EVIDENCE – BASED WELLNESS FOR ANESTHESIOLOGISTS

Robert S. Holzman M.D., MA. (Hon), FAAPChair, Committee on Occupational Health, American Society of Anesthesiologists

Senior Associate in Perioperative Anesthesiology, Children’s Hospital Boston

Professor of Anaesthesia, Harvard Medical SchoolBoston, 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 Compositionsof 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 LoadThe 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

Physical entrapment

Viscosity of fiber

Sugar content

Fat content

Protein content

Acid content

Food processing

Cooking

Type of Starch

• Absorbs less water• Molecules form tight clumps• Slower rate of digestion

• Absorbs more water• Molecules are more open• Faster rate of digestion

Amylose Amylopectin

Lower GI

Kidney beans (28)Uncle Ben’s converted LG rice

(50)

Higher GI

Russet potato (85)Glutinous rice (98)

Physical Entrapment

Endosperm

Bran

Germ

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)

Viscosity of Fiber

Viscous, soluble fibers transform intestinal contents into gel-like matter that slows down enzymatic activity on starch.

Lower GI

Apple (40)Rolled oats (51)

Higher GI

Whole wheat bread (73)Cheerios (74)

Fat & Protein ContentFat and protein slow down gastric

emptying, and thus, slows down digestion of starch.

Lower GI

Peanut M&M’s (33)Potato chips (54)

Special K (69)

Higher GI

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

Sourdough wheat bread (54)

Higher GI

Wonder white bread (73)

Cooking

Cooking swells starch molecules and softens foods, which speeds up the rate of digestion.

Lower GI

Al dente spaghetti – boiled 10 to 15 minutes (44)

Higher GI

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., FAAPProfessor of Anaesthesia

Children’s Hospital BostonHarvard 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 = 40-

50• 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

• 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

Why is VO2 max Important?

• 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.

• 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).

What Should I Be Doing?

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 LOSS6 months 18 months

< 150 min/wk 7 lbs 3 lbs150-200 min/wk 11 lbs 9 lbs

200+ min/wk 13 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.

• 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.

A lifestyle approach can reduce the likelihood of developing type 2 diabetes by 58%:

• 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 theHealth 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 outcome-based 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.”

• But the program began in 2008Wall Street Journal, June 12, 2009:A15

“Misleading claims about Safeway wellness incentives shape health-care bill.” Washington Post, January 17, 2010:G01

CONCLUSIONS & RECOMMENDATIONS1. Lose 5% to 10% of body weight if overweight or obese.2. 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, fat-free (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

Robert S. Holzman M.D., MA. (Hon), FAAPChair, Committee on Occupational Health, American Society of Anesthesiologists

Senior Associate in Perioperative Anesthesiology, Children’s Hospital Boston

Professor of Anaesthesia, Harvard Medical SchoolBoston, MA

WATCH FOR THIS PRESENTATION ON THE ASA WELLNESS WEBSITE:

https://www.asahq.org/Home/ForMembers/MyASA/WorkLifeBalance.aspx

robert.holzman@childrens.harvard.edu