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Health Care GuidelineHealthy LifestylesHow to cite this document:Kottke T,Baechler C,Canterbury M,Danner C,Erickson K,Hayes R,Marshall M,OConnor P,Sanford M,Schloenleber M,Shimotsu S,Straub R,Wilkinson J.Institute for Clinical Systems Improvement.Healthy Lifestyles.Updated May 2013.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-tationsorrevisionsormodificationsmadetothisICSIHealthCareGuideline.Copyright 2013 by Institute for Clinical Systems Improvement www.icsi.org Complete health assessment,with timely feedback providedRedesign for results(R4R):patient-centered systems for healthy lifestylesCommunity interventions for healthy lifestylesSystematically integrate clinical and community interventions for optimal follow-up4Shared decision-making and brief interventions Understand patients views and enhance motivation Provide advice and negotiate individual goals5Provide support and appropriate interventions for healthy lifestyles6Increased physical activityImproved nutritionDecreased tobacco use and exposureDecreased hazardous and harmful drinking/alcohol use6a6b6c6d7Community support forhealthy lifestylesPhysical and social environmentFamily and socialnetworksPublic policyEducators and schoolsEmployers and worksitesHealth plans and payersFaith-based organizationsPracticed positive thinking6eImproved sleephygiene6f231Health Care Guideline:Healthy Lifestyleswww.icsi.org Copyright 2013 by Institute for Clinical Systems Improvement 1 Fifth EditionMay 2013Text in blue in this algorithm indicates a linked corresponding annotation.Return to Table of Contents Institute for Clinical Systems Improvement www.icsi.org2Healthy Lifestyles Fifth Edition/May 2013This decision tree is most effective when the following recommendations are employed:MotivationalinterviewingastheinterventionframeworkAmultidisciplinaryteamapproach,anassessmentofprogramneedsanduseoflocalresourcesImplementationshouldbetailoredorcustomizedforeachhealthcareorganization6a-f.Behavioral Decision TreeAssess:Knowledge:related to the healthy lifestyle behavior Behavior:current healthy lifestyle behavior Status:opportunity for healthy lifestyle behavior improvementAdvise:Health risks Benefits of change/maintenanceAgree:collaboratively set specific,feasiblegoals Minimum Healthier OptimalAssist:Anticipate barriers Problem-solve solutions Complete action planArrange:Specify plan for follow-up Link to clinic and community resourcesReturn to Table of Contents Institute for Clinical Systems Improvement www.icsi.org3Table of ContentsHealthy Lifestyles Fifth Edition/May 2013Work Group LeaderThomas E.Kottke,MD,MSPHCardiology,HealthPartners Medical Group and Regions HospitalWork Group Members Allina Medical ClinicCourtney Baechler,MD,MSCardiologyHealthPartners Medical Group and Regions HospitalPatrick OConnor,MD,MPHFamily MedicineMichael Schoenleber,MDFamily MedicineRebecca Straub,RD,LDDieticianHennepin County Medical CenterScott Shimotsu,PhD,MPH,CPHQData AnalystMayo ClinicJohn Wilkinson,MDFamily MedicineOtter Tail County Public HealthKristin Erickson,RN,BSN,PHNPublic HealthStillwater Medical GroupMarna Canterbury,MS,RDDieticianMartha Sanford,MDGeneral InternistUniversity of Minnesota CliniciansChristine Danner,PhD,LPPsychologyICSIRochelle Hayes,BSSystems Improvement CoordinatorMelissa Marshall,MBAClinical Systems Improvement FacilitatorAlgorithms and Annotations.1-36Algorithm.1Behavioral Decision Tree.2Evidence Grading.4-5ForewordIntroduction.6-7Scope and Target Population.7Aims.7Clinical Highlights.8Implementation Recommendation Highlights.8Related ICSI Scientific Documents.9Definition.9Annotations.10-36Quality Improvement Support.37-46Aims and Measures.38-39Implementation Recommendations.40Implementation Tools and Resources.41Implementation Tools and Resources Table.42-46Supporting Evidence.47-69References.48-55Appendices.56-69Appendix A Health Assessments.56-59Appendix B Intensity Levels of Physical Activity.60-61Appendix C Alcohol Use Disorders Identification Test(AUDIT).62Appendix D Implementation Summary Sheet.63Appendix E Guideline Implementation Tool.64Appendix F ICSI Shared Decision-Making Model.65-69Disclosure of Potential Conflicts of Interest.70-72Acknowledgements.73-74Document History and Development.75-76Document History.75ICSI Document Development and Revision Process.76 Institute for Clinical Systems Improvement www.icsi.org4Healthy Lifestyles Fifth Edition/May 2013Evidence Grading Literature SearchAconsistentanddefinedprocessisusedforliteraturesearchandreviewforthedevelopmentandrevisionofICSIguidelines.Theliteraturesearchwasdividedintotwostagestoidentifysystematicreviews(stageI);andrandomizedcontrolledtrials,meta-analysisandotherliterature(stageII).Literaturesearchtermsusedforthisrevisionarephysicalactivitytracking,dietaryintaketracking,useofdietitiansinclinicalpractice,multidisciplinaryteams,waystoassessphysicalactivitystatus,socialdeterminants,positivethinkingandpositive psychology.They include literature from June 2009 through January 2013.GRADE MethodologyFollowingareviewofseveralevidenceratingandrecommendationwritingsystems,ICSIhasmadeadecisiontotransitiontotheGradingofRecommendationsAssessment,DevelopmentandEvaluation(GRADE)system.GRADEhasadvantagesoverothersystemsincludingthecurrentsystemusedbyICSI.Advantagesinclude:developedbyawidelyrepresentativegroupofinternationalguidelinedevelopers;explicitandcomprehensivecriteriafordowngradingandupgradingqualityofevidenceratings;clearseparationbetweenqualityofevidenceandstrengthofrecommendationsthatincludesatransparentprocessofmovingfromevidenceevaluationtorecommendations;clear,pragmaticinterpretationsofstrongversusweakrecommendationsforclinicians,patientsandpolicy-makers;explicitacknowledgementofvaluesandpreferences;andexplicitevaluationoftheimportanceofoutcomesofalternativemanagementstrategies.This document is in transition to the GRADE methodologyTransitionstepsincorporatingGRADEmethodologyforthisdocumentincludethefollowing:PriorityplaceduponavailableSystematicReviewsinliteraturesearches.AllexistingClassA(RCTs)studieshavebeenconsideredashighqualityevidenceunlessspecifieddifferently by a work group member.AllexistingClassB,CandDstudieshavebeenconsideredaslowqualityevidenceunlessspecifieddifferently by a work group member.AllexistingClassMandRstudiesareidentifiedbystudydesignversusassigningaqualityofevidence.RefertoCrosswalkbetweenICSIEvidenceGradingSystemandGRADE.AllnewliteratureconsideredbytheworkgroupforthisrevisionhasbeenassessedusingGRADEmethodology.Return to Table of Contents Institute for Clinical Systems Improvement www.icsi.org5Crosswalk between ICSI Evidence Grading System and GRADEICSI GRADE System Previous ICSI System High,if no limitation Class A:Randomized,controlled trial Low Class B:observational Cohort study Class C:observational Non-randomized trial with concurrent or historical controls Low Case-control study Low Population-based descriptive study*Low Study of sensitivity and specificity of a diagnostic test*Following individual study review,may be elevated to Moderate or High depending upon study design Class D:observational Low Cross-sectional study Case series Case report Meta-analysis Class M:Meta-analysis Systematic Review Systematic review Decision Analysis Decision analysis Cost-Effectiveness Analysis Cost-effectiveness analysis Low Class R:Consensus statement Low Consensus report Low Narrative review Guideline Class R:Guideline Low Class X:Medical opinion Evidence Definitions:High Quality Evidence=Further research is very unlikely to change our confidence in the estimate of effect.Moderate Quality Evidence=Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.Low Quality Evidence=Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate or any estimate of effect is very uncertain.In addition to evidence that is graded and used to formulate recommendations,additional pieces of literature will be used to inform the reader of other topics of interest.This literature is not given an evidence grade and is instead identified as a Reference throughout the document.Return to Table of Contents Healthy Lifestyles Evidence Grading Fifth Edition/May 2013 Institute for Clinical Systems Improvement www.icsi.org6ForewordIntroductionInthelasthalfofthe20thcentury,chronicdiseasesparticularlyheartdisease,stroke,cancer,diabetesanddepressionemergedasthemajorcausesofdeath,disabilityandrisinghealthcarecostsfortheAmericanpublic.Chronicdiseaseaccountsfor7outof10deathsandaffectsthequalityoflifeof90millionAmericans(Jordan,2008 Low Quality Evidence).Moreover,asignificantportionofthepreventablecomponentforalloftheseconditionscanbetracedtofourbehaviors:poornutrition,inadequatelevelsofphysicalactivity,smokingandexposuretotobaccosmoke,andhazardousdrinkingofalcohol.Infact,40%ofalldeathsintheUnitedStatescanbeattributedtothesefourbehaviorsalone(Mokdad,2004 Systematic Review).Anadditionalfifthbehavioraroundpositivethinkinghasbeenshowntoincreasehappinessanddecreasereportof depression systems(Seligman,2005 Low Quality Evidence).Thereisgrowingevidencethatinterventionstoincreasephysicalactivity,improvenutrition,decreasetobaccouseandexposure,decreasehazardousandharmfuldrinking/alcohol,andadoptpositivementalstrategieswillreducetheburdenofdisease,disabilityandprematuredeath.Aprospectivestudywasconductedonindividualsaged45-64,lookingatfourhealthylifestylebehaviors.Thebehaviorsaredefinedaseatingatleastfivefruitsandvegetablesaday,exercisingaminimumof2.5hoursaweek,maintainingabodymassindexbetween18.5and30,andnotsmoking.Thestudyfoundthatmaintainingahealthylifestylereducedall-causemortalityby40%andcardiovasculardiseaseeventsby35%overfouryears(King,2007 Low Quality Evidence).There is also a growing body of evidence that these changes will lead to a more produc-tive workforce and reduced health care costs(Ozminkowski,2002 Low Quality Evidence;Ozminkowski,2000 Low Quality Evidence;Goetzel,1998 Low Quality Evidence).Intheareaofmentalhealth,practicing appreciating and using signature attributes to help others have been shown to increase reports of happiness and reduce symptoms of depression(Seligman,2005 High Quality Evidence).Inaddition,greateruseofcertainhigh-valuepreventiveservices,particularlysmokingcessationadviceandassistance,andalcoholscreeningandbriefcounselingwillsavelives,withlittleadditionalinvestment(Maciosek,2010 Systematic Review).Aprojectthatmodeledtheimpactofinterventionstopreventandtreatheartdiseasefoundthatthelargestimpact from intervention would accrue from helping people adopt and maintain healthy lifestyles before theydevelopedheartdiseaseorwhiletheywerelivinginthecommunitywithheartdisease.Asignificantportionofthebenefitaccruesfromthefactthatthelifestylesthatpreventheartdiseasealsopreventseveralother chronic diseases(Kottke,2009 Low Quality Evidence).Thereisagrowingrecognitionandunderstandingoftherolethatcommunitynetworks,thephysicalandsocialenvironments,andpublicpolicyallplayinfosteringhealthylifestyles.Individualsareveryoftenactivatedormotivatedtoadoptandmaintainhealthylifestylesbyvarioussocialfactorsandsupports,orotherincentives,originatingwithemployersandtheworkplace,healthplans,communities,socialserviceagencies,andgovernmentpoliciesandprograms.Whilenottheprimaryfocusoftheguideline,wedodiscussexamples of various initiatives in the wider society designed to encourage healthy lifestyles.Medicalgroupscannotbegiventhesoleresponsibilityforpromotinghealthylifestyles;therelativeinfre-quencyofpatientvisits,limitedtimeandreimbursementpressuresonclinicians,andthehighcostofdeliv-eringhealthpromotioninterventionsintheclinicsettingallpresentsignificantbarrierstosuccess.Thereislittleevidencethatthecurrenthealthcaresystem,muchlessindividualclinicianswhentheyareactingalone,canreliablyorconsistentlymotivateoractivateindividualpatientsforhealthylifestyles.Rather,healthcaredeliverysystemsshouldbedesignedandorganized,basedonbestevidence,tosupportalreadymotivatedandactivatedindividuals,andtoeffectivelycollaboratewithotherstakeholders.Return to Table of Contents Healthy Lifestyles Fifth Edition/May 2013 Institute for Clinical Systems Improvement www.icsi.org7Onlyabout5%ofthepopulationhavenoidentifiableriskfactors(Daviglus,2004 Low Quality Evidence).Therefore,nearlyallindividualscouldbenefitfromhealthylifestyleinterventionandassistanceinbehaviorchange.Moreover,themajorityofthediseaseburden,andtheassociatedcosts,originatewithindividualswho are at or not far above the average population risk(Lauer,2007 Low Quality Evidence).Althoughtheaveragechangeinnutritionpatterns,levelsofphysicalactivity,populationsmokingrates,ratesofhazardousdrinkingorchangesinnegativethinkingaresmallinthetrialsthatprovidethedocumentationforthisguideline,individualswhomakesignificantlifestylechangescanexpecttoexperiencelargereductionsinriskofdiseaseandinriskoffuturehealthcarecosts.Furthermore,thesmallchangesinaveragediseaseriskexpectedwiththeinterventions,becausetheywillbespreadwidelyacrossthepopulation,canbeexpectedto result in large reductions in disease rates and health care costs(Rose,1985 Low Quality Evidence).Thereisalsogrowinginterestinwhathassometimesbeentermedprimordialprevention(precedingprimaryprevention),basedongrowingevidencethatchronicdiseasepreventionbeginsinchildhoodbefore physiological risk factors develop.While many of the interventions and concepts presented in this guidelineareeffectiveinadolescentsandchildren,theevidenceforlong-termbenefitsinchildrenisnotyet fully developed(Lavizzo-Mourey,2007 Low Quality Evidence).Therefore,theworkgroupmembersrecommendedthat,fornow,thescopeofthisguidelinebelimitedtoadults.Return to Table of Contents Scope and Target PopulationThisguideline,HealthyLifestyles,outlinestheexistingevidencefortheeffectivenessofstrategiesandprogramsdesignedtohelpadultsoptimizehealthbyadoptinghealthylifestyles(increas
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