Nutrition and Wellness B Navigating Wellness In A ... · Nutrition and Wellness B Navigating Wellness In ... • Exercise effects most body systems • Skeletal muscle demand rises

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DOS Nurse Course 20121 DOS CME Course 20111 October 20101Confidential© Cleveland Clinic 2012

Nutrition and Wellness B

Navigating Wellness InA Dsymetabolic Culture

Damon M Boogaart, ND, MSN, RN, CNPFamily Nurse Practitioner

Department of Family MedicineInstitute of MedicineCleveland Clinic

• Syd returns for follow up 6 mo f/u

• On metformin - HgbA1c 5.9

• Vital signs– T 97.8°F, HR 78, R 20, BP 120/72

– Wt 222 lb (100 kg), Height 72 in (183 cm), BMI 29

• Central obesity– Waist circumference 38 in (96.52 cm)

• He tried multiple diets and has settled on a combination of Weight Watchers and with a DASH focus

• He wants to exercise more and asks for your guidance

Case Discussion

2 DOS Nurse Course 2012

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• 30% of Americans meet the minimal recommendations for physical activity

• >33 % of Americans report no physical activity at all

• Prevalence of obesity has more than doubled since 1990

• Deaths due to physical inactivity/poor diet may soon exceed tobacco use as the leading cause of preventable death (CDC, 2004)

Exercise Statistics


Benefits of Regular Physical Activity

• Reduces the risk of – Dying prematurely– Dying from heart disease– Stroke– Developing diabetes– Developing high blood pressure– Developing colon cancer

• Helps– Reduce BP in HTN– Control weight– Build and maintain healthy bones, muscles and joints– Older adults become stronger, less fall risk

• Promotes psychological well-being– Reduces feelings of depression and anxiety


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• Exercise effects most body systems

• Skeletal muscle demand rises quickly --up to 50x resting rate during heavy exercise.

• Cardiovascular and respiratory responses must adapt rapidly to meet these demands

• Disease in any of theses systems can effect the exercise response with subsequent effects on exercise tolerance.

Exercise Physiology

Exercise physiology; David M Systrom, MD, FRCPC UptoDate 2011


• Highest rate of O2 consumption attainable during maximal or exhaustive exercise

• Maximum O2 uptake attained during incremental bilateral leg exercise used to provide an overall assessment of exercise capacity

• If normal there is likely limited pathology in the musculoskeletal, metabolic, cardiovascular, and respiratory systems

• Increases with training and decreases with age

Exercise Capacity VO2 max

Wilmore JH and Costill DL. (2005) Physiology of Sport and Exercise: 3rd Edition. Champaign, IL: Human KineticsExercise physiology; David M Systrom, MD, FRCPC UptoDate 2011


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• 2 twitch types– Type I - red or slow fibers

–High oxidative capacity, fatigue-resistant, low-level endurance exercise

– Type II - white or fast fibers–High glycolytic capacity, recruited for short bursts of rapid, heavy work

• ATP Energy sources – Hydrolysis of adenosine triphosphate (ATP) results in muscular

contraction – Intracellular stores of ATP are small, must be continually

replenished

• Fatigue depends upon intensity and duration of exercise– Accumulation of metabolic byproducts– Depletion of high energy phosphates– Depletion of glycogen substrate

Skeletal Muscle



• Lactate threshold (LT)– Metabolic rate at which bypass the Krebs cycle and become

anaerobic

• LT occurs at > 40% of predicted VO2 max in normal individuals but earlier in exercise among patients with CV issues

• Exercise intensity must approach LT for optimal training effects to occur

• Endurance athlete will not reach LT until 80 – 90% of VO2max and usually competes at metabolic rate just below LT

Skeletal Muscle



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• Cardiac output– Increases during incremental exercise through changes in both

heart rate (HR) and stroke volume (SV).

• Maximal HR – Decreases as a function of age

– Maximal HR = 220 - age (in years)

• Systemic circulation– Blood flow during exercise is preferentially directed to working

muscle and away from less metabolically active tissues such as gut and kidney

• Pulmonary circulation– Normally receives >95 percent of the cardiac output and does so

with minimal resistance

Circulation



• Children and adolescents (aged 6–17)– ≥ 60 min. physical activity daily

– Most should be moderate to vigorous aerobic activity

– At least 3 days/wk should also involve muscle and bone-strengthening activity

• Adults 18–64 yo and > 65 yo– 150 min/wk of moderate-intensity, or 75 min of vigorous-intensity

aerobic activity, or equivalent combo in ≥10 min increments

– Muscle-strengthening activities that involve all major muscle groups performed on ≥ 2 days/wk

– Older adults - follow the adult guidelines as abilities allow

2008 Physical Activity Guidelines for Americans

http://www.health.gov/PAGuidelines/factsheetprof.aspx


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• Level of effort required to do an activity

• How physical activity affects HR and breathing.– Talk test for relative intensity

– Moderate-intensity activity - can talk but not sing

– Vigorous-intensity activity - can say a few words before pausing for breath.

• Target HR = 70-85% of max HR

• Several meds lower max HR, lower target HR zone– Beta blockers

– Anti-arrhythmic medications

– Calcium blockers and digoxin

– H-2 blockers

Exercise Intensity



• Moderate Intensity– Walking briskly (≥3 mph)– Water aerobics– Bicycling slower than 10 mph– Tennis (doubles)– Ballroom dancing– General gardening

• Vigorous Intensity– Race walking, jogging, or running– Swimming laps– Tennis (singles)– Aerobic dancing– Bicycling ≥10mph– Jumping rope– Heavy gardening (continuous digging or hoeing)– Hiking uphill or with a heavy backpack

Exercise Intensity Activities



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• 45 min vigorous exercise resulted in “burning” additional 190 cal over proceeding 14 hrs

• Total energy expenditure difference between rest days and exercise days is almost 750 calories

• Vigorous exercise creates a positive energy balance that may allow for better wt loss and wt regulation plans

• Exercising can help us feel full

• Exercise changes brain to help us make better food choices

• Exercise aids in inhibitory control

• Increased exercise and physical activity changes brain to help control eating

Exercise, Metabolism and Appetite

A 45-Minute Vigorous Exercise Session Increases Metabolic Rate for 14 HoursPublication Journal: Medicine & Science in Sports & Exercise, January 2011By Amy M. Knab; R. Andrew Shanely; Human Performance Laboratory, Appalachian State University, North Carolina Research Campus, Kannapolis, North CarolinaR. J. Joseph, M. Alonso-Alonso, D. S. Bond, A. Pascua-Leone, G. L. Blackburn. “The neurocognitive connection between physical activity and eating behavior.” Obesity Reviews, Volume 12, Issue 10, October 2011, Pages: 800–812.



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• The Grim Reaper’s preferred walking speed is 2 miles (about 3 km) per hour under working conditions

• Men in the study with walking speeds of 3 miles (about 5 km) per hour or greater had no contact with Death

• For those wishing to avoid their allotted fate, this would be the advised walking speed

Walk Faster To Avoid Death

DOS Nurse Course 201215

BMJ 2011;343:d7679; How fast does the Grim Reaper walk? Receiver operating characteristics curve analysis in healthy men aged 70 and overFiona F Stanaway, Danijela Gnjidic, Fiona M Blyth, David G Le Couteur, Vasi Naganathan, Louise Waite,Markus J Seibel,David J Handelsman, Philip N Sambrook, Robert G Cumming,

• Musculoskeletal injury most common risk of exercise

• Less common risks include arrhythmia, sudden cardiac arrest, and MI

• The benefits of exercise outweigh the potential risks

• Screening medical evaluation for coronary heart disease prior to starting exercise is not necessary for asymptomatic, low-risk patients

Exercise Risk



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• Syd is going to begin exercising more

• Do we need to screen him?– For what?

Case Discussion


Be Creative


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• American College of Cardiology/American Heart Association (ACC/AHA)– Screen those with DM or CHD

• American College of Physicians– No exercise tolerance tests routinely

• American Academy of Family Physicians– Public safety jobs screening

• American College of Sports Medicine– M>40; F>50; multiple CHD risks

• American Diabetes Association– Considered two groups as candidates for screening for CHD with stress

testing– Hx of CAD/PAD– ≥ 35yo sedentary lifestyle who plans to begin vigorous exercise program

Screening Before Exercise?

Screening for coronary heart disease; Frank G Yanowitz, MD Uptodate 2011


• www.myfitnesspal.com

• www.loseit.com

• runkeeper.com/running-app

• www.c25k.com

• www.gymgoal.com

• www.fitnessbuilder.com

Resources


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• Syd has dropped his weight to 210 lbs– Stopped metformin as diabetes has resolved

– Running 3-5 days a week 3 miles/day

– Maintained a low added sugar/salt diet

• With all of these positive changes he is still fatigued– Almost fell asleep while driving

– His wife says he snores

– Nocturia 3x QHS

Case Discussion


• Definition– Natural periodic suspension of consciousness during which the

powers of the body are restored

• Sleep affects every physical process in the human body. Hormone levels, metabolism, mood, pain perception, memory, overall sense of well-being are profoundly affected by sleep.

Sleep


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• Obstructive sleep apnea (OSA) is a potentially life-threatening disorder in which breathing is interrupted during sleep– Associated with possible structural changes

– Associated with episodes of in-effective breathing or shallow breaths, resulting in low PO2

– Chronic loud snoring.

– Frequent arousals resulting in ineffective sleep and chronic sleep deprivation

– Excessive daytime sleepiness

– Decreased life expectancy

Sleep Apnea Definition NIH


• OSA also occurs in children – Enlarged tonsils or adenoids

– Preschool-age

• Treatment for OSA– Behavioral therapy

– Use of continuous positive airway pressure (CPAP)

– Surgery to increase airway size

– Tonsil or adenoid removal usually gives 100% benefit in children

Sleep apnea


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• Diabetes

• Sudden cardiac death

• Obesity

• Mood disorders

• Sexual dysfunction in many cases

• Headaches

• High blood pressure

• Heart attacks

• Arrhythmia

• Stroke

OSA Associated Sequela


• Independent link between OSA and DM2– 77% of pts with DM2 had OSA

– Increase in Hgb A1C between 1.49 and 3.69%

Sleep Apnea Diabetes

CAROL TOUMA and SILVANA PANNAIN n Does lack of sleep cause diabetes? Cleveland Clinic Journal of Medicine 2011; 78(8):549-558; doi:10.3949/ccjm.78a.10165


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• Polysomnogram (PSG) - sleep study

• Gold standard diagnostic test for OSA and other sleep d/o

• During PSG, pt sleeps while connected to monitoring devices, technologist records physiologic variables

• There are no contraindications to PSG and few complications

• Variables assessed: – Sleep stages

– Respiratory effort

– Airflow

– O2 sat

– Electrocardiography

– Body position

– Limb movements

How To Test For Sleep Apnea


• Mild sleep apnea may be improved by wt loss or sleep position

• More severe sleep apnea requires CPAP: Continuous Positive Airway Pressure

• This is administered via nasal/face mask

• Barriers to CPAP– Pride – Access to a machine – Convenience – Portability of the machine

• Men are most resistant to screening and treatment– Relationship to sexual dysfunction

• Surgical management may be option– Managed by ENT

How To Treat Sleep Apnea


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CPAP


• Apnea - hypopnea index (AHI) – Index of sleep apnea severity – Combines apneas and hypopneas. – Must last ≥10 sec– Decrease in blood oxygenation

• Overall sleep apnea severity score – Number sleep disruptions – Degree of oxygen desaturation

• AHI = dividing the number of events by the total hours of sleep– 5-15/hr Mild– 15-30/hr Moderate– > 30/h Severe

• Primary snoring – Snoring without obstructive apnea– Frequent arousals from sleep– Gas exchange abnormalities – Usually considered benign

OSA Hypopnea Severity Scoring System: ASA


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• Symptoms include – Habitual snoring (may have short pauses, snorts, gasps) – Disturbed sleep– Daytime neurobehavioral problems– Daytime sleepiness is uncommon in young children

• Complications include – Neurocognitive impairment – Behavioral problems– Failure to thrive– Cor pulmonale

• Risk factors include – Adenotonsillar hypertrophy– Obesity – Craniofacial anomalies– Neuromuscular disorders

Pediatric Sleep Apnea AAP 2002 Guidelines


• History – Snoring– Labored breathing during sleep– Observed apnea– Restless sleep– Diaphoresis– Enuresis– Cyanosis– Excessive daytime sleepiness– Behavior or learning problems (attention-deficit/hyperactivity disorder)

• Physical Exam– Wakefulness is often normal. – Nonspecific findings related to adenotonsillar hypertrophy

– Mouth breathing, nasal obstruction during wakefulness, adenoidal facies, and hyponasal speech

History and Examination Pediatric Sleep Apnea


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Evaluation

• History and physical examination are poor at predicting OSA

• Screening techniques such as videotaping

• Nocturnal pulse oximetry

• Daytime nap polysomnography tend to be helpful if positive

Complication if untreated

• Systemic hypertension

• Pulmonary hypertension

• Poor growth/obese

Pediatric Evaluation and Complications of OSA


Surgical

• Tonsillectomy and Adenoidectomy

Mechanical

• Continuous Positive Airway Pressure (CPAP)

Environmental

• Avoidance of environmental tobacco smoke

• Avoidance of indoor pollutants

• Avoidance of indoor allergens

• Treatment of accompanying rhinitis

• Weight loss strategies

Treatment in Children


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Sleep Need


• Get up at the same time each day

• Do not lay in bed beyond usual amount of time

• Stop caffeine by 12 pm

• Avoid ETOH, tobacco, and stimulants

• No daytime naps

• Exercise daily- 20 min 4 to 5 hours before bedtime

• Hot bath soaks before bedtime (want to raise body temperature)

• Eat at regular times. Avoid large evening meals.

• Practice relaxation routines

• Maintain comfortable bedroom conditions

• Deal with your worries before bedtime

Sleep Hygiene


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• www.aasmnet.org

• healthysleep.med.harvard.edu/sleep-apnea

• www.sleepfoundation.org

• www.entnet.org

Resources


• Syd is now sleeping better with the aid of a CPAP.

• He does not like it but he is much more productive at work and is less irritable at home.

• He was promoted at work and feels it was in part related to better sleep

• As part of his new job he will be traveling and he needs your help to make sure his travels are safe

Case Discussion


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• Be proactive

• Do your homework. – What you will need to know

– What you will need to bring

– What to expect to make your trip safe and successful

• Find out about the local laws and customs

• Check CDC and DOS websites for recommendations on vaccinations, health warnings, travel notices per country

• Take the phone number and address of the American Embassy or Consulate nearest your destination

3 P’s of Travel: Proactive, Prepared, Protected

http://wwwnc.cdc.gov/travel


• Be prepared!

• Plan ahead for potential illness/injury

• Pack smart

• Plan ahead for illnesses or injuries during your trip– Take sufficient medications, labeled and may need a letter from your

provider, do not put in checked luggage.

• Know what to do if you become sick or injured on your trip

• Know and share important information about your trip with someone else

• Bring multiple copies of all documents, such as passports, vaccination records, prescriptions, and identification cards– Pack one copy in your suitcase – Be sure to leave another copy with a close friend or relative

3 P’s of Travel: Proactive, Prepared, Protected



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• Be protected!

• Practice healthy behaviors during your trip and when you return home

• Pay attention to your health during your trip– Use sunscreen and insect repellent as directed– Be careful about food and water– Do not take risks with your health and safety– Look both ways before crossing the street– Limit alcohol intake, and do not drink and drive– Wear a seatbelt– Wear protective gear when doing adventure activities– Respect host country and people by following local laws and customs– Be aware of potential for altitude sickness

• Pay attention to your health when you come home.

3 P’s Of Travel: Proactive, Prepared, Protected



• Don’t drink tap water in a developing country

• No ice

• Boiled water/drinks are usually safe

• Alcohol (beer, wine) is usually safe

• Carbonated bottled water or sodas are usually safe

• Uncarbonated bottled water may be safe, may be filled from local tap

• Iodine tablets or water filters for camping

• Foods that you peel yourself (bananas) are safe

• Hot, well-cooked foods are usually safe- ? avoid street vendors

• Avoid undercooked meat and seafood

• Foods washed in contaminated water may have a residue of bacteria

Travel Habits Food and Drinking



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• Sitting for long periods of time could put you at higher risk especially if you have additional risk factors– Surgery -- Restricted Mobility

– Congestive Heart Failure -- Cancer

– Respiratory Failure -- Infectious Disease

– Age > 40 -- Overweight/Obesity

– Smoking -- Prior or family history of venous thromboembolism (VTE)

• If traveling for more than four hours you should– Get up and move around every two to three hours

– Keep hydrated and drink plenty of water

– Reduce alcohol or caffeine consumption

– Avoid crossing legs for long periods

Travel Habits DVT prevention

lhttp://www.preventdvt.org/assessment/dvt-risk-assessment.aspx


Travel Habits DVT --Qthrombosis•About you •Age (25-84)•Sex•Smoking status•Do you have any of the following (check all that apply)•Varicose veins•Chronic renal disease•Cancer•Heart Failure•Chronic Obstructive Airways Disease•Crohn’s or Ulcerative Colitis•Admitted to hospital in last 6 months•Are you taking any of the following (check all that apply)•Antipsychotics•Hormone Replacement Therapy (HRT)•Oral contraceptive•Tamoxifen•Height (cm)•Weight (kg)


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Travel Habits DVT --Qthrombosis


• Going West is easier than going East

• Readjustment occurs 1 hr/day when traveling eastward

• Readjustment occurs at 1.5 hr/day while traveling westward

• Jet lag takes days to subside, roughly equal to two-thirds of the number of time zones crossed

• Travelers who remain on home-based hours are less sleepy than those who adopt local sleep hours

• People traveling east would do better by avoiding light exposure on arrival, either by remaining in darkness in the hotel room, or by wearing dark sunglasses when outdoors. Wearing sunglasses during transit to the hotel also helps avoid light exposure.

Jet Lag

BHANU P. KOLLA and R. ROBERT AUGER : Jet lag and shift work sleep disorders: How to help reset the internal clock

Cleveland Clinic Journal of Medicine 2011; 78(10):675-684; doi:10.3949/ccjm.78a.10083


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• Most field studies have found that nightly doses of melatonin (2–8 mg) improve the quality of sleep or alleviate daytime symptoms of jet lag, or both.

• Preflight melatonin has been studied – beginning up to 3 days before departure at clock hours corresponding

to the nocturnal sleep period at the travel destination (consistent times daily), and then for a subsequent 3 to 4 days between a destination time of 22:00 and 00:00 hours (i.e., at bedtime).

• Several other studies further simplified this regimen, with participants taking nocturnal melatonin only on arrival at the destination, either for eastward or for westward travel.

• Melatonin is a nutritional supplement and is not regulated by the United States Food and Drug Administration (FDA), purity may be questionable.

• Short-term use of melatonin in total daily doses of 10 mg or less in healthy adults appears to be safe.

Jet Lag




• Side effects of melatonin– Daytime sleepiness, dizziness, headache, and loss of appetite,

"Heavy head," disorientation, nausea, and unspecified GI problems

• Potential interactions with warfarin and antiepileptics reported but not studied

• Avoid ETOH with melatonin

• Use of hypnotics is common but not evidence-based

• Caffeine has more nocturnal sleep complaints

• Recent trial armodafinil (Nuvigil) found less sleepiness and decrease in jet leg symptoms with a dosage of 150 mg than with placebo

Jet Lag




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• Melatonin for jet lag in children has not been studied

• Melatonin 2-3 mg about 30 min before bed on day of travel when traveling eastward; travelers may take melatonin 30 min before local bedtime for 4 days after arrival

• Hypnotics can help but possible unpleasant effects, some of which are common

Jet Lag




• Travelers should use eating, exercise, sightseeing and exposure to light to try to synchronize their body rhythms with those of the new environment

• Adult travelers crossing five or more time zones are likely to benefit from melatonin, especially if they have prior experience with jet lag

• Travelers crossing two to four time zones may also try melatonin

• Pharmaceutical quality of melatonin not regulated in many countries- buy from a trustworthy source- GMP

Jet Lag Summary




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• CDC website is your best resource

• CDC’s Yellow book is great back up for spotty internet connectivity

• www.preventdvt.org/assessment/dvt-risk-assessment.aspx

Resources


DOS Nurse Course 201252 DOS CME Course 201152

Documents

Nutrition and Wellness B Navigating Wellness In A ... · Nutrition and Wellness B Navigating Wellness In ... • Exercise effects most body systems • Skeletal muscle demand rises