Strategies to Increase Physical Activity.

The benefits of physical activity are well known and well publicized. Healthy People 2020 has determined that physical activity is one of their key interventions to improve health in America. Despite wide acceptance that physical activity is a low-cost alternative to disease treatment and prevention, most Americans still do not exercise the recommended minimum of 150 minutes per week. Underpinning such recommendations is the growing concern that unless we change our behavior around active living, health care costs to treat preventable disease will become unsustainable and have a substantial impact on the financial health of the US. For this reason, physicians, health care executives, and community leaders are working together to improve total health for all Americans. One key intervention to prevent preventable diseases and to make health care more affordable is to increase the percentage of Americans who are physically active. No single intervention will increase activity rates, but a group of interventions working together in synergy may be the stimulus needed to get Americans moving. The five strategies discussed in this paper include 1) measure physical activity as a vital sign; 2) encourage patients to be physically active at least 150 minutes per week; 3) create healthy environments by making it easier for patients to be physically active where they live, learn, work, play, and pray; 4) monitor disease incidence of patients who are physically active vs those who are not physically active; and 5) spread best practices.

Research Letter: Sensor-Based Systems and the Objective Measure of Physical Activity.

Similar to medication adherence, objective measures of physical activity may allow physicians to improve activity rates among individual patients and patient populations, which should improve health care outcomes. Sensor-based systems may become a best practice for objective measurement of physical activity and the management of physical activity programs. Given the ease of tracking with these new devices and the ability to upload information automatically, a sensor-based system has the potential to prevent preventable diseases and lower health care costs.

Nutrition reconciliation and nutrition prophylaxis: toward total health.

Malnutrition by definition may be an abnormality in either under- or overnutrition. Nutrition reconciliation means that all patients have their nutritional status reconciled on admission to and discharge from the hospital. Nutrition reconciliation is defined as the process of maximizing health by helping align an individual's current diet to the diet prescribed for him or her by the health care team. Nutrition prophylaxis is a proactive intervention to prevent a medical complication.

Breast cancer survivorship: a comprehensive review of long-term medical issues and lifestyle recommendations.

As breast cancer becomes a chronic condition rather than a life-threatening illness, survivors not only have the challenge of dealing with multiple long-term side effects of treatment protocols, but may also be forced to address the preexisting comorbidities of their therapies, which often include multiple other issues. It is imperative that the information available regarding survivorship issues be accessible in an organized and useful format. This article is a modest attempt to provide a comprehensive review of the long-term medical issues.

A plant-based diet, atherogenesis, and coronary artery disease prevention.

A plant-based diet is increasingly becoming recognized as a healthier alternative to a diet laden with meat. Atherosclerosis associated with high dietary intake of meat, fat, and carbohydrates remains the leading cause of mortality in the US. This condition results from progressive damage to the endothelial cells lining the vascular system, including the heart, leading to endothelial dysfunction. In addition to genetic factors associated with endothelial dysfunction, many dietary and other lifestyle factors, such as tobacco use, high meat and fat intake, and oxidative stress, are implicated in atherogenesis. Polyphenols derived from dietary plant intake have protective effects on vascular endothelial cells, possibly as antioxidants that prevent the oxidation of low-density lipoprotein. Recently, metabolites of L-carnitine, such as trimethylamine-N-oxide, that result from ingestion of red meat have been identified as a potential predictive marker of coronary artery disease (CAD). Metabolism of L-carnitine by the intestinal microbiome is associated with atherosclerosis in omnivores but not in vegetarians, supporting CAD benefits of a plant-based diet. Trimethylamine-N-oxide may cause atherosclerosis via macrophage activation. We suggest that a shift toward a plant-based diet may confer protective effects against atherosclerotic CAD by increasing endothelial protective factors in the circulation while reducing factors that are injurious to endothelial cells. The relative ratio of protective factors to injurious endothelial exposure may be a novel approach to assessing an objective dietary benefit from a plant-based diet. This review provides a mechanistic perspective of the evidence for protection by a plant-based diet against atherosclerotic CAD.

Prediabetes and lifestyle modification: time to prevent a preventable disease.

More than 100 million Americans have prediabetes or diabetes. Prediabetes is a condition in which individuals have blood glucose levels higher than normal but not high enough to be classified as diabetes. People with prediabetes have an increased risk of Type 2 diabetes. An estimated 34% of adults have prediabetes. Prediabetes is now recognized as a reversible condition that increases an individual's risk for development of diabetes. Lifestyle risk factors for prediabetes include overweight and physical inactivity.Increasing awareness and risk stratification of individuals with prediabetes may help physicians understand potential interventions that may help decrease the percentage of patients in their panels in whom diabetes develops. If untreated, 37% of the individuals with prediabetes may have diabetes in 4 years. Lifestyle intervention may decrease the percentage of prediabetic patients in whom diabetes develops to 20%.Long-term data also suggest that lifestyle intervention may decrease the risk of prediabetes progressing to diabetes for as long as 10 years. To prevent 1 case of diabetes during a 3-year period, 6.9 persons would have to participate in the lifestyle intervention program. In addition, recent data suggest that the difference in direct and indirect costs to care for a patient with prediabetes vs a patient with diabetes may be as much as $7000 per year. Investment in a diabetes prevention program now may have a substantial return on investment in the future and help prevent a preventable disease.

Treatment progress indicator: application of a new assessment tool to objectively monitor the therapeutic progress of patients with depression, anxiety, or behavioral health impairment.

Depression, anxiety, and behavioral health impairment are common in the US. Efforts to treat patients with depression, anxiety, and chemical dependency are surpassed by the great demand for psychiatrist and therapist appointments. Unlike other specialties, psychiatry lacks a vital sign or tests (eg, blood pressure for hypertension and hemoglobin A1c for diabetes) to objectively measure a patient's response to therapy. A new tool called the Treatment Progress Indicator (TPI) appears to offer clinicians an objective approach to assess patients and to monitor therapy over time. The TPI report shows an Expected Treatment Response that allows clinicians to compare their patients' responses to therapy with those of a cohort of patients with a similar diagnosis and severity. The TPI allows for objective population-level management of disease. This should result in sharing of best practices that will lead to more effective and efficient care plans. Widespread implementation of the TPI has the potential to improve the time required to diagnose conditions and triage patients. As a result, implementation of the tool has the potential to improve behavioral health access and affordability.

Physician update: total health.

As an integrated prepaid health care system, Kaiser Permanente (KP) is in a unique position to demonstrate that affordability in health care can be achieved by disease prevention. During the past decade, KP has significantly improved the quality care outcomes of its members with preventable diseases. However, because of an increase in the incidence of preventable disease, and the potential long-term and short-term costs associated with the treatment of preventable disease, KP has developed a new strategy called Total Health to meet the current and future needs of its patients. Total Health means healthy people in healthy communities. KP's strategic vision is to be a leader in Total Health by making lives better. KP hopes to make lives better by 1) measuring vital signs of health, 2) promoting healthy behaviors, 3) monitoring disease incidence, 4) spreading leading practices, and 5) creating healthy environments with our community partners. Best practices, spread to the communities we serve, will make health care more affordable, prevent preventable diseases, and save lives.

Behavior medicine specialist.

Total Health is a vision for the future and a strategy to prevent preventable disease, save lives, and make health care more affordable. Total Health means health of mind (behavior health) and health of body (physical health). To achieve Total Health we need healthy people in healthy communities. A behavior medicine specialist is a psychologist who works in the medical home with the primary care physician instead of in the Mental Health Department with a psychiatrist. The key to achieving Total Health will be to transform our current health care system from a focus on treating disease to a focus on preventing disease. This transformation will require complex behavior change interventions and services not usually provided in the medical home. The behavior medicine specialist will bring the knowledge and experience used to treat mental illness into the medical home to help the primary care physician improve the care of all patients in the medical home. The behavior medicine specialist will help improve outcomes in synergy with the primary care physician by universal screening of high-risk diseases, stepped care protocols, and efficient use of all resources available to care for patients in the medical home (health education classes, wellness coaches, and online social networking lifestyle management programs). These interventions should increase patient satisfaction, increase access to specialty care (psychiatry), and help us achieve Total Health.

Choosing wisely and beyond: shared decision making and chronic kidney disease.

In 2012, the Kaiser Permanente Area Medical Directors of Quality decided to sponsor analytic activities to improve shared decision making for patients with chronic kidney disease. The objective was to move shared decision making for renal replacement therapy or maximal conservative management upstream rather than waiting until the patient presented to the emergency room requiring acute dialysis. Nephrologists have multiple opportunities to discuss treatment options with patients throughout the course of their disease. However, despite these opportunities most patients beginning dialysis have not experienced shared decision making with their physicians. The shared-decision-making process may help patients understand the importance of being prepared to start dialysis and the benefits of maximal conservative management.By having these discussions upstream we may be able to improve survival (save lives), slow down renal disease progression (save kidneys), preserve central veins for future vascular access (save veins), and be better stewards of finite resources needed to care for patients with end-stage kidney disease (save resources).