Health Promotion Disease Prevention

**All names and scenarios are fictional for the purpose of learning education.**

Calandra James is a 66 year old recently retired administrator for City Harvest, a group that gathers leftover food from restaurants and distributes it to food banks and soup kitchens.  She is a recovering alcoholic (sober for 8 years) and she now describes her health as basically good, but says that she struggles with what she calls “an addictive nature”.  This has expressed itself in her history of drinking and a past history of smoking (she quit 5 years ago after a total of 40 pack-years), and more recently she has noted that her eating has an addictive aspect as well.  She says that eating is “a giant issue for me”.  She joined Weight Watchers and lost 75 pounds over a year and a half.  However, she has gained back 15 pounds of it over the past year.  She says, “I spend way too much time trying to stave off hunger, trying to keep calories to 1500-1800/day and pushing myself to get in enough exercise to achieve a daily calorie deficit (she takes long brisk walks, rides a bike to do errands, swims at the local beach during the season, and has a set of free weights and resistance bands that she uses at home).  I am trying to focus on healthful eating and respecting my body, but it’s really a struggle.”  

Her family history includes an alcoholic father and brother who are still actively drinking, a mother who had breast cancer at age 52, but has been cancer free since then and is now 88, and a sister who has Type 2 Diabetes.  She has a long-term lesbian partner who lives a few towns away.  She also has 2 adult sons who live several states away.  She says she is looking forward to retirement because she hopes to find a way to relax and stop beating herself up all the time.  

When you talk to her a little more about her eating habits, you learn that she does not really cook much.  She mostly eats salads and prepared foods from the grocery store.  A typical breakfast is scrambled egg whites with whole wheat toast.  Lunch is a yogurt and sliced fruit with peanut butter spread on it.  Snacks are humus and pita chips and or vegetables, and dinner is salad with some sort of protein.  She allows herself two pieces of dark chocolate (80 calories) as dessert most nights.  She says she finds her current diet tolerable, but “joyless”.  

Other Information:

BP 128/74 T 99 P 68, regular R 18

Hgt  5 ft 6 in Wgt 160 lbs Waist circumference 37 in

Immunizations

• Flu IIV or RIV
• Tdap or TD
• RZV Zoster or ZVL live
• Pneumococcal Polysaccharide PPSV23 ¹

Screenings

• Colonoscopy – over 50 years old ²
• Mammogram – mother had breast cancer ³
• HIV – relationship with same-sex partner 
• Hypertension
• Depression – descriptions of joylessness and low-self esteem 
• Low CT for lung cancer – past history of smoking ⁴
• Pap smear – one every 3 years for women 32-65 yo ⁵

Injury Prevention

• Traffic Safety ⁶

Diet

First, I would commend Ms. James for the drastic changes she has made in her diet. She is eating very clean and exerting diligence in portion control. However, she should not be trying to “stave off hunger” in order to manage her weight. Some of her changes may be too extreme.

Ms. James’ current BMI is 25.8. As normal BMI ranges from 18.5 – 24.9 for her age range, I would encourage her that she is not far from her weight loss goals and does not need to implement drastic weight loss measures.⁷ In fact, most studies indicate that a maximum weight loss of 9-15% over 52 to 72 weeks is sustainable.⁸ For Ms. James, this would look like 14.4- 24 pound weight loss in the course of the year. I would not want her to lose more than two pounds a month. 

At her age, height, weight, and light activity level, it is estimated that Ms. James can consume 1800 calories to maintain her current weight.⁹ I would warn her not to dip too low below that number as she has been trying to maintain a 1500-1800 calorie diet. Instead, I would recommend that she consume a 1650- 1800 calorie diet. With continued physical activity, she should be able to maintain a stable calorie deficit and achieve a slow, yet sustainable weight loss.

As Ms. James is starting retirement, I would also encourage her to try cooking. It sounds that she is very bored by her diet as she describes a“joyless” attitude towards food. I would emphasize that food plays a very large role in our daily lives and should be enjoyed. With more time in her retirement, she can try cooking and introducing more variety to her meals. There are many cooking videos on YouTube and recipes on the internet. I would suggest adding keywords such as “healthy alternatives”, “lower calorie”, or “plant-based” to her search to find appropriate recipes. Taking time to prepare her food may help her find variety and enjoy the act of eating again. 

Exercise

Again, I would commend Ms. James for taking initiative and implementing changes in her physical activity during her weight loss journey. She builds exercise wonderfully well into her daily activities by taking long walks, biking for errands, and using weights at home. However, I am concerned about her mindset towards exercise. She is motivated to exercise in order to maintain a calorie deficit. I would remind Ms. James that she is allowed to and should enjoy her physical activities, too. They are not intended just for weight loss, but also to promote overall health benefits both physically and mentally. Perhaps she can try to participate in exercise with her partner or a group class. This can create a social aspect to exercise that will make it more enjoyable for her. 

Although she is physically active, most of her exercises are low-impact and low-cardio. I would love to see her engage in physical activity that challenges her at least twice a week so that her heart rate reaches 75-128 bpm.¹⁰ Additionally, Ms. James may incorporate more strengthening exercises as that helps mitigate the onset of osteoporosis. Ms. James is sixty-six years old and is at greater risk of developing osteoporosis as it affects one in three women over the age of fifty. ¹¹

Harm Reduction

Although the National Institute on Drug Abuse states that a maximum alcohol consumption of 4 standard drinks per day for women is acceptable, I would choose to leave this information out for Ms. James.¹² As she struggles with an addictive behavior, is a recovering alcoholic, and has a family history of alcoholism, I do not want to provide an openings that may trigger her addictive behavior. For this reason, I would continue to commend her for staying clear from alcohol and cigarette use and encourage her to keep up these habits. 

Brief Intervention 

In our meeting, I would screen Ms. James for depression. In her own words, she has described her lifestyle with negative terms such as “struggling”, “joyless”, and “beating herself up.” As her sons live states away and her partner lives towns away, I am worried she does not have social and emotional support at home. Her past addiction history and family history of alcoholism also raises concern for me. She may not have the tools for a healthy coping mechanism in the event that something terrible happens. I would utilize the 5 A’s of Brief intervention to ensure that Ms. James is aware of her current emotional and mental status and is more mindful towards her future actions.¹³

Ask – “How do you feel about the quality of your life right now?”

Advise – “If you’re having a bad day, could you tell me how you deal with it? Is there someone you usually talk to?”

Assess – “Have you been experiencing any changes in your sleep patterns, motivation, or mental clarity recently?”

Assist – “You say you are looking forward to retirement in order to finally relax. What do you envision an ideal day to like like in your retirement?”

Arrange – “Would you be open towards trying CBT (Cognitive Behavior Therapy)? I think it could be a great space to help bridge your current lifestyle to a more relaxing one in retirement.” “Do you have any additional questions for me?” 

References

1. Adult Immunization Schedule by Vaccine and Age Group. (2020, February 03). Retrieved November 13, 2020, from https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
2. Recommendation: Colorectal Cancer: Screening: United States Preventive Services Taskforce. (2016, June 15). Retrieved November 10, 2020, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
3. Recommendation: Breast Cancer: Screening: United States Preventive Services Taskforce. (2016, January 11). Retrieved November 10, 2020, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
4. Recommendation: Cervical Cancer: Screening: United States Preventive Services Taskforce. (2018, August 21). Retrieved November 10, 2020, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening
5. Draft Recommendation: Lung Cancer: Screening: United States Preventive Services Taskforce. (2020, July 07). Retrieved November 13, 2020, from https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/lung-cancer-screening-2020
6. Gardner, H. (2007, January 01). Office-Based Counseling for Unintentional Injury Prevention. Retrieved November 13, 2020, from https://pediatrics.aappublications.org/content/119/1/202
7. Calorie Calculator. (n.d.). Retrieved November 13, 2020, from https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/calorie-calculator/itt-20402304
8. Hall, K., & Kahan, S. (2018, January). Maintenance of Lost Weight and Long-Term Management of Obesity. Retrieved November 13, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/
9. Calorie Calculator. (n.d.). Retrieved November 13, 2020, from https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/calorie-calculator/itt-20402304
10. Target Heart Rates Chart. (n.d.). Retrieved November 13, 2020, from https://www.heart.org/en/healthy-living/fitness/fitness-basics/target-heart-rates
11. Keen, M. (2020, June 23). Osteoporosis In Females. Retrieved November 13, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK559156/
12. Drinking Levels Defined. (n.d.). Retrieved November 13, 2020, from https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking
13. Brief Interventions. (n.d.). Retrieved November 13, 2020, from https://mdquit.org/cessation-programs/brief-interventions