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RELEVANCE OF BEHAVIOR TO MEDICAL PRACTICE
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Human behavior has a major impact on health and well-being. The patients that you see in medical practice are likely to have behaviors (e.g., smoking, drinking, and eating habits) that place them at risk of developing chronic disease. Equally likely, they may have psychological problems (e.g., depression) that impair their quality of life and undermine their motivation to follow your treatment recommendations. Moreover, if you treat families and see the same patients over many years, you may observe unhealthy behaviors long before you see the emergence of biological risk factors like hypertension, hypercholesterolemia, or hyperglycemia. By helping your patients to address unhealthy behaviors, you have the opportunity to help them prevent the onset or worsening of chronic diseases. Just as in evidence-based medicine, you should know how to find and appraise the evidence base for behavioral (nondrug, nonsurgical) treatments, so you can help your patients with the most appropriate behavioral treatment option. Below is a case you might encounter in the primary care clinic.
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CASE ILLUSTRATION 1
A 43-year-old man presents for a preventive care visit. He has not had any preventive care in over 5 years but at an urgent care visit 4 months ago he was told he had high blood pressure. His past medical history is remarkable only for mild eczema. He is married, has two children, and works as an attorney. He says his work is sometimes stressful but denies a depressed mood or loss of interest in leisure activities. He has no difficulty sleeping. He recently cut back to about five cigarettes per day and has three to four alcoholic drinks almost every night. He does not exercise regularly, but walks about 5 minutes twice a day to the train. He does not follow any particular diet: breakfast is usually coffee and toast; lunch is fast food or a deli sandwich; he snacks on cookies or pastries at work. His wife cooks “healthy food” sometimes and they order from restaurants frequently. On physical examination his weight is 207 lbs with a body mass index of 29.7 kg/m2. An average of three office blood pressures is 139/88 mm Hg. The rest of the examination is normal except for an eczematous rash on his arms. As you prescribe triamcinolone cream for his rash, you consider how best to counsel him about behavior change. The list of changes you think would be beneficial include: (1) stopping smoking; (2) reducing total calories; (3) following a diet low in sodium and high in vegetables, fruits, whole grains, and nonfat dairy products; (4) reducing saturated fat in his diet; (5) reducing alcohol use to no more than two drinks per day; and (6) increasing the amount of moderate-intensity physical activity he does by an additional 90–120 minutes each week.
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APPLYING EVIDENCE-BASED PRACTICE IN PRIMARY CARE
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This patient has several risk factors and behaviors that put his ...