 You are here today for the third vanka, young doctor movement webinar series. The third one, lifestyle medicine, a leap towards a healthy life. I am really happy to see you all today. We have our four eminent speakers, our colleagues with us. Ketika saya mempunyai pergerakanan Spice Root, saya ingin menikmati semua anda. Wabina ini, walaupun ia adalah pergerakanan kualiti YDM yang terkenal oleh Spice Root, YDM South Asia dan Afribon, YDM Ivanka, YDM Afrika. Jadi, kakak saya, kakak Kome, akan bersama saya. Hari ini, saya ingin menikmati semua yang terkenal oleh Spice Root. Orang dari Nigeria, Abdul dari Malaysia, Hela dari Saudi Arabia, dan Marina dari Bosnia. Dan kami ada dua penerbangan, lagi-lagi, kakak kita, Loretta dan Brando. Selain itu, saya ingin menikmati semua pemeriksaan YDM dari seluruh rakyat. Kalau kami bersama kami hari ini, dan dengan itu, saya ingin menikmati anda, pemeriksaan kami, kakak kita, kepada webinar YDM yang terkenal oleh Spice Root, pergerakanan kualiti YDM yang terkenal oleh Spice Root. Kawan kawan-kawan, saya akan beritahu kisah anda sebelumnya. Ini dari Times New York tahun 2012, 24 Oktober. Ini semua tentang kakak YDM, namun Stamatis Moraitis, yang datang ke Amerika. Sebenarnya, dia menghubungi keadaan, hanya untuk mendapatkan perjalanan. Lepas itu, dia selesai di sana. Dan... ini cerita... adalah tentang sebuah hari di 1976. Saya akan menyebabkan magazine Times New York. Sebuah hari di 1976. Moraitis melakukannya. Stamatis Moraitis adalah sebuah panggilan. Dia perlu... dia perlu berhenti bekerja sepanjang hari. Setelah menghubungi keadaan, pemeriksaan kakaknya berakhir bahawa Moraitis telah menghubungi keadaan. Seperti yang dia menyebabkan, 9 orang pemeriksaan kakak yang berkenal telah mengubungi keadaan yang sama. Dan mereka beri dia 9 bulan untuk hidup. Sekarang, apa yang kau fikir dan apa yang kau fikir Moraitis akan telah dibuat? Dia akan sebenarnya duduk di sana dengan sebuah panggilan, tetapi dia memutuskan untuk kembali ke Keraia, semasa dia boleh berhenti dengan perempuan-perempuan ini di sebuah panggilan yang dihubungi oleh pemeriksaan kakak yang menghubungi keadaan. Seorang perempuan ini sebenarnya berkenal ke Keraia dan dia mahu kembali ke sana. Dia pergi ke sana. Apa yang kau fikir berlaku dengan dia? Teman-teman, ini Moraitis setelah banyak tahun pada masa keadaan 100% dia menghubungi pemeriksaan kakak keadaan. Jadi, pemeriksaan kakak mahu tahu apa yang berlaku dengan dia? Bagaimana dia fikir dia menghubungi keadaan daripada keadaan? Dan bagaimana jawapan Moraitis? Dia hanya pergi. Saya sebenarnya kembali ke Amerika sekitar 24 tahun lepas bergerak ke sini untuk melihat jika pemeriksaan boleh beritahu saya. Jadi, apa yang pemeriksaan itu? Dia beritahu saya. Pemeriksaan saya semua berlaku. Pemeriksaan saya semua berlaku. Teman-teman, pesan-pesan ada beberapa tempat lain juga seperti Kheria. Dan mereka disebut pemeriksaan kakak. Anda dapat melihat pemeriksaan kakak dalam gambar ini. Tentu saja, pemeriksaan kakak dikatakan di seluruh dunia. Saya rasa semua pemeriksaan ini mengharapkan semua pemeriksaan kita, bahkan pemeriksaan YDM juga. Jadi, apa yang pemeriksaan itu? Apa yang penting yang akan berlaku di dalam pemeriksaan ini? Pemeriksaan bluzon? Pemeriksaan kita hari ini adalah tentang itu. Saya tidak akan beritahu apa yang penting yang penting. Pemeriksaan pemeriksaan dalam pemeriksaan bluzon. Untuk beritahu itu, kita ada empat pemeriksaan eminam. Pertama, ia akan menjadi Oray. Dr. Oray Makinde adalah pemeriksaan kakak dan juga IBLM, pemeriksaan kakak dan pemeriksaan pemeriksaan daripada Nigeria. Dia juga pemeriksaan pemeriksaan Dr. Oray. Terima kasih banyak, Sankar. Terima kasih untuk mendengar pagi ini. Saya akan bercakap dengan kita tentang pemeriksaan dalam pemeriksaan dan yang dia akan makan. Ini sangat penting untuk kita faham bagaimana kita dapat mengambil pemeriksaan kakak dalam pemeriksaan kakak dan dalam pemeriksaan kakak yang kita nampak dalam pemeriksaan kakak yang saya berkongsi oleh Sankar. Jika anda bergerak, jika anda bergerak, jika anda bergerak, jika anda bergerak, jika anda bergerak, jika anda bergerak, jika anda bergerak. Jika anda bergerak. Daripada時間 rapidement itu, kita juga ingin ambil pelajaran menghormati pelajaran 그렇게 başkan. Masuk standards , pencarahan. Dan yang mereka subjected Ia dibuat oleh kompetensi leksil tahun 2018, yang adalah sebuah karikolam yang ditetapkan di sebuah kelebihan leksil leksil leksil. Ia berkata bahawa leksil leksil leksil memberikan sebuah perjalanan unik. Ia menghargainya sebuah kelebihan sebuah kelebihan leksil leksil leksil, sebuah kelebihan leksil leksil, dan menguruskan kelebihan leksil untuk memperbaiki, memperbaiki, dan memperbaiki kelebihan leksil leksil. Ia berkata bahawa sebuah kelebihan leksil leksil oleh Prof. Gary Eger, yang adalah Prof. Adjant sebuah leksil leksil. Ia berkata bahwa lebih 30 buah dan berkata bahwa lebih 1,000 leksil leksil. Ia berkata bahwa sebuah kelebihan leksil yang menghargainya sebuah kelebihan leksil untuk memperbaiki kelebihan leksil was greatest kelebihan leksil adalah prestosRelit Sebuah kelebihan leksil dan memperbaiki kelebihanleksil Dan it hara Ia berkata y addition strength path dan ia berlaku follower dan terima zain per Tomorrow dida Stress management, avoiding of risky substances as well as positive social connections as a primary modality. And this modality is delivered by clinicians who are trained and certified in the specialty. One of the things that makes lifestyle medicine very distinct is the fact that it is a primary modality. It's a soft specialty for every specialty, but it is primary. That means that is the first line of care for whoever is, it's been prescribed and these are the pillars of lifestyle medicine and we're going to be talking about each of these, not all of them really but we're going to be talking about four of them today. Going on to the next slide, let's share a bit about the history of lifestyle medicine. If you remember Hippocrates and your Hippocratic oath, there is something that Hippocrates said. He said I will remember that there is an art to medicine as well as science and that warmth, sympathy and understanding may outweigh the surgeon's knife or the chemist drug. So lifestyle medicine is distinct in the fact that it goes beyond surgery, it goes beyond the medication that we give our patients. And Hippocrates is often quoted as saying that let your food be your medicine and your medicine be your food. And that's why I'm also going to be talking about healthy eating. We have some other pioneers in lifestyle medicine. Please move on to the next slide. Thomas Edison, this is a quote that says that the doctor of the future will give no medicine, but will interest his or her patients in the care of the human frame in a proper diet and in the course and prevention of disease. So this is one of the leaps that we're taking as the doctors of the future. Next slide. These are some of the pioneers of lifestyle medicine. So it's interesting to note that lifestyle medicine has been around with us since as far back as 1970s. There was this centre known as the Nathan Pretty King Longevity Centre in which people were housed in a residential centre that used nutrition, exercise and education to treat and as well reverse lifestyle related diseases. The similar programme was developed by John MacDougal, also in the 1970s, where he also added stress reduction as one of the things to treat and reverse diseases that are lifestyle related. We have been onish. He started the Lifestyle Heart Trial within a preventive medicine research centre, also established in 1980. And it was interesting to note that the work that he did showed that there was a regression of cardiac stenosis at one year in those people who were placed on this therapeutic intervention that involved the pillars that I mentioned earlier. Similar trials and programmes have been implemented by Cardwell B Essenton, hand to DL, that's the Coronary Health Improvement Project, now known as the Complete Health Improvement Project and has been instituted in several offices and corporates as well as hospitals worldwide. We have the inaugural report by the World Health Organization. This inaugural report was on diets, nutrition and prevention of chronic disease 1990. We also have John Kelly, who was a pioneer, founder of the American College of Lifestyle Medicine. And we have the ABLM that was set up in 2015. That's the American Board of Lifestyle Medicine. And a year after the International Board of Lifestyle Medicine was set up to conduct exams so that we'll have certified and competent people who are trained to deliver the arts and the science of lifestyle medicine. Next slide please. Because the distinction in lifestyle medicine, the emphasis is on behavioural change because the body can repair itself. And I think that's what happened in the life of that man who turned 100 years even after all his doctors had died because he embarked on lifestyle changes that allow the body repair itself. And the focus is on evidence based optimal nutrition, stress management and fitness prescriptions. Patients are active partners in their care, they have to take responsibility for whatever changes they're making in their lifestyle. And another good thing about lifestyle medicine is that it treats the cost of disease. Many times we give a pill for every ear, but we don't look at what the root cause of that disease is. And we're able to educate, guide and support patients to make those behavioural changes. Medications are not excluded, but this time round they're used as an adjunct to the therapeutic lifestyle changes. And the patient's home as well as his community environment are assessed as contributing factors. Next slide please. We learn from conventional medicine where the highest level of care has to do with surgery or pharmaceuticals. And the patient is a passive recipient of care. It focuses on the symptoms and the signs of the disease and not the underlying lifestyle causes. The patient is not expected to make the behavioural changes like you see in lifestyle medicine. And the biomedical model is a usual model of approach and by the physician. We mentioned, medication are the primary therapeutic intervention. And usually the patient's home and community are not typically considered. Next slide. So just to emphasise that lifestyle medicine is different from integrative medicine. It's different from functional medicine because there might be some confusion. And even though some of these practices are evidence based and might be made use of in lifestyle medicine, they are not exactly lifestyle medicine. So integrative medicine, for example, there is a focus on acupuncture, bowel feedback, nutricity calls, as well as some lifestyle interventions which are evidence based. In functional medicine, the emphasis is on the evidence based systems, the biology approach that addresses underlying physiological and biological dysfunction. So here testing is very important. You want to know the levels of the hormones and the metabolites. And then you now make use of pharmaceuticals, biologicals and your citricles to take care of that dysfunction. Next slide. It's different from mind, body, medicine. This talks about interactions between the mind, the body in terms of behaviour, emotion, and mentally, socially and spiritually. Now these modalities include yoga, hypnosis, visual imagery, bowel feedback, tai chi, and some of these are evidence based and used in lifestyle medicine but still not exactly lifestyle medicine. Preventive medicine, which oversees the field of public health is also different. You're looking at interventions such as immunization, screening, protection from bioterrorism but it's still different from lifestyle medicine. Next slide. So what exactly is healthy eating because that's what I'm going to be putting some emphasis on today. And next slide. When you see this, what comes to your mind? We have a photo there, you have all sorts of sweets, you have fries, you have burgers. We have cakes. Some of us take these things day in, day out. They are fast food. And I've heard someone say that when you take fast food, that leads to fast deaths. And that's one of the steps we need to take. We need to change that mindset so that we can adopt primarily healthy food as one of the pillars in lifestyle medicine is healthy eating. So we see this other diagram. You have almonds, you have peas, you have broccoli, you have legumes and all, carrots and much more than this. Next slide. A lot of times I ask my patients which one do we choose between a bottle of Coca Cola and a bottle of water. And I always like telling them that well, I'm not taking a bottle of Coca Cola or even a tea drink in the last three years and they find it amazing. But this is a step towards getting healthy and living a longer life. Next slide. So healthy eating. It's primarily a predominantly whole food, plant-based diets, which consists of legumes, grains, tubas, vegetables and fruits. I often get this question, people feel that lifestyle medicine prescribes a vegetarian diet. But I'm very quick to tell everyone that no, it's not primarily vegetarian diet, even though we are putting an emphasis on a plant-based diet. But that means whatever is grown from the ground, whatever you cultivate in your farmland, it could be beans, it could be rice, it could be nyam, it could be sweet potatoes, all the different types of vegetables and fruits. But what makes a difference is that when you process these meals, when you process these foods, then you get a lot of harmful products. And that's what makes a difference. That's what leads to people developing these lifestyle-related diseases, also known as chronic non-communicable diseases like hypertension, high cholesterol levels, type 2 diabetes, osteoporosis, osteoarthritis. So the basic thing with our foods, when they are processed, is that they lead to inflammation. So we are prescribing minimally processed food for our patients. We want to make sure that the foods are less of canned foods or less of packaged foods. But you take it straight from the ground to your kitchen and you cook it and eat it. That means you need to have less of food from each trees. You have to get less of food from places where you don't have a control over what they are cooking. Avoiding free sugars or added sugars is very important. When food is processed, that's when you get the free or added sugars, which I highlighted in that diagram where you saw a lot of sweets. Minimal dairy is part of what we also encourage in lifestyle medicine, which includes the different types of meats, poultry, and eggs. But even when talking about processed meats, even far more dangerous, and when you're talking about processed meats, we mean things like sausages, bacon, jerky, ham, poultry dogs. They are known as the number one group for causing carcinogens within people, such that they are predisposed to colon cancer, stomach cancer, pancreatic cancers, as well as prostate cancers. Less of saturated and trans fat is also part of healthy eating. The fried meats also contain those carcinogens and then they have high saturated fat, which can block the blood vessels. We have oils, butter, lard, fries, industrially baked goods. All are the things that we give a negative prescription for. Portion control is also important, so you might be eating the right things for how much of it are you taking. Even our fruits should be taken in portions. One medium size of fruits, you could have up to five of that in a day but spread out and just one at a time. So a palm size of your fruits or a medium size just like my fist. Then food timing is also important. We emphasise meals that meals are taken before 7pm so that the body has enough time to digest. And there are some hormones that are released at night that are supposed to help in the metabolic processing and digestion and repair in the body. And this favours weight loss, but for people who tend to eat late, they tend to develop insulin resistance and overweight, obesity and then type 2 diabetes. Mindful eating is also important and that means getting off your devices when you're eating so that you can attain satisfaction from your food. And the cues, you'll be able to recognise the hunger cues within your system and you have less cravings for more food. Next slide. So what are the benefits of a plant-based diet? Number one, it reduces inflammation because it's high in antioxidants and several multivitamins. It reduces the risk of hypertension. It reduces the risk of diabetes. It also boosts molecular cells within the body which helps to reduce the carcinogens within the cells. It lowers the risk of cataracts and improves lung function and also slows the rate of aging. It's important for us to know that there's something in lifestyle medicine known as FP genetics. We're able to switch your genes even if you had a genetic predisposition to disease because of a family trait or a family history. But you can switch that predisposition by taking a healthy leap in your lifestyle and that would reduce mortality. Next slide. These are a few key studies that talk about the evidence behind lifestyle medicine. I mentioned the lifestyle heart trial by Onish et al in which there was cardiac regression in people who had coronary heart disease. There was a regression in the rates of the kadak stenosis just because they applied this basic lifestyle intervention which has to do with dietary change. We also have a study that was done by Norla et al which looked at the reduction in the incidence of type 2 diabetes with a lifestyle intervention. It's proven that we can actually treat and reverse type 2 diabetes with lifestyle interventions. We have the portfolio diet study by Jenkins et al. And this also is an important study. And in this study what was done was that when he looked at a diet that was high in plant-steer rolls, soy protein and fibres and almonds as well. And he compared that to a diet of people in the control group and then the people who were on statins. And at the end of the day the reduction in the rates of prostate cancer were much lower in those who were on the lifestyle intervention without a statin. We also have the geminal study. The geminal study had to do with the changes in prostate gene expression and then going into intensive nutrition and lifestyle intervention. And this also showed that we could reduce the genetic predisposition to prostate cancer just by making intentional lifestyle changes. We also had the diet fits RCT, that's a randomized control trial by Gardner et al. They looked at the effects of low fats, there's a low carbohydrate diet on 12 months with loss in overweight and overweight adults as well as the association with the genotype pattern on insulin secretion. So these are scientific studies that form the baseline for the evidence that we have in prescribing some healthy eating. So this is where I'm going to stop. I bring greetings from members of everyone all over Africa. And I want to thank you for your attention. Thank you very much. These are your references. Yeah, now we have our second speaker is Abdul Hadi in Abdul Manap. He's a lecturer in department of family medicine, UPM and excise in medicine Malaysia National Centre Family Medicine Specialist Association. Over to you, Abdul. Please to talk about being active and exercises. Thank you very much, Tanka, for that kind introduction. All right. Hi and good morning, good evening and good night to everyone. Okay, so my topic that has been given to me is in terms of physical activity. So she's something which I'm passionate about talking about. So the topic which I'm talking about is going to be let's get fit but spell as it. So that natural set is an acronym for what we use in terms of our exercise description whereby it consists of frequency, intensity, timing and even type. So, again, so I'm from the I'm a lecture with the Department of Family Medicine from UPM. And I'm also affiliated with the exercise is medicine Malaysia National Centre and the Family Medicine Specialist Association Malaysia. All right, next slide please. All right, so now let's begin the definition. So what does physical activity mean? Well, physical activity is defined by any body movement generated by the contraction of muscle that raises the energy expenditure above the rest metabolic race. So it is characterized by its modality, the frequency, the intensity, the duration and context of practice. Now the WHO, if you can look in the slide on the slide by the WHO, I recommend that the adult age between 18 to 65 is old be involved with aerobic physical activity of moderate intensity between 150 to 200 minutes. Okay, per week, whereas if you have to be engaged in vigorous intensity physical activity, it is about half of the about 75 to 150 minutes per week. The WHO also recommends that you do muscle strengthening exercises about two or more days per week, which must involve all the major muscle groups in the body. Right, so therefore, any individuals that do not need the WHO recommendations of physical activity is then defined as physical inactive. All right, so physical activity can be defined as those that represent the non achievement of the physical activity guidelines. So then there are some individuals whereby they are meeting the recommendation for the physical activity, for example the 150 minutes per week of moderate intensity, or the 75 to 150 minutes of vigorous intensity, but they can also be sedentary at the same time. So therefore sedentary does not equate, it's not the same as being physical inactivity, those two are two different things. So sedentary can be defined as any weakening behaviors characterized by an energy expenditure of less of 1.5 met, or metabolic equivalent, while in the sitting reclining or even lying costume. Okay, next slide please. Okay, so why the need to talk about physical activity? Well, globally, 23% of adults are not meeting the recommended guidelines by the ratio to be physically active. But what's more worrisome is that 81% of adolescents, those between age 11 to 17 years old, are not meeting these guidelines. So in terms of physical activity, physical inactivity sorry, the prevalence is highest among those in the high income western countries. And the prevalence is lower in the Southeast Asia and the Sub-Saharan African countries. Okay, so but if you look at the prevalence among the adolescents then, the numbers are very worrisome. The prevalence of inadequate physical activity can range between 18% in some countries to even as high as 90.6%. So it has a median range of about 80%. So something close to home Malaysia. We are seeing a reducing trend in terms of the physical inactivity among our adults whereby in 2019, about two years ago, in a study done by our National Health and Mobility Survey, there was a reduction to 25% from 35%. But despite this reduction, it is still worrisome as the prevalence of sedentary behavior in Malaysia is still relatively high whereby about one out of every four individuals are classified as sedentary. So, why could it be that the prevalence of sedentary and physical activity could be so high? Well, if you look nowadays, you know, people are engaging less and less in terms of being physical play. They are playing more game time, more twin time. And even with the recent pandemic, they are proceeding to online classes. So why is this a problem for in the future is because this can lead to an earlier presentation of comabilities. As you know, I'm pretty sure all of you have seen whereby we are seeing earlier and earlier presentations of diabetes, hypertension. You know, even heart disease in our patients whereby previously it will be like in the 50 years old, but now we are seeing it even in 30 years old. So this is worrying for us. Now, okay, so looking at this trend, so I want you guys to focus on the left, upper left hand corner whereby there's a figure shown on the physical inactivity by age group according to the WHO region. As mentioned just now, the highest prevalence of or higher proportions of physical inactivity is among the high income western countries such as America, Eastern Mediterranean and Europe. And the lower proportions are in the African countries and Southeast Asia. But if you look at the graph, I mean it all tells a similar story. As you age, the proportion of you being sedentary is getting higher and higher. So you tend to get, sorry, you tend to get to be less physically active as you age as you grow older. Now, if you look at that, there are two figures that shows here. It shows the average map or the average metabolic equivalent among those who are doing their among our occupation. And you can see as the decade go by from 1960s to 1010s, our average occupation map in the top right hand corner that is gradually declining. Okay. And if you look at the bottom right hand left hand corner, if you look at the physical activity energy expenditure among the US mothers, it is even more so, it is even more telling among those mothers who have children more than the age of five years old and less than 18 years old. It is even less physically active. All right. Next slide please. So why is this a problem? Well, physical inactivity and sedentary has been very well established that it increases the risk of developing non-communical diseases, as mentioned by the orators now. And physical inactivity is directly responsible for the global burden of many diseases in the world. Okay. For example, like coronary heart disease, type 2 diabetes, and even breast cancer. And in 2013 was estimated that the global health care related cost attributed to physical inactivity was 53 billion. Imagine that. So physical inactivity and sedentary has also been shown to increase the risk of premature mortality among patients. It has also been shown to have a significant dose response association between sitting time and all cost of all cost and severity mortality. So among those who report sitting almost all the time versus those who report sitting almost none of the time, those who report sitting almost all the time had 50% higher risk of dying from all causes of all causes of mortality and CBD. And tau and all noted that it's a hazard ratio of 1, 1.02, and 1.05 for every one hour increase in sitting between zero to three hours, between three to seven hours, and more than seven hours of daily sitting. Okay. Next slide please. Now, so we know touring. Okay, we know what's the effect it can do to us, but something can be done about it. All right. If you look in this figure here, it shows that the more hours spent being physically active in moderate to vigorous intensity of exercise of physical activity. It helps to lower your hazard ratio for cardiovascular disease mortality. And this is even more so among those whom are very sedentary or very inactive in daily life. Okay, which represents those who are inactive for more than eight hours per day. All right, or sedentary more than eight hours per day. They develop the most benefit by being by getting more and more physically active and getting it done regularly. Okay, next slide please. All right. So now, now let's talk about the differences between exercise and physical activity. In terms of exercise, okay, exercise is a subset of physical activity. All right. So exercise consists of a plan, structure and repetitive bodily movement. And when it is done, it is to improve and or maintain one or more components of your physical fitness. All right. So now if you take household chores, for example, doing household chores. Yes, it does constitute being physically active, but it is not the same as exercise. All right. Okay, moving on to the next slide. Okay, here what I want to show is are the components of fitness, right? Of physical fitness. Well, physical fitness can be divided into two different components. The health-related physical fitness component and the skill-related physical fitness component. In terms of the skill-related physical fitness component, this is more relevant to sports-related activities or exercises or it can be more related to improvement in your performance. But what I want to focus more on here is in terms of the health-related physical fitness component. All right. So when we are prescribing exercise, it will help to improve all these components here under the health-related sub-tactile here. Okay. It can improve your cardiovascular endurance. It improves your body composition such as improving your muscle mass and reducing your fat mass. It can improve your muscle strength and endurance and even helps to improve the flexibility, the range of motion available at a joint. Okay. Next slide, please. So why should we advise our patients to be more physically active? Well, I mean, if you can see here, the benefits are plentiful, from improving your cardiovascular and respiratory function to reducing your cardiovascular disease respective such as reducing arrest and blood pressure, reducing inflammation, reducing harmful cholesterol and increasing a good cholesterol. Physical activity can also reduce your mobility and mortality related to your coronary artery disease and even reduces or lower the incidence rate of certain cancers such as even colon and breast cancer. Being physically active is beneficial even for the elderly as it can improve their cognitive function, feelings of well-being and it can even help to reduce their risk of fall and even injuries from their fall. Okay. Next slide, please. So now that we know the importance of being physically active, so after knowing the why, we need to go to the how to get them started. So the how is, we can start with pre-participation screening. So what does pre-participation screening do? Well, it recognizes number one, those who requires medical clearance before participating in any form of physical activity or exercise, those who require medical supervised exercise program and lastly, those that need to be excluded from exercise until their health condition stable. All right. One such form for pre-participation screening is the 2021 physical activity readiness questionnaire for everyone. All right. It is a self-administered questionnaire and it is able to detect those that requires medical clearance and this is freely available online for everyone to use for. Okay. Moving on to the next slide. Okay. This is just to show the continuation from the 2021 SparkQ. All right. And was it answering to any, answering yes to any one of these questions would then require the patient to see their physician to get medical clearance before engaging in certain intensities of physical activity or exercise. Okay. So next one. Well, now if you look here, the American College of Sports Medicine has also released their own flowchart for exercise pre-participation health screening. All right. And this is usually used by the exercise prescribers. So what it does is it determines the level of intensity and individual can safely exercise depending, number one, on the regularity of exercising. The presence of comorbidities such as bone cardiovascular diseases, metabolic diseases or renal diseases and the presence of science systems suggested for those comorbidities of CV metabolic and renal disease. From then, it will then determine where the medical clearance is needed and lastly to what intensity can they safely exercise. Now, going to medical clearance, okay, for example, like exercise testing, it is up to the discretion of the physician whether they need to proceed or not. So if on a case-to-case basis, it's personalised. All right. All right. So if you can see this picture here of two, you know, of horn vlogging, you know, the ACSF and the United States Emergency Services Task Force has differing opinions whether need to do exercise testing prior to engaging in exercise or not. So again, it is up to the discussion of the doctors or whether or not and what do they want to proceed for their patient. Okay. Now, if you look at the next slide, why all this commotion, why all the hassle before exercising? Well, mainly it is to reduce the risk of developing sudden cardiac death during exercise, you know, or acute myocardial infarction during exercise. Now, sudden cardiac death or AMI during exercise, it commonly occurs during vigorous part of exercise and among those whom accidently. Okay. Now, this risk reduces as an individual becomes gradually more and more active. So if you can look at a slide, as the subject, you know, the sensory subject becomes gradually more and more active, their risk, their relative risk of developing acute myocardial infarction when engaging in vigorous exercise part, more and more as they engage more and more in terms of their physical activity. So for low and moderate intensity of exercise, it's in generally safe for most. All right. So what you want to do with your patient is you want to start low and you want to start and go slow and gradually you want to progress them. Okay. So remember, it's progression, not perfection. Now, if you look at the next slide, all right. Now, we reach to the next slide. So what can we do is we can start by asking. Okay. How? We start by asking them by using the physical activity vital sign or otherwise known as the P-A-V-S. All right. Now, the physical activity vital sign is very short. We only consist of two questions. If you can see in the physical activity vital sign picture there, question number one is on average how many days per week do you engage in moderate to moderate. All right. And there are examples there being given for moderate intensity and vigorous intensity. And question number two is on average how many minutes do you engage in exercise at this level and this is answered in minutes. And what you do is you take the question number one and you multiply it by question number two and you will get the minute per week and from this you can determine whether your patient are actually achieving the WHO recommendations of being physically active or not. All right. Yes, there are others, for example your GPEC your IPEC even your MAQ but the thing about the PADS compared to the others is it's very brief. Okay. The others are more for research tool based and their questions are very lengthy and the PADS is comparable to the others. Okay. It has a high validity where it can be set up to 91% of those that do not to fill the WHO recommendations. Okay. So, we will be able to estimate the risk of a disease the existence of a disease and the severity of a disease. It can also help to determine the effectiveness of a treatment and can also be used as an education tool for your patient and that's where the PADS fulfill this criteria. Okay. The PADS will be able to detect those who are inedically physically active. It can drive the importance of being physically active. And it's also as part of an initiative to inform that exercise is part of medicine, exercise is medicine. Okay. Alright. Now, if you look at the next table, yes, this table here, you can see the metabolic equivalence of physical activities. Now, this is just a table that shows the common physical activities and it is classified as light, moderate and regression sensitivity. So, according to a certain exercise for your patient, now, we can determine what exercise would be more suitable or what physical activity would be more suitable for them according to the level of fitness based on the pre-partition screening just now. Okay. Now, quickly, just to recap back in terms of the exercise description. Alright. The double-edged recommended we should do at least 150 to 200 minutes of vigorous intensity of exercise. Not to forget that you should also do muscle strengthening on that involves majority of your muscle group and should be done on two or more days of the week. Alright. And you should reduce the student three times. Okay. And it is also recommended to more than what is recommended. Okay. That means if you do more than the 200 minutes or more than 150 minutes of exercise physical activity, there are many other additional benefits, health benefits Well, okay. Now this is coming to the exercise description. So this time I'm just going to quickly run through in terms of exercise description for aerobics physical activity or exercise game. Now the F stands for frequency. So for patients it is recommended for them to exercise more than five times per day. Okay. And for the in terms of intensity for the moderate and vigorous intensity is recommended except for those who are very sedentary or very condition. For those they are recommended to go for light moderate intensity. Now in terms of the time it is recommended between 20 to 60 minutes per day of getting physically active or exercise but even for those who are sedentary and decondition even up to less than 20 minutes per day it is still very beneficial for them. Now in terms of the type it should be of the most muscle group and should be in a continuous and with me in nature. Okay. Now what's interesting is it's like it is recommended putting about 20 to 60 minutes but the thing is it's like this can be divided. Okay. So a minimum of 10 minutes per session. So if let's say on the start it's your patients with 30 minutes of exercise per day and you do not have that 30 minutes straight what you can do is you can ask them to divide it into 10 minutes of 15 minutes so you can do it during different times or 15 minutes and 15 minutes depending on them so that's the beauty of it. Okay. So again remember to start slow and go slow this is a symptom for progression as this will have to reduce your burn out soreness injury and days of being physically inactive and subsequently will improve your adherence. Okay. Moving on to the resistance training prescription. All right. Okay. So in terms of the frequency it should be trained on about 2 to 3 days per week. All right. So in terms of the what I want to focus more on here is in terms of the repetitions and in terms of the sets. Okay. So in general it should be about 2 to 4 sets. Okay. And in terms of the repetitions it depends on our objective for our patients what is it that we want to achieve with them whether we want to achieve strength and power or is it muscular endurance so let's take for the general doubt to go for strength and power it would generally about 8 to 12 repetitions but if you want to go for muscular endurance then it will be higher repetitions for about 15 to 25 reps. Okay. Now moving on to the next slide. Okay. So oh well this one I just want to show this is what we do over here in our clinic. So okay this is what we do in our clinic we have a putra with it clinic and lastly the next slide please. And the next slide. Okay. That's all. So again I would like to thank everyone for your kind attention. Thank you all. Thank you very much Abdul for that informative presentation and it was very well organized and gave a lot of information. Now we have spoke about diet that's healthy eating already done it very well and now Abdul talked about exercises that is active living. Now very important thing we are going to talk about that is reducing stress. So we have our next speaker for this that is Khela Altman from Saudi Arabia She is a family fission there and we will be talking about reducing stress another very important pillar of lifestyle medicine Over to you Helam. Ya. Greetings everyone Hopefully that you still enjoying our presentation and you still waking up. My name Khela Altman I am family fission from Saudi Arabia Thank you so much for inviting me today I will talk about how to reduce stress in our daily life. Next slide please and here's my objective I will start with stress and the unhealthy lifestyle and describe the nature of stress and to identify most common of the stress and then I will analyze how to screening tool to find the stress and the evaluating evaluated management options and then we will design how to do a basic action and relaps relaps plan Last I will define the rule how positive psychology in lifestyle Next slide please So before I will begin I will just talk a little bit about small reduction worldwide how it affects in our worldwide 70% of our primary care provider visit are related to stress and lifestyle issue In the time of stress people are less likely to do healthy habits prolonged stress can be affect neuroendocrine balance suppress the immune system and also to lead opacity in other medical disease There is a study in UK it says that individual who eat unhealthy diet show higher rate of stress and depression but with a good successful treatment it can be treated and there is one study includes 220,430 finished workers between the age of 19 to 62 and different jobs look the effect of how extra work hours can affect them for 7 years follow up they found it's increased heart rate disease and for women it's been increased the incidence of time 2 diabetes by 2 fault in another study so what is the nature of our stress the nature of our stress as you see in the left picture like one he have many external event that can cause internal event that leading an alarm inside our body so the physiological response it works what is called Sympathetic Nerve System Sympathetic Nerve System it will lead to activation and over-estimulation of the flight and fight response so what will have with time especially if someone he have pre-current stress over time over the years sometimes it will shut down all the response and will have mal-adapting coping and break down of the emotion which will affect him in his daily life next slide so the stress have a complex and many intelligent there is something modifiable factor things that we can control all and the second thing the non-modifiable factors which are as a basic genetics and political and prenatal infection the modifiable factors it's by today our talk is about nutrition the environment sedentary lifestyle smoking, heavy alcohol use and other medical diseases like hypertension, obesity, depression sleep disorder anxiety psychological problem next slide so what our rule as a physician to help our patient and client in our clinic the first thing is to screen and to diagnose significant stress to make sure what is the diagnosis the second thing is to develop an emotional wellness plan which will be clear from your side and also for the patient side and the third thing is you need to have a team member in your clinic a team member that will help you and help the patient for teaching them about self-management technique for relapse prevention plans plan this one I will discuss it further next slide please so this picture says how we select our patient and how we can screen them probably so next slide the stress scale assessment was originally created by psychological Dr. Sheldon and this test you can use it in your clinic it's between 10 item questionnaire 10 item each item have specific grades and the scoring grades if the scoring grades between 0 to 13 that means the patient he have low stress threshold and he can control his daily life but if it was from 14 to 26 that means he have moderate stress and he need more intervention from from intervention and the third one if it was higher between 27 to 40 that mean he have very high severe stress that probably will affect and already been affect his life next slide so this is the first one the first screening assessment you can do but the second most important you need to rule out any other in the lying mood disorder the most common the first thing is the depression disorder depression disorder we usually use it at a clinic with a screening test is the patient health questionnaire we usually ask two questions if it was positive both of them we will go further for the next other question years the first question is we can ask over the past two weeks have you felt down depressed and hopeless if it was positive ask the next question over the past two weeks have you felt a little interest or pleasure in doing things if the two question are positive you are going through the next other questions like it's leaving disorder any psychomotor agitation fatigue feeling worthless or excessive guilt crying concentration deficiency recurrent and also you need to screen about societal idea to make sure that you don't have any safety problem and if and usually if it was 5 and more of the symptoms are positive usually that means we don't ask the patient that he's depression and we treat him so the most having stress that this patient experiences depression depression usually we use it and treat it with treatment and other non-pharmacological treatment if the patient he's not have depressed and all of that's negative we need to screen another assessment rule next slide please the next assessment is we need to rule out an anxiety disorder an anxiety disorder we usually use jad assessment which is have two questionnaires if it was positive we going through the next questions so the first question is if it was positive ask the next question in the last two weeks how often you have not been able to stop or to control worrying if the both questions are positive you are going through the next question symptoms like do you have restlessness easily fatigue difficulty concentration irritability, muscle tension and any sleep disturbance if it was positive and 5 and more we can end over if it was more than half of the days have these symptoms for at least 6 months that means that your patient he have experience an anxiety that his affect and increase his stress in his life but if he's not have any anxiety and this patient not related to obsessive convulsive disorder or aneroxia or was traumatic syndrome disorder you rule out all of these symptoms and it's not related to substance abuse you can diagnose the patient that he have underlying as a chronic stress not related to psychological and not related to substance abuse and not related to any other problem that make him under critical stress next slide please so how we can treat our patient in the clinic and we make sure that back to their normal most of the stress what we will discuss here today for the lifestyle is non-pharmacological method pharmacological or the treatment we are not get information about it so I will focus more non-pharmacological so what we have you can see a list of things that can help our patient and also maybe you can help yourself and your beloved one to reduce their stress in their life like mindfulness exercise meditation relaxation I will explain more in the future abdominal breathing breathing technique how they can do it at home and also to teach the patient how to do expressive and creative things that he love like movement dancing playing musical instrument if they sing very well good to learn about art tai chai exercise yang dapat reduce stress serabu yang menggunakan sebuah buku yang mempunyai meditasi itu bermakna jika seseorang mencari dan untuk membantu tentang website self-help 7.1 bantuan untuk berkongsi untuk saya saya selalu berkongsi bantuan saya untuk apa-apa yang anda suka tidak perlu mempunyai sesuatu sebabnya hanya anda rasa yakin dan tidak mempunyai stress semasa anda melakukannya banyak orang terutamanya juga masa biasa ini adalah sebuah pilihan yang baik tapi terutamanya tolong beritahu seseorang beritahu seseorang jika anda mempunyai sebuah pilihan dan yang terakhir tentang aktiviti seseorang semua ini boleh menjadi bantuan dan anda boleh beritahu seseorang dan setiap seseorang seperti anda akan melihat di klik anda dan bergantung dengan seseorang mereka sangat berbeza sangat berbeza dan bergantung dengan seseorang dalam hidup mereka kemudian bagaimana untuk mempromosikan teknik pengalaman ini yang anda perlukan dan teman anda untuk membantu seseorang untuk belajar bagaimana untuk membuat dan mempercayai diri pertama untuk mempercayai seseorang yang baik seperti yang saya katakan sebelumnya satu kali, dua kali kita boleh mempercayai diri tetapi dengan keadaan yang berlaku kadang-kadang keadaan yang anda mempercayai dalam hidup anda tidak akan mempercayai seperti sebelumnya jadi anda perlu belajar dan beritahu seseorang bagaimana untuk membuat keadaan yang baik seperti mempelajari keadaan kemahiran bagaimana untuk mempelajari keadaan masalah bagaimana untuk mempelajari keadaan yang baik dan juga untuk mempercayai satu keselamatan kadang-kadang seseorang dengan keadaan dan dengan banyak keadaan dia akan mengelakkan keadaan atau mempercayai hidup anda dan juga untuk belajar bagaimana untuk mengelakkan teknik, bagaimana keadaan dalam hidup anda dan juga untuk mengelakkan orang yang akan mempunyai keadaan yang sangat keras kadang-kadang mereka akan menghormati keadaan yang negatif jadi cuba untuk melihat mereka dengan cara positif untuk dihormati keadaan yang lain untuk dihormati keadaan yang lain pada kali pertama jika anda melihat seseorang yang sedap untuk beritahu mereka apa yang harus dilakukan dan apa yang harus dihormati tetapi dengan mengelakkan biasanya seseorang menjadi sangat mengalami apa yang anda katakan dan bagaimana mereka dapat mengelakkan keadaan yang lain dan juga jika mereka mempunyai untuk menggunakan sokongan sosial kerana sokongan sosial sangat membantu dan juga anda perlu tahu untuk mengelakkan keadaan yang tidak dihormati oleh seseorang network sosial yang mempunyai fizikal atau klinik yang dapat menjadi membantu support media digital itu sangat menarik sekarang semuanya mengalami video sosial group sosial Facebook dan sebagainya sangat menarik bagaimana society kita terutamanya dengan perkara ini dapat menjadi sangat membantu dan juga anda perlu mengelakkan seseorang bagaimana untuk mengelakkan keadaan yang tidak dihormati dengan keadaan yang lain yang sebelumnya jika seseorang ada melihat keadaan dari keadaan yang lain anda boleh beritahu ada keadaan yang lain yang anda boleh melihat dari situasi itu dan tidak membantu dan mempunyai tidak membantu untuk menghormati keadaan yang tidak dihormati dan untuk dihormati dalam mode anda boleh mencari slide yang sebelumnya? tolong ini slide yang mencari berapa kesejaian untuk menghormati hubungan anda dan seseorang anda perlu mengelakkan dan menghormati keadaan yang lain dan keadaan yang baik kerana keadaan yang baik seorang seseorang itu adalah betul-betul berbeza anda perlu mengelakkan dan menghormati keadaan yang lain menghormati keadaan yang baik menghormati jika anda bersama dia atau tidak anda perlu menghormati kerana ini adalah yang hanya mencari seseorang yang akan datang jika dia tidak akan merasa bahawa anda menghormati keadaan anda dan keadaan anda ia tidak akan kembali dan juga untuk menghormati keadaan yang baik tetapi masalah yang terbaik anda perlu melindungi segala-galanya dan tidak menghormati keadaan yang lain dan yang paling penting sebagai menjalani keadaan yang paling baik yang kan tidak bisa diberikan pada klonik anda buatan yang lain ini adalah asas yang paling memilih yang boleh sangat membantu pada klonik anda nächste hadiah jadi anda perlu mengetahui sekarang yes, plan berkesan bagaimana untuk pembantu plan berkesan yang gila? jadi jika ada sokongan sosial atau orang yang dia percayakan untuk membuat plan yang dipercayai. Ini adalah penting yang paling penting, plan yang harus dipercayai. Pada masa yang tersebar, pilih pilihan pilihan pilihan yang dipercayai dan menggantikan pilihan pilihan yang dipercayai. Dan juga untuk membuat pilihan pilihan pilihan. Untuk pilihan yang lain, dia akan periksa chart dan akan melihat apa yang berlaku, apa pilihan pilihan pilihan pilihan. Dan juga, ia akan membantu kerja sebagai pilihan untuk pilihan pilihan pilihan. Dan selalu beritahu pilihan pilihan pilihan pilihan yang dipercayai. Ia adalah perkara yang hebat. Dan anda perlu beritahu pilihan pilihan yang dipercayai. Ia akan berlaku, dipercayai dengan pilihan pilihan. Ia bukan akhir hidup. Semuanya akan berjalan dengan baik. Mungkin wang pertama ia tidakkan berjumpa, tapi wang kedua dan wang ketiga selalu ialah. Baru kemudian, saya akan beritahu bagaimana untuk membuat pilihan pilihan pilihan yang sangat spesif kepada sounds. Jadi anda dapat idea awal yang saya menyebut sebelumnya. Jadi perkara pertama, untuk setiap pilihan spesifik. Apa khabar yang mengudahkan pasukan yang akan dipercayai di mana hidup-hidup yang berubah untuk pesakit. Bagaimana komitmen, timbulan dan follow-up? Siapa yang akan menggunakan ini? Dan siapa yang akan melihat pesakit? Seperti ada contoh yang berlainan. Pertama, pilihan pertama saya mempunyai perjalanan emosi, perjalanan yang pesakit berlainan. Untuk memperbaiki emosi, bermula dengan perjalanan. Bagaimana perjalanan yang dapat dipercayai? Seperti menulis, perjalanan, perjalanan, dan anda perlu melakukannya dalam perjalanan yang berlainan. Satu kali, tiga kali, atau dua kali perjalanan, anda perlu mempunyai perjalanan. Seperti 20 menit, 1 jam, 1.5 jam, anda perlu memperbaiki pesakit kerana lebih memperbaiki perjalanan yang lebih baik untuk anda dan untuk pesakit anda. Dan juga anda perlu memastikan bahawa anda mempunyai sistem perjalanan. Sekarang, suami saya akan berjalan dengan saya dan memperbaiki saya berlainan. Dan kami akan memperbaiki dua minggu dengan telefon atau dengan perjalanan di klinik tentang bagaimana berlainan dan bagaimana berlainan. Semoga ini bersih untuk membuat plan perjalanan. Lalu, sebelum anda beritahu pesakit, anda perlu mempunyai plan perjalanan yang berlainan. Seperti yang saya katakan, itu berlainan, tidak masalah. Bersihkan pesakit untuk pesakit pada masa atau keadaan keluarga. Ia seperti spekulasi tentang apa yang akan berlainan apabila apa yang akan berlainan, apa yang dia akan lakukan. Dia atau dia akan lakukan. Untuk memutuskan masa untuk berkata dan apa yang berlainan untuk berlainan dalam perjalanan. Dan juga untuk memperbaiki keluarga atau kawan atau orang yang berlainan atau yang berlainan dengan hidup berlainan dan keadaan keluarga. Yang paling penting, jika anda berkongsi dengan orang dalam perjalanan sosial lebih baik lebih baik dan juga anda boleh belajar daripada teknik lain atau mungkin kadang-kadang anda menghargai sesuatu dan itu tidak mengalami. So, setelah anda selesai, anda akan melihat apa yang akan berlainan. Selanjutnya, tolonglah. Ada dua perjalanan yang saya perlu bercakap dengan anda sebelum saya selesai. Sesuatu yang dipanggil adalah psikologi positif. Psikologi positif adalah sebahagian perjalanan yang berlainan dan komuniti yang berlainan. Apa itu bermakna? Itu bermakna ia untuk menguruskan bahagia tetapi tidak mengelakkan bahagia. Ia bermakna anda perlu mengalami komitmen. Anda perlu mempunyai pengalaman dengan masa depan dan berlainan dan juga untuk berharga untuk masa depan. Dan apa yang saya berkongsi adalah bahagian perlu fokus pada kuasa ini untuk mempunyai integriti dan koreasiti. Ia bukan mempunyai perjalanan tapi ia adalah sebuah hidup. Ini bagaimana berlainan. Berlainan berlainan, berlainan untuk orang lain, bahagian untuk perkara yang kecil atau masa yang menikmati. Ia berlainan sepanjang hari. Dan juga, jika beberapa orang suka berlainan, jika mereka berlainan akan membantu mereka untuk mengelakkan perkaraan. Ia sangat bagus. Berlainan berlainan berlainan. Kadang-kadang orang akan mendengar perkaraan. Mereka berlainan tetapi dengan berlainan, semuanya akan lebih mudah. Dan juga, hidup untuk hidup akan lebih baik. Boleh saya mempunyai hidup berlainan? Lainan lain adalah mindfulness. Mindfulness adalah sebuah cara memasang situasi yang berlainan. Mereka membuat potensi untuk berlainan sepanjang hari. Mereka bermakna memperkenalkan hubungan dengan minda dan sebuah kawasan dan membantu membuat perjalanan. Membuat perjalanan sepanjang hari dan stres. Dan kekerjaan sebuah situasi. Maksudnya, sebuah kawasan dan stres yang membuat anda berfikir lebih baik untuk mempunyai hidup berlainan sepanjang hari dan stres. Bukan fokus atau memperkenalkan atau membuat sesuatu yang lain atau membuat sesuatu yang lain. Seperti sebuah cara membuat perjalanan sepanjang hari untuk berlainan dan membuat perjalanan sepanjang hari dan membuat anda lebih baik. Ini maksud saya. Dan kemudian kemudian kemudian, kemudian sebelum saya bercakap tentang kemudian, kemudian, kemudian kemudian, kemudian tepung dan kehidupan untuk menghadap kerasaan panjang. Anda mendapat bahagian terbaik. Bukan sepanjang hari sepanjang hari tapi anda sedang sering di sini. You need to be thinking for your future and to have savoring the moment and to build for your future. And just remember that positive emotion increase life satisfaction and this last satisfaction increase the will being. Resilience, building the resilience and also to increase the well being. Next slide. So this is a website that idea about the positive ratio.com is to check how's your positive to negative emotion ratio and it's measure how you really resilience to your life's daily life. It's very helpful to see are you flexible in your life or it's very difficult to overcome the obstacles. It usually have a lot of questions you can submit it through this website and they will show you how much you are struggling or you are kind of overcome the obstacles. You can try it after the course it's very interesting and very nice and you can use it by yourself or your others or even your clinic to try it at free time. So the next slide. The next slide is the last slide about able to website to mindful based stress reduction programs both of them very good. One of them stress and mindfulness and how to think and how to do reduce stress to you and your patient. Both the programs usually have nine classes over eight weeks usually have a lot of lectures online practicing participation is very beneficial if you are planning to open your clinic for lifestyle stress management. You can check it later and hopefully that you had very beneficial. Next slide. In the end, stay curious please. This is your life. Don't be judgmental for anyone. An open minded for a great life. Hopefully you are enjoying my presentation and have a stress life list. Thank you. If you have any question just put it in Q&A and so I will be very happy to answer any question. Thank you. Thank you very much Hela for that comprehensive presentation and many resources as well. As we are running short of time, we will just move to the next speaker. We have Marina Jotik Ivanovich from Bosnia and Herzegovina. She is family efficient and Marina I want to you straight up you can start. Thank you, Sanja. I see we do not have much time for the presentation so we can start. Next slide please. So a little bit of history we all know that tobacco came to Europe from the new world after Christopher Columbus discovered it. Next please. Next slide. And as you can see the first farm was in Santo Domingo in 1531 and the first tobacco vending machine was created in 1610. Next please. Before we need to know and ask ourselves why people actually smoke. There are many reasons like addiction, everyone does it social activity after a meal stress relief when having coffee or tea emotional support bonding and acceptance. Next please. Also we have to distinguish two things what is nicotine dependence and what is tobacco use. Tobacco use includes the intake of tobacco smoke from cigarettes, cigars, pipes and hooks, either by the individual smoking or oral absorption of the nicotine. And cigarette smoking is the most common for other tobacco products include water pipe, tobacco various smokeless tobacco products, cigarettes, etc. We also know that tobacco consists of more than 4000 very harmful substances and one of them is nicotine and nicotine is the one to blame for the dependence and for that nicotine dependence occurs when you need a nicotine and you cannot stop using it using it. Next slide please. Nicotine acts as a nicotine cholinergic receptors triggering the release of neurotransmitters that produce psychoactive effects that are rewarding. Next please. As you can see ICD10 classification classifies nicotine dependence in mental and behavioral disorders due to psychoactive substance use. Next please. So tobacco in numbers. If we can see the WHO report we see that 8 million deaths are caused by tobacco every year. And 1 million deaths is due to second hand smoke exposure. Of deaths also tobacco threatens the poverty and around 226 million people globally are poor because they use tobacco and in low income countries sometimes more than 10% of household income spend on tobacco. Next slide please. Also this is a chart for WHO where we can see the prevalence of tobacco smoking among persons age 15 years and older. It is a report from 2015. As we can see the prevalence is higher in the part of Russia in the part of South America also in Asian countries but there are some countries like most countries in Africa that is very low. Next please. Tobacco and smoking affects most of the organs and it is related to various cancers, heart attack and heart disease, stroke, COPD and also miscarriages, premature births, atherosclerosis and high blood pressure. Next please. So what is our goal? Our goal is to help our patients to quit using tobacco or to quit smoking. We have to persuade them that they can quit smoking and to show them steps and to give them support during this period. Next please. What are the actual health benefits of smoking cessation? There are long term and immediate benefits. Immediate benefit is that within 20 minutes your heart rate and blood pressure will drop. But if we look in the long term health benefits we see that after 5 years your stroke risk will reduce to death of a non-smoker. 10 years after your risk of lung cancer falls to about half death of a smoker and your risk of cancers of mouth, throat, esophagus, bladder, cervix and pancreas also decreases. And 15 years after quit smoking the risk from heart and coronary disease is like the non-smokers. Next one. Next please so we can move. All adults should be screened routinely for tobacco use and all smokers should be encouraged to quit at every clinical contact. Also motivational interventions should be used with patients who are not yet ready to quit smoking. Next one please. Motivational advising we usually use 5R strategy of motivating patient. Components are relevant. We encourage the patients to identify reasons to stop smoking that are personally relevant. Risk advise the patient of the harmful effects of continued smoking both for the patient and for the others. Rewards ask the patient to identify the benefits of smoking cessation. Roadblocks explore what barriers to cessation that the patient may encounter. RIP include aspects of the 5Rs in each clinical contact with unmotivating smokers. Next what we should never do. Lecturing, confronting patient and threatening him. Next. I saw in one webinar that was in collaboration of ELMO and ENSP and tobacco and e-cigarettes consumption through lifestyle interventions. There is a link I put that you can see and here it clearly states that there are three things involved in the process. It is a patient, it is an expert and it is a coach. The question is who is the patient and who is the expert and who is the coach. The patient is always the expert of his own life in the office and how he implements the treatment. And the doctor ourselves we are the coaches. We have to understand the patient, his needs, his view on the situation and we have to show empathy. We have to accept their wishes, their ideas and we have to accept their personal choices. Next one please. We also need to know where is our patient today. And for that we use the trans theoretical model of change. That is prohaska deployment model. That is consisted of four phases. Phase of pre-contemplation, phase of contemplation, phase of preparation of action and of maintenance. In every of these phases we have to have a motivation of intervention. In the phase of pre-contemplation, our patient isn't ready to quit smoking. And here we devote like three to five minutes just to give the patient some basic advices about that he should quit smoking. But the decision we leave to the patient. In the contemplation phase, in this phase the person thinks of quitting the smoking and it is ideal to discuss what are the benefits of quitting and what are the disadvantages of smoking. But also in this phase the patient is left with the decision. In the phase of preparation, here the smoker has decided that he will quit smoking. So in this phase the consultation that we give must be the longest. And usually it lasts 20 to 30 minutes. And in this phase we advise the patient about some specific information about the possible obstacles that he might find during the phase of cessation about withdrawal syndrome, about changes of behavior, etc. And it is the best that the patient in this phase declares the exact time and date when he will quit the smoking. It is the best that happens in the next two to four weeks. And it is advised that a day before that date, the patient gets rid of anything that might look and drive him to smoke. He should throw out all the cigarettes, the likers, everything. And also he needs to tell his family, his friends, his co-workers about the decision that he wants to quit smoking. And to find some member of the family or friend who will be the person to support him. So it is the best idea that in this phase we give consultations like two to six consultations, minimal tool. In the phase of action, the patient has stopped smoking and we here consult and arrange a follow-up by the patient needs. Also, it is very important to stay in the phase of maintenance. And in this phase, we should congratulate the patient and we should support him to stay like that. But in every of these phases, the relapses may occur. If the relapse occurs, we should not judge the patient. We should not confront him. We need to along with the patient to describe what were the motives, what were the circumstances of that relapse. And to identify them and to encourage our patient to continue in the process of smoking secession. Next slide, please. Also, there is a 5A counseling strategy that is used by American guideline. Ask, advise, assess, assist and arrange. And it is been developed to allow physicians to incorporate smoking secession counseling into busy clinical practices. Like ask, you ask the patient if he smokes and you enter these data in his electronical chart. Advise, you advise him that he should stop smoking. Assess, you assess the motivation of that smoker if he is willing to quit or not. And you will get the motivation interview. Assist, you will help him make a plan for this decision and arrange a follow-up. You will follow the smoker in the shorter period that you have to. Next slide, please. Challenges that we might face on this road are many. For the patient, it is the time after awakening, stress situation, urge for smoke, friends and families and relatives that smoke. Next slide, please. The challenges for us as health professionals may be re-positioning of health promotion and disease prevention activities in national public health. Strong lobbying from tobacco and alcohol industry. Lack of time during regular visits. That is the most common challenge. Lack of training for smoking and alcohol cessation activities. Although we have the guidelines, we have all we need, but we need to know how to implement them in practice. Next slide, please. Also, we have to give other healthy advices like that person should start eating healthy and regularly. We have talked about this during this webinar. Also, physical activity. Also, choose water first and other beverage, etc. Next slide, please. VHO has created an online platform for help quitting tobacco use. And it's called Meet Florence. She can help you quit tobacco. There is also a link to this platform. But what we need to worry and what our new goals should be is how to prevent young people, kids to go in this circle of tobacco use. This new goal is also a goal of tobacco industry and they target the young ones. But we need to find ways to help the young ones not to go in that trap. And we have to let the secret out. Next slide. What are the ways that tobacco industry uses to target new generations? By direct advertising, by indirect advertising, by promotion of tobacco products at popular events for young people. They do sponsorship like major sporting events and teams that includes their logos. Also, they sponsor like concerts and some other events. And also they make like flavors for new tobacco products. Next slide, please. What is the key strategy and measures that we need to take? We have to stay that second hand smoke also kills. We have to do pictorial health warnings. We have to ban on tobacco advertising. We have to raise the taxes on tobacco. And we need to help people quit tobacco. Next slide, please. One of the responses came from WHO. It is six empower measures to monitor tobacco use and prevention policies to protect people from tobacco use, offer help to quit tobacco use, warn about the dangers of tobacco, and force bans on tobacco advertising and promotion and sponsorship. Next slide, please. And as we can see, tobacco concerns us all, individuals, families, communities, states. So we all need to act with one goal to quit tobacco and tobacco use. Thank you all for listening. I want to thank Wonka Young Doctors Movement. I want to thank Spice Road, everyone. And also, I want to thank Rida Jem for choosing me. And I want to thank my colleague, Austin Gogdemir, and she helped me with this presentation. Thank you very much. Thank you very much, Marina. That was excellent. Thank you so much. We would invite a few questions. We were short of time by a few minutes. So if anyone has any question, can you please unmute your mic and then share? Any question? We've also provided opportunity for you to enter your questions either in the chat box or in the Q&A box. Some of the questions have been responded to. So we'll just give ourselves a few seconds if anyone has any question. You can raise your hand or you unmute and then ask your question. Resource persons are available to respond. Right. There was one question in the Q&A box. I think that was to Orey about which kind of oil is considered healthy oil. Orey, can you respond? Is there any oil, any kind of oil that we consider as healthy oil? Terima kasih, Kwame. Saya cuba menjawab itu di Q&A. Apa yang berlaku adalah banyak oil yang kita ada akan datang kembali apabila kita memasukkan mereka untuk memasukkan tempatan. Jadi kita boleh menggunakan sedikit oil jika kita mempunyai sedikit oil dalam makanan kita. Itu boleh datang dari kanula oil. Ia boleh datang dari oliv oil. Ia boleh datang dari penut oil. Sissime oil. Ia adalah sesuatu yang bagus. Tapi apabila kita memasukkan mereka pada tempatan yang sederhana, kita akan mulakan untuk mendapat produk bahagian yang bahagian. Terima kasih banyak. Saya telah menerima komentar di Q&A box dan semua orang sangat gembira dengan webinar ini. Komentar seperti ini. Ia sangat menarik. Ia sederhana. Saya tidak boleh menerima lebih kurang. Dalam jangcha ini, saya mahu berterima kasih kepada kakak Sanka dengan yang semua orang telah memasukkan webinar ini. Saya sangat gembira untuk Haris dan sekolah kakak-sekretariat untuk memasukkan platform UZOOM untuk kami berkongsi. Terutama saya mahu berterima kasih untuk interpretasi yang hebat. Mereka telah sibuk selamanya. Terima kasih banyak untuk kerja yang hebat. Sekarang ke panelist kami, Orey dari Nigeria, kami sangat gembira. Abdul, terima kasih. Terima kasih, Hella. Terima kasih, Marina. Dan Osten juga telah berada di belakang. Saya juga mahu berterima terima kasih dari Raja Kuma, dari Vasco da Gamma, dari Spice Route. Semua orang. Kamu semua bersama dalam sesi ini untuk membuatnya berjaya. Apabila saya periksa, kita telah mempunyai 100 orang. Dan itu sangat menarik. Jadi, mari kita kembali dan tinggalkan kembali. Biar kita membantu klien-klien untuk hidup kembali. Kita berharap bahawa pelajaran yang kita belajar hari ini akan berkongsi dengan kami dan juga akan berkongsi dengan kami. Terima kasih banyak-banyak. Terima kasih. Terima kasih. Selamat tinggal.