动员患者采取健康生活方式

MotivatingOurselvesandOurPatientstobeHealthy鼓励我们自己和病人保持健康MarieShieh,M.D.2008October241谢医师简介Americanboard-certifiedfamilyphysicianpracticingmedicineinBeijingforthelast6yearsatBJU.Ihad3yearsexperiencebeforethatintheU.S.andNewZealandinprivatepractice.Iammarriedwith2sons.

IhavewantedtobeafamilyphysiciansinceIwas4yearsold.美国家庭医学科专科医师，近六年在BJU工作。曾在美国和新西兰从事私人医生职业3年。我已经结婚并有2个儿子，我从4岁起就想成为一名家庭医生了。2Patientstory病人的故事40yearoldAsianwoman40岁亚裔女性Fulltimejoband2children全职工作和两个孩子NonsmokerandnoETOH不吸烟不喝酒Diet:lessthan5vegetablesandfruitsdaily食谱：每天少于5种蔬菜水果Activity:onceperweek运动：每周一次Wellbeing:stressedandtiredmuchofthetime健康状态：压力很大，大部分时间困倦BMI23.5BMI23.5Nottakingregularmedicationforchroniccondition未因慢性病规律服药3Whatisahealthylifestyle?怎样才是一种健康的生活方式?Notsmoking不吸烟Gooddiet良好饮食Physicalactivity体育活动Wellbeing安康快乐FollowingDoctor’sadvice听从医生的建议4SmokingandTobaccoUse

吸烟与烟草制品使用Howmaymenworldwidesmoke?世界上有多少男性吸烟？1outof3men三分之一的男性Howmanyteens(13-15yo)smoke?有多少未成年人（13-15虽）吸烟？1in5teens五分之一未成年人Howmanychildrenstartsmokingeveryday?每天有多少孩子开始吸烟？80-100,0001/2oftheseareinAsia其中一半是在亚洲MultipleHealthRiskstoSelfandFamily对自身和家人的多重健康威胁BadBreath口臭Earlywrinkles早生皱纹YellowTeeth黄牙Money耗费钱财5HealthyDiet健康饮食Colorfulandvariety色彩鲜艳且种类多Vegetablesandfruits-5servings(7-9ideal)蔬菜与水果5份（7-9份最理想）Wholegrains全谷类Notmuchfattyfoodslikemeatsanddairy没有太多脂类食物例如肉类与乳制品2-3portionsoffish2-3份鱼Limitsaturatedfat-iffryinguseolive,canola,sunflowerorrapeseedoil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USPTF1996andJAMA2002;288:2569and6VegetablesandFruits蔬菜与水果Wholegrains全谷类Dairy乳制品Processedfood加工食品BeansandMeats豆类与肉类7PhysicalActivity体育运动Aging老年HeartDiseaseandDiabetes心血管疾病以及糖尿病ColonandBreastCancer结肠和乳腺癌MusculoskeletalProblemsandOsteoporosis肌肉骨骼问题与骨质疏松DepressionandAnxiety抑郁和焦虑MostAmericans-nophysicalactivity大部分美国人-没有体育运动Australians:65%donotmeetminimalactivity澳大利亚人：65%没有达到最低运动量China?中国？Whatisminimumactivity?什么是最低运动量8Breastcancerandexercise

乳腺癌与运动ArchivesIntMed2007:110,000women,20-79yearsold.6yearstudy.110,000名年龄20～79岁的妇女，长达6年的研究5hourswalkingperweekvslessthan0.5hoursperweek每周5小时不行vs不足0.5小时20%reductioninbreastcancer(RR0.8)乳腺癌风险降低20%（RR风险比0.8）Lessinvasivecancer-ER+inexercisegroup较低度恶性肿瘤－在运动组中ER＋JAMA2003Prospectivestudy－70,000women.50-79yearsold.5yearstudy.前瞻研究－70,000女性50～79岁，5年研究14-18%reductioninbreastcancer乳腺癌减少14~18%BestifwomenwerebelowBMI24.1体重指数低于24.1最佳Overweightwomenalsobenefited超重妇女同样收益于运动10hoursperweekbriskwalkingbest每周10小时快走最佳1.25-2.5hoursalsobeneficial1.25~2.5小时同样有益9PancreaticCancerandExercise

胰腺癌与运动JAMA2001-cohorttrial队列研究46,000menand100,000women46,000男性和10,000女性ForthosewithBMIover25,exercisesignificantlyreducedriskofpancreaticcancer对于体重指数高于25者，运动显著减少胰腺癌的风险10ColonCancer

结肠癌与运动CancerCausesControl1997-metaanalysis癌症病因控制1997－荟萃分析Inverserelationofexercisetocoloncancer运动和结肠癌之间的反比例关系50%reductioninincidenceofcoloncancerinthemostactiveparticipants最积极运动者结肠癌发病率降低50%BritishJournalofCancer2001-prospectivestudy不列颠癌症杂志2001－前瞻研究75,000Norwegians75,000挪威人12yearsfollowup12年随访Inverserelationofexercisetocoloncancer运动和结肠癌之间的反比例关系BMInotcorrelatedwithcoloncancerrisk体重指数和结肠癌风险之间不相关11DepressionandExercise

抑郁与运动PsychosomaticMedicine2000身心医学2000156adultswithMajorDepressiveDisorder156名重度抑郁成人HamiltonandBeck’sscoresover10months进行10个月Hamilton和Beck评分3groups:Equallyeffective3组同等有效Sertraline(zoloft)-fastestresponse

舍曲林－反应最快Exercise-lowerrelapserate运动－复发率低Sertralineandexercise二者联合12Howmuchphysicalactivity?多大的运动量合适？

(NationalPhysicalActivityGuidelinesforAustraliansandUSCDC

澳大利亚国家体育运动指南）13IntensityofExercise

运动强度60-75%ofmaximumheartrate最大心率的60~75%"Maximumheartrate=220-age

最大心率＝220－年龄

75%ofmaximumheartrateisthedesiredrateformoderatetoheavyintensityexercise“75%最大心率是中度到剧烈运动的目标心率14Linkbetweenfitnessandlongevity健康与长寿之间的联系Inthelargeststudytoexaminethelinkbetweenexercisecapacityandmortalityriskinaraciallymixedcohort,mortalitydropped12%to15%withevery1metabolicequivalentinexercisecapacity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.PublishedonlineJanuary22,2008NEJM2002studywith6000men:12%improvementinsurvivalwithevery1METofexercisecapacity。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%。FitnessorMETexercisecapacityisdirectlylinkedtoamountofexercise健康或者代谢当量运动能力与运动量直接相关。StresstreadmilltocheckourMETcapacity踏旋器应力试验可测量我们的代谢当量能力。15Circulation200316Actualyearsgained实际可多活的年数17HealthandWellbeing健康福祉HostilityandHeartDisease敌意与心脏病HostilityandLungFunction敌意与肺功能Alsoassociatedwithmoredaysoffwork也与更多假日相关18HostilityQuestions敌意问询AttimesIfeellikesmashingthings有时候我想要把东西砸碎Ieasilybecomeimpatientwithpeople我很容易对人失去耐心I’vebeensoangryattimes,I’vehurtpeopleinafight.有时候我非常生气以至于在打架时伤害了别人。19CharacteristicsofPhysicians
that

IncreaseRiskforBurnout

增加医生对工作失去兴趣机会的特质Perfectionismandcompulsiveness完美主义和强迫人格Needforcontrol什么都要管Exaggeratedsenseofresponsibility过分的责任感Difficultyaskingforhelp较难求助于人Excessive,unrealisticguilt过多的不现实的内疚Suppressionoffeelings情感的压抑Difficultytakingvacationsandenjoyingleisuretime较难休假和享受闲暇时光20FollowingDoctor’sRecommendations

听从医生的推荐Lifestylechanges生活方式改变Followupappointments回诊Otherremedies其他疗法Prescribedcoursesofmedications开几个疗程的药Surgery手术21Canwemakeadifference?

我们能起作用么？Evidencesupportsdoctor’sinterventioninquittingsmoking有证据支持医生帮助戒烟的作用Evidencesupportsphysiciancounselingaboutexercise有证据支持医生建议运动的作用Evidencesupportsphysiciancounselingaboutdiet有证据支持医生建议饮食的作用Evidencesupportsphysiciancounselingaboutwellbeing有证据支持医生建议福祉的作用Evidencesupportsphysiciansupportedhealthcare有证据支持医生参与的医疗保健22Motivation动机Intrinsic内部的Internalsatisfaction-feelingbetter内心满足-感觉更好Betterhealth更健康LoveandAcceptanceinternal自身的爱与接受Extrinsic外部的Externalreward-lookingbetter外部奖励-看起来更好Approval-loveandacceptanceexternal鼓励-外人的爱与接受Connection关系PositiveFeedback正性反馈23FiveA’s五个AASK询问ADVISE建议ASSESS评估ASSIST协助ARRANGE安排AustralianFamilyPhysicianandAmericanFamilyPhysicianJournals2008Whitlock,EP,Orleans,CT,Pender,N,Allan,J.Evaluatingprimarycarebehavioralcounselinginterventions:anevidence-basedapproach.AmJPrevMed2002;22:26724ASKandLISTEN询问与倾听Doyousmoke?您吸烟么？Doyoueatatleast5vegetablesandfruitsaday?Breakfast,LunchandDinner您每天至少吃5种蔬菜水果么？包括早、中、晚餐Howmuchactivitydoyougetinatypicalweek?Whatkind?Howvigorous?您一般一周做多少运动？哪种？多激烈？Howislife?Howiswork?Howisyourmarriagegoing?Howisyourfamily?Doyouhavegoodsupportsaroundyou?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？Areyoufollowingyourdoctor’sadvice?您是否听从您的医生的建议？Anythingelse?还有其他问题么？25ADVISE建议EDUCATE教育Handouts印刷品CD’sCDDVD’sDVDWebsites网页Localresources当地资源BESUPPORTIVEANDNONJUDGMENTAL(ofyourselfandyourpatients)要支持不要评判（对你自己和你的病人）26ASSESS评估Howwillingareyouoryourpatienttomakechanges?您或者您的病人有多愿意做改变？Doyouwanttoquitsmoking?您是否愿意戒烟？Doyouwanttobemoreactive?您是否希望更积极？Areyoureadytochangeyourdiet?您是否准备改变您的饮食？Howbalancedisyourlife?您的生活有多平横？QuestionnairesandTools问卷与用具27QuestionairesandTools

问卷与用具TranstheoreticalModel跨理论模式Precontemplation预期前Contemplation预期Preparation准备Action(20%)行动（20%）Motivation动机Relapse回复WheelofLife生命之轮HPAmericanLungAssociationquestionnaire美国肺脏协会问卷28Smokingquestions吸烟的问题Doyousmokeyourfirstcigarettewithing30minutesofwakingupinthemorning?您是否在早晨醒后30分钟之内吸您的第一根香烟？Doyousmoke20cigarettesormoreaday?您是否每天吸烟20支或者更多？Attimeswhenyocan’tsmokeordonothavecigarettes,doyoucraveone?有时候当你不能吸烟或者没有烟，你是否会渴望获得一支？Isittoughforyoutokeepfromsmokingformorethanafewhours?几个小时不吸烟对你来说是不是很难？Whenyouaresickenoughtostayinbed,doyoustillsmoke?当你卧病在床时候是否仍然要吸烟？Yesto2ormore,addictedtocigarettes.2个以上回答是即为吸烟成瘾。29SmokingTriggers吸烟的触因Eating饮食Alcohol喝酒AfterSex性交之后Coffee咖啡Driving驾驶Askyourpatientabouttheirtriggers询问您的病人他们的触因30ASSISTandAGREE协助与赞同Barrierstolifestylechange

(Risk)生活方式改变的障碍（危险）Benefitstolifestylechange(Benefit)生活方式改变的收益（收益）SMARTgoalSMART目标ContractsandRewardsandConsequences合同、奖励与后果Lifestyleprescriptions生活方式处方Helpfromfamilyandfriendsandcommunity来自家庭、朋友和社区的帮助Homeworkforpatients病人的家庭作业Medicationtohelpquitsmokingorhelpwiththeirdisease帮助戒烟或治疗病人疾病的药物31Barriers障碍Negativethoughts负面的想法Fear恐惧Habit习惯Laziness懒惰Fatigue疲劳LackofTime没有时间LackofMoney缺钱NotKnowing不知道32Benefits收益Imaginehowyoufeel?想象一下你的感觉Imaginehowyoulook?想象一下你看起来会怎样Imaginehowyousmell?想象一下你闻起来会怎样HealthandLongevity健康长寿Rewards–ceremony奖励-庆典Imaginewhatyourfriendsandfamilywillsay想象一下你的家人朋友会怎样说Imaginewhatyourdoctorwillsay想象一下你的医生会说什么FinancialBenefits经济收益33SMARTGOALSSMART目标Specific详尽Measurable可测Achievable可达Accountable可靠Results/RewardOriented结果/奖励为导向TimeSpecific时间具体34LifestyleprescriptionsandContracts生活方式处方与合同Writeonprescriptionpad书写于处方笺1copytopatient,anothertochart一联给病人一联留在病历Contractwitharewardorpunishment签订一个奖励或处罚合同Contracttodosomething为做某事签的合同Appointreferee任命裁判Ifyoudonotfulfillyourcontract,moneyisdonatedtocharityororganization如果没有履行自己的合约，钱会被捐往慈善事业或者机构RedCross,CARE,DoctorsWithoutBorders,FeedtheChildren,NatureConservancyandmore红十字会，CARE，无国界医生等等35ContractsandSocialPsychology

合同与社会心理学-foundedbyYaleEconomicsProfessorDeanKarlanContracttodosomething为做某事签的合同Appointreferee任命裁判Ifyoudonotfulfillyourcontract,moneyisdonatedtocharityororganization如果没有履行自己的合约，钱会被捐往慈善事业或者机构RedCross,CARE,DoctorsWithoutBorders,FeedtheChildren,NatureConservancyandmore红十字会，CARE，无国界医生等等Moneycanalsobegiventoorganizationyouoppose金钱也可交给你反对的组织BasedonBehavioralEconomics建立在行为经济学上1.Peopledon‘talwaysdowhattheyclaimtheywanttodo,and人们并不总能做到他们宣称想做的事，并且2.Incentivesgetpeopletodothings诱因或刺激物促使人们行动起来36Communityresources社区资源Accountability可靠性Fellowworkmates同伴同事Friends朋友Family家庭You你Yourboss你的老板Groupsupportslike类似AA的支持小组Yourdoctor你的医生WellnessProgram健康计划37ARRANGE安排Followup随诊AsymmetricalPaternalism非对称性家长主义SetupNextAppointment,Now现在就定好下次回诊时间SetupNextBloodTest,Now现在就定好下次血检MakeReferralAppointmentNOW现在就定好转诊看病时间MAKEITHARDERTODOTHEUNHEALTHYTHING(Patientha