APPROACH TO THE PATIENT & HEALTH MAINTENANCE

1. APPROACH TO THE PATIENT & HEALTH MAINTENANCE CHAPTER 1

2. PATIENT COMPLIANCE WHAT’S THE PROBLEM? • Compliance is difficult, and is a problem. • 50% fail • 1/3 never take their meds. • drop out prematurely. • Short-term compliance better • Long-term difficult • Compliance better with- • Medication taking • Not good with non medication advise

3. PATIENT COMPLIANCE HOW CAN WE HELP? 1) Define / agree on treatment goals. 2) Spell out the treatment plan. 3) Emphasize the importance of compliance, and the consequences of non-compliance. 4) During follow-up, ask detailed questions about how they are complying. 5) Educate, educate, educate!Tell them why you want them to do X 6) Enlist Family help 7) Set up mutually understood goals for compliance • “To cure sometimes, to relieve often, to comfort always. • “The secret of the care of the patient is in caring for the patient.”

4. National Commission Prevention Priorities • 2004 data: (<50% utilization) • Aspirin usage for prevention • Tobacco use screening and interventions • Immunizing children, older adults • Young women screens for chlaymydia

5. HEALTH MAINTENANCE & DISEASE PREVENTION • GENERAL. • PREVENTION OF INFECTIOUS DISEASE. • PREVENTION OF CARDIOVASCULAR DISEASE. • PREVENTION OF PHYSICAL INACTIVITY. • PREVENTION OF OBESITY / OVERWEIGHT. • CANCER PREVENTION. • PREVENTION OF INJURIES & VIOLENCE. • SUBSTANCE ABUSE.

6. HEALTH MAINTENANCE & DISEASE PREVENTION: 2009 GENERAL • ESTIMATED DEATHS FROM PREVENTABLE CAUSES: • TOBACCO- 467,000 • HGH BLOOD PRESSURE – 395,000 • POOR DIET- 216,000 • PHYSICAL INACTIVITY- 191,000 • HIGH BLOOD GLUCOSE- 190,000 • HIGH CHOLESTEROL - 113,000 • HIGH SALT DIET- 102,000 • HIGH TRANS FATS- 82,000 • LOW SEAFOOD- 84,000 • LOW FRUITS/VEGS- 58,000 • LOW PUFA- 15,000 • ACLOCHOL ABUSE- 64,000

7. CARDIOVASCULAR PREVENTION • Abdominal Aortic Aneurysm (AAA)-65-75 smoking males • Aspirin Use- • BP Screening • Serum lipid screening • Counseling healthy diet • Counseling to promote physical activity • Diabetes screening • Smoking cessation and quit

8. HEALTH MAINTENANCE & DISEASE PREVENTION GENERAL • The #1 cause of preventable death in the U.S. is from tobacco-related diseases. • Therefore, if you had to tell patients one thing they could do to improve their health and alter the age at which they die, and from what they die, it would be smoking cessation. • Of the 70% of smokers who see a physician each year, only 20% receive information on quitting. • Smokers whose physicians advise them to quit are 1.6 times more likely to attempt to quit. • See text pages for smoking cessation strategies, tricks, etc.

9. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF INFECTIOUS DISEASES • IMMUNIZATIONS- “Best means of preventing many infectious diseases.” • In the U.S., have nearly eradicated: measles, mumps, rubella, polio, diphtheria, pertussis, tetanus. • Still have work to do on: hepatitis A & B, influenza, pneumococcal infectious (50,000-70,000 deaths per year in the U.S.).

10. Last update:10/28/2007

11. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF CARDIOVASCULAR DISEASE • CIGARETTE SMOKING. • LIPID DISORDERS. • HYPERTENSION. • CHEMOPREVENTION.

12. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF CARDIOVASCULAR DISEASE MODIFIABLE RISK FACTORS: • 1) Smoking. • 2) Lipid disorders. • 3) Hypertension. • 4) Lifestyle / behavioral factors- activity level, diet, weight control, alcohol, etc. • 5) Diabetes. • 6) Type “A” personality, stress.

13. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF CARDIOVASCULAR DISEASE NON-MODIFIABLE RISK FACTORS: • 1) Gender. • 2) Age. • 3) Family history. • The good news is that many of the modifiable risk factors can be addresses by the same modifications: diet, exercise, weight control, etc., which happen to be the same things one would do to prevent physical inactivity and obesity.

14. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF PHYSICAL INACTIVITY • An “older” non-smoking male who walks at least 2 miles per day has a 50% reduction in cardiovascular mortality. • Relative risk of stroke is less than 1/6th that of those who are inactive. • Benefits are dose-dependent – there is a major difference between no exercise and mild- moderate exercise, but less difference between moderate and vigorous exercise. • Any activity is better than no activity. • Gym membership, fancy-schmancy equipment, organized sports not required; activity can be incorporated into anyone’s daily routine: stairs instead of elevator, park farther away from the office / H.E.B, etc. • Baby steps.

15. LIFESTYLE MODIFICATION DIET –OBESITY A risk factor for cancers of the: • Breast, colon & rectum, and lung, even in non-smokers. • Increased BMI* and hypertension associated w/ increased risk of renal cell carcinoma in men. • *BMI= body mass index kg/m2 • http://apps.usa.gov/bmi-app/ • 2007 Survey: 63% of Americans are overweight, with 26% now in the obese category (a BMI of 30 or more)

16. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF OBESITY & OVERWEIGHT • These data show an increase in the prevalence of obesity of 74% compared to 1991. • Obesity is associated with an increase in: type II diabetes, hypertension, cancer (lots of ‘em), osteoarthritis, cardiovascular disease, obstructive sleep apnea, and asthma. • With the rise in obesity since 1991, the prevalence of type II diabetes has increased 30-40%. • BMI > 40 associated with a death rate from cancer 52% higher for men and 62% higher for women compared to the non-obese.

17. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF OBESITY & OVERWEIGHT • Nine million are obese and also smoke • Obesity and smoking are primary risk factors for from early death from several chronic conditions • 5.3% of men and 4.2% of women are in the dual-risk subgroup (African Americans (7%) than among other racial or ethnic groups, and also among people in lower-income (6.5%) and low-education brackets (6.1%).)

18. http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid/index.htmlhttp://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid/index.html • Start with exercise. • Focus on food, not grams • Go with plants. • Cut way back on American staples. • Take a multivitamin, and maybe have drink.

19. HEALTH MAINTENANCE & DISEASE PREVENTION CANCER PREVENTION • Primary prevention. • Screening and early detection.

20. HEALTH MAINTENANCE & DISEASE PREVENTION CANCER PREVENTION: PRIMARY PREVENTION. • Smoking. • UV exposure. • Obesity- esp. of breast and colon. • Occupational- asbestos etc. • Not mentioned in your text is dietary, such as diets rich in fiber, Vitamins A, C, & E, and lower in sugars and fats are associated w/ a decreased risk of colon cancer. (ONLY Calcium and Aspirin!)

21. HEALTH MAINTENANCE & DISEASE PREVENTION SCREENING & EARLY DETECTION • See text, table 1-2, 1-9 for specifics. • High yield w/ screening for breast, colon, and uterine cervix. • Controversial for prostate.

22. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF OBESITY & OVERWEIGHT • “Weight management is simple, but it isn’t easy.” • It’s about the balance of calories consumed and calories burned. That’s the simple part. • It’s about permanent life-style, dietary, behavioral, and psychological changes. It’s not about “dieting”, magic bullets, supplements or any of that “burn fat while you sleep” stuff, which I can’t believe we let them get away with. That’s the part that isn’t easy. • Did I mention that these changes need to be permanent? As in for life, forever, and always.

23. HEALTH MAINTENANCE & DISEASE PREVENTION PREVENTION OF INJURIES & VIOLENCE • MVA’s- seat belts, helmets, etc. • Domestic violence- • Alcohol (again)- as it relates to MVA’s, domestic violence, suicide. • Prevention of falls in the elderly.

24. HEALTH MAINTENANCE & DISEASE PREVENTION SUBSTANCE ABUSE • Alcohol, prescription drugs, illegal drugs including inhalants. • “Clinician identification and counseling may improve the chances of recovery.”

25. COMPLEMENTARY & ALTERNATIVE MEDICINE

27. CAM • AN OVERVIEW. • HERBAL MEDICINES. • DIETARY SUPPLEMENTS. • ACUPUNCTURE. (see reading resource supplement f-MRI datasets)

28. WHAT IS CAM? ACCORDING TO THE NIH, IT IS: • “A group of diverse health care systems, practices, and products that are not PRESENTLY considered to be part of conventional medicine.” • Maybe what is considered to be conventional is in the eye of the beholder.

29. WHAT IS CAM? 5 MAJOR CATEGORIES • 1) BIOLOGICALLY BASED- substances found in nature- herbs, special diets, vitamins. • 2) ENERGY MEDICINE- Reiki, external Qigong, therapeutic touch. • 3) MANIPULATIVE / BODY-BASED- massage, chiropractic, etc. • 4) MIND-BODY- meditation, prayer, imagery, etc. • 5) WHOLE MEDICAL SYSTEMS- acupuncture, ayurveda, homeopathy, naturopathy, shaman, (Tibetan) traditional Oriental medicine,

30. FACTS AND FIGURES CDC NHIS SURVEY 2003 • 38% of American Adults used some form of CAM in the previous 12 months. • When prayer and megavitamins included → 68%. • Most popular therapy was prayer, 2nd were the “biologically-based therapies”: herbs, dietary supplements. • 1997- $36 billion, mostly out of pocket.

31. Prayer-Self, 43% Prayer by others, 24% Natural products 19 % Deep breathing exercises,12% Prayer group for own health, 10 % Meditation, 8% Chiropractic care, 8% Yoga, 5 % Massage, 5 % Diet-based therapies (such as Atkins, Pritikin, Ornish, and Zone diets), 4 %. 55 percent: use CAM combined with conventional medical treatments; 50 percent: CAM “interesting to try” 26 percent used CAM as prescribed by MD and 13 percent used CAM because conventional medicine was too expensive. CAM Usage

32. ?CAM Users • women • people with higher education • those who had been hospitalized within the past year • former smokers, compared to current smokers or those who had never smoked

33. FACTS AND FIGURES CDC NHIS SURVEY 2003 These patients used CAM therapies for: • Musculoskeletal complaints. • Colds. • Anxiety, depression. • GI problems. • Sleep disorders. Same as for most primary care practices.

34. FACTS AND FIGURES THE BAD NEWS • Only 12% sought CAM treatment advice from a licensed CAM practitioner. • The rest used CAM on their own. THE GOOD NEWS • The other 88% is your potential patient base. • CAM spending by public $47billion (1997) • Includes $20billion out of pocket spending

35. HERBAL MEDICINES FACTS & FIGURES • Used by 1 in 3 Americans. • $40 billion annually. • Fewer than half discuss the matter with a conventional health care provider. • Why is this? • What does it matter?

36. HERBAL MEDICINES REGULATORY ISSUES • DSHEA - 1994 – Dietary Supplement & Health Education Act. • Classified vitamins, minerals, herbs, and amino acids as dietary supplements, and allows for their marketing (and sale) as long as no claims are made for their use in the diagnosis, treatment, cure, or prevention of disease.

37. HERBAL MEDICINES REGULATORY ISSUES • DSHEA - 1994 – Dietary Supplement & Health Education Act. • Can make “structure and function” claims – supports urinary health, for example. • No need to show it is safe and effective, which is the standard required by the FDA of drugs.

38. ACUPUNCTURE • The NIH Consensus Conference on Acupuncture, 1993. • JAMA. 1998 Nov 4: 280(17): 1518-24. • Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AMK, Hochberg MC. Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee: A Randomized, Controlled Trial. Annals of Internal Medicine. 2004; 141(12):901-910.

39. NIH CONSENSUS • Promising results have emerged showing efficacy of acupuncture in: √nausea and vomiting: adult postoperative and chemotherapy related √ in postoperative dental pain √ addiction √ stroke rehabilitation √ headache √ menstrual cramps √ tennis elbow √ fibromyalgia, myofascial pain, √ osteoarthritis, low back pain, carpal tunnel syndrome √ asthma “Further research is likely to uncover additional areas where acupuncture interventions will be useful.”

40. COMPLICATIONS • “adverse events.” • Frequency estimated at between 1:10,000 - 1:100,000. • 14 year review of the world literature identified 193 complications (I suppose they meant “adverse events” also), another 30 year review identified 300.

41. Potential adverse events associated with acupuncture

42. Precautions for needling certain areas of the body

43. Risk factors for complications of acupuncture

44. COMPLICATIONS • Most frequent are vasovagal syncope and sedating reactions, drowsiness. • Cardiac Tamponade (Chest. 2000;117:1510-1511.) • If ya do it right, there shouldn’t be any cases of transmission of blood-borne infections. HOWEVER…… According to Memorial Sloan Kettering…. ▲ Pregnant women ▲ Patients with lymphedema ▲ Those wearing pacemakers, or ▲ Those with low platelet count should inform their practitioners before receiving treatment.

45. COMPLICATIONS • Can be reduce by Excellent Training!* • less than 1 year’s training resulted in 2.07 adverse events per year; • 37 to 48 months’ training reduced this to 1.35 adverse events per year; and • 49 to 60 months’ training reduced this further to 0.92 adverse events per year *Bensoussan A, Myers SP. Towards a safer choice. The practice of traditional Chinese medicine in Australia. Sydney, Australia: Macarthur; 1996.