3: Key Clinical Processes in LM

Question 1

LM Vital Signs

What are the 4 validated dietary assessments?

Answer 1

Starting the Conversation (8-items)
Mediterranean Diet Adherence (MEDAS)
ASA24 - NCI
DHQ - National Cancer Institute (NCI)

Question 2

PA vital sign
its an aspect of daily total energy expenditure (TEE)
which people have control. rest and thermic effect from food can change with increased muscle mass or types of food buy may longer to see or have a smaller impact.

Answer 2

TEE= Resting energy expenditure+ PA+ Diet induced Thermogenesis
TEE= 60-75% of TEE+15->30% of TEE+10% of TEE

Question 3

LM Vital Signs

What are the two items in the PAVS assessment?

Answer 3

1. how many days a week do you engage in moderate to strenuous exercise such as brisk walking.

2.on average how many minutes per day do you exercise at this level.

sufficiently active = 150 minutes or more per week

Question 4

advantages of strength

question to ask: how many days a week do you engage in strength training or resistance exercises?

Answer 4

training increase resting energy expenditure

improves activities of daily living, reduce the risk of falls especially in elderly.

Question 5

diet vital sign
based on US department of agriculture dietary guidelines for Americans 2020-2025. Its better to assess for whole foods or eating patterns rather than isolated nutrients. looking at specific nutrients is complicated and misleading

Answer 5

Question to ask: how many serving s of Veg do you have in a day? repeat the question with Fruit, Whole grains, Beans, Legumes, nuts, seeds, herbs and spices then low fat diary products.

Question 6

typical shortfall nutrients are

Answer 6

Vitamin A,D, E, C, folate, calcium, magnesium, Fiber and potassium they are found in veg fruit, whole grains, beans, legumes and low fat diary products.

Question 7

National institute of health had validated tools.

Answer 7

A
1.dietary screener questionnaire in the National health and nutritional examination survey (NHANES)
2.Dietary screener in National Health Interview Survey (NHIS) Cancer control Survey (CCS)
3. Dietary screeners in the California health interview survey (CHIS)
4.Fruit and vegetables intake screeners in Eating at Americas Table Study (EATS)
5. Percentage of energy from fat screener.
6.Multifactor screener in observing protein and energy nutrition (OPEN) study.
B
The Mediterranean DASH diet intervention for neurodegenerative delay (MIND) diet score is a dietary screening tool. A positive score is associated with slower decline in global cognitive score, but findings needs to replicate in an intervention trial.
C.
The SOS free ( Salt/oil/sugar free) diet screener from T Colin Campbell centre for nutrition studies
Food included: vegetables 10-30 + servings per day
fruit 4-10+ servings per day, Whole grains 0-10+ servings per day, Legumes 0-5+ servings per day, Nuts and seeds 1 ounce per day.
food not included: animal products, added sugar, salt and oil, refined grains, other processed foods.
D.
A short form food frequency questionnaire (SFFFQ) for primary care patient but didnt show significant agreement with a 24 hours telephone based diet recall.

Question 8

Perceived stress scale assessment

Answer 8

10 item questionnaire scale 0- never to 4- very often over the last one month
1. upset because of something happened unexpectedly.
2. unable to control the important things in your life.
3.Felt nervous and stressed.
4. Felt confident about your ability to handle your personal problems.
5. felt that things were going your way.
6.could not cope with the things that you had to do.
7.able to control irritations in your life
8.felt that you were on top of things.
9.angered because of things that happened that were outside of your control.
10. felt that difficulties were pilling up so high that you could not overcome them.
Negatively phrased questions: 1,2,3,6,9,10
never =0
almost never=1
sometimes=2
fairly often=3
very often=4
Positively Phrased: 4,5,7,8
Never=4
almost never=3
sometimes =2
fairly often=1
very often=0
higher the score more perceived stress one is under.

Question 9

The Dundee stress state questionnaire is a short stress state questionnaire

Answer 9

24 item assessing 3 aspects: task engagement, distress, worry

Question 10

Sleep Vital sign

Answer 10

mini sleep assessment ask
1.typical weekend hours of sleep
2.typical weekend hours of sleep
3.perceived sleep quality
Epworth sleepiness scale (ESS) 8 question assessment for daytime sleepiness. high scores consistent with moderate to severe excessive day time sleepiness.

Question 11

Emotional well being vital sign

Answer 11

ask scale 1= lowest to 5= highest
1.in most ways my life is close to my ideal
2.i am satisfied with my life.
these two questions are from satisfied with life scale (SWLS) total 5 questions.
older age, higher education and higher income associated with greater subjective well being.

lower satisfaction= not being white, black and hispanic, lowest level of education and lower household income.

Question 12

Tobacco use vital sign

Answer 12

current, past or never used.

cigarettes cigars, chew and e cigarettes amount and years

Question 13

Alcohol consumption vital sign

Answer 13

screen at every visit if regular drinker otherwise annually.
AUDIT-C The Alcohol Use disorders Identification Test-Concise 3 items 0= never low number of occurrences to 4=often high number of occurrences.
1. how often do you have drink containing alcohol.
2.how many drinks containing alcohol do you have on a typical day when you’re drinking?
3. how often do you have six or more drinks on one occasion?

Question 14

BMI vital Sign

Answer 14

BMI= weight in Kg/ (height in metres)2

imperial (weight in pounds/ (height in inches)2) x703

Question 15

underweight <18.5
normal 18.5-24.9  (18-22 lowest risk)
overweight 25-29.9
obese
class 1 30-34.9
class 2 35-39.9
class 3 >= 40

Answer 15

asians 18.5-22.9= normal
23-24.9= overweight
>=25 =obese

Question 16

Risk Factor Measurement

Answer 16

1 Screening tools are helpful to start early discussion of lifestyle factors/intervention.
2. CVD
1.life’s simple 7 questionnaire
2.ASCVD ( Atherosclerotic CVD) risk estimator plus by the American college of cardiology.
*the assessment indicates the patient’s risk of MI in the next 10 years.
*20-79 years age without heart disease
* non hispanic white and african americans
underestimate risk = in American indian, some asian american of south asian ancestary and some hispanic ( Puerto ricans)
overestimate risk in = Asian americans of east asian ancestary and some hispanics ( Mexican Americans)
* age, gender, total cholesterol, HDL-C, LDL-C, Smoking status, Diabetes history, Treatment for HT, such as use of aspirin and or statin therapy.
* low risk, borderline risk, intermediate risk and high risk

Question 17

2015 MESA ( multi ethnic study of atherosclerosis) look at coronary calcium score

Answer 17

10 year coronary heart disease risk in multiethnic study

39% non hispanic whites, 12% chinese americans, 28% african americans 22% hispanic americans.

Question 18

Reynolds risk score for women

Answer 18

considers family history and high sensitivity CRP which predicts risk of global CVD.

Question 19

LM physical evaluation and examination

Answer 19

1. Waist circumference
2. Waist/Hip ratio
3. Bioimpedence analysis
4. pulse
5. BP
6. Measure of fitness
7. Fitness testing options.

Question 20

waist circumference

Answer 20

increased risk of diabetes, HT and CVD relative to increased weight and waist circumference
waist circumference is increase if
>=40 inches or >=102cm in men
>=35 inches or >=88cm in women

Question 21

waist/hip ratio

Answer 21

<=0.90 for men

<=0.85 for women

Question 22

BP

Answer 22

*AHA/ ACC 2017
normal BP <120/80
Elevated BP systolic 120-129/<80
stage 1 - 130-139/80-89
stage 2- >= 140/>=90
*high mortality from heart disease, stroke and other vascular disease.
high morbidity from CVD incidence, angina, MI, Heart failure, stroke, PVD and AAA
* prevalence of HT increases with age 42
more than 50% on adult over 60 have HT
*screen for HT at each periodic visit every 6-12 months.
* 2 mm Hg reduction= stroke 6% coronary heart disease 4% total 3%
3= 8,5,4
5= 14,9,7

Question 23

Screening and diagnostic tests in LM

Answer 23

U&ES LFTs Blood Glucose, Blood proteins, Acid base balance, FBC Fasting lipids ( TC, HDL-C, LDL-C, TG, High sensitivity CRP). HbA1c, OGTT, Fasting serum insulin, possibly c peptide, Homeostatic model assessment for insulin resistance ( HOMA-IR) Vitamin D, TFTs.

Question 24

If the TC is <150mg/dl or 3.879 mmol/L the risk of heart disease is low.
LDL-c Friedewald equation LDL=TC-HDL- (TG*2) not validated if TG is >400 ( 4.516mmol/L)

Answer 24

particle size has been shown to help stratify risk. particle density alone doesnt completely describe the role and function of cholesterol fractions.

TG elevation is often associated with low HDL and increase girth waist circumference.

Question 25

C peptide is used to assess endogenous insulin production in order to identify how well b-cell are functioning to meet demands of insulin production. its used to determine if patient has type 1 or type2 DM.

Answer 25

HOMA-IR is an estimate of insulin sensitivity and beta cell function based on the fasting plasma glucose concentration, fasting plasma insulin or c peptide measurements.

Question 26

lab testing for diabetes based on evidence based national guidelines.
Diabetes

Answer 26

HbA1c of >6.5% but this diagnose 1/3 fewer cases of undiagnosed diabetes then looking at fasting plasma glucose test
Fasting serum glucose >126mg/dl or 7 mmol/L
2 hours postprandial glucose of >=200mg/dl ( 11.1mmol/L) during in OGTT

Question 27

Prediabetes

Answer 27

fasting serum glucose of >= 100 mg/dl (5.6mmol/L)but <126 mg/dl (<7 mmol/L)
2 hours serum glucose in the 75gm OGTT of 140-199mg/dl (7.8-11 mmol/L)
HbA1c 5.7-6.4%

Question 28

test diabetes in all who are overweight or obese BMI >25with any of the additional risk factors below
1. Physical inactivity
2. first degree relative with type 2 DM
3.asian americans, black, latino, native americans or pacific islanders
4.wome who delivered a baby >9 pounds or 4.1 kg or received a diagnosis of gestational diabetes.
5.HT bp >140/90 or on HT meds.
6.women with PCOS.
7.prediabetes.
8.signs of insulin resistance acanthosis nigricans.
9h/o CVD

Answer 28

if no risk factors begin screen at 45 years and then 3 yearly

Question 29

office systems and tools
screening frequency, test results and follow ups.
frequency of reporting
HEDIS reported once a year.
LM changes are tracked more frequently.
If the patient is enrolled on ITLC program lab work and tests are collected 1-4 weeks into program.
timeline for collecting LM measurements: before the start of the lifestyle changes, 2-4 weeks into making changes then 3 ,6,12 monthly to show sustainability.

Answer 29

Healthcare effectiveness data and information set. HEDIS most widely used healthcare improvement tool.
HEDIS rates health plans, programs and providers on their quality and public can review the rating online.
In LM tracking is essential for patient care, treatment analysis and reimbursement and follow up.
EMR electronic medical records. can often helpful in traking metrics and high risk patient. it is improtant to know what EMR is traking and how the info is stored, maintained and if automatic prompts are possible.

Question 30

collaborate with inegrative medicine professionals.

Answer 30

Acupunctures and oriental medicine 2-4 years training
National certification commission for acupuncture and oriental medicine NCCAOM

chripractice DC- 4 years training
federation of chiropractic licensing boards. FCLB

Midwifery CPM, variable training
North American Registry of midwives

massage therapy, 500-1000 hours training
National certification board for Therapeutic massage and bodywork NCBTMB

naturopathic medicine 4 year training
North American Board of Naturopathic examiners NABNE

Question 31

7 online referral resources for nutrition and exercise

Answer 31

Academy of nutrition and dietetics
National association of nutrition professionals.
American colleage of sports medicine ( registered clinical exercise physiologist, certified clinical exercise physiologist, certified perosnal trainer)
US registry of exercise professionals.
Certified Medical fitness Facility
personal trainer directory
The Yale Griffin Prevention research centre tips for Chronic disease prevention.

Question 32

10 characteristics of inter-disciplinary team

Answer 32

1. positive leaderships and management attributes.
2. communication strategies and structures.
3. Personal rewards, training and development.
4. Appropriate resources and procedures.
5. appropriate skill mix.
6. supportive team climate.
7. individual characterisitics that support interdisciplinary teamwork.
8. clarity of vision
9. quality and outcomes of care.
10. respecting and understanding roles.

Question 33

Resources that support healthy lifestyles/ lifestyle change that are available nationally.

Answer 33

1. National diabetes education program
2. Centre for disease control and prevention National diabetes prevention program.
3. California smokers helpline.
4. american heart association
5. Million heart initiative.
6. Human services referrals and information
7. state or area agency on aging
8. Classes and educational resources offered by local health systems, hospitals and public health departments.
9. local parks and recreation classes and services.
10. senior centre services.

Question 34

What are 6 benefits of GROUP VISITS?
(includes shared medical appts, drop-in group)

Answer 34

1. improved access to care
2. increased patient adherance, satisfaction, lower hospiltalization rates, higher trust in providers, improved access for complex and elderly patient, better monitoring, received greater education from group discussions and peer support, improved access, gain additional choices in their care treatment options) and
3. provider satisfaction (more efficient use of time, enhances quality, outocomes patients’ health experiences while containing cost and improving income, something different interesting and fun, reduces repitition allows more time and more frequent contact with patients, Group support and collaborative care is helpful in managing difficult, time consuming and psychologically needy patients)
4. reduce cost. among uncontrolled type 2DM patients group visits reduce total health care expenditure cost by ~30%
5. group visits also increases physician’s productivity.
6. billiable when billing criteria are met.

Question 35

evidence collaborative and chronic care model on improved lifestyle outcomes and use of allied health professionals.

Answer 35

Interdisciplinary team is associated with

1. hgh level of treatment compliance
2. improved health outcomes.
3. enhanced patient engagement and chronic disease self management.
4. enhanced weight loss after one year compared to standard care when provider or dietitian and dietitian/dietitian bth provided educational interventions

Question 36

What are 4 modes of collaborative and chronic care models their associated improved lifestyle outcomes ?

Answer 36

Interdisciplinary team is associated with

1. hgh level of treatment compliance
2. improved health outcomes.
3. enhanced patient engagement and chronic disease self management.
4. enhanced weight loss after one year compared to standard care when provider or dietitian and dietitian/dietitian bth provided educational interventions

Healthy eating activites and lifestlye programs are associated with

1. weight reduction
2. improved in BP and PA parameters
3. Maintained behaviour change at 5 months after the program’s completion.

Training Lay healht educator is associated with improved implentation of lifestlye intervention in rural senour centres.

life style modification in primary care.
acceptance and referral to a collaborative or chronic care program from a primary care practice needs regular communications, follow ups to be easy and make sure doesnt take much of primary care time. Primary care nurse help with that.

Question 37

Examples of team implementation from chronic care model.

Answer 37

1. Ornish spectrum program
   2.Medical fitness collaboration
   1.Ornish: intensive cardiac rehad program
   Team:
   registered nurse:education, biometric assessments, continuity of care, follow up of chrnoci conditions.

Exercise physiologist: Physical activity rediness questionnaire assessment, individual and group exercise supervision. biometric assessment, fitness safety and principles presentation.

health coach: consistent source of social support throughout change

stress management specialist: mid body techniques, group facilitation and support, participation in group and individual fitness instriction.

registered dietitian: recipe referral, nutrition counselling individually and group presentation on nutrition guidelines.

chef and food services: training in food selection and prep, removes barriers on healthy eating.

group support specialist.focus on lifestyle impact of intervention, facilitating dyanamic and group growth.

administration and medical assistant.
Marketing director.

2 Medical fitness collaboration.
medically supervised inegrated outcomes and accountability based fitness program: active and regular medical oversight, qualified and crednetial staff. disease management and clinical integration of pragrams. individual exercise prescriptions. help transition from structured clinical treatment setting to community or home based exercise program. helpful for patient who need medical oversight and counselling

Question 38

chronic care model components and implementation

Answer 38

1. innovative care for chronic conditions (ICCC). report by the WHO at Micro level: patient and family
   meso level: health care organisation and community,
   Macro level: policy
   2.Collaborative care model by the agency for healthcare research and quality (AHRQ) patient. nurse practitioner/ physician assistant, clinical expert, resident, interdisciplinary care team. they coordinate and facilitate patient care.
2. Value based care: financial incentives for accountable care organisations.
   4.Chronic care model created by MacCall institute and Ed Wagner: helpful in explaining the involvement of the community and health care system in chronic disease care. they must work with local community: local gyms, politicians, community centres, oraganisations and faither systems.
3. implementing ch care model
   6.the US deptt of veterans affairs hospital system comprehensive multisite model of care called ‘whole health model’ of care.

Question 39

guidelines for implementing Chronic care model

Answer 39

1. implementing the chronic care model into the a local medical practice.
2. health care delivery support
3. self management support
4. delivery system design
5. decision support
6. clinical information system.

Question 40

primary care and office based models for lifestyle modification such as
PRESCRIPTION FOR HEALTH Model

Answer 40

• funded by Robert wood Johnson foundation in collaboration with the agency for healthcare research and quality (AHRQ)
• 22 primary care based research network (PBRNs) that developed, piloted and evaluated 27 evidence based strategies to improve delivery and effectiveness of healthcare behaviour in the field of primary care.
• four health risk behaviours: tobacco use, Risky alcohol use, unhealthy diet, lack of PA.
• findings- **primary care offices were capable and wanted to address health behaviour when funding and support were available via PBRNs.
• **health care delivery model such as patient centre medical home was important.
• *substantial practice design needed to occur with the integration of public health and community resources.
• • dozens of studies were published
• • prescription for health toolkit not accessible now.
• *AHRQ developed electronic preventive services selector (ePSS) used by provider at time of visit for decision support with screening, counselling and preventive services. website and app.