Fall 2024 Assignments, Midterms and Finals PDF

Richard Bucciarelli PhD, MS, R.Kin., CSCS Fall 2024  Assignments, Midterms and Finals  In-Class Assignment 1 – Oct. 2, 2024  Midterm 1 – Week 5 – Oct. 2, 2024  In-Class Assignment 2 – Nov. 6, 2024  Midterm 2 – Week 9 – Nov. 6, 2024  Final Exam - During exam period  Assignment – Will dis...

Richard Bucciarelli PhD, MS, R.Kin., CSCS Fall 2024  Assignments, Midterms and Finals  In-Class Assignment 1 – Oct. 2, 2024  Midterm 1 – Week 5 – Oct. 2, 2024  In-Class Assignment 2 – Nov. 6, 2024  Midterm 2 – Week 9 – Nov. 6, 2024  Final Exam - During exam period  Assignment – Will discuss in next week's lecture  To get a good grade in this class, you must: Show up Pay attention Take written notes Study from your notes with a 1:1 time ratio Make a friend in the class, study together, and review each other’s notes when studying  (Former) Athlete  Coach  Sports Scientist  PhD in Sports Science  Entrepreneur/Small Business Owner  Teacher/Lecturer 4 6 7 LO 2 8 9 LO 2 10  LO 1 There are six dimensions of wellness: 1. Physical 2. Emotional 3. Intellectual 4. Interpersonal 5. Spiritual 6. Environmental 11 LO 1 12 13  Income/income distribution  Social safety net, and  Education network  Unemployment/job security  Health Services  Employment and working  Gender conditions  Race  Early childhood development  Disability  Food insecurity  Housing  Social exclusion 14 LO 2 15 https://www.ontario.ca/page/ontario-basic-income-pilot 16 17  What does this mean?  Who is or isn’t health literate?  https://youtu.be/_8w9kdc  Why is this an issue? RgsI  https://ed.ted.com/on/yyFI uYXz#watch Source: http://www.nccmt.ca/professional-development/eiph   http://www.biorxiv.org/content/early/2017/07/25/08769 2  https://www.sciencedaily.com/releases/2017/08/1708 27101750.htm  https://www.ncbi.nlm.nih.gov/pubmed/25089347 Source: http://www.weightymatters.ca/2017/08/dear-reporters-cure-for- obesity-is.html 22  http://www.mayoclinic.org/  https://www.cdc.gov/  http://www.who.int/en/  https://www.healthevidence.org/  http://www.cochranelibrary.com/ MENTAL HEALTH AND PSYCHOLOGICAL DISORDERSKin1010 -Week Two Dr. Richard Bucciarelli 9/15/20 2  Updates Overview of mental health issues Common psychological disorders Stress response Stress management strategies 9/15/20 2  LO 1 PSYCHOLOGICAL HEALTH IS… Important to every dimension of wellness. Our capacity to think, feel, and behave in ways that contribute to our ability to enjoy life and manage challenges. Not merely the presence of wellness or the absence of sickness… Psychological health is influenced by a variety of factors (e.g., diet, sleep patterns, relationship issues). 3  LO 2,3 ACHIEVING HEALTHY SELF-ESTEEM Begins in childhood by feeling loved, feeling one can give love, and having a sense that one can accomplish goals. Integration, or feeling that one has created their own self-concept rather than adopting an image that others have created, is essential to a positive self-concept. Stability depends on the integration of the self and its freedom from contradictions. 4  LO 2 Everyone must learn to cope with life's large and small challenges. Throughout our lives, we will continue to grow psychologically, developing new and more sophisticated coping mechanisms. 5  Adapting well in face of adversity, trauma, tragedy, stress “bouncing back” from difficult experiences It is not a personality trait, Resilience is a set of behaviours, actions, thoughts that people use to get through these stressful and traumatic life events. What factors are associated with resilience? Having caring & supportive relationships Capacity to carry out realistic plans Positive view of self and self-confidence in abilities Communication and problem-solving skills Being able to manage feelings and impulses 6 Source: APA  Maximum Mental Health Diagnosis of a serious No illness or disorder illness but copes well and and positive mental has positive mental health health Maximum Minimal Mental Disorder Mental Disorder Diagnosis of a serious No diagnosable illness illness and poor mental or disorder but has health poor mental health Minimal Mental Health Associations between mental and physical health include: 1. Poor mental health is a risk factor for chronic physical conditions 2. People with serious mental health conditions are at high risk of experiencing chronic physical conditions 3. People with chronic physical conditions are at risk of developing poor mental health.  Social determinants of health impact chronic physical conditions and mental health 10  LO3 PSYCHOLOGICAL DISORDERS Generally the result of many factors and can include genetics, learning and life events, exposure to trauma, and parental & peer influences  LO 4 ANXIETY DISORDERS Anxiety is another word for fear, especially a feeling of fear that is not in response to any definite threat. When fear is disproportionate to the actual danger, it can be considered a problem. Anxiety disorders are the most common of psychological disorders among Canadians. 12  LO 4 PSYCHOLOGICAL DISORDERS: ANXIETY DISORDERS Simple, or specific, phobia ◦ Fear of something definite (e.g., snakes, heights) Social phobia ◦ Fear of humiliation or embarrassment while being observed by others 13  LO 4 PSYCHOLOGICAL DISORDERS: ANXIETY DISORDERS Panic disorders Sudden unexpected surges in anxiety Rapid and strong heart beat Shortness of breath Loss of physical equilibrium Feeling of losing mental control Agoraphobia 14  LO 4 Generalized Anxiety Obsessive-Compulsive Disorder (GAD) Disorder (OCD) Excessive, uncontrollable worry Obsessions – recurrent, about a variety of things unwanted thoughts anxiety in many Compulsions – situations repetitive, unwanted actions 15  LO 4 Behavioral Addictions Urges to engage in behaviour creates anxiety; Engaging in the behaviour brings relief Post-Traumatic stress disorder (PTSD) Reaction to a severely traumatic event by reliving it through dreams, flashbacks, hallucinations 16  LO 4 PSYCHOLOGICAL DISORDERS: TREATING ANXIETY DISORDERS Medication (e.g., anti- anxiety medication) Psychological interventions (e.g., cognitive-behavioural therapy) Alternative therapies (e.g., yoga, meditation) 17  www.calm.com  Research on effectiveness: https://www.ncbi.nlm.nih.gov /pu bmed/22700446 www.headspace.com 18 9/15/20 19  LO 4 PSYCHOLOGICAL DISORDERS: MOOD DISORDERS Depression affects about 11% of Canadians at some point during their lifetime Women have depression rates that are 2X higher than men 20  LO 4 PSYCHOLOGICAL DISORDERS: MOOD DISORDERS Depression takes different forms but usually involves demoralization and can include: A feeling of sadness and hopelessness Loss of pleasure in doing usual activities Poor appetite/weight loss Insomnia/disturbed sleep Restlessness or fatigue Thoughts of worthlessness and guilt Trouble concentrating or making decisions Thoughts of death or suicide 21  LO 4 PSYCHOLOGICAL DISORDERS: MOOD DISORDERS } Dysthymic disorder may be diagnosed in those who experience persistent symptoms of mild or moderate depression for two years or longer.  Suicide is one of the principal dangers of severe depression.  Although a suicide attempt can occur unpredictably and unaccompanied by depression, the chances are greater if symptoms are numerous and severe. 22 What are some of the challenges or barriers for people with mental illness in accessing physical activity programs? http://www.enablingminds.ca/ http://www.enablingminds.ca/resource- library/testimonials/ritas-story/ https://youtu.be/B_0fM6zWoio 23 What are the benefits of exercise for people with mental health issues?  http://www.mindingourbodies.ca/  https://www.youtube.com/watch?v=13Tv4HRACfc&playerMode=embe dded 24  Recommended exercise guidelines Type of exercise WHY Benefits 9/15/20 25 LO 5 26  LO 5 RECOGNIZING THE WARNING SIGNS OF SUICIDE Expressing the wish to be Suicide by a dead family member or friend Increasing social withdrawal/isolation Readily available means of committing suicide Sudden inexplicable lightening of mood History of substance abuse or eating disorders History of previous attempts Serious medical problems 27  LO 4 PSYCHOLOGICAL DISORDERS: MOOD DISORDERS Helping yourself or a friend… Expert help is essential Don' t be afraid to discuss suicide Do not leave a person alone if you feel the danger of suicide is immediate. Talk with an expert. 28  LO 6 PSYCHOLOGICAL DISORDERS: MOOD DISORDERS Treating Depression 80% of Canadians respond well to treatment, however only 10% of Canadians with depression will seek treatment Treatment can be drug therapy, psychotherapy, or a combination Severe depression may be treated with electroconvulsive therapy (ECT) Seasonal affective disorder (SAD) is typically treated with light therapy 29  LO 6 NERVE CELL COMMUNICATION 30  LO 6 PSYCHOLOGICAL DISORDERS: MOOD DISORDERS Mania and Bipolar Disorder Gender differences Equal numbers of men and women suffer Schizophrenia General characteristics Disorganized thoughts Inappropriate emotions Delusions Auditory hallucinations Deteriorating social and work function Uncertain about what causes it 31 https://www.ted.com/talks/elyn_saks_seeing_mental_illness 32  Study of the strengths https://ppc.sas.upenn.edu/ that enable individuals and communities to thrive What is happiness? Founded on belief that https://www.youtube.com/ watch?v=1HFL9MnGdrw people want to lead meaningful lives, cultivate what is best within themselves, and enhance The benefits of happiness their experiences of love, https://www.youtube.com/ work and play watch?v=IcUtVAeZwYo 33  http://campusmentalhealth.ca/blog_post/performance-and- anxiety/ https://studybreaks.com/2017/09/10/5-changes-to-make-this- school- year-alter-your-life/ 34 Kinesiology students, back to school can be stressful, visit 2nd floor LRC building & wegotyou.humber.ca for student wellness services and support 35 Drugs, opioids, & marijuana  Agenda Addictive behaviours and risk factors Alcohol absorption and metabolism of alcohol Opioids and marijuana Tobacco use and nicotine addiction Health effects of alcohol, tobacco and other drugs Population health/policy approaches to reducing harms In the news…  Addiction Videos http://www.cbc.ca/2017/wearecanada/dan- werb-is-on-a-mission-to-change-how-we- think-about-drug-addiction-1.4077259 https://torontolife.com/city/crime/doctor- perfect-life-got-hooked-fentanyl/  What is addiction? use despite craving loss of control compulsion to consequences use Just a Characteristics habit? Addiction of addicts? no compulsion reinforcement no need to increase dose loss of control escalation negative consequences http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/drug-use- addiction/Pages/addiction.aspx  Risk and protective factors for addiction https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/soa_2014.pdf  Neurophysiology of addiction 1) Limbic system (controls emotions) 2) Reward system Reward pathway of the brain: ventral tegmental area (VTA) – neurons contain dopamine – dopamine released in nucleus accumbens and prefrontal cortex nucleus accumbens prefrontal cortex https://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-ii-reward-pathway-addiction/3-reward-pathway  Effects of drugs on our bodies 1. Brain chemistry- neurotransmitters and receptors  Effects of drugs on our bodies 2. Drug factors dose-response time-action tolerance method of administration colourbox images http://www.merckmanuals.com/professional/clinical_pharmacology/pharmacodynamics/dose-response_relationships.html  Effects of drugs on our bodies 3. Individual factors estrogen regulates cannabinoid receptors? Br J Pharmacol. Jun 2010; 160(3): 544–548.  prefrontal cortex https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/soa_2014.pdf  Harm reduction “Policies, programs and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. - HARM REDUCTION INTERNATIONAL Examples: helping people learn safer ways to use substance helping people learn how to recognize the signs of an overdose providing clean needles and other injection equipment (“works”) for injection drug use (to reduce transmission of infections such as HIV/AIDS and hepatitis C through needle sharing) substituting a safer drug for the one a person is using (e.g., substituting methadone for heroin) http://globalnews.ca/news/2099947/evolve-festival-drops-plans-to-test-quality-of-attendees- drugs/ https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/soa_2014.pdf https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/soa_2014.pdf http://www.hqontario.ca/Portals/0/documents/system-performance/infographic-9-million-prescriptions-en.pdf Source: https://www.cihi.ca/en/13-canadians-hospitalized-each-day-for-opioid-poisoning-infographic  Marijuana https://globalnews.ca/t ag/marijuana- legalization/  Medical Marijuana https://globalnews.ca/t ag/medical-marijuana/  Marijuana Source: https://www.drugabuse.gov/publications/research-reports/marijuana/how-does-marijuana-produce-its- effects  Lower risk cannabis use guidelines Source: https://www.cpha.ca/lower-risk-cannabis-use-guidelines-canada  Canada’s Legislative Framework Legalization and Regulation of Cannabis https://globalnews.ca/news/4285946/marijua na-legal-date-october-17-canada-trudeau- confirms/ https://www.ontario.ca/page/cannabis- legalization  CBD or THC https://youtu.be/qVFmsEf5dnM  Taxing the drug could generate $5 -$22 million annually… http://www.huffingtonpost.com/2012/09/19/pot-could-be-tax-windfall_0_n_1897910.html  Acute neurophysiology effects 1. Marijuana 2. Meth 3. Ecstasy 4. LSD (hallucinogen) http://learn.genetics.utah.edu/content/addiction/mouse/ image- colourbox  Chronic health effects https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/soa_2014.pdf Amygdala- involved in emotional learning, generation of fear Hippocampus- memory A A H H (Psychosis)  Chronic health effects: marijuana carcinogenic – oral cancers, esophagus, leukemia, testicular impair immunity, decrease resistance to infection chronic bronchitis possibly lowers testosterone and sperm production, disrupts ovulation Lancet 1998; 352: 1611–16 Alcohol. 2005 Apr;35(3):265-75. Alcohol & Tobacco KIN1010 Alcohol  Wasted https://gem.cbc.ca/media/the-nature-of- things/season-55/episode-10/38e815a- 00958f704e9 Please watch minutes 17-25. The rest is very interesting too  Substance use: Alcohol What is binge drinking? In 2 hours… 4 drinks – women 5 drinks – men http://pubs.niaaa.nih.gov/publications/Hangovers/beyondHangovers.pdf  Alcohol Use and Canada’s LO 3 Low-Risk Alcohol Drinking Guidelines Reduce long-term risk of diseases and conditions caused by several years of alcohol consumption Reduce short-term risk of injury, harm, and/or acute illness Population specific guidelines: } Delay youth drinking until their late teens } Young adults should not excessively drink and have non- drinking days } Older adults should be aware of prescriptions and follow guidelines for limited alcohol intake 5  Approx. 5 drinks for men or 4 for women consumed within Binge Drinking about two hours (BAC>0.08) Frequent binge drinkers: 3-7X more likely to engage in unplanned or unprotected sex, to drive after drinking, and to get hurt or injured. 7  Alcohol Intake and Blood Alcohol Concentration Blood alcohol concentration (BAC) is a measure of intoxication: – amount of alcohol consumed in a given amount of time – influenced by body weight, percentage body fat, sex, rate of alcohol metabolism due to genetic factors and drinking behaviour Food can slow the rate of alcohol absorption Metabolic rate cannot be influenced by exercising, breathing deeply, eating, drinking coffee, or taking other drugs. 8  Absorption 20% 75% Rate of absorption is affected by many factors Carbonation Food in the stomach Alcohol concentration image- colourbox  Factors affecting absorption 1. Women have proportionally more body fat than men – alcohol is not very fat soluble => enters bloodstream faster 2. Women's bodies have proportionately less water than men's bodies => alcohol doesn't become as diluted as in men 3. Alcohol dehydrogenase (in stomach) is more active in men 4. Smaller body size 5. Alcohol is more quickly absorbed during the premenstrual phase of a woman’s cycle. Women using birth control pills absorb alcohol faster than usual – slow down rate of alcohol elimination  Metabolism and Excretion The main site = liver World J Gastroenterol. 2014 Oct 28;20(40):14672-85. doi: 10.3748/wjg.v20.i40.14672.  Alcohol and Marijuana https://www.youtube.com/watch?v=zTeaOTkj ut0  Gender, Setting, and Population Differences Men more than women report drinking patterns that exceed Canada’s low-risk drinking guidelines for both chronic and acute effects Women tend to become addicted to alcohol later in life than men and have fewer years of heavy drinking Alcohol abuse is widespread and severe health problem in First Nations Communities 15  What causes a hangover? Dehydration Inflammatory response from your immune system Glucose metabolism Sleep deprivation Immediate Effects of Alcohol on Health Alcohol-related injuries and violence are a result of impaired judgment, weakened sensory perception, reduced inhibitions, impaired motor coordination, and increased aggressiveness and hostility Alcohol is associated with more acts of aggression and violence than any other legal or illegal drug Alcohol seriously affects your ability to make wise decisions about sex. 17  Drinking and Driving In Canada, drinking and driving remains the single largest criminal cause of death. The highest rate of impaired driving deaths occurs at age 19. Dose-response function – Driving with a BAC of 0.14% is more than 40 times more likely to be involved in a crash. When BAC is greater than 0.14%, the risk of fatal crash is estimated to be 380 times higher. 18 LO 2 Chronic health effects LO 2 Alcohol health impacts https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/soa_2014.pdf  Chronic health effects Alcohol metabolism-induced oxidative stress – Alcohol-induced fatty liver disease affects 80% of heavy drinkers (80g alcohol per day over time) standard drink = 10 g – Steatohepatitis – liver inflammation, type of fatty liver disease – Cirrhosis – late stage of scarring (fibrosis) of the liver TOBACCO http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/ctums-esutc_2012-eng.php#tabc  Psychological and Nicotine rewards Nicotine alters social forces are smoking the brain at work Acquired ‘drive’ (hunger) Dopamine release Beliefs about Urge to smoke if Signal to notice and stress control abstinent for a while repeat Identity Reminders (cues) Camaraderie increase urge Pairing of stimuli DOPAMINE!  Acute health effects As cigarette burns… 1. Tar released 2. Carbon monoxide (CO) Most harmful component of tobacco smoke – CO attaches to hemoglobin in the blood => forms carboxyhemoglobin – unable to transport oxygen to the tissues and cells 3. Heat – Hot gases and vapours damage/weaken tissues and contribute to cancers  Chronic health effects Every cigarette reduces life expectancy by 11minutes, one carton represents a day and half of lost life  Chronic health effects Smoking contributes to 12% to 14% of all stroke deaths Smoking increases stroke risk Acutely: effects on thrombus formation Chronically: increased burden of atherosclerotic disease MRI of Brain With an Acute Ischemic Stroke Goldstein et al. Stroke. 2006;37:1583-1633; http://www.ucihs.uci.edu/stroke/whatisastroke.shtml. Other forms of tobacco: Pipes & Cigars Becoming more popular among youth and women! Pipe/cigar smokers have the same rate of cancer frequency as cigarette smokers with: Mouth, larynx, throat, esophagus Most cigars have as much nicotine as several cigarettes. Cigarettes contain an average of about 8 milligrams (mg) of nicotine, but only deliver about 1 to 2 mg of nicotine to the smoker. Many popular brands of larger cigars contain between 100- 400 mg of nicotine. http://www.cancer.org/cancer/cancercauses/tobaccocancer/cigarsmoking/cigar-smoking-cigars-vs-cigarettes  Smokeless tobacco a.k.a. “Dip” / “Chew” Contains more nicotine than cigarettes Major risk is leukoplakia Impairs sense of taste, receding gums, tooth decay, damage to teeth, jawbone Presence of fiberglass – create cuts in mouth to increase uptake of nicotine  E-Cigarettes Are they safe? Are they better than regular cigarettes? Do they contain nicotine? Source: http://otru.org/research- evaluation/e-cigarettes/  Dangers of Vaping - CBC https://www.cbsnews.com/news/vaping- health-effects-rising-use-among-teens/ Advertising in Tobacco  Tobacco Control Pricing/Regulation Advertising bans Smoking bans Smoke-free campuses Smoke-free housing Quitting Cessation approaches: ‘Cold turkey’ Apps Counselling Motivational interviewing ‘Run to Quit’ Medication such as Champix, NRT  KIN 1010 What is a healthy weight? flickr: department of foreign affairs and trade  Learning objectives… Compare and contrast methods for assessing body weight and body composition Discuss the use of BMI in practice as a health care professional (i.e., Kinesiologist) Discuss the concept of metabolically healthy obesity Compare and contrast types of eating disorders Chronic Disease Risk Factors What is your ideal body? Are these “healthy” ideals? Why or why not?  Disordered eating & exercise 1. Anorexia nervosa: fear of gaining weight 2.Bulimia nervosa: binge eating and purging (vomiting, laxatives, enemas) 3.Binge eating disorder: binge eating NO PURGING 4. EDNOS (“Not Otherwise Specified”) 5.Body dismorphic disorder: obsession with body’s flaws, to the point of interfering with daily activities  Risk Factors for ED Family Genetics/Being female Life stage Personality characteristics Sport  Excessive exercise Sign of an ED Overtraining Injury Sleep disturbance Amenorrhea in women Mental health http://www.dailymail.co.uk/femail/beauty/article-1195336/Body-dysmorphic- disorder-Four-beautiful-women-distorted-way-THEY-themselves.html http://www.dailymail.co.uk/femail/beauty/article-1195336/Body-dysmorphic- disorder-Four-beautiful-women-distorted-way-THEY-themselves.html  Case study 1 Marlene is a 34-year-old female that you are meeting for the first time. During your fitness assessment of her you learn that she has never really followed a specific exercise routine, but she does walk ~ 2km/day at a moderate pace. She has no health concerns. Marlene is 170 cm and is not sure how much she weighs. You bring her over to the scale but Marlene states that she doesn’t want to get weighed.  Should you weigh her? Yes No 1. to calculate BMI 1. depends on her goals? 2.to determine is she is if weight loss isn’t a goal for overweight/obese her, should it be a goal for you? other goals are ok too risk of chronic diseases (strength, body fat distribution) CVD, diabetes, OA, 2. might be discouraging gallbladder disease, rather than encouraging cancers, immune disorders 3. to determine if she is underweight risk of premature OP, immune disorders, reproductive disorders  Case study 1 State and explain at least 1 reason why it doesn’t matter if Marlene is weighed. – Weight change does not necessarily need to be the goal – Other goals can be: strength, endurance and change in body composition – People of the same weight may have different body composition – The distribution of body fat is also important. Excess abdominal fat increases the risk of certain cancers, and overall mortality. We can assess abdominal obesity by monitoring waist circumference (more than 102 cm for men and more than 88 cm for women has been associated with increased disease risk) – We can also monitor improvements in lab values such as cholesterol, blood sugars, and blood pressure in other instances  Ideal body weight 1. BMI 2. Waist circumference, WHR 3. BodPod 4. DXA 5. BIA  BMI Ratio of weight to height (kg/m2) 50kg/1.67/1.67 Universally adopted Used by CSEP-PATH protocol for risk stratification  Mortality and BMI Which curve depicts the relationship between BMI and mortality the best? A: Excess mortality below and above an ideal value B: Disadvantage to being below an ideal value, but much more disadvantageous to be ABOVE ideal value C: No disadvantage to having low BMI  Mortality and BMI Which curve depicts the relationship between BMI and mortality the best? A: Excess mortality below and above an ideal value B: Disadvantage to being below an ideal value, but much more disadvantageous to be ABOVE ideal value C: No disadvantage to having low BMI  PROs and CONs of BMI Pro: roughly classifies people according to disease risk fast, cheap reproducible (scale and stadiometer) Con: does not consider distribution of fat does not consider composition of body  Waist circumference & WHR Index of subcutaneous (superficial) and visceral (deep) adipose tissue around abdomen and hips Waist circumference + BMI for risk prediction WC Cut-off: >102 cm for men, >88 cm for women WHR Cut-off: >0.95 for men, >0.80 for women Android Gynoid  Thresholds vary based on outcome, sex and ethnicity! European Journal of Clinical Nutrition (2010) 64, 42–61; doi:10.1038/ejcn.2009.70 Some studies show that WHR might be superior to WC! Circulation. 2008; 117: 1658-1667  Pros and Cons of WHR and WC Pros easy to assess cheap index of visceral and subcutaneous fat beyond BMI, risk stratification Cons error between assessors (different protocols) does not differentiate between visceral, subcutaneous fat, ectopic fat  BodPod (aka air density plethysmography) measures air displacement uses variation in pressure and volume in chamber to estimate body density and % body fat https://www.youtube.com/ watch?v=pJD7BsP6AIs Ginde S et al. Obes Res. 2005 13(7)  Dual x-ray absorptiometry (DXA) Works by passing x-ray through body Attenuation of x-rays is related to type of tissue Determine % body fat  Bioelectric impedance analysis (BIA) Passes electrical current through body and measures resistance to the flow adipose tissue- lower water content, more resistance skeletal muscle- higher water content, less resistance BIA: changes after bariatric surgery higher the number, less resistance, less adipose tissue Obes Surg. 2014 Jun;24(6):847-54  Pros and Cons of Pros BodPod, BIA, DXA all assess % body fat could contribute to risk stratification Cons: does not differentiate between subcutaneous fat, ectopic fat and visceral fat more expensive (cheapest = BIA) BIA influenced by hydration DXA radiation BodPod claustrophobia, wear minimal clothes  Case Study 2 Larry is a 47-year-old male. He has come to see you because his family doctor has told him that his weight is putting him at risk for heart disease. Currently his blood pressure, blood cholesterol and fasting blood sugar levels are normal. He has come to you to help with weight loss as suggested by his doctor.  Case study 2 State 5 risk factors for excess fat/obesity. – Genes: Influence body size, shape, body fat distribution and metabolic rate – Metabolism: affected by genes, weight and body composition – Hormones: In particular leptin and ghrelin. Leptin, made by fat cells, mediates long-term regulation of energy balance, suppressing hunger. Obese people may be leptin resistant. Ghrelin is a fast-acting hormone playing a role in meal initiation by increasing hunger. – Fat cells: Can be stored in unlimited amounts. Some people are born with above-average number of fat cells – Eating: What we eat, how often we eat, why we eat (emotional eating) – Physical activity/inactivity – Social determinants of health Larry is considered metabolically healthy overweight/obese.  Obesity 1 kg body fat = 7,000 kcal… extra 22 kcal per day = 1kg weight gain over the year… in 10 years, that’s 10 kg! But, is it as easy as saying calories out should be > calories in? The stigma of obesity… obesity network image bank Insel et al. Core Concepts in Health. 2011 Portion obese Obesity Trends update  Risk factors for obesity Genetics: BMR, fat distribution Hormones: leptin (suppresses hunger) Obesogenic environment: – stress – sleep – portion sizes – how we eat (TV dinners, eating at computer) – sedentariness  Obesogenic factors Quebec Family Study risk factors for overweight/obesity Adjusted Change in body weight (6 yr) OR No participation in 2.03* 1.23 kg high intensity PA High dietary lipid 1.64* 0.61 kg intake High alcohol intake 1.37* 0.39 kg Short sleep 3.81* 1.65 kg duration Low dietary Ca 2.88* 1.3 kg *p vulnerability to pressure sores  less insulation of body to cold (also affected by diminished blood flow to skin & extremities) & heat  Atrophic changes in sweat glands  Thickened fingernails & toenails  Generalized loss of body hair and head hair  Decrease in # of functioning pigment-producing cells-- >graying  Some remaining pigment cells enlarge--> “age spots”  Skin changes increase. vulnerability to infections/disorders  “Arthritis & allied bone and muscular conditions are among the most common of all disorders afffecting people 65 years of age and over.” (Kart & Kinney, p. 76)  Arthritis: A generic term that refers to an inflammation or degenerative change in a joint  Occurs world wide & is one of the oldest known diseases  Osteoarthritis  Cause not known  Also referred to as degenerative joint disease  A gradual wearing away of joint cartilage that results in the exposure of rough underlying bone ends  Can do damage to internal ligaments  Most commonly associated w/ weight bearing jnts  Rheumatoid Arthritis  A chronic, systemic, inflammatory disease of connective tissue  2-3 times more common among women than men  currently viewed as an autoimmune disease  may occur at any age -- most common onset between 20 & 50  Osteopenia --> Osteoporosis:  Gradual loss of bone that reduces skeltal mass without disrupting the proportions of minerals & organic materials  For many, it is asymptomatic  Bones most critically involved: vertebra, wrist, hip  Sarcopenia:  Loss of muscle mass that occurs with aging  Cause not completely understood  Preventable/reversible with regular physical activity  Atophy of secretion mechanisms  Decreasing motility of the gut  Loss of strength/tone of muscular tissue & supporting structures  Changes in neurosensory feedback  Enzyme & hormone release  Innervation of the tract  Diminished response to pain & internal sensations  The phenomenon of referral is common in the GI--I.e. signs & symptoms often associated with one part of the tract may actually be associated with another part of the tract. “Discomfort perceived as originating in the stomach may actually be coming from the lower GI tract.” (p. 79)  The GI symptoms often have their origins in psychosocial factors  In the absence of disease, the heart tends to maintain its size  Heart valves tend to increase in thickness with age  BP tends to go up with age  Systolic stabilizes at about age 75  Diastolic stabilizes at about 65 then may gradually decline  Atherosclerosis  Developed by an overwhelming # of people in industrialized nations  A narrowing of arterial passageways as a result of the development of plaques on their interior walls  Reduces the size of the passageway--even to the pt of closing it off. A cause of ischemic heart tissue (tissue deprived of adequate blood supply)  Arteriosclerosis:  A generic term referring to the loss of elasticity of arterial walls  Often referred to as “hardening of the arteries”  Considered a general aging phenomenon  Airways & tissues become less elastic & more rigid with age  Osteoporosis may alter the size/shape of the chest cavity  Power of respiratory & abdominal muscles becomes reduced-- hinders diaphramatic movement  “The bladder of an elderly person has a capacity of less than half (250ml) that of a young adult (600 ml) and often contains as much as 100 ml of residual urine”. (p. 81)  Micturation reflex is delayed-- usually activated when bladder is half full; in OAs, not until bladder is nearly at capacity  “The genital system is characterized by a number of age- related changes in physiology and anatomy. On the whole, very few age-specific disorders are associated with this body system. With the exception of declining levels of testosterone, most of the problems of sexuality and aging are sociogenic or psychogenic”. (p. 83)  External genitalia  Folds become less pronounced  Skin becomes thinner  Vasculariy & elasticity decrease  Becomes more susceptible to tissue trauma & itching  # of glands decreas, as does level of secretion  Internatal reproductive organs  Uterus decreases in size & becomes more fibrous  Uterus has fewer endometrial glands  Cervix reduced in size  Uterine tubes become thinner  Ovaries take on an irreguar shape  Ovulation stops--menopause (50% between ages 45 and 50)  Continues to produce germ cells (sperm) and sex hormones (testosterone) well into old age, declining with advancing age  Size & firmness of the testes decrease  Reduced sperm production due to age-related fibrosis which constricts the blood supply  Fibrosis may also affect the penis since erection is a purely vascular phenomenon  Flickr: Opensource.com Intro to the Canadian Healthcare System  Learning objectives… 1. Describe key events leading to the development of the Canadian healthcare system. 2. Describe the Canada Health Act.  What we know Doctors are self-employed, not government employees Canada has a publicly-funded healthcare system Vast majority of doctors do not work for the government Patient is free to choose which doctor they wish to visit Doctors earn money by billing their provincial government for the services they provide to patients "Canadian healthcare system," has has distinct health systems for each of the provinces and territories Canada Health Act outlines the basic tenets for healthcare to be universal and accessible for essential physician and hospital health services across the country Provincially determined Federal government has responsibility for Aboriginal and Veteran healthcare  1914 Flickr: James Tworow medical clearance appointments Flickr: NIAID Flickr: Seattle Municipal Archives  1917 Flickr: National Library of Scotland H a l i f a Flickr: Beaton institute, BiblioArchives Canada’s first government funded healthcare 11:00 am- explosion 10:00pm- Harvard doctors depart  1918, 1919: Creation of the “Department of Health” Glenbow Archives, NA-4548-5 A public health nurse uses a doll to show young women how to bathe a baby, Winnipeg, 1916. High infant mortality and general bad health among the population prompted government agencies to introduce public health education programs. Archives of Manitoba, Foote Collection, N 2663 1920s- public hospitals and great depression $10/patient  Early 1920- 77.5% of 1929-1939 Great Depression people could pay for care, By 1929, 50% of people could pay… A room at St. Michael’s Hospital, Toronto, circa 1930. During the Depression, hospital incomes declined because fewer patients could afford private care in a comfortable room like this one. St. Michael’s Hospital Archives, AA-9. From Irene McDonald, C.S.J., For the Least of My Brethren: A Centenary History of St. Michael’s Hospital (Toronto: Dundurn Press, 1992), p. 105.  1968- Pierre Elliot Trudeau implements Medicare Just go to bed, take two aspirins, and send Ottawa $35,000,000 a year! people concerned about cost! In Alberta, public demand and the loss of revenue combined to force Harry Strom’s Social Credit government to join the federal medicare plan on July 1, 1969. Edd Uluschak published this cartoon just before July. Library and Archives Canada, C-138656. 1972, 1974- Enter Marc Lalonde Marc Lalonde’s green paper, A New Perspective on the Health of Canadians, presented in May 1974, inspired Andy Donato’s cartoon of the Liberal Cabinet members. Library and Archives Canada, Acc. No. 1993-169-348, e008315955 1983- Canada Health Act Public Portable Universal Accessible Comprehensive Flickr: Jessica, AJC1, Elizabeth Prata, enigmabadger, Dennis Jarvis  Public Administration This criterion applies to the health insurance plans of the provinces and territories (not to hospitals or the services hospitals provide). The health care insurance plans are to be administered and operated on a non-profit basis by a public authority, responsible to the provincial/territorial governments and subject to audits of their accounts and financial transactions. 13  Comprehensiveness The health insurance plans of the provinces and territories must insure all insured health services (hospital, physician, surgical-dental) and, where permitted, services rendered by other health care practitioners. 14  Universality One hundred percent of the insured residents of a province or territory must be entitled to the insured health services provided by the plans on uniform terms and conditions. Provinces and territories generally require that residents register with the plans to establish entitlement. 15  Portability Residents moving from one province or territory to another must continue to be covered for insured health care services by the "home" province during any minimum waiting period, not to exceed three months, imposed by the new province of residence. After the waiting period, the new province or territory of residence assumes health care coverage. Residents temporarily absent from their home provinces or territories, or from the country, must also continue to be covered for insured health care services. 16  Accessibility The Canada Health Act of 1984 added accessibility to make five principles The health insurance plans of the provinces and territories must provide: reasonable access to insured health care services on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by: – charges (user charges or extra-billing) – others (age, health status, SES). 17  Accessibility … Reasonable access in terms of physical availability of medically necessary services has been interpreted under the Canada Health Act using the "where and as available" rule. Thus, residents of a province or territory are entitled to have access to insured health care services at the setting "where" the services are provided and "as" the services are available in that setting; Reasonable compensation to physicians and dentists for all the insured health care services they provide, and payment to hospitals to cover the cost of insured health care services. 18  CHA – THE CONDITIONS 1. Information — the provincial and territorial governments are to provide information to the Minister of Health as may be reasonably required, in relation to insured health care services and extended health care services, for the purposes of the Canada Health Act. 2. Recognition — the provincial and territorial governments are to appropriately recognize the federal contributions toward both insured and extended health care services. 19  CHA - Extra-billing and User Charges The cost of the new plan were to be shared 50/50 by the federal and provincial governments They were also to be shared in a way that would serve to redistribute income between the poorer and richer provinces 20  CHA - Extra-billing and User Charges … 1. Extra-billing — this occurs if a physician or a dentist directly charges an insured person for an insured service that is in addition to the amount that would normally be paid for by the provincial or territorial health insurance plan. For example, if a physician were to charge patients five dollars for an office visit that is insured by a health insurance plan, the five-dollar charge would be extra-billing. 21  CHA - Extra-billing and User Charges … 2. User charges — these are direct charges to patients, other than extra-billing, for insured services of a province or territory's health insurance plan that are not payable, directly or indirectly, by the health insurance plan. For example, if patients were charged a fee before being provided treatment at a hospital emergency department, the fee would be considered a user charge. 22  What is the money being spent on? About 60% of total expenditure in 2017 was directed to hospitals, drugs and physicians Out-of-pocket health expenditure  Health Status of Canadians Source yourhealthsystem.cihi.ca/inbrief 30  Demands on the healthcare system Hospitals Physician services Specialized drugs such as biologics and antivirals Chronic disease management for elderly – 50 years ago… avg age = 27, focus on acute care – Now… avg age = 57, focus on chronic disease – Senior stay $1000/day vs. $130/d in LTC vs $55/d for home care fewer practitioners (Geriatricians)