動(dòng)員患者采取健康生活方式

1、動(dòng)員患者采取健康生活方式Motivating Ourselves and Our Patients to be Healthy鼓勵(lì)我們鼓勵(lì)我們自己和病人保持健康自己和病人保持健康Marie Shieh, M.D.2008 October 24動(dòng)員患者采取健康生活方式謝醫(yī)師簡(jiǎn)介謝醫(yī)師簡(jiǎn)介lAmerican board-certified family physician practicing medicine in Beijing for the last 6 years at BJU.lI had 3 years experience before that in the U.S. and N

2、ew Zealand in private practice.lI am married with 2 sons. I have wanted to be a family physician since I was 4 years old.l美國(guó)家庭醫(yī)學(xué)科?？漆t(yī)師，近六年在BJU工作。l曾在美國(guó)和新西蘭從事私人醫(yī)生職業(yè)3年。l我已經(jīng)結(jié)婚并有2個(gè)兒子，我從4歲起就想成為一名家庭醫(yī)生了。動(dòng)員患者采取健康生活方式Patient story病人的故事病人的故事l40 year old Asian woman40歲亞裔女性lFull time job and 2 children全職工作和兩個(gè)孩子lN

3、on smoker and no ETOH不吸煙不喝酒lDiet: less than 5 vegetables and fruits daily食譜：每天少于5種蔬菜水果lActivity: once per week運(yùn)動(dòng)：每周一次lWellbeing: stressed and tired much of the time健康狀態(tài)：壓力很大，大部分時(shí)間困倦lBMI 23.5BMI 23.5lNot taking regular medication for chronic condition未因慢性病規(guī)律服藥動(dòng)員患者采取健康生活方式What is a healthy lifestyle?怎

4、樣才怎樣才是一種健康的生活方式是一種健康的生活方式?lNot smoking不吸煙lGood diet良好飲食lPhysical activity體育活動(dòng)lWellbeing安康快樂lFollowing Doctors advice聽從醫(yī)生的建議動(dòng)員患者采取健康生活方式Smoking and Tobacco Use吸煙與煙草制品使用吸煙與煙草制品使用How may men worldwide smoke?世界上有多少男性吸煙？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雖）吸煙？1 in 5 teens五分

5、之一未成年人How many children start smoking everyday?每天有多少孩子開始吸煙？80-100,000 1/2 of these are in Asia其中一半是在亞洲lMultiple Health Risks to Self and Family對(duì)自身和家人的多重健康威脅lBad Breath口臭lEarly wrinkles早生皺紋lYellow Teeth黃牙lMoney耗費(fèi)錢財(cái)動(dòng)員患者采取健康生活方式Healthy Diet健康飲食健康飲食lColorful and variety色彩鮮艷且種類多 lVegetables and fruits -

6、5 servings (7-9 ideal)蔬菜與水果5份（ 7-9份最理想）lWhole grains全谷類lNot much fatty foods like meats and dairy沒有太多脂類食物例如肉類與乳制品l2-3 portions of fish2-3份魚lLimit saturated fat - if frying use olive, canola, sunflower or rapeseed oil限量的飽和脂肪酸-如果油炸使用橄欖、油菜籽、向日葵或者油菜油來烹飪動(dòng)員患者采取健康生活方式Vegetables and Fruits蔬菜與水果Whole grains全

7、谷類Dairy乳制品Processed food加工食品Beans and Meats豆類與肉類動(dòng)員患者采取健康生活方式Physical Activity體育運(yùn)動(dòng)體育運(yùn)動(dòng)lAging老年lHeart Disease and Diabetes心血管疾病以及糖尿病lColon and Breast Cancer結(jié)腸和乳腺癌lMusculoskeletal Problems and Osteoporosis肌肉骨骼問題與骨質(zhì)疏松lDepression and Anxiety抑郁和焦慮lMost Americans - no physical activity大部分美國(guó)人-沒有體育運(yùn)動(dòng)lAustral

8、ians: 65% do not meet minimal activity 澳大利亞人：65%沒有達(dá)到最低運(yùn)動(dòng)量lChina?中國(guó)？lWhat is minimum activity?什么是最低運(yùn)動(dòng)量動(dòng)員患者采取健康生活方式Breast cancer and exercise乳腺癌與運(yùn)動(dòng)乳腺癌與運(yùn)動(dòng)lArchives Int Med 2007: 110,000 women, 20-79 years old. 6 year study. 110,000名年齡2079歲的婦女，長(zhǎng)達(dá)6年的研究 5 hours walking per week vs less than 0.5 hours per

9、week 每周5小時(shí)不行 vs 不足0.5小時(shí) 20% reduction in breast cancer (RR 0.8) 乳腺癌風(fēng)險(xiǎn)降低20%（RR風(fēng)險(xiǎn)比0.8） Less invasive cancer - ER + in exercise group 較低度惡性腫瘤在運(yùn)動(dòng)組中ERlJAMA 2003 Prospective study70,000 women. 50-79 years old. 5 year study. 前瞻研究70,000女性5079歲，5年研究 14-18% reduction in breast cancer 乳腺癌減少1418% Best if women

10、were below BMI 24.1 體重指數(shù)低于24.1最佳 Overweight women also benefited 超重婦女同樣收益于運(yùn)動(dòng) 10 hours per week brisk walking best 每周10小時(shí)快走最佳 1.25-2.5 hours also beneficial 1.252.5小時(shí)同樣有益動(dòng)員患者采取健康生活方式Pancreatic Cancer and Exercise胰腺癌與運(yùn)動(dòng)胰腺癌與運(yùn)動(dòng)lJAMA 2001 - cohort trial 隊(duì)列研究 46,000 men and 100,000 women 46,000男性和10,000女性

11、 For those with BMI over 25, exercise significantly reduced risk of pancreatic cancer 對(duì)于體重指數(shù)高于25者，運(yùn)動(dòng)顯著減少胰腺癌的風(fēng)險(xiǎn)動(dòng)員患者采取健康生活方式Colon Cancer結(jié)腸癌與運(yùn)動(dòng)結(jié)腸癌與運(yùn)動(dòng)lCancer Causes Control 1997 - meta analysis癌癥病因控制1997薈萃分析 Inverse relation of exercise to colon cancer 運(yùn)動(dòng)和結(jié)腸癌之間的反比例關(guān)系 50% reduction in incidence of colon

12、cancer in the most active participants 最積極運(yùn)動(dòng)者結(jié)腸癌發(fā)病率降低50%lBritish Journal of Cancer 2001- prospective study 不列顛癌癥雜志2001前瞻研究 75,000 Norwegians 75,000挪威人 12 years follow up 12年隨訪 Inverse relation of exercise to colon cancer 運(yùn)動(dòng)和結(jié)腸癌之間的反比例關(guān)系 BMI not correlated with colon cancer risk 體重指數(shù)和結(jié)腸癌風(fēng)險(xiǎn)之間不相關(guān)動(dòng)員患者采取健

13、康生活方式Depression and Exercise抑郁與運(yùn)動(dòng)抑郁與運(yùn)動(dòng)lPsychosomatic Medicine 2000 身心醫(yī)學(xué)2000 156 adults with Major Depressive Disorder 156名重度抑郁成人 Hamilton and Becks scores over 10 months 進(jìn)行10個(gè)月Hamilton和Beck評(píng)分 3 groups: Equally effective 3組同等有效lSertraline(zoloft) - fastest response 舍曲林反應(yīng)最快lExercise - lower relapse ra

14、te 運(yùn)動(dòng)復(fù)發(fā)率低lSertraline and exercise二者聯(lián)合動(dòng)員患者采取健康生活方式How much physical activity? 多大的運(yùn)動(dòng)量合適？多大的運(yùn)動(dòng)量合適？(National Physical Activity Guidelines for Australians and US CDC澳大利亞國(guó)家體育運(yùn)動(dòng)指南）澳大利亞國(guó)家體育運(yùn)動(dòng)指南）5-18 yo5-18歲18-65 yo18-65歲Over 65 yo65歲以上Frequency頻率Each day每天Minimum 5 days per wk 至少每周5天Minimum 5 days per wk 至少

15、每周5天Intensity強(qiáng)度Moderate to vigorous 中等至激烈3-6 METS3-6代謝當(dāng)量Moderate intensity (5-6 out of 10) 中等強(qiáng)度Duration持續(xù)時(shí)間Accumulate 60 mins/day- at least 累計(jì)至少每天60分鐘Accumulate 30 mins/day - at least累計(jì)至少每天30分鐘30 minutes/day -at least至少每天30分鐘Prevent weight gain 預(yù)防增重60 mins most days 大部分天數(shù)60分鐘60 mins most days大部分天數(shù)60

16、分鐘60 mins most days大部分天數(shù)60分鐘Sustain weight loss維持減重60-90 mins daily每天60-90分鐘60-90 mins daily每天60-90分鐘60-90 mins daily每天60-90分鐘動(dòng)員患者采取健康生活方式Intensity of Exercise運(yùn)動(dòng)強(qiáng)度運(yùn)動(dòng)強(qiáng)度l60-75% of maximum heart rate 最大心率的6075%lMaximum heart rate = 220-age 最大心率220年齡 l75% of maximum heart rate is the desired rate for mo

17、derate to heavy intensity exercise“ 75%最大心率是中度到劇烈運(yùn)動(dòng)的目標(biāo)心率動(dòng)員患者采取健康生活方式Link between fitness and longevity健康與長(zhǎng)壽之間的聯(lián)系健康與長(zhǎng)壽之間的聯(lián)系lIn 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

18、in exercise capacity在混雜人種隊(duì)列中調(diào)查運(yùn)動(dòng)能力與死亡風(fēng)險(xiǎn)的最大的研究中發(fā)現(xiàn)，運(yùn)動(dòng)能力每增加1代謝當(dāng)量，死亡率下降12%-15% (Circulation. Published online January 22, 2008lNEJM 2002 study with 6000 men: 12% improvement in survival with every 1 MET of exercise capacity。NEJM2002年對(duì)6000人的研究：運(yùn)動(dòng)能力每增加1代謝當(dāng)量生存率提高12%。lFitness or MET exercise capacity is dir

19、ectly linked to amount of exercise健康或者代謝當(dāng)量運(yùn)動(dòng)能力與運(yùn)動(dòng)量直接相關(guān)。lStress treadmill to check our MET capacity踏旋器應(yīng)力試驗(yàn)可測(cè)量我們的代謝當(dāng)量能力。動(dòng)員患者采取健康生活方式Circulation 2003動(dòng)員患者采取健康生活方式Actual years gained實(shí)際可多活的實(shí)際可多活的年數(shù)年數(shù)QuickTime and aTIFF (Uncompressed) decompressorare needed to see this picture.動(dòng)員患者采取健康生活方式Health and Wellbe

20、ing健康福祉健康福祉lHostility and Heart Disease敵意與心臟病lHostility and Lung Function敵意與肺功能lAlso associated with more days off work也與更多假日相關(guān)0246810121416182080%Percentile Ho ScoresEpisodes of Incident CHD動(dòng)員患者采取健康生活方式Hostility Questions敵意問詢敵意問詢lAt times I feel like smashing things有時(shí)候我想要把東西砸碎lI easily become impat

21、ient with people我很容易對(duì)人失去耐心lIve been so angry at times, Ive hurt people in a fight.有時(shí)候我非常生氣以至于在打架時(shí)傷害了別人。動(dòng)員患者采取健康生活方式Characteristics of Physiciansthat Increase Risk for Burnout增加醫(yī)生對(duì)工作失去興趣機(jī)會(huì)的特質(zhì)lPerfectionism and compulsiveness完美主義和強(qiáng)迫人格lNeed for control什么都要管lExaggerated sense of responsibility過分的責(zé)任感l(wèi)Dif

22、ficulty asking for help較難求助于人lExcessive, unrealistic guilt過多的不現(xiàn)實(shí)的內(nèi)疚lSuppression of feelings情感的壓抑lDifficulty taking vacations and enjoying leisure time較難休假和享受閑暇時(shí)光動(dòng)員患者采取健康生活方式Following Doctors Recommendations聽從醫(yī)生的推薦聽從醫(yī)生的推薦Lifestyle changes生活方式改變Follow up appointments回診Other remedies其他療法Prescribed cour

23、ses of medications開幾個(gè)療程的藥Surgery手術(shù)動(dòng)員患者采取健康生活方式Can we make a difference?我們能起作用么？我們能起作用么？lEvidence supports doctors intervention in quitting smoking有證據(jù)支持醫(yī)生幫助戒煙的作用lEvidence supports physician counseling about exercise有證據(jù)支持醫(yī)生建議運(yùn)動(dòng)的作用lEvidence supports physician counseling about diet有證據(jù)支持醫(yī)生建議飲食的作用lEvidenc

24、e supports physician counseling about wellbeing有證據(jù)支持醫(yī)生建議福祉的作用lEvidence supports physician supported healthcare有證據(jù)支持醫(yī)生參與的醫(yī)療保健動(dòng)員患者采取健康生活方式Motivation動(dòng)機(jī)動(dòng)機(jī)lIntrinsic內(nèi)部的 Internal satisfaction - feeling better內(nèi)心滿足-感覺更好 Better health更健康 Love and Acceptance internal自身的愛與接受lExtrinsic外部的 External reward - look

25、ing better外部獎(jiǎng)勵(lì)-看起來更好 Approval - love and acceptance external 鼓勵(lì)-外人的愛與接受 Connection關(guān)系 Positive Feedback正性反饋動(dòng)員患者采取健康生活方式Five As五個(gè)五個(gè)AlASK詢問lADVISE建議lASSESS評(píng)估lASSIST協(xié)助lARRANGE安排Australian Family Physician and American Family Physician Journals 2008lWhitlock, EP, Orleans, CT, Pender, N, Allan, J. Evaluat

26、ing primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med 2002; 22:267動(dòng)員患者采取健康生活方式ASK and LISTEN 詢問與傾聽詢問與傾聽lDo you smoke?您吸煙么？lDo you eat at least 5 vegetables and fruits a day? Breakfast, Lunch and Dinner您每天至少吃5種蔬菜水果么？包括早、中、晚餐lHow much activity do you get in a

27、typical week? What kind? How vigorous?您一般一周做多少運(yùn)動(dòng)？哪種？多激烈？lHow is life? How is work? How is your marriage going? How is your family? Do you have good supports around you?Balance?生活怎樣？工作怎樣？您的婚姻生活怎樣？您的家庭怎樣？您身邊有很好的支持么？生活平衡否？lAre you following your doctors advice?您是否聽從您的醫(yī)生的建議？lAnything else?還有其他問題么？動(dòng)員患者采取

28、健康生活方式ADVISE建議建議lEDUCATE教育 Handouts印刷品 CDs CD DVDs DVD Websites 網(wǎng)頁(yè) Local resources 當(dāng)?shù)刭Y源lBE SUPPORTIVE AND NONJUDGMENTAL ( of yourself and your patients)要支持不要評(píng)判（對(duì)你自己和你的病人）動(dòng)員患者采取健康生活方式ASSESS評(píng)估評(píng)估lHow willing are you or your patient to make changes?您或者您的病人有多愿意做改變？lDo you want to quit smoking?您是否愿意戒煙？lDo

29、 you want to be more active?您是否希望更積極？lAre you ready to change your diet?您是否準(zhǔn)備改變您的飲食？lHow balanced is your life?您的生活有多平橫？lQuestionnaires and Tools問卷與用具動(dòng)員患者采取健康生活方式Questionaires and Tools問卷與用具問卷與用具lTranstheoretical Model跨理論模式 Precontemplation預(yù)期前 Contemplation預(yù)期 Preparation準(zhǔn)備 Action (20%)行動(dòng)（20%） Motiva

30、tion動(dòng)機(jī) Relapse回復(fù)lWheel of Life生命之輪lHlPlAmerican Lung Association questionnaire 美國(guó)肺臟協(xié)會(huì)問卷動(dòng)員患者采取健康生活方式Smoking questions吸煙的問題吸煙的問題lDo you smoke your first cigarette withing 30 minutes of waking up in the morning?您是否在早晨醒后30分鐘之內(nèi)吸您的第一根香煙？lDo you smoke 20 cigarettes or more a day?

31、您是否每天吸煙20支或者更多？lAt times when yo cant smoke or do not have cigarettes, do you crave one?有時(shí)候當(dāng)你不能吸煙或者沒有煙，你是否會(huì)渴望獲得一支？lIs it tough for you to keep from smoking for more than a few hours?幾個(gè)小時(shí)不吸煙對(duì)你來說是不是很難？lWhen you are sick enough to stay in bed, do you still smoke?當(dāng)你臥病在床時(shí)候是否仍然要吸煙？lYes to 2 or more, addic

32、ted to cigarettes.2個(gè)以上回答是即為吸煙成癮。動(dòng)員患者采取健康生活方式Smoking Triggers吸煙的觸因吸煙的觸因lEating飲食lAlcohol喝酒lAfter Sex性交之后lCoffee咖啡lDriving駕駛lAsk your patient about their triggers詢問您的病人他們的觸因動(dòng)員患者采取健康生活方式ASSIST and AGREE協(xié)助與贊同協(xié)助與贊同lBarriers to lifestyle change (Risk)生活方式改變的障礙（危險(xiǎn)） lBenefits to lifestyle change (Benefit) 生

33、活方式改變的收益（ 收益）lSMART goal SMART目標(biāo)lContracts and Rewards and Consequences合同、獎(jiǎng)勵(lì)與后果lLifestyle prescriptions生活方式處方lHelp from family and friends and community來自家庭、朋友和社區(qū)的幫助lHomework for patients 病人的家庭作業(yè)lMedication to help quit smoking or help with their disease幫助戒煙或治療病人疾病的藥物動(dòng)員患者采取健康生活方式Barriers障礙障礙lNegativ

34、e thoughts負(fù)面的想法lFear恐懼lHabit習(xí)慣lLaziness懶惰lFatigue疲勞lLack of Time沒有時(shí)間lLack of Money缺錢lNot Knowing不知道動(dòng)員患者采取健康生活方式Benefits收益收益lImagine how you feel?想象一下你的感覺lImagine how you look?想象一下你看起來會(huì)怎樣lImagine how you smell?想象一下你聞起來會(huì)怎樣lHealth and Longevity健康長(zhǎng)壽lRewards ceremony獎(jiǎng)勵(lì)-慶典lImagine what your friends and fa

35、mily will say想象一下你的家人朋友會(huì)怎樣說lImagine what your doctor will say想象一下你的醫(yī)生會(huì)說什么lFinancial Benefits經(jīng)濟(jì)收益動(dòng)員患者采取健康生活方式SMART GOALS SMART目標(biāo)目標(biāo)lSpecific詳盡lMeasurable可測(cè)lAchievable可達(dá)lAccountable可靠lResults/Reward Orientedl結(jié)果/獎(jiǎng)勵(lì)為導(dǎo)向lTime Specific時(shí)間具體動(dòng)員患者采取健康生活方式Lifestyle prescriptions and Contracts生活方式處方與合同生活方式處方與合同lW

36、rite on prescription pad 書寫于處方箋l1 copy to patient, another to chart一聯(lián)給病人一聯(lián)留在病歷lContract with a reward or punishment簽訂一個(gè)獎(jiǎng)勵(lì)或處罰合同 Contract to do something為做某事簽的合同 Appoint referee任命裁判 If you do not fulfill your contract, money is donated to charity or organization 如果沒有履行自己的合約，錢會(huì)被捐往慈善事業(yè)或者機(jī)構(gòu) Red Cross, CA

37、RE, Doctors Without Borders, Feed the Children, Nature Conservancy and more紅十字會(huì)，CARE，無國(guó)界醫(yī)生等等動(dòng)員患者采取健康生活方式Contracts and Social Psychology合同與社會(huì)心理學(xué)合同與社會(huì)心理學(xué)l - founded by Yale Economics Professor Dean Karlan Contract to do something為做某事簽的合同 Appoint referee任命裁判 If you do not fulfill your contract, money i

38、s donated to charity or organization 如果沒有履行自己的合約，錢會(huì)被捐往慈善事業(yè)或者機(jī)構(gòu) Red Cross, CARE, Doctors Without Borders, Feed the Children, Nature Conservancy and more紅十字會(huì)，CARE，無國(guó)界醫(yī)生等等 Money can also be given to organization you oppose 金錢也可交給你反對(duì)的組織lBased on Behavioral Economics 建立在行為經(jīng)濟(jì)學(xué)上 1.People dont always do wha

39、t they claim they want to do, and 人們并不總能做到他們宣稱想做的事，并且 2.Incentives get people to do things 誘因或刺激物促使人們行動(dòng)起來動(dòng)員患者采取健康生活方式Community resources社區(qū)資源社區(qū)資源lAccountability可靠性lFellow workmates同伴同事lFriends朋友lFamily家庭lYou你lYour boss你的老板lGroup supports like 類似AA的支持小組lYour doctor你的醫(yī)生lWellness Program健康計(jì)劃動(dòng)員患者采取健康生活方式ARRANGE安排安排lFollow up隨診lAsymmetrical Paternalism非對(duì)稱性家長(zhǎng)主義 Set up Next Appointment, Now現(xiàn)在就定好下次回診時(shí)間 Set up Next Blood Test, Now現(xiàn)在就定好下次血檢 Make Refer