Transcript evidence * based wellness for anesthesiologists

EVIDENCE – BASED WELLNESS FOR
ANESTHESIOLOGISTS
Robert S. Holzman M.D., MA. (Hon), FAAP
Chair, Committee on Occupational Health, American Society of Anesthesiologists
Senior Associate in Perioperative Anesthesiology,
Children’s Hospital Boston
Professor of Anaesthesia, Harvard Medical School
Boston, MA
IMPORTANT DISCLOSURES
1. I have no special expertise beyond
anesthesiology – I am not a psychiatrist,
nutritionist, nor physical therapist.
2. I do have a bias toward physiology and
biomathematics.
PREVALENCE OF LIFESTYLE-RELATED BEHAVIORS
1 in 5 smokes
2 in 5 exposed to second-hand smoke
3 in 4 do not get enough physical activity
4 in 5 need to significantly improve their diet
2 in 3 need to lose weight
< 1 in 4 uses the recommended combination of caloric
restriction and physical activity to lose weight.
1 in 3 exceeds the daily or weekly alcohol recommendation, 1
in 5 binge drinks at least occasionally.
1 in 3 adults 30 to 64 years old averages ≤6 hours of sleep
per day.
1 in 33 are at healthy weight, non-smoking, physically
active and consume ≥ 5 fruits and vegetables per day
Yusuf, S. INTERHEART Study The Lancet 2004;364:937-52
http://video.google.com/videoplay
Free water requirements are ultimately
proportional to caloric demands
• (1) The consumption of 1,000 mL of oxygen generates 4,825
calories.
• (2) If VO2 is equal to 10 X kg3/4 (mL/min) in adults, then heat
production per hour is =
• (3) 10 X kg ¾ X 4,825 X 60
1,000
• (4) the calories required for 1 mL of water to evaporate are 63 cal.
This plus 540 calories are required to achieve the heat of
vaporization (total 603 cal / mL of water). This modifies the above
equation to: mL water / hour = 10 X kg 3/4 X 4,825 X 60
1,000 X 603
≈ 5 X kg3/4
DIET: show me the evidence
Moderate and well-balanced
calorie restriction is more
effective than any other diet (32
RCTs)
• average weight loss of about 5 kg after one
year.
• a caloric deficit of about 500 kcals per day is
the optimal goal for most.
Sacks, F. Comparison of Weight-Loss Diets with Different Compositions
of Fat, Protein, and Carbohydrates. NEJM 2009;360(9):859-73
DIET: show me the strategy
Reduce Portion Sizes: Several well-controlled,
laboratory-based studies have shown that larger
food portions lead to increases in energy intake.
Large portion sizes have been shown to override
hunger and satiety signals.
A Lower Energy Density Diet: we eat a fairly
consistent volume of food day-to-day, rather than a
consistent number of calories; the number of
calories in a particular volume or weight of food is
its energy density. Eating low-energy-dense foods
(e.g., fruits, vegetables, and soups) maintains
satiety while reducing energy intake.
Whole Grains
•
Inverse relation between whole grain intake and BMI
(National Health and Nutrition Examination Survey (NHANES)
• Replacing refined grains with whole grains helps reduce weight
gain and can lead to significant weight loss.
• Weight gain has been inversely associated with the intake of
high-fiber, whole-grain foods and positively related to the
intake of refined-grain foods.
• The Nurses' Health Study showed that women in the highest
quintile of dietary fiber intake had a 49% lower risk of major
weight gain than women in the lowest quintile.
Fruits and Vegetables
• The Nurses' Health Study also showed that those with highest
fruit and vegetable intake had a 24% lower risk of becoming
obese than those with lowest intake, after controlling for other
dietary factors.
• Legumes: NHANES 1999-2002 data showed that greater
consumption of legumes (beans) led to higher intakes of
dietary fiber, potassium, magnesium, iron, and copper, and a
lower body weight and a smaller waist circumference relative to
those who did not consume legumes.
Glycemic Load
The glycemic index (GI) is an in-vivo measure of the effects of carbohydrates
on blood sugar levels.
Carbohydrates that break down quickly and release glucose rapidly have a
high GI; carbohydrates that break down more slowly, releasing glucose more
gradually, have a low GI.
•
A Cochrane review of 6 RCTs that compared a low glycemic index diet
(LGI) with higher glycemic index diets in overweight or obese people
showed that those on LGI diets lost more weight and had
more improvement in lipid profiles than those on other
diets.
•
Body mass, total fat mass, BMI, total cholesterol and LDL-cholesterol all
decreased significantly more in the LGI group.
•
Lowering the glycemic load of the diet appears to be more effective in
promoting weight loss and improving lipid profiles in obese than nonobese
individuals.
Type of starch
Cooking
Food processing
Physical entrapment
Viscosity of fiber
Acid content
Sugar content
Protein content
Fat content
Type of Starch
Amylose
Amylopectin
• Absorbs less water
• Absorbs more water
• Molecules form tight clumps • Molecules are more open
• Slower rate of digestion
• Faster rate of digestion
Lower GI
Higher GI
Kidney beans (28)
Uncle Ben’s converted LG rice (50)
Russet potato (85)
Glutinous rice (98)
Physical Entrapment
Bran
Endosperm
Bran acts as a physical barrier that
slows down enzymatic activity on the
internal starch layer.
Lower GI
All Bran (38)
Pumpernickel bread (50)
Higher GI
Bagel (72)
Corn Flakes (92)
Germ
Viscosity of Fiber
Viscous, soluble fibers transform intestinal
contents into gel-like matter that slows down
enzymatic activity on starch.
Lower GI
Higher GI
Apple (40)
Rolled oats (51)
Whole wheat bread (73)
Cheerios (74)
Fat & Protein Content
Fat and protein slow down gastric emptying,
and thus, slows down digestion of starch.
Lower GI
Higher GI
Peanut M&M’s (33)
Potato chips (54)
Special K (69)
Jelly beans (78)
Baked potato (85)
Corn Flakes (92)
Acid Content
Acid slows down gastric emptying, and thus,
slows down the digestion of starch.
Lower GI
Higher GI
Sourdough wheat bread (54)
Wonder white bread (73)
Cooking
Cooking swells starch molecules and softens
foods, which speeds up the rate of digestion.
Lower GI
Higher GI
Al dente spaghetti – boiled
10 to 15 minutes (44)
Over-cooked spaghetti –
boiled 20 minutes (64)
Mediterranean Diet
• A 3-year prospective study showed that a
traditional Mediterranean diet reduced the
likelihood of overweight people becoming
obese.
• A higher degree of adherence to the
Mediterranean diet is associated
– with a reduction in total mortality (adjusted hazard
ratio (aHR) 0.75 (95% CI 0.64-0.87)
– inversely with death due to coronary heart disease
(aHR 0.67 (95% CI 0.47-0.94)
– inversely with death due to cancer (aHR 0.76 (95%
CI 0.59-0.98).
The Mediterranean Diet Food Pyramid
Hu, F. N Engl J Med 2003;348:2595-6
Assy et al. World J Gastroenterol 2009;15(15):1809-15
Nunn et al Nutrition & Metabolism 2009
Make a food diary.
Keep track of what you eat.
• Convert EVERYTHING to calories and
nutrients.
Where do you get your information?
Food and Nutrient Database for
Dietary Studies (FNDDS)
http://199.133.10.140/codesearchwebapp/28ufcz3uu0dj5xpr55wlhapjqy29/codesearch.aspx
Exercising Your Right to Achieve a
Better Professional Life (VO2 and Me)
James A. DiNardo, M.D., FAAP
Professor of Anaesthesia
Children’s Hospital Boston
Harvard Medical School
VO2 max (mL/kg/min)
Put in Perspective
• average male 20-29 years old = 38-43
• average male on college track team =48-53
• female volleyball or male baseball player = 4050
• elite cyclist or runner > 75 (Armstrong 85)
• highest female value (Nordic skier) = 77
• highest male value (Nordic skier) = 96
• thoroughbred racehorse = 180
• Siberian sled dog = 240
Why is VO2 max Important?
• Higher VO2 max associated with better
survival in healthy populations and in
populations with significant morbidities
• Higher VO2 max associated with lower
incidence of stroke
• Exercise reverses or partially reverses
metabolic syndrome
• Exercise is important when trying to lose weight, but is
even more important when it comes to maintaining
weight loss.
• Most RCTs show only modest weight loss with exercise
alone, and slight increases in weight loss when exercise is
added to dietary restriction.
• A meta-analysis of 43 studies (3,476 participants) found
that, compared with no treatment, exercise resulted in
small weight losses across studies but was associated with
improved CVD risk factors, even when no weight was lost.
What Should I Be Doing?
• 450-900 MET⋅min⋅wk-1
• 75 minutes (1.25 hrs) of vigorous
intensity (> 6 METs) aerobic activity per
week
• 150 minutes (2.5 hrs) of moderate
intensity (3-6 METs) aerobic activity per
week
•
•
A metabolic equivalent (MET) = ratio of metabolic rate
during a specific physical activity to a basal metabolic
rate of 3.5 mL O2/kg/min or 1 kcal/kg/hr.
MET values of physical activities range from 0.9
(sleeping) to 18 (running at 17.5 km/h (11 mph).
9 RCTs and 7 non-RCTs of the dose-response
relationship between aerobic exercise and
visceral fat reduction found that at least 10
METs of aerobic exercise (brisk
walking, light jogging or stationary
cycling) is required for visceral fat
reduction.
ACTIVITY a WEIGHT LOSS
< 150 min/wk
150-200 min/wk
200+ min/wk
6 months
7 lbs
11 lbs
13 lbs
18 months
3 lbs
9 lbs
14 lbs
• A Cochrane review concluded that diet
•
combined with exercise
produced a 20% greater initial weight loss than diet
alone, and a greater likelihood that the weight loss
would be sustained.
Numerous studies have shown that regular exercise in conjunction
with diet results in an average weight loss of 5% to 10%.
• Exercise with no change in diet results in a consistent small weight
loss across studies, but must be combined with diet to yield
satisfactory results.
A lifestyle approach can reduce the likelihood
of developing type 2 diabetes by 58%:
• (U.S.) Diabetes Prevention Program evaluated a
lifestyle approach to prevent Type 2 diabetes in obese individuals
–
• it was stopped early because the results were
indisputable:
– 2 years - 5% of lifestyle group vs. 22% of control developed
diabetes,
– 4 years - 20% (lifestyle) vs. 37% (control) developed diabetes.
A lifestyle approach can reduce the likelihood
of developing type 2 diabetes by 58%:
• Finnish Diabetes Prevention Study evaluated diet
and exercise in people with impaired glucose tolerance.
– After 6 years, fewer than 20% of diet/exercise group vs.
greater than 40% of control developed type 2 diabetes.
– A significant reduction in prevalence of metabolic
syndrome (OR = 0.6) and abdominal obesity (OR = 0.5)
were observed in the Finnish Diabetes Prevention Study.
• Moderate-intensity lifestyle interventions can delay type 2
diabetes by an average of 11 years and reduce the number
of new cases by 20%. This is much greater than what can
be achieved with pharmacotherapy (delayed onset by 3
years, reduced cases by 8%).
• The combination of diet and exercise interventions was
significantly more effective than either diet or exercise
alone. Two out of three cases were reversed with the
combination vs. about 1 in 3 in each of the other
groups.
• Compared with no prevention program, the DPP lifestyle
approach can reduce a high-risk person's 30-year
likelihood of developing diabetes from about 72% to 61%,
the chance of a serious complication from about 38% to
30%, and the chance of dying of a complication of
diabetes from about 14% to 11%.
PROFILE OF A PHYSICIAN AT HIGH RISK
FOR SUICIDE
Sex
Male or Female
Age
45 years or older (female); 50 years or older (male)
Race
White
Marital status:
Divorced, separated, single, or currently having marital
disruption
Risk factors:
Depression, alcohol or other drug abuse, workaholic, excessive
risk taking (e.g. high-stakes gambler, thrill seeker)
Medical status:
Psychiatric symptoms or history (depression, anxiety), physical
symptoms (chronic pain, chronic debilitating illness)
Professional:
Change in status-threats to status, autonomy, security, financial
stability, recent losses, increased work demands
Access to means:
Access to legal medications, access to firearms
Silverman, M in The Handbook of Physician Health: Essential Guide to Understanding the
Health Care Needs of Physicians. American Medical Association. 2000
Lepnurm et al. The Canadian Journal of Psychiatry 2009;54(3):170-80
CRH=corticotrophin releasing hormone; NPY=neuropeptide Y; NA=noradrenaline; AVP=arginine vasopressin; ACTH =
adrenocorticotrophic hormone; GABA=gamma aminobenzoic acid/benzodiazepine receptor complex;
5HT/Ach=serotonin/acetylcholine.
Exercise, light therapy, alternative medicines,
and counseling have demonstrated benefits over
placebo and may enhance remission rates in
combination with antidepressants.
• Exercise seems to improve depressive symptoms in people
with depression, to a similar degree as cognitive therapy.
– A Cochrane review of exercise interventions for depression
yielded 25 RCTs that together showed a large clinical effect.
When just the 3 highest quality trials were included, the effect
was moderate.
– A meta-analysis of the effects of exercise on depression in the
elderly found that exercise was effective in treating depression
and reducing depressive symptoms in the short-term.
AREAS OF UNCERTAINTY
• Unintended consequences of emerging technology / dietary regimens, specific
biomechanical disadvantages of exercise regimens - will require ongoing evaluation of impact via
scientific and population studies.
• Advances in genomics will identify predispositions of specific groups. Unforeseen medical and
social pressures may emerge which will impact treatment as well as lifestyle care and potentially,
occupational choices.
•
As Wellness Programs become integrated into health benefit entitlements, the sharing of
responsibility for interventions and management may blur the criteria for disability. For
example, should very overweight staff members qualify as disabled vs. impaired? Similarly,
geographical and time boundaries for the maintenance of wellness may become blurred, producing
questions such as:
– Is Wellness maintenance integral to the workplace and workday, or should it occur on the
employee’s own time? Does the business have an interest in providing such time and facilities
because ultimately it may result in improved worker performance and customer (patient)
safety?
– If such a program is integral to the work contract, does it imply liability on the part of the
organization for failure to identify, engage and succeed with an employee?
– Could such failure become the basis of a breach of contract between the employer and the
employee?
Beginning in 2014, employers may
use up to 30% of the total amount
of employees’ health insurance
premiums (50% at the discretion of
the secretary of health and human
services) to provide outcomebased wellness incentives.
• Discount or rebate of a premium or
contribution.
• Waiver of all or part of a cost-sharing
mechanism (such as deductibles,
copayments, or co-insurance).
• Absence of a surcharge.
• The value of a benefit that would
otherwise not be provided under the
plan.
Unfortunately, based on a flawed study…
• “Safeway Supermarkets had achieved flat
health care costs from 2005 – 2009 by tying
employees’ health insurance premiums to
outcome-based wellness incentives.”
Wall Street Journal, June 12, 2009:A15
• But the program began in 2008
“Misleading claims about Safeway wellness incentives shape health-care bill.”
Washington Post, January 17, 2010:G01
CONCLUSIONS & RECOMMENDATIONS
1.
2.
Lose 5% to 10% of body weight if overweight or obese.
Achieve weight loss by reducing kcal intake by about 500 kcal per day and
gradually increase physical activity to 60 minutes per day.
3. Consume a diet rich in vegetables and fruits, at least 2 fruits, 3 vegetables per day.
4. Choose whole-grain, high-fiber foods (at least half of grains as whole grains).
5. Limit intake of saturated fat to <10% of energy, trans fat to <1% of energy, and
cholesterol to <300 mg/day; choose lean meats and vegetable alternatives, fatfree (skim) or low-fat (1% fat) dairy products and minimize intake of partially
hydrogenated fats.
6. Consume fish, especially oily fish, at least twice a week,
7. Minimize intake of beverages and foods with added sugars.
8. Use alcohol only in moderation, if at all - limit to 2 servings/day for men, 1 for
women.
9. Get at least 30 minutes of moderately intense physical activity at least 5 days a
week, preferably every day.
10. Quit smoking, if a smoker.
EVIDENCE – BASED WELLNESS FOR
ANESTHESIOLOGISTS
WATCH FOR THIS PRESENTATION ON THE ASA WELLNESS WEBSITE:
https://www.asahq.org/Home/ForMembers/MyASA/WorkLifeBalance.aspx
Robert S. Holzman M.D., MA. (Hon), FAAP
Chair, Committee on Occupational Health, American Society of Anesthesiologists
Senior Associate in Perioperative Anesthesiology,
Children’s Hospital Boston
Professor of Anaesthesia, Harvard Medical School
Boston, MA