© Springer International Publishing Switzerland 2017
Maggi A. Budd, Sigmund Hough, Stephen T. Wegener and William Stiers (eds.)Practical Psychology in Medical Rehabilitation10.1007/978-3-319-34034-0_88. Behavioral Medicine: Nutrition, Medication Management, and Exercise
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Department of Ophthalmology, University of Alabama at Birmingham, Callahan Eye Hospital, 1720 University Blvd., Suite H-405, Birmingham, AL 35294, USA
Keywords
Behavioral medicinePhysical activityNutritionMedication managementTopic
Behavioral medicine is the interdisciplinary approach dedicated to the (1) study of the biopsychosocial interactions between behavior, psychosocial, and biomedical science knowledge, (2) development of techniques relevant to the understanding of health and illness, and (3) application of this knowledge and techniques to the prevention, diagnosis, treatment, and rehabilitation [1]. These evidence-based practice methods are focused on improving the well-being of individuals, families, communities, and populations. Topics and health issues relevant to behavioral medicine may include health maintenance behaviors (e.g., exercise/physical activity and nutrition) and adherence to medical regimens (e.g., medication management) for conditions/disabilities such as traumatic brain injury (TBI), spinal cord injury (SCI), pain, diabetes, obesity, cancer, HIV/AIDS, cardiovascular disease, diabetes, multiple sclerosis (MS), and respiratory disease. For the purpose of this brief chapter, we focus on the importance of nutrition, medication management, and physical activity (PA) as they all are behaviors that play a key role in the treatment and prevention of a range of adverse health outcomes relevant to overall health, rehabilitation, and recovery.
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Key Concepts
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Nutrition/Dietary Intake
Dietary guidelines for Americans recommend a balanced diet containing nutrient dense foods such as vegetables, fruits, whole grains, low-fat dairy products, and lean protein foods containing dietary nutrients without too many calories. Nutrient dense foods and beverages should not be diluted by the addition of calories from added solid fats, sugars, or refined starches, or by the solid fats naturally present in food. Evidence has shown that people who are successful in managing their weight have found ways to monitor how much they eat in a day.
Caloric intake needs may vary slightly depending on individual circumstances, and it is important to keep in mind that recommendations for foods, nutrients, and supplements may be restricted or adjusted for certain groups depending on an individual’s stage in life, their gender, and activity level (e.g., hospitalized patients, pregnant women, and older adults).
Over the course of rehabilitation and into recovery , the key to achieving and sustaining appropriate body weight is by caloric balance. In other words, weight maintenance depends on the relationship between calories consumed from foods and beverages and calories expended in normal body functions (i.e., metabolic processes and physical activity). Calories consumed must essentially equal calories expended for a person to maintain body weight. Consuming more calories than expended will result in weight gain. Conversely, consuming fewer calories will result in weight loss.
Nutrition and Rehabilitation Achieving and maintaining adequate nutrition following a traumatic injury requiring rehabilitation (e.g., SCI, stroke, heart attack, and TBI) is a critical goal for recovery [2]. Depending on the type of injury, dietary intake may require complete assistance (e.g., feeding tube) with daily monitoring by hospital staff, and then a gradual adjustment as functioning is regained. Immediately postinjury, appetite and weight are influenced by complex anatomical, biochemical, and endocrine pathways in the central nervous system that may be disrupted by the trauma [3]. During the acute phase of recovery, individuals tend to lose weight because of hypermetabolism, hypercatabolism, reduced caloric intake, and altered gastrointestinal function. Nutritional supplementation through a gastric feeding tube may be provided within the first 24-h of a major trauma.
Over the course of the following days/weeks postinjury other issues, such as dysphagia (problems with swallowing) or soreness of throat muscles, may result. Thus, the need for assisted nutrition may continue across recovery with most patients regaining their nutritional independence within the first 6-month postinjury.
In the later phases of recovery, the situation is often reversed. Feeding is well established, there is a reduced energy expenditure relative to an increased caloric intake, along with a relatively sedentary lifestyle after injury, all of which can result in weight gain. A hypothalamic disorder that impacts endocrine control (i.e., growth hormone or thyroid deficiency) can also influence weight gain [4], as can medications. Without an appropriate adjustment for the dietary caloric intake, energy intake can easily exceed daily energy requirements, which predisposes affected individuals to weight gain during the later phases of recovery.
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Medication Management
Medication adherence refers to the extent to which patients take medication as prescribed by their doctors. This involves factors such as filling prescriptions, remembering to take medications on time, taking the correct amount, and understanding the directions (e.g., taking medications with meals, checking insulin levels).
Poor adherence can interfere with the ability to manage many diseases or injuries, leading to greater unnecessary secondary health problems/complications (e.g., infections, progression of a disease or health condition, and relapse), additional health care costs, and thereby lower quality of life.
Medication Management and Rehabilitation Taking medications as prescribed is critical for a variety of reasons post injury (e.g., preventing infections as well as secondary health conditions and controlling symptoms). Health care providers monitor medications closely during hospitalization and rehabilitation. However, upon discharge, patients and/or their caregivers must immediately take over medication management. Depending on the medication regimen and number of health conditions, this can be quite a complex undertaking.
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Physical Activity (PA)
Recommended guidelines based on current evidence indicate that getting at least 150 min per week (e.g., 2 h and 30 min) of moderate PA (e.g., brisk walking) or 2 or more days a week or 1 h and 15 min (75 min) of vigorous-intensity aerobic activity (i.e., jogging or running) every week and muscle-strengthening activities that work all major muscle groups (e.g., legs, hips, back, abdomen, chest, and shoulders/arms) helps to promote health and prevent secondary health problems.
Similar to healthy dietary intake, engaging in regular PA and exercise is important for overall health, independence, prevention of chronic diseases, and engaging in activities of everyday living (e.g., climbing stairs, walking around to shop, employment). Inactivity associated with sedentary lifestyles can result in changes in body composition as evidenced by an increase in body fat and a concomitant reduction in lean body mass, particularly over extended periods of inactivity. It has been shown that persons with disabilities are at an even greater risk for obesity than nondisabled persons.
Physical Activity and Rehabilitation Physical activity is often compromised immediately following a traumatic injury due to factors such as orthopedic injuries, pain, hemiparesis, loss of muscle strength and tone, poor balance, cervical injury, medications, and/or mood. Limitations for PA depend on the nature of the trauma, severity, type, and location, and the reason for hospitalization. At the onset of acute inpatient hospitalization, patients are often restricted to bed rest. However, gradual resumption of PA intensity and frequency occurs as participation in physical therapy begins to take place. Encouraging gradual PA can help to minimize risk for secondary health conditions (e.g., obesity) [5].
Determining the type, quantity, and frequency of PA to prescribe following an injury or disability should rely on strict guidance from allied health professionals including physicians as well as physical therapists, occupational therapists, and dietitians. This is important for safety considerations. Other factors for consideration should include medical limitations, medications, and weighing of risks/benefits postinjury is particularly important when making PA recommendations.
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Other Determinants Influencing Health Behaviors
Neurocognitive, psychological (e.g., stress, depression, and personality) and environmental factors (e.g., lack of access to healthy foods, transportation, uneven paths to walk in neighborhoods, safety concerns/high crime rates, and affordability) can also influence healthy lifestyle behaviors and choices postinjury. For example, everyday tasks necessary for achieving and maintaining a balanced and healthy diet high in nutrition often include daily meal planning, grocery store shopping, food selection, meal preparation, and cooking, which can be difficult for a person with a traumatic injury. For example, performing these tasks requires a person to understand nutritional information, attend to information, plan and organize, read ingredients on labels, select among different types of foods that vary in nutritional value, chop/cut/process and prepare foods correctly and safely, understand and follow the sequence of recipes, divide attention when cooking, and operate appliances (oven, microwave, blender, and food processor). These tasks are often challenging for persons with normal cognitive/motor functioning due to busy schedules and daily demands. Persons with a disability are more likely to struggle with this important activity in daily living due to problems with motivation/drive, planning/organization, initiation, attention, memory/forgetfulness, sequencing, speed of processing, vision, visual scanning, self-regulation, fine/gross motor functioning, fatigue, depression and/or stress.
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Importance
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Epidemiology
Nearly half of the United States (U.S.) adults have at least 1 of 10 chronic health conditions and approximately 25 % have at least 2 that account for most of health care expenditures [6]. Ten of the 15 leading causes of death in the U.S. were chronic health conditions. Estimates also indicate that at least 13 % of the U.S. population has a disability; or 56 million people according to the Centers for Disease Control and Prevention (CDC). By 2020, 48 % of the population is estimated to be living with a chronic disease.
According to the CDC , a major cause for this state of affairs is problems with self-managing lifestyle behaviors (i.e., PA, poor nutrition/eating habits, and medication management) all of which are modifiable, thus can be treated or possibly prevented with behavioral medicine approaches.
Unfortunately, adults with both disabilities and chronic conditions receive fewer preventative services and are in poorer health than individuals without disabilities who have similar health conditions.
Additionally, it has been estimated that among patients with chronic illness, approximately 50 % do not take medications as prescribed. Poor medication adherence has been linked to increased morbidity and death, as well as unnecessary complications, progression of disease, and/or hospitalizations.
Chronic health conditions contribute to substantial financial expenditures and societal burdens on global health care systems (e.g., lost productivity and medical expenses) [7]. Recent estimates indicate that the provision of care for people with disabilities and health conditions is very costly; in 2010, total spending for the Medicare population was more than $300 billion. However, primary and secondary chronic health conditions that impact life expectancy and health can often be prevented and/or managed by engaging patients in modifiable lifestyle behaviors.
Given the projected increase in the epidemiology of chronic health conditions, life expectancy, and risk for comorbid health conditions over the next decade [8, 9], the application of evidence-based behavioral medicine techniques is critical, particularly for individuals with a disability.
Immediately following a diagnosis of a chronic health condition or traumatic injury is an opportune time for rehabilitation providers to challenge patients’ attitudes and changing unhealthy behaviors early on in recovery or in the disease management process (i.e., PA, dietary intake, and medication management). Changing health behaviors involves learning new adaptive behaviors and attitudinal changes that providers with a behavioral medicine approach can help address across the recovery continuum.
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Challenges to Changing Health Behaviors Among Persons with a Disability People with disabilities can often experience unique challenges related to changing in such behaviors compared to nondisabled populations. Challenges related to establishing healthy nutrition and dietary intake may include lack of healthy food choices or resources (e.g., money, transportation, social support, and options for fresh food) as well as difficulty preparing meals (due to cognitive or motor deficits), chewing or swallowing food, sensitivity to taste, substance abuse (e.g., smoking and alcohol), manual dexterity or motor functioning and ability to feed self, poor or excessive appetite (e.g., due to depression, stress, and medications), or cultural factors. Challenges with physical activity may include lack of accessible environments (e.g., adaptive exercise equipment, parks, and sidewalks), energy, pain, depression, fatigue, medications that cause weight gain or loss, and physical limitations, as well as limited resources (e.g., money, transportation, and support). Lastly, problems related to medication adherence may include health literacy, poor cognitive functioning (e.g., comprehension, memory, and planning), poor doctor–patient communication, prescription of complex medication regimes and dosing schedules, adverse side effects, heath beliefs, length of treatment, and/or cost.Related posts:
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