Eating for Whole Health Day 2 Afternoon

Eating for Whole Health Day 2 Afternoon
Prevention of Cancer The Whole Health Visit: Creating a Personal Health Plan Implementation Exercises

Nutrition Slides, Day 2 AM edits 11. Prevention of Cancer
Eating for Whole Health

Nutrition Slides, Day 2 AM edits
Tonya’s Goals: Prevention of Breast Cancer

Nutrition and Cancer Prevention Tell the audience what you’re going to tell them Then tell the audience Then tell the audience what you told them

Outline: The Landscape, the Forest, and the Trees
Nutrition Slides, Day 2 AM edits Outline: The Landscape, the Forest, and the Trees Landscape Cancer + geographic dietary patterns Forest Epidemiological studies Trees Individual foods/nutrients + cancer Crucifers, Alliums, PUFA, Phytoestrogens, Vitamins Other food-related topics Obesity + cancer Food preparation Photo: We will start to look at cancer from a 10,000 foot view, a foot view , and a close look at the molecular level: the landscape, the forest, and the trees

The Landscape The 10,000 foot view: geographic dietary patterns
Nutrition Slides, Day 2 AM edits Which country has the highest cancer rate? The landscape: geographic cancer rates. Cancer rates differ significantly by geographic region Which country has the highest cancer rate?

World Cancer Rates Red- highest Yellow-lowest ( For an anti-inflammatory teabag….) This is a great geography review…who can identify which countries have the highest incidence of Cancer? Denmark, France, Australia, Belgium, Norway, US. And the lowest risk countries? (in yellow) Niger , Gambia, Namibia, Bhutan, Yemen, Nepal, Mauritania Can anyone guess who has the lowest cancer rate of all countries where it is measured? The highest?

World Cancer Rates by Country
Nutrition Slides, Day 2 AM edits World Cancer Rates by Country The highs and lows are not where you might expect them to be. More developed countries, which have more sophisticated care, have more cancer. They may also have longer lifespans and better surveilance, which could account for some of the discrepancy.

World Cancer Rates

Cancer Rates by State Here is a map of cancer rates by state. Where we live makes a difference. ( Say something about where you are lecturing) Courtesy CDC:

The Forest The 1,000 Foot View: Epidemiologic Studies
Nutrition Slides, Day 2 AM edits We looked at the overall landscape – geographic patterns of cancer that demonstrate that different geographic environments are associated with different rates of cancer occurrence. That tells us that something in the environment could be causing cancer. Is it chemical exposure? Is is lifestyle stress? Is it diet? Lets look closer, first at the forest, and then at the trees. ( This is not really a forest, it is a broccoli patch. Broccoli is going to be important here: that’s a hint!)

European Prospective Investigation Into Cancer and Nutrition Trial
Nutrition Slides, Day 2 AM edits EPIC: the European Prospectiv Investigation into Cancer and Nutrition_ is the largest prospective cohort study looking at nutrition ( and other environmental effects) and cancer. They have collected a lot of data over 15 years. Other studies preceded this but this is the most important and comprehensive study today 10 different countries from 23 centers in Northern Europe and the Mediterranean

EPIC: European Prospective Investigation into Cancer & Nutrition Nutrition Slides, Day 2 AM edits Largest prospective cohort study in the world investigating relationship btw diet, nutritional status, environmental & lifestyle factors and incidence of cancer and other chronic disease Recruited from 1992 – 1999 accumulated data until 2015 N= 521,000, ages >/= 20 years Nordic region and N Europe Mediterranean areas over 10 countries, 23 centers from Greece to Denmark Data continues to be collected from EPIC but no longer enrolling people. Individual were over age 20 and from the Nordic region and North Europe and the Mediterranean area. Obviously there are not many individuals of African or Asian decent in this region so it is important to realize that.

Lessons from EPIC: Mortality Adherence to Mediterranean Diet and mortality N= 4,607 men and women, aged 60 or more No preexisting coronary heart disease, stroke, or cancer at enrollment Diet scored on a 9 point “Mediterranean scale” Extent of adherence to a Mediterranean diet using a 9 point scale reduced mortality by 8% Trichopoulou A et al. Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. BMJ Apr 30;330(7498):991. PMID: Some of the lessons from EPIC: those who adhered most to a Mediterranean diet had a reduction in mortality attributable to diet up to 8%. That alone was a significant factor impacting cancer risk! This is study with very strong conclusions and often quoted. We will be sharing other strong studies with you also.

Lessons from EPIC: Colon Cancer Vitamin D Levels and Colon Cancer Participants with 25(OH)D levels in the highest quintile before diagnosis of colorectal cancer had decreased mortality from colorectal cancer (CRC) compared to those in lower quintiles. Takeaway: Low vitamin D levels may put patients at risk for developing colorectal cancer Fedirko V Cancer Pre-diagnostic 25-Hydroxyvitamin D, VDR and CASR Polymorphisms, and Survival in Patients with Colorectal Cancer in Western European Populations Epidemiol Biomarkers Prev 2012 April ; 21(4): 582–593. doi: / EPI The individuals in this study were divided into 5 segments (quintiles). Through this study we also learned about Vitamin D and its preventive effect on colon cancer . It is hard to show a nutrient is preventive as you have to separate out all the other potential factors.

Lessons from EPIC: Cancer and Alcohol Consumption Nutrition Slides, Day 2 AM edits Burden of cancer attributable to alcohol consumption Men Women Total cancer 10 % 3 % Upper (esophageal, tracheal, etc.) 44 % 25 % Liver 33 % 18 % Colorectal 17 % 4 % Breast 5 % A substantial part of the alcohol-attributable fraction was associated with alcohol consumption higher than the recommended upper limit. EPIC also looked at cancer attributable to overconsumption of alcohol ( listed as “higher than recommended amounts”) Over 4 oz wine/women, and over 8 oz/men IF <65yo We saw an increased risk in Men; especially in esophageal and tracheal cancers Schütze M et al. Alcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study. BMJ Apr 7;342:d1584. PMID:

Diet and Cancer Prevention
Nutrition Slides, Day 2 AM edits Diet and Cancer Prevention This is a paper from 2008 that has been often quoted. It looks at a broad array of literature on the environmental associations with cancer and assigns percentages that are due to certain etiologies.

Nutrition Slides, Day 2 AM edits Diet and Cancer Prevention 5–10% of cancer diagnoses are due to genetic defects 90–95% environment and lifestyle Lifestyle factors: cigarette smoking, diet, alcohol, sun exposure, pollutants, infections, stress, obesity, physical inactivity Cancer-related deaths: 25–30% are due to tobacco 15–20% due to infections 10-15% other factors 30–35% are linked to DIET Anand et al Pharmaceutical Research, Vol. 25, No. 9, September 2008 Encapsulation of previous slide 30-35% of cancer overall can be attributed to diet! To quote Walter willett from the Harvard School of Public Health- “Why do we spend most of our $$ in Cancer on treatment? Why don’t we spend more in prevention?” Answer this for yourself…. ( not a lot of money in prevention) How many of you guys have heard of the American Institute For Cancer Research (AICR)? This is a nonprofit organization that fully devotes itself to nutrition prevention for cancer reduction

Nutrition Slides, Day 2 AM edits To what percentage is each cancer attributed to DIET? Now we have set the stage for talking about specific nutrition patterns, foods and nutrients and their value in cancer prevention High percentage attributed to nutritional factors Tends to be underplayed a lot in medicine Anand et al Pharmaceutical Research, Vol. 25, No. 9, September 2008

Anand et al Pharmaceutical Research, Vol. 25, No. 9, September 2008

The Trees: Individual Foods and Nutrients
Nutrition Slides, Day 2 AM edits The Trees: Individual Foods and Nutrients Zooming in on specifics How stuff works Antioxidants Crucifers Alliums PUFA Phytoestrogens Green Tea Multivitamins We have looked at incidence of cancer from a geographic point of view, then looked at studies from EPIC with European and Mediterranean populations Now we will drill down to the “tree level” looking at individual foods, food components, and nutrients. Isn’t it helpful if we can emphasize specific foods to recommend vs. using just general recommendations?

1. How Antioxidants Work Nutrition Slides, Day 2 AM edits Vitamin C Stable Compound Free Radical Now we are going to look at a few biochemical mechanisms. Vitamin C is considered a master antioxidant….it stabilizes free radicals. ( like how you might spray a rust inhibiting agent on your car) A free radical is like a domino that sets off a chain reaction. While it is looking for an electron to fill an open space in its structure, it causes damage to other molecules, and they go on to affect the area around them. Vitamin C comes along and supplies an electron and stabilizes the situation. Too many free radicals can start messing up the cell. When stable, there is less of a chance of becoming carcinogenic. Where we have more inflammation we will have more cancer.

2. Detoxification of Carcinogens
Nutrition Slides, Day 2 AM edits Phase II (+ molecule) for increased solubility & elimination more likely to decrease toxicity Phase I (Breakdown) makes carcinogens more or less active The liver is an amazing organ; it carries out hundreds of important reactions. Your liver can deactivate foreign invaders. Any carcinogen we take in has to go through two important phases of detoxification. (Body has to excrete it somehow.) How do we do this? In two phases. Phase I: methylation / conjugation breaks the compound down, which can make the compound more active or less active; if Phase I is very active it can give rise to the presence of compounds with increased activity ie carcinogens. That is why we have Phase II compounds standing by to add a compound to increase water solubility and therefore elimination through stool or urine. Cruciferous veg have a lot of phase 2 enzymes, which decreases the toxicity and increases the body’s ability to eliminate them Eating these foods can help our bodies to detox. What can we do to keep everything in balance? Eat at least 1 serving of crucifers/day. By the way, toxins are often stored in our adipose (fat) tissue and then released at a later time Crucifers have more Phase II enzymes! Image:

3. How Phytochemicals Inhibit Angiogenesis
Nutrition Slides, Day 2 AM edits 3. How Phytochemicals Inhibit Angiogenesis VEGF: Vascular Endothelial Growth Factor VEGF Cancer cells are really good at hijacking their own food supply and try to recruit blood vessels to feed themselves. When tumors are forming they secrete VEGF which stimulates new blood vessel formation which they need in order to develop as dangerous tumors ; The VEGF receptor in cells allows cancer cells to invade neighboring tissue. Many healthy plant compounds inhibit tumor growth by inhibiting the VEGF receptor. This is just one mechanism of how food can be cancer preventative. This may be a mechanism of cancer remission as well 1.5 cups (12 oz) of green tea daily inhibits the VEGF receptor (Beliveau)

The Crucifers Arugula Bok choi Broccoli Broccoli rabe Brussels sprout Cabbage Cauliflower Chinese broccoli Chinese cabbage Collard greens Daikon Garden cress Horseradish Kale Kohlrabi Komatsuna Land cress Mizuna Mustard leaves Pak choi Radish Romanesco Rutabaga Tatsoi Turnips Root greens Wasabi Watercress Look at these beauties! Crucifers are a large and diverse group of plants from the family Brassica. Crucifers are so named because the leaves form a four sided cross if we look at a cross section Everyone can find a crucifer to love!

The Crucifers: Glucosinol
Nutrition Slides, Day 2 AM edits G l u c o s i n o l a t e s Isothiocyanate (ITC) detoxification of carcinogens induction of apoptosis inhibition of angiogenesis What is unique about the crucifers is that they are abundant in glucosinolates, which are enzymes (myrosinases) that become active when a plant cell is broken down. The glucosinolates are hydrolyzed into the biologically active isothiocyanate (ITC) which have multiple mechanisms of action: including inhibition of carcinogen-activating enzymes, inhibition of angiogenesis, detoxification of carcinogens, induction of apoptosis, and arrest of cell cycle progression (5). Mechanisms. This is why crucifers are so helpful. Sets a timer on cancer cells. Helps kill them faster. Pop the cancer cells. If it was a drug we’d pay a fortune for it but it’s amazing that its available in the grocery store  Which crucifer has the most anti-cancer nutrients? inhibition of carcinogen-activating enzymes Zhang Y, Yao S, and Li J: Vegetable-derived isothiocyanates: antiproliferative activity and mechanism of action 2006 P Nutr Soc 65, 68–75

The Crucifers: Cell Detox Activity GST (Glutathione S-Transferase)
Nutrition Slides, Day 2 AM edits Broccoli: Cabbage Shutterstock: Brussels sprouts Shutterstock: Most cancer fighting compounds: Broccoli, followed by cabbage, followed by Brussels sprouts

Crucifers and Colon Cancer:
Nutrition Slides, Day 2 AM edits Crucifers and Colon Cancer: Meta-analysis examines the epidemiological evidence to characterize the association between cruciferous vegetable intake and risk of developing colorectal neoplasms Inverse association between total cruciferous vegetable intake and risk of developing colorectal neoplasm In most of the epidemiological studies the effect of cruciferous vegetables was not completely separated from the effect of total vegetable consumption Tse G, Eslick G Cruciferous Vegetables and Risk of Colorectal Neoplasms: A Systematic Review and Meta-Analysis Nutrition and Cancer, 2014; 66(1), 128–139 DOI: / In conclusion, our findings support that higher intake of fruits and vegetables, and specifically cruciferous and yellow/orange vegetables, may reduce the risk of breast cancer, especially those that are more likely to be aggressive tumors Staying on the topic of prevention- this is a nice meta analysis, or the combination of multiple separate studies (mainly American studies) , looking at the association between consumption of crucifers and development of colon cancer. This is one of the cancers that we have the best data for prevention associated with crucifers. Breast cancer is another.

Crucifers and Breast Cancer: Nurses Health Study (NHS/ NHS II)
Nutrition Slides, Day 2 AM edits N= 182,145 in the Nurses’ Health Study/ NHSII 1980–2013; 10,911 invasive breast cancer cases Greater intake of total fruits and vegetables, especially cruciferous and yellow/orange vegetables, was associated with significantly lower breast cancer Lower risk especially associated with estrogen receptor negative tumors with additional servings/day In conclusion, our findings support that higher intake of fruits and vegetables, and specifically cruciferous and yellow/orange vegetables, may reduce the risk of breast cancer, especially those that are more likely to be aggressive tumors. Farvid M et al Fruit and vegetable consumption and breast cancer incidence: Repeated measures over 30 years of follow up Int J Cancer 2019 (144) In conclusion, our findings support that higher intake of fruits and vegetables, and specifically cruciferous and yellow/orange vegetables, may reduce the risk of breast cancer, especially those that are more likely to be aggressive tumors This data is from the Nurses Health Study, looking at the association between intake of fruits and vegetables and development of Breast Cancer. There is an inverse association between fruits and veg and development of breast cancer. What stands out in that group are the crucifers and yellow/ orange vegetables. They are especially protective against more aggressive forms of breast cancers This is actually a very concrete message we can share in talking with our patients ; and in this case with Tonya, as we want to be able to speak to breast Cancer risk. It may be helpful for her to know which foods specifically can be helpful to include in her diet to help limit risk.

The Alliums Nutrition Slides, Day 2 AM edits Onion Garlic Scallion Shallot Leek Chives AEROMATICS. Alliums are the family of foods that include onions, garlic, scallion, leeks, chives, etc…..

The Alliums FLAVANOIDS Neutralize free radicals ORGANOSULFUR COMPOUNDS Thiosulfanate compounds Glutathione formation inhibition of P450 2E1 carcinogen- activating enzymes block nitrosamine formation and hepatic pre- carcinogens The Alliums contain organosulfur compounds. Responsible for ‘cooked egg’ odor , imparts savory flavor to foods. What is special about alliums and cancer, is that they are natural toolkit for disabling cancer growth. Enzymes that are released upon mechanical pressure of the allium will activate sulphur containing compounds which inhibit carcinogen activators, deactivate carcinogens, and contribute to formation of glutathione, which acts like a mop to clean up Sengupta A, et al Allium Vegetables in Cancer Prevention: An Overview Asian Pacific J Cancer Prev, ,

Alliums and Cancer Prevention
Nutrition Slides, Day 2 AM edits Alliums and Cancer Prevention 10 minutes Chef’s tip – chop/mince your garlic FIRST, and let it sit for at least 10 minutes while you prep the rest of your food. The contact with air activates a component in garlic called ALLICIN, with anti-inflammatory and anti-oxidant properties. If you want the most activity sprinkle some fresh chopped garlic on your food. Holly L. Nicastro, Sharon A. Ross, and John A. Milner Garlic and onions: Their cancer prevention properties Cancer Prev Res 2015;8(3):181–189

Polyunsaturated Fatty Acids: PUFA
Nutrition Slides, Day 2 AM edits PUFA: Omega-3 and Omega-6 Ω3:Ω6 Ratio of 4:1 modulates the stiffness / flexibility of cell membranes this affect the responsiveness of receptors in the cell membranes We will introduce the essential fatty acids here and talk more about them when we discuss pain. Here is how we arrive at nomenclature for Omega 3 and Omega 6: we count the position of the first double bond from the end Need both, but make sure ratio is good. The desired ratio is 4:1 We want a higher amount of omega 3 because it affects how well cell membrane functions and also how well it regulates gene expression. EFA contribute to the lipid layer around every cell in the body. They also help determine the balance between stiffness and flexibility in the cell membrane which in turn contributes to how the receptors on the cell membrane will function Fat layer around every cell matters.

Polyunsaturated Fatty Acids: PUFA Nutrition Slides, Day 2 AM edits Omega-3 Polyunsaturated Fatty Acids EPA and DHA potentiation of chemotherapeutic agents Fish Shutterstock ID: Long chain fatty acids. Our bodies can make these but is helpful if we can get these through food. Even wonderful organic flax, still omega 3, but only 10% of it ends up as EPA and DHA. Have to eat a lot of flax to meet essential fatty acid needs. Products like salmon have a lot more preformed EPA and DHA. EPA- eicosapentaenoic acid ; DHA- docosahexaenoic acid regulation of apoptosis regulation of gene expression inhibition of angiogenesis Azrad M et al Current evidence linking polyunsaturated fatty acids with cancer risk and progression Frontiers in Oncology 2013 Volume3 (224) 1-12

Phytoestrogens Phytoestrogens: Isoflavones Legumes (soybeans) Genistein Dadzein Lignans Flaxseed, seaweed, whole grains Stilbenes Resveratrol Coumestans Legumes: Grapes DepositPhotos ID: Flax Seeds: Genistein and dadzein both in soy bean Can bind to human estrogen receptor Are they dangerous? Reality is that most are weakly activated, not as strong as human estrogens, so tend to block more aggressive estrogens from binding. This is one of the way that is postulated that they actually help, so women doesn’t go into estrogen failure. Block some of our native estrogens from binding.

Phytoestrogens in breast / gyn cancers??
Nutrition Slides, Day 2 AM edits Phytoestrogens in breast / gyn cancers??

Phytoestrogens: Repeating The Story Nutrition Slides, Day 2 AM edits Beans, grapes, fruits, and vegetables Phytoestrogens detoxification of carcinogens induction of apoptosis This is a repeating story! Phytoestrogens have some of the same effects as the other foods we have talked about: detoxification of carcinogens, inhibiting carcinogen activators, inhibiting angiogenesis (blood flow) , inducing apoptosis (cell death)…. inhibition of carcinogen-activating enzymes inhibition of angiogenesis Kyung-A Hwang and Kyung-Chul Choi Anticarcinogenic Effects of Dietary Phytoestrogens and Their Chemopreventive Mechanisms Nutrition and Cancer, 2015; 67(5), 796– DOI: /

Polyphenols in Green Tea
Nutrition Slides, Day 2 AM edits Polyphenols in Green Tea Epicatechin (EC) Epigallocatechin (EGC) Epicatechin gallate (ECG) Epigallocatechin gallate (EGCG) 66% Japanese green tea Shutterstock: Green and black tea are the same plant: Camillia sinensis. Black tea is fermented green tea; Oolong is partially fermented. Tea was packed in bales when they were crossing the ocean…and it would ferment Most anticancer benefits Green tea in America is nowhere near the quality from Japan.

Green Tea and Cancer Prevention
Nutrition Slides, Day 2 AM edits Green Tea and Cancer Prevention Green Tea ECGC Here we go again: The flavonoid ECGC regulates apoptosis/ inhibition of angiogenesis/ suppression of cell proliferation regulation of apoptosis inhibition of angiogenesis suppression of cell proliferation Yuan JM Am J Clin Nutr 2013;98(suppl):1676S–81S

Green Tea and Oral-Digestive Tract Cancer
Nutrition Slides, Day 2 AM edits Green Tea and Oral-Digestive Tract Cancer “…evidence in support of a protective role of green tea intake and oral-digestive tract cancer or an inhibitory role of oral supplementation of green tea extract on a precancerous lesion of oral cavity. An inverse association between green tea intake and lung cancer risk has been observed among never smokers but not among smokers. If you’re going to switch off coffee, highly recommend trying green tea. Pop audience quiz – what color is the green tea that you get from commercial venues? More dark yellow? Or vibrant green? The color, especially of MATCHA – powdered green Japanese ceremonial tea, is vibrant, bright GREEN – it’s actually the whole leaf , from the first harvest of the spring that is taken whole, powdered and consumed. It’s whipped up into a thick frothy drink. Slurp it with two hands, please! Am J Clin Nutr 2013;98(suppl):1676S–81S

Tea and Bladder Cancer Incidence
Nutrition Slides, Day 2 AM edits Tea and Bladder Cancer Incidence Decreased risk of oral and bladder cancers The addition of milk (as they do in Britain), unfortunately negates some of the benefits of drinking tea. Not to mention sugar bombing your tea… Milk blocks some of the tea’s benefits. Positive tea studies: come out of Asia when they don’t add milk to the tea. Eur J Cancer Prev 2015;24(4):353–362

What About Multivitamins?
Nutrition Slides, Day 2 AM edits Consensus or Guidelines Statements “There is little evidence that dietary supplements can reduce cancer risk. Some high-dose supplements can increase risk” American Cancer Society, Kushi et al 2012 “Limited evidence support any benefit from vitamin and mineral supplements for cancer prevention.....two trials in men [PHSII and SU.VI.MAX] found modest lower cancer risk, but no evidence in women” USPSTF Systematic Review, Fortman et al 2013 “Evidence is insufficient to determine the balance of benefits and harm of multivitamins for cancer prevention” USPSTF Recommendation Statement 2014 Shutterstock ID: We always hear this question from our patients, friends and even family members… What about MVI? Food beats food-based supplements EVERY time. Like Michael Pollan says “Eat FOOD”… he didn’t say ‘eat food-derived supplements” Can we just take a pill instead of eating broccoli ? The closer to nature it is, the better it is for our bodies. Putting things in a pill = always losing something. Bottom like- there is no magic pill. You can’t replace food.

Summary / Monday Morning Action Plan
Nutrition Slides, Day 2 AM edits Cancer has been shown in to be in part due to modifiable risk factors, including diet Certain foods, including crucifers, alliums, polyunsaturated fatty acids, and legumes have been shown to have cancer – prevention properties Overall, nutrients in the form of food have more evidence for cancer prevention than nutrients in the form of supplements Increase in two or more servings of fruits and veg per day is associated with decreased risk of breast cancer

Resources American Institute for Cancer Research From the amazing chef Rebecca Katz! She also has a book, The Cancer-Fighting Kitchen.

Resources Benefits of fruits and vegetables in cancer prevention How farming affects the quality of nutrients in our fruits and vegetables From the amazing chef Rebecca Katz! She also has a book, The Cancer-Fighting Kitchen.

Nutrition and Cancer Prevention

Questions?

Practical Exercise Consider a patient, family member, or friend who you have previously counseled on cancer prevention or treatment. In their specific case, what dietary resources would you provide them to prevent a first episode or recurrence of cancer? What are three key dietary suggestions you would make?

Nutrition Slides, Day 2 AM edits 12. Creating a Personal Health Plan
Eating for Whole Health

Objectives Identify how to create a Personal Health Plan by integrating information and discussion from review of the PHI Create a personal statement (“Elevator Speech”) about how the Whole Health Approach to care is beneficial Practice creating a Personal Health Plan (PHP) using the PHI in combination with the PHP template

The Personal Health Plan: Central to the WH System
This is a graphic depiction of the Whole Health system and the 3 main parts of that system which we discussed earlier. We’ll talk more about the stages involved in Personal Health planning and then working through the steps of actually doing Personal Health Planning with a partner. The personal health plan is really the key unifying document that guides the goals and care for the individual. It is owned by the patient and follows them throughout the system wherever they receive care.

The Big Questions, Mission/Aspiration and Purpose
Self-Reflection/Exploration involves the Veteran’s consideration of what is important to them and the area(s) in their lives which they prioritize for behavior change. This process leads to identification of their Mission/Aspiration/Purpose (MAP), to which all goals in the PHP will relate.

Synthesizing Information: The Whole Health Assessment
The WH assessment is the next stage in the PHP process and includes an examination of an individual’s overall whole health. In this step you bring together information from both the patient’s perspective and your perspective as a clinician and subject matter expert.

Whole Health Assessment: Patient Self Reflection Tools
When the WH assessment occurs in the clinical setting or visit there are several kinds of information that informs the health plan. 1) The patient’s Self reflection- The patient may bring in their thoughts about what matters to them (mission/aspirations/purpose -MAP) which could have been developed through a Pathway course or they may have completed the PHI If they have not, the provider can simply ask them several of those questions to solicit what really matters to them as they begin the appointment.

Goal Setting : Shared Goals, SMART Goals
The next step is Shared goal setting done collaboratively by the Veteran and their health care team member- in service of the Veteran’s MAP. Health care team members that participate in the development of Shared Goals are those who bring their expertise and recommendations to the interaction (e.g., clinicians, CIH providers) as opposed to team members whose roles are primarily intended to help facilitate the Veteran’s self-exploration and discovery (e.g., WH Partners).

Shared Goals Shared Goals facilitate common ground and align the health team and Veteran so all are “on the same team”. They bring together the WH assessment and what matters to the patient, as well as their health risk, diagnostics, clinical exam & the provider’s expertise. Goal setting is most effective when the veteran guides the process rather than the provider prescribing solutions. Remember, this is a shared activity. The veteran is the expert on themselves/what matters to them; the provider is the clinical expert. Both parties bring their knowledge and ideas to the table and work together to identify meaningful goals that will help vet live life more fully. This approach helps engage and activate the patient, which are important contributing factors in health behavior change. Goals set based on external factors (i.e. someone else’s priorities) are less likely to be sustained or even achieved. Shared Goals may be clinically focused on health outcomes (such as lowering a blood pressure), but could also be focused on a particular aspect of self-care or other activities (such as being able to go hiking with one’s family members again). They are used as a foundation and source of motivation for setting and achieving SMART goals. VHA uses the SMART goals framework (specific, measureable, action-oriented, realistic and time-based). Veterans identify concrete, specific things he/she can do to improve their health, focused on behavior, not outcome, starting small and building over time, with a short, defined time frame. SMART goal tools are widely used in VHA and in Primary Care PACTs.

SMART Goals S= Specific M= Measureable A= Action Oriented R= Realistic T= Time Sensitive EXAMPLE Food and Drink Goal: I going to start eating more vegetables in my diet Made SMART: I will eat at least two cups of vegetables per day for at least 5 days/week, starting tomorrow

Skills and Tools: Education, Skill Building, Resources and Support
And the 4th and final step is to then provide Skill-building through education and training and access to resources and tools empowers Veterans with the skills, knowledge and confidence they need to succeed in achieving their SMART goals. This can include exploring the Veteran’s strengths and past successes in meeting goals. TEACH and MI skills can be helpful here.

Elements of the Personal Health Plan
Personal Mission (MAP) Shared Goals Self-care Professional care Skill-building/education Consults/referrals Timeline and follow-up These are the main elements that should be incorporated into a PHP. At this time, there is no one way to document the PHP and sites may explore various options to develop a documentation and communication plan that is as seamless, simple, and effective as possible. Share this additrional info only if questions are asked: Use a shared template format for the PHI so that anyone can pull it into their existing note, and it can still be searched for those health factors. Consider using radio buttons for each aspect of the PHP, including COHWB. Once selected, this will open text boxes that can be used to document Shared and SMART goals. If possible, the PHP may be best be housed under the “Postings” tab. This allows it to be easily searchable and updated.

The PHP Process is an ongoing process
Both the PHI and the PHP are living documents

Case study: Gary Johnson

Gary’s Story I am now going to share a true story with you about a WWII Veteran who allowed the staff at the Madison VA to capture his story. The Madison VA received a grant to fund a narrative medicine project. Through this project they hired students from UW Madison and community volunteers to meet with Veterans who were interested and willing to allow these individuals to write up and document their personal experiences and life history. These stories would then be shared with other providers or caregivers to help them have an understanding of that individual’s unique experiences and what matters to them to enhance their care and relationship.

2/15/2020 What did we learn about Gary? Relationships are very important to him He was very determined to survive He was incredibly resilient Works at strong commitments (marriage of 61 years, friendships, family, successful businesses) Retired at 51 years old; had a “wonderful life” His wife and son both passed away; he is alone now This is truly an incredible story. What things stood out to you as you listened to Gary’s story? From a psychosocial perspective…what qualities or attributes do you feel Gary possesses or demonstrated ? What does he value?

2/15/2020 Physical Challenges Gary Endured He experienced significant trauma, including head trauma, loss of fellow soldiers while in battle, and was a POW He experienced extreme hunger for a prolonged time and lost ~ 76 pounds as a POW and had food insecurity issues Do these conditions raise any potential concerns?

Past and Current Medical History
Nutrition Slides, Day 1 AM edits 2/15/2020 Past and Current Medical History He was diagnosed with type 2 diabetes 12 years ago His most recent HbA1c is 8.4 and he has early (stage 3a) kidney disease His blood pressure is 138/88, but he has not been formally diagnosed with hypertension He has a history of mild-moderate depression and PTSD His weight has increased over the last 4 years since his wife passed, and he currently weighs 220lbs (BMI 33.5)

Gary’s Potential Circle of Health
If we were to look at the Circle of Health which areas do you think were highly significant and impacted in Gary’s situation of being captured and then rescued? Surroundings were terrible- POW Relationships were strong Food and Drink was significantly impacted/restricted Power of the Mind was very strong as he had a strong survival instinct

Gary’s Potential PHI 2/15/2020 I feel my best when I am doing something to help others. Friendships and relationships are very important to me… MAP: I think I need to find ways to connect with other people.

Gary’s Areas of Self Care Rankings
Nutrition Slides, Day 1 AM edits Gary’s Areas of Self Care Rankings 2/15/2020

Gary’s Reflections Reflections
Now that you have thought about what matters to you in all of these areas, what is your vision of your best possible self? What would your life look like? What kind of activities would you be doing? I want to be able to stay independent as long as possible. I think I need to eat a little better (limiting sweets and convenience foods) and try to get more active and stronger so I can stay in my own home. I get lonely at times and would like to find a way to meet more people. Are there any areas you would like to work on? Where might you start? Food and drink- I need to work on my food choices and choose things that are better for my diabetes and blood pressure. Moving the body- I should work on increasing my strength and activity.

Gary’s Reflections Now that you have thought about what matters to you in all of these areas, what is your vision of your best possible self? What would your life look like? What kind of activities would you be doing? I want to be able to stay independent as long as possible. I think I need to eat a little better (limiting sweets and convenience foods) and try to get more active and stronger so I can stay in my own home. I get lonely at times and would like to find a way to meet more people. Are there any areas you would like to work on? Where might you start? Food and drink- I need to work on my food choices and choose things that are better for my diabetes and blood pressure. Moving the body- I should work on increasing my strength and activity.

Creating Gary’s PHP Goals:
Find new interests in my life, something to make me feel helpful and connected to others Strengths: Surroundings, Professional Care Resilience Challenges/Opportunities for Support: Family and friends have been a strength in his life, but he recently rated this as a 2 r/t continued grief and loneliness after loss of wife 4 years ago and son 18 years ago If we were to try to create a PHI what do you think might be some strengths and areas for growth for him?

Creating Gary’s PHP Continued
Challenges/Opportunities for Support: Though Gary is able to afford food, he is still always concerned about not having enough food or not being able to afford food. This leads to buying cheaper (and often unhealthier) processed foods when shopping Gary hasn’t been very active and feels he needs to increase strength to maintain his independence

Gary’s PHP – Self-Care Food and Drink- Working your Body-
Mindful Awareness: Try to notice if I am really hungry when I eat Areas of Self-Care: Food and Drink- Stop drinking sugary beverages like cola and iced tea by cutting down to no more than 1, twice a week max, starting Monday Attend Healthy Teaching Kitchen class next Thursday Working your Body- Increase walking/hiking to 3 days per week, 30 minutes per session starting Monday

Gary’s PHP – Professional Care
Health Concerns: DM, Htn, Kidney Disease, PTSD, Depression, Obesity Prevention/Screening: Up to date Treatment: Continue meds as prescribed Use home blood pressure cuff to check BP daily (keep log)

Education, Skill Building, Resources, Support
Referrals/Consults: Dietitian Whole Health Coach Community Resources Senior Center for community lunch program Prescription for volunteering Resources BP Log sheets Follow up RTC in 4 weeks to check BP and A1C

How do you start to work the PHI and PHP into your conversations with patients and other staff and into your practice? This is a question that many of you are probably wondering…

Telling Others About Whole Health: The Elevator Speech Exercise
pp20 Draft a 30-second elevator speech using the form in the course manual Can use suggested elements or add your own Give your speech to a partner, and listen to your partner’s speech Offer constructive feedback We will invite volunteers to share with the large group CM 50 Everyone on the team needs to feel comfortable with describing the Whole Health approach, and what it means to do Personal Health Planning (PHP). claybanksstudio.com Your task is to create an oral presentation – an elevator speech - that is about 30 seconds long. The idea is that you will be able to share this you can share with patients or colleagues quickly to let them know about what Whole Health and PHP are all about. claybanksstudio.com

PHP Practical Exercise
Nutrition Slides, Day 2 AM edits PHP Practical Exercise Choose a partner you didn’t previously know Introduce Whole Health (your elevator speech) Review PHI and/or ask the “big questions” Discuss the circle, pick an area of Food and Drink Generate a SMART goal Discuss referrals, team members, skills, resources, follow up Take 10 minutes each CM 53

Nourishing and Fueling
Food in Context Cultural needs Transportation Finances Peer support Dietitians Include whole family Setting the table Nutrition Resources (see list in manual) Cookbooks Recipes Websites Nutrition classes Community programs Food & Drink Nourishing and Fueling Cooking Tips Grocery shopping Using kitchen tools Try a new recipe Cooking classes General Guidelines Follow a specific eating plan Macronutrients Micronutrients Phytonutrients Meal timing & frequency Prevention A way to reduce cancer risk A step to prevent heart disease An approach to blood glucose More Guidelines Fruits, veggies, nuts Dessert frequency Hydration Alcohol and caffeine Because we have learned so much in this course about food and drink we would like you to try incorporating at least one or two food and drink recommendations Specific Health Issues Referrals Diet & depression Diet & sleep Eliminating certain foods Probiotics Mindful Eating Start a daily practice Number of chews Pacing eating Eating without distractions Observing cravings Stress management

Sharing Your Experience
What went well? What might you try differently next time? Are there any tools you might look for to assist you in feeling more confident doing this?

Questions?

Faculty Q&A Panel From questions you submitted on note cards

13. Nutrition and Whole Health: Transforming the System Eating for Whole Health

Implementation Exercise #2: Implementation Work Groups Whole Health Implementation

Group Exercise Instructions
Separate into assigned groups Choose one person in charge of recording information on the worksheet and one person in charge of ing project details to your implementation team and cc ___________ at _______________. Prompt: come up with an implementation project or a professional smart goal to apply whole health at your work site Group recorder: use the whole health implementation worksheet we provided and turn in your plan to the nutrition faculty members before leaving Reconnect with your project team within 2 weeks to revise the plan based on feasibility and begin implementing it

Prompt: come up with an implementation project or a professional smart goal to apply whole health at work Optional alternative prompt for travelers: strategize how you can begin to advance whole health within your depts and at your sites Post small group discussion teams here

Implementation Exercise #3: Self-Reflection Activity Whole Health Implementation

Self-Reflection Exercise Prompts
Question #1: Consider the speed dating exercise, group discussions during modules, and the group implementation exercise we just completed. What ideas did you get from other groups, and what may you want to bring back to my clinic? Question #2: When you return to work tomorrow, how will you start implementing whole health nutrition in your own practice? Lay out some initial steps to help bring what you have learned back to your clinic and colleagues.

Closing Remarks And Pulse Check: Day 2 Evaluations THANK YOU!
Page 69-70 Closing Remarks And Pulse Check: Day 2 Evaluations THANK YOU! Eating for Whole Health

Eating for Whole Health Day 2 Afternoon

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