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Behavioral Medicine in the Metabolic Syndrome

Behavioral Medicine in the Metabolic Syndrome. Etiology, Interventions and Sample Cases. THE METABOLIC SYNDROME. Diabetes type 2. Hyperlipidemia. Essential Hypertension. Obesity. OVERLAPPING ETIOLOGY. Genetic Predisposition Behavior (Inactivity, Appetite) Chronic Stress

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Behavioral Medicine in the Metabolic Syndrome

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  1. Behavioral Medicine in the Metabolic Syndrome Etiology, Interventions and Sample Cases McGrady 2012

  2. THE METABOLIC SYNDROME Diabetes type 2 Hyperlipidemia Essential Hypertension Obesity McGrady 2012

  3. OVERLAPPING ETIOLOGY • Genetic Predisposition • Behavior (Inactivity, Appetite) • Chronic Stress • Negative Emotion McGrady 2012

  4. Chronic Stress: Biological Effects Nervous and Endocrine Systems Vascular constriction, tachycardia, heart rate variability, inflammation Disordered breathing Sleep disruption Renin angiotension system McGrady 2012

  5. Psychological Factors and the Metabolic Syndrome Depression, Anger, Hostility, Anxiety Mediators : Hypothalamic pituitary axis Sympathetic adrenal medullarysystem Disturbed Biorhythms Behavior Metabolic Syndrome Goldbacher & Matthews, 2007 McGrady 2012

  6. Emergence of the Metabolic Syndrome Vulnerability Vitaliano et al 2002 Little Social Support Few Personal Resources Distress Metabolic Syndrome Chronic Stress UnhealthyHabits McGrady 2012

  7. Choice Driven Behaviors and Body Weight • Short term : the hypothalamus and higher brain centers interpret signals to either increase or decrease food intake to maintain balance between consumption and energy needs (Widmaier, Raff, & Strang, 2004). • Long term: leptin is released by fat cells, travels through the blood stream to the feeding center in the hypothalamus (Froy, 2009). Leptin combines with receptors in the hypothalamus, signals to decrease appetite and food intake. Other hormones: cortisol, neuropeptide Y, and ghrelin are appetite stimulants. McGrady 2012

  8. Stress Effects on Behavior • Anxiety • Less efficient time management • Forget blood glucose & BP monitoring • Substance use • Insomnia and fragmented sleep • Depression • Low energy for medical regimen • Poor food choices (comfort foods) • Terminal insomnia McGrady 2012

  9. Measurement of blood glucose Average blood glucose for the past 3 months is indicated by a blood test glycosylated hemoglobin (HbA1c), which represents the values of blood glucose for that time; normal values are 6% or less (ADA, 2009). McGrady 2012

  10. Pre-diabetes • The condition of pre-diabetes or glucose intolerance is a critical period during which the onset of diabetes can be slowed or prevented. • Diet, exercise, problem solving nutritional challenges, and sometimes medical management are recommended for pre-diabetes (Hankonen, Absetz, Haukkala, & Uutela, 2009; Knowler et al., 2002). McGrady 2012

  11. TYPE 2 DIABETES Hyperglycemia: elevated blood glucose Insulin resistance: cell membrane impedes the entry of glucose Standard Treatment: oral hypoglycemic agents, insulin, diet and exercise McGrady 2012

  12. DM- #1 in behavioral demands Patient is often fearful • Unresolved core fears surface (Abandonment, isolation, rejection, losing control, injury, confinement) Genetic predisposition exists to fear stimuli that are dangerous McGrady 2012

  13. Fear Conditioning Defensive actions to painful and non-painful, threatening stimuli are quickly learned and hard to unlearn. Single exposure to threatening stimuli can result in long term emotional responses. McGrady 2012

  14. Stress, Depression and Blood Glucose • Depression affects physiological regulation of glucose levels in the blood and tissues, and undermines self-care behaviors (Anderson, Freedland, Clouse, & Lustman, 2001; Fisher, Thorpe, DeVellis, & DeVellis, 2007; Li, Ford, Strine, & Mokdad, 2008). • Depressed patients with elevated salivary cortisol levels (indicating a type of depression and the presence of chronic stress) had central obesity, a major predictor of elevated blood glucose (Weber-Hamann et al., 2002). McGrady 2012

  15. Stress and obesity • Persons with fat concentrated in the abdominal regions demonstrate high plasma cortisol levels, impaired leptin sensitivity, low serotonin, increased free fatty acids, and indicators of chronic, low level inflammation. • Negative emotions are related to waist-hip ratio which indicates the amount of fat in the abdominal region (Ahlberg et al., 2002). McGrady 2012

  16. Stress and obesity • Fat cells (adipocytes) secrete not only leptin, but also pro-inflammatory molecules such as IL6 and TNIF-alpha. • Stress promotes beta adrenergic activity and inhibits parasympathetic activity, but also induces the release of cytokines from adipocytes, linking stress, inflammatory processes and obesity. McGrady 2012

  17. Anxiety may be related to lack of nurturing and social support Mother rats normally groom and lick their pups; the pups (as adults) will do the same. • Stressed mother rats don’t groom/lick pups; these pups will not nurture their own. • Enriching the environment and decreasing stress on mothers reverses the effects on pups and grand-pups. McGrady 2012

  18. Modifiers of the Stress Effects: Exercise Regular physical activity produced positive effects beyond weight loss alone, called “residual effects” which are protective against elevated blood glucose and DM (Carnethon & Craft, 2008). McGrady 2012

  19. Modifiers of the Stress Effects • Stress is less potent in elevating HBA1c in patients with higher resilience and more positive coping (self esteem, self efficacy, self mastery, and optimism). • Resilience buffered the negative effects of stress on blood glucose. (Yi, Vitaliano, Smith, Yi, & Weinger, 2008) McGrady 2012

  20. Biofeedback/Relaxation in Type 2 DM • Research evidence from McGrady, McGinnis et al. McGrady 2012

  21. GROUP COMPARISON OF AVERAGE BLOOD GLUCOSE (mg/dl) . Group difference p < .008 155 (53) 151 (40) 149 (43) BLOOD GLUCOSE mg/dl 136 (22) McGrady 2012

  22. McGrady 2012 F (1, 23) = 9.0 p = .006 (McGinnis, McGrady et al 2005)

  23. The Case of Rosa • Rosa was a 35 year old woman of Italian descent, who was diagnosed with type 2 DM five years ago, and treated with an oral hypoglycemic agent. • Rosa was approximately 30-35 lbs. overweight; her HbA1c levels were elevated (8.0%) and she struggled with glycemic control. • Rosa’s major sources of stress were her part-time job, her diabetes, and her 15 year old son Frankie, who began to get into trouble when he entered 9th grade. Frankie’s grades were poor and he became belligerent towards his teachers and his parents when he was told to do something. • Rosa was given the diagnosis of adjustment disorder with depressed and anxious mood. McGrady 2012

  24. Intervention • Mindful breathing • Mindful eating (Albers, 2008). • Progressive Relaxation • Physical exercise • Surface electromyography (SEMG) and temperature biofeedback gave Rosa a sense of control over her physiological responses to stress. This sense of control could be applied to her blood glucose, her weight, and her mood. McGrady 2012

  25. Intervention • Mindfulness meditation, biofeedback, and Acceptance and Commitment Therapy (ACT) (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Gregg,Callaghan, Hayes, & Glenn-Lawson, 2007; McGinnis, McGrady, Cox, & Grower-Dowling, 2005). • Daily practice of mindfulness allowed Rosa to slow time down and to find minutes of enjoyment during the course of a normal day. McGrady 2012

  26. Balancing Life-Diabetes Complete the Eco Map and use as a visual aid to view the various relationships/entities in your life. Eco Map Relationship Codes: An arrow pointing away from you signifies you are sending energy out, and arrow point towards you is energy coming to you. • Strong/Supportive • Weak ------------------------ • Stressful

  27. Support groups for people with diabetes • Support group sessions mobilize social support as participants share stories of challenges faced and their solutions. • Challenges: fear of complications, feeling of helplessness, exaggerated physiological responses, demands of management to stress (Karlsen, Idsoe, Dirdal, Hanestad, & Bru, 2004). McGrady 2012

  28. How Does This Work • Forehead muscle tension: decreased tension, relaxed muscles • Finger temperature: increased temperature, general relaxation • Empowerment: less depressed • Better control of anxiety McGrady 2012

  29. BEHAVIORAL MEDICINE IN ESSENTIAL HYPERTENSION McGrady 2012

  30. Measurement of BP • Blood pressure (BP) values are expressed as systolic/diastolic in millimeters of mercury (mmHg). Systolic BP (SBP) is defined as the maximum pressure that occurs during ejection of blood from the heart, and diastolic BP (DBP) is the minimum pressure that occurs during cardiac relaxation. McGrady 2012

  31. Variations in BP • BP varies throughout the waking hours of the day, depending on physical activity, emotion and environment. During sleep, persons with normal BP exhibit a drop in both SBP and DBP of about 10%, called “dipping.” • Family history of hypertension, African American ethnicity, male gender, and negative emotions have been correlated with non-dipping, which results in higher risk for cardiovascular disease (Linden et al. 2008; Kario, Schwartz, Davidson & Pickering, 2001). McGrady 2012

  32. ESSENTIAL HYPERTENSION Chronically elevated BP SBP > 139; DBP > 89 mmHg Standard treatment: antihypertensives, diet, exercise PreHypertension SBP 120-139; DBP 80-89 mmHg (JNC 7 2003) McGrady 2012

  33. Heart rate variability • Low heart rate variability (HRV), an indicator of poor cardiac health, is found in patients with depression who have coronary disease or a recent history of acute myocardial infarction (Carney et al, 2005). • Variations in heart rate are normally correlated with breathing in a complex pattern termed respiratory sinus arrhythmia (RSA), where greater heart rate variability is a sign of cardiac health (Force, 1996) McGrady 2012

  34. Modifiers of the Stress-BP Relationship • Social support buffers the effects of stress on many physiological systems (Schwerdtfeger & Friedrich-Mai, 2009). Being married influences heart rate variability in a positive way, independently of age (Randall, Bhattacharyya & Steptoe, 2009). • A sense of mastery or self efficacy in simple self care tasks or more challenging activities seems to be influential in maintaining heart health (Sarkar, 2007; Surtees, Wainwright, Luben, Wareham, Bingham, Khaw, 2010;. McGrady 2012

  35. Modifiers of the Stress-BP Relationship: Anxiety • Lower level chronic anxiety or panic attacks are associated with elevated BP and increase risk for heart disease • Depression is an independent and significant risk factor for the development of heart disease and stroke (Surtees, Wainwright, Luben, Wareham, Bingham & Khaw, 2008), and the relationship appears to be bi-directional (Khawaja et al, 2009). • Psychological state not only affects daytime BP, but hostility, for example, also interferes with nighttime BP dipping (Mezick 2010) McGrady 2012

  36. Modifiers of the Stress-BP Relationship: Depression • Depressed patients with risk factors for ischemic heart disease compared to non-depressed controls have evidence that their circulating platelets have increased platelet “stickiness” through several different pathways. • (Bruce, E and Musselman, D. Psychosomatic Medicine, 2005) McGrady 2012

  37. Modifiers of the Stress-BP Relationship: Depression • SSRI effects on platelet reactivity • Significantly decreased platelet secretion in response to collagen after 6 weeks open label treatment with sertraline. Markowitz et al Am. J. Psychiatry (2000) McGrady 2012

  38. “Depression and Anxiety as Predictors of 2-Year Cardiac Events in Patients with Stable Coronary Artery Disease”Arch Gen Psych Jan 2008 804 patients • 57 MDD, 43 GAD, 220 BDI>14, 333 HAD-S>8 • Outcomes of major cardiac events (Cardiac Death, MI, Cardiac Arrest, Nonelective Revascularization) (MACE’s) • All diagnostic and self report symptoms of depression and anxiety significantly predicted major cardiac events McGrady 2012

  39. Cochrane review of relaxation in hypertension (metanalysis) • Twenty five trials with up to 5 yrs (mean 20 wks) follow-up 1100 patients. No change meds • Small statistically significant reductions in SBP (5.5) and DBP 3.5 compared to controls • Subgroups: biofeedback 5.9 and 3.3 mm Hg • Initial BP impacted effect on SBP, not DBP Dickinson et al. J. Human Hypertension. 2008) McGrady 2012

  40. STRESS MANAGEMENT EFFECTS ON BP (Linden et al 2001) • N = 23 treated, 26 wait list controls Ambulatory, clinic and home BP measured • 10 weeks of individualized treatment based on patient’s psychological risk factors McGrady 2012

  41. 24 Hr Ambulatory SBP Over Time mmHg SBP: F (1,47) = 4.3; p = .04 (Linden et al 2001) McGrady 2012

  42. Device Guided Breathing(RESPeRATE) • 150 hypertensive patients: device group + BP monitoring or monitoring alone • Slow breathing with device • Results depended minutes spent practicing • **Significant decreases in SBP in device group compared to BP monitoring group; (up to15 mm Hg) • Elliott et al. 2004 McGrady 2012

  43. Abdominal breathing + EMG BF • Women with pre-hypertension • Reduction of 8.4 SBP and 3.9 DBP • Compared to breathing training alone • Wang et al. 2010 J. Altern Complement Med. McGrady 2012

  44. Case of Marquise, 46 yr old male • African American, 15 year history of essential hypertension. Medication regimen (calcium channel blocker and diuretic) Chobanian 2003. • Marquise had a heart attack. He had a stent placed, and began cardiac rehabilitation, but he did not complete the program. • Family history of heart disease, diabetes and obesity. • Marquise demonstrated several unhealthy behaviors, including using alcohol as a self soothing agent, lack of exercise and maladaptive interpretations of stressful work situations. • His scores on the psychological inventories were 16 (Beck Depression Inventory – BDI-II) and 22 (Beck Anxiety Inventory – BAI) indicating moderate depression and significant anxiety. McGrady 2012

  45. Interventions • Move - slowly increase the amount of daily movement . • Relaxation skill building • Return to cardiac rehabilitation. • Mindful breathing techniques • Progressive relaxation   • CBT • Heart rate variability biofeedback • Stress Eraser (Muench, 2008) • Respirate device (Elliott, Izzo, & White, 2004) • AMBP to evidence nighttime dipping (Pickering, Shimbo, & Haas, 2006). McGrady 2012

  46. Case Summary • CBT emphasized countering negative attitudes about exercise, changing beliefs about “failure,” and altering all or none thinking. • Reversal of negative cognitive patterns decreases risk for recurrence of heart attack (Witkower & Rosado, 2005; Guilliksson, Burnell, Vessby, Lundin, Toss & Svardsudd, 2011). • Mindful breathing (Mourya, Mahajan, Singh & Jain, 2009; Schneider et al, 2005) Relaxation techniques, biofeedback and CBT (Rainforth 2007). • HRV biofeedback was the key intervention because of the evidence supporting interdependency between cardiac health and respiration (Lehrer, 2007; McCraty, Atkinson, Tomasino, 2003). McGrady 2012

  47. Effects of Psychological State on Outcome of Cardiac Rehab • McGrady, McGinnis et al. 2009 JCRP McGrady 2012

  48. Cardiac Rehabilitation Program Enrollment & Informed Consent N=380 Psychological Assessments (BDI-II, BAI, SF36) N=266 Physical Assessment (Walk Test) N=281 Program – 36 weeks Exercise, lifestyle counseling, stress management, smoking cessation Completion of Program N=190 McGrady 2012

  49. Demographics and Diagnoses of the Participants McGrady 2012

  50. Analysis of Baseline and Post Program Values in Completers (means (SD) • Paired t-tests: significant differences between baseline and post program • t = -9.5; p < .001 b. t = 4.2; p < .001 • c. t = 5.4; p < .001 d. t = -10.6; p < .001 • e. t = -3.6; p < .001 McGrady 2012

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