8. Health Promotion - Richard Kent Zimmerman and Mary Patricia Nowalk
Reduction in risk for a variety of chronic diseases can be achieved through the adoption and maintenance of healthy lifestyles. Smoking, low levels of physical activity, excess body weight, and other conditions related to high-fat, calorically dense diets contribute to development or worsening of many forms of cancer, coronary heart disease (CHD), diabetes, osteoarthritis, gallbladder disease, sleep apnea, and hypertension (Fig. 8.1). An estimated 700,000 deaths (33%) in the United States in 1990 were attributable to tobacco use, dietary factors, and activity patterns.1 Health promotion practices by primary care physicians in the form of assessment, assistance with lifestyle change, and encouragement in general, are low cost in comparison to the benefit to patients.
It is estimated that 48 million adult Americans (25%) currently smoke.2 Approximately 3,000 young people become regular smokers each day, and the number of frequent smokers among high school students has increased to 16%.3 Demographic characteristics of persons more likely to smoke are male gender, socioeconomic status below poverty level, education level less than 13 years, and Native-American and Alaskan-Native ethnicity.4
Smoking has long been recognized as the single largest cause of preventable death in the United States, causing more than 430,000 deaths annually.5 Smoking contributes to morbidity and mortality both directly and indirectly. By-products of tobacco are among the most potent of human carcinogens and are linked to 30% of all cancer deaths annually, especially neoplasms of the lung, mouth and throat, pancreas, kidney, bladder, and uterine cervix.1 Smoking is responsible for 180,000 deaths due to cardiovascular disease and is related to respiratory illness such as bronchitis and emphysema, gastrointestinal disorders, and cerebrovascular disease. Smoking during pregnancy accounts for about one fifth of low birth weight neonates and about one twentieth of perinatal deaths.
Environmental tobacco smoke (ETS) contains over 4,000 chemical compounds, many of which are toxic and/or known carcinogens. ETS causes an estimated 3,000 deaths from lung cancer and 35,000 to 40,000 deaths from heart disease and a variety of respiratory problems among nonsmokers. Among children, ETS increases the risk of lower respiratory tract infections, resulting in 7,500 to 15,000 hospitalizations, exacerbation of asthma, and increased ear infections.2
In the United States alone, the financial burden of medical treatment for smoking-related diseases, lost productivity and earnings, and premature death total nearly $100 billion.3 In 1990 cigarette smoking resulted in 5 million estimated years of potential life lost prior to life expectancy.6
The health benefits of smoking cessation are immediate and profound. Within a half hour of quitting, blood pressure returns to precigarette levels. After only 1 day, the risk of heart attack decreases. Lung function improves by as much as 30% within 3 months.7 Smoking cessation reduces all-cause mortality as well as the risk of cancer, myocardial infarction, stroke, chronic obstructive pulmonary disease mortality, peripheral artery disease, and low birth weight.8 Although the risk of CHD death is reduced by 50% in 1 year, a 50% reduction in the risk of cancer requires approximately 10 years. Compared to women who smoke throughout pregnancy, those who stop by the 30th week of gestation have infants with higher birth weights and lower perinatal mortality.
Although many adults express interest in quitting, it is not easily achieved. Nicotine is the addictive drug in tobacco; however, other factors contribute to tobacco dependence. They include habit cued by daily activities, pleasure, and selfmedication to reduce negative affect and withdrawal symptoms.9Furthermore, nicotine produces euphoria similar to that from other addictive psychomotor stimulants and has addictive pharmacologic and behavioral properties that are similar to heroin and cocaine. Symptoms of nicotine withdrawal include depression, irritability, restlessness, headache, fatigue, increased appetite. Both the smoking habit and its associated activities, as well as nicotine withdrawal symptoms, make smoking cessation physically and psychologically difficult. Recidivism is high. Therefore, tobacco dependence is increasingly viewed as a chronic disease that requires ongoing assessment and intervention.
The U.S. Public Health Service has recently issued clinical practice guidelines for treating tobacco use and dependence.5 This comprehensive document challenges health care providers to treat tobacco dependence as a chronic disease and to recognize that effective treatments are available, and recommends health system changes that promote assessment and treatment and reimburse providers for their efforts. The guidelines recommend using the five A's: Ask about tobacco use, Advise to quit, Assess willingness to quit, Assist in quit attempt, and Arrange follow-up (Table 8.1). An algorithm is available to guide the process (Fig. 8.2). The primary interventions to reduce tobacco use are counseling, support, and pharmacotherapy.
All patients who are willing to attempt to quit should be provided with counseling. There is a strong dose-response relationship between the amount of counseling time provided and successful quitting.5Some of the topics that can be discussed are setting a plan for quitting, problem-solving skills, relapse prevention, obtaining social support, the availability of pharmacotherapy, and scheduling follow-up visits with the clinician to assist with cessation efforts. Telephone support, initiated either by the provider or by the patient, has also been recommended as part of a multicomponent smoking cessation program.10
It is now recommended that all patients without contraindications be offered pharmacotherapy such as bupropion or nicotine replacement therapy (Table 8.2). Clonidine and nortriptyline are second-line medications and may be considered if the aforementioned first-line medications are not effective. Information to guide choice of pharmacotherapy is given in Table 8.3.
A meta-analysis estimated the abstinence rate for bupropion SR at 30.5% compared to 17% for placebo (Table 8.2). Possible adverse effects include seizures, bronchospasm, and atrioventricular (AV) block. The dose is 150 mg orally for 3 days and then 150 mg twice a day for 7 to 12 weeks. In one study, the abstinence rates at 12 months were 15.6% in the placebo group, 16% in the nicotine-patch group, 30% in the bupropion group, and 35.5% in the group given both bupropion and the nicotine patch.11
Cessation rates at one year for counseling (4-9%) double for nicotine patches (9-25%).5 Similar rates are noted for nicotine gum (Table 8.2).12 Nicotine patches may cause skin irritation, dizziness, tachycardia, headache, nausea, vomiting. Nicotine gum can cause throat irritation, mouth ulcers, hiccups, nausea, and tachycardia. Side effects of nicotine nasal sprays are nasal and throat irritation, which generally subside after 1 to 2 weeks. Inhalers also cause coughing and throat irritation.
Weight gain is often a concern of smokers, yet research has shown that weight gain during quitting averages 10 pounds, with women gaining more weight than men. Because the health risks of smoking are more immediate and dangerous than the risks of modest weight gain, potential weight gain should not prevent attempts at smoking cessation. Many of the behavioral techniques used to quit smoking can later be modified and used to shape dietary behavior for weight loss.
Smokers who are unwilling to quit should be advised of the risks of continued smoking and the personal benefits of quitting. It is recommended that these issues be addressed at every visit,5 when feasible.
It is also important to prevent initiation of tobacco use. Most adults report that they started smoking as teenagers.2 Antitobacco messages should be given to children and young adults to reduce the chances that a person will begin smoking. A meta-analysis of behavioral impact of antitobacco messages showed that the best results occur from programs with a social reinforcement orientation.13 Using role playing and extended practice, such programs develop abilities to recognize social pressure, develop skills to resist it, and identify immediate social (bad breath) and physical (decreased athletic ability) consequences of tobacco use.
Tobacco dependence treatment during routine physician visits has been shown to be cost-effective and in fact has been called the "gold standard" for preventive medicine.5 The average cost per smoker of effective smoking cessation treatment is estimated to be $165.61.3 One early meta-analysis found that 5.8% more smokers remained abstinent in the intervention groups (counseling, literature, nicotine replacement therapy, or a combination) than the control groups after 1 year of follow-up.14 Although this effect may seem modest, the impact (effect size) when applied to the entire United States is large.
Several organizations have resources available for patients and clinicians, including the American Academy of Family Physicians (1-800-274-2237; www.aafp.org ![[Preview]](https://online.statref.com.ezp-prod1.hul.harvard.edu/Images/view12.gif)
), the National Cancer Institute (1-800-4CANCER; www.nci.nih.gov ), the American Lung Association (212-315-8700; www.lungusa.org), the American Cancer Society (1-800-ACS-2345; www.cancer.org ), and the U.S. Public Health Service (www.surgeongeneral.gov ), which recently released a clinical practice guideline on treating tobacco use and dependence.
), the National Cancer Institute (1-800-4CANCER; www.nci.nih.gov ), the American Lung Association (212-315-8700; www.lungusa.org), the American Cancer Society (1-800-ACS-2345; www.cancer.org ), and the U.S. Public Health Service (www.surgeongeneral.gov ), which recently released a clinical practice guideline on treating tobacco use and dependence.
A sedentary lifestyle increases the risk of mortality from all causes. A prospective cohort study revealed increases in all-cause mortality from 18.6 per 10,000 for the most fit men to 64 per 10,000 for the least-fit men.15 A similar increase was seen in women; the corresponding values were 8.5 and 39.5 per 10,000, respectively. Other data show that the relative risk (RR) of death from coronary heart disease is double (RR 1.9; 95% confidence interval 1.6-2.2) for sedentary versus active occupations.16 Overall, exercise can add up to 2 years of life and eliminate one third of the excess deaths due to coronary heart disease.
Other benefits of exercise include better mental health, lower risk of hip fracture, and lower risk of adult-onset diabetes mellitus (DM). In one cohort study, each 500-kcal increase in energy expended on leisure-time physical activity resulted in a 6% reduction in risk of developing DM.17 Despite the evidence about the benefits of exercise, more than half of the adults in the United States do not engage in regular physical activity.
Persons who start exercising at a moderate level (≥4.5 metabolic equivalents) have a 23% lower risk of death than those who do not exercise (95% confidence interval 4-42%).18 Furthermore, men who change their status from unfit to fit experience a 44% reduction in mortality.19 Each minute increase in maximal treadmill time results in a 7.9% decrease in mortality.19
Exercise improves cardiovascular fitness, lipoprotein profiles, insulin sensitivity, pulmonary physiology, and bone mass (Table 8.4). The most important change is improved myocardial oxygen balance, which occurs by improved blood supply to the heart, reduced heart rate, reduced blood pressure, and improved stroke volume. Improved fibrinolysis, decreased platelet aggregation, lower sensitivity to catecholamine, and decreased insulin resistance also contribute to the decrease in mortality and morbidity from coronary heart disease.
Moderate exercise has mental health benefits as well. In anxious sedentary adults, it increases aerobic fitness, decreases tension and anxiety, decreases depression, decreases confusion, and increases perceived coping ability.20 Moderate exercise has also been shown to reduce tension and anxiety in the general population21 (see Chapters 31 and 32).
Concerns about starting an exercise program include injury rates and potential impact on arthritis. In a study of elderly persons who were starting an exercise program, injury rates were 9% for strength training, 5% for walking, and 57% for jogging, although there was one person who discontinued exercising due to injury.22 Running has not been shown to accelerate the development of radiographic or clinical osteoarthritis of the knees.23 Thus, beginning an exercise program with more strenuous activities such as jogging may lead to an increased rate of injuries, especially in the elderly, but does not predispose to arthritis.
Cost-effectiveness data reveal that the cost for each quality-adjusted life year gained from physical activity is $11,313, which is similar to that from other interventions to prevent coronary heart disease.24
In one study, brief physician advice to patients about exercise resulted in increased duration but not frequency of exercise.25 Another study found that risk factor education and counseling in the primary care office increased regular exercise.26 Although exercise has been shown to increase longevity and physician advice may be effective, many physicians do not routinely incorporate the exercise counseling into their practices.
Experts from the American College of Sports Medicine (ACSM) and the Centers for Disease Control and Prevention (CDC) concluded that every adult should exercise for 30 minutes on most days of the week at a moderate intensity level of 3 to 6 metabolic equivalents (Met).27 Examples of activities at various Met levels are given in Table 8.5. The ACSM and CDC noted that because enjoyment of an activity is related to participation, moderate-intensity activities are more likely to be continued than high-intensity ones. Consequently, they recommended "30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week." They noted that the health benefits of physical activity accrue in proportion to the total amount of activity performed, measured as calories or minutes of activity. Furthermore, the daily 30 minutes of exercise can be accrued over shorter intervals, as three 10-minute bouts of exercise result in a significant increase in maximal oxygen uptake, although the increase was not as high as for 30 minutes of continuous exercise.28
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Persons with cardiac risk factors such as hypercholesterolemia, hypertension, diabetes mellitus, tobacco use, or a family history of heart disease may need an exercise stress test prior to beginning an exercise program. Persons of age 40 years or younger with two or more cardiac risk factors and persons of ages 41 years or older with one or more cardiac risk factors generally should have an exercise stress test prior to beginning an exercise program.
The exercise prescription should identify activity, frequency, duration, intensity, and program elements. These aspects of the exercise prescription should be individualized to the patient; activity, frequency, and duration have been discussed previously. Intensity is based on a set percentage of the maximal predicted heart rate (MPHR), which can be determined by the formula 220 - age (Table 8.6). Sedentary persons may start by achieving 60% of MPHR and gradually progress to higher percentages; 90% is the maximum recommended. Program elements should include warm-up for 5 minutes with stretching exercises, the activity itself, and a 2- to 3-minute cool-down period.
Good nutrition is essential throughout the life span to ensure proper growth and development, maintenance of health, recovery from acute illness, and prevention of chronic disease. In the United States, undernutrition resulting from inadequate food intake exists only in certain high-risk population groups. However, overnutrition and nutrient imbalances contributing to overweight, obesity, and a variety of chronic diseases are widespread among Americans. Unlike smoking or alcohol use, eating is a daily behavior that cannot be completely eliminated. Moreover, eating behavior is entwined with religious, cultural, and regional traditions that are not easily abandoned. Despite recommendations for healthful eating, taste and cost have been found to best predict food choices,30 and individuals will preferentially choose foods with which they are more familiar.31 This section addresses principles of good nutrition for maintenance of health and prevention of chronic diseases for the general population.
Caloric needs are determined by basal metabolic rate (BMR) and level of physical activity. BMR is highest during periods of growth and development, is proportional to the percentage lean body mass, and generally decreases with age. BMR accounts for approximately 80% of total caloric needs in sedentary persons and 60% for very active individuals. Table 8.7 shows recommended caloric intake for adults. Maintaining caloric intake near these levels will help adults prevent weight gain. A caloric excess of only 100 kcal/day will result in a 10-lb weight gain in 1 year. Therefore, it is essential to make routine adjustments in caloric intake or expenditure to maintain one's weight. To lose weight, it is necessary to reduce caloric intake below levels needed to maintain weight or to increase caloric needs through physical activity. In addition to increasing caloric expenditure, physical activity also helps to increase BMR among sedentary individuals and to offset the decrease in BMR that accompanies caloric restriction.
Dietary source of calories is just as important for prevention of chronic disease as is total intake of calories. High fat intake, especially saturated fat has been linked to CHD, colon cancer, and breast cancer. Reduction of total fat and saturated fat intakes has been shown to reduce blood cholesterol levels, and lower total and saturated fat intakes are associated with decreased risk of hyperlipidemia and CHD. Although total fat and saturated fat intakes have declined over the past 30 years, they are still above recommended levels, at 33% and 11%, respectively.32 Current guidelines recommend a maximum 30% of calories from all types of fat, with <10 10="" 2="" 300="" 50="" 60="" a="" and="" at="" be="" blood="" by="" calories="" carbohydrate="" carbohydrates="" chd.="" cholesterol="" class="tdsLink" day="" diet="" fat="" for="" from="" g.="" g="" guidelines="" heart="" high="" in="" individuals="" institute="" intake="" issued="" kcal="" lung="" mg="" more="" national="" of="" or="" protein.="" protein="" recent="" recommend="" risk="" saturated="" should="" the="" total="">33
Fat is the most calorically dense macronutrient providing 9 kcal/g, compared with about 4 kcal/g for both carbohydrates and protein. Nutrition fact labels on most foods provide consumers with the information needed to determine whether or how much of a given food is an appropriate choice.
A simple way to ensure that individuals eat a balanced diet is to base food choices on the Food Guide Pyramid (Fig. 8.3). The pyramid recommends 6 to 11 servings from the bread, cereal, rice, and pasta group, 3 to 5 servings from the vegetable group, 2 to 4 servings from both the milk, yogurt, and cheese group and the meat, poultry, fish, dry beans, eggs, and nuts group. Individuals with lower caloric needs should eat the smaller number of servings and those with higher caloric needs should eat the larger number of recommended servings. Within each food group there is a wide variety of foods available and selection of foods from all groups is encouraged.
Studies have shown inverse relationships between physical activity levels and intake of nutrients associated with chronic disease, i.e., fat, saturated fat, and cholesterol. More active individuals consumed more fiber, vitamins, calcium, and less total fat and saturated fat than sedentary individuals.34,35
The recently revised Dietary Guidelines for Americans36 address the interactions among diet, body weight, and physical activity by encouraging all Americans to make sensible food choices, be physically active on a daily basis, and achieve a healthy body weight. The Food Guide Pyramid is the daily food choice guide incorporated into the dietary guidelines.
Recent guidelines on the treatment of overweight and obesity37 have highlighted the need for comprehensive evaluation and treatment of a health condition that has reached epidemic proportions. There are an estimated 97 million Americans who are overweight or obese. Both conditions lead to increased risk of diabetes, hypertension, CHD, stroke, gallbladder disease, osteoarthritis, dyslipidemia, sleep apnea, and cancer of the colon, breast, prostate, and endometrium. All- cause mortality also increases with increasing body weight.37
Overweight is defined as body mass index (BMI) = 25-29.9 kg/m2; obese is BMI >30 kg/m2. To determine BMI using pounds and inches, BMI = [weight (lbs.) × 703] ÷ [height (in.) × height (in.)]. Alternatively, waist circumference can be used as a measurement of weight related risk. For men, waist circumference >40 inches (102 cm) and for women, waist circumference >35 inches (88 cm) are considered to be high risk. Among those who are overweight, goals for weight loss should be to (1) reduce body weight; (2) maintain a lower body weight over the long term; and (3) at a minimum, prevent further weight gain.
The role of the health care provider is to assess level of overweight and other risk factors, assess patient's readiness to attempt weight loss, assist patient in setting realistic goals, provide patient with behavioral techniques for achieving goals, and provide support and follow-up. An appropriate weight loss goal for most patients is 1 to 2 lbs/week, or a caloric deficit of 3500 to 7000 calories. Intake and increases in activity should reflect such a difference from baseline levels. Specific techniques to facilitate weight loss include selfmonitoring; realistic goal setting; making small changes; substituting lower calorie foods; increasing nutrient-dense, low-calorie foods; and increasing physical activity. Techniques used may vary from person to person. For patients with severe obesity or moderate obesity with comorbidities, pharmacotherapy or surgery may be considered.
Several other nutrients warrant special mention because of their association with a number of chronic diseases. These include calcium, fiber, vitamins, and other minerals. Calcium intake over the lifetime, but especially before age 30, is associated with peak bone mineral density and ultimately to the risk of osteoporosis. The greater the bone mineral density, the less susceptible bone is to breakage due to bone resorption that occurs with aging, but especially following menopause. Calcium intake of 1300 mg for adolescents and 1000 mg for adults,38 while not difficult to achieve, requires thoughtful food selection. Dairy products are the primary source of calcium; however, replacement of liquid milk by other beverages such as carbonated drinks, sport drinks, and coffee contributes to low average calcium intakes. Calcium fortification of such foods as orange juice, breakfast cereals, and other grain products should help to reverse this trend. Patients should be encouraged to choose calcium-fortified products if they do not regularly consume dairy products.
Fiber, though not a nutrient per se, is an essential part of a healthful diet, as it provides bulk, aids digestion and elimination, and may lower low-density lipoprotein levels. Dietary fiber, the nondigestible portion of plant foods, is found in whole grains, vegetables, and fruits that are consumed in a state as close to natural and as unrefined as possible. High-fiber diets are generally lower in total and saturated fat, and are associated with lower risk of CHD and several forms of cancer including colon cancer (also see Chapters 76 and 92).
Daily needs for vitamins and minerals can generally be met with consumption of a varied, balanced diet as delineated in the Food Guide Pyramid. For individuals whose intake is limited by choice or amount of foods, a multivitamin/mineral supplement is recommended. Most adolescent girls and premenopausal women should take an iron supplement, as it is difficult to meet the recommended daily intake (15 mg) from foods alone. Women intending to conceive should be aware of recommendations to increase folate consumption before conception; pregnant women should consume 600 ug folate per day. Many grain foods are also fortified with folate, along with other B vitamins. Several vitamins (fat soluble) and minerals (such as selenium) are dangerous in large amounts. Toxic levels of these nutrients can be attributed to use of high-dose, single-nutrient supplements.
Dietary supplements, herbals, botanicals, enzymes, and metabolites are part of a growing multibillion dollar business. Some of the reasons people are turning to such products are prevention or treatment of chronic disease, supplementation of poor diet, weight loss, and distrust or cost of approved pharmaceuticals. Yet most dietary supplements are not regulated by the Food and Drug Administration (FDA). The responsibility for identity, purity, quality, strength, and composition of dietary supplements is left to the manufacturer.39 It is important to assess patients' use of dietary supplements, as many supplements interact with medications or may influence diagnostic test results. Furthermore, some patients may delay treatment for certain conditions because they are using dietary supplements.
There are many resources available for clinician and patient reference regarding nutrition and weight loss issues, including the American Dietetic Association (800/366-1655), National City for Nutrition and Dietetics Information Line (www.eatright.org ), Food and Nutrition Board of the Institute of Medicine (www4.nas.edu/IOM/IOMhome.nsf), Food and Nutrition Information Center (www.nalusda.gov/fnic ), and the Food and Drug Administration (www.fda.gov ). The Practical Guide for the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults can be obtained from NHLBI at www.nhlbi.nih.gov .
), Food and Nutrition Board of the Institute of Medicine (www4.nas.edu/IOM/IOMhome.nsf), Food and Nutrition Information Center (www.nalusda.gov/fnic ), and the Food and Drug Administration (www.fda.gov ). The Practical Guide for the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults can be obtained from NHLBI at www.nhlbi.nih.gov .
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