Heart Healthy Overview Meghan Dawes, PharmD Meghan Donovan, MS, RD, LDN Rachel Thomas, PharmD Mandi Boykin, PharmD Jenelle Hall, PharmD nature.com

Overview Gain a better understanding of pre-diabetes Why should you care? Identify risk factors for heart disease Blood Pressure Goal blood pressure per ADA Treatment Dietary changes Medications High Cholesterol Goal per ADA Discuss ways to lower risk for heart disease Review of the ABC’s Specifically medications under the DHP nature.com

What is Pre-Diabetes? Several questions about this topic….. Well it depends on which reference you refer too as to what this is….. Something that came to light in the past 2 years to us. Up until recently HRA did not include A1c. We are able to identify now people maybe not identified in the past as pre-diabetic. Depending on what references you look at depends on the number. But all of the references say…. nature.com

Pre-Diabetes “Intermediate group of individuals whose glucose levels, although not meeting criteria for diabetes, are nevertheless too high to be considered normal.” Not trying to label you…people don’t like to be called pre-diabetic ADA. Standards of Medical Care in Diabetes. 2013. nature.com

What is Pre-Diabetes? American Diabetes Association (ADA) Pre-diabetes is the same as impaired fasting glucose. No one really took this seriously. When you start changing the name to pre-diabetes people start listening. Aace American Association of Clinical Endocrinologists define pre diabetes as A1c bet 5.5-6.4%, ADA defines it differently. 5.7-6.4% So keep this in mind Numbers may be different but you are not high enough to be diabetic and not low enough to be in the normal range. A1C values between 5.5% and 6.4% should be a signal to do more specific glucose testing (Grade D; BEL ADA. Standards of Medical Care in Diabetes. 2013. healthy-ojas.com nature.com

Pre-Diabetes Statistics 1 in 3 Americans has pre-diabetes 79 million Americans Interestingly, 1 in 3 individuals in the United States has pre-diabetes, which equates to roughly 79 million people. However, only 11% of these individuals who do have pre-diabetes know they have it (which is roughly 8.7 million people. Why do we think this is??????? MD appts etc, don’t go unless sick. They are not looking at an A1c. Don’t check unless have risk factors… ADA. Diabetes Statistics. 2013. nature.com

Why You Should Care About Pre-Diabetes? Beta cells = cells in pancreas that produce insulin. 6-10 years before diagnosis of diabetes. The majority of patients do not know they have pre-diabetes usually because it takes time for the disease to progress and for symptoms to begin occurring. By the time you have a diagnosis of diabetes 50% of beta cell function is decreased and a reduction of beta bell mass of up to 60%. This is why it is important to know your A1c. If you have the risk factors then you should be screened but not even one has these risk factors. Table 6 Prediabetes Risk Factors Suggesting a Need for Screening (2 [EL 4; consensus NE]) Family history of diabetes mellitus Cardiovascular disease Being overweight or obese Sedentary lifestyle Nonwhite ancestry Previously identified impaired glucose tolerance, impaired fasting glucose, and/or metabolic syndrome Hypertension Increased levels of triglycerides, low concentrations of high-density lipoprotein cholesterol, or both History of gestational diabetes mellitus Delivery of a baby weighing more than 4 kg (9 lb) Polycystic ovary syndrome Antipsychotic therapy for schizophrenia and/or severe bipolar disease Adapted from UKPDS grp, Diabetes 1995;44:1249-1258. nature.com

Why You Should Care About Pre-Diabetes? Normal Diabetes Caution: Take steps to prevent type 2 diabetes. This is why we do the HRA. This is why we have pre-diabetes and/or impaired FBG. Majority of people with pre-diabetes develop diabetes in 10 years U.S. Department of Health and Human Services. ADA. National Diabetes Clearinghouse. 2013. nature.com

What is going on? Cells are unable to use the insulin being produced by the pancreas because of resistance Pancreatic cells that produce insulin become tired and overworked, and begin to make less insulin As we talked about in class 1….Insulin resistance = when the cells do not open up the door when insulin knocks to let glucose in If we can identify pre-diabetics and get them under control at this time then we can take steps to prevent it. Knowledge is power….i know I have prediabetes- I can now take steps to prevent it. I have type2 diabetes….I am now going to take steps to prevent the complications esp those we have discuss in previous classes. ADA. Standards of Medical Care in Diabetes. 2013. nature.com

What is the Link Between Heart Disease and Diabetes? Not sure if I like this nature.com

Heart Disease and Diabetes If you are a diabetic we need to take steps now to prevent complications, so we need to get our blood sugars under control. increased risk for heart disease of coronary stents implanted in 2011 heart attacks annually higher heart disease morbidity and mortality rates chance of dying from heart disease rehabilitateyourheart.wordpress.com nature.com

Helpful Hint…. The Good News is….. We can CONTROL this!!!! Diabetes is 1 of the 7 major controllable risk factors for cardiovascular disease American Heart Association nature.com

Risk Factors for Heart Disease Factors that we can NOT change: Gender male Age 65 and older Family history of heart disease Females that are post-menopausal Race African Americans, American Indians, and Mexican Americans Modifiable Age: About 82 percent of people who die of coronary heart disease are 65 or older per American Heart Association Don’t have the protective hormones after menopause American Heart Association. www.heart.org nature.com

Risk Factors for Heart Disease Factors that we can CHANGE: Blood pressure Cholesterol levels Amount of exercise Weight Uncontrolled Diabetes Uncontrolled stress and anger Smoking Blood pressure- high High cholesterol Amount- meaning too little Katherine will talk more about exercise in next class Being over Weight Uncontrolled diabetes American Heart Association. www.heart.org nature.com

Risk Factors For Heart Disease High Blood Pressure (hypertension) High blood pressure- This is something that can be changed ~65% of diabetics develop high blood pressure (>140/90 mm Hg) OR require medication for high blood pressure American Heart Association. www.heart.org londonderrynh.net nature.com

High Blood Pressure Blood Pressure measures the force on the artery walls 2 Forces: Pumping of the heart = Systolic (top number) Resting of the heart = Diastolic (bottom number) Per ADA, goal blood pressure is < 140/90 mmHg accuratebloodpressure.com American Heart Association. www.heart.org www.accuratebloodpressure.com nature.com

High Blood Pressure However, I always gets asked whats normal? See…the pre category gets brought up again with pre-hypertension. Not yet high blood pressure but not normal. accuratebloodpressure.com American Heart Association. www.heart.org www.accuratebloodpressure.com nature.com

High Blood Pressure Why do you need to keep your blood pressure controlled? Arteries are made of muscle and flexible tissue Increase in force of the heart beat = more stretching by the arteries Increased stretching over time leads to arteries stretched beyond its healthy limit Think about arteries as a balloon. As I blow the balloon expands until the balloon stretches until it can’t stretch anymore. We don’t want arteries to get too flexible and pop. Need two readings on two different days to be hypertension. If blood pressure is elevated too much can rupture the artery causing an internal bleed (stroke) www.hcahamilton.com What is one way to help decrease blood pressure????? Decrease sodium AHA. www.heart.org; www.hcahamilton.com nature.com

Total Amount of Salt a Day Shaking the Salt ↑ sodium leads to ↑ fluids in the body thus leading to higher blood pressure AHA/ADA recommendations for persons with diabetes: Where you have salt then you have fluid. If we get rid of salt then we can get rid of fluid then we can lower the BP AHA/ADA recommendations for the general public are 2300mg of salt per day Total Amount of Salt a Day Less than 1500mg nature.com

Shaking the Salt One Big Mac has 1010 milligrams of sodium! What is 1,500 mg of Salt? 1/4 teaspoon salt = 600 mg sodium 1/2 teaspoon salt = 1,200 mg sodium 3/4 teaspoon salt = 1,800 mg sodium 1 teaspoon salt = 2,400 mg sodium Also would state is almost your whole daily allowance at ONE meal … and this doesn’t include the fries! One Big Mac has 1010 milligrams of sodium! nature.com

Shaking the Salt Where can you find Salt? Sodas Restaurant and fast food meals Convenience and packaged foods Condiments Canned foods Frozen vegetable vs canned vegetables Processed foods Deli meats Cheeses Sodas Sodas- Diet coke = 12 oz = 40 mg 12 oz can of regular coke classic= 45 mg of sodium Thus it is just better to drink water eatright.org nature.com

Ways to Lower Your Blood Pressure Healthy diet Decreasing sodium intake Regular physical activity Maintain healthy weight Manage stress Quit smoking Decrease caffeine Medications Limit alcohol nature.com

Limiting Alcohol Limit the amount of alcohol you drink In small amounts alcohol can lower your blood pressure by 2 to 4 mmHg 1 drink a day for women & men over age 65 2 drinks per day for men age 65 and younger Too much alcohol can increase sodium and that will increase blood pressure Mayoclinic.com One drink = Key Point: If you don't normally drink alcohol, you shouldn't start drinking as a way to lower your blood pressure! nature.com

Medications help lower blood Pressure

Circulatory System Circulatory system. Blood pressure medications work on this system. We are going to discuss the most commonly prescribed medications. So remember this list is not a complete. We will focus on those medications covered by the DHP. When your heart pumps blood where do you think the majority goes? It goes to your kidneys so that is why so many drugs work on the kidney. nature.com

Treatment for Blood Pressure Overview Medications that work on the kidney Drug Class Examples of Medications ACE-Inhibitors Zestril (Lisinopril), Vasotec (Enalapril) Monopril (Fosinopril) ARB’s Cozaar (Losartan), Micardis (Telmisartan) Benicar (Olmesartan) Diuretics Hydrocholorthiazide Chlorthalidone Lasix (Furosemide) 80-85% of blood that leaves your heart goes to your kidneys. These medications work on the vessels around your kidney. ACEI= “end in pril” ARB= “end in sartan” Sister drug That is why these are first line medications for patients with diabetes. These help decrease blood pressure by working on blood flow to the kidneys. Diuretic decrease BP by decreasing sodium therefore decrease fluid. First line for people with out diabetes to help decrease blood pressure. Decrease BP by decreasing fluid in the body so may have to go to the bathroom more so take in the day time versus at night nature.com

Treatment for Blood Pressure Overview Blood pressure medications that work on the heart Lowers blood pressure AND heart rate Class of Medications Examples of Medications Beta Blockers Toprol XL (Metoprolol) Lopressor (Metoprolol) Coreg (Carvedilol) Tenormin (Atenolol) Calcium Chanel Blockers Calan (Verapamil) Cardizem (Diltiziam) Norvasc (Amlodipine) “end in olol” Can mask signs/symptoms of low blood sugar Lets review from class 1 the symptoms of low blood sugar. Therefore, beta blockers can hide jitteriness and fast heart rate. If you have symptom of sweating it will not mask that. Therefore, this may be your only sign. Heard of Target Heart Rate???? Meds can increase HR and some may decrease heart rate (BB). Make sure your trainer knows the medications you are on because your heart rate is not going to increase due to medications. Your maximum heart rate in beats per minutes is based on how old you are -- it's 220 minus your age.) For most people, the American College of Sports Medicine recommends a target heart rate while exercising of 50% to 85% of your maximum heart rate. nature.com

Blood Pressure Medications (covered by DHP) Some medications help protect the Kidney from damage caused from diabetes: ACE-Inhibitors: Zestoril (Lisinopril), Lotensin (Benazepril), Vastotec (Enalapril) ARB’s: Cozaar (Losartan), Benicar (Olmesartan), Micardis (Telmisartan) Side Effects: Cough (ACE-I) Edema (swelling) Hypotension Increase in potassium nature.com

Risk Factors For Heart Disease High Cholesterol (hyperlipidemia) Only going to focus on medications that are most commonly prescribed to pts with high cholesterol. They all work in different ways on different areas. American Heart Association. www.heart.org nature.com

Cholesterol What is cholesterol? Where does it come from? Waxy substance found in all cells in the body that travel in the blood as small particles Where does it come from? 75 % made by the liver Food: Animal Products Egg yolks Fatty meat Whole milk Whole cheese As we have more cholesterol then we get more plaque Thus in the pictures the top one does not have plaque and blood can flows more easily NIH patientnavigatortraining.org Cholesterol makes hormones, vit D and helps breakdown food The higher the animal fat, the more cholesterol it will have. Plant based foods have zero cholesterol Average 3oz chicken breast still has 70-85 mg of cholesterol of Dietary Cholesterol you Eat to less than 200 mg/day nature.com

Total Amount of Cholesterol a day Why do we need cholesterol? Hormones Vitamin D Substances that help breakdown food Your body makes all the cholesterol it needs!! Don’t need to have extra cholesterol. That is why what you need to consume is such a low number Total Amount of Cholesterol a day Less than 200mg nature.com

Cholesterol LDL HDL “BAD” cholesterol Can cause build up in the arteries HDL “GOOD” or “Healthy” cholesterol Carries cholesterol back to the liver Liver then removes from the body Cholesterol itself is like the top of the iceburg. It is made up of 3 components HDL is like a pac man and goes around in your body and picks up the bad cholesterol and takes it to your liver so then it can be removed NIH http://www.nhlbi.nih.gov/health/health-topics/topics/hbc/ These are the different forms of cholesterol….. nature.com

Cholesterol Triglycerides Total Cholesterol Found in the blood Unused calories that are stored in your fat cells For an accurate reading you must fast for 9 to 12 hours prior to lab work Total Cholesterol Total cholesterol = GOOD + BAD + TG Formula: LDL=TC-HDL-TG/5 (mg/dL) Food will increase your triglycerides. It is 1 component that is very much affected by the food you consume. Reason why this formula is important is because if you have a lot of TG then you will not will be able to tell what your LDL is LDL is what we worry about with heart disease and complications. If TG >500 then that is extremely high and treatment can change nature.com

Targets of Nutrition Therapy for Lowering Cholesterol Total Fat Saturated Fat Trans Fat Cholesterol Point of this slide is when you have no plaque blood flows easily. But as cholesterol increases that it is harder for blood to flow www.nature.com nature.com

Limit Total Fat Keep total fat to less than 35% of daily calories In general aim for: 40-75 grams of fat daily Make most of your fats heart healthy fats like olive oil, peanut butter, nuts, avocado Increase vegetables and whole foods Eat more omega 3 heart healthy fats from flaxseed, canola, soybean oils, cold water fish We want you to increase the amount of heart healthy fasts Fish examples: Cold-water varieties of fish like mackerel, tuna, salmon, sardines and herring contain high amounts of omega-3 fatty acids. Salmon Artic char Mackerel Trout, lake Herring Tuna, bluefin Sardines, canned Sturgeon Tuna, albacore1 Whitefish, lake Anchovies Bluefish Read more: http://www.rd.com/health/healthy-eating/omega-3-rich-fish/#ixzz2pOifQUn9 nature.com

Limit Saturated Fat Fatty meat Poultry skin Bacon Sausage Whole milk Foods high in Saturated Fat Foods low in Saturated Fat Fatty meat Poultry skin Bacon Sausage Whole milk Cream Butter Lean meats Remove the skin from chicken Turkey bacon Turkey sausage 1% milk or skim milk Reduced fat creams I Can’t Believe it is Not Butter Lean meats- chicken, turkey and fish Cheeses- high in saturated fat better choices are mozzarella and ricotta cheese To lower saturated fats you want to reduce high fat animal products and switch to skim milk, To avoid trans fats you want to avoid partially hydrogenated oils. Found in pastries, Goal Saturated Fat: Less than 12-15 grams/ per day nature.com

Limit Trans Fat Foods high in Trans Fat Foods low in Trans Fat Stick margarine Shortening Cake mixes Fried foods Packaged foods (like microwave popcorn) Commercially prepared muffins, pastries, etc Fruits and vegetables Lean meats Nonfat dairy products Vegetarian proteins like tofu, beans, soy, peanut butter, etc Whole wheat and whole grain products What are trans fat: Trans fat can make food taste good, last longer on grocery-store shelves, and more hazardous for your heart. Trans fats raise your bad cholesterol just like saturated fats, but they also increase inflammation and lower the good cholesterol that protects us against heart disease To lower saturated fats you want to reduce high fat animal products and switch to skim milk, To avoid trans fats you want to avoid partially hydrogenated oils. Found in pastries and commerically prepared foods. Goal Trans Fats: 0-2 grams per day nature.com

Keep Total Cholesterol as Low as Possible In general aim for : Less than 200 mg daily Plan to eat more plant based meals Check the food labels for cholesterol Increase vegetables and whole foods Example: 3 oz chicken and lean meat has 75-85mg cholesterol Becky to add food label nature.com

Cholesterol by the Numbers To recap, we want to keep fats, trans fats limited As we age our cholesterol increases American Heart Association nature.com

Medications that lower Cholesterol

Treatment for Cholesterol Overview Fibric Acid Fenofibrate Bile Acid Sequestrant Welchol, Cholestyramine, Colestipol HMG-COa reductase Inhibitors (Statins) Simvastatin, Lovastatin, Atorvastatin, Rosuvastatin, Fluvastatin, Pravastatin Miscellaneous Niacor Fibric acid- decrease TG Bile Acid Seq: group of resins used to bind certain to cholesterol thereby preventing its reabsorption from the gut. In general, they are classified as hypolipidemic agents, although they may be used for purposes other than lowering cholesterol. They are used in the treatment of chronic diarrhoea due to bile acid malabsorption. Statins Niacor form of niacin that increases HDL and decrease LDL. All of these medications are covered at $0 co-pay under the DHP nature.com

Treatment for High Cholesterol “Statin” Medications Simvastatin (Zocor) Lovastatin (Mevacor) Atorvastatin (Lipitor) Rosuvastatin (Crestor) Fluvastatin (Lescol) Pravastatin (Pravachol) Rosuvastatin, Fluvastatin, Pravastatin nature.com

Treatment for High Cholesterol How do statins work? Improve your cholesterol panel by: Stabilizing plaque ↓ LDL (“bad” cholesterol) ↑ HDL (“good” cholesterol) ↓ Triglycerides

Treatment for High Cholesterol Possible side effects: Muscle pain/weakness Increase in liver enzymes When do I take this medication? It depends on the medication! Anytime of the Day Before Bed Atorvastatin (Lipitor) Rosuvastatin (Crestor) Pravastatin (Pravachol) Lovastatin (Mevacor) Simvastatin (Zocor) fluvastatin (Lescol) Muscle pain and weakness- all over like the flu not just in arms or legs Increase in liver enzymes 3 times upper limit. nature.com

What can I do to help lower my risk for heart disease? nature.com

Ways to Prevent Heart Disease Decrease weight Watch your diet Exercise Avoid smoking Better control your diabetes Better control your blood pressure Take your medications Follow up with your doctor Exercise: 150 minutes/week and skip more than 2 days in a row nature.com

Exercise 150 minutes of moderate intensity physical activity every week and do not skip more than 2 days a week Overall risk of heart disease by 14% Weight A1c Blood pressure Stress nature.com

Decrease LDL “bad cholesterol” Know your ABC’s Target: Less than 7% Less than 140/90 mmHg Decrease LDL “bad cholesterol” nature.com

Meghan Dawes, PharmD Meghan Donovan, MS, RD, LDN Rachel Thomas, PharmD Healthy Lifestyles Meghan Dawes, PharmD Meghan Donovan, MS, RD, LDN Rachel Thomas, PharmD

Overview Stress Reduction Wheel of Health Activity Setting SMART goals Foods to Fuel a Healthy Life Exercise Ways to Move More

Stress Reduction

Why Does Stress Matter? Stress can prevent the body from properly releasing insulin among those with Type 2 diabetes Individuals with Type 2 diabetes may be more sensitive to stress hormones Individuals with diabetes are 2x more likely to suffer from chronic depression Why are stress & depression so common? Diabetes is "one of the most psychologically and behaviorally demanding of the chronic medical illnesses.” Stressors that are a result of diabetes occur from: The daily routine of caring for your diabetes (injections, maintenance of strict diet, required daily physical activities, medications, etc.) Feeling of being “nagged” by family and/or physician to keep up with diabetes care maintenance Frustration with little or no improvement in blood glucose, cholesterol, blood pressure levels despite care regimen Additional medical issues that arise as a result of diabetes

Wheel of Health Please complete the wheel of health activity on the DHP website. Think about each of these areas of your life. Draw a dot where you feel you are in that area. Connect the dots and use the wheel to make a plan. Think about your optimal health vision, choose the area that you would like to work on. Nutrition Movement, Exercise & Rest Physical Environment Fun & Recreation Spirituality & Personal Growth Career & Professional Development Mind-Body Connection Relationships & Communication This is called the wheel of health. What we would like for you to do is to think about each of these areas of your life and how satisfied you are with each of them. There are no right or wrong answers. Think of each ring of the circles as a ranking from 0 at the center to 10 on the very outer edge. Draw a dot on where you feel you are in that area. For the nutrition category, think about how well you do at eating a balanced, healthy diet in terms of what is realistic for you at the current moment. The movement, exercise & rest category can include activities of daily living like cleaning and gardening as well as dancing, yoga, walking, running, or cycling, balanced with adequate rest and relaxation. For the physical environment category, think about how you feel about the light, noise, toxins, and colors where you live and work as well as the landscapes surrounding those spaces. The relationships & communication category includes spending time with family, friends or coworkers who are supportive and with whom you communicate effectively. Fun and recreation is self explanatory. Are you able to relax and have a good time? Do you spend your days laughing or scowling? The mind-body connection means paying attention to the effects your mind and body have on each other. Do you use techniques such as breathing practices, meditation, progressive muscle relaxation or guided imagery to activate the body’s relaxation and healing response? The career and professional development section is not just about money. It includes developing your own abilities, talents and interests. Are you where you’d like to be in your career? Is your job fulfilling? Do you set goals and work towards attaining them? Do you measure, monitor and adjust to assure your actions continue to be in alignment with your goals? Spirituality means seeing purpose and meaning in something larger than one’s self. It may include religious affiliation or other areas such as nature or the arts. Personal growth can include seeking self-knowledge and being compassionate towards yourself.

Making Lifestyle Changes Factors that Enable Change Establish the right mind-set, positive attitude and commitment. Recognize that gradual changes are lasting changes. Eat mindfully: enjoy each bite. Plan ahead and have a daily game plan. Plan purposeful physical activity each day. Set S.M.A.R.T. goals specific, measurable, action oriented, relevant, timed

Making Lifestyle Changes Initiating Change Identify your trouble spots (habits, sweets, snacks, restaurants, etc.). Establish solutions. List your barriers to change. Create solutions. Take one step at a time, including one change at a time if necessary. Look for support. Be accountable to yourself and others. Hang in there and persevere!

Looking at Your Barriers to Change Strategies, Solutions, & Goals Time Plan ahead and be prepared to have portable, healthy food with you! Select healthier fast food alternatives Convenience Know 4-5 quick fix meals for daily last minute cooking Knowledge Read labels and apply knowledge gained for DHP classes Attitude Don’t deprive yourself Remember that small changes add up to big ones in the long run Habit Know your challenges. Replace old habits with new ones. Portions Eat off smaller plates and bowls.

Healthy Living

Nutrition Overview Recap : Carbohydrate Counting Plate Method Eating Healthy at NHRMC Recipe Modification Making Better Choices Easy Food Prep at Home Eating on the Run This class will help you find strategies that work for your lifestyle to change health behaviors for the better!!!!!

Menu Planning: Carbohydrate Counting Women 30-45 grams per meal 15-30 grams per snack Men 45-60 grams per meal 15-30 grams per snack These are general guidelines. Some people in the room may need a little lower, some may need more.

Menu Planning: Plate Method With a packed lunch In the main cafeteria At the deli station ½ Plate Non-starchy vegetables ¼ Plate Lean Protein ¼ Plate Starchy Vegetables, Grains, Fruit or Dairy

Healthy Eating at NHRMC Look for the 5 under 5 options at all NHRMC cafeterias Use the salad bar to increase vegetables consumed at lunch or dinner Choose mindful items at Lighthouse and NHRMC cafeteria Grilled chicken sandwich Veggie burger Deli sandwich on wheat thins

Healthy Eating at Au Bon Pain Breakfast Sandwich Choice Egg whites & Cheddar Eggs with cheddar and avocado on a skinny whole wheat bagel, hold the lemon aioli Sandwiches Classic Chicken salad sandwich (half) Caprese sandwich (half) Black angus roast beef and herb cheese signature sandwich (half) Soups(8oz serving) Southwest vegetable Tomato basil bisque Specialty Salads (without dressing) Garden salad Thai peanut chicken salad

Foods to Fuel a Healthy Life Choose minimally processed foods are from the 5 basic food groups Eat each color of the rainbow daily Try almonds to reduce LDL cholesterol Avocados offer more potassium than bananas Broccoli has more vitamin C and calcium than milk or oranges Eating healthy does not have to be cost prohibitive. Incorporating more fresh, frozen and natural foods can fit any budget. Beans are very inexpensive and serve as a great protein alternative. Beans can be substituted for meat at any meal and provide a much cheaper alternative to cuts of steak, chicken and beef. Also frozen produce is a great option if living alone or in general when vegetables are out of season. Vegetable and produce boxes are available during the spring and summer.

How Do I Keep My Favorite Foods Around? “You can have them all….but not all at once.” - Bethenny Frankel

Recipe Modification Visit DHP website for stovetop and baking swaps Save CALORIES, CARBOHYDRATES, AND FAT!

Did you know? 2 slices Pepperoni Pizza = 596 calories, 24 g fat, 74 g CHO To burn off these calories you’d have to spend 78 minutes on the elliptical 91 minutes walking Cheeseburger plus fries = 1270 calories, 74 g fat, 101 g CHO 2 hours and 20 minutes on the elliptical 4 hours of walking Based on 200 lb person

Re-do Recipes Visit the DHP website (www.nhrmc.org/dhp) for the following recipe re-dos that will save you calories, fat, and carbohydrates! Homemade Veggie Pizza Cheeseburger Sweet Potato French Fries

Tips To Save Calories While Dining Out Ask for a to go box at the start of your meal; save half for a later meal. Hold the cheese, mayo and sauce or order on the side. Choose a baked potato, non-starchy vegetables or a salad as your side. Chew slowly and savor your food Share with a friend!

Quick Dinner Competition To-go from Chick-Fil-A Harris Teeter (2) Chargrilled Chicken Sandwich Combos - $12.98 + 8pc. Chicken Nugget Combo - $5.95 (1) 6 pc. Chicken Nugget Kid’s Meal - $3.99 = TOTAL - $22.82 Harris Teeter Whole Roasted Rotisserie Chicken - $7.49 + 16oz. Harris Teeter California Blend Frozen Vegetables - $1.55 (2) Uncle Bens Whole-Grain Brown Ready Rice - $3.34 = TOTAL - $12.38 The Harris teeter quick dinner option is not only more cost effective but healthier with whole grains, vegetables and lean proteins. Consider this for your next quick family meal.

Eating on the Go Always plan ahead: Use smart phone apps and websites to look up calorie counts. www.calorieking.com “Undress” your food: Ask for dressing and sauces on the side. Downsize portions: Ask for less, Order child-size items, Save half for later Did you know? Starbucks has a short size - they just don’t advertise it.

Exercise Have the group stand up for the first 2 slides and then tell them to be seated after you explain exercise and stress. It will seem pointless at first, but you can drive it home with the consequences of sitting slides towards the end of the presentation. The point is every minute counts!

Why Exercise? 150 minutes of moderate intensity physical activity every week and do not skip more than 2 days a week Overall risk of heart disease by 14% Weight A1C Type 2 Diabetes risk lowered by 58%! Blood pressure Stress nature.com

Why Exercise? 150 minutes equals: 30 to 45 min on 3-5 days/week For a 200 lb. individual, a weight loss of 14 pounds (over a period of 3-6 months) Sources: NIH, New England Journal of Medicine

Why Exercise? Exercise improves insulin action Improved insulin action = better blood glucose control Exercise lowers blood glucose by: Increasing insulin sensitivity Allowing glucose to be used more efficiently Over time, this may help lower HbA1c! Sources: ECU, AACE

Being Proactive for Prevention Regular exercise can: Improve blood glucose control Prevent or delay Type 2 diabetes Positively influence lipids Improve blood pressure Reduce risk for cardiovascular events Improve quality of life As discussed in last year’s Diet, Exercise & Fitness class, the benefits of exercise go well beyond what is listed on this slide. Exercise as medicine is an important and impactful movement that is becoming more widespread each day. I can’t say it enough - diet and exercise are the most flexible treatment options we have, especially when implemented in balance with proper medication compliance. Any of these benefits are within our power. Although we emphasize the impact of exercise on blood glucose control (highlighted in red), it is important to understand that regular exercise can positively influence cholesterol, triglycerides, blood pressure and overall risk for future health complications. Exercise is one of the best ways to increase our healthy HDL cholesterol and may help reduce our stress levels. Sources: MayoClinic, ADA

How Does Exercise Relieve Stress? Release of endorphins – “feel good” chemicals that help reduce pain and improve mood Relaxes the body Improves self-esteem Enhances overall well-being Improves sleep Reduces risk for chronic depression Improves physiological function So, how does exercise reduce stress? First, exercise results in the release of endorphins, which help reduce pain and improve our mood. These chemicals are responsible for what some refer to as the “runner’s high”. Exercise also relaxes the body and improves self-esteem, sleep quality and physiological function. Exercise may reduce risk for chronic depression – which, as discussed in last year’s Reducing Risk & Preventing Complications class, is common among individuals with diabetes. Sources: MayoClinic, ADA

Types of Exercise Aerobic Running Walking Biking Anaerobic Exercise Flexibility Yoga Stretching Resistance bands Bodyweight Exercises Water Bottle Workout

EFC Programs 12toLife: 12 weeks to a new lifestyle Weight Loss Challenge Stay Fit Challenge FITastic Kids Program Other programs to consider: Group exercise classes Personal training Massage therapy No Excuses Workout (N.E.W.) found on EFC website The EFC programs are an amazing resource to all NHRMC employees and dependents. 12toLife was designed for beginner exercisers and is perfect for those in the Diabetes Health Plan who are ready to work towards becoming a confident, independent exerciser. This program emphasizes team work, goal setting, nutrition, exercise safety and technique. Individuals meet with a trainer 2x/wk and work in a team of 5 throughout the 12 weeks. The transition program has just been added and is an extension of the 12toLife program. This lasts for 8 weeks and is designed to help those who aren’t quite ready to move on to the next step after they complete the 12toLife program. The weight loss challenge is a little more advanced and focuses on maintaining a healthy lifestyle and losing weight. The stay fit Challenge is the most advanced program offered at the EFC and challenges participants to continue working towards greater physical fitness and overall health. There are also many group exercise classes available, and as mentioned before, you can always ask for modifications if needed. Don’t be afraid to try any new class. Just talk to the instructor if you are new or if you have concerns or special needs related to a condition or injury. There are a variety of wonderful personal trainers at our EFC and their bios are available online. Check them out and see if any of the trainers may be able to help you reach your health and wellness goals. Finally, the massage therapists are very talented and can help you reduce stress, improve sleep quality, reduce pain and much more! Call the EFC if you have questions or would like to set up an appointment with a trainer or massage therapist.

EFC Group Fitness In Gear Yoga Barre Pilates Boxing Bootcamp Spin Combo Club Spin Century Strength Zumba ABS Circuit Strength Kids Camp (5-8 yr olds & 9-12 yr olds) Bands & Balance Training Bootcamp Zumba Toning Boxing Express Track Conditioning Olympic Weightlifting Spin Abs Kick - Boxing Bootcamp Hydra Tone Strength & Endurance Kettle Bell Strength SPIN This is a snap shot of part of the group fitness schedule offered at the EFC. The full schedule is available online or at the EFC front desk. Remember: ask for modifications and talk to the instructor if you are new to a class or if you have special concerns or needs. The full schedule is available on the EFC website or at the EFC front desk!

Consequences of Sitting How often do you sit? The average person sits 8-10 hours per day! The few minutes you spent standing at the beginning of the exercise slides probably seemed rather pointless – but it wasn’t! Every minute counts. We sit more often than ever due to advancements in technology. Our work may be less physically demanding than ever before; thus, our level of inactivity has increased over time. We sit while driving, working, eating, watching TV and much more! The average person sits 8-10 hours per day, and that doesn’t include time spent sleeping. Research has shown that prolonged sitting and sedentary work increases risk for chronic disease and other health complications.

Flexibility Stretch at work and during breaks Maintain a neutral spine Stretch your calves and feet when wearing certain types of shoes (i.e., high heels) Use a foam roller or assisted stretching equipment if needed Flexibility is important, but remember that you need to be warmed up before you begin stretching. Therefore, the ideal time to stretch is after a short break, walk or exercise session. Take short breaks at work and be sure to stretch afterwards. Focus on your calves and feet when wearing certain types of shoes – for example, high heels shorten the calves and reduce flexibility, which in turn can cause tightness and discomfort in the legs. Be sure to stretch often if you wear these types of shoes. You may also invest in a foam roller or assisted stretching equipment, if needed. These are great for individuals who do not want to get directly onto the floor to stretch or for those who need additional attention for tight or fatigued muscles.

Fit Exercise Into Your Day! Walk at work! - Walking paths at NHRMC, Cape Fear and Business Center locations Check the NHRMC website! Short breaks throughout the work day 10 minute increments Group exercise class or activity with co-workers during breaks Find resources in your community Independence Mall walking program So, now that we know what types of activities we need to do, when and how can we fit them into our daily routine? First, you can walk at work. There are walking paths at NHRMC, Cape Fear and the Business Center. Walking maps are available on the Good For You website at the very bottom of the page. Visit the link listed here. Remember that short intermittent sessions are just as effective as longer duration workouts. Every minute counts – duration is more important than intensity! Take short walking and/or stretch breaks throughout the day, especially if you work at a desk or in an office. Take a look at the Desk Cycle pictured here. These are available at a cost of $20 up to $175, but are a great way to stay active while working in the seated position. Try the EFC, other exercise facility or group exercise class. There are some classes offered at our Employee Fitness Center specifically tailored to those who are out on their lunch break. Be sure to look for resources in your community, and the DHP team is here to help. We want you to stay active and enjoy the exercises you participate in. If you aren’t sure where to start or where to go, contact us. We will be happy to help!

Let’s Get Moving! Short walks (2-3 minutes every hour) Physical activity after every meal Stand while working Park in the back of the lot Take the stairs Walk your grocery cart back into the store Go inside for fast food or drinks Become more aware of how often you sit Here are some ways we can become more active. Take short breaks throughout the day and stand whenever possible. See if you qualify for a standing workstation. Walk more often, whether it be in a parking lot, at a grocery store or at a fast food restaurant. Go inside to pick up your food and avoid the drive thru whenever possible. Become more aware of how often you sit and try to reduce it. Every minute counts and prevention is key.

Contact Information For appointments with a Dietitian or Pharmacist: Contact Dee Freeman at 667-5183 or Diabetes.Pharmacy@nhrmc.org DHP Questions or Concerns: Contact DHP Administrator at 667-5959 DHP Hotline 667-7777 Questions?

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