Health Promotion and Disease Prevention: Considerations and Interventions

Health promotion and disease prevention strategies for a healthy neurological system need to be appropriate for each specific individual, so you should carefully consider all collected data, both subjective and objective. Subjective data collection involves asking the client about risk factors, social determinants, and other considerations. This kind of inquiry should be integrated throughout the entire assessment. You will ask many probing questions during the subjective assessment, but also formulate additional questions based on critical reflection of the data you have collected during the subjective and objective assessment. Together, the findings will inform your clinical judgement for each specific client and the health promotion needed.

Healthy Blood Pressure and Weight

High blood pressure and obesity are linked to cardiovascular-related illnesses that can cause neurological problems. For example, clients should monitor their weight and blood pressure to decrease the risk of stroke and other common problems associated with the neurological system such as cerebral aneurysms.

Probing questions may include:

• Have you ever been diagnosed with high blood pressure?
• When was the last time you had your blood pressure taken?
• Do you know what your blood pressure normally is?
• Have you had any recent changes in your weight?
• Do you have any concerns about your weight?

In collaboration with the client, discuss an approach to maintaining a healthy blood pressure and weight. Many interventions related to healthy eating, activity/exercise, and stress management can help facilitate a healthy blood pressure and weight. Discuss with the client any factors that might affect their ability to eat a healthy diet, exercise, and manage any stress. Nurses can also advocate on behalf of clients and take actions to develop and advance equitable healthy public policies.

Diet

Diets that are high in saturated and trans fats, cholesterol, sodium, sugar, and those low in fibre are risk factors that contribute to atherosclerosis and diabetes. This kind of diet is a risk factor related to other neurological-related conditions such as Parkinson’s and dementia.

Probing questions related to diet include:

• Tell me about your usual diet?
• What have you eaten in the last 24 hours? Is that your usual diet?
• Have you had any recent changes in your life that have affected your diet?
• Do you add sugar and salt to your food?
• How much fluid do you typically drink in a day? What fluids (e.g., water, caffeinated beverages, alcohol)?

You may want to assess a client’s familiarity with Health Canada’s (2019) Food Guide and discuss with them how to use it. Be aware that this new version of the food guide still has a Eurocentric bias, so it is best to collaborate with the client about its relevance in the context of their cultural food practices. The Food Guide is now offered in multiple languages that you can refer clients to, and many resources are available about food safety for Indigenous peoples.

Some key elements of Canada’s Food Guide are:

• Be mindful of eating patterns.
• Choose water as the drink of choice.
• A dinner plate should be one-half vegetables/fruit, one-quarter protein, and one-quarter whole grains.
• Make time to enjoy eating meals with others.
• Cook when possible, as opposed to eating processed meals or purchasing fast foods.
• Reduce sodium, saturated and trans fats, and sugar, and monitor portion sizes.

Canada’s guidelines now suggest that there are health risks associated with any level of alcohol consumption, although negligible with two drinks or less weekly (Paradis et al., 2022). Although some previous research had suggested some positive benefits to alcohol, this is now being disputed: new findings indicate that drinking alcohol of any kind does not decrease risks of heart disease, and high levels of consumption increase the risk for coronary artery disease, myocardial infarction, heart failure, hypertension, and stroke (Paradis et al., 2022).

Many types of diets can be heart healthy, but some research points especially to the benefits of the Mediterranean and DASH diets. The American Heart Association (2020) recommends the Mediterranean diet as heart healthy: it includes plenty of fruits and vegetables, grains, potatoes, legumes, nuts and seeds, and olive oil, along with small amounts of dairy, eggs, fish, and poultry. The Heart and Stroke Foundation of Canada (n.d.) recommends the DASH (Dietary Approaches to Stopping Hypertension) diet as heart healthy and helpful to lower blood pressure: it is rich in vegetables, fruit, and low-fat dairy foods, and lower in saturated fat, total fat, and cholesterol. The two diets are very similar and may be used in combination; the Mediterranean diet typically emphasizes more fish and less dairy products than the DASH diet.

Healthy eating involves behavioural actions but also relational and structural actions. First, individuals need access to healthy food and the financial capacity to purchase it; this is referred to as food security. The rising cost of food globally has made this a challenge, and in many remote regions of Canada’s North, access to nutritious food is limited in terms of availability; even when available, the costs are excessive.

Socioeconomic status is known to affect food purchasing: individuals from socioeconomically disadvantaged communities – those with lower household income – purchase fewer healthy foods like fruits and vegetables (Turrell et al., 2002). This can be due to the high cost of food and living in areas that are considered a food desert. Therefore, health promotion efforts should focus on narrowing socioeconomic differences in food purchasing. As a nurse, you should work in partnership with disadvantaged individuals and tailor a health promotion approach to their particular needs and attend to structural and economic barriers (Turrell et al., 2002). For example, you could direct clients to organizations that partner with vulnerable communities to support access to healthy foods, skill development, and capacity-building in terms of community-led initiatives (Turrell et al., 2002). You could also advocate on behalf of these communities for more effective social policy to address food insecurity (Turrell et al., 2002). The Government of Canada provides tips on Healthy eating on a budget.

Activity and Exercise

A sedentary lifestyle with limited activity and exercise is another risk factor that contributes to cardiovascular disease, diabetes, and other common problems associated with the neurological system including neurodegenerative diseases.

Probing questions related to activity are:

• Do you have any concerns about your level of activity?
• Tell me about your daily pattern of activity? What activity are you involved in?
• What exercise do you engage in? How long do you do this type of exercise? How many days a week do you exercise? If a client plays sports, ask about their use of protective equipment.

You can collaborate with clients to create an activity/exercise care plan that is specific to their needs and goals. Assess the client’s symptoms (e.g., paresis, balance, incoordination) to maintain optimal client safety during activity/exercises. Start at a realistic and attainable level, depending on physical capability, energy level, and health status. Many interventions are available to support clients to achieve their activity goals: community walking groups, fitness apps, local gyms, and group activities. Additionally, it may be worthwhile to refer clients to physiotherapy and occupational therapy. The participACTION website is a helpful resource for activity guidelines.

Nurses should use a relational health promotion approach when addressing activity. A community of support can promote activity, so you should assess the client’s access to support (e.g., friends, family, acquaintances) who may have similar activity interests or goals. A structural approach to health promotion can also help address and eliminate inequities. For example, some clients may not be able to afford gym memberships or sports registration fees. They may have little time to exercise due to the need to work multiple jobs. Additionally, those in urban areas may have more access to specific activities or rehabilitation programs than those living in rural or remote regions such as Northern regions of Canada. You will need to consider these factors and tailor activity programming to each client. For example, some clients who use public transportation could get off one or more stops early and walk the rest; this might be reasonable for some clients, but you also need to consider issues that might inhibit this such as safey. You could also advocate for policies to address inequities.

Stress

Stress is subjective and can have emotional, physical, mental, social, and financial effects. It is a risk factor for neurological-related illness and can exacerbate symptoms. Stress is usually caused by a combination of multiple stressors. How a person talks about themselves, their life, and their situation can indicate potential concerns and areas that need further assessment.

Probing questions related to stress could include:

• Tell me about the stress in your life?
• Have you experienced stress recently? Physically? Emotionally?
• Have you had any recent changes in your life? (Tell me more?)
• How does stress affect you?
• How do you handle this stress?
• Tell me about the coping strategies you use?

Stress management and coping strategies may include:

• Regular physical activity.
• Getting adequate sleep.
• Spending time with family and friends.
• Taking time for personal interests and hobbies.
• Practicing relaxation techniques such as meditation, deep breathing exercises, and tai chi.

From a relational and structural health promotion perspective, it is important to be aware that stress does not exist in a vacuum: how it is experienced, perceived, and managed is affected by relationships with others. All clients experience stress sometimes, but structural factors influence whether a client is more at risk for stress or able to manage stress. For example, racism is a major determinant that can lead to highly stressful experiences. Apply an anti-racist approach to stress and stress management to understand how the client is being influenced by racism and microaggressions, and how best to support them. Socioeconomic status can also influence a person’s access to resources to cope with stress. When collaborating with clients to develop stress management techniques, you must be aware of these larger structural influences.

Alcohol

Alcohol can affect the neurological system because it can increase the risk for many neurological-related problems. For example, alcohol use can be associated with diabetes, cardiovascular health (e.g., cerebral aneurysms), seizures, movement disorders, dementia, cancers, cause inflammation, and increase the risk for injury and infections. The most recent Canadian guidelines now suggest that there are health risks associated with any level of alcohol consumption, although negligible with two drinks or less weekly (Paradis et al., 2022). Alcohol is considered a carcinogen and can affect the arteries (Paradis et al., 2022).

Reflect on your own biases about alcohol. The use of these substances can be stigmatized, so self-reflection is crucial to help facilitate a non-judgmental approach to care.

Probing questions may include:

• Tell me about how much alcohol you consume in a day? If the client does not consume alcohol daily, you can assess consumption based on weekly, monthly, or none. If the client’s answer is affirmative, ask probing questions such as: How much (e.g., ounces a day)? What type of alcohol (e.g., red wine, beer)? For how long have you been drinking? Can you tell me the reasons that you began drinking?
• If you do not currently consume alcohol, have you ever? If affirmative, ask similar probing questions, including why the client quit.

The liver is the main organ that processes alcohol, and heavy drinking over a long period can damage the liver and lead to cirrhosis. The liver processes many medications, so a damaged liver can affect how medications are absorbed and their effects. Overall, the key is to abstain or consume limited amounts of alcohol.

Smoking Tobacco and Vaping

Smoking tobacco and vaping are major risk factors that can affect health.

The chemicals in tobacco cause inflammation of the blood vessels and contribute to plaque buildup and narrowing of the blood vessels. Smoking is a common risk factor for problems associated with the neurological system such as stroke, cerebral aneurysm, and seizures.

Vaping involves the inhalation of heated aerosols from a vaping device (e.g., electronic cigarettes, vape pens); the aerosols frequently contain nicotine (Miech et al., 2019). Although vaping aerosols may contain less chemicals than cigarettes, many toxins in vaping can cause lung damage among other health problems (Park et al., 2021). The long-term health effects of vaping are still being determined.

Probing questions related to smoking and vaping tobacco-related products include:

• Do you smoke (or vape) cigarettes or any tobacco-related products? If the answer is affirmative, ask probing questions: how much do you smoke or vape (e.g., how many packs of cigarettes a day)? For how many years? Can you tell me about the reasons that you began smoking or vaping?
• If you do not currently smoke (or vape), have you ever? If the answer is affirmative, ask similar probing questions, including why the client quit.
• If relevant: Have you ever tried quitting? If the answer is affirmative, ask probing questions: What made you want to quit? How long did you quit for? Did you use any strategies to help you quit?
• If relevant: Have you ever thought of quitting? If the answer is negative, respond in a non-judgmental way: “If you ever want to discuss quitting let me know; there are many resources to help you.”

Client interest in quitting smoking/vaping and collaborative intervention are both important for a successful outcome. Interventions must be tailored to each client; many options are available: counselling, cognitive-behavioural therapy, support groups, pharmacology treatments (e.g., nicotine replacement therapy), smartphone applications, and short text message services. Sometimes even a brief discussion about the risks and a recommendation to quit smoking or vaping is sufficient.

You should consider both relational and structural health promotion approaches related to smoking and vaping tobacco-related products. For example, a client’s success in cessation can be affected by their intimate and physically close relationships with family, friends, and work colleagues. Another issue to consider is that access to smoking or vaping cessation resources can be costly and are not necessarily covered by provinces and territories. Many primary care clinics may offer group support, counselling, and access to nicotine replacement at no charge, so it can be helpful to encourage clients to access these resources. You may also advocate for healthy social policy around smoking and vaping cessation and support and participate in the development of educational campaigns and resources about how smoking affects health.

Cannabis

Cannabis can have positive and negative effects on the neurological system (Miller et al., 2027; Newton & Newton, 2020). Some research has reported that cannabidiol (CBD) oral solution can be used effectively to help control seizures (Miller et al., 2020; Newton & Newton, 2020), although Health Canada’s external Science Advisory Committee has recommended more research (Government of Canada, 2022). Cannabis can affect a person’s cognition, cause drowsiness, fatigue, dizziness, headaches, impair balance, and lead to dry mouth/eyes (Government of Canada, 2022; Newton & Newton, 2020). When cannabis is used as a treatment, it should be approved by Health Canada and followed according to standards (Government of Canada, 2020). In addition, clients should discuss cannabis use with their primary healthcare provider prior to consuming.

Probing questions related to cannabis could include:

• Do you smoke, vape, or ingest cannabis? If affirmative, ask similar probing questions as noted above in the section on smoking. Also ask if it is medically prescribed or recreational.
• If you do not currently consume cannabis, have you ever? If affirmative, you can ask similar probing questions as above, including the reason that the client quit.
• Have you had an allergic reaction to cannabis? If affirmative, ask probing questions such as: What is the reaction? When did it start? How do you treat it?

Health promotion education should focus on each client’s lifestyle and reasons for consuming cannabis. ​​Interventions related to using safely or quitting the consumption should be tailored to each client and could include counselling, cognitive-behavioural therapy, and support groups. You should also consider the relational promotion approach: for example, a client’s consumption can be influenced by their surrounding environment (e.g., family, friends, workplace).

If the client is interested in using medical cannabis, your role as a nurse is to understand their interest and guide them to find appropriate learning resources. You can also advocate for educational resources about medical cannabis if a client’s healthcare setting or community lacks resources or support. Additionally, your practice as a nurse should be informed by any legislation or regulatory bodies in your region. In Canada, refer to the Cannabis Act and in Ontario, refer to the CNO Scope of Practice standard and CNO Medication practice standard: see additional information.

Sleep

Adequate sleep is important for restoration of the body and mind: 6–8 hours is usually considered adequate sleep. Pulse and blood pressure lower during deep sleep, known as non-rapid eye movement, which is important for neurological health. Lack of sleep quality and quantity has been linked to illnesses such as hypertension, obesity, myocardial infarction, stroke, seizures, dementia, and migraines.

Probing questions related to sleep include:

• How much sleep do you get each day/night? How many hours? Do you rest during the day?
• Do you have any concerns about your sleep?
• Tell me about your sleep routine? What do you do before you go to bed? Do you take any medications to help you sleep?
• Do you wake up during the night? If so, why? Are you able to fall back to sleep?
• Do you feel rested when you wake up?

One behavioural intervention is a sleep journal. Ask the client to record how much sleep they get. If less than recommended, address potential triggers that may be disrupting the client’s sleep, such as stress or pain. Limiting screen time two hours prior to bedtime can also be helpful. You may also discuss the possibility of naps with the client.

The physical and social environment affects sleep. Siengsukon (2020) reported that sleep may be affected by factors including:

• Living in an unsafe or noisy neighbourhood or home.
• Not having access to private transportation and needing to get up early to commute via public transportation.
• Living in congregate or multigenerational housing, which might mean that clients share bedrooms or beds.
• Being a caregiver for a child, spouse, or parent, or living with someone who works long hours or shift work.

Note that many of these physical and social factors influencing sleep are associated with race, ethnicity, and socioeconomic status (Siengsukon, 2020).

References

American Heart Association (2020). What is the Mediterranean diet? https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/mediterranean-diet

CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. https://www.nicotinedependenceclinic.com/en/canadaptt/PublishingImages/Pages/CAN-ADAPTT-Guidelines/CAN-ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf

Government of Canada. (2022). Review of cannabidiol: Report of the Science Advisory Committee on Health Products Containing Cannabis. https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/health-products-containing-cannabis/review-cannabidiol-health-products-containing-cannabis.html

Government of Canada. (2020). Cannabidiol (CBD). https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/about/cannabidiol.html#a10

Newton, M., & Newton, D. W. (2020). Cannabidiol or CBD oil: Help, hope, and hype for psychiatric and neurologic conditions. Journal of the American Psychiatric Nurses Association, 26(5), 447–457. https://doi.org/10.1177/1078390320929410

Health Canada (2109). Canada’s Dietary Guidelines for health professionals and policymakers. https://food-guide.canada.ca/en/guidelines/

Heart & Stroke Foundation of Canada (n.d.). The DASH diet to lower high blood pressure. https://www.heartandstroke.ca/healthy-living/healthy-eating/dash-diet

Miech, R., Johnston, L., O’Malley, P., & Bachman, J. (2019). Adolescent vaping and nicotine use in 2017-2019 – US national estimates. New England Journal of Medicine, 380(2), 192-193. https://doi.org/10.1056/NEJMc1814130

Miller, I., Scheffer, I. E., Gunning, B., Sanchez-Carpintero, R., Gil-Nagel, A., Perry, M. S., Saneto, R. P., Checketts, D., Dunayevich, E., & Knappertz, V. (2020). Dose-ranging effect of adjunctive oral cannabidiol vs placebo on convulsive seizure frequency in Dravet Syndrome: A randomized clinical trial. JAMA Neurology, 77(5), 613-. https://doi.org/10.1001/jamaneurol.2020.0073

Paradis, C., Butt, P., Shield, K., Poole, N., Wells, S., Naimi, T., Sherk, A., & the Low-Risk Alcohol Drinking Guidelines Scientific Expert Panels. (2022). Update of Canada’s Low-Risk Alcohol Drinking Guidelines: Final Report for Public Consultation. Ottawa, Ont.: Canadian Centre on Substance Use and Addiction.

Park, J., Alexander, L., & Christiani, D. (2021). Vaping and lung inflammation and injury. The Annual Review of Physiology, 84(18). https://doi.org/10.1146/annurev-physiol-061121-040014

Siengsukon, C. F. (2020). The link between social determinants of health, sleep, and cardiovascular disease. Cardiopulmonary Physical Therapy Journal, 31(1), 5-10.https://doi.org/10.1097/CPT.0000000000000130

Turrell, G., Hewitt, B., Patterson, C., Oldenburg, B., & Gould, T. (2002). Socioeconomic differences in food purchasing behaviour and suggested implications for diet-related health promotion. Journal of Human Nutrition and Dietetics, 15(5), 355-364. https://doi.org/10.1046/j.1365-277X.2002.00384.x