Department of Public Health, Faculty of Medicine, Masaryk University
1
Lifestyle-oriented counselling
in prevention
Assessment methods and recommendations
Department of Public Health, Faculty of Medicine, Masaryk University 2
Basic points - outline
̶ Introduction (goals, determinants of health, importance of lifestyle)
̶ System of general preventive examinations in the Czech Republic
̶ Examination methods (Examination = the basis for individualized recommendations)
 General personal and medical history
 Lifestyle assessment (retrospective)
Smoking - active, passive – SHS (Second Hand Smoke), ETS (Environmental Tobacco Smoke)
Dietary habits
Alcohol
Physical activity
 Objective examination a measurements
Nutritional status - anthropometry
Physical condition (fitness)
Blood pressure
Selected biochemical examination
̶ Generally valid recommendations based on EBD principles
 Dietary guidelines
 Physical activity guidelines
 Guidelines on the primary prevention of Cardiovascular Disease
 Primary prevention of Cancer
̶ Intervention methods, work with motivation, counseling techniques
Lifestyle-oriented counselling in prevention
Department of Public Health, Faculty of Medicine, Masaryk University 3
Preventive examinations by law (in the Czech Republic)
̶ Decree No. 70/2012 Coll. “Decree on preventive examinations”
 + DECREE of 21 September 2016 amending Decree No. 70/2012 Coll
 § 1 -Types of preventive examinations and providers performing them
 § 2 - Contents and timetable of the general preventive examination
 § 3 - Content and timetable of general preventive examination in children
Lifestyle-oriented counselling in prevention
̶ §1 - Types of preventive examinations and providers performing them
a) General medical practice - „General preventive examination"
b) GP for children and adolescents - „General preventive examination of children"),
c) Dentistry - „Dental preventive check-up"),
d) Gynecology and obstetrics - („Gynecological preventive examination").
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§ 2 - Content and scheduling of the general preventive examination
a) History
 Completing including social history, focusing on changes, risk factors and professional risks
 In FH (family history) emphasis on: CVD, pulmonary, hypertension, DM, lipid metabolism disorders,
cancer, addictions
b) Checking of vaccination
c) Complete physical examination
 BP, BMI, eyesight
 Oncological prevention
Risk assessment in terms of history (family, personal, occupational), skin examination, in case of suspicion, per
rectum examination, in men with a positive family history or other signs, testicular examination
 Women from 25 years with positive FH or other risk factors - clinical breast examinations, breast selfexamination
instruction
d) Urine examination with diagnostic paper
e) Checking and evaluating the results of ordered preventions. examination
1) Chol, HDL, LDL, TGA - in 18, 30, 40, 50 a 60 years of age
2) Glycaemia – At 18, and then at 30, and from 40 at 2-year intervals since the last one
3) ECG - at 40, then four-year intervals
4) FOBT (Fecal Occult Blood Test) from 50 yrs., from 55 can be replaced by colonoscopy once every 10 yrs.
5) Women over 45y. - mammography result not older than 2 years
6) Serum creatinine and glomerular filtration rate estimation in patients with DM, hypertension or HF
complications over 50 years at 4-year intervals
A general preventive examination is performed every 2 years, usually after 23 months after the last general preventive
examination. The content of the general preventive examination is:
Lifestyle-oriented counselling in prevention
Department of Public Health, Faculty of Medicine, Masaryk University
̶ To Reduce the risk of disease (primary prevention)
̶ To Improve present physical condition (body composition - obesity, BP,
cholesterol, glycaemia, fitness, immunity…)
̶ To address any pre-pathological phases non-pharmacologically
(non-pharmacological intervention – therapy)
̶ For existing diseases, to reduce the need for drugs and improve
the condition, preventing progression
Who and when provides the counselling:
Department of Public Health, Faculty of Medicine, Masaryk University
5
Lifestyle-oriented counselling in prevention
Objectives of counseling (not by law, generally)
̶ General practitioner
 As part of the general preventive examination
 In any therapeutic contact with the patient
̶ Any specialist
 Within treatment (and prevention - primary, secondary, tertiary)
Department of Public Health, Faculty of Medicine, Masaryk University 6
How to proceed - steps:
̶ Asses
 To obtain the patient's individual risk profile (based on examination, both
lifestyle and objective)
̶ Inform
 To inform the patient about the result
 To explain impact and importance of lifestyle as a health determinant
̶ Advise (recommend) and motivate, set goals
 General population recommendations - guidelines (on nutrition, physical
activity, alcohol)
 Individualized recommendations according to health status and current
lifestyle
 Motivational techniques
̶ Monitor, control, assist (progress and effect monitoring, compliance
support)
Lifestyle-oriented counselling in prevention - Introduction
Department of Public Health, Faculty of Medicine, Masaryk University 7
Determinants of overall health
Lifestyle-oriented counselling in prevention - Introduction
https://www.publichealthpost.org/databyte/public-health-spending-mismatch/
Department of Public Health, Faculty of Medicine, Masaryk University
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Determinants of health vs expenditure
Lifestyle-oriented counselling in prevention - Introduction
Department of Public Health, Faculty of Medicine, Masaryk University
9
Determinants of health vs expenditure
Lifestyle-oriented counselling in prevention - Introduction
Department of Public Health, Faculty of Medicine, Masaryk University
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Attitudes, Beliefs, Lifestyle
Lifestyle factors – behavioral determinants of health
̶ Smoking
̶ Nutrition – dietary behavior
̶ Physical activity
̶ Alcohol
̶ Illicit drug use
̶ Personal hygiene, washing hands
̶ Social contacts
̶ Work/Occupation
̶ Stress coping
̶ Sexual activity
̶ Sleep patterns
̶ Sun exposure behavior
̶ Motor vehicle behavior
Lifestyle-oriented counselling in prevention
̶ All present diseases
̶ Medications
̶ Health restrictions/limitations (incl. diets, mobility restrictions, etc.)
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History (anamnesis)
FH (Family history)
̶ Family history of premature CVD (defined as fatal or non-fatal CVD
event./diagnosis of CVD in first degree relatives – male <55 yrs., female <65 yrs.
̶ DM (type 2)
̶ Obesity
̶ Cancer
PH (Personal/medical history)
Not only genetic predispositions
are inherited, but also lifestyle
SH (Social history)
OH (Occupational history
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health, Faculty of Medicine, Masaryk University
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Smoking
Lifestyle-oriented counselling in prevention
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Smoking - the impact of smoking on health
Lifestyle-oriented counselling in prevention
Department of Public Health, Faculty of Medicine, Masaryk University
Burden of disease attributable to 20 leading risk factors for both sexes in 2010, expressed as a percentage of UK disabilityadjusted
life-years Lancet 2013; 381: 997–1020
The negative percentage for alcohol is the
protective effect of mild alcohol use on
ischaemic heart disease and diabetes.
CancerCardiovascular diseasesChronic respiratory diseases
Smoking is the strongest risk factor for:
• Cancer
• Cardiovascular diseases
• Chronic respiratory diseases
Smoking is the strongest influenceable determinant of health
Smoking is responsible for 50% of all avoidable deaths in smokers
A smoker on average will lose 10 years of life
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Examination of smoking status, categorization
̶ Ask: To detect patient's smoking status and passive exposure
 Active smoking (first-hand smoke, main stream)
 How many cigarettes do you smoke on average during the day? *
 How old did you start smoking regularly
 Have you ever tried to quit smoking?
 What was the longest time you lasted not to smoke one cigarette a day
 Passive smoking (exposure), ETS – Environmental Tobacco Smoke
 SHS (Second Hand Smoke, side stream)
• At work - occupational
• Family members
• Elsewhere (friends, acquaintances…)
 THS (Third Hand Smoke)
• From materials in the indoor environment - furniture, plasters, fabrics, carpets, plastics
*Table: Smoking status:
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health, Faculty of Medicine, Masaryk University
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Smoking - recommended intervention in contact with a smoker
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Examination methods – Smoking
The “Five As” for a smoking cessation strategy for routine practice:
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Smoking - Fagerström Test of Nicotine Dependence, FTND
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Examination methods – Smoking
17
Pharmacological assistance in smoking cessation
http://www.kardio-cz.cz/data/upload/Doporuceni_pro_lecbu_zavislosti_na_tabaku.pdf
̶ NRT - Nicotine Replacement Therapy
 Nicotine substitution to alleviate withdrawal symptoms
 Various forms of NRT: chewing gum, transdermal nicotine patches, nasal spray, inhaler, sublingual tablets
̶ Bupropion (antidepresant, brand name Zyban)
 Noradrenaline and dopamine reuptake inhibitor (NDRI), which has antidepressant activity and reduces withdrawal
symptoms during smoking cessation.
 Bupropion suppresses craving and withdrawal symptoms after nicotine withdrawal due to increased levels of dopamine
and noradrenaline
̶ Vareniclin (partial nicotine receptor agonist, Champix)
 Partial agonist of acetylcholine-nicotinic receptors, which decreases craving for a cigarette and other withdrawal
symptoms from nicotine deficiency (agonist effect) while blocking the nicotine effect on the brain (antagonist effect)
 Agonist activity of Vareniclin alleviates the withdrawal symptoms of nicotine deficiency and its antagonistic function
reduces the sense of satisfaction from smoking and thus the smoker's attachment to the cigarette
̶ Combination
 Combining more types increases effectiveness and chance of quitting
 The most common combination is a nicotine patch with one of the oral forms of nicotine, bupropion and nicotine, or
bupropion and varenicline.
 Varenicline with nicotine can also be combined, especially in heavily dependent patients, but they compete for the same
receptors.
̶ Other forms
 Both individual and group behavioural interventions are effective in helping smokers quit. Support from the
individual’s partner and family is important.
 There are no reliable data that acupuncture, acupressure, laser therapy, hypnotherapy or electrostimulation are
effective for smoking cessation.
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Examination methods
Following the failure of advice, encouragement and motivational interventions, or in addition to them
• There is a strong evidence base for brief interventions with advice to stop smoking, all types of nicotine replacement therapy (NRT),
bupropion, varenicline and greater effectiveness of drugs in combination, except for NRT plus varenicline.
• The most effective are brief interventions plus assistance with stopping using drug therapy and follow-up support.
• Electronic cigarettes (e-cigarettes) may help in smoking cessation but should be covered by the same marketing restrictions as cigarettes.
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Nutrition
Lifestyle-oriented counselling in prevention
̶ Dietary (nutritional) history
̶ 24-hours diet recall (with computerized evaluation)
̶ FFQ – Food Frequency Questionnaire
̶ Brief methods, scoring (e.g. WHO nutritional score)
.
Department of Public Health, Faculty of Medicine, Masaryk University
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Nutrition - dietary assessment (dietary habits, d. consumption)
Taught earlier in Public Health II subject, topic “Evaluation of nutritional habits”
Retrospective methods:
Lifestyle-oriented counselling in prevention – Examination methods
Prospective methods:
̶ Usually not applicable - too demanding (Dietary records, Double portions etc.)
Department of Public Health, Faculty of Medicine, Masaryk University
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Lifestyle-oriented counselling in prevention – Examination methods
Nutritional history
Gender:
Age:
Height (cm):
Weight (kg):
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A brief dietary assessment
Lifestyle-oriented counselling in prevention – Examination methods
̶ A Form for 24 hours recall and quick manual assessment:
What is one serving for each food group (aid for counting the number of servings):
1. Cereals: 1 slice of bread (60g) or 1 roll or 1 bowl of oatmeal or 1 scoop of cooked pasta or rice about 125 g
2. Vegetables: 100g piece of pepper or carrot or about 2 tomatoes or bowl of salad
3. Fruit: 1 apple, orange or banana approx. 100 g or 1 bowl of strawberries, currant or blueberry or glass of fruit
juice undiluted with water
4. Milk and dairy products: 1 glass of milk or 1 cup of yoghurt about 200 ml or 55 g of average cheese
5. Meat, poultry, fish…: 80 g of fish, poultry or other meat or 2 cooked egg whites or 1 bowl of soybeans or
lentils
6. Other: 10 g sugar or fat (caution - even hidden)
Rating:
10 points: Your nutrition is excellent,
perfectly fine! It will be very appropriate to
eat according to the same principles as
before.
9 to 7 points: There are still reserves in
the quality of the diet, but it will not be too
difficult to make positive changes to make
the nutrition completely error-free.
6 to 4 points: Nutrition is not sufficient in
terms of quality. Major changes are
needed in order to assess it at least as
sufficient.
3 to 0 points: Absolutely inadequate
nutritional quality, immediate and vigorous
remedy required.
Ústav ochrany a podpory zdraví LF MU 22
Nutritional score (by WHO)
Lifestyle-oriented counselling in prevention – Examination methods
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NutriPro – An example of computerized dietary assessment
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health,
Faculty of Medicine,
Masaryk University
• Input of data from 24hod
recall/record is required
• Meals/foods and their
quantities are entered
• The procedure is relatively
demanding
• Software is not free (quite
costly)
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Older software used at our dept. for dietary assessment
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health,
Faculty of Medicine,
Masaryk University
• The pyramid chart
compares graphically
the "ideal" (desirable)
and actual consumption
of different food groups.
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ASA24 – Computerized dietary assessment of 24hr recalls
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health, Faculty of Medicine, Masaryk University
https://asa24.nci.nih.gov/demo
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ASA24 – An example of computerized dietary assessment
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health, Faculty of Medicine, Masaryk University
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ASA24 – An example of computerized dietary assessment
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health, Faculty of Medicine, Masaryk University
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ASA24 – An example of computerized dietary assessment
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health, Faculty of Medicine, Masaryk University
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Dietary
guidelines
Lifestyle-oriented counselling in prevention
Ústav ochrany a podpory zdraví LF MU
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Basic forms of reference values and nutritional recommendations
Dietary guidelines
 Numerical reference values for daily intake of individual nutrients (by sex, age,
pregnancy, lactation). Multiple options (lowest, average, recommended, tolerable income). They
are intended for experts.
 Other possible terms:
RDI – Recommended Dietary Intake
 RDA – Recommended Dietary Allowances
 GDA* - Guideline Daily Amount * Food labeling
 Current valid documents:
 DACH Reference values for nutrient intake (D= Germany, A= Austria, CH = Confœderatio Helvetica (Switzerland).
Therefore, it refers to German-speaking Europe.
 European DRV – EFSA (European Food Safety Authority)
Lifestyle-oriented counselling in prevention
Dietary Reference Values (DRV)
General nutritional recommendations (dietary guidelines)
 Verbal nutrition recommendations - guidelines that are not primarily quantitative, but rather
guidelines for changing consumption. They can be both for professionals and public.
 Specific examples:
 Nutritional recommendations for the population of the Czech Republic (Nutrition Society, 2012)
FBDG – Food Based Dietary Guidelines
 Transformation into a practically applicable verbal (or graphic) form, working with whole foods and food
groups. It is „translation" for ordinary people, based on DRV and scientific knowledge.
 An attempt to translate the evidence base on the relationship between food, eating habits and health into
concrete, culturally appropriate and applicable recommendations.
• Simple messages on healthy eating, aimed at the general public
• Nutrition education tool translating scientific knowledge and dietary standards and
recommendations into an understandable and practical form for use by those who have little
or no training in nutrition.
• FBDG are generally based upon scientific evidence on the relationship between diet and
chronic disease risk, taking into account nutrient recommendations.
• They give an indication of what a person should be eating in terms of foods rather than
nutrients, and provide a basic framework to use when planning meals or daily menus.
• Foods are classified into basic groups according to similarity of nutrient content or some
other criteria.
WHY? BALANCED, ADEQUATE AND VARIED DIET
• To help consumers in planning an overall healthy diet, while achieving an adequate nutrient
intake
Food Based Dietary Guidelines (FBDG)
Lifestyle-oriented counselling in prevention
Department of Public Health, Faculty of Medicine, Masaryk University
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FBDG - Graphic format
Czech Food Pyramid
Definice porce pro jednotlivé potravinové
skupiny:
1. Obiloviny, těstoviny, rýže, pečivo:
1 krajíc chleba (60g) nebo 1 rohlík či 1
miska ovesných vloček nebo 1 kopeček
vařených těstovin či rýže cca 125 g
2. Zelenina:
100g kus papriky nebo mrkve nebo cca 2
rajčata nebo miska salátu
3. Ovoce:
1 jablko, pomeranč nebo banán cca 100
g nebo 1 miska jahod, rybízu nebo
borůvek nebo sklenice ovocné šťávy
neředěné vodou
4. Mléko a mléčné výrobky:
1 sklenice mléka nebo 1 kelímek jogurtu
cca 200 ml nebo 55 g průměrného sýra
5. Maso, drůbež, ryby…: 80 g rybího,
drůbežího či jiného masa nebo 2 vařené
bílky nebo 1 miska sójových bobů nebo
čočky
6. Ostatní:
10 g cukru nebo tuku (pozor – i
skrytých)
Obiloviny, těstoviny rýže, pečivo: 3-6 porcí denně
Mléko a mléčné
výrobky: 2-3
porce
Zelenina:
2-3 porce
Sůl, tuky, cukry: 0-2 porce
Maso, drůbež,
ryby, vejce,
luštěniny,
ořechy:
1-2 porce
Ovoce:
2-4 porce
Lifestyle-oriented counselling in prevention
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FBDG - Graphic formats
Germany
DGE-Ernährungskreis (nutrition circle)
Austria
Die österreichische Ernährungspyramide
Swiss Food Pyramid
Slovakia
UK – Eatwell guide (2016)
Lifestyle-oriented counselling in prevention – Guidelines, recommendations
Czech Food Pyramid
Slovenia
US My Plate
Japan – spinning top
Portugal
Roda dos alimentos
Saudi Arabia
https://ec.europa.eu/jrc/en/health-knowledge-gateway/promotion-prevention/nutrition/food-based-dietary-guidelines
Belgium
inverted pyramid
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Lifestyle-oriented counselling in prevention – Guidelines, recommendations
UK - 2016
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Norwegian dietary guidelines
Lifestyle-oriented counselling in prevention
Department of Public Health, Faculty of Medicine, Masaryk University 36
Nutrition information - Food labelling
Lifestyle-oriented counselling in prevention
̶ Nutrition declaration
 The mandatory nutrition declaration shall include:
Energy value
The amounts of fat, saturates, carbohydrate, sugars, protein and salt
̶ Nutrition claim
 Any claim which states, suggests or implies that a food has
particular beneficial nutritional properties due to:
The energy (caloric value) - provides in reduced or increased rate
The nutrients - provides in reduced or increased rate
̶ Health claim
 Any statement about a relationship between food and health
The Commission authorises different health claims provided they are based on
scientific evidence and can be easily understood by consumers. The European
Food Safety Authority (EFSA) is responsible for evaluating the scientific evidence
supporting health claims
Regulation (EC) No 1924/2006
Permitted nutrition
claims:
o Low sugars
o Low fat
o High fibre
o High omega-3 FA
Permitted health claims:
o "Vitamin D is needed for
the normal growth and
development of bone in
children.“
o „Iodine contributes to
normal functioning of the
nervous system.“
Department of Public Health, Faculty of Medicine, Masaryk University 37
Lifestyle-oriented counselling in prevention
GDA - Guideline Daily Amounts
• GDAs are guidelines for healthy adults and children about the approximate amount of calories, fat, saturated
fat, total sugars, and sodium/salt.
• The GDA labels have the percentage of daily value per serving and the absolute amount per serving
of these categories.
• The front-of-packages (FOP) GDAs must at least have calories listed
• The back-of-package (BOP) GDAs must list, at a minimum, these five key nutrients: Energy, Fat,
Saturates, Sugar and Salt
To help consumers make sense of the nutrition information provided on food labels, they translate science into consumer
friendly information, providing guidelines on pack that help consumers put the nutrition information they read on a food label
into the context of their overall diet.
FOP - Front-of package: BOP – Back-of-package:
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Mediterranean
diet, alternative
diets
Lifestyle-oriented counselling in prevention
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Lifestyle-oriented counselling in prevention
Mediterranean diet
The Mediterranean diet is not a single diet but rather an eating pattern that takes inspiration from the diet of southern European countries.
There is an emphasis on plant foods, olive oil, fish, poultry, beans, and grains
The diet draws together the common food types and healthful habits from the traditions of several different regions, including Greece, Spain,
southern France, Portugal, and Italy.
Studies suggest that people who live in the Mediterranean area or follow the Mediterranean diet have a lower risk of various diseases,
including obesity, diabetes, cancer, and cardiovascular disease. They are also more likely to enjoy a longer life than people in other
regions.
Key ingredients of the diet include fresh fruits and vegetables, unsaturated fats, oily fish, a moderate intake of dairy, and a low
consumption of meat and added sugar. Studies have linked these factors with positive health outcomes.
There is no single definition of the Mediterranean diet
Definition of the Mediterranean Diet: A Literature Review: Nutrients 2015 7(11):9139-9153 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663587
https://www.medicalnewstoday.com/articles/149090.php#diet
The main components of
Mediterranean diet include:
• Daily consumption of vegetables,
fruits, whole grains and healthy
fats.
• Weekly intake of fish, poultry,
beans and eggs.
• Moderate portions of dairy
products.
• Limited intake of red meat
• Along with food, the
mediterranean diet emphasizes
the need to spend time eating
with family and physical activity.
Typical ingredients in Mediterranean diet:
Vegetables: Tomatoes, peppers, onions, eggplant, zucchini,
cucumber, leafy green vegetables, plus others.
Fruits: Melon, apples, apricots, peaches, oranges, and lemons, and so
on.
Legumes: Beans, lentils, and chickpeas.
Nuts and seeds: Almonds, walnuts, sunflower seeds, and cashews.
Unsaturated fat: Olive oil, sunflower oil, olives, and avocados.
Dairy products: Cheese and yogurt are the main dairy foods.
Cereals: These are mostly whole grain and include wheat and rice
with bread accompanying many meals.
Fish: Sardines and other oily fish, as well as oysters and other
shellfish.
Poultry: Chicken or turkey.
Eggs: Chicken, quail, and duck eggs.
Drinks: A person can drink red wine in moderation.
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Lifestyle-oriented counselling in prevention
Mediterranean diet
Definition of the Mediterranean Diet: A Literature Review: Nutrients 2015 7(11):9139-9153 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663587
It is not only food but an outlook on life that contributes to the
success of the Mediterranean diet. As well as a focus on plant-based
foods, a philosophy that emphasizes the following is essential:
 Moderation and variety
 Living in harmony with nature
 Valuing relationships with others, including sharing meals and
enjoying a chat around the table
 Having an active lifestyle, but relaxing after a meal
Vegetables: Include 3 to 9 servings a day.
Fresh fruit: Up to 2 servings a day.
Cereals: Mostly whole grain from 1 to 13 servings a day.
Oil: Up to 8 servings of extra virgin (cold pressed) olive oil a
day.
Fat — mostly unsaturated — made up 37% of the total calories.
Unsaturated fat comes from plant sources, such as olives and
avocado. The Mediterranean diet also provided 33 grams (g) of
fiber a day.
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Lifestyle-oriented counselling in prevention
Mediterranean diet
Definition of the Mediterranean Diet: A Literature Review: Nutrients 2015 7(11):9139-9153 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663587
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Alcohol
Lifestyle-oriented counselling in prevention
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Impact of alcohol consumption on health
̶ He
 u
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Alcohol
Lancet Psychiatry 2018; 5: 987–1012
DALYs (Disability-Adjusted Life-Years) attributable to alcohol use in 2016:
Central Europe :
Albania, Bosnia and Herzegovina,
Bulgaria, Croatia, Czech Republic,
Hungary, Macedonia, Montenegro,
Poland, Romania, Serbia, Slovakia,
Slovenia
Western Europe:
Andorra, Austria, Belgium, Cyprus, Denmark,
Finland, France, Germany, Greece, Iceland, Ireland,
Israel, Italy, Luxembourg, Malta, Netherlands,
Norway, Portugal, Spain, Sweden, Stockholm,
Sweden, Switzerland, United Kingdom
Eastern Europe:
Belarus, Estonia, Latvia, Lithuania, Moldova,
Russia, Ukraine
Cardiovascular diseases Cirrhosis Pancreatitis Alcohol use disorders Cancer Injuries
Age-standardised DALYs per 100 000 people attributable to alcohol:
Mediterranean:
Nordic:
The main diseases caused by alcohol use:
1) Cardiovascular (CHD, Hypertension, Stroke,
Arrytmias, Cardiomyopathy)
2) Cancer (Mouth, Pharynx and Larynx,
Oesophagus, Stomach, Liver, Colorectum, Breast)
3) Cirrhosis
4) Alcohol use disorders
5) Pancreatitis
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Health problems associated with alcohol use
A) Alcohol dependence
B) Health harm
Because alcohol misuse can produce medical harm without the presence of dependence, ICD-10 introduced the term
harmful use into the nomenclature. This category is concerned with medical or related types of harm, since the purpose of
ICD is to classify diseases, injuries, and causes of death. Harmful use is defined as a pattern of drinking that is already
causing damage to health. The damage may be either physical (e.g., liver damage from chronic drinking) or mental (e.g.,
depressive episodes secondary to drinking).
Alcohol dependence syndrome is a cluster of cognitive, behavioural, and physiological symptoms. A diagnosis of
dependence should only be made if three or more of the following have been experienced or exhibited at some time in the
previous twelve months:
 A strong desire or sense of compulsion to drink;
 Difficulties in controlling drinking in terms of onset, termination, or levels of use;
 A physiological withdrawal state when alcohol use has ceased or been reduced, or use of alcohol to relieve or avoid
withdrawal symptoms;
 Evidence of tolerance, such that increased doses of alcohol are required to achieve effects originally produced by lower
doses;
 Progressive neglect of alternative pleasures or interests because of alcohol use;
 Continued use despite clear evidence of harmful consequences.
ICD-10:
F10 – Alcohol related disorders
F10.2 - Alcohol dependence
F10.1 - Harmful alcohol use (alcohol abuse)
Note: In fact, somatic damage is much more common (and caused by lower doses) than the
damage reported as dg. F10.1 - due to the attributable contribution to diseases such as cancer,
cardiovascular diseases, etc.!
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Alcohol
45
What is hazardous - harmful drinking
According to WHO:
Hazardous (heavy) drinking: Alcohol consumption that is likely cause adverse health effects if these
habits continue (*20-40 g/day for women, 40-60 g/ day for men – but currently the limits getting stricter!)
Harmful drinking: Alcohol consumption that results in physical or psychological harm. (*regularly >40 g
per day for women,>60 g for men – but currently the limits getting stricter!)
Heavy episodic (binge) drinkig :>60 g on one occasion
Risky patterns of drinking
 Heavy single occasion drinking
 Episodic heavy drinking (binge drinking)
 Regular (daily) heavy drinking (exceeding weeklyy thresholds)
Setting criteria for riskiness:
 For single dose size (= on one occasion)
 For total weekly consumption
 For drinking pattern
̶ Riskiness threshold for 1 dose:
 Generally defined as a dose that raises blood concentration
(BAC) to a level of intoxication
 This also corresponds to the definition of "binge drinking"
 0.08 BAC (0.8 ‰) is considered the limit of intoxication
 This corresponds to drinking about 4-5 units of alcohol.
 Example:
 For 80kg men 5 units (á10g = 50g) leads to BAC 0.87 ‰
 For 70 kg women 4 units (á10g = 40g) leads to 0.98 ‰)
 In fact, the BAC depends on a number of factors (body
weight, gender, body water content, etc.)
 In grams, the most commonly reported value is 60 g (this is
also taken as a criterion for binge drinking)
 In the UK 6-8 units (but have 1 unit = 8g), in the US 3 and 4
units
̶ Risk of regular long-term consumption:
 WHO:
 Hazardous drinking: 20-40 g / day for women, 40-60 g/day
for men
 Harmful drinking:> 40 g per day for women,> 60 g for
men
 Cancer risk: limit of 30 g/day for men and 20 g/day for
women - but in fact a threshold-free risk!
 Most frequently cited weekly limits:
 Previously: men 21 units/week, women 14 units/week
 Currently: men 14 units/week, women 7 units/week
 NIAA (The National Institute on Alcohol Abuse and Alcoholism):
 No more than 4 drinks per day and no more than 14
drinks per week - men age 65 and younger
 Not more than 3 drinks / day and not more than 7
drinks/week - women and men +65
 Germany: 12g/day women and 24g/day men, at least 2
days a week without alcohol
Lifestyle-oriented counselling in prevention – alcohol
Department of Public Health, Faculty of Medicine, Masaryk University
*Most authorities and
recommendations currently set
stricter limits, see below
46
Alcohol consumption screening
̶ SF, QF
 Simple Frequency, Quantified Frequency
̶ BSQF
 Beverage Specific Quantified Frequency
̶ GF
 Graduated Frequency
̶ WR
 Weekly Recall
A) Identification of alcohol-related problems (problem drinking, addiction, alcohol-related
disorders)
B) Quantification of consumption (of any, even moderate)
̶ CAGE
 Cut down, Angry, Guilty, Eye opener
 (Short test using 4 questions)
̶ AUDIT
 Alcohol Use Disorder Identification Test
 (Test to identify alcohol-related disorders)
̶ SASQ
 Single Alcohol Screening Question
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Examination methods – Alcohol
Output for A:
• Scoring showing the risk
or degree of dependence
or alcohol-related
problems (to detect
„alcoholics“, or potential
alcoholics]
Output for B:
• Amount of alcohol
consumed, in units or
grams/week;
• Frequency of exceeding
5/4 units / day
47
CAGE Questionnaire
Developed by Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Carolina at Cahpel Hill, CAGE is an internationally used assessment instrument for identifying alcoholics. It is
particularly popular with primary care givers. CAGE has been translated into several languages.
The CAGE questions can be used in the clinical setting using informal phrasing. It has been demonstrated that they are most effective when used as part of a general health history and should NOT be preceded by questions
about how much or how frequently the patient drinks (see “Alcoholism: The Keys to the CAGE” by DL Steinweg and H Worth; American Journal of Medicine 94: 520-523, May 1993.
The exact wording that can be used in research studies can be found in: JA Ewing “Detecting Alcoholism: The CAGE Questionaire” JAMA 252: 1905-1907, 1984. Researchers and clinicians who are publishing studies using the
CAGE Questionaire should cite the above reference. No other permission is necessary unless it is used in any profit-making endeavor in which case this Center would require to negotiate a payment.
References
Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984 PMID 6471323 "CAGE Substance Abuse Screening Tool" (PDF). Johns Hopkins Medicine. Retrieved 30 July 2014. Kitchens JM (1994). "Does this
patient have an alcohol problem?". JAMA 272 (22): 1782–7. doi:10.1001/jama.1994.03520220076034. PMID 7966928. Bernadt, MW; Mumford, J; Taylor, C; Smith, B; Murray, RM (1982). "Comparison of questionnaire and laboratory tests in the
detection of excessive drinking and alcoholism". Lancet 6 (8267): 325–8. doi:10.1016/S0140-6736(82)91579-3. PMID 6120322.
Cut down, Angry, Guilty, Eye opener
Lifestyle-oriented counselling in prevention – Examination methods – Alcohol
48
AUDIT- Alcohol Use Disorders Identification Test
Lifestyle-oriented counselling in prevention – Examination methods – Alcohol
AUDIT-C + AUDIT = Total score:
Department of Public Health,
Faculty of Medicine, Masaryk University
49
SASQ, M SASQ
Single Alcohol Screening Question
M SASQ scoring:
● A total of 0 to 1 indicates lower risk drinkers
● A total of 2 to 4 indicates increasing or higher risk drinkers
● An overall total score of 2 or above is M SASQ positive
M SASQ is an alcohol harm assessment tool consists of one question from the full alcohol use disorders
identification test (AUDIT). This single question test was developed for use in emergency departments.
Lifestyle-oriented counselling in prevention – Examination methods – Alcohol
When was the last time you had more then x* drinks in 1 day?
In the past month (in some versions less than 3 months) is a positive result
*X = 4 units for women and 5 units for men (in UK 6 and 8)
SASQ:
M SASQ (= Modified SASQ):
Department of Public Health,
Faculty of Medicine, Masaryk University
50
Alcohol quantification - concept of alcohol unit
Definition of alcohol unit (in grams)
by country:
Expression of alcohol content in beverages:
• ABV - Alcohol by Volume (in %)
• ABW - Alcohol by Weight -% alcohol content by weight
• Proof - spec. for spirits - 100o Proof = 57.15% ABV (Gunpowder soaked in rum does not burn if
ABV of rum <57.15% )
The term "alcohol unit" (one drink):
• It is a simple way to express the amount of alcohol - the equivalent of a certain amount
• It corresponds to the alcohol content in g in the usually served volume for each type of alcoholic
beverage
• There is no international agreement - see tab. on right
Conversion of ABV to ABW: ABW (g) = ABV (ml) x 0.789
E.g. 330 ml 5% beer = 3.3 x 5 x 0.789 = 13 g
 Australia: 8 – 10 g
 USA: 12 g, 14 g
 Japan 23.5 g
 CZ: 10 g, 12g, 16g
Beer:
Spirits:
Wine:
1 glass of beer (0,3 L) ≈ 1 glass of wine (1 dcl) ≈ 1 glass of spirit (30ml) ≈ 1 unit (10g), 1 „drink”
Lifestyle-oriented counselling in prevention – Examination methods – Alcohol
Department of Public Health, Faculty of Medicine, Masaryk University
51
Biochemical markers of high alcohol consumption
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Examination methods – Alcohol
̶ CDT - carbo-hydrate-deficient transferrin
Currently the most appropriate indicator - the highest dg
validity:
 High specifity (80-95 %)
 It responds flexibly to current changes in alcohol intake
Liver enzymes (serum transaminases):
̶ GGT (GMT) – gama glutamyl transferase
̶ AST - aspartate aminotransferase
̶ ALT – alamino transferase
Another:
̶ MCV – mean corpuscular volume
̶ HDL-C
̶ Acetaldehyd adducts
Time intervals of laboratory markers during chronic abuse
and in the period of abstinence:
Screening of alcohol abuse:
Blood examination:
52
Biochemical markers of high alcohol consumption
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Examination methods – Alcohol
53
Physical
activity
Lifestyle-oriented counselling in prevention
54
Physical activity assessment
Taught also earlier in ”Public Health II” subject (6th semester) topic “Assessment of physical activity”
Lifestyle-oriented counselling in prevention
Department of Public Health, Faculty of Medicine, Masaryk University
Physical Activity: The Secret—Not So Secret—to Prevent and Revert Metabolic Dysregulation in People of All
Sizes. November 2019, Mayo Clinic Proceedings 94(11):2164-2165, DOI:10.1016/j.mayocp.2019.09.018
̶ Self-Report Questionnaires
 These questionnaires are the most common method of PA assessment and rely on
participants' recall ability
̶ Self-Report Activity Diaries/Logs
̶ Direct Observation
Devices:
̶ Pedometers
̶ Accelerometers
̶ Heart-Rate Monitors
̶ Multiple sensors, e.g. Armbands
More complex – scientific measurements:
̶ Indirect calorimetry
̶ Double labelled water
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3915355/
55
Physical activity assessment
Lifestyle-oriented counselling in prevention – Examination methods – Physical activity assessment
Department of Public Health, Faculty of Medicine, Masaryk University
https://www.nccor.org/tools-mruserguides/individual-physical-activity/overview-of-physical-activity-assessment-tools/
Physical Activity Assessment Tools and Their Relative Positions on the Feasibility/Validity Continuum:
Department of Public Health, Faculty of Medicine, Masaryk University
56
IPAQ short - International Physical Activity Questionnaire
Lifestyle-oriented counselling in prevention – Examination methods – Physical activity assessment
• Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder that normal.
• Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder that normal.
57
IPAQ-short scoring
A) Continuous score
B) Categorical score
Expressed as MET-min per week: MET level x days/week x minutes/day
Total MET-min/week = sum of walking, moderate and vigorous PA
An example of calculation - each activity 5 days a week, 30 min / day:
MET levels:
• Walking = 3.3 METs
• Moderate intensity = 4.0 METs
• Vigorous intensity = 8.0 METs
Lifestyle-oriented counselling in prevention – Examination methods
Department of Public Health, Faculty of Medicine, Masaryk University
Bouts of activity lasting less than 10 minutes duration are not counted!
HEPA level (Health-Enhancing Physical Activity), which is a
more active category: People who
• exceed the minimum public health physical activity
recommendations, and
• are accumulating enough activity for a healthy
lifestyle.
What can fulfill "High" category:
• Walking: 130 min/day (3,3 x 7 x130 = 3003)
• Moderate a.: 110 min/day (4 x 7 y 110 = 3 080)
• Equivalent in steps: at least 12 500 steps/day
Cut-off for Moderate (basal) category in steps:
at least 5 000 steps/day
MET is a multiple of estimated resting energy expenditure.
58
Physical activity recommendations
̶ Global recommendations on physical activity for health
 WHO 2011
 https://www.who.int/dietphysicalactivity/factsheet_recommendations/en/
̶ Physical Activity Guidelines for Americans - 2nd edition
 U.S. Department of Health and Human Services, 2018, 118 pp.
 https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf
̶ EU physical aktivity guidelines (Doporučená politická opatření na podporu
zdraví upevňujících pohybových aktivit)
 EU 2008
 x
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry
Department of Public Health, Faculty of Medicine, Masaryk University
59
Global recommendations on Physical Activity for Health (2011)
These guidelines are relevant to all healthy adults aged 18–64 years, unless specific medical conditions indicate to the contrary,
irrespective of gender, race, ethnicity or income level. They also apply to individuals in this age range with chronic
noncommunicable conditions not related to mobility such as hypertension or diabetes. These recommendations can be applied to
adults with disabilities.
18-64 years old
Recommendations:
1. At least 150 min of moderate-intensity aerobic physical activity throughout the week
or
At least 75 min of vigorous-intensity aerobic physical activity throughout the week
or
An equivalent combination of moderate - and vigorous-intensity activity.
2. Aerobic activity should be performed in bouts of at least 10 min duration.
3. For additional health benefits, adults should increase
moderate intensity aerobic physical activity to 300 minutes per week,
or
engage in 150 minutes of vigorous-intensity aerobic physical activity per week,
or
an equivalent combination of moderate - and vigorous-intensity activity
4. Muscle-strengthening activities should be done involving major muscle groups on 2 or more
days a week.
Lifestyle-oriented counselling in prevention – Guidelines, recommendations
Department of Public Health, Faculty of Medicine, Masaryk University
60
Physical Activity Guidelines for Americans - 2nd edition
This second edition of the Physical Activity Guidelines for Americans provides science-based guidance to help
people ages 3 years and older improve their health through participation in regular physical activity. It reflects
the extensive amount of new knowledge gained since the publication of the first Physical Activity Guidelines for
Americans, released in 2008. This edition of the Guidelines discusses the proven benefits of physical activity
and outlines the amounts and types of physical activity recommended for different ages and populations. For
example, new aspects include discussions of:
 Additional health benefits related to brain health, additional cancer sites, and fall-related
injuries;
 Immediate and longer term benefits for how people feel, function, and sleep;
 Further benefits among older adults and people with additional chronic conditions;
 Risks of sedentary behavior and their relationship with physical activity;
 Guidance for preschool children (ages 3 through 5 years);
 Elimination of the requirement for physical activity of adults to occur in bouts of at least
10 minutes;
 Tested strategies that can be used to get the population more active.
https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf
U.S. Department of Health and Human Services, 2018, 118 pp.
What‘s new in th second edition 2018 vs 1st ed 2008:
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Guidelines, recommendations
61
Physical Activity Guidelines for Americans - 2nd edition
https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf
U.S. Department of Health and Human Services, 2018, 118 pp.
Key guidelines for adults:
 Adults should move more and sit less throughout the day. Some physical activity is
better than none. Adults who sit less and do any amount of moderate-to-vigorous
physical activity gain some health benefits.
 For substantial health benefits, adults should do at least:
‒150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of
moderate-intensity, or
‒75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a
week of vigorous-intensity aerobic physical activity, or
‒an equivalent combination of moderate- and vigorous-intensity aerobic activity.
Preferably, aerobic activity should be spread throughout the week.
 Additional health benefits are gained by engaging in physical activity beyond the
equivalent of 300 minutes (5 hours) of moderate-intensity physical activity a week.
 Adults should also do muscle-strengthening activities of moderate or greater
intensity and that involve all major muscle groups on 2 or more days a week, as
these activities provide additional health benefits.
Lifestyle-oriented counselling in prevention – Guidelines, recommendations
Department of Public Health, Faculty of Medicine, Masaryk University
62
Physical Activity Guidelines for Americans - 2nd edition
Department of Public Health, Faculty of
Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Guidelines, recommendations
Therefore, its translation into actionable consumer messages and resources helps individuals, families, and
communities achieve the recommendations in the Guidelines. The Move Your Way campaign was created by the
Office of Disease Prevention and Health Promotion within the US Department of Health and Human Services to
be used by communities, health professionals, educators, and others to communicate to consumers in plain
language about the recommendations from the Guidelines, promote the health benefits of meeting the
recommendations, and provide tips for how consumers can meet the recommendations
63
Implementation of Physical Activity Guidelines thru Move Your Way
https://health.gov/MoveYourWay/Activity-Planner/
https://health.gov/paguidelines/moveyourway/
Older adults
Department of Public Health, Faculty of Medicine, Masaryk University
Lifestyle-oriented counselling in prevention – Guidelines, recommendations
Ústav ochrany a podpory zdraví LF MU 64
Implementation of Physical Activity Guidelines thru Move Your Way
Lifestyle-oriented counselling in prevention – Guidelines, recommendations
65
Anthropometry
Lifestyle-oriented counselling in prevention
Department of Public Health, Faculty of Medicine, Masaryk University 66
Recommended anthropometric methods
̶ Weight, Height → BMI
̶ Abdominal circumference
̶ BFP – body fat percentage (by impedance)
Lifestyle-oriented counselling in prevention - Anthropometry
67
BMI classification
Source: WHO 1995, 2000, 2009
BMI = weight (kg) / height2 (m2)
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry
Department of Public Health, Faculty of Medicine, Masaryk University
68
Oliveros E, Somers V, Sochor O, Goel K, Lopez-Jimenez F: The concept of normal weight obesity. Progress in cardiovascular diseases, 2014, 56, 426-433
Men Women
Healthy < 20 < 30
Overfat 20 - 25 30 - 35
Obese > 25 > 35
Biospace: Standard body fat percent is 15 % (range 10 - 20) for men and 23 % (range 18 - 28) for women
Category OK Overweight Obesity
BMI < 25 25 – 30 > 30
% fat men < 20 % 20 – 25 % > 25 %
% fat women < 32 % 32 – 38 % > 38 %
Measured PBF corresponding to BMI cut-offs: (Galagher et al.)
BFP – Body Fat Percentage – diagnostic criteria (cut-offs)
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry - Bioimpedance
Bioimpedance Measurement of Body Composition with Inbody S10 (Biospace)
69
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry - Bioimpedance
Department of Public Health, Faculty of Medicine, Masaryk University
̶ Body fat - %, kg
̶ Skeletal muscles (lean mass) - %, kg
̶ Water - %, L (total, extracellular, intracellular)
̶ Mineral mass (osseus, non-osseus fraction)
̶ Abdominal visceral fat
̶ Segmental analysis
70
Inbody S10 – result report
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry
71
Abdominal circumference
WHO: Midpoint between
the last palpable rib and
top of the iliac crest
Risk: OK Increased Substantially
increased
Men < 94 94 - 102 > 102
Women < 80 80 - 88 > 88
Waist – taken in level of the
umbilicus (navel)
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry
Department of Public Health, Faculty of Medicine, Masaryk University
Not here!
Where to measure:
Navel position is OK
Where to measure:
72
Examination
Abdominal circumference
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry
Després J P, Lemieux I, Prud'homme D: Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ. 2001 Mar 24;322(7288):716-20
WHR interpretation pitfallsAC correlation with abdominal fat (and metabolic risk):
Misleading information provided by follow up of changes in
waist hip in women followed over 20 years.
73
 Metabolic syndrome is a clustering of at least three of the five following medical conditions: abdominal obesity,
high blood pressure, high blood sugar, high serum triglycerides and low high-density lipoprotein (HDL) levels.
 Metabolic syndrome is associated with the risk of developing cardiovascular disease and type 2 diabetes.
Metabolic syndrome
If BMI is >30 kg/m2, central obesity can be assumed and waist circumference does not need to be measured
> 80 / 94 cm (88/102)
The new International Diabetes Federation (IDF) definition
Lifestyle-oriented counselling in prevention – Examination methods
74
Blood
pressure
Lifestyle-oriented counselling in prevention
75
Blood Pressure
Definition and classification of blood pressure levels:
BP thresholds for definition of hypertension with
different types of BP measurement
Lifestyle-oriented counselling in prevention – Examination methods
76
Age reader
̶ Úxx
̶ V
 Ob
Principle:
The AGE Reader is a non-invasive monitoring device that uses
ultra-violet light to excite autofluorescence in human skin tissue.
The autofluorescence is from the level of Advanced Glycation End
products (AGEs). The measurement of AGEs provides an
immediate cardiovascular risk prediction in 12 seconds
Age Reader Identifies:
 Individuals with increased CV risk
 individuals with an increased risk of diabetes and additionally the
metabolic syndrome
 early detection of (diabetes) patients at risk of developing
cardiovascular complications
 identify people with increased levels of AGEs to improve skin
care and reduce aging
Lifestyle-oriented counselling in prevention – Examination methods – New
Department of Public Health, Faculty of Medicine, Masaryk University
77
Age reader report
̶ Úxx
̶ V
 Ob
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry
Department of Public Health, Faculty of Medicine, Masaryk University
78
Cholesterol
Lifestyle-oriented counselling in prevention
79
Biochemical markers
 Possibility of immediate evaluation of plasmatic
parameters directly medical office during examination
and counselling
 Total Chol
 HDL-chol
 Triglycerides
 Glycaemia
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry
Reflotron:
80
MNA
Lifestyle-oriented counselling in prevention
81
Validated Nutritional Assessment Tests for Malnutrition
(Elderly, Hospitalized Patients)
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry
 MNA – Mini Nutritional Assessment
 SGA – Subjective Global Assessment
 NRS (resp. NRS 2002) – Nutritional Risk Screening
 MUST – Malnutrition Universal Screening Tool
82
Lifestyle-oriented counselling in prevention – Examination methods – Malnutrition screening tests
MNA
83
Intervence
Lifestyle-oriented counselling in prevention
84
Doporučení dle nemocí – Cardiovascular Diseases
2016 European guidelines on CD prevention in clinical practice
How to intervene at the individual level: risk factor intervention - behaviour change
Recommendations for facilitating changes in behaviour:
Principles of effective communication to facilitate behavioural change:
Ten strategic steps to facilitate behaviour change:
85
Intervention
Lifestyle-oriented counselling in prevention – Examination methods – Anthropometry