Health Tobacco Alcohol Diet and Exercise Michael Clark MD Associate Medical Director Partners Behavioral Health Management 1 Examination of how four factors of poor health tobacco alcohol diet and exercise impact on mental health as well as physical health and the reas ID: 777174
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Slide1
Impacting
Four
Causes of Poor
Health
:
Tobacco
,
Alcohol
,
Diet
and
Exercise
Slide2Michael Clark, MD
Associate Medical Director
Partners Behavioral Health Management
Slide31. Examination
of how four factors of poor health (tobacco, alcohol, diet and exercise) impact on mental health as well as physical health and the reasons they are a concern for all
clinicians2. The importance of brief assessments and monitoring 3. Brief and effective interventions will outline actions that can be a part of any clinical appointment
Objectives
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Slide4Public Health Impact
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Slide5Associated with 40% of
causes of
death worldwideEnvironmental tobacco or second-hand smoke, 30 percent (in industrialized countries) of cancers worldwide.Nearly all lung cancers (about 87-91 percent in men and 57-86 percent in women) Most cancers of the esophagus, larynx, and oral cavity.
Significant risk factor for cancers of the bladder, pancreas, kidney, stomach, cervix, and nose, as well as myeloid
leukemiaTwice as likely to die from coronary
heart. Serious
risk for sudden
cardiac death
due to acute coronary thrombosis and
50,000 deaths from ischemic heart disease are associated with secondhand smoke annually
Tobacco – Physical Health Risks
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Slide6Although about
25 percent
in the U.S. have behavioral health conditions, they account for nearly 40 percent of all cigarettes smoked.Improvement in mental health and addiction recovery outcomes:decrease depression, anxiety, and stress.increase
positive mood and quality of life.increase long-term abstinence from alcohol and other drugs for those in
treatment for substance use disorders
Tobacco – Mental Health Risks
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Slide7High
blood pressure, heart disease, stroke, liver disease, and digestive
problems (ulcers, pancreatitis)Cancer of the breast, mouth, throat, esophagus, liver, and colonWeakened Immune System: Chronic drinkers more liable to contract diseases like pneumonia and tuberculosis. Excessive drinking on a single occasion
affects up to 24 hours after intoxication
Social problems, including lost productivity, family problems, and unemployment
Alcohol – Physical Health Risks
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Slide8Learning
and memory problems, including dementia and poor school
performanceMental health problems, including depression and anxietyAlcohol dependence, or alcoholism.Alcohol – Mental Health Risks
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Slide9From CDC, around
365,000 adults across the U.S.
die from obesity-related illnesses each year.Risk-Factors for:Cardiovascular diseaseDiabetesStrokeRespiratory illness (sleep apnea, asthma)Many forms of cancer (breast, ovary, endometrium, esophagus,pancreas, colon, rectum, and kidney)
Reducing weight by even 5-10% significantly reduces obesity-related health
risks.Diet – Physical Health Risks
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Slide10Cognitive decline and
dementia
link between excess weight in midlife and risk of cognitive decline and dementia, including Alzheimer’s diseaseDepressionmay increase risk of depression by as much as 55%, also increases risk of obesity by 58%Quality of
lifereduced emotional, physical, social
and feelings of well-beingPoor self-esteem from stigma and
discrimination
Diet
– Mental Health Risks
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Slide11Increased
risk
for diabetes and hypertension. Higher risk for some types of cancer (breast, colon)Greater loss of bone densityExercise – Physical Health Risks
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Slide12Losing thinking
, learning, and judgment skills
with ageIncreasing risk for depression Reducing quality of sleepExercise – Mental Health Risks3/29/2017
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Slide13Adequate Screening
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Slide14Goal to
identify everyone who
may have risk factorsEstablishment of cut-off scoresIf in the positive score, referral for further assessment.Format for recording the results of the screening.Necessary Components of Screening/Assessment Tools
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Slide15Standard Drink
0.6
ounces (14.0 grams or 1.2 tablespoons) of pure alcohol. 12-ounces of beer (5% alcohol content).8-ounces of malt liquor (7% alcohol content).5-ounces of wine (12% alcohol content).1.5-ounces of 80-proof (40% alcohol content) distilled spirits or liquor (e.g., gin, rum, vodka, whiskey).4Excessive drinking
Binge drinking, heavy drinking, and any drinking by pregnant women or people younger than age 21.Binge drinking, the most common form of excessive drinking,
For women, 4 or more drinks during a single occasion.For men, 5 or more drinks during a single occasion.Heavy
drinking
For women, 8 or more drinks per week.
For men, 15 or more drinks per week.
Moderate Drinking
From Dietary Guidelines for
Americans, up to 1 drink/day for women and up to 2 drinks/day
for men
Alcohol Screening
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Slide16CAGE - Recommendations
from the National Institute of Alcohol Abuse and Alcoholism (NIAAA
)Quantity and Frequency (Q&F) questions with the CAGE questionnaire for screening for alcohol problems. The Q&F questions can elicit whether the patient is over the recommended levels for moderate drinking and therefore “at risk” for illness and injury. The CAGE questionnaire is better for identifying dependence.
Since the CAGE was originally designed for lifetime prevalence, it may be helpful to specify “during the past 12 months.”
Asking Q&F questions, then adding the CAGE questions if the responses exceed moderate levels is one way to use the screens.
Alcohol Screening
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Slide17Substance Use Disorder Screenings
Other Examples
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Slide18Substance Use Disorder Screenings
Other Examples
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Slide19Body
Mass Index (BMI)
Most widely used indicator of healthy weight and of body fatness, without directly measuring body fat. Limitations: include Not differentiate between fat mass and lean mass (e.g. muscles, bones). Not assess fat distribution.
BMI CalculatorA BMI calculator can be found at
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html
Diet
Screening
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Slide20BMI Weight
Ranges (weight (kg) / [height (m)]
2)18.5 - 24.9 = Normal; maintain a healthy weight and avoid weight gain ≥25 - 29.9 = Overweight; avoid weight gain and consider weight loss (BMI ≥27 with comorbidity: consider medications) ≥30 = Obese; support weight loss and consider medications ≥40 (or ≥35 with co-morbidity) = Support weight loss and consider medical weight loss options
Diet
Screening
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Slide21Waist
Circumference
These waistlines are associated with higher risk of developing obesity-related conditions: A man whose waist circumference is more than 40 inches A non-pregnant woman whose waist circumference is more than 35 inches To measure waist size (circumference), place a tape measure around the bare abdomen just above the hip bone. Be sure that the tape is snug, but does not compress the skin, and is parallel to the floor. Ask the client to relax, exhale, and then measure the waist.
Diet Screening
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Slide22Target Heart Rate and Estimated Maximum Heart Rate
For moderate-intensity physical activity, a person's target heart rate should be 50 to 70% of his or her maximum heart
rate, based on the person's age. An estimate by subtracting the person's age from 220. For 50-year-old person, the estimated maximum age-related heart rate would be calculated as 220 - 50 years = 170 beats per minute (bpm). The 50% and 70% levels would be:50
% level: 170 x 0.50 = 85 bpm, and70% level: 170 x 0.70 = 119 bpm
Exercise Screening
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Slide23Borg Rating of Perceived Exertion (RPE
)
Fairly good estimate of the actual heart rate during physical activity* (Borg, 1998).12 to 14 score suggests that physical activity is at a moderate intensity. Intensity of the activity
is adjusting by speeding up or slowing down the movements
Exercise Screening
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Slide24Borg Rating of Perceived Exertion
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Slide25Interventions
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Slide26Precontemplation
— EngagementEducate/InformContemplation and Preparation — PersuasionEducation
, goal setting, and building awareness of problem through motivational counselingAction — Active treatment
Counseling and treatment based on cognitive-behavioral techniques, skills training, and support from families and self-help groups
Maintenance — Relapse prevention
Continued counseling and
treatment,
skill building, and ongoing support to promote recovery
Stages of Change
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Slide27Stages of Change
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Slide28Express empathy
Unconditional
acceptanceReflective listeningNormal ambivalenceDevelop discrepancyPatient presents arguments for changeCreate a change in perception without coercion
Motivational Interviewing
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Slide29Roll
with resistance
Avoid arguing for changeResistance is not directly opposedChange perception through reframing/insightResistance is a signal to respond differentlySupport self-efficacyBelief that change is possible
Patient carries out changeProvider’s belief
becomes a self-fulfilling prophecyMotivational Interviewing
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Slide30Specifically, ask every patient who presents to a health care facility if s/he uses tobacco (Ask), advise all tobacco users to quit (Advise), and assess the willingness of all tobacco users to make a quit attempt at this time (Assess)
Tobacco
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Slide31The
“5 A's” model for treating tobacco use and dependence
Ask about tobacco use. Identify and document tobacco use status for every patient at every visit. Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit. Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time? Assist in quit attempt. For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. For
patients unwilling to quit at the time, provide interventions designed to increase future quit attempts. Arrange
follow-up. For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date.
For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.
Tobacco
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Slide32The
“5 A's” model for treating tobacco use and dependence
1- to 3-minute intervention limited to one of the "5 A's" increases by 40% the likelihood that the patient will quit.And spending 30 minutes counseling patients raises the chances of quitting to 90%Tobacco
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Slide33Express
empathy
The importance of addressing smoking or other tobacco use (e.g., “How important do you think it is for you to quit smoking?”)Concerns and benefits of quitting (e.g., “What might happen if you quit?”)Use reflective listening to seek shared understanding:
Reflect words or meaning (e.g., “So you think smoking helps you to maintain your weight.”).
Summarize (e.g., “What I have heard so far is that smoking is something you enjoy. On the other hand, your boyfriend hates your smoking, and you are worried you might develop a serious disease.”).
Normalize
feelings and concerns (e.g., “Many people worry about managing without cigarettes
.”).
Support
the patient's autonomy and right to choose or reject change (e.g., “I hear you saying you are not ready to quit smoking right now. I'm here to help you when you are ready
.”)
Tobacco
- Motivational
Interviewing
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Slide34Develop discrepancy
Highlight the discrepancy between the patient's present behavior and expressed priorities, values, and goals (e.g., “It sounds like you are very devoted to your family. How do you think your smoking is affecting your children?”).
Reinforce and support “change talk” and “commitment” language: “So, you realize how smoking is affecting your breathing and making it hard to keep up with your kids.”“It's great that you are going to quit when you get through this busy time at work.”Build and deepen commitment to change: “There are effective treatments that will ease the pain of quitting, including counseling and many medication options.”
“We would like to help you avoid a stroke like the one your father had.”
Tobacco
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Slide35Roll with resistance
Back off and use reflection when the patient expresses resistance:
“Sounds like you are feeling pressured about your smoking.”Express empathy: “You are worried about how you would manage withdrawal symptoms.”Ask permission to provide information: “Would you like to hear about some strategies that can help you address that concern when you quit
?” Support self-efficacy
Help the patient to identify and build on past successes: “So you were fairly successful the last time you tried to quit
.”
Offer
options for achievable small steps toward change:
Call
the quitline (1-800-QUIT-NOW) for advice and information.
Read about quitting benefits and strategies.Change
smoking patterns (e.g., no smoking in the home).Ask the patient to share his or her ideas about quitting strategies
.
Tobacco
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Slide36Patients Not Ready To Make A Quit Attempt Now (The "5 R's
")
Relevance - Encourage the patient to indicate why quitting is personally relevant.Risks - Ask the patient to identify potential negative consequences of tobacco use.Rewards - Ask the patient to identify potential benefits of stopping tobacco use.Roadblocks - Ask the patient to identify barriers or impediments to quitting.
Repetition - The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.
Tobacco
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Slide37Tobacco
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Slide38Annals of
Internal Medicine, 3 May 2016
Measurements:The primary outcome measure was prolonged validated abstinence from smoking 4 weeks after quit day. The secondary outcome was prolonged, validated, 6-month abstinence.Results:At 4 weeks, 39.2% (95% CI, 34.0% to 44.4%) of the participants in the gradual-cessation group were abstinent compared with 49.0% (CI, 43.8% to 54.2%) in the abrupt-cessation group (relative risk, 0.80 [CI, 0.66 to 0.93]). At 6 months, 15.5% (CI, 12.0% to 19.7%) of the participants in the gradual-cessation group were abstinent compared with 22.0% (CI, 18.0% to 26.6%) in the abrupt-cessation group (relative risk, 0.71 [CI, 0.46 to 0.91]). Participants who preferred gradual cessation were significantly less likely to be abstinent at 4 weeks than those who preferred abrupt cessation (38.3% vs 52.2%; P = 0.007).
Conclusion
:Quitting smoking abruptly is more likely to lead to lasting abstinence than cutting down first, even for smokers who initially prefer to quit by gradual reduction.
Gradual Versus Abrupt Smoking Cessation
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Slide39The
“5 A's”
ModelAsk - Raise the subjectAdviseAssess Assist - Setting realistic goals. Developing practical strategies. Including steps to manage challenges.Arrange - Referral and follow-up
Alcohol
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Slide40SBIRT
Screening
, Brief Intervention, and Referral to TreatmentConducted in medical settings, including community health centers, and has proved successful in hospitals, specialty medical practices such as HIV/STD clinics, emergency departments, and workplace wellness programs such as Employee Assistance ProgramsAlcohol
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Slide41Screening
Typical
screening process: brief 1-3 question screenIf positive, then do a longer alcohol or drug use evaluation, using a standardized risk assessment tool (ie AUDIT, ASSIST).Brief
InterventionIntended for less severe alcohol or substance use problems
Depending on severity and risk, a 5-10 minute discussion or a longer 20-30 minute discussion
(often conducted by behavioral
health
professionals)
SBIRT: Core Components
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Slide42Brief Intervention (cont.)
Given
information about their substance use based on their risk assessment scores.Advised in clear, respectful terms to decrease or abstain from substance use.Encouraged to set goals to decrease substance use and to identify specific steps to reach those goals.Taught behavior change skills that will reduce substance use and limit negative consequences.Provided with a referral for further care, if needed.
Referral to TreatmentOften provided at specialized addiction treatment
programsHandling the referral process properly and ensuring that the patient receives the necessary care coordination and follow-up support services is critical
SBIRT: Core Components
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Slide43Reduced
healthcare costs
20% fewer emergency department visits, 33% fewer nonfatal injuries, 37% fewer hospitalizations, 46% fewer arrests and 50% fewer motor vehicle crashesDecreases severity of drug and alcohol useIn 2002, analysis of more than 360 controlled trials on alcohol use treatments found that screening and brief intervention was the single most effective treatment method of the more than 40 treatment approaches
studied.Effective in helping
people recognize and change unhealthy patterns of use.Studies have found that patients identified through screening as having unhealthy patterns of drug or alcohol use are more likely to respond to brief
intervention.
SBIRT:
Outcomes
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Slide44Keeping
track
Keep track of how much you drink. Find a way that works for you, such as a 3x5" card in your wallet, check marks on a kitchen calendar, or a personal digital assistant. If you make note of each drink before you drink it, this will help you slow down when needed. Counting and measuring Know the standard drink sizes so you can count your drinks accurately. One standard drink is 12 ounces of regular beer, 8 to 9 ounces of malt liquor, 5 ounces of table wine, or 1.5 ounces of 80-proof spirits. Measure drinks at home. Away from home, it can be hard to know the number of standard drinks in mixed drinks. To keep track, you may need to ask the server or bartender about the recipe. Setting goals
Decide how many days a week you want to drink and how many drinks you’ll have on those days. You can reduce your risk of alcohol dependence and related problems by drinking within the
limits. It’s a good idea to have some days when you don’t drink.Pacing and spacing
When you do drink, pace yourself. Sip slowly. Have no more than one drink with alcohol per hour. Alternate “drink spacers”—nonalcoholic drinks such as water, soda, or juice—with drinks containing alcohol
.
Strategies for Cutting Down
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Slide45Including
food
Don’t drink on an empty stomach. Have some food so the alcohol will be absorbed more slowly into your system. Avoiding “triggers” What triggers your urge to drink? If certain people or places make you drink even when you don’t want to, try to avoid them. If certain activities, times of day, or feelings trigger the urge, plan what you’ll do instead of drinking. If drinking at home is a problem, keep little or no alcohol there.
Planning to handle urges When an urge hits, consider these options: Remind yourself of your reasons for changing. Or talk it through with someone you trust. Or get involved with a healthy, distracting activity. Or “urge surf”—instead of fighting the feeling, accept it and ride it out, knowing that it will soon crest like a wave and pass.
Knowing your “no”
You’re likely to be offered a drink at times when you don’t want one. Have a polite, convincing “no, thanks” ready. The faster you can say no to these offers, the less likely you are to give in. If you hesitate, it allows you time to think of excuses to go along.
Strategies for Cutting Down
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Slide47Medication-Assisted
Treatment (MAT).
Medicine to treat substance use disorders in combination with counseling and behavioralMedications for Alcohol Use DisordersAcamprosate, Naltrexone, Disulfiram.Medications
for Tobacco Use DisordersNicotine replacement medications, Bupropion,
VareniclinePharmacology
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Slide48The
“5 A's”
ModelAsk - Obtain permission to address the issue of weightAdvise - Excess weight can negatively affect health.Assess - BMI, nutrition, physical activity, medical conditions, medications, readiness to changeAssist - Setting realistic goals. Developing practical strategies for weight loss. Include steps to manage challenges.Arrange - Referral and follow-up
Diet
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Slide49Developed
by the United States Department of
AgricultureMy Plate 3/29/201749
Slide50My Plate
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Slide51O
live
oil as the main source of fat, whole grain cereals, a variety of fresh vegetables (and fruits (as the main and usual dessert), frequent consumption of fish,Moderate but consistent wine consumption with mealsRelatively low amounts of red meat
High monounsaturated/saturated fat ratio and omega-3 fatty acidsE
thanol intake at moderate levelsHigh
intake of
fiber
, vitamins
, folate
, and natural antioxidantsMediterranean
Diet
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Slide52USDA Food Access Research Atlas
:
A tool for mapping food deserts and exploring access to healthy and affordable foods nationwide.http://www.ers.usda.gov/data-products/food-access-research-atlas/go-to-the-atlas.aspx#.The USDA Snap-ed:Health eating on a budgethttp://
snap.nal.usda.gov/basic-nutrition-everyone/healthy-low-cost-recipesThe Good and Cheap
cookbook:Nutritious and inexpensive
recipes
www.leannebrown.ca/cookbooks
Access to Health Foods
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Slide53SMILES
Study: Felice
Jacka and Michael Berk, Food & Mood Centre at Deakin University in Victoria, AustraliaIncrease consumption of foods in 12 food categories (whole grains, fruits, vegetables, nuts and legumes, and lean meats, chicken, and seafood) decrease consumption of foods that are correlated with a higher risk for depression: empty carbohydrates, refined starches, and highly processed
foods7.1-point difference on the Montgomery-Asberg Depression Rating Scale (MADRS) in favor of the treatment
group. 2.2-point reduction in the MADRS for every 10% adherence to the healthier dietary pattern.Eating
for brain health costs less. The average Australian spends $138 a week on food. Those
in
the study spent just $112.
Diet to Treat Depression
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Slide54Children and adolescents:
60
minutes (1 hour) or more of physical activity per day is recommended, including aerobic activity, muscle strengthening, and bone strengthening.Adults and older adults (65 years and older who are generally fit and have no limiting health conditions):150 minutes (2.5 hours) a week of moderate to vigorous activity spread out during the week for at least
10 minutes at a time, including aerobic activity and muscle strengthening. Activities
as simple as walking and gardening will provide a level of physical activity sufficient to achieve health
benefits
.
Physical Activity
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Slide55Limit Screen
Time
Under 2 years old: None2 years old: 1-2 hours of quality screen time daily3-4 years old: 1-2 hours daily but not in the bedroom5-21 years old: 2 hours non-academic dailyPhysical Activity
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