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TUTORIAL 1:

Medical student and doctor wellbeing and lifestyle Docs hav lower overall rate mortality rates lower rate of smoking related illness Poorer wellbeing on measures of mental health and drug and alcohol-related illness 4 most common stressors : o Talking to psiachiatric pt o Effects on personal life o Presenting cases o Dealing with death and suffering Strongest negative feelings : relationship with condultants Male % higher in psychological stress, anxiety, depression, suicide Sleep problem lead to sedative-alcohol abuse 45% medical students abuse alcohol and have used illicit substances

Work as determinant of health Monday morning : strokes and heart attacks Tuesdays ; headaches Winter : CVD events Weekends : reduced incidence of cardiac events

Burnout,mental health and errors Maslachs Burnout Inventory : emotional exhaustion, depersonalisation, lack of personal accomplishment Need self care for patient safety and reduce medical errors

Most frequent stressors: Time pressure to see pt Paperwork Phone interruptions

Most severe stressors: Threat litigation Cost of practice overheads Negative media comments

Interventions mindfulness based therapy 3 main dimension workplace stress: Control Support Demand

TUTORIAL 2: EXERCISE
CVD:

60-70% of VO2 max =

Obesity - Not just due overeating but also inactivity- energy saving devices - Pear distribution of fat predominantly on females- consume lots of money - Energy expenditure = resting basal metabolic rate +TEE +TEF - Metabolic syndrome- Syndrome X o Central obesity o HTN o Hyperlipidemia o Impaired glucose tolerance

CHF:

Osteoporosis DM:

Prevent or delay the onset of complications of IDDM and NIDDM Reduce the insulin requirements in well controlled IDDM Increase in muscle mass Aerobic fitness and energy expenditure

Weight bearing exercise Ca intake hormones

MSK Ostoporosis: dev of peak bone mass, maintain bone density, outdoor-increase sun exposure OA:increase mobility, stregth, diminish pain, stiffness and swelling, weight control General : maintain mobility, reduce incidence of falls, gain stregth, flexibility and balance Cancer: physical inactivity is a risk factor

Mental health: antidepressant and anxiolytic effects

dementia: protective against cognitive decline later in life and stimulates neuronal growth at any age. Improve academic performance by

Immunity:

The inactive:

Types: Aerobic - fitness and metabolic effects Resistance - strength and increase muscle mass Mobility- increase balance, flexibility and focus

'moderate intensity'= rise in RR, light sweating, healthy glow of the cheeks, 'healthy tired' at the completion, be able to talk The barrier: Lack of time : exercise in the morning prior to breakfast is better Lack of motivation: doc interest, encouragement and offer of supervision, training partner, commercial programs

Lack of money: walking is free Physical injuries: swimming

Prescription: Start slow Very vigorous exercise in a person who is not used to it is known to be a risk factor for sudden cardiac events Appropriate cardiac Ix- exercise stress test Changes is everyday activity level

At least 30-45 mins of moderate intensity on most of the day Weight management - need negative energy balance

Firstly get people to walk. Whatever activity they can do and for however long they can do it Double the number of steps taken in an normal day w/o added exercise VO2 max= 220-age

TUTORIAL 4: FOOD AS MEDICINE


1. Food? -fuel -obtaining energy -taste sensation and treat -example: -folic acid : prevent neural tube defect -omega-3 fats: cardio protective effect, anti-inflammatory effect, dementia reduction, lower cholesterol, reduce telomerase shortening -low GI food: manage and prevent DM -calorie restriction: reduce oxidative stress, cancer risk, heart disease, DM, greater longevity -coeliac: avoid wheat, barley, rye, oats 2. What influence food choices? -personal preference -habit -ethnic heritage or tradition -social interactions -availability, convenience & economy -+ve & -ve associations -emotional comfort -values -body weight & image -nutritional needs

3. Nutrients come from food? -energy: carbohydrates, protein, fats -fibre: carbs compound cellulose, hemicelluloses, pectin+lignin&gums -vits and minerals -H20 -phytochemicals -antioxidants Doctors & nutrition counselling 4. Reasons y doctors hv been slow to incorporate dietary advice into their Rx protocols: -lack of evidence/ evidence distribution -restricted time in consultations -limited information provided in training (under&post-graduate) -considered an unsophisticated intervention -too low key&not dramatic enough -pts poor compliance-tablets and fast food are easier -ve perception of healthy food 5. Lifestyle & nutrients -stress -increase bodys requirements for vit B2, B5, B6, C -alcohol-increase bodys requirements for vit B, C, Zn, Mg, Ca -OCP and abx -deplete d body of nutrients -vit D deficient (dark skin, reduce sun exposure, cultural): osteoporosis, MS, cancer, CVD, poor brain development, mental illness

Food concept 6. Dfrnces -colour -taste -texture -smell -seasonality-root vegetables autumn and winter, salad greens -heating/cooling qualities-chilli hot, ginger warming, salad greens -cooked vs uncooked 7. SLOW food -seasonal -local -organic -whole 8. Colour -orange&yellow: high in B-carotene (carrots)vit Askin, hair, nails, against night blindness, xtivates thymus gland & immune system, enhance RNA production -green: (spinach)detoxification, reduce inflammation, prevent bacterial growth in wounds, benefit for anaemia, 9. Seasonality

-winter: soups & casseroles incorporating root vegetables -summer: cooling light foods (salad vegetables) 10. Organic -hv soil as the best quality and nutrient density -no pesticides, insecticides, herbicides usage -results: -fruits&veges: higher levels of vit C, Fe & Zn -milk: more vit E -cheese: more nutrients -tomatoes, wheat, potatoes, cabbage, onions: more antioxidants -spinach, cabbage: more Fe, Cu, Zn 11. Preparation & cooking -Vit C -destroyed by heat -Broccoli -Ca protxtive effects -diminished by cooking -fresh has 3x more than cooked -effected by heat and light -cancer protective quality -higher in cooked tomatoes -hi levels than transported long distances & sitting in shops/home

-Folate -Lycopene

-Snap frozen vege

-Cook -Stir fry: minimise nutrient loss, tasty, good texture -Dont overcook -Light cooking and steaming better than deep-frying/prolonged boiling -Use little oil: enhances fat-soluble vits absorption and carotenoids -omega 3-fatty acids degraded by hi-temp.

12. Whole foods -supplements cant replace nutritious diet - lung cancer protection: natural B-carotene and natural and supplementation of Bcarotene -taking vit A, C, E, B-carotene

Food as medicine
1. Cancer -3 major risk fxtors: low intake vege&fruits, low phy xtivity, obese -Major contributors of to cancer: -diet -smoking -infxion -hormones -radiation -UV -alcohol

-occupation -pollution -inxtivity -obesity -depression -stress

Hi Ca risk - red meat -Weight gain: sweet drinks (colas & fruit squashes)

Low Ca risk -flax seed lignan frxion -allium & cruciferous vege - sulforophane -oral digestive enzymes & probiotics -fish -lower energy-dense foods (vege, fruits, wholegrains, h20, unsweetened coffee/tea)

-cabbage, broccoli, brussel sprouts, kale, watercress, bok choy, turnip and cauliflower: lightly cook and chewed: sulfurophane -garlic+onion: antibacterial, crushed, chopped or chewed -citrus fruits -oranges, grapefruits, mandarins & lemons, flavanones (anti-scurvy) & terpenes, reduce leukemia -grapefruit juice not to take with statins (block the liver enzyme) -red grapes -resveratrol inhibit the stages of disease development: initiation, promotion, progression, has antiproliferation and chemoprevention: -COX 1, 2 (induce apoptosis in tumor cells) inhibition -trigger p21-, p53 fx -DNA replication inhibition -phase S and G2 cycle arrest -enhanced vit D3 receptor expression -antiestrogenous effect in E2-dependent tumour -cereals, breads, pasta -hi fibre -low colorectal Ca -meat -hi risk in Ca -dietary fat -flaxseed oil -salt -hi risk stomach Ca -green tea -catechins, cervical lesions -strawberries, raspberries, blueberries, cranberries -hi antioxidants & proanthocyanidin -soy -against colorectal Ca -genistein, Tamoxifen drug like action -the earlier the better -still need to be cautious -tumeric -anti-inflammatory -apoptosis -anticarcinogenetic effects Prevention , early detection and management of colorectal Ca -energy intake -dietary fat -fruit and vege -fibre

-Ca2+ -selenium -antioxidant vitamins Symptoms that affects ability to eat: -loss of appetite -changes in weight -sore mouth/throat -dry mouth -dental and gum probs -changes in sense of taste or smell -N+V -diarrhoea -lactose intolerance -constipation -fatigue/depression Ornish Program prostate Ca -Soy -Fish oil -Vit E -Selenium -Vit C -Moderate aerobic exercise -Stress mx techniques -1 hr support group

The Gerson therapy regimen -fresh, raw carrot/apple and green-leaf juices -vegetarian meals -fresh fruit dessert -supplements and enemas regime 2. Diabetes -Diabetes Prevention Program Research Group and Finnish Diabetes Prevention Study -plus metformin -individualised counselling advice on achieving the intervention goals: -aim at reducing weight -fat total intake less than 30% -low saturated fat intake -increasing fibre -moderate exercise of 30 mins per day Type of carbs Low GI food

-decrease postprandial BG rise -increase satiety -promote weight loss -improve insulin sensitivity -enhance lipid profile

-absorbed into the blood stream very slowly : consistent glucose flow into the blood over a long period of time Chromium -role in glucose and insulin control -found in wholegrain breads, etc.. -reduce risk of CVD -found in nuts, etc. -inversely associated with T2DM

Mg

3. Cardio disease Recommended diet: -fruit n veges -whole grain cereals and cereal products -low in saturated and trans fatty acids, achieved by replacing with PUFA and MUFA -low in added salt -hi in dietary fibre DASH (Dietary Approach to Stop HT) - Dietary to lower BP -veges, fruit, low fat dairy food (fish, poultry, whole grains, nuts, reduce red meats, fats, sugarsweetened foods and beverages, limit alcohol) -rich in K+, Mg, fibre, Ca2+, protein, low saturated fatty acid, low total fat & cholesterol CoQ10 -antioxidant in red meat -useful in ppl with CCF -improve the efficiency of energy produxion in the heart muscle -hv anti-atherogenic effects, +ve effects on endothelial dysfx, cardiac contractility, anti-aggregatory ability -low levels would lead to impaired anti-oxidant protection oxidative stress -statins reduce CoQ10 Legumes and soy-lower LDL cholesterol Nuts and seeds-Mg2+ (normal heart rythm, low triglycerides, lower BP), omega 3 fats, can also weight gain Tea-antioxidants, prevent fatty deposits build-up, anti blood clotting agent, improve blood vessel dilation Food contain vitamin E -antioxidant, against bad cholesterol, Garlic & onion-contains allicin, lower blood cholesterol, antiHT Ginger-anti platelet action, anti nausea B3 niacin-symptoms of deficiency (Dementia, Dermatitis, Diarrhoea, Death) Promegranate juice-reduce cardiac ischemia, antioxidants Mediterranean diet

Polymeals-wine, fish, dark choc, fruit, vege, garlic, almonds 4. Menopause -soy bean (genistein and diadezin) Super foods-(rich in particular nutrients) -linseeds (omega 3), honey (abx), garlic (lower cholesterol), etc.

TUTORIAL 5: LONGEVITY
Predictors of longevity -public health, sanitation, deprivation, contemporary diet (fast and processed food), over nutrition Aspects associated with poor health and shorter life: -excessive alcohol -smoking -little physical activity -being obese -sleeping fewer/more than 7-8 hours -eating between meals -not eating breakfast Other aspects -social connectedness and personal relationships -mature coping mechanisms depression, happiness -role of meaning

THE DALY -how many years an illness might take off life-expectancy -relative disability that one lives with due to illness -ischemia HD, Ca, HIV, etc. Life expectancy in the future Potential prob -inc level of obesity, inxtivity, and T2DM in children -diminish h20 and air quality - inc substance abuse, illicit & prescribed - inc stress, anxiety, depression level in young ppl -economic effects of overcrowding, poverty, inequity, especially, for subgroups of urban population -increasing long term effect of social isolation -reduction in protective effect of spirituality in d community -increase rates of medical prescribing and technology ass. with increase in medical misadventure and interactions -trends in employment -potentially ve impact of some forms of medias, music, IT -potential wild-cards

Community may need to get back to basics -community building -relationships -education -health promotion

Tutorial 6: Meaning and Health


1. Widespread decline in mental health in Western society- Lack of meaning and spiritual fulfilment in increasingly secular and materialistic society 2. We are more often concerned with risk factors of youth suicide, violence and depression compared to protective factors for them. 3. Religiosity (religious commitment-R/C)- Participation in or endorsement of practices, beliefs, attitudes, or sentiments that are associated with an organised community of faith 4. Extrinsically religious VS Intrinsically religious- Intrinsic more protective for mental health 5. Spiritual- personal views and behaviours that express a sense of relatedness to the transcendental dimension or to something greater than self (harder to define) 6. Religiosity and Spiritual overlaps enormously BUT they are not the same. 7. R/C associated with a reduced incidence and quicker recovery from depression for elderly. 8. Medical staff that have least likely religious beliefs are psychiatrists- They call themselves spiritual but not religious. 9. Doctors with strong religious beliefs are less likely to refer to psychiatrists and more likely refer to clergy or religious counsellors for mental health problems. 10. It is important to incorporate spiritual and religious in management of patients 11. Clinicians should not prescribed refer to clergy or religious counsellors. 12. Spiritual history taking 4 simple questions: a. Is faith (religious, spirituality) important to you? b. Has faith been important to you at other times in your life? c. Do you have someone to talk about religious matters? d. Would you like to explore religious, spiritual matters with someone?