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Health Care GuidelineHealthy LifestylesHow to cite this document:Kottke T,Wilkinson J,Baechler C,Danner C,Erickson K,OConnor P,Sanford M,Straub R.Institute for Clinical Systems Improvement.Healthy Lifestyles.Updated January 2016.Copies of this ICSI Health Care Guideline may be distributed by any organization to the organizations employees but,except as provided below,may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement,Inc.If the organization is a legally constituted medical group,the ICSI Health Care Guideline may be used by the medical group in any of the following ways:copies may be provided to anyone involved in the medical groups process for developing and implementing clinical guidelines;the ICSI Health Care Guideline may be adopted or adapted for use within the medical group only,provided that ICSI receives appropriate attribution on all written or electronic documents and copies may be provided to patients and the clinicians who manage their care,if the ICSI Health Care Guideline is incorporated into the medical groups clinical guideline program.All other copyright rights in this ICSI Health Care Guideline are reserved by the Institute for Clinical Systems Improvement.The Institute for Clinical Systems Improvement assumes no liability for any adap-tations or revisions or modifications made to this ICSI Health Care Guideline.Copyright 2016 by Institute for Clinical Systems Improvement www.icsi.org Health Care Guideline:Healthy Lifestyleswww.icsi.orgCopyright 2016 by Institute for Clinical Systems Improvement 1 Sixth EditionJanuary 2016Table of ContentsWork Group LeadersThomas E.Kottke,MD,MSPHCardiology,HealthPartners Medical Group and Regions HospitalJohn Wilkinson,MDFamily Medicine,Mayo ClinicWork Group Members Allina Medical ClinicCourtney Baechler,MD,MSCardiologyHealthPartners Medical Group and Regions HospitalPatrick OConnor,MD,MPHFamily MedicineRebecca Straub,RD,LDDieticianOtter Tail County Public HealthKristin Erickson,MS,APHN-BC,RNPublic HealthStillwater Medical GroupMartha Sanford,MDGeneral InternistUniversity of Minnesota CliniciansChristine Danner,PhD,LPPsychologyICSI StaffJodie Dvorkin,MD,MPHProject Manager,Health Care ConsultantAnnotations.1-28Evidence Grading.2ForewordIntroduction.3Scope and Target Population.4Recommendations Table.5Implementation Recommendation Highlights.6Related ICSI Scientific Documents.6Definition.6Annotations.7-28Quality Improvement Support.29-36Aims and Measures.30Implementation Recommendations.31Implementation Tools and Resources.32Implementation Tools and Resources Table.33-36Supporting Evidence.37-53References.38-46Appendices.47-53Appendix A Healthy Lifestyle Behaviors Survey.47Appendix B ICSI Shared Decision-Making Model.48-53Disclosure of Potential Conflicts of Interest.54-56Document History and Development.57-58Document History.57ICSI Document Development and Revision Process.58Text in blue in this document indicates a link to another part of the document or website.Institute for Clinical Systems Improvement www.icsi.org2Evidence Grading Literature SearchA consistent and defined literature search and review is used in the development and revision of ICSI guide-lines.Two literature searches were conducted for this guideline.The first search included systematic reviews and meta-analyses from 2008 through February 2015.The search was limited to adults over 18 years of age.The terms included healthy lifestyles,patient activa-tion,employer/worksite initiatives,physical and social environment,health assessments,health education programs,worksite physical activity programs,healthy food choices,readiness for change,lifestyle-related screening,motivational interviewing,physical activity,nutrition,tobacco cessation,hazardous drinking,harmful drinking,alcohol abuse/dependence,substance use,positive thinking,positive psychology,sleep hygiene,self-management,pedometer,sugar-sweetened drinks,dietary changes/behaviors,telephone-based counseling,computer-tailored education,brief interventions for healthy behaviors,tobacco telephone quit lines,e-cigarettes,brief alcohol interventions,brief tobacco cessation interventions,brief interventions for primary care,personalized feedback intervention,problem drinking,school-based community education,individually adapted behavior changes,built environment and community-based prevention activities.The second search included randomized controlled trials and observational studies from 2008 through 2015.The search was limited to adults over 18 years of age.The terms included positive psychology,positive thinking,sleep habits and sleep hygiene.In addition to the literature searches,articles were obtained by work group members and ICSI staff.Those vetted by the work group were included in the guideline when appropriate.GRADE MethodologyICSI utilizes the Grading of Recommendations Assessment,Development and Evaluation(GRADE)meth-odology system.GRADE has advantages over other systems including the former system used by ICSI.Advantages include:development by a widely representative group of international guideline developers;explicit and comprehensive criteria for downgrading and upgrading quality of evidence ratings;clear separation between quality of evidence and strength of recommendations that includes a transparent process of moving from evidence evaluation to recommendations;clear,pragmatic interpretations of strong versus weak recommendations for clinicians,patients and policy-makers;explicit acknowledgement of values and preferences;and explicit evaluation of the importance of outcomes of alternative management strategies.GRADE involves systematically evaluating the quality of evidence(high,moderate,low,very low)and developing a strength of recommendation(strong,weak).For more detailed information on GRADE,please go to:http:/www.gradeworkinggroup.org/.Return to Table of Contents Healthy Lifestyles Sixth Edition/January 2016 Institute for Clinical Systems Improvement www.icsi.org3ForewordIntroductionThis guideline,Healthy Lifestyles,summarizes evidence-based best practices that can be used to assess,advise,seek patient agreement and assist patients as they work towards healthy lifestyle behaviors(lifestyles related to physical activity,tobacco,alcohol,nutrition,healthy thinking and sleep).Most of the preventable burden of chronic disease death,disability and health care costs,particularly from heart disease,stroke,cancer,diabetes and depression is attributable to just four behaviors:poor nutrition,inadequate levels of physical activity,tobacco use and exposure to tobacco smoke,and hazardous drinking of alcohol(McGinnis,1993).There is additional evidence that healthy thinking and healthy sleep patterns can help individuals flourish and achieve a state higher than the mere absence of disease(Keyes,2012;Institute of Medicine,2006).The need for intervention is great;only about 5%of the population have no identifiable risk factors and are functioning at an optimal level(Keyes,2012;Daviglus,2004).Moreover,the majority of the disease burden and associated costs originate with individuals who are at or not far above the average population risk(Lauer,2007).The relative infrequency of patient visits,limited time,reimbursement pressures on clinicians,and the high cost of delivering health promotion interventions in the clinic setting all limit the impact of clinical interventions to increase healthy behaviors.However,this is not to say that clinical interventions have no effect.This guideline presents evidence-based interventions that clinicians can provide to their patients to improve rates of healthy behaviors.Community networks,the physical and social environments,and public policy also have a role in fostering healthy lifestyles.Individuals are very often activated or motivated to adopt and maintain healthy lifestyles by various social factors and supports(including policy,system and/or environmental changes)such as those facilitated by employers and the workplace,health plans,communities,social service agencies,and government policies and programs.We expect that individuals and systems will use this guideline in various ways,depending on their needs and interests.We outline routine brief interventions supported by the evidence for all patients(e.g.,helping patients become tobacco-free,helping patients recognize and modify hazardous drinking patterns).For the other healthy behaviors,we outline evidence-based interventions that clinicians and health care systems can recommend to motivated patients(both what and how to recommend)through a process of shared decision-making.This guideline provides a framework for health care delivery systems to design and organize themselves around evidence-based best practices as well as collaborate with other stakeholders to support patients.It is through collaborative clinical and community interrelationships(as illustrated by the health impact pyramid)that healthy lifestyle behaviors can be encouraged and supported.Return to Table of Contents Healthy Lifestyles Sixth Edition/January 2016 Institute for Clinical Systems Improvement www.icsi.org4Scope and Target PopulationThis guideline summarizes evidence-based best practices,which can be used to assess,advise and elicit patient agreement,and assist patients as they work toward the lifestyle behaviors(physical activity,nutri-tion,tobacco,alcohol use,healthy thinking and sleep)that affect health and well-being.This guideline focuses on clinical interventions that can be adopted and integrated into the workflow of both individual clinicians and health care systems.Information about complementary community interventions has been extensively and rigorously reviewed by the Community Preventive Services Task Force(CPSTF)and is summarized in The Community Guide,found at http:/www.thecommunityguide.org.There is growing evidence that the antecedents of many chronic diseases begin in childhood(Lavizzo-Mourey,2007),and the benefits of healthy lifestyles are increased with earlier adoption.While many of the concepts and interventions presented in this guideline are important for adolescents and children,the evidence for how to implement them is not yet fully developed and is beyond the scope of the current guideline.Therefore,for now,the target population of this guideline is adults greater than 18 years of age.Return to Table of Contents Healthy Lifestyles Foreword Sixth Edition/January 2016 Institute for Clinical Systems Improvement www.icsi.org5Recommendations TableTopic Recommendation Quality of Evidence Strength of Recommendation Relevant Resources Physical Activity Consider prescribing a pedometer for individuals who are trying to increase their level of activity.Moderate Strong Kang,2009;Bravata,2007 Consider referring a community program to elderly individuals who have insufficient levels of physical activity.High Strong March,2015 Tobacco Consider offering behavioral or pharmacologic interventions to patients who use tobacco.Given its superior effectiveness,the combination of pharmacotherapy and behavioral interventions should be provided if acceptable to the patient.Guideline Strong Siu,2015 There is insufficient evidence to make a recommendation regarding electronic cigarettes(e-cigarettes).E-cigarettes may be as effective as other types of nicotine replacement therapy,but they may also have unrecognized harms;the potential benefits cannot currently be shown to outweigh the potential risks.Insufficient N/A Ebbert,2015;Leventhal,2015;Siu,2015;McRobbie,2014;Orr,2014 Alcohol Consider offering a brief behavioral intervention for individuals who screen positive on a validated tool for risky/hazardous drinking.Moderate Strong Alvarez-Bueno,2015;Moyer,2013;Jonas,2012;Bertholet,2005 Nutrition Consider advising motivated patients who are not at goal to increase their consumption of fruits and vegetables each day.Moderate Strong Oyebode,2014;Wang,2014;Bellavia,2013 Consider prescribing a Mediterranean-style or the DASH dietary pattern for individuals wanting to improve their nutrition status.Moderate Strong Harmon,2015;Koloverou,2016;Estruch,2013;Kastorini,2011;Sofi,2010;Feart,2009 Consider recommending self-monitoring(food journals,phone apps,tracking websites,advanced meal planning)for obese and overweight patients.Strong Strong Lyzwinski,2014;Lieffers,2012;Acharya,2011;Burke,2011 Healthy Thinking Consider positive psychology interventions for patients interested in increasing their healthy mental habits.Moderate Weak Ouweneel,2014;Bolier,2013;Gander,2013;Sin,2009;Emmons,2003 Healthy Lifestyles Foreword Sixth Edition/January 2016Return to Table of Contents Institute for Clinical Systems Improvement www.icsi.org6Implementation Recommendation HighlightsThe guideline work group recommends utilization of the following system and environmental changes to support guideline implementation.Insert healthy lifestyle promotion into organizational goals.Embed information regarding healthy lifestyle promotion into clinician and staff training and orien-tation materials.Embed information regarding team-based care roles into clinician and staff training and orientation materials.Embed motivational interviewing training into clinician and staff training and orientation.Embed decision supports in electronic medical records to trigger clinicians and staff members to deliver guideline components.Offer and promote health assessments at or prior to clinic visit.Place healthy lifestyle-related materials such as posters,pamphlets,videos,website links and/or quick response(QR)codes throughout the facility.Return to Table of ContentsRelated ICSI Scientific DocumentsGuidelines Major Depression in Adults in Primary Care Prevention and Management of Obesity Adults Preventive Services for AdultsReturn to Table of ContentsDefinitionClinician All health care professionals whose practice is based on interaction with and/or treatment of a patient.Return to Table of Contents Healthy Lifestyles Foreword Sixth Edition/January 2016 Institute for Clinical Systems Improvement www.icsi.org7AnnotationsFive As Model of Patient-Centered Care and Self-Management SupportThe 5As Model of Self-Management Support(Glasgow,2003;Whitlock,2002)is the framework around which this guideline is organized:Assess:Ask about or assess lifestyle behaviors(physical activity,tobacco,alcohol,nutrition,healthy thinking and sleep)on a routine basis.Patient-centered assessment:Brief Standardized Offers feedback and tracks the progress of both patients and team Considers patients goals and values and satisfaction with his or her progress Advise:Give specific information about the benefits and goals of a healthy lifestyle and specific behaviors.Patient-centered advice Includes information about benefits of a healthy lifestyle and how behaviors affect various outcomes Tailored to patients goals,values and environmentAgree:Through a process of shared decision-maki
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