Implementing Lifestyle Interventions: Where the Rubber Meets the Road Hour 1

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Implementing Lifestyle Interventions Where the
Rubber Meets the Road(Hour 1)

• Thomas L. Lenz, Pharm.D.
• Michael S. Monaghan, Pharm.D.
• Creighton University
• Eleventh Annual Prairie Health Ventures
• Membership Conference
• May 22, 2008
• Lincoln, Nebraska

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Objectives

• Explain the basic components of weight control,
  tobacco cessation and health behavior change
  strategies
• Apply the basic concepts of weight control,
  tobacco cessation and health behavior change
  strategies to sample case patients

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Weight Control
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Approximately 71 of women and 62 of men in
America are attempting to lose weight at any
given time.
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Body Mass Index (BMI)

• Normal 18.5 to 24.9 kg/m2
• Overweight 25 to 29.9 kg/m2
• Obese Class I 30 to 34.9 kg/m2
• Obese Class II 35 to 39.9 kg/m2
• Obese Class III gt40 kg/m2
• Also called Extreme Obesity

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Body Fat

• Essential body fat
• Males 3
• Females 12 to 15
• Storage body fat
• Male-type obesity (also called android-type
  obesity)
• accumulated in abdomen (deep visceral) due to
  over production of the hormone cortisol
• highly metabolically active and can easily
  mobilize
• Female-type obesity (also called gynoid-type
  obesity)
• accumulated in hips, buttocks, and thighs

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Girth Measurement

• Waist Circumference
• High Risk
• Men gt40 inches
• Women gt35 inches

Reference National Heart, Lung and Blood
Institute. http//www.nhlbi.nih.gov/guidelines/obe
sity/e_txtbk/txgd/4142.htm
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Weight Control

• Three phases
• 1. Cessation of weight gain
• 2. Weight loss
• 3. Weight maintenance
• Strategies for weight control
• Dietary therapy, physical activity, behavior
  therapy, pharmacotherapy, and surgery
• Combination therapy provides the best
  opportunity for weight loss and long-term weight
  control

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Weight Loss Recommendations

• 10 weight loss in 6 months
• Significant health benefits even if not at goal
  weight
• Rate of weight loss
• 0.5 to 2 pounds / week

Reference Clinical Guidelines on the
Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults. Bethesda, Md.
National Institutes of Health, U.S. Department of
Health and Human Services 1998. NIH Publication
No. 98-4083.
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Dietary Therapy and Weight Control

• Success is more dependent on dietary therapy for
  the weight loss phase than other strategies.
• Minimum calorie intake
• Men 1200 to 1600 kcal/day
• Women 1000 to 1200 kcal/day
• A diet that is individually design to create a
  deficit of 500 to 1000 kcal/day should be
  adequate to produce a 1 to 2 pound weight loss
  per week

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Keys to Success for Weight Loss

• 1. Educate the patient regarding the calorie
  value of foods and the food composition (i.e.,
  carbohydrates, fats, proteins)
• 2. Avoid overconsumption of high calorie foods
• 3. Reduce portion size
• 4. Maintain adequate water intake

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Keys to Success for Weight Maintenance

• 1. Make realistic changes to the eating plan
  that the patient can adhere to
• 2. Maintain a relatively consistent caloric
  intake on a daily basis
• 3. Incorporate a structured exercise regimen, as
  this has been shown to help maintain changes to
  the eating plan

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Physical Activity and Weight Control

• Similar to general exercise recommendations,
  however, many patients may need to begin at a
  lower intensity depending on current activity
  level.
• IMPORTANT physical activity duration should
  progress to 60 minutes or more per day
• Emphasize increasing the duration of the activity
  over the intensity

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Case Patient-Weight Control
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Nutritional Goals

• 10 weight loss in 6 months
• Current body weight 245 lbs
• Goal body weight 220 lbs
• Decrease caloric intake by 500 kcal/d
• Current caloric intake 3422 kcal/day
• Goal caloric intake 2922 kcal/day
• Expend approx. 1200 kcal/d initially with
  exercise
• Lose weight at a rate of approx. 1-2 lbs/wk

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Tobacco Cessation
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Smoking Cessation in Clinical Practice

• Rx for Change Clinician Assisted Tobacco
  Cessation
• http//rxforchange.ucsf.edu/

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Algorithm to Treat Tobacco Use
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Smokers Willing to Make a Quit Attempt
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Assisting in the Quit Attempt
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Smokers Unwilling to Make a Quit Attempt
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Case Patient-Tobacco Cessation
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Tobacco Cessation Goals

• ASK if LL currently smokes and if he has ever
  tried to make a quit attempt.
• ADVISE LL of the many risks associated with
  smoking and inform him of a program that is
  available to help him quit.
• ASSESS LLs willingness to make a quit attempt at
  this time.

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Tobacco Cessation Goals

• ASSIST LL in his quit attempt
• Set a quit date
• Suggest ways to avoid his triggers
• ARRANGE follow-up phone calls for encourage and
  trouble shooting

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Health Behavior Change
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Health Behavior Change

• World Health Organization estimates that
  adherence to long-term therapy for those with
  chronic disease averages only 50.

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Health Behavior Change

• Physical inactivity, unhealthy food consumption
  and smoking significant health behavior leading
  to CHD
• 75 of US adheres to recommendations not to
  smoke
• 25 of US adheres to physical activity
  recommendations
• 20 of US adheres to nutrition recommendations
  for fruit and vegetable intake
• 7.2 of US with CHD adheres to all three
• 5.1 of US without CHD adheres to all
  three
• Adherence is the rate limiting step to disease
  prevention!

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Barriers to Adherence
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Patient Related Strategies to Improve Adherence

• Patient-centered approach
• Trust building
• Communication
• Interest and empathy
• Active listening
• Log books
• Patient self-efficacy
• Modifying patient beliefs

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Program Related Strategies to Improve Adherence

• Simplicity
• Convenience
• Goal setting
• Enjoyable
• Variety
• Rewards and incentives
• Self-management
• Frequent contact

• Social support
• Cost and time of implementation
• Multidisciplinary approach
• Lead by example
• Evaluating adherence

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Case Patient-Health Behavior Change

• Assess readiness to change lifestyle behaviors
• Assess confidence to change lifestyle behaviors
• Identify patient specific barriers to
  implementing healthy behaviors
• Offer specific strategies to help the patient
  adhere to the program
• See handout for Hour 3 for examples

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Questions?