Wk 19 Public Health.pdf

WEEK 19 Public Health Susan Gault Dale 121 [email protected] 1 PHA113 MPharm WEEK 19 Learning Outcomes • Understand what we mean by public health • Know how public health fits in with the pharmacy contract • Understand the role of the pharmacist in lifestyle interventions • Be...

WEEK 19 Public Health Susan Gault Dale 121 [email protected] 1 PHA113 MPharm WEEK 19 Learning Outcomes • Understand what we mean by public health • Know how public health fits in with the pharmacy contract • Understand the role of the pharmacist in lifestyle interventions • Be able to make lifestyle interventions for patients who: • Are at risk of high blood pressure • Are overweight • Are smokers 2 PHA113 MPharm WEEK 19 Recap • Last week we covered: • What public health is and where it sits within community pharmacy • The behavioural change cycle • Risk factors for high blood pressure • Advice to help patients reduce their high blood pressure by looking at their modifiable risk factors 3 PHA113 MPharm WEEK 19 4 Weight Management PHA113 MPharm WEEK 19 5 Weight Management PHA113 MPharm WEEK 19 6 The Costs of Obesity PHA113 MPharm WEEK 19 7 Obesity and Health Inequalities PHA113 MPharm WEEK 19 How do we measure obesity • World Health Organisation defines overweight or obesity as an abnormal or excessive fat accumulation that may impair health • Measured as BMI > 30 8 PHA113 MPharm WEEK 19 Causes of Obesity • Poor diet • Calorie Imbalance • Frequency of eating • Convenience foods • Lack of physical activity • Medical conditions / medication • Alcohol intake • Psychological factors • Genetics • Social factors 9 PHA113 MPharm WEEK 19 10 Dietary Advice PHA113 MPharm WEEK 19 Dietary Advice • Base meals on carbohydrates • potato, bread, rice, pasta, cereals • wholegrain better • Lots of fruit and veg • 5 a day • Eat fish • 2 portions a week (one oily) • Reduce saturated fat intake • 30g/men, 20g/women • Reduce sugar intake • fizzy drinks, breakfast cereals • >22.5g/100g is high content 11 PHA113 MPharm WEEK 19 Dietary Advice • Less salt • max 6g/day for adults • >1.5g/100g of food is high • Get active • try cutting down calorie intake and begin regular exercise • Avoid getting thirsty • 6 to 8 glasses/day • avoids dehydration and aids digestion • Avoid missing breakfast • replenish body’s low blood sugar 12 PHA113 MPharm WEEK 19 Alcohol Guidelines • Guidelines for both men and women are: • Don’t drink more than 14 units a week on a regular basis • Spread your drinking over three or more days. • If you have one or two heavy drinking episodes a week, you increase your risk of death from long-term illness, accidents or injuries 13 PHA113 MPharm WEEK 19 14 Tips for reducing alcohol intake PHA113 MPharm WEEK 19 15 Exercise and Physical Activity PHA113 MPharm WEEK 19 16 Exercise and Physical Activity PHA113 MPharm WEEK 19 Other treatment options for obesity • Consider starting drug treatment in overweight people with a BMI of 27 with associated risk factors (e.g. type 2 diabetes, hypertension, or dyslipidaemia). • Be aware that drug treatment for people with obesity or overweight should: • Only be considered once dietary and physical activity interventions have been evaluated. • Form part of an integrated approach to weight management, which should include advice, support, counselling on diet and physical activity, and behavioural strategies. • Drug options • Orlistat • Saxenda 17 PHA113 MPharm WEEK 19 Other treatment options for obesity • Consider the need for bariatric surgery (gastric band/gastric bypass) • First line option for people with a BMI > 50, (instead of lifestyle intervention or drug treatment) when other interventions have not been effective. • An option for people with a BMI of 35–50, if certain criteria are fulfilled. • E.g. other significant diseases linked that would be improved by weight loss • All appropriate non-surgical measures have been tried and were unsuccessful • The person is generally fit for anaesthesia and surgery • The person commits to long-term follow up • Local criteria and policies on access to bariatric surgery may vary. • Usually referral for surgery will be made via a specialist obesity management service. 18 PHA113 MPharm WEEK 19 Smoking Cessation 19 PHA113 MPharm WEEK 19 Health burden of smoking (NHS digital 2020) In 2019/20........ • 506,100 hospital admissions attributable to smoking. • Similar to 2018/19 but 10% higher than 2009/10 when it was 461,700 • 74,600 deaths attributable to smoking. • Decrease of 3% from 2018 (77,000) and 9% from 2009 (82,000) • 710 thousand prescription items to help people stop smoking dispensed. • Decrease of 4% from 2018/19 (740 thousand) and 71% from 2009/10 (2.48 million) https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2020 20 PHA113 MPharm WEEK 19 Smoking: Public Health Interventions • All people who smoke should be advised to quit. • How might we affect change to promote healthy behaviours? • • • • Smoking ban Increased taxation on cigarettes Plain packaging campaign Highlighting the dangers/increasing awareness of second hand smoke • Incentivise quitting by educating on the damage caused by smoking • Supporting people to quit 21 PHA113 MPharm WEEK 19 Smoking Cessation • Smoking cessation refers to activities that aim to support people who smoke to stop smoking. • Health care professionals should opportunistically ask people if they smoke during a consultation. If the person does smoke, very brief advice (VBA) for smoking cessation should be provided. • If a person smokes, it is important to find out about their: • Smoking behaviour. • Level of nicotine dependence. • Previous quit attempts. 22 PHA113 MPharm WEEK 19 People who are ready to quit… • Preferred management is referral to the local NHS Stop Smoking Services. • If they decline referral they should be: • Informed about sources of information and support for smoking cessation. • Offered practical advice. • Advised to stop abruptly. • Offered drug treatment to reduce withdrawal symptoms. • nicotine replacement therapy (NRT), varenicline or bupropion. • Varenicline or combination NRT have been shown to be the most effective treatments. 23 PHA113 MPharm WEEK 19 People who do not want to quit… • If an adult does not want to or is not ready to stop smoking, they should be asked whether they would like to try a harm reduction approach, such as: • Stopping smoking, but continuing to use NRT. • Cutting down before stopping smoking, with or without NRT. • Smoking reduction, with or without NRT. • Temporary abstinence from smoking, with or without NRT. • NRT may be used as long as necessary to prevent relapse. 24 PHA113 MPharm WEEK 19 NHS Stop Smoking Services • Intervention types • Settings • • • • • • Closed group Couple/ family Drop-in clinics One-to-one support Open group Telephone support • • • • NRT Bupropion Varenicline Combinations of the above • Pharmacotherapy 25 PHA113 • • • • • • • • • • • • • Children’s centres Community Community psychiatric Dental General Practice Hospital Maternity Military base Pharmacy Prison Psychiatric hospital School Workplace MPharm WEEK 19 Helping people quit: Physical addiction • Reducing nicotine intake in smokers causes withdrawal symptoms • Short term withdrawal symptoms include: • Light headedness, difficulty concentrating, sleep disturbance, depressed mood, irritability and restlessness • Longer term patients may experience: • Increased appetite and weight, constipation and mouth ulcers • Most last only up to 4 weeks • The urge to smoke can continue for more than 10 weeks after quitting 26 PHA113 MPharm WEEK 19 Helping people quit: Re-normalisation of the body • After quitting cigarette smoking, the body begins to re-normalise: • Blood pressure returns to normal • Pulse rate returns to normal • Reduction in carbon monoxide in lungs (can also be used for monitoring purposes) • Oxygen levels return to normal • Coughing as cilia in the lungs being to work and breathing becomes easier • Lung function increased 27 PHA113 MPharm WEEK 19 28 What happens when you quit? PHA113 MPharm WEEK 19 Smoking Cessation Services • Behavioural support • Important in combination with all pharmacological treatments • Structured programme of usually up to 12 weeks • Consultation with a trained smoking cessation adviser every 1-2 weeks • Information on: • • • • • • 29 • consequences of smoking • withdrawal symptoms Assess current readiness to quit and past quit attempts Setting a quit date and preparation for stopping smoking Carbon monoxide testing Addressing any ‘slips’ Reinforce importance of abstinence and ‘not a puff’ rule Supports development of ‘coping’ mechanisms and relapse prevention PHA113 MPharm WEEK 19 Smoking Cessation Services - Measuring Dependence Q1 How soon after you wake up do you smoke your first cigarette? Q2. How many cigarettes per day do you usually smoke? Within 5 minutes 3 10 or less 0 6-30 minutes 2 11-20 1 31-60 minutes 1 21-30 2 After 60 minutes 0 31 or more 3 Scores Known as HSI – Heaviness of Smoking Index 1-2 = low dependence 3 = low to moderate dependence Scores can influence NRT choices 4 = moderate dependence 5-6 = high dependence 30 PHA113 MPharm WEEK 19 Carbon Monoxide Testing • Measures the quantity of carbon monoxide in expired air • Used to assess nicotine dependence objectively • Used at initial assessment and to validate quit status at 4 weeks • Clients hold their breath for 15-20 seconds then blow into the detector • Non-smoker should have <10ppm CO • Can be used as a motivational tool • False positives can include CO poisoning • Only represents smoking activity over the previous 24 hours 31 PHA113 MPharm WEEK 19 Nicotine Replacement Therapy (NRT) • Facilitates the gradual withdrawal of nicotine • Available in a range of formulations and dosage routes • Combinations can be used to help provide a ‘baseline’ of nicotine that can be ‘topped up’ at point of increased urge to smoke • Mainly chosen based on patient preference • Tailored based on level of dependence • Counselling on use and managing patient expectations is an important aspect of their use • Although contains nicotine, safer than smoking! • Widely available as GSL medicines 32 PHA113 MPharm WEEK 19 NRT Products • • • • 33 • Inhalator • Nasal spray • Oral spray Transdermal patches Lozenges Chewing gum Sublingual tablets PHA113 MPharm WEEK 19 NRT Products – Choosing the right product(s) for the patient • Points to consider: • doses, strengths, flavours, onset time, side effects, compatibility with patient, advantages/disadvantages • Patches (steady release over time) • 16hr: put on in the morning and removed at bedtime • For those who don’t smoke immediately after waking, most commonly used, no sleep disturbances • Initially 25mg for those smoking > 10 per day, 15mg for those smoking < 10 per day • 24hr: worn for 24 hours then replaces • For those who smoke during the night or immediately after waking, can cause nightmares • Initially 21mg for those smoking > 10 per day, 14mg for those smoking < 10 per day 34 PHA113 MPharm WEEK 19 NRT Products – Choosing the right product(s) for the patient • Quit rates are higher when using a second NRT product in combination with the patches • Faster acting NRT products help with cravings • • • • • • Lozenges Gum Microtabs Oral spray Nasal spray Inhalator • Choice of product is based on patient preference 35 PHA113 MPharm WEEK 19 Other treatment options for smoking cessation • Varenicline (Champix ) POM • Currently unavailable • Partial agonist at nicotinic receptors • Reduces withdrawal symptoms • Prevents ‘reward’ from intake of nicotine • Reduces severity of withdrawal symptoms and reduces urge to smoke • Start 1-2 weeks before quit date • Bupropion (Zyban) POM • Noradrenaline and dopamine re-uptake inhibition • Reduces severity of withdrawal symptoms • Reduces urge to smoke • Start 1-2 weeks before quit date 36 PHA113 MPharm WEEK 19 Other treatment options for smoking cessation • E-cigarettes • More recently large scales reviews in the UK and US have found that regulated e-cigarettes are safer than regular smoking. • The latest government evidence update on e-cigarettes can be found here: • Nicotine vaping in England: 2022 evidence update main findings - GOV.UK (www.gov.uk) • The most recent update for the government’s tobacco control plan can be found here: • Smoke-free generation: tobacco control plan for England - GOV.UK (www.gov.uk) • The aim is to have a smoke free generation by the year 2030 in England 37 PHA113 MPharm WEEK 19 Resources • Scenario: Management | Management | Obesity | CKS | NICE • Scenario: Management | Management | Hypertension | CKS | NICE • How to screen | Diagnosis | Alcohol - problem drinking | CKS | NICE • Scenario: Adults | Management | Smoking cessation | CKS | NICE • The Eatwell Guide - NHS (www.nhs.uk) 38 PHA113 MPharm