The Health Promotion of the Unsuspecting Individual


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The Health Promotion of the Unsuspecting Individual

  1. 1. HEALTH PROMOTION OF THE UNSUSPECTING INDIVIDUAL In accordance with HIPAA Federal Law (The Health Insurance Portability and Accountability Act of 1996), this human subject has given explicit consent for use of her identifiers. Presentation by: Heather L. O’Leary
  2. 2. WHO? Lois, a 71-year-old Caucasian female, retired from administrative assistant positions
  3. 3. HEALTH HISTORY • Type II Diabetes Mellitus for 16 years • Hypertension for approximately 30 years • Dyslipidemia for approximately 20 years • Coronary artery disease status post PTCA with stent of LAD March 2007 • Degenerative disks with two herniations for approximately 25 years • Osteoarthritis for approximately 25 years
  4. 4. HEALTH ASSESSMENT • Body mass index at lower end of obesity range (value withheld per patient request) • Waist-to-hip ratio indicative of android figure (value withheld per patient request), thus increasing risk of obesity-related diseases and early mortality (Jarvis, 2004) • Hemoglobin A1c 6.4% (high); HDL 35mg/dL (low); LDL 70mg/dL (normal); triglycerides 130mg/dL (normal) as of September 3, 2008 • Blood pressure 128/72; resting pulse 78, regular; respirations 14, regular, even, and unlabored; temperature 36.8°C • Medications include Glucophage 800mg twice daily; Amaryl 1mg daily; Byetta 10mg twice daily; Lipitor 40mg daily; Toprol XL 50mg daily; Norvasc 5mg daily
  5. 5. Psychosocial and Cultural Concepts • Middle-class, suburban dweller entire life; residency solely limited to Lorain, Ohio • High-school education, with some college courses, but no degree/diploma • Divorced after 16 years of marriage in 1986 with two daughters • Born at the end of the Great Depression; heard many recounts of period, but does not feel as though ever personally affected • Practicing Jehovah’s Witness • Full confidence in Western medicine; skeptical of holistic approaches • Maintains network of friends with regular scheduled and unscheduled outings • Never considered self physically active “because ladies were not . . . unless housework counts”
  6. 6. “ No, because ladies were not expected to be physically active “ unless housework counts. ” EXERCISE?
  7. 7. Psychosocial and Cultural Concepts (continued) • Ex-smoker, 3 pack-per-day habit, beginning at age 15 until age 44 with short periods of cessation secondary to quitting attempts and pregnancies • Socially consumes alcohol, 2 drinks biweekly • Relates not experiencing much stress after retiring six years ago, with the exception of occasional financial concerns; recognizes that such concerns are often due to “retail therapy” • Expresses some distaste for polypharmacy secondary to act of consumption itself alone
  8. 8. Health Beliefs • Acknowledges having some control over health (e.g. improving diet and increasing physical activity) yet states, “It is also taken care of with medicine.” • Recent visit of similarly-aged friend in nursing home revealed new perspective: “I guess I should be very thankful I’ve been so fortunate with my health. Before seeing her, I just thought I was old and felt average for my age.” • Now rates health as “above-average” but recognizes “room for improvement”
  9. 9. VS “ [My health] is also taken care of with medicine.
  10. 10. RISK FACTORS • History of diabetes, hypertension, dyslipidemia, and coronary artery disease • Familial history of paternal hypertension and multiple cerebrovascular accidents, paternal multiple falls with resultant hip fractures; questionable maternal diabetes with vascular disease, maternal myocardial infarction; sister with ovarian cancer, hypertension, coronary artery disease with three myocardial infarctions; brother with hypertension and multiple stents secondary to coronary artery disease • Lack of regular physical activity • Lack of health-conscious diet • Non-adherence to regular measurements of blood glucose levels • Mild obesity
  11. 11. DO YOU MONITOR? “ Sometimes it’s just easier not to know what my sugar is. ”
  12. 12. …time for change! PLAN OF ACTION #1 Education #2 Discussion
  13. 13. PART ONE: Education
  14. 14. Education: PASS ON DESSERTS Teach implications of less-than-optimal diet and failure of self-monitoring blood glucose: #1 Risk for fractures #2 Diabetic complications, including worsening of coronary artery disease (i.e. additional PTCA/stents/possible bypass) as well as cerebrovascular accident, vascular issues, neuropathy, nephropathy, retinopathy and subsequent diagnoses (American Diabetes Association, 2008)
  15. 15. BLOOD IS THICKER Education: THAN WATER Correlate implications of history: Correlate implications with particular emphasis on diabetic complications with personal and familial health histories to show relevancy
  16. 16. Education: LET’S GET PHYSICAL Teach implications of physical inactivity: Provide information regarding physical activity improving current conditions, and delay and/or prevention of others (American Heart Association, 2008; National Institute of Diabetes and Digestive and Kidney Diseases, 2006)
  17. 17. Education: KEEP ON PRICKIN’ Teach implications of poor blood glucose monitoring: Provide information regarding blood glucose control and effects upon present diagnoses and possible complications of poor control; show chart explaining identical Hemoglobin A1c of 8.0% being not indicative of good glucose control as chart proves can be great daily variances during 30-day measurement period, 1/3 less than the required 90 days to determine A1c value (Kovatchev, 2007)
  18. 18. (American Diabetes Association, 2008)
  19. 19. Education: KEEP ON PRICKIN’ Teach implications of poor blood glucose monitoring: Reinforce necessity of daily glucose checks as “HbA1c levels increase steadily as the number of lipid abnormalities increase . . . [with] low HDL [being] the most common high-risk abnormality (59.8%) . . . and women [being] much more likely to have multiple lipid abnormalities” (Brown, Nichols, Hayes, & Bowman, 2004) Capitalize on “lifestyle changes” aspect to include “glycemic control”
  20. 20. Education: IT’S NEVER TOO LATE Teach value of physical activity: Enforce research that has determined “it’s never too late to become physically active” and that “even a small amount of activity can result in better health” (Agency for Healthcare Research and Quality and the Centers for Disease Control, 2002)
  21. 21. Education: PLAY “RATE YOUR PLATE” Teach value of a well-balanced meal: Play “Rate Your Plate”, available from the American Diabetes Association on diabetes/chan_eng/i3/i3p4.htm; results were Lois’ plate often consisting entirely of carbohydrates, as opposed to the ¼ recommendation; discussed proportions of ½ non-starch vegetables and ¼ lean protein (American Diabetes Association, 2008)
  23. 23. HEALTH DISCUSSION: BELIEFS Although the Health Belief Model is only appropriate for disease- preventing behavior as opposed to health-promoting, Lois contends that,“nothing quite motivates me like a threat” (Pender, Murdaugh, & Parsons, 2006)
  24. 24. PERCEIVED DISCUSSION: BENEFITS + Perceived benefits to action are verbalized as “my health won’t deteriorate as quickly without the changes”; “maybe I won’t have to take as many pills”; and “since I have such an addictive personality, maybe I can make this a habit”
  25. 25. PERCEIVED DISCUSSION: BARRIERS - Perceived barriers to action are verbalized as “I find exercise boring”; “I have never enjoyed sports”; and “I don’t want to hurt myself . . . I can be so clumsy”
  26. 26. INCREASING DISCUSSION: PHYSICAL ACTIVITY Emphasized benefits and addressed barriers; discussed how regular physical activity can increase coordination as well as means of finding enjoyable activities and Lois decided upon walking: one 15- minute session of walking either outdoors or on the treadmill agreed upon for the first week for 3 days, increasing to 4 days the next, and 5 days the following; once 5 days of activity is achieved weekly, the time spent shall increase by 5 minute increments weekly
  27. 27. FOOD & DISCUSSION: BLOOD GLUCOSE MONITORING • Carbohydrates will be decreased to ½ or less of the plate for one month, then to ¼ the next month • Blood glucose levels will be checked daily for one month then results to be discussed with her endocrinologist to determine any further adjustments necessary
  28. 28. DISCUSSION: SUPPORT Both the level of readiness and barriers were evaluated to be relatively low, necessitating high-intensity cues—e.g. her “retail therapy” was dependent upon adherence to physical activity agreement; friends and family were recruited as support; primary care physician, cardiologist, and endocrinologist were informed of plan
  29. 29. RESOURCES
  30. 30. AMERICAN RESOURCES: DIABETES ASSOCIATION • Founded in 1940, the mission is “to prevent and cure the lives of all people affected by diabetes” • Vision is “to make an everyday difference in the quality of life for all people with diabetes”; core values are “integrity, leadership, ownership, inclusion, trust, [and] passion for making a difference” • ADA “funds research, publishes scientific findings, provides information and other services to people with diabetes, their families, health health professionals, and the public. [It] is also actively involved in advocating for scientific research and for the rights of people with diabetes.” • The agency reports to the board of directors whose Chair is R. Stewart Perry • Senior management is overseen by CEO Larry Hausner • Departments include accounting, administrative and clerical, communications, community initiatives, customer service, finance, fund-raising, government relations and advocacy, human resources, information systems, legal, marketing, publications, and research
  31. 31. AMERICAN RESOURCES: DIABETES ASSOCIATION (continued) • Funding is via corporate and private donations • The National Office and Service Center in Alexandria, VA employs 302 people; other offices are dispersed nationwide, with the majority in the eastern half of the United States • The vast array of information provides an invaluable resource to Lois; she has located a support group at St. John Westshore Hospital; she was astounded during the navigation of the site with the data available (e.g. diet, exercise, and solutions to common questions; she feels she is “much more inclined to find answers since I always forget while I’m in the doctor’s office. I also forget to bring the list of questions that I’ve written down. I don’t want to call and bother anybody, and hopefully I won’t forget by the time I reach the [ADA] website. Or forget the website. I tell ya, it’s you- know-what getting old!” (The ADA was made Lois’ homepage in order address the aforementioned.) (American Diabetes Association, 2008)
  32. 32. RESOURCES: WEIGHT WATCHERS • Founded in early 1960’s by Jean Nidetch by inviting a group of friends to her home to discuss weight loss strategies; mission now is “to help people lose weight in a sustainable way by helping them adapt a healthier lifestyle and a healthier relationship with food and activity” • The agency consults with a “Scientific Advisory Board” but ultimately defers members to their own private healthcare provider • David Kirchhoff is the president and CEO • Funding is received by donations, sales, and membership fees • Employees consist of leaders who conduct group meeting, weigh members, and provide motivation and instruction on the Weight Watchers plan; and receptionists who personally welcome, assist, encourage, and support members as well as collect and tally all fees and sales, weigh members, and distribute materials; no figure is available for number of employees
  33. 33. RESOURCES: WEIGHT WATCHERS (continued) • By supporting the recommendations of the American Diabetes Association, the American Heart Association, the National Institute of Diabetes and Digestive and Kidney Diseases, and the Agency for Healthcare Research and Quality and the Centers for Disease Control, Weight Watchers aims to “help make healthy eating decisions, and encourage [members] to enjoy [themselves] by becoming more active.” (Weight Watchers, 2008). • Lois admittedly attended her first meeting solely due to the interpersonal influence of her daughter: “If it will help you”; however, she found the meetings to be enjoyable and informative; by feeling “accountable every week to someone other than myself” she is motivated to pay closer attention to her intake and activity
  34. 34. EVALUATION: FOLLOW-UP • Lois has adhered to the plan in its entirety at the third week interval… perhaps under the not-so-accurate-and-not-corrected-when-presumed pretense that it affects the grade of the project. • She has lost 9 lbs. and her glucose monitors have ranged from 72-148. She has noticed a decrease in the blood glucose levels as her activity increases. She has an appointment with her endocrinologist October 30th, 2008 to review her medications and discuss the frequency of the glucose monitoring as she states on every occasion that an audience is present during her routine, “This [the fingersticks] is only because I love my children.” • Discussion with her primary care physician has led to repeat lipid profiles during the first week of December with referral to her cardiologist, as necessary.
  35. 35. EVALUATION: FOLLOW-UP • Lois has verbalized feeling “less achy” and an ability to now “power-shop” since she experiences less fatigue during the day “which I had never realized that I had before.” • Lois notes that it is at times difficult to initiate the physical activity, but once she has started, she consistently “feels so much better that I did, both physically and because I am honoring my commitment.” This positive activity-related affect increases her perceived self-efficacy, thus enabling her to continue the behavior with higher likelihood. She has also placed a television in front of her treadmill to enhance the situational influence of indoor walking. • Lois states that reducing her carbohydrate intake to ½ of her plate was “easier than I thought” because prior to her plan, she concedes to “never really paying attention to the type of food that I was eating.” She states that the ADA website and Weight Watchers meetings seem to compliment each other in their teachings.
  36. 36. HEALTHY PEOPLE 2010 OBJECTIVES Healthy People 2010 Objectives that have been addressed in this project are: • 5 -7 Reduce deaths from cardiovascular disease in persons with diabetes by implementing lifestyle changes, Lois has the capability to decrease her risk. • 5-17 Increase the proportion of adults with diabetes who perform self-blood-glucose-monitoring at least once daily. Lois has been adherent to this objective for 3 weeks and verbalizes commitment to the plan until speaking with her endocrinologist. • 12-11 Increase the proportion of adults with high blood pressure who are taking action (for example, losing weight, increasing physical activity, or reducing sodium intake) to help control their blood pressure.
  37. 37. HEALTHY PEOPLE 2010 OBJECTIVES Healthy People 2010 Objectives that have been addressed in this project are: • 22-2 Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day. • 22-4 Increase the proportion of adults who perform physical activities that enhance and maintain muscular strength and endurance. Lois has increased her physical activity to walking 20 minutes 5 times weekly and has lost 9 lbs. in 3 weeks. • 19-2 Reduce the proportion of adults who are obese. Lois states she has a better understanding of the term obese as it relates to body mass index values and has verbalized a goal of a BMI less than 30 before January 1, 2009.
  39. 39. REFERENCES • Agency for Healthcare Research and Quality and the Centers for Disease Control (2002). Physical activity and older Americans. Retrieved October 7, 2008 from • American Diabetes Association. (2008). The American Diabetes Association. Retrieved October 5, 2008 from • American Diabetes Association. (2008). Complications of diabetes in the United States. Retrieved October 5, 2008 from • American Diabetes Association. (2004). Dyslipidemia management in adults. Diabetes Care. Retrieved October 5, 2008 from • American Heart Association. (2008). Older Americans and physical activity. Retrieved October 5, 2008 from <>. • Brown, J. B., Nichols, G. A., Hayes, R. P., & Bowman, L. (2004). Poorer glycemic control is associated with dyslipidemia in type 2 diabetes. Retrieved October 5, 2008 from • Jarvis, C. (2004). Physical examination and health assessment (5th ed.). St. Louis:Elsevier. • Kovatchev, B. (2007). Continuous glucose monitoring reduces risks for hypoglycemia and hyperglycemia and glucose variability in diabetics. [Webcast]. Retrieved October 6, 2008 from <…inicial=../content/ADA2007/sync/CT- OR01/&Speed=Modem&current_slide=1>. • National Institute of Diabetes and Digestive and Kidney Diseases. (2006). Tips to help you get active. Weight-control Information Network. Retrieved October 6, 2008 from • Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health promotion in nursing practice (5th ed.). New Jersey: Pearson. • U. S. Department of Health and Human Services. (2008). Healthy people 2010. Retrieved October 8, 2008 from • Weight Watchers. (2008). History and philosophy. About us. Retrieved October 9, 2008 from