Maintenance of Health: Check In & Check Up

1. Maintenance of Health:Check In & Check Up James B. Broadhurst, MD, MHA 25th Annual Public Sector Psychiatry Conference June 17, 2009

2. Relevant Program Objectives • To learn the role of prevention and health maintenance in the care of persons with serious mental illness • To learn what resources are available in all formats, e.g., print, online, local, national, and international to improve the health and wellbeing of persons with serious mental illness

3. Pediatric Obesity - Intervention • breastfeeding (SOR A) • no television or computer screen time (SOR C) • avoiding premature introduction of solid foods (SOR C) • limiting intake of juice to less than 6 oz/day (SOR C) • avoiding high-calorie beverages with low nutritional value (SOR C) • educating parents to be role models of healthy lifestyles (SOR C) • switching to reduced-fat milk during the preschool years and beyond (SOR A)

4. Pediatric Obesity - Prevention • Low or high birth weight • low socioeconomic level • poor eating • a change >3–4 BMI units per year • Depression • >2 hours/day of sedentary activity such as watching television or playing computer games • minority status (all are SOR C)

5. Behavioral Therapy in Weight Loss • self-monitoring • stress management • stimulus control • problem-solving • contingency management • cognitive restructuring • social support

6. Exclusions from Weight Loss Therapy • most pregnant or lactating women • Serious uncontrolled psychiatric illness such as a major depression • variety of serious illnesses and for whom caloric restriction might exacerbate the illness. • Refer for specialized care • active substance abuse • history of anorexia nervosa or bulimia

7. …self-efficacy - a patient’s report that she or he can perform the behaviors required for weight loss - is a modest but consistent predictor of success. Obesity: The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI Obesity Education Initiative, North American Association for the Study of Obesity, 2000, NIH pub no 00-4084, p21.

8. Look AHEAD Trial(Action for Health in Diabetes) • Multicenter, randomized trial (n=5,145) • Effects of intensive lifestyle interventions on cardiovascular morbidity and mortality on obese (BMI > 30 kg/m2) patients with Type 2 diabetes • Randomized to: • DSE – diabetes support and education with regular medical care • ILI – intensive lifestyle interventions with regular medical care • Baseline: 58 yrs, BMI 36, Wgt 100kg, 60% ♀ • Projected trial ends in 2013-2014 Interim Results presented at the American Diabetes Association 69th Scientific Session, New Orleans, LA, 6/7/09

9. Intensive Lifestyle Interventions • Meal replacements • Monthly maintenance visits – individual or group • Months 1-6: weekly contact 3 group and 1 individual • Months 7-12: 2 group and 1 individual per month • Years 2-4: 1 individual visit per month, 1 phone/e-mail per month, periodic refresher courses/campaigns 2-3 times per year lasting 6 to 8 weeks • Resource toolbox including orlistat • Encourage physical activity for 175 min/week

10. 4.7% weight loss 35% had 7% weight loss “clinically significant weight loss” 1.1% weight loss 18% had 7% weight loss Weight loss not “clinically significant” No CV endpoints Look AHEAD at 4 years DSE ILI

11. Look AHEAD Messages • Meal replacements helpful in weight loss • Physical activity is key • More frequent patient contact appears to enhance likelihood of success • BUT… • Given current provider supply (MA health reform lesson) and access issues is the trial frequency of contact achievable or cost-effective?

12. BARI 2D Trial* • Patients with type 2 diabetes referred for evaluation of CAD • N=2368 • Randomly assigned to • CABG v PCI • Medical therapy v revascularization • Insulin provision v insulin sensitization Bypass Angioplasty Revascularization Investigation 2 Diabetes NEJM, 360:2503-2525, June 11, 2009

13. BARI 2D Trial Conclusions • Followed for 5 years • No significant difference medical v revascularization and insulin provision v sensitization • Note - initial Rx strategy for patients with diabetes and CAD rarely remains constant over a 5 year treatment period

14. BARI 2D Trial - Secondary • Secondary endpoints: death, MI, CVA • Insulin-sensitizing rx associated with fewer secondary endpoints than insulin • CABG group (not PCI) fewer major cardiac events than optimal medical therapy group

15. BARI 2D Trial – Take Home • For many patient with diabetes and CAD, optimal medical therapy is an excellent first-line strategy • When revascularization is indicated several studies now support CABG over PCI • Comparative effectiveness of rapidly evolving treatments is a moving target

16. Older Adults – Fall Prevention • 1/3 of adults >65 will fall annually • Leading cause of non fatal injuries in this age group • Risk factor for premature death • Tai chi reduces fall risk (SOR A) • Balance • Strength training • Well controlled HTN – OK to initiate exercise • Calcium intake -  bone density

17. The Prevention Gold Standard US Preventive Services Task Force (USPSTF)

18. USPSTF Background • Department of Health & Human Services • Agency for Healthcare Research and Quality • 1st convened by US Public Health Service in 1984 • Moved to AHRQ in 1998 • to evaluate the benefits of individual services based on age, gender, and risk factors for disease • which preventive services should be incorporated routinely into primary medical care and for which populations

19. USPSTF Ratings 1

20. USPSTF Ratings 2

21. USPSTF – Breast Cancer • The USPSTF recommends screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.Grade: B Recommendation. • The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer.Grade: I Statement. • The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE).Grade: I Statement.

22. USPSTF – Cervical Cancer 1 • The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. Grade: A Recommendation. • The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer (go to Clinical Considerations). Grade: D Recommendation. • The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease. Grade: D Recommendation.

23. USPSTF – Cervical Cancer 2 • The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer. Grade: I Statement. • The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer. Grade: I Statement.

24. USPSTF – Colorectal Cancer • The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.  Grade: A Recommendation. • The USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient. Grade: C Recommendation. • The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years. Grade: D Recommendation. • The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer. Grade: I Statement.

25. USPSTF – Prostate Cancer • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years. Grade: I Statement. • The USPSTF recommends against screening for prostate cancer in men age 75 years or older. Grade: D Recommendation.

26. USPSTF – Vitamins (Ca & CAD) • The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease. Grade: I Statement. • The USPSTF recommends against the use of beta-carotene supplements, either alone or in combination, for the prevention of cancer or cardiovascular disease. Grade: D Recommendation.

27. Vitamin C is finally goodfor more than Scurvy… • Cohort trial of ~47,000 Men • Surveyed Vitamin C & new onset Gout • 20 Years Follow up • Compared to < 250 mg/d 500-999 mg/d RR= 0.83 1000-1499 mg/d RR= 0.66 >/= 1500 mg/d RR = 0.55 p<0.001 Arch Intern Med 2009 169(5): 502

28. USPSTF – Hormone Replacement Therapy • The U.S. Preventive Services Task Force (USPSTF) recommends against the routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women. Grade: D recommendation. • The U.S. Preventive Services Task Force (USPSTF) recommends against the routine use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. Grade: D recommendation.

29. USPSTF – Osteoporosis • The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures Grade: B Recommendation. • The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures. Grade: C Recommendation.

30. Osteoporosis Risk Factors • Lower body weight (weight <70 kg ) is the single best predictor of low bone mineral density • no current use of estrogen therapy • Age • Less evidence • smoking, weight loss, family history, decreased physical activity, alcohol or caffeine use, or low calcium and vitamin D intake) as a basis for identifying high-risk women younger than 65 • At any given age, African-American women on average have higher bone mineral density (BMD) than white women

31. SOME words are betterthan others… • Comparison 20 FPs; 224 Pts; P/P survey • “Is there anything else you want..” • “Is there something else you want..” • 37% had > 1 concern • Intervention % Concerns Met ANY 53.1% SOME 90.3% • All Visit Ave: 11.4 Min +/- 5.0 Min • Ask: “Is there SOMETHING else you want to discuss” Heritage; JGIM 2007; 22(10): 1429

32. Number of New Non-Medical Users of Medications NSDUH 2002

33. Prescription Opiates • Prescription Opioids now cause more drug overdose deaths than cocaine and heroin combined. • 40% of teens and an almost equal number of their parents think abusing prescription painkillers is safer than abusing "street" drugs • FDA Fact Sheet 2008

34. Unintentional Pain Med Fatalities Opioid overdoses are driving up the number of accidental poisoning deaths. Here is the annual number of deaths associated with inadvertent narcotic or hallucinogenic drug overdoses among those ages 15-64: 30 deaths per day by 2005 CDC National Center for Health Statistics

35. What Puts Me At Risk? • Smoking • Diabetes • High Blood Pressure • High Cholesterol • Physical Inactivity • Overweight • Family History

36. OKHow Do I Lower My Risk? • Don't smoke, and if you do, quit • Aim for a healthy weight • Get moving • Eat for heart health • Know your numbers.  Ask your doctor to check your blood pressure, cholesterol (total, HDL, LDL, triglycerides), and blood glucose.

37. The American Heart Association's Nutrition Committee strongly advises these fat guidelines for healthy Americans over age 2:

38. AHA Fat Dietary Guidelines - 1 • Limit total fat intake to less than 25–35 percent of your total calories each day; • Limit saturated fat intake to less than 7 percent of total daily calories; • Limit trans fat intake to less than 1 percent of total daily calories; 

39. AHA Fat Dietary Guidelines - 2 • The remaining fat should come from sources of monounsaturated and polyunsaturated fats such as nuts, seeds, fish and vegetable oils; and • Limit cholesterol intake to less than 300 mg per day, for most people.  If you have coronary heart disease or your LDL cholesterol level is 100 mg/dL or greater, limit your cholesterol intake to less than 200 milligrams a day.

40. LDL Targets • 160 mg/dL is considered a high LDL. • 130 mg/dL and lower is a good target for most healthy people. • 100 mg/dL is the target if you have other risk factors for heart disease. • 70 mg/dL is the target if you already have heart disease.

41. 10 True statements regarding the consumption of trans-fatty acids include which of the following? • In the United States the main sources are meats and dairy products • They result in a rise in LDL-cholesterol and a reduction in HDL-cholesterol • They have been linked to vascular inflammation and elevation of C-reactive protein • Consumers can avoid them by consuming foods with zero trans-fatty acids listed on the nutrition label • Consumers should be advised to avoid foods containing hydrogenated oils

42. Trans Fatty Acids • Linked their consumption to both sudden cardiac death and the development of diabetes (Level 2 Evidence) • Increase LDL-cholesterol, reduce HDL-cholesterol, increase serum triglycerides, and reduce the size of the LDL particle (Level 3 Evidence) • Systemic inflammation has also been linked to the consumption of TFAs, with increased activity of the tissue-necrosis factor system and increases in interleukin-6 and C-reactive protein • TFAs are formed during partial hydrogenation of vegetable oils

43. Trans Unsaturated fat Saturated fat Cis - Unsaturated fat

44. http://www.badfatsbrothers.com/BFB.html

45. How to Lower Cholesterol • Follow a low saturated fat, low cholesterol diet • Be more physically active • Lose weight if you are overweight

46. Monounsaturated Fat • remains liquid at room temperature but may start to solidify in the refrigerator. Foods high in monounsaturated fat include olive, peanut and canola oils. Avocados and most nuts also have high amounts of monounsaturated fat.

47. Polyunsaturated fat • is usually liquid at room temperature and in the refrigerator. Foods high in polyunsaturated fats include vegetable oils, such as safflower, corn, sunflower, soy and cottonseed oils.

48. Omega-3 fatty acids • are polyunsaturated fats found mostly in seafood. Good sources of omega-3s include fatty, cold-water fish, such as salmon, mackerel and herring. Flaxseeds, flax oil and walnuts also contain omega-3 fatty acids, and small amounts are found in soybean and canola oils.

49. Can measuring CRP help? • C-reactive protein • Non-specific measure of inflammation • The infamous JUPITER trial • Can you spell B-I-A-S? • Not routine in primary care • Limited role now • Asymptomatic patient with strong family history and borderline high total cholesterol and LDL

50. An aspirin a day… • 81mg daily recommendation dates from primary prevention studies such as the Framingham Heart Study • Risk reduction then in the order of 30 events per 10,000 treated • Recent review in the Lancet (5/09) showed nearly equal benefit and risk • Reduce non-fatal MI by 5 per 10,000 • Cause 4 bleeds per 10,000 (1 CVA, 3 GI)