle Medicine Program

Hospital social visits at The University of Princeton Medical Center during the week if you are admitted to the hospital for an extended stay. This will allow us to stay better connected with you during your hospitalization.

Priority in-office laboratory testing for your convenience.

Lifestyle Coaching Private phone line Cellphone hours with your doctor Emailing with your doctor Extra time at office visits Hospital Social Visits

Larry Schmidt, BSc, MD, CCFP, FCFP

Rebecca Brown, MSW, RSW, CHWC

Larry Schmidt – I have no disclosures to declare

Rebecca Brown – I have no disclosures to declare

How

Lifestyle

Medicine

Changed

our

Lives

What a difference

a year makes:

• Attended America College of Life

Medicine Conference in San Diego

• Decided we needed to do something!

• Integrated Lifestyle Medicine into daily

practice

• Started a national organization in

Canada to promote the

implementation of Lifestyle Medicine

into the health care system

• A grass roots approach

Lifestyle Medicine in our lives

Rebecca

Certified Health & Wellness Coach (Wellcoaches)

Private practice coaching

Conferences/Workshops on Vicarious Trauma & Resilience

Focus on Lifestyle Choices: stress, mindfulness, nutrition & exercise

Larry

Integrated Lifestyle Medicine into every patient visit

Talks on LM to faculty, residents, students & community

Changing practice location to Advanced Medical Group

Medical Director Canada’s 1st Lifestyle Medicine based medical center

• Describe our Lifestyle medicine course

• Feedback from participants

• Describe the essence of the syllabus

• Offer the syllabus as a tool for promoting LSM

teaching for medical students and doctors

• Lectures on nutrition, exercise, sleep medicine, sexuality and

health, personal health, smoking cessation and stress

• Workshops and experiential learning of behavioral

change techniques such as coaching and motivational

interviewing, yoga and exercise lessons

• Practical clinical project: accompanying and supporting a

patient in the process of lifestyle health behavior change

The courses were co- directed with Dr Adva Zuk Onn, Family medicine and geriatric specialist

Available to the audience ( English version )

Please contact:

Dr. Lilach Malatskey

Primary editor of the syllabus,

Head of the Israeli Society of Lifestyle Medicine,

Email: lilach.malatskey@gmail.com

Acknowledgements to the team of writers and editors of the syllabus: Executive Members of the Israeli Society of Lifestyle Medicine

The panel of experts consulting and support team

• Prof. Amnon Lahad and Dr. Eli Rosenberg; Program initiative for a healthy future 2020 The Israeli Ministry of Health

• Lianov L, Johnson M; Physician competencies for prescribing lifestyle medicine. JAMA 2010;

• Dacey M, Arnstein F, Kennedy M A, Wolfe J & Phillips E; 2013. The impact of lifestyle medicine continuing education on provider knowledge, attitudes, and counseling behaviors; Medical Teacher

• Polak R, Tzuk Onn A, Shani M, Malatskey L; Family Physician Prescribing Lifestyle Medicine – Implementing a national training program; Unpolished data.

• The syllabus English translation was sponsored by the Israeli Association of Family Physicians

EXERCISE AS MEDICINE

Krutika Parasar

3rd Year Medical Student at Rutgers Robert

Wood Johnson Medical School

I HAVE NO DISCLOSURES

Topics:

The Exercise is Medicine Movement

The Importance of Introducing Exercise into

the Medical School Curriculum

Steps We Have Taken to Achieve this Goal!

ROBERT WOOD

JOHNSON

PACEMAKERS

SPREADING

THE WORD!

EXERCISE, SLEEP, AND STRESS

IN FIRST AND SECOND YEAR MEDICAL SCHOOL STUDENTS

A Journey Towards WellnessA Journey Towards Wellness

Karen Sherritt, MDPrimary Care InternistInstructor in MedicineInstructor in Medicine  Harvard Medical School

“The Journey of a thousand miles begins with a single step.”

‐Lao Tzu

DisclosuresDisclosures

• NoneNone

ObjectivesObjectives

• Share the story of my journey• Share the story of my journey–Life as it was–The crisis The first step–The first step

–One step follows another

Lif A It WLife As It Was

•High achiever

•Doing it all

l l•People pleaser

•Working hardWorking hard

•Looking good

The CrisisThe Crisis

•Exhaustion

A i t•Anxiety

•AngerAnger

•Desire to quit

The First StepThe First Step

•Intentional change of  attitude/perspectiveattitude/perspective

•Practice of•Practice of Gratefulness

One Step Followspthe Next

Commitment to self careE i⁻Exercise⁻Sleep⁻Low Carbohydrate DietLow Carbohydrate Diet⁻Reconnecting with GFs⁻Counselingg⁻Mindfulness Meditation

Tools/Tips/ p

Compassionate self‐care:

•Awaken to now•Note the effect of attitude• Take small steps• Be kind to yourself• Seek support• Seek support• Share with others 

Courage, Integrity, Connectedness, Hope, Vision

ReferencesReferences

H l Th S lf•Heal ThySelf, Saki Santorelli

•www.Gratefulness.org,Brother David Steindl‐Rast

•I Thought It Was Just Me (b i i ' ) B B(but it isn't), Brene Brown

“Instructions for living a life.P tt tiPay attention.Be astonished.Tell about it ”Tell about it.

Mary Olivery

Nancy M. Enos, FACMPE, CPMA, CPC-I, CEMC

Billing and Coding for

Lifestyle Medicine

Approved

Instructor

Approved instructorApproved instructor

Coding and Billing for Lifestyle Medicine

Presented by:

Nancy M. Enos, FAMPE, CPC-I, CPMA, CEMC CPC

Tools for Healthy Change

June 27, 2015

Approved

Instructor

Approved instructor

Disclosures

• Enos Medical Coding does not provide legal advice and the information in this presentation is based on the coding guidelines in the Current Procedural Terminology (CPT) Manual published by the American Medical Association (AMA) and Evaluation and Management Coding Guidelines from the Centers for Medicare and Medicaid (CMS)

• CPT codes, descriptions and material only are copyright 2015 American Medical Association. All Rights Reserved.

• No fee schedules, basic units, relative values or related listings are included in CPT.

• The AMA assumes no liability for the data contained herein.

Approved

Instructor

Approved instructor

Objectives

• Understanding Documentation Guidelines and key components of E/M Services– History, Exam, Medical Decision Making– Time based E/M Services

• Understanding coding guidelines and identify risk areas for E/M services with: – Patient Status– Billing for Time Spent Counseling– Obesity Counseling – diagnosis and CPT codes– Preventative with Sick Visits– Welcome to Medicare Physicals– Medicare Annual Wellness Visit– E/M Modifiers

Approved

Instructor

Approved instructor

New versus Established

• E/M codes are divided on the patient status

• A new patient is one who has not received any face-to-face professional service from a provider of the same specialty or exact same subspecialty in the same group practice, within three years

– New group

– New Specialty

• If a provider is covering, the encounter is classified as it would have been by the patient’s provider.

Approved

Instructor

Approved instructor

TIME For coding purposes, face-to-face time for

office/outpatient visits or consult services is defined as only that time that the physician spends face-to-face with the patient and/or family.

When greater than 50% of the face-to-face time is spent in counseling or coordination of care, time may be considered in selecting the code level for the encounter

Tip: If the visit does not include any interval history ( “S” of SOAP note), no Physical Exam (“A”), such as a return visit to discuss test results, treatment options, compliance with treatment plan, etc. this lengthy visit would qualify for the “Time” component for code selection.

Approved

Instructor

Approved instructor

Time and Counseling Coding Issues

Physicians will often need to utilize the “Time” factor and frequently undercode counseling types of services

Diagnosis code sequencing is essential for follow-ups; avoid denials……..

– After Depression or any other mental health diagnosis, etc. is determined, what physicians are actually providing is medication management. Use the V code for the subsequent encounters.

V58.83 Encounter for therapeutic drug monitoring or if it is a long term current use drug, use the appropriate V58 code series

Nancy Enos, FACMPE CPC CPC-I

Approved

Instructor

Approved instructor

Time Spent Counseling

• Does the note state the total time of the visit?

• Does the note describe the content of counseling/coordination of care?

• Does the note reveal that more than half of the time was spent counseling and/or coordinating care?

Nancy Enos, FACMPE CPC CPC-I

Approved

Instructor

Approved instructor

Time and Counseling Diagnosis Coding Issues- Signs and Symptoms

• Anorexia - 783.0 (loss of appetite)

• Abnormal loss of weight 783.2X

• BMI V85.0-V85.54

• Excludes:anorexia nervosa (307.1)

• Anorexia is an unexplained loss of appetite. Do not use this code to report anorexia nervosa, which is found in category 307

Nancy Enos, FACMPE CPC CPC-I

Approved

Instructor

Approved instructor

Overweight and Obesity

• ICD-9 code is 278.00

– Morbid Obesity 278.01

– Overweight 278.02

– Obesity hypoventilation syndrome 278.03

– Localized adiposity 278.1

– Use Additional Code to identify Body Mass Index (BMI) if known, with V85.0-V85.54

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Body Mass Index (BMI)

• V85.0 BMI less than 19, adult

• V85.1 BMI between 19-24, adult

• V85.2 BMI between 25-29, adult

• V85.3 BMI between 30-39, adult

• V85.4 BMI 40 and over, adult

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Weight Management

• Health and Behavior Assessment or Intervention:

– For dietitians, certified diabetes counselors, nurses, or behavioral health professionals for identifying the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. These services do not represent and should not be reported on the same day as preventive medicine counseling services.

Nancy Enos, FACMPE CPC CPC-I

Approved

Instructor

Approved instructor

Weight Management

• CPT 96150 - Health and behavior assessment (e.g. health-focused clinical interview, behavioral observations, psycho-physiological monitoring, and health-oriented questionnaires) each 15 minutes face-to-face with the patient, initial assessment

• CPT 96151 - Health and behavior reassessment (e.g. health-focused clinical interview, behavioral observations, psycho-physiological monitoring, and health-oriented questionnaires) each 15 minutes face-to-face with the patient, initial assessment

• CPT 96152 - Health and behavior intervention, each 15 minutes, face-to-face, individual• CPT 96153 - Health and behavior intervention, each 15 minutes, face-to-face, group (2

or more)• CPT 96154 - Health and behavior intervention, each 15 minutes, face-to-face, family

(patient present)• CPT 96155 - Health and behavior intervention, each 15 minutes, face-to-face, family

(patient not present)• *Use of the appropriate E&M service code should be filed when these services are

performed by a physician.

Nancy Enos, FACMPE CPC CPC-I

Approved

Instructor

Approved instructor

Prolonged Services Face-to-Face

• 99354-99355 Outpatient

• 99356-99357 Inpatient

– minimum of 60 minutes

– Beyond the normal time frame

– Actual treatment vs. Counseling

– Add on to E&M code at any level

– Document time

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Code SelectionCODE Office Visit Est. 2/3 HISTORY EXAM MDM Time

99211 Office visit, No. Phys. Required N/A N/A minimal 5 min

99212 Office visit, Est. (Prob focused) Problem Focused 1 Straightforward 10 min

99213 Office visit, Est (Low) Exp. Problem Focused 2-4 Low 15 min

99214 Office visit, Est. (Mod.) Detailed 5-7 Moderate 25 min

99215 Office visit Est. (High Comprehensive 8 High 40 min

CODE Office Visit New 3/3 HISTORY EXAM MDM Time

99201 IOV (No Referral) Problem Focused 1 Straightforward 10 min

99202 IOV (No Referral) Exp. Problem Focused 2-4 Straightforward 20 min

99203 IOV (No Referral) Detailed 5-7 Low 30 min

99204 IOV (No Referral) Comprehensive 8+ Moderate 45 min

99205 IOV (No Referral) Comprehensive 8+ High 60 min

Office Consults 3/3 HISTORY EXAM MDM Time

99241 Office Consult minimal Problem Focused 1 Straightforward 15

99242 Office Consult Prob. Focused Exp. Problem Focused 2-4 Straightforward 30

99243 Office Consult (Low) Detailed 5-7 Low 40

99244 Office Consult (Mod.) Comprehensive 8+ Moderate 60

99245 Office Consult (High) Comprehensive 8+ High 80

Prolonged Services Time

99354 Office Prolonged Service add on to base code 60

99355 Each Additional 30 minutes 1 unit each 30 min 30

Nancy Enos, FACMPE CPC CPC-I

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Instructor

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Is the Service a Consultation?

Was the advice or opinion of the provider requested? Was the opinion issued as per guidelines? Are these facts clearly documented in the medical record? “Six R’s”

Request (From whom?) Reason for consultation Review of previous records Render patient evaluation (H&P) Recommendation for plan of treatment Report (separate if not shared record)

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Consultations –not covered by Medicare and others following Medicare rule

• 99241 – 99245: Outpatient Consultations

– Office consults must be requested by another physician

– Example- Medicare will pay for surgical clearance

– Use if patient is considered observation status or consult is requested in ED and patient is discharged

• 99251 – 99255: Initial Inpatient Consultations

– Use if patient status is inpatient admission

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Preventative Medicine

Codes are based on New vs. Established New and Established Patient

Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available.

Nancy Enos Medical Coding

Approved

Instructor

Approved instructor

Preventative Medicine Issues

The extent and focus of the service will vary based on the age of the patient

If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported

Approved

Instructor

Approved instructor

Preventative Medicine Issues

• Modifier 25 should be added to the Office/ Outpatient code to indicate that a significant, separately identifiable Evaluation and Management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

• An insignificant or trivial problem or abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service, should not be reported.

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Preventative or Sick?

• A 72 year old established patient presented for a well check-up. The patient’s daughter claimed the patient had been walking with a limp and complaining of lower leg pain for the past 3 days after falling from the bed.

• The provider focused on further (extensive) evaluation of these symptoms and indicated a plan of x-ray and possible referral to orthopedics. The preventative exam was completed. The bill would look something like this:

Approved

Instructor

Approved instructor

Preventative Medicine and E/M

CPT: 99397

(Est.) Preventive medicine, 65+ years

DX 1: V70.0 Physical Exam

and also

CPT: 99213-25 E/M Service-(EPF,EPF,LC)

DX 2: 729.5 Pain in limb

DX 3: E880.9 Fall-Other stairs or steps

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Nurse Visits 99211

• According to the CPT manual, a 99211 is an office or other outpatient visit "that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services."

• Unlike the rest of the office visit codes, 99211 does not have any documentation requirements for the history, physical exam or complexity of medical decision making. The nature of the presenting problem need be only "minimal," such as monthly B-12 injections, suture removal, dressing changes, allergy injections with observation by a nurse, and peak flow meter instruction

• Do not use for “shot visits” the administration codes include the work of 99211

• Remember, if you bill a 99211 you must collect a copay

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Counseling/Risk Factor

99401 (weight management)

Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual without a specific illness for which the counseling might otherwise be part of a treatment- 15 minutes

99402

30 minutes

99403

45 minutes

99404

60 minutesNancy Enos Medical Coding

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Instructor

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Behavior Change/Interventions

• 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

– 99407 greater than 10 minutes

• 99408 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

– 99409 greater than 30 minutes Nancy Enos Medical Coding

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Medicare Screening Services

The Patient Protection and Affordable Care Act (PPACA) changed coverage of preventative care services to Medicare

Since January 1, 2011 CMS covered Annual Wellness Visits

Other screening services may be covered based on frequency and patient risk

Check Medicare’s billing guide for G-Codes to report screening procedures and V-codes allowed as diagnoses

http://www.medicarenhic.com/providers/pubs/REF-EDO-0002_Preventive_Services_Billing_Guide.pdf

Approved

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Approved instructor

Medicare Covered Screening Services

• Bone Mass Measurement

• Cardiovascular Screening

• Colorectal Cancer Screening

• Diabetes Screening

• Flu (Influenza) Injections

• Glaucoma Screening

• Hepatitis B Injections

• Initial Preventive Physical Examination

• Mammography Screening

• Medical Nutrition Therapy

• Pneumococcal Pneumonia

Vaccination (PPV)

• Prostate Cancer Screening

• Screening Pap Smears

• Screening Pelvic Examinations

• Smoking and Tobacco-Use

Cessation

• Ultrasound Screening for

Abdominal Aortic

Aneurysm

Approved

Instructor

Approved instructor

Advanced Beneficiary Notice (ABN) Requirements

• A physician should obtain an Advanced Beneficiary Notice (ABN) when services provided fall outside of Medicare coverage requirements. The ABN can be found on the CMS website at: http://www.cms.gov/cmsforms/downloads/cmsr-131-g.pdf.

• Physicians, practitioners and hospitals will be liable for Screening services unless they issue an appropriate Advanced Beneficiary Notice

Approved

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Approved instructor

Medicare Preventative Services

• Under PPACA (Patient Protection and Affordable Care Act, or Healthcare Reform) coverage for preventative services has been expanded.

• Medicare continues to define the conditions of coverage of preventative services

• Not all commercial plans will follow the Medicare Guidelines

Approved

Instructor

Approved instructor

Welcome to Medicare” Exam (IPPE)

Once in a lifetime exam

Covered within the first 12 months of enrollment in Medicare Part B

Includes: Height, weight, body mass index

Referrals for necessary diagnostic testing

Blood Pressure

Education, counseling and health risk assessment

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Welcome to MedicareCode Definition

G0402 “Welcome to Medicare” – Initial Preventative Physical Exam

G0403 Electrocardiogram, routine ECG w/12 leads; screening for the initial preventative PE

G0404 ……”tracing only, without interpretation and report

G0405 ……”interpretation and report only

G0403, G0404, G0405 can be billed in addition to G0402. EKG is no

longer a required part of IPPE. No specific diagnosis (ICD-9) is

required.

Co-insurance, co-pay and/or deductible waived only for G0402.

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Annual Wellness Visit (AWV)

Once in a lifetime exam including Personalized Prevention Plan Services (PPPS)

Person Covered-

One who is no longer within 12 months after the effective date of first Medicare Part B Coverage

One who has not received either an initial preventative physical exam or an AWV within the past 12 months.

Approved

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AWV Includes

Establish or update the individual’s medical and family history.

List the individual’s current medical providers and suppliers and all prescribed medications.

Record measurements of height, weight, body mass index, blood pressure and other routine measurements.

Detect any cognitive impairment.

Establish or update a screening schedule for the next 5 to 10 years including screenings appropriate for the general population, and any additional screenings that may be appropriate because of the individual patient’s risk factors.

Furnish personalized health advice and appropriate referrals to health education or preventive services.

Approved

Instructor

Approved instructor

Annual Wellness Visit (AWV)

Review of individual’s potential for depression

Including current or past experiences

Review functional ability and level of safety based on direct observation or screening questions/questionnaire

Approved

Instructor

Approved instructor

Annual Wellness Visit (AWV)

• Establish a written screening schedule for

the individual, such as a checklist for the

next 5-10 years, as appropriate

• Patient’s health status

• Screening History

• Age appropriate preventive services

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Annual Wellness Visit (AWV)

• Community-based lifestyle interventions to reduce health risks and promote self-management and wellness

– Weight loss

– Physical activity

– Smoking cessation

– Fall prevention

– Nutrition

Approved

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Annual Wellness Visit (AWV)

• Any other element(s) determined appropriate by the Secretary of

• Health and Human Services through the National Coverage Determination (NCD) process

• Not subject to “incident-to”

• Who may perform?

– Doctor of medicine, – Doctor of osteopathy

– Nurse practitioner, – Physician assistant, – Clinical nurse specialist

– Health professional, which includes:

– Health educator, • Registered dietitian

– Nutrition professional, • Team of such medical professionals who are working under the direct supervision of a physician

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Subsequent Wellness Visit (SWV)

• Performed 11 months after AWV & includes

– Update to medical/family history

– Measurements of weight (or waist circumference), blood pressure and routine measurements as deemed appropriate

– Update to list of current medical providers/suppliers

– Detection of any cognitive impairment

– Update to written screening schedule

– Update to list of risk factors

– Furnish appropriate health advice and referral as appropriate

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Annual & Subsequent Wellness Codes

HCPCS Code Description

G0438 Annual Wellness Visit, includes Personalized Prevention Plan of Service (PPPS), first visit

G0439 Annual Wellness Visit, includes PPPS, Subsquent Visit

No specific diagnosis (ICD-9) is required. Co-insurance, co-pay and/or

deductible waived. When a significant, separately identifiable medically

necessary E/M service in addition to the SWV, use 99201-99215 with

modifier -25; however co-pay, deductible, co-insurance required for E/M

Service.

E/M Service must be separately documented, no “double dipping” in

history or exam.

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Instructor

Approved instructor

Guidance from the CDC on Health Risk Assessment

• At the request of the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC) is providing initial guidance on the development of a health risk assessment tool.

• http://www.cms.gov/coveragegeninfo/downloads/healthriskassessmentsCDCfinal.pdf

Approved

Instructor

Approved instructor

Insurance Coverage Issues

• Insurance plans vary on the range of services covered by a patient’s policy

• High deductibles, copays, co-insurance should be verified before providing a service

• Medical Necessity is key

• Preventive services are often covered but research your contacted payers for their reimbursement policies

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References

CMS Evaluation and Management Guide

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

CMS Annual Wellness Visit

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf

Risk Assessment

http://www.cms.gov/coveragegeninfo/downloads/healthriskassessmentsCDCfinal.pdf

CMS Preventive Services Guide

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

Approved

Instructor

Approved instructorApproved instructor

Nancy M Enos, FACMPE, CPMA CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group. Mrs. Enos has 35 years of experience in the practice

management field. Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer. In July 2008 Nancy established an independent consulting practice, Nancy Enos Medical Coding.

As an Approved PMCC and ICD-10 Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses, outsourced coding services, chart

auditing, coding training and consultative services and seminars in CPT and ICD-9and ICD-10 Coding, Evaluation and Management coding and documentation, and Compliance Planning.

Nancy frequently speaks on coding, compliance and reimbursement issues to audiences including National, State and Sectional MGMA conferences, and at hospitals in the provider

community specializing in primary care and surgical specialties.

Nancy is a Fellow of the American College of Medical Practice Executives. She serves s as a College Forum Representative for the American College of Medical Practice Executives. She is

on the board of Eastern Section MGMA and serves as Past President.

About the Speaker

Joji Suzuki, MD

Motivational Interviewing: The Evidence-Based Strategies that

Produce the Best Results

Talking about change:

Principles of motivational interviewing Joji Suzuki MD

Instructor in Psychiatry, Harvard Medical School

Department of Psychiatry, Brigham and Women’s Hospital

Member, Motivational Interviewing Network of Trainers

A typical conversation about behavior change can

quickly turn into an argument

You need to stop

using drugs. If you don’t stop using

drugs you will end up

dead.

I know why I need to

stop, but right now it’s

just not my priority.

Yes, I know I

need to stop, but

it’s so hard….

Change!

Yes but no!

How do conversations about behavior change* make you feel?

*reducing or stopping alcohol, drugs, or tobacco, changing dietary habits, exercising, taking medication,

checking blood sugar, keeping appointments, going to psychotherapy, flossing, getting a colonoscopy...

This is

frustrating

It feels futile

to even try

He obviously doesn’t

care about his own

health

This feels like

a waste of

time I don’t like

this

I feel

powerless

You would rather feel less frustrated and be

more effective in helping patients change

Psychotherapy

Stages of change model

Decisional balance (pros and cons)

For every patient in every situation

Easy to attain competence

British J Gen Practice 55: 305-312, 2005

Meta-analysis of 72 randomized controlled trials of MI

MI outperformed traditional advice giving in 80% of studies

Positive outcomes in 64% of studies (7/11) with encounters <20 minutes

Proportion of studies with positive outcomes obtained when MI delivered by:

Physician: 83% (19/23)

Psychologist: 79% (33/42)

Other: 46% (5/11)

Weak Comparison

groups

Strong Comparison

groups

Effect

Size

Difference

in success

rate (%)

Effect

Size

Difference in

success rate

(%)

Burke et al 2003 0.35 17 0.04 2

Hettema et al 2005 0.27 13 0.32 15

Vasilaki et al 2006 0.40 19 0.27 13

Lundahl et al 2009 0.28 14 0.09 5

Engaging

Focusing

Evoking

Planning

Engaging The relational foundation

and patient-centered communication

Spirit of MI

Acceptance

Evocation

Partnership

Compassion

Reflections

Reflective listening

I know how you must feel.

It must have been difficult

for you.

What the

speaker actually

meant to say

What the

speaker said

What the listener

thinks the speaker

meant to say

What the

listener heard

Reflectio

n

Simple reflections stay close to what the patient

said

I think I should

quit drinking.

You want to quit

drinking.

Simple reflections stay close to what the patient

said

I don’t know if I’m

ready to quit

drinking.

You’re not sure if

you’re ready.

Complex reflections add substantial meaning

I nned to stop

drinking.

Losing your job was

a wake-up call.

Complex reflections add substantial meaning

I’m not sure I can

quit drinking.

You’re not as

confident as you’d

like to be.

Complex reflections add substantial meaning

I’d like to get

sober.

On the one hand you like

your beer, and on the

other hand you want to

be there for your family.

Using reflections to “Roll with resistance”

I know I need to

stop heroin, but

cocaine is not a

big deal.

You’re not sure if cocaine

use is really that much of

a problem, although you

know heroin has ruined

your life.

Using reflections to “Roll with resistance”

I’m not going to

stop smoking pot. For now, changing how

you smoke marijuana is

not your priority.

Affirmations

Affirmations

Statements of appreciation for patient’s efforts or strengths

Genuine words of understanding

“You” statements, not “I”

Focus on specific behaviors

Nurture a competent self

I’m here to detox.

You’ve been to detox

five times already, and

you’re willing to try

again. It takes a lot of

courage to do that.

I can’t continue to

drink like this.

It’s important for

you to be a

responsible

husband.

Engaging

Focusing

Evoking

Planning

Focusing Agreeing what to talk about and

agenda setting

Focus clear

Several options

No clear path

Ask-Tell-Ask

1) Ask permission, or what they already know

2) Provide information or give advice

3) Ask what they think of that information

Ask

Tell

Ask

Ask-Tell-Ask

1) “What is the most important issue for us to

discuss today?”

2) “Great, we will definitely address your concerns

about the pain. I also want to make sure we

have a chance to discuss your blood test from

last visit.”

3) “Would that be ok with you?”

Ask

Tell

Ask

Skill #1: Giving Information or Advice (Ask-Tell-

Ask)

1) “Would it be ok if I shared some thoughts I have

the importance of exercise?”

2) “Increasing your physical activity level can

provide a lot of health benefits by reducing your

risk for a variety of illnesses, such as diabetes,

heart disease, and certain types of cancer.”

3) “What are your thoughts about that?”

Ask

Tell

Ask

Giving Information or Advice (Ask-Tell-Ask)

Engaging

Focusing

Evoking

Planning

Evoking Increasing motivation

External motivations are imporant, and sometimes

they are crucial

You should

stop smoking.

But ultimately, patients themselves have to find the

internal motivation to change

But we can’t directly see internal motivation

Most patients are ambivalent about most

unhealthy behaviors.

Most patients are ambivalent about most

unhealthy behaviors.

I don’t want

to change I want to

change

This side of the

ambivalence is

called Change Talk

This side of the

ambivalence is

called Sustain Talk

If pushed to change, patients who are ambivalent

often go to the other side of the ambivalence

I don’t want

to change I want to

change

You need to

change!

Instead, the goal of MI is to evoke change talk

I don’t want

to change I want to

change

We want patients

to argue for this

themselves

Change Talk (DARN-CAT)

D: Desire I want to…, I wish…, I’d like to….

A: Ability I could…, I know I can…., I could try….

R: Reason I want to change because…..

N: Need I should…, I need to…., I must….

C: Commitment I will…., I promise to…., I guarentee…

A: Activating I am ready to…., I am willing to…

T: Steps Taken I’ve tried…

Evoking change talk

Taste of MI questions

1) Is there something you would like to do for your health in the

next 1-2 weeks?

2) If you were to stop using cocaine, how would you go about

doing it?

3) What are the 3 most important reasons to stop using cocaine?

4) On a scale of 1 to 10, 10 being completely ready, 1 being not

at all ready, how ready are you to cut stop using cocaine?

Followup with: Why did you pick that, and not a lower number?

Selective responding to strenghten change talk

I don’t drink any more

than my friends. Sure I

sometimes feel a little

foggy the next day, but its

no big deal.

You feel a little

foggy the next

day. Tell me more

about that.

I don’t drink any more

than my friends. Sure I

sometimes feel a little

foggy the next day, but its

no big deal.

You are worried about

how it’s affecting your

work. What do you

already know about

how alcohol impacts

the brain?

Selective responding to strenghten change talk

It’s such a hassle to take

Prozac. I know I’m

supposed to take them,

but I don’t even have

them with me half the

time. There are good

reasons to be on them,

but it’s just not possible.

You have good

reasons to take them.

Tell me about that.

It’s such a hassle to take

the medication. I know

I’m supposed to take

them, but I don’t even

have them with me half

the time. There are good

reasons to be on them,

but it’s just not possible.

Despite the hassle,

you find a way to take

them some of the

time. How are you

successful half the

time?

Selective responding to strenghten change talk

I know I need to exercise

and eat better. But I’m so

tired to cook by the time I

get home, gym

membership is really

expensive. Besides, I’m

not that upset about my

weight anyway.

You’re ok with your

weight, and yet a part

of you is still bothered

by it.

I know I need to exercise

and eat better. But I’m so

tired to cook by the time I

get home, gym

membership is really

expensive. Besides, I’m

not that upset about my

weight anyway.

You’ve given a lot of

thought on what you

could be doing. What

would it take for you to

be successful?

(Moyers et al Alc Clin Exp Res 31, 2007)

-0.5

-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

0.3

0.4

0.5

0.6

Drinks per drinking days Percent days abstinent

More change talk

More sustain talk

*p < 0.05

- 36%*

+ 47%*

+13%

- 37%*

(Moyers et al Alc Clin Exp Res 31, 2007)

0

5

10

15

20

25 Likelihood of evoking Change Talk Likelihood of evoking Sustain Talk

MI Consistent behaviors

MI Inconsistent behaviors + 17%

+ 9%

+ 0.02% 0%

More

Sustain Talk Less change

MI inconsistent

behaviors

More

Change Talk More change

MI consistent

behaviors

You are in full control here. Patients are in full control

here.

Engaging

Focusing

Evoking

Planning

Planning Translating motivation into action

The KEY question

Building motivation

A B

What will you do?

Where should we

go from here?

Where does that

leave you?

Specific:

Measurable:

Achievable/Re

alistic:

Timely:

What will you do?

For how long? how much? how

many?

What have you done before that’s

worked?

When will you start?

Action Planning

Specific:

Measurable:

Achievable/Re

alistic:

Timely:

Walk to the park and back in the

evenings, Mondays and

Wednesdays

Walk for 10 minutes

Has done this before, and

confident about succeeding with

plan

Start tonight

Skill #6: Action Planning

Confidence scaling

On a scale of 1-10, 1 being not at all confident,

and 10 being completely confident, how

confident are you that this plan will work for

you?

Add some accountability

When can we meet again to discuss your

progress?

When would you like to meet with our care

manager to discuss how things are going?

If you’d like, we could talk more about this

during the next visit.

You would rather feel less frustrated and be

more effective in helping patients change

Further training

Practice, practice, practice

Listen to how patients respond

Introductory MI training (2 days)

Advanced MI training (1-2 days)

Feedback on your practice by coach/supervisor/peer/patients

Sat Bir Singh Khalsa, PhD

Sleep

Sleep

June 27, 2015

Lifestyle Medicine 2015

Harvard Medical School CME Course

Sat Bir S. Khalsa, Ph.D.

Assistant Professor of Medicine, Harvard Medical School

Research Associate, Benson Henry Institute for Mind Body Medicine

Brigham & Women’s Hospital Harvard Medical School

Conflicts of Interest / Disclosures

• I have no financial conflicts of interest with commercial entities

• I am funded in part by non-profit charitable organizations that support yoga practice

• I am strongly biased in favoring behavioral and mind-body medicine as a first-line treatment strategy

Objectives

• To describe the underlying characteristics of sleep and its importance

• To describe major sleep disorders, their etiology and their lifestyle implications

• To describe lifestyle behaviors and strategies for improving sleep and sleep disorders

Sleep

• A biological need

• Sleep : Wakefulness

• An active process

• A complex process

Physiologic Determinants

Sleep and Wakefulness

• Biological Time of Day (circadian phase)

• Number of Hours Awake & Nightly Sleep

Duration

Sleep Disorders

Three major categories:

• Parasomnias

• Disorders of excessive daytime

sleepiness

• Insomnia

Sleep DisordersSocioeconomic Consequences

• 40 million Americans suffer from chronic disorders of

sleep and wakefulness.

• 95% of these remain unidentified and undiagnosed.

• The annual direct cost of sleep-related problems is $16

billion, with an additional $50-$100 billion in indirect

costs (accidents, litigation, property destruction,

hospitalization, and death).

• More than 100,000 motor vehicle accidents annually

are sleep-related.

• Disasters such as Chernobyl, Three Mile Island,

Challenger, Bhopal, and Exxon Valdez were officially

attributed to errors in judgement induced by sleepiness

or fatigue.

Disorders of Excessive Daytime

Sleepiness

Defining Hypersomnolence

• Must be distinguished from fatigue.

• Is a tendency to fall asleep

unintentionally in passive situations:

– Reading

– Watching television

– Driving

– Lectures

Differential Diagnosis

of Excessive Daytime Sleepiness

Increased Sleep Drive:

• Narcolepsy

• Primary Central Nervous System Hypersomnolence

Sleep Disruption:

• Obstructive Sleep Apnea

• Periodic Limb Movement Disorder

• Restless Legs Syndrome

Inadequate Sleep:

• Self Imposed Sleep Restriction

• Shift Work

Other

Sleep Apnea

Sleep Apnea Recording

Sleep Apnea Recording

Hyoid Bone

Mandible

Maxilla

Nasal Passage

Trachea

Epiglottis

Tongue

(Genioglossus)

Soft Palate

Choanae

Anatomy of the Upper Airway

Sleep Apnea

Risk Factors and Consequences

From: Risk factors for obstructive sleep apnea in adults. Young T, Skatrud J,

Peppard PE. Journal of the American Medical Association 291:2013-2016, 2004.

Sleep Apnea

Treatments

From: Obstructive sleep apnea

syndrome: Diagnosis and management,

Goodday RHB, Precious DS, Morrison

AD, Robertson CG, Journal of the

Canadian Dental Association, 67:652-

658,2001

From: Norman JF, Von Essen SG, Fuchs RH, McElligott M., Exercise training

effect on obstructive sleep apnea syndrome. Sleep Res Online. 000;3(3):121-9.

Sleep Apnea

Behavioral Treatment

Self-Restricted Sleep

Self-Restricted Sleep

From: QuickStats: Percentage of Adults Aged >18 Years Who Reported an Average of <6

Hours of Sleep per 24-Hour Period, by Sex and Age Group --- National Health Interview

Survey, United States, 1985 and 2006, MMWR Morbidity and Mortality Weekly Report,

Centers for Disease Control and Prevention 57:209, 2008.

From: The cumulative cost of additional wakefulness: dose-response effects on neuro-

behavioral functions and sleep physiology from chronic sleep restriction and total sleep

deprivation. Van Dongen HP, Maislin G, Mullington JM, Dinges DF. Sleep 26:117-26, 2003.

Cumulative Sleep Deprivation

Cognitive Function

From: Effect of sleep deprivation on response to immunization. Spiegel K, Sheridan JF,

Van Cauter E. Journal of the American Medical Association 288:1471-2, 2002.

Cumulative Sleep Deprivation

Immune Function

From: Sleep loss: a novel risk factor for

insulin resistance and Type 2 diabetes,

Spiegel K, Knutson K, Leproult R, Tasali

E, Van Cauter E. Journal of Applied

Physiology 99:2008-19, 2005.

Cumulative

Sleep

Deprivation

Endocrine

Function

From: Sleep loss: a novel risk factor for insulin resistance and Type 2 diabetes, Spiegel

K, Knutson K, Leproult R, Tasali E, Van Cauter E. Journal of Applied Physiology 99:2008-

19, 2005.

Cumulative Sleep Deprivation

Appetite Control

ChronicSleep Deprivation

ObesityMetabolic SyndromeDiabetes

Sleep ApneaSelf-restricted Sleep

Impairment/Dysfunction- Cognitive- Immune- Autonomic

Insomnia

“…the overall prevalence estimate of broadly defined insomnia (23.6%)

is considerably higher than the 6% to 10% prevalence range widely

reported in reviews of previous epidemiological studies.”

“Insomnia is…associated with substantial decrements in perceived

health.

America Insomnia Study

From: Roth T et al., Prevalence and perceived health associated with insomnia based

on DSM-IV-TR; International Statistical Classification of Diseases and Related Health

Problems, 10th Rev.; and Research Diagnostic Criteria/ICSD, 2nd Ed. criteria: results

from the America Insomnia Survey, Biological Psychiatry 69(6):592-600, 2011.

“…insomnia is much more strongly related to presenteeism than

absenteeism. This means that workers with insomnia generally

put in the same number of work hours as other workers, but

that their on-the-job performance is lower than other workers.”

“…estimate of $59.8 billion annual lost productivity…”

From: Insomnia and the performance of US workers: results from the America insomnia

survey, Kessler RC, Berglund PA, Coulouvrat C, Hajak G, Roth T, Shahly V, Shillington

AC, Stephenson JJ, Walsh JK, Sleep, 34:1161-71, 2011.

Insomnia Presentation

Sleep onset insomnia

Sleep maintenance insomnia

Poor quality/non-restorative sleep

Insomnia Diagnostic Criteria

Sleep onset latency > 30 minutes

Wake time after sleep onset > 30 minutes

Frequency at least 3 times/week

Duration at least 6 months

Significant daytime impairment

Medicationsand substances

• Acute use• Chronic use• Withdrawal

Circadian Factors• Jet lag• Shift work• Advanced, delayed

sleep phases

Medical/NeurologicalFactors

• Pain, discomfort• Specific disorders

Psychiatric orPsychological Factors

• Depression or Anxiety • Bereavement• Acute stress

EnvironmentalFactors

• Physical discomfort• Noise• Light

PrimarySleep Disorders• Restless Legs Syndrome• Periodic limb movements• Respiratory arousals• Parasomnias

INSOMNIA

From: The evaluation and treatment of

insomnia, Buysse DJ, Perlis ML, Journal

of Practical Psychiatry and Behavioral

Health. 10:541-553, 1987.

Medicationsand substances

• Acute use• Chronic use• Withdrawal

Circadian Factors• Jet lag• Shift work• Advanced, delayed

sleep phases

Medical/NeurologicalFactors

• Pain, discomfort• Specific disorders

Psychiatric orPsychological Factors

• Depression or Anxiety • Bereavement• Acute stress

EnvironmentalFactors

• Physical discomfort• Noise• Light

PrimarySleep Disorders• Restless Legs Syndrome• Periodic limb movements• Respiratory arousals• Parasomnias

Behavioral,Psychophysiological,

and Conditioning Factors• Fear, frustration with insomnia• Sleep-incompatible behaviors• Increased arousal

INSOMNIA

Behavioral,Psychophysiological,

and Conditioning Factors• Fear, frustration with insomnia• Sleep-incompatible behaviors• Increased arousal

INSOMNIA

Models of Primary Insomnia

Conditioning

Emotional Arousal

Cognitive Arousal

Physiological Arousal

Insomnia Treatment

• Treat underlying cause (secondary insomnia)

• Pain, depression, anxiety, sleep disordered

breathing, RLS/PLMD

• Pharmacological Treatments

• Behavioral Treatments

Insomnia Treatment

Pharmacological Treatment

Antihistimines / Melatonin / Valerian (Over-the-counter)

• Little or no efficacy as nighttime hypnotics, mild sedation

• Antihistamines have daytime sedative effects (hangover) and

anticholinergic side effects

Hypnotics

• Recommended mostly as adjunctive therapy for transient or

intermittent insomnia with minimal dosing for brief periods

• Primarily benzodiazepines or a few non -benzodiazepines

• Half - life should be tailored to sleep disturbance

• Side effects include paradoxical insomnia or disruption of

sleep architecture, anterograde amnesia, withdrawal

symptoms

• Tolerance is common

Behavioral Treatments for Insomnia

Sleep Hygiene General sleep-specific recommendations for facilitating sleep

Stimulus control Association/Reassociation of the bed/bedroom solely for sleep or sex

Cognitive therapy Challenge dysfunctional beliefs andmisperceptions about sleep and insomnia

Sleep restriction Improve sleep continuity by limitingtime spent in bed

Relaxation training Relaxation treatments employing cognitive and/or somative techniques to reduce tension and arousal

• Avoid stimulants such as caffeine 4-6 hours before bedtime.

• Avoid drinking alcohol 4-6 hours before going to bed.

• Eat a light, easily digestible snack before bed but avoid large

meals before bedtime.

• Adopt a regular exercise program

• Avoid exercising within 3-4 hours of bedtime.

• Give yourself a quiet period or calm time for at least one or two

hours before bed.

• Develop a regular pre-sleep routine.

• Improve the comfort of your bed if needed.

• Reduce noise and disruptions.

• Reduce light in the bedroom.

• Maintain a regular temperature.

Behavioral Treatments for Insomnia

Sleep Hygiene

• Establish the bed and bedroom as a place for sleep and

sex only

• Avoid reading, watching TV, eating, worrying and other

sleep-incompatible behaviors in the bed and bedroom

• Go to bed only when sleepy regardless of circumstances

• Get out of bed whenever awake for more than 15-20

minutes

• Establish regular hours and a standard wake-up time

• Refrain from daytime napping

Behavioral Treatments for Insomnia

Stimulus Control

1. Identify thoughts about sleep that tend to make sleeping more difficult

2. Replace these thoughts with more constructive thoughts

The more important it is to get a good night's sleep, the less sleep is possible.

Belief that a poor night's sleep is a disaster only generates more anxiety

and worry about sleep. For example, beliefs such as "everyone needs 8

hours of sleep to function well during the day" or "insomnia is necessarily

detrimental to physical and mental health" only create performance anxiety

and worsen sleep problems. Challenge this thinking and consider

alternative thoughts that minimize the negative consequences of insomnia

(i.e. "It's no big deal", "I'll be a little tired and cranky tomorrow but nothing I

can't handle.").

The more you try to control your sleep, the less you sleep. Sleep is a natural

body response. Telling yourself that you must sleep and trying to force

yourself to sleep only puts pressure on you and makes your sleep worse.

Paradoxical Intention as a cognitive treatment.

Behavioral Treatments for Insomnia

Cognitive Restructuring

• Limits amount of time in bed thus increasing

homeostatic sleep drive to reduce the amount of

wakefulness

• Eliminate daytime naps

• Calculate total sleep time from sleep wake logs and

use this as a prescription for time in bed, 4 hour

minimum

• Increase time in bed as sleep efficiency increases

Behavioral Treatments for Insomnia

Sleep Restriction

Adam K et al, J Psychiatr Res, 1986

Physiological Arousal in Insomnia

Bonnet MH & Arand DL, Sleep, 1995

Johns MW et al., Psychosom Med, 1971 Bonnet MH & Arand DL, Psychosom Med, 1998

Insomnia as Disorder of Hyperarousal

“…primary insomniacs suffer from a disorder of

hyperarousal and that the elevated arousal produces

the poor sleep and other symptoms reported by

patients. It is therefore suggested that new treatment

strategies directed at reduction of arousal level be

considered in these patients.”

“Treatments for insomnia, such as relaxation, exercise

training, and some medications…may provide long-term

benefits over and above short-term improvement in

reported sleep quality.”

From: Heart rate variability in insomniacs and matched normal sleepers,

Bonnet MH & Arand DL, Psychosomatic Medicine 60:610-615, 1998.

From: Hyperarousal and insomnia, Bonnet MH & Arand DL, Sleep Medicine

Reviews 1:97-108, 1997.

Relaxation Treatments for Insomnia

• Progressive muscle relaxation

• Biofeedback

• Guided imagery

• Autogenic training

• Meditation

• Yoga

Mind-body interventions were able to improve sleep efficiency and total sleep

time. Most can ameliorate sleep quality; some can reduce the use of hypnotic

drugs in those who are dependent on these drugs.

According to the studies we selected, self-reported sleep was improved by all

mind-body treatments, among them yoga, relaxation, Tai Chi…

From: Perceived benefits

in a behavioral-medicine

insomnia program: a

clinical report,

Jacobs,G.D.; Benson,H.;

Friedman,R., American

Journal of Medicine

100:212-216, 1996

Multi-

component

Behavioral

Treatment

for

Insomnia

Yoga for

Sleep

Sleep in Yoga Practitioners

From: Subjective sleep quality and hormonal modulation in long-term yoga practitioners,

Vera FM, Manzaneque JM, Maldonado EF, Carranque GA, Rodriguez FM, Blanca MJ,

Morell M, Biological Psychology 81:164-8, 2009.

Sleep in Elderly Yoga Practitioners

From: Impact of long term Yoga practice on sleep quality and quality of life in the elderly,

Bankar MA, Chaudhari SK, Chaudhari KD, Journal of Ayurveda and Integrative

Medicine, 4:28-32, 2013.

Perceptions of Yoga on Health

From: National survey of yoga practitioners: mental and physical health benefits,

Ross A, Friedmann E, Bevans M, Thomas S, Complementary Therapies

Medicine, 21:313-23, 2013.

Yoga Practice Associations

From: Frequency of yoga practice predicts health: results of a national survey of

yoga practitioners, Ross A, Friedmann E, Bevans M, Thomas S, Evidence

Based Complementary and Alternative Medicine, 983258, 2012.

Yoga on Sleep in the Elderly

From: Influence of Yoga & Ayurveda on self-rated sleep in a geriatric population,

Manjunath NK, Telles S, Indian Journal of Medical Research 121:683-690, 2005.

5.5

5.7

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7.3

Pretreatment Posttreatment Followup

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(H

ou

rs) Yoga Controls

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Pretreatment Posttreatment Followup

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Yoga Controls

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Sleep Onset Latency

Baseline Wk 1-2 Wk 3-4 Wk 5-6 Wk 7-8 FollowupAvera

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nset Late

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min

ute

s)

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Sleep Efficiency

Baseline Wk 1-2 Wk 3-4 Wk 5-6 Wk 7-8 Followup

Avera

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leep E

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%)

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Total Wake Time

Baseline Wk 1-2 Wk 3-4 Wk 5-6 Wk 7-8 Followup

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hr)

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1.0

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2.6Total Sleep Time

Baseline Wk 1-2 Wk 3-4 Wk 5-6 Wk 7-8 Followup

Avera

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ota

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leep T

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hr)

5.5

6.0

6.5

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7.5

Sleep Diary Data

Kripalu | center for yoga & health

“Now, when I can’t sleep I can watch a little TV.”

http://www.aasmnet.org

American Academy of Sleep Medicine

http://www.nhlbi.nih.gov/health/public/sleep

National Heart Lung and Blood Institute

http://www.users.cloud9.net/~thorpy

Sleep Medicine Home Page

http://www.sleepnet.com

Sleepnet.com

http://www.sleepfoundation.org/default.cfm

National Sleep Foundation

Website Links

Fatima Cody Stanford, MD, MPH

Obesity and Sleep

Fatima Cody Stanford, MD, MPH, MPA

Obesity Medicine & Nutrition

Massachusetts General Hospital

Harvard Medical School

American Board of Obesity Medicine Diplomate

Disclosures

American Academy of Nutrition and Dietetics-Speaker

Medscape- Consultant

Objectives

• Define prevalence of obesity in the United States

• Learn obesity and sleep pathophysiology

• Evaluate the role of sleep in childhood obesity

• Evaluate the role of sleep in adult obesity

• Ascertain role of sleep on energy intake and expenditure

• Outline steps for good sleep hygiene

1 CDC.gov – All numbers from 2012 or 2013 summary data

Obesity Compared to other Diseases in US0 50 100 150 200 250

Prevalence in the US inmillions

Own a Smartphone

Own a TV

Obesity

NAFLD

Diabetes

All Cancers

Breast CA

Colon CA

HIV

Obesity: A Multi-factorial Disorder

Genetics Environment Development Behavior

Regulation of Food Intake

http://www.cellbiol.net/ste/alpobesity2.php

Regulation of Food Intake

Nature Reviews Genetics 10, 431-442 (July 2009)

Regulation of Food IntakeSubstance Production Site Effect

(Relevant for Feeding)

Ghrelin (grow) •Stomach (fundus region,entero-endocrine cells)

•Neurons in the hypothalamus

Appetite (orexigenic)

Anandamide(endocannabinoide, ananda;

bliss, delight + amide )

Small intestine Appetite (orexigenic)

Insulin(insula; island or islet)

Pancreas(β-cells in islets of Langerhans)

•Satiety (anorexigenic)•glycogen and lipid storage

Leptin(leptos, thin)

•Adipocytes (long term)•Stomach (short term)

Satiety (anorexigenic)

CCK(cholecystokinin,

“move the bile-sac”)

Small intestine •Early satiety (anorexigenic)•release of digestive enzymes from exocrine pancreas, bile

from the gallbladder andH+ from parietal cells in stomach

PYY(peptide tyrosine tyrosine)

•Ileum•colon

Satiety (anorexigenic)

http://www.cellbiol.net/ste/alpobesity4.php

Central Nervous System regulates weight

Sleep

Sleep quality is most important

Duration varies for individuals

Take note if a patient:

Snores

Wakes up gasping for breath

Stops breathing in the middle of the night

Daytime hypersomnolence

Morning Headache

Circadian Rhythm Disturbances Loss of circadian resonance appears

to contribute to human obesity

Availability of artificial light leads to progressive disintegration of rhythms of human sleeping

Circadian desynchrony (CD) leads to alterations in:

glucose homeostasis

feeding behavior

metabolic rate

Bioassays 35 :921-924(2012)

Susceptibility to Obesity and Migration

Obes Res 8: 620-631 (December 2000)

Circadian Rhythm and Metabolism

Journal of Applied Physiology 107 (6): 1972-1980(December 2009)

Circadian Rhythm Regulation

Nature 437 :1257-1263 (October 20o5)

Sleep needs across the lifespanAge Recommended Hours

of SleepAppropriate Range

Newborns (0-3 months) 14 to 17 hours 11 to 19 hours

Infants (4-11 months) 12 to 15 hours 10 to 18 hours

Toddlers (1-2 years) 11 to 14 hours 9 to 16 hours

Preschoolers (3-5 years) 10 to 13 hours 8 to 14 hours

School-Aged Children(6-13 years)

9 to 11 hours 7 to 12 hours

Teenagers (14-17 years) 8 to 10 hours 7 to 11 hours

Young Adults (18-25 years)

7 to 9 hours 6 to 10 hours

Adults (26-64 years) 7 to 9 hours 6 to 10 hours

Older Adults ≥ 65 years 7 to 8 hours 5 to 9 hours

Sleep Health Foundation

Sleep and Childhood Obesity Project Viva- a prospective observational cohort study

of gestational diet, pregnancy outcomes, and offspring health

1676 mother-infant pairs in a pre-birth cohort study

Evaluated mothers’ report of their infants’ average 24-hour sleep duration at 6 months, 1 year, and 2 years of age.

Infants slept mean (SD) durations of 12.2 (2.0) hours/day at 6 months, 12.8 (1.6) hours/day at 1 year, and 11.9 (1.3) hours/day at 2 years.

Acad Pediatr 10 (3):187-193(May-June 2010)

Sleep and Childhood Obesity

Shortened sleep duration at 1 and 2 years of age associated with:

Maternal antenatal depression

Introduction of solids < 4 months

Infant TV/video viewing were associated with shorter sleep durations at both 1 and 2 years of age

Variation in sleep apparent by racial and ethnic background

Acad Pediatr 10 (3):187-193(May-June 2010)

Sleep and Childhood Obesity

Acad Pediatr 10 (3):187-193(May-June 2010)

Sleep and Childhood Obesity

Obesity 19(2):353-361 (February 2011)

Long Term Impact of Childhood Sleep on Obesity

Sleep and Adult Obesity

Sleep and Adult Obesity

Sleep and Adult Obesity

Sleep and Adult Obesity

Sleep Deprivation and Energy Intake

PLoS Med. 2004 Dec; 1(3): e62.

Sleep Deprivation and Energy Intake

PLoS Med. 2004 Dec; 1(3): e62.

Sleep Deprivation and Energy Intake

Am J Clin Nutr 2008;89:126-133.

Sleep Deprivation and Energy Intake

J Physiol Anthropol Appl Human Sci. 2002; 21:115-20..

Sleep Deprivation and Energy Intake

J Physiol Anthropol Appl Human Sci. 2002; 21:115-20..

Sleep Deprivation and Energy Intake

J Physiol Anthropol Appl Human Sci. 2002; 21:115-20..

Sleep Deprivation and Energy Expenditure

May be a decrease in physical activity

May be a drop in body temperature

Conflicting results in studies

Case 44 year old woman Past medical history:

Hypertension Anxiety/ Depression Asthma Fibromyalgia Bipolar disorder Gastroesophageal reflux disease Obstructive sleep apnea Metabolic syndrome X

History of being on several weight promoting: Ziprasidone, Quetiapine, Duloxetine, Citalopram, Fluozetine, Zolpidem, Trazodone, Atenolol, Pregablin, and Nortriptyline

Postpartum weight retention of 20 pounds Poor sleep- daytime hypersomnolence, snoring, morning headache

BMI: 33.5

BMI: 26.5

CPAP

45 year old woman

Sleep Hygiene Tips

1. Avoid Caffeine, Alcohol, Nicotine, and Other Chemicals that Interfere with Sleep

2. Turn Your Bedroom into a Sleep-Inducing Environment

3. Establish a Soothing Pre-Sleep Routine

4. Go to Sleep When You’re Truly Tired

5. Don’t Be a Nighttime Clock-Watcher

6. Use Light to Your Advantage

http://healthysleep.med.harvard.edu/healthy/getting/overcoming/tips

Sleep Hygiene Tips

7. Keep Your Internal Clock Set with a Consistent Sleep Schedule

8. Nap Early—Or Not at All

9. Lighten Up on Evening Meals

10. Balance Fluid Intake

11. Exercise Early

12. Follow Through

http://healthysleep.med.harvard.edu/healthy/getting/overcoming/tips

Conclusion

Obesity is multifactorial disease process

There are different reasons why a person may struggle with weight

Sleep plays a role in weight regulation

Strategies should target individual to determine the best strategy that will help one to achieve a healthy weight

Thank you for your time!Fatima Cody Stanford, MD, MPH

Obesity Medicine & NutritionMassachusetts General Hospital

Harvard Medical SchoolAmerican Board of Obesity Medicine Diplomate

Cheri Blauwet, MD

What Really Gets Patients

(Even Reluctant Ones)

to Effect Health Change

What Really Gets Patients (Even Reluctant Ones)

to Effect Healthy Change

Cheri Blauwet, MDinstructor, Physical Medicine and Rehabilitation

Sports Medicine Service, SRH/BWHChair, Int’l Paralympic Committee Medical Commission

Disclosures

• My disclosures include:

– Travel and accommodation support from the International

Paralympic Committee in my role with the Medical Commission

– Grant reviewer for the Craig H. Neilsen Foundation (Quality of Life

Grant Review Board) and the Foundation for PM&R

– Associate Editor for the PM&R Journal and ad hoc reviewer for

several others

Objectives

• To discuss concepts of who is or is not “active” and

various barriers to physical activity for different populations

• To consider the paradigm of “Universal Design” as a

useful road forward in building opportunities for physical

activity and exercise

• To understand that we, as physicians, truly can make a

difference in effecting change for our patients

Overview – Key Points and Questions

• The beauty of human diversity– “If you have a body, you are an

athlete”

• “No Brakes” – my personal story

• Three principles for effecting change

• Example of the road forward -Universal Design

• Wrap up – and tools for you

The Beauty of Human Diversity

• We come in all shapes, sizes, and levels of ability …

The Paradigm Shift

• Nike slogan: “To bring innovation and inspiration to every athlete* in the world”

*If you have a body, you are an athlete

WHO - ICF Framework (2001)

CDC - Physical Activity Guidelines

• You’ve heard this before!

• Adults (age 18-64) need at least: – 150 minutes of moderate-intensity aerobic activity every week, and…

– Muscle strengthening activities 2 or more days a week that work all

major muscle groups

– Etc etc.

• For aerobic activity, generally-speaking the more the

better

… But, what are the barriers to involvement?

The Barriers are Real - Physical

• Survey of 83 adults with unilateral stroke

• Major barriers to exercise: – Cost of the program (61%)

– Lack of awareness of where to go (57%)

– No means of transportation (57%)

– Unaware of how to exercise (46%)

– Lack of interest (16%)

– Lack of time (11%)

– Fear it will worsen condition (1%)

(Rimmer J, Rehabil Res Dev 2008)

Barriers - Physical

• Accessibility of health clubs for people with mobility and visual disabilities

• Assessment of 35 facilities in 6 topic areas:

– Built environment

– Equipment

– Swimming pool

– Information

– Policies

– Professional behavior

(Rimmer J, Am J Pub Health, 2005)

Barriers - Physical

• Findings:

– Few facilities with accessible showers, power-assisted doors, ramps

meeting ADA specs

– <10% with cardio machines that offered anything aside from traditional

lower extremity modalities

– 50% with pool lifts

– <25% with information in accessible formats

– >85% asked person with disability if they would like help prior to

providing assistance

(Rimmer J, Am J Pub Health, 2005)

My Mantra - “No Brakes”

• No Brakes

– People with disabilities do not expect or want “breaks” or special exceptions – treat us as your equal

– Do not hold us back under the premise of false “brakes”

• Brakes may be necessary, but

they should be self-imposed

The Journey Begins

“Do the things you can be good at”

Introduction to Sport

Wait – I’m an “athlete?”

Taking it All the Way

Three Paralympic Games, Seven Paralympic Medals

Taking it All the Way

Three Paralympic Games, Seven Paralympic Medals

Taking it All the Way

Boston Marathon Wins – 2004, 2005

Taking it All the Way

Boston Marathon Wins – 2004, 2005

Taking it All the Way

One Epic Crash

And Then… This Happened

Through it All – Values of Olympism

• “The goal of the Olympic

Movement is to contribute to

building a peaceful and better

world by educating youth through

sport practiced without

discrimination of any kind and in

the Olympic spirit, which requires

mutual understanding with a spirit

of friendship, solidarity, and fair

play.” (Olympic Charter)

The Transformative Power of Sport

Confidence, Self-Respect

Physical Empowerment Expanded World View

Academic Pursuits

Rapid Growth of the Paralympic Movement

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One of the fastest rates of growth in all of sport

A New Field: Paralympic Sports Medicine

• Athletes with disabilities remain underserved

• Many sports medicine physicians “fear” this population– Feel as though they lack expertise

• Extremely interesting work at the intersection of disability/rehabilitation and sports performance

• Compelling argument for public health impact

Paralympic Sports Medicine – IPC

• IPC Medical Committee– Standards for sports medicine services

– Therapeutic Use Exemptions (TUEs)

– Injury and Illness Surveillance Study

– Athlete and coach education

Bringing the Games to Boston?

Back To “No Brakes”

• No Brakes

– People with disabilities do not expect or want “breaks” or special exceptions – treat us as your equal

– Do not hold us back under the premise of false “brakes”

• Brakes may be necessary, but

they should be self-imposed

So – What’s the Bottom Line?

• We have a long road ahead, but we can get there

• The barriers have been defined

• It’s not impossible

Keys to Effecting Healthy Change

• Ultimately, it all boils down to this: 1. Tell people you believe in them

2. Meet them where they are at

• Not “us” vs. “them,” but “we”

3. Give them the tools to succeed

• The challenge – this will mean something slightly

different for everyone!

• The opportunity – the principles remain constant!

One Example - Universal Design

• Universal Design: Design that is usable by the widest

range of people without need for special or separate

programs

• Applies to

– Places

– Things

– Policies

Universal Design - Places

• “Places”: Applies to the built infrastructure– Full ADA Guidelines applied to fitness facilities

(www.adachecklist.org)

Universal Design - Things

• “Things”: Applies to the tools and materials we use within our

environment– Upper body spin class

Universal Design - Policy

• “Policies”: Applies to the laws we create that ensure universal

access…

Rehab Act

of 1973

ADA of

1990

DOE

Guidance

2013

IDEA of

1990

CRPD

2006

1970 1980 1990 2000 2010 2025

Universal Design – Elite Sport

• Policy in Sport: Eastern College Athletic Conference

A Paradigm Shift

Changing the paradigm…

And with it, changing society’s expectations

Back to the Three Principles

1. Tell people you believe in them

2. Meet them where they are at

3. Give them the tools to succeed

Example – Casey Martin

Take Home Points

• The beauty of human diversity

– “If you have a body, you are an athlete”– The barriers to change are real, but not

insurmountable

• Three principles for effecting change

• Example of the road forward -Universal Design

• The tools are now in your hands -let’s push the envelope together!

Thank You

• Many thanks to…

– Institute for Lifestyle Medicine

– Dr. Eddie Phillips and Dr. Beth Frates

– Mary Alice Hanford

– HMS/Spaulding Department of PM&R

– Brigham and Women’s Hospital

– International Paralympic Committee

– All of you!

References

Center for Disease Control and Prevention. 2008 Physical Activity Guidelines for Americans.

Atlanta: Center for Disease Control and Prevention; 2008.

Rimmer JH, Wang E, Smith D. Barriers associated with exercise and community access for

individuals with stroke. J Rehabil Res Dev 2008; 45:315-22.

Rimmer JH, Riley B, Wang E, Rauworth A. Accessiblity of health clubs for people with mobility

disabilities and visual impairments. Am J Pub Health. 2005 Nov 95(11);2022-8.

World Health Organization. International Classification of Functioning, Disability, and Health.

Geneva: World Health Organization; 2001.

Supplemental Material