Maintenance of Health:Check In & Check Up

James B. Broadhurst, MD, MHA

25th Annual Public Sector Psychiatry Conference

June 17, 2009

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

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)

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)

Behavioral Therapy in Weight Loss

self-monitoring stress management stimulus control problem-solving contingency management cognitive restructuring social support

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

…self-efficacy - a patient’sreport 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.

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 Association69th Scientific Session, New Orleans, LA, 6/7/09

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

Look AHEAD at 4 years

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

DSE ILI

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?

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 DiabetesNEJM, 360:2503-2525, June 11, 2009

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

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

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

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

The Prevention Gold Standard

US Preventive Services Task Force

(USPSTF)

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

USPSTF Ratings 1Grade Definition Suggestions for Practice

A The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Offer/provide this service.

B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer/provide this service.

C The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.

Offer/provide this service only if other considerations support the offering or providing the service in an individual patient.

USPSTF Ratings 2D The USPSTF recommends against

the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I Statement The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

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.

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.

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.

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.

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.

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.

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= 0.831000-1499 mg/d RR= 0.66>/= 1500 mg/d RR = 0.55

p<0.001

Arch Intern Med 2009 169(5): 502

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.

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.

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

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

Number of New Non-Medical Users of Medications

NSDUH2002

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

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:

5921 60486398

8125

90669615

10829

3.2 3.3 3.4

4.3

4.75

5.5

3000

6000

9000

12000

1999 2000 2001 2002 2003 2004 2005

2

3

4

5

6

7

8

Deaths Age-Adjusted rate per 100,000 populationCDC National Center for Health Statistics

30 deaths per day by 2005

What Puts Me At Risk?

Smoking Diabetes High Blood Pressure High Cholesterol Physical Inactivity Overweight Family History

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.

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

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; 

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.

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.

True statements regarding the consumption of trans-fatty acids include which of the following?

1 2 3 4 5

0% 0% 0%0%0%

1. In the United States the main sources are meats and dairy products

2. They result in a rise in LDL-cholesterol and a reduction in HDL-cholesterol

3. They have been linked to vascular inflammation and elevation of C-reactive protein

4. Consumers can avoid them by consuming foods with zero trans-fatty acids listed on the nutrition label

5. Consumers should be advised to avoid foods containing hydrogenated oils

10

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

Saturatedfat

Cis - Unsaturatedfat

TransUnsaturated

fat

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

How to Lower Cholesterol

Follow a low saturated fat, low cholesterol diet

Be more physically active Lose weight if you are overweight

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.

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.

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.

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

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)

Aerobic Exercise 1

Group exercise was found to be superior to other group activities in treating older depressed patients already on similar pharmacotherapy (SOR B)

In a study of older men with established coronary heart disease, light and moderate levels of physical activity (e.g., walking, gardening, and recreational activity) were associated with a significant reduction in all-cause and cardiovascular mortality rates. The benefit was seen in men both younger and older than 65. Even those with chest pain or severe breathlessness achieved significant benefit from these lighter activities (SOR A)

Aerobic Exercise 2 The American Heart Association recommended target

heart rate range for adequate aerobic exercise intensity is 50%–75% of a patient’s maximum heart rate, or 75–113 beats/min for 70-year-old adults. The formula used to derive this range is 220 (maximum heart rate in young adults) minus patient age times 0.55–0.75 (SOR C)

Data from the Centers for Disease Control and Prevention indicate that about 28%–34% of adults aged 65–74 and 35%–44% of adults age 75 or older are inactive, meaning they engage in no leisure-time physical activity. Inactivity is more common in older people than in middle-aged men and women. Women were more likely than men to report no leisure-time activity (SOR C).

AHA Choose To Move Program

Manage stress and weight Feel better about yourself Aim for 30 min a day That is about 10,000 steps! Lowers your risk of heart disease Lowers your risk of stroke

Adding Steps! Take a walk with your spouse, child, or friend Walk the dog Use the stairs instead of the elevator Park farther from the store Better yet, walk to the store Get up to change the channel Window shop Plan a walking meeting Walk over to visit a neighbor Get outside to walk around the garden or do

a little weeding

What Haven’t I Talked About…

Vaccines Tdap Boostrix®, Adadel® HPV Gardasil® 9-26 Zoster Zostavax® >60 Pneumococcal Pneumovax® Influenza many brands

Relationships - intimacy Longevity – deathbed wish

Life in Primary Care in 2009

2009 Life as a “PCP”

Evidence based care Pay for performance Physician scorecards

GIC in Massachusetts Quality and Cost

Prescribing practices Carve outs – MH and SA

“Black box” thinking REACH OUT – COORDINATE CARE!

What About

Chocolate?

A study at Penn State University found that people who ate lots of chocolate had higher anti-oxidant levels in their blood and lower levels of LDL-cholesterol – the type that in implicated in hardening of the arteries

Cocoa seems to keep down the blood pressure of the Kuna Indians who live off the coast of Panama and eat lots of locally grown cocoa that is high in flavenoids.

At Brigham and Women’s Hospital in Boston, volunteers had less arterial stiffness after consuming 100 grams of good quality , plain chocolate. Researchers speculate that cocoa helps dilate blood vessels, improves kidney function, and lowers blood pressure.

At the University of California, volunteers ate 25 grams of semi-sweet chocolate. Two and six hours later, the platelets of the chocolate eating group took significantly longer to close an opening compared with those of a control group who ate bread.

Researchers concluded that eating small amounts of chocolate could have the same anti-clotting effect as aspirin and might reduce the risk of deep vein thrombosis when flying.

Thank You!

James.Broadhurst@umassmemorial.org

Question References - Obesity

Michigan Quality Improvement Consortium: Prevention and identification of childhood overweight. Michigan Quality Improvement Consortium, 2006.

Council on Sports Medicine and Fitness; Council on School Health: Active healthy living: Prevention of childhood obesity through increased physical activity. Pediatrics 2006;117(5):1834-1842.

Krebs NF, Jacobson MS, American Academy of Pediatrics Committee on Nutrition: Prevention of pediatric overweight and obesity. Pediatrics 2003;112(2):424-430.

NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults; North American Association for the Study of Obesity Practical Guide Development Committee: 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.

Question References – Falls Falls among older adults: An overview. Centers for Disease

Control and Prevention, 2007. Li F, Harmer P, Fisher KJ, et al: Tai chi and fall reductions

in older adults: A randomized controlled trial. J Gerontol A Biol Sci Med Sci 2005;60(2):187-194.

Verhagen AP, Immink M, van der Muelen A, et al: The efficacy of Tai Chi Chuan in older adults: A systematic review. Fam Pract 2004;21(1):107-113.

Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49(5):664-672.

Question References - Exercise Mather AS, Rodriguez C, Guthrie MF, et al: Effects of

exercise on depressive symptoms in older adults with poorly responsive depressive disorder: Randomised controlled trial. Br J Psychiatry 2002;180:411-415.

Wannamethee SG, Shaper AG, Walker M: Physical activity and mortality in older men with diagnosed coronary heart disease. Circulation 2000;102(12):1358-1363.

American Heart Association: Target heart rates. AHA recommendation.

Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention: Physical activity and older Americans: Benefits and strategies. 2002.

Health Maintenance Resources

What’s New in Preventive Services –AHRQ www.ahrq.gov/clinic/prevnew.htm

US Preventive Services Task Force – Home www.ahrq.gov/clinic/uspstfix.htm

USPDF Topic List www.ahrq.gov/clinic/uspstf/uspstopics.htm

Oral Health www.smilesforlife2.org/home.html