Wellness, Health Promotion and Disease Prevention 3.

Reinforcing positive lifestyles

Dr. Arlette A. Santiago-Samaniego -if you want to praise the patient, you can.
-if you want to advise the patient on a bad thing, do it privately
Health (WHO 1947) -put yourself in the patient’s shoe
-a state of complete physical, mental and social well-being, and not ex. adult immunization,
merely the absence of disease and infirmity - for you to advise on this you need to experience it too
Wellness -so that you can imbibe the good effects to the patient
-method or strategy to achieve health
ex. diet, exercise, sleep, peaceful thoughts 4. exploding myths
-health beliefs educate yourself on these
Health Education
-involves communicating information, imparting and interpreting Heath Promotion
technical knowledge, reinforcing positive lifestyles and exploding myths -combines the objective of disease prevention with techniques of health
-essential first step to health promotion education
-part of wellness -combination of simple and complex strategies that encourage physical,
mental, social, economic or general wellness
1. communicating information -can be simple or complex strategies
ICM - active listening skills simple strategies
communicating information -two-way ex. proper hand washing, toilet manners, self-breast examination
a. understand the patient the way the patient wants to be understood complex strategies
and ex. malaria prevention, dengue prevention
headache- pain perception- not exactly measured by visual perspective-
subjective- it is possible that a patient who looks well does have the Role of the Physician
symptoms he is complaining about. -unique position as wellness advocate
if the doctor doesn’t want to understand the patient, he is being -application of preventive medicine principles
indifferent -forestall the initiation of progression of the disease
b. when you give instructions the way you want to be understood -provide appropriate advice on lifestyle change
-antibiotics taken every 8 hours are not equivalent to 3x a day -you need to educate your patients on these preventive measures not
-meds taken every after meals is not the same as every 8 hours because it is common sense to you doesn’t mean they already know it.
c. do not underestimate communication. many medical errors are -you want to advocate wellness
caused by these
-asthmatic patient- Singulair, Seretide, Symbicort, Flixutide—used as Stages of Prevention
maintenance drug for asthma  because we don’t want the patient to Prevention are strategies in managing the patients
manifest acute attacks these lessen the inflammation Primary Secondary Tertiary
-a patient who is not given the proper instructions can take these meds - Prevention Prevention Prevention
as needed in acute attacks- instead of taking it for at least 2 weeks Pre- Pathogenesis stage
(optimum period where these drugs will take effect) or up to 2 years pathogenesis
stage
1. Possible factors encountered on the doctor’s side:
-the knowledge of the doctor on how to administer the said drug -before the Asymptomatic Acute/ Complicated Rehabilitation
-if the doctor is continually updating himself to the current trend or is he disease uncomplicated symptoms
practicing begins symptoms
-we should interpret the ethical knowledge A. Primary Prevention
-the patient should be educated on how to use this drug so that he can Pre-pathogenesis
understand how it works ex.
=analogy of doc= =history of hypertension in the family
when you go to a hardware store to buy screws, you want to know what prevention
they are for. But if the salesman doesn’t know what it is for then why did -low salt diet, low cholesterol
you bother going? She stressed that why would you attend as a -read nutrition facts on salt content, saturated fat content
salesman if you don’t know your product -lifestyle modification in your family to prevent your children from
2. Possible factors on the patient’s use: manifesting it too
- doesn’t know how to and when to administer the said drug =cancer
-good history taking and PE -educate not to smoke
- decrease frequency of exposure to carcinogenic food
2. imparting and interpreting technical knowledge B. Secondary Prevention
-remember that the patient wants to feel good Pathogenesis stage
-for example, diabetes Asymptomatic
-- be considerate and be kind to explain it to the patient -ID risk factors
--it is important to make the patient understand that their disease is -rational choice of diagnostic procedure
chronic and lingering disease ex.
--They need to adjust their lifestyle. =pap smear (HPV)

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-sexually active- pap smear on yearly basis Obesity
=prostate gland enlargement - is usually measured using the BMI
-in 50 years aged male patients ultrasound -Waist circumference is a surrogate marker of visceral fat
=smokers
-smoking causes target organ damage screening
=Hepa B
-endemic in the Philippines
-HbSAg screening

Uncomplicated symptoms
-treatment
-hypertension controlled

C. Tertiary Prevention
Complicated symptoms
=hypertensionheart attack, stroke, peripheral artery disease,
hemiparesis
=DM nephropathy
=vehicular accidentsrehabilitation

*most preventions can be applied in the different stages of prevention.

ex. low salt diet
-they just appear as a different strategy depending on the case
presented in the patient

Lifestyle modification Recommendation

Modification Recommendation SBP
Reduction
(mmHg)
Weight Maintain normal body weight (BMI 5-20 per 10-
Reduction 18.5- 24.9 kg/m2) kg weight
loss
DASH eating plan Adopt a diet rich in fruits, 5-14
vegetables, and low-fat dairy
products with reduced amount of
saturated and total fat
Dietary sodium Reduce dietary sodium intake to 2-5
reduction 100 mmol per day (2.4g sodium or
For obesity risk stratification
6 g sodium chloride)
Aerobic physical Regular exercise, physical acitivty 4-9 -use of waist circumference and BMI to measure possible risk of co-
activity (e.g. brisk walking) at least 30 morbidities
minutes per day, most days of the Waist circumference
week -measure the distance between the lowest rib and the highest point of
Moderation of Men: limit to  2* drinks per day 2-4 the iliac crest
alcohol Women and lighter weight persons: -not the anterior iliac spine.
consumption limit to  1 drink* per day -take the distance and in between these points
*1 oz or 30 mL ethanol; e.g. 24 oz beer, 10 oz wine or 3 oz 80-proof
-measure with only one thin layer of clothing
whiskey
Asian Caucasian
Male 90cm/35 in 102 cm
Weight management Female 80cm/31 in 88cm
Ideal body weight obesity VS overweight
Male: 105- 106 lbs for first 5 feet plus 5-6 lbs per inch thereafter obesity
Female: 100 lbs for first 5 feet plus 5 lbs per inch thereafter - adipose body deposition
½ inch – 2.5lbs -abdominal obesity
in FEU: 106 + 6 per inch overweight
- above the range of normal BMI
ex. female – 5ft 2 ½ in – 100+ (2.5* 5) =112.5 lbs
-range of determining overweight- up to 10% of IBW
-integration in your life, apply it at home.
-determine your and your family’s IBW

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Body Mass Index (BMI) water:
high humidity, very warm coutry patient needs to be more hydrated
carbohydrates”
eat carbohydrate, if not sufficient proteins are used as
energymuscle wasting
eat in proportion
5ft 2 ½ in
fruits:
1 ft= 12 in
carrot juice, kamote juice, kangkong juice
fruit juice not as powdered juice

The following are considered as 1 serving of fruit

1 small apple
10 pieces grapes
1 medium slice melon
½ cup undiluted fruit juice
BMI- normal 1 medium banana
1 small mango
for example: 1 medium slice papaya
BMI- normal; waist circumference - increased 1 medium slice pineapple
the patient has increased risk of having co-morbidities Source: FNRI Food Exchange List
-diet and lifestyle modification of at least 2-4 weeks
If increased, moderate or severe risk vegetable:
- pharmacological management -organically grown
-preserve vitamins (x in running water, basin of water)
DASH Diet milk:
Dietary Approach to Stop Hypertension -supplement Ca in lactose intolerant
- formulated for hypertension --Harvey fresh- lactose –free
- used to counteract anti-oxidants -if you want to supplement protein in the meal
-rich in fruits and vegetables -- soymilk is sufficient
-low-fat dairy (low content of saturated and total fat) proteins:
ex. Cloud 9, Dewberry trim down the fat ex. chicken skin solid fat
- high in saturated fat/ hydrogenated fat ex. be cautious with beans- high in uric acid, protein substitute
-more hydrogen attached, the more they are converted to body fats matchbox sized meat size of the palm of your hand, thickness of your
Low sodium ( 100mmol/dau / 2.4 g sodium/ 6g NaCl) pinky finger trim the fat
assignment: know how much is 6 grams (about 3-4 grams) Fats/Oil:
little of fats, sugar and salt
Filipino Pyramid Food Guide
*walk the talk

Atkins Diet- not practiced

South Beach Diet
What is the SBD?
-NOT a low-carbohydrate diet
-NOT a low-fat diet
-The SBD teaches patients to rely on the right carbohydrates and the
right fats
What are the expected results?
-Patient becomes healthy and will lose weight somewhere between 8-
13 lbs in the next 2 weeks alone
What are the Basic rules of the SBD?
-Eat NORMAL-SIZED helpings of meat, chicken, turkey, fish, shellfish
-Eat PLENTY of vegetables eggs, cheese and nuts
-have salads with REAL olive oil in the dressing
salads (Dressing) use extra virgin olive oil
balsamic vinegar
crushed garlic/ rosemary
Developed by:
white/black pepper
Sanirose S. Orbeta, MS, RD, FADA
pepper flakes
Clinical and Sports Nutritionist
salt
Food ad Nutrition Research Institue (FNRI)
then blend
Filipino Pyramid

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-Have 3 BALANCED MEALS a day -30 minutes per day most days of the week (JNC7)
-eat so hunger is satisfied -at least 2 days a week
-Have snacks in mid-morning and mid-afternoon
-have dessert after dinner Exercise prescription
-Drink water plus coffee or tea as desired THR/ Target heart Rate
*can be modified for diabetic patients THR= (220- age) x __% activity
No previous exercise _______________ 60-65%
How is the SBD done? Minimal to some previous exercise_____ 70-75%
PHASE I: (First 2 weeks) Previous regular exercise____________ 80%
-NO bread, rice, potatoes, pasta or baked goods common in people who are sedentary, 60-65%
-NO fruits people who goes to gym regularly—70-75%
-NO candies, cake cookies, ice cream or sugar athletes—80%
-NO beer or alcohol
Expected results: ex.
1. loss of 8-13 lbs- this will come from the mid-section THR= 220-20* 60%= 120
2. patient would have corrected the way the body reats to food Titrate HR up to your goal. by 3rd week.
3. physical cravings will be done
Rationale of weight loss: Remember:
The weight loss is not because of eating less but because of eating fewer All the previously discussed intervention can be applied to primary,
foods that created the excess in weight and fats secondary and tertiary prevention.
It is best if done on the primary prevention
PHASE II:
Begin adding back some of the banished fods BUT will NOT be able to Immunizations
have all of them all the time -always primary prevention!
Expected results: if the patient already got the infection, this defeats the purpose.
Will continue to lose weight. Will have to remain in Phase II until the 1. Rubella 6. Anti-=influenze +H1N1
desired weight is achieved. Weight loss is 1-2 lbs a week 2. Hepatitis B 7. Pneumonia
Rationale of weight loss: 3. Hepatitis A 8. Varicella
Will still enjoy the food again but less enthusiastically 4. Tetanus 9. Typhoid
5. Polio 10. human papilloma virus vaccine
PHASE III
Diet throughout life Rubella Vaccination/measles/mumps/german measles
Will eat normal foods in normal-sized poritons Rational
Expected results: -occurrence of congenital defects is
Will maintain ideal body weight -50% or greater if infection occurs during the first month of gestation,
Will significantly alter blood chemisty -20-30% if during second month,
Rationale of weight loss: -and 5% if during the third or fourth month
maintenance of ideal body weight -commonly given at 12 months
*vegetable based diet --if given before 12 months (ex. 9 months), should be given boosters or
in combination (MMR)
Moderate alcohol consumption (age of last birthday- is a prarameter used in immunization)
Male -limit to  2 drinks/ day Common anomalies
Female and lighter wieght persons -limit to  1 drink /day -cataracts, retinopathy, congenital glaucoma
*1 drink= 12 oz beer/ 5 oz wine/ 1.5 oz 80 proof whiskey -patent ductus arteriosus
french paradox-risk for CVD- is lessened- wine drinking country -sensinoneural deafness
wine -mental retardation
- rich in resveratrol Schedule
- powerful antioxidant against heart disease -MMR I at 12 to 15 months
-skin of grapes -MMR II (booster) at 4 years old and above
-protect your cardiac status (if given two years old you need a booster)
more than 1 drink intoxication (if given at four years old you only need one)
-cannot be cummulative -MMR to all women not vaccinated previously (f no available pure
-can be more than 1 drink occasionally not to get drunk rubella vaccine)
-not good if you don’t really drink alcohol side effect Precautions
Aerobic exercise -no pregnancy within28 days of immunization
-cardio benefit males though do not directly affect the development, should still be
-brisk walking walk very fast, does not enlarge the heart vaccinated
-ballroom dancing--salsa *HAVE YOUR VACCINATION, because in the future you will be exposed
-biking to these disease
-swimming-learn to swim *review your vaccination schedule

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 Hepatitis B Vaccination Anti-pneumonia
Rationale Schedule
-Hepatitis B infection may result in severe disease in the mother and CHILDREN
chronic disease in the newborn (80-90%), adult (10-20%) -given starting 2 y/o
Schedule ADULTS
-0, 1 and 6 months -given at 50 y/o and repeated after 5 years
Precautions -strongly recommended at age 50 y/o together with anti-influenza
-pregnancy is not a contraindication to immunization in women
 HBsAg (hepatitis B surface antigen) Varicella/Chickenpox
 HBsAb or Anti-HBs (hepatitis B surface antibody) Schedule
What is the hepatitis B surface antigen (HBsAg)? -preferably given after 1 y/o with booster at 4 y/o
-given for 2 doses at 1 month interval if first dose is given at 4 y/o or
-This tests for the presence of virus. A "positive" or "reactive" HBsAg test
older
-result means that the person is infected with the hepatitis B virus,
--which can be an "acute" or a "chronic" infection. Typhoid
-Infected people can pass the virus on to others through their blood and Schedule
infected bodily fluids. -oral or intramuscular given every 3 years
What is the hepatitis B surface antibody (HBsAb or anti-HBs)? Secondary prevention
-A "positive" or "reactive" HBsAb (or anti-HBs) test result -early intervention to detect and treat asymptomatic disease
--indicates that a person has successfully responded to the hepatitis B -colorectal screening, cervical cytological testing, blood pressure
screening and self-breast examination
vaccine or has recovered from an acute hepatitis B infection.
-This result means that you are immune to future hepatitis B infection
Digital Rectal Examination (DRE)
and you are not contagious. -screening for colorectal diseases
-This test is not routinely included in blood bank screenings. -screening for prostatic hypertrophy

Hepatitis A Vaccination Cervical Cancer screening

-seen in street foods with poor hygeine -is done every year except when abnormalities are identified for which a
Rationale repeat smear can be done 3-6 months later
-hepatitis A infection is highly communicable 1. Traditional Pap smear/ Papanicolaou test
Schedule -for early detection and prevention of cervical cancer
-0 and 6 months -high false- negative rate: 10-29%
specificity: 97-100%
Tetanus sensitivity: 29-56%
Rationale therefore, best suited for detecting high grade dysplasia
-prevention of neonatial tetanus 2. Thin Prep
Schedule -they address false-negative rate due to poor sampling, uneven cell
-Tetanus toxoid for 2 doses at least 2 weeks apart distribution or improper slide fixation
and second dose given at least 2 weeks before delivery
Precautions Process of Cervical Change
-tetanus toxoid is not contraindicated in pregnancy Metaplasia
-process of cell growth or cell repair which is benign
Polio Dysplasia
Precautions -increase in the number of cells formed which do not mature as
1. immunization during pregnancy generally should be avoided because expected
of theoretical risks to the fetus -the higher the grade of dysplasia, the more likely that it will progress to
2. Babies immunized with oral polio vaccines (OPV) invasive cancer
-polio virus may be excreted through the feces up to 2 weeks; therefore, -refer to gynecologist
pregnant mothers must exercise utmost care in hand-washing after
handling these babies Screening for hypertension
*feces must be disposed properly -start at 18 years old
Classification of hypertension
Anti-influenza Systolic (mmHg) Diastolic (mmHg)
Schedule Normal <120 <80
-annually starting 9 months of age Hypertension
-2 doses at 1 month interval for ages < 8y/o if receiving the vaccine for Stage 1 140-159 90-99
the first time Stage 2 160 and above 100 and above
-given 1 month before peak season -blood pressure reading at two separate intervals
-all other once yearly; never ending vaccine --140/90- high bp
-NOW COMBINED WITH H1N1; --140/60- high bp

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-- should be taken when the patient is in a well-rested position, feet on
the ground
Technique for measuring blood pressure
In the office: 2 readings, 5 minutes apart, sitting in a chair. Confirm
elevated reading on the contralateral arm
Ambulatory BP monitoring: indicated for evaluation of “white coat
hypertension”. Absence of 10-20% BP decrease dring sleep may indicate
increased CVD risk
Patient self- check: provides information on response to therapy. May
help improve adherence to therapy and is useful for evaluating “white
coat hypertension”

Physical Activity
-refer to exercise prescription
talk test- screening if your patient is fit for physical activity
ex. if the patient goes up the stairs and is gasping for breath- not yet
suitable
if he can go up and can still speak without gasping for breath, then he is
suitable to do physical activity

most frequent exercise: walking

-3x a week
-use appropriate sportswear
ex. basketball- use your own basketball shoes
Nutrition
A. Calcium
-osteoporosis
Natural sources:
1. Leafy green vegetables
-broccoli, kale and collards
2. Lime processed tortillas
3. Calcium-precipitated tofu
4. Soft bones of fish
-salmon and sardines
Before examining a patient’s breast, clearly state how the procedure will 5. Tips of poultry leg bones
be done step-by-step procedure Recommended Dietary Allowance (RDA)
Male Adults 1000mg/day
*undescended testis  palpation of testes in 2 y/o males prevent Female Adults
testicular CA Non-menopausal 1000mg/day
Post-menopausal on ERT 1200mg/day
Tertiary Prevention Post-menopausal w/o ERT 1,500mg/day
-settles established disease to avoid complications and disability and to *ERT-estrogen replacement therapy
assist in rehabilitation Deficiency: Osteoporosis
-medical and surgical therapy Risk factors for Osteoporosis:
Disease Prevention and Health Examination 1. age (>60 y/o)
1. Periodic health examination 2. gender (female)- estrogen protection
a. screening estrogen hormone supplement- risk of breast CA and osteoporosis
-secondary prevention 3. race (Asian)
b. periodic physical examination 4. low BMI (<19)
-annual PE -secondary prevention -screening 5. diet low in calcium and vitamin D
c. health risk appraisal 6. smoking
d. immunization and chemoprophylaxis 7. excessive alcohol or caffeine consumption
-immunization after PE, considered as primary prevention -osteoclast destroys your bone increase risk of osteoporosis
2. Health educational counseling -tea, chocolate, soft drinks, coffee
-alcohol- if you cannot tolerate even one drink- it’s not healthy for you
8. lack of physical activity
-osteoclast effect
9. drugs (steroids)

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Activities that enhance calcium metabolism Spina bifida:
1. moderate weight bearing exercises -400 mcg folic acid/day (women of child-bearing age)
-use of dumbbells, water-filled bottles -500 mcg folic acid/day (if a relative or child has NTD)
2. cessation of smoking Natural sources:
first-hand smoking- you yourself are smoking 1. green leafy vegetables
second-hand smoking- near an area where someone smokes 2. legumes
third-hand smoking- leaves effect on clothes 3. fresh fruits
3. avoidance of alcohol 4. liver
4. an adequate vitamin and mineral intake Supplements:
-calcium -more bio-available at cellular level
Objective: increase bone density -not subject to inactivation by cooking or food processing
-drink milk (usual Ca content of 1 glass- 150-200mg of Ca)
--drink in the right portion and mixture- to get the right amount of Stress awareness
nutrients from that milk
-vitamins C,D, B6, E, K
- -active vitamin D- sunlight evaluation of
Awareness of ID of specific
usual coping
--take calcium in portions, 500mg per meal stress stressors
methods
-zinc

relaxation and
coping
stress
strategies
management

Techniques that aid stress management:

1. Progressive relaxation
2. Meditations
3. Imagery or visualization
4. Biofeedback

Environmental sensitivity
-Integral dimension of wellness
B. Iron -advocate environmental consciousness and improvement of living
-anemia conditions
Heme Iron --chemical contamination
-more stable --air pollution
-meat products ---exposure to noxious substances caused from grilling food
Non-heme Iron ---smoking second-hand smoking
-from vegetables --noise pollution
-make sure not to overcook, to preserve Fe content --waste dumps to include toxic wastes
Natural sources:
1. Meat Role of physician:
2. Eggs -inform patients about these hazards
3. Vegetables -urge self-responsibility in monitoring environmental health
4. Fortified cereal products -advocate health promotion
Forms of Iron
Ferrous Sulfate 20% iron Common in the market
Ferrous fumarate 33% iron High Fe content; used in
pregnant women
Ferrous gluconate 12% iron If intolerant to other Fe
(Sangobion forms
Ferrous lactate 19% iron

C. Folic Acid
-important for RBC production
-derangement of methionine-homocysteine metabolism
was found in approximately 20% of Neural tube Defects (NTDs),
recurrent miscarriage and placental infarcts (abruption)

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