Motivating Ourselves and Our Patients to be Healthy 鼓励我们自己和病人保持健康Marie Shieh, M.D. 2008 October 24 Patient story 病人的故事40 year old Asian woman40 岁亚裔女性Full time job and 2 children 全职工作和两个孩子Non smoker and no ETOH 不吸烟不喝酒Diet: less than 5 vegetables and fruits daily 食谱：每天少于5 种蔬菜水果Activity: once per week 运动：每周一次Wellbeing: stressed and tired much of the time 健康状态：压力很大，大部分时间困倦BMI 23.5BMI 23.5 Not taking regular medication for chronic condition 未因慢性病规律服药What is a healthy lifestyle? 怎样才是一种健康的生活方式? Not smoking不吸烟Good diet良好饮食Physical activity体育活动Wellbeing安康快乐Following Doctor’s advice听从医生的建议Smoking and Tobacco Use 吸烟与烟草制品使用Multiple Health Risks to Self and Family 对自身和家人的多重健康威胁Bad Breath 口臭Early wrinkles 早生皱纹Yellow Teeth 黄牙Money 耗费钱财How may men worldwide smoke? 世界上有多少男性吸烟？1 out of 3 men 三分之一的男性How many teens (13-15 yo) smoke? 有多少未成年人（13-15 虽）吸烟？1 in 5 teens 五分之一未成年人How many children start smoking everyday? 每天有多少孩子开始吸烟？80-100,000 1/2 of these are in Asia 其中一半是在亚洲Healthy Diet 健康饮食Colorful and variety 色彩鲜艳且种类多Vegetables and fruits - 5 servings (7-9 ideal) 蔬菜与水果5 份（7-9 份最理想）Whole grains 全谷类Not much fatty foods like meats and dairy 没有太多脂类食物例如肉类与乳制品2-3 portions of fish2-3 份鱼Limit saturated fat - if frying use olive, canola, sunflower or rapeseed oil 限量的饱和脂肪酸- 如果油炸使用橄榄、油菜籽、向日葵或者油菜油来烹饪USPTF 1996 and JAMA 2002;288:2569 and www,patwww.book118.com Physical Activity 体育运动Aging 老年Heart Disease and Diabetes 心血管疾病以及糖尿病Colon and Breast Cancer 结肠和乳腺癌Musculoskeletal Problems and Osteoporosis 肌肉骨骼问题与骨质疏松Depression and Anxiety 抑郁和焦虑Most Americans - no physical activity 大部分美国人- 没有体育运动Australians: 65% do not meet minimal activity 澳大利亚人：65% 没有达到最低运动量China? 中国？What is minimum activity? 什么是最低运动量Breast cancer and exercise 乳腺癌与运动Archives Int Med 2007: 110,000 women, 20-79 years old. 6 year study. 110,000 名年龄20 ～79 岁的妇女，长达6 年的研究5 hours walking per week vs less than 0.5 hours per week 每周5 小时不行vs 不足0.5 小时20% reduction in breast cancer (RR 0.8) 乳腺癌风险降低20% （RR 风险比0.8 ）Less invasive cancer - ER + in exercise group 较低度恶性肿瘤－在运动组中ER ＋JAMA 2003 Prospective study －70,000 women. 50-79 years old. 5 year study. 前瞻研究－70,000 女性50 ～79 岁，5 年研究14-18% reduction in breast cancer 乳腺癌减少14~18% Best if women were below BMI 24.1 体重指数低于24.1 最佳Overweight women also benefited 超重妇女同样收益于运动10 hours per week brisk walking best 每周10 小时快走最佳1.25-2.5 hours also beneficial 1.25~2.5 小时同样有益Pancreatic Cancer and Exercise 胰腺癌与运动JAMA 2001 - cohort trial 队列研究46,000 men and 100,000 women 46,000 男性和10,000 女性For those with BMI over 25, exercise significantly reduced risk of pancreatic cancer 对于体重指数高于25 者，运动显著减少胰腺癌的风险Colon Cancer 结肠癌与运动Cancer Causes Control 1997 - meta analysis 癌症病因控制1997 －荟萃分析Inverse relation of exercise to colon cancer 运动和结肠癌之间的反比例关系50% reduction in incidence of colon cancer in the most active participants 最积极运动者结肠癌发病率降低50% British Journal of Cancer 2001- prospective study 不列颠癌症杂志2001 －前瞻研究75,000 Norwegians 75,000 挪威人12 years follow up 12 年随访Inverse relation of exercise to colon cancer 运动和结肠癌之间的反比例关系BMI not correlated with colon cancer risk 体重指数和结肠癌风险之间不相关Depression and Exercise 抑郁与运动Psychosomatic Medicine 2000 身心医学2000 156 adults with Major Depressive Disorder 156 名重度抑郁成人Hamilton and Beck’s scores over 10 months 进行10 个月Hamilton 和Beck 评分3 groups: Equally effective 3 组同等有效Sertraline(zoloft) - fastest response 舍曲林－反应最快Exercise - lower relapse rate 运动－复发率低Sertraline and exercise 二者联合How much physical activity? 多大的运动量合适？(National Physical Activity Guidelines for Australians and US CDC 澳大利亚国家体育运动指南）Intensity of Exercise 运动强度60-75% of maximum heart rate 最大心率的60~75% "Maximum heart rate = 220-age 最大心率＝220 －年龄75% of maximum heart rate is the desired rate for moderate to heavy intensity exercise“75% 最大心率是中度到剧烈运动的目标心率Link between fitness and longevity 健康与长寿之间的联系In the largest study to examine the link between exercise capacity and mortality risk in a racially mixed cohort, mortality dropped 12% to 15% with every 1 metabolic equivalent in exercise capacity 在混杂人种队列中调查运动能力与死亡风险的最大的研究中发现，运动能力每增加1 代谢当量，死亡率下降12%-15% (Circulation. Published online January 22, 2008 NEJM 2002 study with 6000 men: 12% improvement in survival with every 1 MET of exercise capacity 。NEJM2002 年对6000 人的研究：运动能力每增加1 代谢当量生存率提高12% 。Fitness or MET exercise capacity is directly linked to amount of exercise 健康或者代谢当量运动能力与运动量直接相关。Stress treadmill to check our MET capacity 踏旋器应力试验可测量我们的代谢当量能力。Circulation 2003 Actual years gained 实际可多活的年数Health and Wellbeing 健康福祉Hostility and Heart Disease 敌意与心脏病Hostility and Lung Function 敌意与肺功能Also associated with more days off work 也与更多假日相关Hostility Questions 敌意问询At times I feel like smashing things 有时候我想要把东西砸碎I easily become impatient with people 我很容易对人失去耐心I’ve been so angry at times, I’ve hurt people in a fight. 有时候我非常生气以至于在打架时伤害了别人。Characteristics of Physicians that Increase Risk for Burnout 增加医生对工作失去兴趣机会的特质Perfectionism and compulsiveness 完美主义和强迫人格Need for control 什么都要管Exaggerated sense of responsibility 过分的责任感Difficulty asking for help 较难求助于人Excessive, unrealistic guilt 过多的不现实的内疚Suppression of feelings 情感的压抑Difficulty taking vacations and enjoying leisure time 较难休假和享受闲暇时光Following Doctor’s Recommendations 听从医生的推荐Lifestyle changes 生活方式改变Follow up appointments 回诊Other remedies 其他疗法Prescribed courses of medications 开几个疗程的药Surgery 手术Can we make a difference? 我们能起作用么？Evidence supports doctor’s intervention in quitting smoking 有证据支持医生帮助戒烟的作用Evidence supports physician counseling about exercise 有证据支持医生建议运动的作用Evidence supports physician counseling about diet 有证据支持医生建议饮食的作用Evidence supports physician counseling about wellbeing 有证据支持医生建议福祉的作用Evidence supports physician supported healthcare 有证据支持医生参与的医疗保健Motivation 动机Intrinsic 内部的Internal satisfaction - feeling better 内心满足- 感觉更好Better health 更健康Love and Acceptance internal 自身的爱与接受Extrinsic 外部的External reward - looking better 外部奖励- 看起来更好Approval - love and acceptance external 鼓励- 外人的爱与接受Connection 关系Positive Feedback 正性反馈Five A’s 五个A ASK 询问ADVISE 建议ASSESS 评估ASSIST 协助ARRANGE 安排Australian Family Physician and American Family Physician Journals 2008 Whitlock, EP, Orleans, CT, Pender, N, Allan, J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med 2002; 22:267 ASK and LISTEN 询问与倾听Do you smoke? 您吸烟么？Do you eat at least 5 vegetables and fruits a day? Breakfast, Lunch and Dinner 您每天至少吃5 种蔬菜水果么？包括早、中、晚餐How much activity do you get in a typical week? What kind? How vigorous? 您一般一周做多少运动？哪种？多激烈？How is life? How is work? How is your marriage going? How is your family? Do you have good supports around you?Balance? 生活怎样？工作怎样？您的婚姻生活怎样？您的家庭怎样？您身边有很好的支持么？生活平衡否？Are you following your doctor’s advice? 您是否听从您的医生的建议？Anything else? 还有其他问题么？ADVISE 建议EDUCATE 教育Handouts 印刷品CD’s CD DVD’s DVD Websites 网页Local resources 当地资源BE SUPPORTIVE AND NONJUDGMENTAL ( of yourself and your patients) 要支持不要评判（对你自己和你的病人）ASSESS 评估How willing are you or your patient to make changes? 您或者