Characteristics of the smoking cessation stages [26].
\\n\\n
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"6655",leadTitle:null,fullTitle:"Medical Internet of Things (m-IoT) - Enabling Technologies and Emerging Applications",title:"Medical Internet of Things (m-IoT)",subtitle:"Enabling Technologies and Emerging Applications",reviewType:"peer-reviewed",abstract:"The recent developments in biomedical sensors, wireless communication systems, and information networks are transforming the conventional healthcare systems. The transformed healthcare systems are enabling distributed healthcare services to patients who may not be co-located with the healthcare providers, providing early diagnoses, and reducing the cost in the healthcare section. The developments in medical internet of things (m-IoT) would enable a range of applications, including remote health monitoring through medical-grade wearables to provide homecare for elderlies; virtual doctor-patient interaction to have any time and place access to medical professionals; wireless endoscopic examination; and remotely operated robotic surgery to extend the access to highly skilled surgeons. Wireless body area networks (WBAN) are key enablers of these transformations. These networks connect sensors and actuators to external processing units, which could be placed on the surface of the patient's body or implanted inside the body to connect specific sensors and/or actuators inside, on, and around the body to the data collection points. The success of these networks highly relies on the advent of low-power, low-delay, reliable, and low-cost wireless connectivity solutions. This book covers recent developments in wireless healthcare systems to provide an insight to the technological solutions (e.g. for body area channel propagation models, communication techniques, and energy harvesting/transfer) for wireless body area networks, and emerging applications of medical internet of things and wireless healthcare systems.",isbn:"978-1-78985-092-5",printIsbn:"978-1-78985-091-8",pdfIsbn:"978-1-83962-047-8",doi:"10.5772/intechopen.71858",price:119,priceEur:129,priceUsd:155,slug:"medical-internet-of-things-m-iot-enabling-technologies-and-emerging-applications",numberOfPages:134,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"af6863294c037ec8e4f13785cb65e6fb",bookSignature:"Hamed Farhadi",publishedDate:"February 27th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/6655.jpg",numberOfDownloads:7413,numberOfWosCitations:5,numberOfCrossrefCitations:10,numberOfCrossrefCitationsByBook:1,numberOfDimensionsCitations:13,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:28,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 30th 2017",dateEndSecondStepPublish:"November 20th 2017",dateEndThirdStepPublish:"January 19th 2018",dateEndFourthStepPublish:"April 9th 2018",dateEndFifthStepPublish:"June 8th 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"171143",title:"Dr.",name:"Hamed",middleName:null,surname:"Farhadi",slug:"hamed-farhadi",fullName:"Hamed Farhadi",profilePictureURL:"https://mts.intechopen.com/storage/users/171143/images/5594_n.jpg",biography:"Hamed Farhadi is a researcher at Ericsson Research, Stockholm, Sweden. He received his PhD degree from KTH Royal Institute of Technology, Stockholm, Sweden in 2014. He was a Postdoctoral Research Fellow at Harvard University, Cambridge, MA, USA in 2016, and a postdoctoral researcher at Chalmers University of Technology, Gothenburg, Sweden in 2015. His research interests mainly lie in statistical signal processing and machine learning for a broad range of applications including wireless healthcare systems, micro-robotic surgery, clinical data analysis, and wireless information networks. He has been the recipient of several academic awards including ICASSP 2014 best student paper award. Dr. Farhadi was the co-chair of IEEE International Symposium on Medical Information and Communication Technology (ISMICT) in 2015.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Royal Institute of Technology",institutionURL:null,country:{name:"Sweden"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1016",title:"Medical Instrument Technology",slug:"medical-instrument-technology"}],chapters:[{id:"61381",title:"Internet of Things in Emergency Medical Care and Services",doi:"10.5772/intechopen.76974",slug:"internet-of-things-in-emergency-medical-care-and-services",totalDownloads:1931,totalCrossrefCites:7,totalDimensionsCites:9,hasAltmetrics:1,abstract:"Emergency care is a critical area of medicine whose outcomes are influenced by the time, availability, and accuracy of contextual information. In addition, the success of emergency care depends on the quality and accuracy of the information received during the emergency call and data collected during the emergency transportation. The success of a follow medical treatment at an emergency care unit depends too on data collected during the two phases: emergency call and transport. However, most information received during an emergency-call is inaccurate and the process of information collection, storage, processing, and retrieval, during an emergency-transportation, is remaining manual and time-consuming. Emergency doctors mostly lack patient’s health records and base the medical treatment on a set of collected information including information provided by the patient or his relatives. Hence, the emergency care delivery is more patient-centered than patient-centric information. Wireless body area network and Internet of Technology (IoT) enable accurate collection of data and are increasingly used in medical applications. This chapter discusses the challenges facing the emergency medical care services delivery, especially in the developing countries. It presents and discusses an IoT platform for a patient-centric-information-based emergency care services delivery. The study is focused on a case of road traffic injury. Results of conducted experiments are discussed.",signatures:"Thierry Edoh",downloadPdfUrl:"/chapter/pdf-download/61381",previewPdfUrl:"/chapter/pdf-preview/61381",authors:[{id:"234682",title:"Ph.D.",name:"Thierry",surname:"Edoh",slug:"thierry-edoh",fullName:"Thierry Edoh"}],corrections:null},{id:"60004",title:"Investigations of MIMO Antenna for Smart Mobile Handsets and Their User Proximity",doi:"10.5772/intechopen.75002",slug:"investigations-of-mimo-antenna-for-smart-mobile-handsets-and-their-user-proximity",totalDownloads:1131,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"In this chapter, a monopole antenna with compact size, simple structure, easy to fabricate is reported which covers LTE700 (band13/14) (746–798 MHz), GSM1800 (1710–1885 MHz), PCS1900 (1850–1990 MHz), and LTE2600 (2500–2690 MHz) band based on 6-dB return loss. The proposed MIMO antenna consists of two radiating elements. The main radiating element is a composition of driven element, which is directly fed with microstrip line, and one parasitic element. The parasitic element provides the resonance at higher frequency band and the combination of driven elements and parasitic elements provide above-said frequency bands. The current distribution, far-field radiation patterns, and diversity parameters are checked out for the MIMO antenna in free space. Further performances are studied in the presence of user proximity.",signatures:"Hari Shankar Singh",downloadPdfUrl:"/chapter/pdf-download/60004",previewPdfUrl:"/chapter/pdf-preview/60004",authors:[{id:"226314",title:"Dr.",name:"Hari",surname:"Singh",slug:"hari-singh",fullName:"Hari Singh"}],corrections:null},{id:"62726",title:"Wireless Body Area Networking: Joint Physical-Networking Layer Simulation and Modeling",doi:"10.5772/intechopen.79251",slug:"wireless-body-area-networking-joint-physical-networking-layer-simulation-and-modeling",totalDownloads:933,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"An electronic device equipped with sensors and antennas is the main part of the wireless body area networking (WBAN). Such a device is placed near human body and it usually works in a populated environment with many surrounding objects (e.g., building walls). The human body and the objects can change the radiation characteristics of the antenna and impact the performance of the wireless communication system. The wireless communication system’s performance is also affected by the networking layers established on top of the physical layer. Therefore, any designing method for WBAN application should be pervasive, offering a joint physical-networking layer simulation and modeling strategy. To this end, in this chapter, a comprehensive simulation and modeling method is presented. First, antenna design limitations and challenges for wireless body area networking are studied with emphasis on evaluating the antenna’s performance near the human body. Then, the antenna miniaturization techniques to reduce the antennas’ dimension are reviewed. Later, a system level analysis and modeling are used to study short-range communication between the wearable antennas with remote nodes using IEEE 802.11g wireless networking protocol.",signatures:"Mojtaba Fallahpour",downloadPdfUrl:"/chapter/pdf-download/62726",previewPdfUrl:"/chapter/pdf-preview/62726",authors:[{id:"237161",title:"Dr.",name:"Mojtaba",surname:"Fallahpour",slug:"mojtaba-fallahpour",fullName:"Mojtaba Fallahpour"}],corrections:null},{id:"59062",title:"Robust Optimal Power Distribution for Hyperthermia Cancer Treatment",doi:"10.5772/intechopen.73281",slug:"robust-optimal-power-distribution-for-hyperthermia-cancer-treatment",totalDownloads:702,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"We consider an optimization problem for spatial power distribution generated by an array of transmitting elements. Using ultrasound hyperthermia cancer treatment as a motivating example, the signal design problem consists of optimizing the power distribution across the tumor and healthy tissue regions, respectively. The models used in the optimization problem are, however, invariably subject to errors. To combat such unknown model errors, we formulate a robust signal design framework that can take the uncertainty into account using a worst-case approach. This leads to a semi-infinite programming (SIP) robust design problem, which we reformulate as a tractable convex problem that potentially has a wider range of applications.",signatures:"Nafiseh Shariati, Dave Zachariah, Johan Karlsson and Mats\nBengtsson",downloadPdfUrl:"/chapter/pdf-download/59062",previewPdfUrl:"/chapter/pdf-preview/59062",authors:[{id:"233776",title:"Dr.",name:"Nafiseh",surname:"Shariati",slug:"nafiseh-shariati",fullName:"Nafiseh Shariati"},{id:"233777",title:"Dr.",name:"Dave",surname:"Zachariah",slug:"dave-zachariah",fullName:"Dave Zachariah"},{id:"233778",title:"Dr.",name:"Johan",surname:"Karlsson",slug:"johan-karlsson",fullName:"Johan Karlsson"},{id:"233779",title:"Prof.",name:"Mats",surname:"Bengtsson",slug:"mats-bengtsson",fullName:"Mats Bengtsson"}],corrections:[{id:"66777",title:"Corrigendum to: Robust Optimal Power Distribution for Hyperthermia Cancer Treatment",doi:null,slug:"corrigendum-to-robust-optimal-power-distribution-for-hyperthermia-cancer-treatment",totalDownloads:null,totalCrossrefCites:null,correctionPdfUrl:null}]},{id:"59250",title:"Gait-Based Smart Pairing System for Personal Wearable Devices",doi:"10.5772/intechopen.74195",slug:"gait-based-smart-pairing-system-for-personal-wearable-devices",totalDownloads:896,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"With the rapid development of embedded technology and mobile computing, we have seen a growing number of Internet of Things (IoT) devices on the market. As the number of wearable devices belonging to the same user increases rapidly, secure pairing between legitimate devices becomes an important research problem. In this chapter, we propose the first gait-based shared key generation system that assists two devices to generate a common secure key by exploiting the user’s unique walking pattern. The system is based on the fact that sensors on different positions of the same user exhibit similar accelerometer signal when the user is walking. Therefore, the acceleration can be used as a shared secret information to generate a common key on different devices independently. Our experimental results show that the key generated by two independent devices on the same body is able to achieve 100% bit agreement rate. The proposed key generation protocol can establish a 128-bit key in 5 s (about 10 steps) with entropy varying from 0.93 to 1. We also find that the proposed scheme can run in real time on modern smartphone and require low system cost.",signatures:"Weitao Xu and Guohao Lan",downloadPdfUrl:"/chapter/pdf-download/59250",previewPdfUrl:"/chapter/pdf-preview/59250",authors:[{id:"232773",title:"Dr.",name:"Weitao",surname:"Xu",slug:"weitao-xu",fullName:"Weitao Xu"},{id:"233834",title:"Dr.",name:"Guohao",surname:"Lan",slug:"guohao-lan",fullName:"Guohao Lan"}],corrections:null},{id:"64865",title:"Using Smartphone Sensors for Localization in BAN",doi:"10.5772/intechopen.80472",slug:"using-smartphone-sensors-for-localization-in-ban",totalDownloads:1052,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Nowadays, various sensors are embedded in smartphone, making it a great candidate for localization applications. In this chapter, we explored and listed the localization sensors in smartphone, their characteristics, platforms, coordinate system and how they can be used in BAN. These sensors can be roughly divided into three types: physical IMU sensors (accelerometer, gyroscope and magnetometer), virtual IMU (gravity, step counter and electronic compass) and the environmental sensors (barometer, proximity and other miscellaneous). By applying different mathematical methods, the location of the target or the users can be calculated and used for further use, such as navigation, healthcare or military purpose.",signatures:"Julang Ying, Kaveh Pahlavan and Liyuan Xu",downloadPdfUrl:"/chapter/pdf-download/64865",previewPdfUrl:"/chapter/pdf-preview/64865",authors:[{id:"234653",title:"Mr.",name:"Julang",surname:"Ying",slug:"julang-ying",fullName:"Julang Ying"},{id:"245996",title:"Prof.",name:"Kaveh",surname:"Pahlavan",slug:"kaveh-pahlavan",fullName:"Kaveh Pahlavan"},{id:"245997",title:"Dr.",name:"Liyuan",surname:"Xu",slug:"liyuan-xu",fullName:"Liyuan Xu"}],corrections:null},{id:"60420",title:"Systems of Preventive Cardiological Monitoring: Models, Algorithms, First Results, and Perspectives",doi:"10.5772/intechopen.75921",slug:"systems-of-preventive-cardiological-monitoring-models-algorithms-first-results-and-perspectives",totalDownloads:771,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The results of work on creating methods, models, and computational algorithms for remote preventive health-monitoring systems are presented, in particular, cardiac preventive monitoring. The main attention is paid to the models and computational algorithms of preventive monitoring, the interaction of the computing kernels of a remote cluster with portable ECG recorders, implantable devices, and sensors. Computational kernels of preventive monitoring are a set of several thousand interacting automata of analog of Turing machines, recognizing the characteristic features and evolution of the hidden predictors of atrial fibrillation(AF), ventricular tachycardia or fibrillation (VT-VF), sudden cardiac death, and heart failure (HF) revealed by them. The estimation of the time for reaching the heart events boundaries is calculated on the basis of the evolution equations for the ECG multi-trajectories determined by recognizing automata. Evaluation time of heart event (HE) boundaries to achieve is calculated on the basis of the evolution equations for ECG multi-paths defined by recognizing machines. Ultimately, the computational cores reconstruct the ECG of the forecast and give temporary estimates of its achievement. Cloud computing cluster supports low-cost ECG ultra-portable recorders and does not limit the possibilities of using a more complex patient telemetry containing wearable and implantable devices: CRT and ICD, CardioMEMS HF System, and so on.",signatures:"Sergey Kirillov, Aleksandr Kirillov, Vitalii Iakimkin, Michael Pecht and\nYuri Kaganovich",downloadPdfUrl:"/chapter/pdf-download/60420",previewPdfUrl:"/chapter/pdf-preview/60420",authors:[{id:"4148",title:"Prof.",name:"Michael",surname:"Pecht",slug:"michael-pecht",fullName:"Michael Pecht"},{id:"234788",title:"Dr.",name:"Sergey",surname:"Kirillov",slug:"sergey-kirillov",fullName:"Sergey Kirillov"},{id:"235391",title:"Dr.",name:"Aleksandr",surname:"Kirillov",slug:"aleksandr-kirillov",fullName:"Aleksandr Kirillov"},{id:"235394",title:"Dr.",name:"Yuri",surname:"Kaganovich",slug:"yuri-kaganovich",fullName:"Yuri Kaganovich"},{id:"247701",title:"Dr.",name:"Vitalii",surname:"Yakimkin",slug:"vitalii-yakimkin",fullName:"Vitalii 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Wrought magnesium alloys are one of the most promising lightweight materials of special interests in structural applications due to their homogeneous microstructure and improved mechanical properties compared to as-cast Mg alloys [1]. Mg alloys are one of the most reactive metals that have poor corrosion resistance and low mechanical properties, which limit its applications in industries. Therefore enhancement of mechanical properties and corrosion resistance has led to greater interest in magnesium alloys because of its special applications [2, 3, 4]. Presently much effort is required for preparation of magnesium alloys with a grain size lower than 1 μm, i.e. ultrafine-grained (UFG) materials to improve the strength and corrosion resistance of Mg alloys, many researchers worked and finally developed a severe plastic deformation (SPD) process which greatly contributes towards grain refinement and distribution of secondary phases to enhance mechanical and corrosion properties [5]. However, in SPD, ECAP is most developed and frequently used metalworking technique for significant materials hardening due to increasing dislocation density and considerable grain size reduction to sub-micro-level [6]. Finally, ultra-fine grain structure and uniformly distributed secondary phase particles increase re-passivation tendency, which exhibits the improved mechanical properties and corrosion resistance. The ECAP process was planned with two equal channels: traversing at particular angles called the die channel angle (
Wrought AZ80 and AZ91 commercially available magnesium-based alloy, was selected as a workpiece material because of its high strength and low cost when compared to other magnesium-based alloys. The Mg alloy was procured in the form of a rod with dimensions 18 mm diameter and 200 mm length, from Exclusive Magnesium Pvt. Limited, Hyderabad, India. The chemical composition of AZ80/91 Mg alloys. Also, chemical composition presented along with the microstructure shown in Figures 1 and 2.
AZ80 Mg alloy (a) microstructure (b) EDS results.
AZ91 Mg alloy (a) microstructure (b) EDS results.
Die-Material: Hot Die steel (HDS) was used for die making. The ECAE die design was done by using solid edge V.7 software and fabrication was carried out at Government Tool Room and Training Centre (GTTC) Baikampady, Mangalore, Karnataka, India. Figure 3 depicts the ECAE die having 900 and 1100 channel angle and 300 corner angle. An equal channel angular extrusion thermo-mechanical apparatus is provided grain refinement to improve mechanical properties and corrosion resistance of magnesium alloys. ECAE is promising extrusion technique to achieve ultra-fine equiaxed grains without changing the shape of the workpiece. The extrusion die assembly having two angles such as channel angle (
ECAP die having 900 and 1100 channel angle and 300 corner angle (Naik et al. Copyrights: Diary number: 14668/2018-CO/L., Reg. No: L-79923/2018).
Equal channel angular extrusion experimental setup.
A lubricant as Molybdenum disulfide (MoS2) was used to minimize the frictional effects between samples and die. After attaining the required temperature, the sample is pressed by applying a load at the rate of 1 mm/sec ram speed using plunger attached to the UTM for deformation of the specimen. The channels are intersected to impose the total strain on the material to get a fine grain structure. This process is repeated by using route R, where the samples were inverted from its initial position between two successive passes as shown in Figure 5(a). The processed samples after ECAP operation is shown in Figure 5(b) [7, 8, 9, 10, 11, 12].
(a) Route-R and (b) ECAPed sample.
This section focuses on all characterization techniques of ECAPed magnesium alloys including all forms of microscopy and analysis especially microanalysis and surface analytical techniques. The methodology of microstructure analysis and phase identification are also discussed.
Specimens for microstructure inspection were prepared by mechanical polishing with silicon carbide abrasive papers (grades of 400, 800, 1000, 1200, 1500, 2000) followed by cloth polishing using diamond paste and kerosene for obtaining mirror finish surface and finally cleaned with acetone. Further, Etching was carried on the polished surface for approximately 3 to 5 s, in a solution of 4.2 g picric acid, 10 ml acetic acid, 10 ml distilled water and 70 ml ethanol for 3–5 s [8, 9, 10, 11, 12]. So that sample turns light brown and washed with running distilled water and dried. Microstructures and elements distributions were observed and analyzed using optical microscopy by image analyzer facilitated BIOVIS material plus software, and average grain sizes were measured by linear intercepts method according to ASTM E-112. Same samples were observed under a scanning electron microscope.
Scanning electron microscope (SEM) equipped with energy dispersive spectroscopy (EDS) Backscattered electron (BSE) detector coupled with the EDS allows for composition identification of materials. Scanning Electron Microscopy Model: JEOL JSM–638OLA from JEOL, USA, operated at 30 kV; Magnification range-3,00,000×, which allows studying the microstructures and surface morphologies.
X-ray diffraction (XRD) is one of the primary techniques used for the characterization of crystalline solids and determination of their structure or phases. XRD measurements are carried out in M/s Proto Manufacturing Ltd., CANADA make PROTO–iXRD MGR40, wherein the analysis was carried out 2θ: an angular range of 20° to 90° at a scanning speed of 20/min. The XRD patterns obtained were analyzed with the help of PCPDFWIN software to identify the formation of primary, secondary and ternary phases.
Microhardness test is also performed on as-received heat-treated and some of the deformed or ECAPed samples. The measurements were carried out at a load of 100gm and dwell of 13 s the microhardness was calculated using the expression [13]. Microhardness Model: MVH–S–AUTO from OMNI TECH, PUNE, INDIA.
The tensile test is used to evaluate the strength and ductility of as-received and equal channel angular extruded sample. Specimens were prepared according to the ASTM-E8 standard with 16 mm gauge length. The tensile properties of magnesium alloys were measured using UTM-Shimadzu AG-X plus™ equipped with 100 kN load cell and operated with a steady cross-head speed of 0.25 mm/min during all the tensile tests. Three samples were tested for each condition and uniaxial tensile testing was accomplished at room temperature and average reading was calculated and presented.
Corrosion study of AZ80/91 wrought Mg alloys was investigated using electrochemical corrosion analyzer, model: Gill AC-1684, supplied by Tech-science Pvt. Limited, Pune (India). The potentiodynamic polarization tests were conducted in 3.5 wt.% NaCl solution to estimate corrosion resistance or rate of corrosion of AZ80/91 wrought alloys. The auxiliary electrode (AE) was made of graphite (Gr) and the reference electrode (RE) was made of a saturated calomel electrode (SCE). 1cm2 area of the working electrode (AZ80/91 alloys) was exposed to the 3.5 wt.% NaCl solution. Before the electrochemical corrosion test, specimens were polished with 600, 800, 1000, 1200, 1500, 2000 grit emery papers and washed with ethanol. The specimens were kept in corrosion cell kit in NaCl solution for 20 min to stabilize the open circuit potential (OCP). Further, the AC impedance test of starting frequency 10 kHz and ending frequency 10 MHz with a scan speed of 5 mV/s and cyclic sweep experiments with −250 to +250 mV was carried on the electrochemical analyzer. Surface morphology of the corroded samples was examined by SEM. The corrosion product was removed using 200 g/L of chromic acid and 10 g/L of AgNO3 solutions. The corrosion rate of the alloy was calculated by using Eq. (1).
where CR is the corrosion rate in miles per year, A is the molar mass (for magnesium 24.3 g/mol),
So far, many simulation studies have been executed to examine the impact of different die parameters on deformation homogeneity, strain rate, workflow etc. Although many researchers have been carried out on the efficiency of ECAP process routes and influences of various ECAP parameters on the strain behavior [14], there is limited work on a study of the effect of channel angle on grain size and other material properties through experimentally. In this chapter, the effect of ECAP channel angle on grain size, microhardness, tensile behavior and corrosion rate for different passes were analyzed using working temperatures of 598 K Furthermore, die A was used for examining above said material properties since this die gives the best results.
The optical microstructures of as-received, homogenized at 673 K-24 h sample and those after ECAP processed specimens are shown in Figures 6 and 7. The microstructure of the as-received AZ80 Mg alloy presents the α-Mg and β-Mg17Al12 secondary phases along the grain boundaries indicated in Figure 6(a). After homogenized at 673 K for 24 h secondary phases were partially dissolved along the grain boundaries as shown in Figure 6(b) this partial dissolution of secondary phases was achieved before ECAP and this sample is designated as 0P specimen. Figure 7 presents the optical images of the ECAPed AZ80 Mg alloy processed through two ECAP die of 2 and 4 passes at 598 K processing temperature, in which the white and black contrast within the grains and along the grain boundaries represents α-Mg primary phase and β-Mg17Al12 secondary phases respectively. Also, the presence of α-Mg and β-Mg17Al12 phase in AZ80 alloys was confirmed through by the XRD analysis shown in Figure 8. The microstructure of the ECAPed Mg alloy showed significant grain refinement and bi-modal grains after ECAP of two passes for both die A and B, as shown in Figure 7(a) and (c). These heterogeneous grains were typically obtained under the condition of lower deformation. When ECAP passes were gradually increased up to four passes bi-modal grain structure disappeared due to a large amount of induced plastic strain, as a result of the average grain size of ECAP-4P through die A was ~6.35 μm and the secondary phases are uniformly distributed throughout the material as shown in Figure 7(b). Whereas ECAP-4P processed through die B exhibited slightly larger grains compared to die A, the obtained grain size is of about ~9.77 μm. Hence, the effectiveness of grain refinement can be enhanced based on a channel angle, particularly, material processed through 90° channel angle exhibited better grain refinement.
Optical images of (a) as-received (b) homogenized at 673 K-24 h.
Optical images for die A: (a) 2P (b) 4P and die B: (c) 2P and (d) 4P ECAP passes.
XRD analysis on AZ80 Mg alloys (a) as-received (b) homogenized at 673 K-24 h (c) die A: 2P at 598 K (d) die A: 4P at 598 K. XRD analysis on AZ91 Mg alloys (e) as-received (f) homogenized at 673 K-24 h (g) die A: 2P at 598 K and (h) die A: 4P at 598 K.
Figure 9 shows the microstructure of the as-received and homogenized AZ91 Mg alloy. The microstructure of the as-received AZ91 Mg alloy shows a coarse α-Mg phase and β-Mg17Al12 secondary phase along the grain boundaries which is confirmed through XRD analysis as shown in Figure 8.
Optical images of (a) as-received (b) homogenized at 673 K-24 h.
The mean grain size of as-received Mg alloy is ~58.69 μm as shown in Figure 9(a), measured by the linear intercept method (ASTM E 112). From Figure 9(b), it could be found that after homogenization treatment at 673 K for 24 h the slight increase of mean grain size of Mg alloy of ~59.82 μm was observed this is due to grain growth effect during the homogenization process. Similar observations are made by Nikulin et al. [15]. After ECAP, the microstructure of the alloy is effectively refined by dynamic recrystallization process (DRX) [16]. From Figure 10, it was observed that two-pass pressing through die A and die B exhibited bimodal grain structure and more fine grains appeared for the processing in the 900 die than the 1100 die. The effectiveness of the grain refinement was observed after four passes of pressing in the 900 die as shown in Figure 10(b). Also, it is noticed that with the increase in the number of ECAP passes, the amount of fine grains is increased greatly.
Optical images for die A: (a) 2P (b) 4P and die B: (c) 2P and (d) 4P ECAP passes.
Figure 11 displays the variation of average grain size of processed and unprocessed AZ80 and AZ91 Mg alloys of 2 and 4 ECAP passes through die A and die B. As it could be observed from Figures 6 and 9 as-received and homogenized (0P) Mg alloy has moderately large grain size approximately ~50.20 μm and ~50.70 μm for AZ80 and 58.69 μm, 59.82 μm for AZ91 alloy respectively. The increased average grain size of Mg alloy after homogenization treatment AZ80/91 Mg alloy at 673 K-24 h is due to the phenomenon of grain growth effect [8, 17, 18]. Further, it can be shown that after 2P and 4P ECAP volume fraction of grains increases compared to as-received and homogenized Mg alloy. Mean grain size of AZ80 Mg alloy after ECAP-2P and 4P were ~28.87 μm and ~6.35 μm respectively for die A. Similarly, the average grain size of same Mg alloy processed through die B is ~36.14 μm and ~9.77 μm for ECAP-2P and 4P respectively. Further, an average grain size of AZ91 Mg alloy after 2P and 4P of ECAP were ~30.86 μm, ~7.58 μm for die A and ~36.14 μm, ~9.7 μm for die B respectively. It is apparent that the obtained grain refinement is due to DRX during ECAP and they increase in many ECAP passes which result in much smaller grain structure. However, from this it is noticed that the alloy processed with 900 die shows smaller grain sizes than 1100 die for both alloy, this is due to the accumulation of very large plastic strain while processing with a low angle die [19, 20]. The calculated equivalent plastic strain for 1100 to be ~0.742 and ~1.015 for 900 indeed, the strain developed by 4P ECAP through 900 die is higher than that of 1100 die. Therefore, large strain in the material exhibited more dislocation density lead to the formation of fine grains during this process. Therefore, undoubtedly it is evident that ECAP die angles significantly affect the deformation homogeneity and this influences the variation in microstructure [21, 22, 23].
Variation of average grain size with two different die.
Also, the microstructural change contributes towards improved mechanical properties and corrosion resistance. Finally, in general, AZ Mg alloy processed through die A and die B showed the same trend of decreasing grain size from the homogenized condition. By extruding in the die A, the mean grain size of AZ80 and AZ91 Mg alloy decreased by 35% and 22% when compared with material processed through die B [19, 20]. Also, from the result, it was observed that AZ80 Mg alloy processed through die A at 598 K exhibited fine grain structure of about ~6.35 μm after four ECAP passes, which is lower when compared to ECAPed AZ91 Mg alloy processed at same processing temperature.
The X-ray diffraction patterns of AZ80/91 Mg alloy before and after ECAP processes as shown in Figure 8. The XRD patterns of the as-received, homogenized at 673 K and ECAPed AZ Mg alloys revealed two sets of peaks, one for the α-Mg primary phase and another one for the β-Mg17Al12 secondary phase. But as-received alloy of AZ80 has shown new peaks corresponding to the formation of the ternary phase appeared at 41.4° as shown in Figure 8(a) which is disappeared after homogenization treatment and ECAP depicts in Figure 8(b)–(d) due to diffusion annealing treatment and dynamic precipitation during the ECAP process. Further, Figure 8(c) and (d) presents the XRD patterns for ECAPed AZ80 Mg alloys for 2P and 4P processed with die A at processing temperature 598 K. It was observed that the peak intensities were increased after 4P ECAP when compared to the ECAP-2P sample. This is due to an increased volume fraction of secondary phases and more homogenous microstructure. But 2P ECAP processed sample presented lower peak intensity this is mainly due to non-homogeneity in the microstructure and crystal defects.
Furthermore, Figure 8(e)–(h) shows the XRD spectra of AZ91 Mg alloy (e) as-received (f) the homogenized at 673 K for 24 h (g) the two-passed AZ91 Mg alloy ECAPed with die A at 598 K and (h) the four-passed AZ91 Mg alloy ECAPed with die A at 598 K. Regardless of the number of ECAP pass, the as-received and processed samples contained α-Mg and β-Mg17Al12 phase. The intensity of the peak in the ECAP processed specimens at 598 K is lower than that of the as-received specimen. Also, it can be seen that there exists great difference on the magnitude of the peak intensity of ECAP processed specimen at 598 K for two and four passes this is mainly due to induced plastic strain during ECAP similar results has been observed by Avvari et al. [24, 25, 26, 27, 28].
This section explains the effect of ECAP die channel angle on mechanical properties of as-received and ECAPed AZ80/91 Mg alloys.
Figure 12 shows the impact of channel angle on microhardness during ECAP of AZ80/91 Mg alloys. From the results, it was observed that AZ80/91 Mg alloy processed through lower channel angle of 90° (die A) exhibited enhanced microhardness when compared to material processed through die B at 598 K after 4 Passes of ECAP. The improved microhardness is mainly due to the accumulation of large plastic strain while processing at 90° channel angle and obtained more equiaxed microstructure.
Variation of microhardness for AZ80/91 Mg alloys after processing through two different dies.
Hence, die A which has 90° channel angle is considered as an optimal die parameter to get the highest Microhardness for both AZ80/91 Mg alloys. Also, from Figure 12 it was established that there is a significant increase in Microhardness after a four pass of ECAP in AZ91 Mg alloy after processing using a die A compared to AZ80 Mg alloy processed through the same die and this is anticipated from measurements of the effective refinement of grain size.
The engineering stress-strain curves of un-ECAPed and ECAPed AZ80/91 Mg alloys at two different dies are shown in Figure 13. The stress-strain curves show that ultimate tensile strength and ductility of ECAP-4P processed AZ80 specimens at 598 K are about 489.17 MPa, and 19.03%, respectively for die A, Along with this, the same material processed through die B 4P-ECAP exhibited UTS and %elongation is 451.01 MPa and 11.76% respectively, which are higher than that of an as-received and homogenized specimen of AZ80 Mg alloys. Similarly, the AZ91 Mg alloy processed through die A has greatly improved ultimate tensile strength and ductility. Particularly, as-received AZ91 alloys have 372.74 MPa and 7.84% of UTS and ductility respectively, which is further enhanced to 432.81 MPa and 19.13% after processing through die A for 4 passes and 410.35 MPa and 13.22% of ultimate tensile strength and ductility was observed after processing through die B for 4 passes. From this result, it was found that compared with the ECAPed AZ91 Mg alloys processed with die A, the AZ80 Mg alloy processed through die A exhibited enhanced tensile properties compared to die B. This is due to an induced large amount of plastic strain during ECAP.
Variation of tensile strength for different ECAP die.
This section illustrates the effect of ECAP die channel angle on corrosion behavior of as-received and ECAPed AZ80/91 Mg alloys. Also, presents the morphology study on corroded surfaces of as-received and ECAPed AZ80/91 Mg alloys.
The corrosion results of AZ80/91 Mg alloy processed through die A and die B at 598 K after 4-ECAP passes including as-received and homogenized samples were shown in Figure 14.
Corrosion rate vs. ECAP die.
From Figure 14, it was observed that the channel angle of ECAP significantly influences the grain refinement and distribution of secondary phases which contribute towards corrosion resistance. ECAP processing through die A at 598 K leads to lower corrosion rate after 4 passes of ECAP compared to die B under the same conditions for both AZ80/91 Mg alloys. This is mainly due to the lower dislocation density at recrystallization temperature [29]. Therefore the reduction of the grain size and the increase of the distribution of secondary phases can cause an improved corrosion resistance. In other words, the column chart shows the variation of corrosion rates of Mg alloys before and after ECAP process for both AZ80/91 Mg alloys. The more ECAP passes are related to the nobler corrosion potentials and the lower current density. The Mg alloy processed through die A and die B after four ECAP passes results that the ECAPed Mg processed through die A has nobler Ecorr and Icorr values, leads to more corrosion resistance than the specimen extruded through die B, as-received and homogenized. Specifically, AZ91 Mg alloy processed through ECAP after 4 passes exhibited improved corrosion resistance than the ECAPed AZ80 Mg alloys this mainly due to elemental composition of AZ91 Mg alloy.
Figure 15 depicts the polarization plots for AZ80 and AZ91 Mg alloys processed with die A at 598 K. From Figure 15(a) it was observed that the anodic branches of the unprocessed and processed AZ80 specimen showing the continuous active dissolution of the metal this indicate that AZ80 Mg alloy exhibit poor passivity [30]. Although, Ecorr values of ECAP processed AZ80 Mg alloys are significantly shifted to the less negative potentials and highly reduced the magnitude of Icorr after 2 passes. A similar observation was made by Ambat et al. [31]. Further, the polarization plot of the 4P ECAPed with 900 die exhibits a corrosion potential of −1.375 VSCE this is higher than corrosion potential of other ECAP passes. This indicates that AZ80 Mg alloy processed with 900 die sample has higher pitting corrosion resistance. Moreover, polarization results specify that the ECAPed AZ80 Mg processed with 900 die has nobler Ecorr values. Further, the potentiodynamic polarization curves of as-received and ECAPed AZ91 Mg specimens in 3.5 wt.% NaCl was also shown in Figure 16(b). The experimental results revealed that the Ecorr, corrosion potential of 4P-ECAPed AZ91 Mg alloys was −1.453VSCE, which was less negative compared with the as-received alloy and other ECAP passes (Figure 16(b)). This phenomenon specifies that the cathodic reaction was more difficult in fine-grained Mg alloys compared to the coarse grain alloy. Therefore, with the ECAP, the corrosion potential (Ecorr) shifted to −1.536 VSCE and −1.453 VSCE after two and four ECAP passes which are considerably nobler in comparison with the as-received alloy (−1.540 VSCE). However, the corrosion potential increases with the grain refinement after ECAE in the alloy. Also, the corrosion current density (Icorr) of 2P and 4P ECAPed AZ91 Mg alloy was 0.0173 mA/cm2 and 0.0053 mA/cm2 respectively, which is lesser than that of as-received AZ91 Mg alloy (0.0263 mA/cm2). The obtained results revealed that the ECAPed Mg sample after 4 passes has nobler corrosion potential and lower current density when compared with as-received and ECAPed-2P. Therefore, ECAE increased the corrosion resistance of Mg alloy this is due to grain refinement and distribution of secondary phases, which is shown in OM and SEM microstructure in Figure 16. Similarly, Shahar et al. [32] explored that the grain refinement and secondary phase distribution through ECAP improves the corrosion resistance of Mg alloys.
Polarization curves of Mg alloys processed through die A (a) ECAPed AZ80 Mg alloys and (b) ECAPed AZ91 Mg alloys.
Corrosion morphology of AZ80 Mg alloys (a) as-received (b) homogenized at 673 K-24 h (c) 4P-598 K and (d) XRD for a corroded specimen of as-received.
The corrosion morphologies of as-received and as-processed specimens of AZ80 and AZ91 Mg alloys immersed in 3.5 wt.% NaCl solution observed through scanning electron microscopy and is shown in Figures 16 and 17.
Corrosion morphology of AZ91 Mg alloys (a) as-received (b) homogenized at 673 K-24 h (c) 4P-598 K and (d) EDX for corroded ECAP-4P specimen.
From Figures 16(a), (b) and 17(a), (b), it was observed the adequate amount of corrosion attack on the surface of the as-received and homogenized AZ80 and AZ91 Mg alloys after potentiodynamic polarization test. The ECAP performed samples of Mg alloys after the corrosion test exhibited comparatively less localized pits on the surface of ECAPed AZ80/91 Mg alloys have shown in Figures 16(c) and 17(c). This obtained result showed that pitting corrosion resistance of ECAPed Mg alloys are significantly improved through grain refinement and this is due to the distribution of secondary phases [33, 34, 35]. It is worth to declare that this appeared improved for AZ80/91 Mg alloy was due to the grain refinement, distribution of secondary phases and formation of magnesium hydroxides formed on their surfaces which proved through microstructure and X-ray diffraction analysis shown in Figures 16(d) and 17(d) for AZ80 and AZ91 Mg alloys respectively. The existence of such metal oxide partially protects the Mg surface from further dissolutions under this circumstance the breakdown of the film and the consequential nucleation and growth of a pit become more difficult. Moreover, the higher Ecorr value for ECAPed Mg alloys at higher passes revealed that the surface of Mg alloys was more passivated against corrosion this is due to slow dissolution rate of fine grains structure [30, 31]. Finally, from the results, it was concluded that the severe corrosion attack was observed on as-received AZ80 and AZ91 Mg alloys and further continuous reduction in corrosion attack was observed for ECAPed samples. Similar kind of results and trends is reported by many authors in their studies [29, 36, 37].
AZ80/91 Mg alloy processed through both die A and die B at 598 K were discussed in this chapter. Indeed, Mg alloy processed through die A has significantly shown fine grains than die B. Since the grain size and distribution of secondary phases are a major factor in determining the strength and corrosion resistance of the material respectively, therefore die A is considered as optimal to achieve fine grain structure in our work. As a result, the fine grains obtained through die A exhibited improved mechanical and corrosion resistance discussed in the earlier sections. Also, based on the experimental results and discussion, the following conclusions were drawn.
Increase in ECAP passes lead to homogeneous microstructure due to dynamic recrystallization which occurred during ECAP process. The secondary β-Mg17Al12 phase was reduced and uniformly distributed throughout the extruded material. Here, the effectiveness of ECAP with die A in grain refining of AZ80/91 Mg alloys was quite significant because of imposing large plastic strain of ~5.06 after four ECAP passes.
The average grain size of AZ80 and AZ91 Mg alloy was found to be reduced to 6.35 μm and 7.58 μm respectively after processing through die A at 598 K.
Microhardness, ultimate tensile strength and ductility for both AZ80 and AZ91 Mg alloy has been enhanced by refining grain size with an increasing number of passes. Ultimate tensile strength of the AZ91 Mg alloy decreased when compared to AZ80 Mg alloy after ECAP this is due to the presence of the secondary
Mechanical properties such as ultimate tensile strength, ductility and microhardness of the AZ80/91 Mg alloy are directly proportional to the ECAE passes.
Potentiodynamic polarization test showed reduced corrosion current density (Icorr) which indicates higher corrosion resistance for the ECAP processed samples due to the presence of equiaxed fine grain microstructure and homogeneously distributed secondary particles (Mg17Al12).
Polarization results showed that passive behavior of ECAPed AZ80/91 Mg sample enhances compared to as-received AZ80/91 Mg alloy owing to the grain refinement and distribution of secondary phase. An AZ80/91 Mg alloy processed with die A (90°) showed higher pitting corrosion resistance compared to die B (110°), by showing less negative pitting potential during 4P-ECAP. Also, the obtained polarization data have good agreement with the corrosion surface morphology.
The health sector is increasingly changing from a disease model to a health model. Salutogenesis is a term coined by Aaron Antonovsky, a professor of medical sociology. The term describes an approach focusing on factors that support human health and well-being, rather than on factors that cause disease (pathogenesis) [1]. It has become just as important to consider levels of vitality and healthfulness as degrees of impairment and disability. The quality of our health is strongly influenced by lifestyle habits [2]. The probability of illness and death is directly related to our lifestyle and health behaviour, including tobacco use, nutrition, physical activity or inactivity, alcohol consumption, drug use, sexual behaviour and so forth [3]. Hypertensive and coronary heart disease are in important part related to dietary patterns, smoking, sedentary lifestyle at work and in leisure time [4].
\nBecause lifestyle habits play a central role in influencing the state of health of each individual, the effectiveness of future treatments may greatly depend on the extent to which patients and clients are involved in improving their state of health by actively changing their health habits. Although it can be interpreted discouraging to realize that our behaviour contributes directly to today\'s health problems, it can also be empowering to know that we can significantly improve the health of our patients and society at large by encouraging them to participate in healthy lifestyle habits [5]. Due to our profession, health professionals such as physicians, psychologists, nurses and physiotherapists come across a large number of people with negative and unhealthy lifestyle behaviour within a therapeutic framework. We can give individual, repeated advice and support to our patients [6]. Performing early intervention to reduce chronicity, increasing intervention rate and improving the quality of counselling could help many more people: probably there is no field of medical education and preventive medicine that contributes to a higher level of health, saves more lives and reduces medical costs than lifestyle changes [7].
\nAlthough attention is focused on the risks of unhealthy habits in professional literature and public media, information alone is often not enough to change a patient\'s behaviour. To get rid of or change deeply rooted negative lifestyle habits, it often requires professional help. Physicians and health professionals frequently pay limited attention to changing the unhealthy habits of patients. They provide information and point out the negative consequences and appeal to the rationality and good intentions of the patients. Knowledge of the risks of unhealthy habits and good intentions to change are only a prerequisite but not enough to change unhealthy habits for most patients. The traditional “fix-it“ role of the general practitioners may be sufficient for the minority of patients who are ready to change, but it is only the first of many steps needed for the majority of patients who are reluctant or ambivalent about the change [8]. Unfortunately, the dominant but unspoken Cartesian reductionism of modern medicine that views the body as a machine and medical professionals as technicians whose job is to repair that machine is not effective in this field [9]. The existential philosophy of Martin Buber is a milestone in developing the inherent asymmetric clinician-patient interaction towards healing relationships. For Buber, relationship and dialogue are not issues for medicine; rather, medicine is a matter of relationship and dialogue. Healing relationships start from a more symmetrical attitude valuing patient’s contribution and power. An abiding commitment to appreciate and foster patient’s own competencies and self-confidence leads to a relation based on trust and hope. Hence, building up a healing relationship is mandatory for the patient to become a co-producer of his or her health [9].
\nHowever, a problem with smoking cessation is physicians\' inadequate preparation for the treatment of cigarette-dependent patients. Special training in smoking counselling to improve the efficiency of medical interventions can increase the frequency and quality of smoking cessation [10] and is often meaningful as a mandatory, targeted and practical training course [11]. WHO guidelines recommend that all health professionals, including students in medical training programmes, should receive education in tobacco use and addiction treatment. Many students in the medical field have nevertheless received inadequate training in the treatment of tobacco consumption and addiction [12]. We therefore developed and evaluated an efficient 4-hour smoking cessation counselling workshop for medical students that will be in the first part be presented in this chapter. It is an easy-to-implement course. As discussed later, much content may also be adapted to other unhealthy lifestyle behaviour counselling situations.
\nEvery switch from a pathogenesis-oriented “patient management” to a “resource integrating salutogenetic mode of patient counselling” requires a fundamental change in the attitude and the role behaviour of health professional towards the patient during the consultation. Digging only for failures and pathology is frequently not helpful. For building up relational trust and needed energy for difficult change processes, it becomes mandatory to build up resources from patient’s experience of earlier attempts and by this appreciating and integrating them. This shift of focus might be even more difficult as all pathogenetic distractors may seduce students and health professionals alike to switch back in a traditional top-down or directive role, which may be less helpful in enabling patients to intrinsically change to a healthier lifestyle.
\nOur chapter is aimed to give students, physicians and other health care professionals an introductory overview on the role of lifestyle behaviour that may affect the health of their patient or clients: be it smoking, be it another subject, to be best prepared to encourage, influence and motivate lifestyle changes.
\nBehavioural and pharmacological interventions in combination with professional counselling seem necessary to improve smoking cessation rates. In order to ensure benefit, effective courses on preventive medicine content are needed in the curricula of medical students. Only a part of medical students and later also few physicians and other therapists receive formal training in smoking cessation [13, 14]. Fear and the feeling of being ill-prepared for practice are common for medical but less for psychology students [15]. In order to satisfy the importance of smoking in practically all areas of medicine, a 4-hour comprehensive smoking cessation course was offered for the first time in 2006 at the Medical Faculty of the Saarland University in Homburg/Saar, Germany. The course was thoroughly evaluated, and its results were published [16].
\nThe course is a compact, comprehensive and interactive 4-hour smoking cessation course for medical students with the aim of teaching students how to offer smoking cessation counselling tailored to the individual willingness and motivation of the smoker including pharmacological therapy. Conducted by a doctoral student, it is thus a course “by medical students for medical students”, with full-time supervision by a medical expert with smoking-specific medical education and many years of experience in the field of smoking counselling. The course consists of an introductory theoretical part (1/4) and a practical part (3/4) and is based on the stages-of-change model of Prochaska et al. [17]. This is an evidence-based model of behavioural change that has been developed and tested over the past decade relating to smoking cessation [18]. The theoretical part included a presentation and relevant literature on communication, changes in health behaviour and smoking cessation. In the practical part, the theoretical basics were trained by role plays. Each student received a case report corresponding to a phase of the six stages of change of Prochaska and DiClemente. The counselling interview was played and learned in the form of a role playing according to the “stages-of-change model” by Prochaska and DiClemente, once being the patient and once being the therapist at any stage situation. Depending on the stage, a certain approach is efficient and may therefore be optimal for a successful counselling. Each case was discussed after the role playing, and one received the direct feedback from the students, the doctoral student and the supervisor. The course was voluntary and could be attended by all medical students.
\nFor the evaluation of the course, pre-course and follow-up assessments (4 weeks after the course) were carried out in five courses with a total of 87 students. Questionnaires and video recordings were blindly evaluated to examine the outcome regarding the competence of the students who attended the course. For the purpose of an efficient training methodology and an appropriate evaluation of the topic of smoking cessation, competence was differentiated into the components “knowledge”, “skills” and “attitude” [19] as discussed in more detail in Chapter 3. Another part of the evaluation was the anonymous course valuation directly after the course, which all students completed to optimize future courses.
\nThe study confirms that a compact comprehensive 4-hour interactive smoking cessation workshop for medical students is effective in terms of a profound short-term effect on the participants’ counselling abilities. Significant and relevant increases in the competence dimensions of medical students (knowledge, skills and attitude) were measured for successful patient-centred smoking cessation counselling. Knowledge of smoking counselling and smoking cessation has been significantly (
Upper left: assessment of student with a figured patient. The film material was analysed in a blinded fashion to the situation before or 4 weeks after the student course. Lower left: improvement of knowledge according to question scores before and 4 weeks after the course. Upper right: improvement of attitude to address smoking in any consultation before and 4 weeks after the course: a huge shift towards addressing the problem of smoking is observed. Lower right: the course changed another attitude, it led to more tolerance towards smokers.
In detail, significant gains were observed in the investigation of the motivation to quit smoking, in recommendations for stopping smoking, and suggestions for practical strategies to facilitate smoking cessation and prevent relapse. The evaluation of the duration and amount of tobacco consumption was determined more adequately, and the encouragement of the patient to reflect on present smoking behaviour was driven by the elaboration of arguments for and against smoking. Increased information was provided on smoking cessation and withdrawal process, and nicotine replacement therapy and support were offered for smoking cessation by arranging further appointments.
\nThe attitude of the students changed significantly (
The most important results may be this remarkable shift in attitude, probably most influencing in the long-term behaviour towards patients. The course seems highly effective in promoting future physicians’ ability in smoking cessation counselling and thus in the long-term retention of medical students’ preventive medical competence. The stage-of-changes model proved advantageous for promoting behavioural change in addiction. Such trained competences may foster general counselling competences in further areas as discussed later [20].
\nCompetence in medicine is defined by various authors as “the usual and reasonable use of communication, knowledge, technical skills, clinical thinking, emotions, values and reflection” [21] or “medical knowledge, care for the patient, professionalism, communication and interpersonal skills, practice-based learning and improvement of what has been learnt“ [22]. There are many definitions of the term “competence”, but in the end, it amounts to the same concept. It depends on a person\'s ability to adapt the own abilities to requirements and tasks and to cope with a certain situation. Thus, competence is context-dependent.
\nWhat kind of knowledge is important for smoking counselling? Based on the evaluation points of the smoking counselling interviews in Swiss courses [23, 24], the knowledge questions examined in the study by Purkabiri et al. relate to a basic knowledge of the procedure for counselling, the steps leading to a smoking stop and its effects, cigarettes, nicotine and nicotine replacement therapy [16]. Knowledge is therefore the basis for finding well-founded arguments, identifying the right time for a suitable strategy, drawing up an individual weaning plan and understanding the importance of smoking counselling.
\nThe main topics in the courses of other studies are broadly similar to those of the smoking counselling course presented in this chapter [7, 25]. The contents refer especially to cigarette smoking and the associated diseases, the pharmacology of nicotine and the medicinal and therapeutic treatment methods of cigarette addiction. The smoking counselling strategies based on the theories of Prochaska and DiClemente [26] and Humair et al. [6, 10, 23, 24, 27] were taught in the Homburg courses.
\nSkills are defined as the abilities gained through learning, practice and experience. By using a good strategy to solve a particular problem, the performer responds appropriately to the task. Of course, there are many strategies, but the term “skills” includes selecting and applying the most effective ones. In the case of smoking counselling, it would be the choice and application of proven strategies for smoking cessation, which the doctor masters through practice and experience.
\nSkills consist of three main components:
Awareness of goals or problems and understanding of all relevant factors: Recognizing that smoking presents a high health risk, the problems associated with it and the difficulties of weaning, and how they may be addressed.
Choosing the reaction: making a decision: How do I react to the problem of smoking and how do I solve the problem of smoking counselling.
Implementation of the selected strategy/reaction: It usually requires coordination and “timing”—consulting based on efficient strategies at the right time and in the right way.
Thus, the skills include communication factors, emotions and reflective thinking, as presented in the competence definition of other authors [21, 22]. The skills that should be taught in the courses correspond to the ability to give practical counselling to smokers. It is checked whether the student has addressed the most important points of the smoking counselling, such as the recognition of nicotine dependence, information on health and other consequences of smoking, nicotine replacement therapy and so on. Before a visible change of behaviour is possible, an inner sensitization, awareness and motivation process must take place in which the individual explores and sorts out his or her contradictory values, expectations and feelings (ambivalence). The successful handling of this ambivalence reflectively listening in the form of giving feedback what we have perceived and what the patient or client has said and encouraging to come up with possible own solutions or alternative behaviour, and thus, the dissolution of resistance to change is a prerequisite for lasting changes in behaviour (theory of “motivational interviewing” [28]). Elements of motivational interviewing can provide useful help in this important task of counselling. Motivational interviewing [29] is a direct, patient-centred style of counselling that encourages behavioural change by helping patients to explore and resolve their ambivalence [28].
\nValuable therapeutic communication is virtually exclusively possible with empathy and symmetry: it is the door to therapeutic intervention. The above-mentioned imparting of empathy, which is regarded as pivotal for motivational interviewing, is a skill aspect of medicine that has been sometimes in part neglected. Thus, it was crucial to promote this empathy in the courses.
\nThe skills were evaluated, among other things, by video analyses of a counselling interview (see \nFigure 1\n, upper left). One advantage of the filmed sequences is the precise recording of different dimensions, such as the quality of counselling. The individual film sequences can be viewed as often as you like, and thus, different criteria such as attitude, body posture and facial expressions can be evaluated. Furthermore, video recordings offer the possibility of blinded evaluation, which was done in the study presented here. The examiner did not know whether the recording was before or after the course. In principle, simulated patients are being used much more frequently to test and evaluate the skills of a medical student [21, 30].
\nAttitude means “spirit” or “perspective” for an assessment of topics, people and objects. This attitude consists of a cognitive and an emotional component. This mixture of opinions, beliefs and values has to do with respect for the individual and his or her socio-cultural environment, a strong sense of responsibility and care, empathy, patience, perseverance and trust in the opposite person as well as in himself or herself. The “attitude” changes in the course of life through different experiences [31]. For example, someone may have the competence to do a task but not the “attitude” to do it. In other words, being competent does not necessarily mean that you want to achieve something. Just because someone knows how to give advice to smokers [32] and has the skills to do so does not mean that they are necessarily interested in giving advice to smokers and are motivated to do so.
\nThe question, therefore, arises whether health care professionals will use this competence in the future, that is, whether they will give advice to smokers. That depends on whether and how much sense they see in the counselling of smokers. It depends on their point of view, their attitude and their tolerance towards smokers and the recognition of the smoker as a serious person and smoking as an addictive disease. It also depends on whether they recognize the possibility and necessity of helping a patient. Attitude is subjective and based on emotions. It corresponds to what a person thinks and feels and what he or she is motivated to do. And precisely because the best competence is usually only put into practice when there is a correspondingly open, positive attitude towards patients who smoke, so much emphasis is placed on conveying attitudes in smoking counselling courses and measuring their change. In the discussions and in the role playing, the students were able to experience and live the attitude conveyed in the course, “to do everything for the smoker and do nothing against him/her”, which was well understandable and was ultimately adopted to a large extent. The remarkable change in attitudes resulting from a smoking counselling course can best provide positive outcomes in the long term, as it is likely that behaviour towards the patient is most strongly influenced in this dimension. Attitude is therefore extremely important in order to be able to apply an existing competence and thus a prerequisite for a successful result. In the case of smoking counselling, the latter does not only mean the ultimate goal of stopping smoking but also every step towards weaning.
\nThis chapter introduces concepts that are useful for advice. The concepts in this chapter are applied to smoking counselling, but they can also be used for counselling where other behavioural changes are in focus. At the end of the chapter, there is a handout that can be used as an overview and cheat sheet for the consultant.
\nSmoking is an addiction, and smoking cessation follows certain stages that merge into each other [26]. The doctor can help with this process, but the patient has to make the decision to quit smoking. The doctor can contribute to this decision by informing the patient using targeted strategies and arguments and leading the smoker to the next stage. This is already considered a success, and in some cases, when the smoker reaches a high level of motivation, the doctor can take the preparations for a smoke stop and accompany him/her.
\nDuring the cessation of smoking, the smoker experiences different stages of motivation. The different stages are described in the “stage-of-change” model of Prochaska and DiClemente [26, 33]. Depending on the stage, the probability of becoming a non-smoker increases.
\nThe smoker is initially at the stage of carelessness (“pre-contemplation”), followed by the intellectual debate (“contemplation”) and the preparation (“preparation”). In order to help the smoker specifically with smoking cessation, the doctor must find out to what extent the patient is motivated to quit smoking. After that, the doctor can gradually guide him/her to the stage of action. Finally, the maintenance of abstinence after a smoke stop (“maintenance”) must be achieved, and a relapse must be avoided by successfully maintaining it [23] (see \nFigure 2\n and \nTable 1\n).
\nStage of change model according to Prochaska and Di Clemente.
Characteristics of the smoking cessation stages [26].
In our society, approximately 70% of patients are in the stage of pre-contemplation, 20% are in the stage of contemplation and about 10% are in the stage of preparation [33].
\nOn average, a smoker needs several cessation attempts as “learning episodes”—up to seven times is not uncommon. Since passing through the various stages of smoking cessation process is a learning process, it is not a waste of time, but rather a further success. Ex-smokers are usually considered permanently smoke-free in studies after 1 year abstinence (\nTable 2\n).
\nObjectives of the medical intervention [24].
The following five As have proven their worth in smoking counselling. It is an easy to follow scheme that summarizes the practical smoking advice and can serve as an aide memoire (“cheat sheet”) during the counselling interview [34].
\n
\n
\n
\n
\n
Every patient should be questioned about his or her smoking habits during a doctor\'s visit as discussed above. According to the guidelines, the doctor has to advise the smoker to give up smoking with clear and specific words. The following two sentences could be said in this regard: “It is important that you stop smoking immediately. I can help you.” or “I am your doctor and must point out to you that stopping smoking is the most important thing you can do for your present and future health. I will support you in this.” The advice must be personal and tailored to the smoking person\'s situation, health and social environment. For example, the danger to children can be mentioned [34].
\nEfforts to quit smoking will only be successful if the smoker has sufficient motivation and a strong will to stop smoking. In patients who are unwilling to quit smoking, the recommendation of a withdrawal program may be premature and has no effect. Details how to increase a patient\'s motivation to quit using tobacco products are giving in motivational interventions. Motivational interventions can be divided into five basic types, or the five Rs: relevance, risks, rewards, roadblocks and repetition [35].
\nThe five Rs are effective in increasing a client’s motivation to quit tobacco use. Using the five Rs, strategy gives clients the opportunity to express their motivation for quitting in their own words and provides the opportunity to tailor their responses to meet the specific needs of the client. The five Rs are discussed in more detail later.
\nThe patient is encouraged to look for the reasons why the attempt to quit is personally relevant to him/her. In order to motivate the patient, the inclusion of the personal situation is most effective, that is, status or risk of illness, family or social situation (e.g., children at home), health concerns, age, gender and other important factors for the person (e.g., previous cessation attempts and personal barriers on the way to a smoke stop).
\nThe patient should identify potential negative effects of tobacco use. The doctor should highlight those risk factors that are the most important in this case. It should be noted that smoking cigarettes and other forms of tobacco use (smokeless tobacco, cigars and pipes) do not eliminate these risks. Examples of acute risks are shortness of breath, exacerbation of asthma, endangerment of the child to be born, impotence/infertility and increased serum carbon monoxide level. And long-term risks are, for example, myocardial infarction, stroke, lung cancer and other tumour diseases (larynx, oral cavity, throat, oesophagus, pancreas, bladder and cervix), chronic obstructive pulmonary disease (chronic bronchitis and emphysema), permanent disability and thus loss of autonomy and need for help. There are also risks for the environment: increased risk of lung cancer and heart disease for the spouse, increased probability that children will smoke, increased risk of children being born underweight or developing respiratory infections and increased risk of sudden infant death [36].
\nThe patient should be asked to mention the advantages of smoking cessation. The physician should highlight the advantages that are most important in this case. Examples of potential benefits are better health, improved sense of taste and smell, financial savings, you feel more comfortable in general, clothes as well as house or car don\'t smell like cigarette smoke, better breath, no more worrying about a possible smoking cessation and exemplary function towards the children.
\nThe patient should be asked to name the disadvantages or barriers when stopping and to look for possible countermeasures (problem solution and pharmacotherapy). Typical obstacles are withdrawal symptoms, fear of failure, weight gain, lack of support, depression and desire to smoke.
\nThe intervention to increase motivation should be repeated each time patients express doubts about the smoking stop. Tobacco consumers who have experienced unsuccessful attempts to stop smoking should repeatedly be made aware that several serious attempts to stop smoking are the rule [24].
\nSmoking is an addiction; addiction is a disease, and it needs to be treated. Dependence is not imagination. Not only will, but also the right way is decisive (see \nFigures 3\n and \n4\n). The physician should give the patient didactic information that can help stop smoking:
Smoking means nicotine addiction. Therefore, smoking cessation is just as serious as any other drug withdrawal. The will alone is often not enough. The patient must declare the smoke stop to be the highest priority.
After the cessation date, total abstinence should be the goal.
The patient should know that unpleasant nicotine withdrawal symptoms can occur. For most people, the symptoms start to appear a few days after smoking has stopped and disappeared after 1 to 2 weeks.
The patient should be made aware of situations that can jeopardise abstinence at the very beginning of the smoke stop and should, therefore, be avoided. These can be events, states of mind, behavioural habits or activities that are associated with smoking and can, therefore, lead to recidivism (e.g., negative emotions, society of other smokers, alcohol consumption and celebrations).
The patient should learn appropriate cognitive and behavioural techniques to prevent the desire or need for a cigarette. Examples of cognitive techniques are recalling the reasons for smoking cessation, saying that desire passes and repeating the phrase “smoking is not a solution”. During craving, auto-suggestion could be performed, for example, combined with deep inspiration mimicking cigarette inhalation: “And I am so happy that I manage not to need a cigarette”.
Behaviours that can be used to resist the temptation to smoke are leaving the place, dealing with a distracting activity, deeply inhaling and seeking support in the social environment [23].
Smoking cessation: assessment and advice. Tobacco weaning—assessment and counselling [
Smoking cessation: medical treatment.
To find out which areas of a patient\'s or client\'s behaviour are problematic and which are not and to what extent he or she wants to change this behaviour, patients or clients and health care professionals can use illustrative tools as shown in \nFigures 5\n, \n6\n, \n7\n [37, 38].
\nAxes of motivation.
Spider graph assessment of different life style axes.
Therapeutic aspects of life style change.
In the civilized first world, the change from nomadic life with constant daily activity of moving eight or many more hours a day and with scarce nutrition to a world of highly diverse working activity with much more non-physical, sedentary work, more spare time and with physically passive sitting transportation has become of importance and results in a number of new psychosocial problems. Time spent in sedentary posture is highly associated with waist circumference and cardiovascular risk [39]. In the past century, a dramatic shift from non-industrialized countries suffering from communicable diseases to industrialized or modernized countries burdened with chronic diseases has taken place and also affects densely populated countries such as China and Brazil [40]. This increase in chronic disease rates has created an enormous social, emotional and economic burden. However, society underestimated the problem for a long time focused too much and fostered individualised motor vehicle traffic. It thus sacrificed concepts of walkability and bikeability in most areas from little villages up to hugest towns and exposed children and their residual playing areas as well as the whole society including animals to motor traffic dangers including physical accidents, air, ambient and thus food and water pollution, noise and light.
\nAlready nearly 2400 years ago, sedentary behaviour was considered harmful by Plato, living from 427 to 347 before Christ: “Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it”.
\nIt is only since 2012 that we know the real impact of physical inactivity on health. Inactivity has to be attributed to a shortening of life expectancy of about 10–11 years of individuals exposed to such lifestyle. It, therefore, became at least as important as smoking in the Western society, leading to the health slogan “Inactivity is the new smoking”.
\nIn the light of such social development, it became increasingly important to address more lifestyle questions than only smoking in diverse health-related work. We therefore obtained to broaden the spectrum of her smoking cessation counselling student course to those normal fields and therefore aim to describe as a series of algorithms some “good” aims for a number of common problems including some substance addictions and process addictions of our patients or clients. In the forthcoming sections, he, therefore, describes very prudently, focally and not covering the whole area, and usually with only few evidence, but hopefully with the common sense of a multifaceted team of persons active in patient care, such as conceptual bases.
\nAs already mentioned in Chapter 5, one of the hugest changes in our lives is the change from daily seeking nutrition to a world that offers extremely diverse jobs, many of them very sedentary, and that offers mobility without important individual physical activity, and much spare time, again with in part huge sedentary activities such as TV and Internet.Over 10,000 years, the human body has been optimized and genetically programmed to move frequently [41]. While modern technology has made life easier, it has become an obstacle to physical activity. For example, sitting in front of a laptop all day will make a person less physically prone to move around: of seminal importance may then be residual physical activities besides laptop activity [42]. There is little evidence to suggest that reduced occupational physical activity leads to compensatory increases during leisure time or vice versa. Studies from Europe, the United States and Australia found that adults spend half of the working days sitting (4.2 hours/day) and about 2.9 hours/day of leisure time sitting [39]. Time spent in sedentary posture is associated with waist circumference and cardiovascular risk.
\nPhysical inactivity actually accounts for up to one third of Western world persons reducing life expectancy by about 10–11 years [43] and, therefore, became as central as smoking. Physically inactive children and adolescents develop less cognitive skills than more active cohorts [42]. Sedentary living is a risk factor for global mortality that is associated with arterial hypertension and all consequences of vascular disease including coronary heart disease and stroke and with undiagnosed or diagnosed metabolic disorders especially including diabetes mellitus, obesity, liver disease and overweight. It is furthermore associated with sleep disordered breathing, with muscular and osteo-articular consequences including pain and disability, but also with increased risks of a number of cancers including breast, endometrial, lung, prostate and colon cancer [43, 44], and probably also with low-grade inflammation [41]. Muscle mass, strength and function seem to play positive roles in recovering from illness, and muscle gain seems even to be anti-inflammatory [45]. Sarcopenia, the deterioration of muscle mass and quality, is a sign of aging but can usually be reversed by training. Muscle is of importance in self-determination in life due to independent deambulation and is necessary to circumvent home care in the elderly or to self-help: standing up without the help of one hand or of two hands differs concerning health prognosis, and many sarcopenic people cannot get up from the floor at all without help.
\nPhysical activity is one of the three biological component modulators of health, that is, physical activity, enough and recovering sleep and adequate nutrition. However, key further elements are psychosocial aspects including relationship and sexuality; family, friends and social surrounding and professional situation. Physical activity is an effective means of curbing the prevalence of child obesity. Fundamental skills are important determinators leading to physically active or inactive behaviour in children: teaching movement skills to young children at the age of about 4 years seem therefore important [46], as motor skills in preschool age and physical activity at school age and probably later are much related [47].
\nPhysical activity and exercise should be viewed as a medication, frequently surpassing health benefits of conventional medications, and in the absence of side effects. They change the underlying mechanisms for physiological functioning and cause increased myocardial oxygen supply, decreased myocardial oxygen demand, increased myocardium electrical stability and overall improved myocardial function [40]. There is a dose-response relationship: health benefits are gained with physical activity and exercise 150 minutes/week, but more health benefits are seen when 300 minutes of moderate physical activity is achieved [40].
\nConcerning physical activity recommendation, we stick to the World Health Organization recommendation.
\nIn adults, physical activity includes leisure time physical activity, transportation (e.g., walking or cycling), occupational (i.e., work), household chores, play, games, sports or planned exercise, in the context of daily, family and community activities.
\nThe recommendations in order to improve cardiorespiratory and muscular, fitness and bone health, reduce the risk of anxiety and depression and aim at physical activity and exercise as a part of our everyday life [40]:
Adults (aged 18–64) should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.
Aerobic activity should be performed in bouts of at least 10-minute duration.
For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week or engage in 150 minutes of vigorous-intensity aerobic physical activity per week or an equivalent combination of moderate- and vigorous-intensity activity.
Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.
For older adults, there are further recommendations. They should increase their moderate-intensity aerobic physical activity to 300 minutes per week or engage in 150 minutes of vigorous-intensity aerobic physical activity per week or an equivalent combination of moderate- and vigorous-intensity activity. Older patients, with poor mobility, should perform physical activity to enhance balance and prevent falls on 3 or more days per week.
\nSome factors can contribute to physical activity. A buddy or a group event, for example, for training can help a person to keep activity due to the group or peer pressure. Appointments should be treated at the same level of priority as professional appointments; weather should in most instances not lead to cancelling exercise. It would be of profit to integrate sports as physical activity or part of it with the partner, although there might be differences in physical strength, in endurance and so on. Sometimes the differences can well be circumvented, for example, by one partner doing only part of a jogging trial, by doing biking with a normal and the less physically performing partner with an electric bike and so on. It would be of profit to plan weekends and holidays aiming at high physical activity level. For very old and highly frail and disabled or highly impaired (e.g., COPD, respiratory failure, cancer, etc.) patients, there are to our knowledge no clear data on minimal muscle mass or on data to prevent falls [48]. Note that one of the first signs of sarcopenia is motoric uncertainty. One reasonable guess of recommendation may be to achieve at least 800 steps per day in order to sustain independence in deambulation. Also, 30 times 1-minute activity per day could be an option.
\nOverweight is epidemic in Western civilizations, in the USA affecting nearly 70% and obesity (body mass index ≥ 30 kg/m2) one third of Americans. They result from the imbalance between caloric intake and caloric use [49]. Together with type 2 diabetes and dyslipidaemia, weight problems became one of the most serious health problems worldwide. Weight is crucial, and guidelines for type 2 diabetes may have too much focused on reducing blood sugar levels through drug treatments. One study showed that 9 of 10 people in the trial who lost 15 kg or more could lead their type 2 diabetes into remission [50]. Overweight after smoking is the second most frequent preventable factor for cancer prevention, including not only post-menopausal breast cancer, endometrial cancer, oesophageal adenocarcinoma, gastric cardia cancer, liver, pancreatic and kidney cancer, but also colorectal cancer, cancers of the thyroid, the gallbladder, meningioma and multiple myeloma [51]. Hormonal (adipokines) and growth factor production and metabolism by fat tissue seem responsible. In the USA, estimated 10% to one third of cancers could thus be preventable by weight control. Estimations also link a body mass increase by 5 kg/m2 to 10% additional cancer risk [52].
\nA part of obesity is attributed to physical exercise and activity pattern including work and spare time (sitting, television, computer, aids of car, escalator, electric dishwasher, washing machine, robotic lawn mower, robot vacuum cleaner and electric toothbrush) as above. However, body weight regulation is complex: it is dependent on appetite regulation, nutritional factors and eating behaviours, which includes biological and genetic mechanisms evidenced by heritability not only of modest effect size as in twin studies but also of epigenetic factors, and is not completely under personal control [53]. Why we eat, what and how much we eat are determined by portion size, taste, caloric density and setting. Peripheral signals from our gut and fat stereos relay information in a bidirectional pathway to our brain to tell us when we are hungry or full. While some signals translate into conscious decision-making, many do not. Therefore, many questions remain actually open on what we eat, particularly when food is always available. Known are habit, convenience, opportunity, cost and social factors [49]. Eating patterns are affected by more than the caloric and nutritional value of food. Consumptive behaviours are driven by previous experiences, timing and emotional and pleasurable aspects of eating. Modern foods and drinks are extremely highly processed, frequently with added sugar and fat and extremely appealing, and seductive to consume even more, so that we are a bit “addicted”. Often we are unaware that we are eating too much. Usually, we underestimate the caloric intake quite highly even when trying to count calories, as shown by Lichtman et al. who showed the difference of 1000 calories per day on average between perceived intake and actual intake [54]. During aging, a reduction in muscle mass and physical activity leads to a lower metabolism and therefore gives tendency to weight gain that should be adapted with less caloric intake.
\nOverweight is very clearly visible in most patients. It is in many instances, and society-specific, perceived as an important psychosexual burden. Many patients feel ashamed and, by that, additionally lose quality of life besides that of somatic origin that is inherent with worse mobility, higher exhaustion and so on. There is an evidence of inequities of employment, stigma from health care providers, bias from educators, weight based-stereotypes in the media and rejection and exclusion in interpersonal relationships. This weight discrimination has become one of the most commonly reported types of discrimination in the Western world, and among youth, being overweight is one of the most prevalent reasons for victimization and harassment at school [55, 56].
\nIndividuals experiencing weight stigma are vulnerable to psychological stress, including depression, anxiety, low self-esteem, poor body image, substance use disorder and suicidal thoughts and behaviours. Perhaps the consecutively increased risks of binge eating, unhealthy weight control behaviours, increased calorie intake, avoidance of physical activity, reduced motivation to diet and elevated physiological stress are less intuitive, but consistently demonstrated, all of which can reinforce obesity and weight gain [57, 58]. Such weight discrimination increases further odds of becoming and remaining of these over time [59, 60]. Reduced quality of health care and avoidance of health care owing to experience of weight stigma have been reported [61]. Actual evidence contradicts public perceptions that fat shaming will provide the concerned individuals with incentive or motivation to lose weight. Instead, such stigma reduces the quality of life and may inadvertently worsen weight-related health outcomes [53].
\nBoth, losing weight and, more important, maintaining weight loss, are two different entities and require distinct skills and attitudes. During weight loss, adaptive responses of metabolic, neuroendocrine and autonomic pathways try to reset weight to the previous higher weight, for example, by the systemic rise of the hunger hormone ghrelin, the decline of leptin as the key adiposities and suppressor of food intake; the resting metabolic rate—the biggest contributor to energy expenditure—declines, and skeletal muscle adapts to become more efficient, requiring fewer calories for the same work [49]. A couple of diseases not only hypothyroidism, lipoedema, M. Cushing, syndrome X and polycystic ovary syndrome hormonal changes but also sometimes depression and chronic stress are associated with more difficulty for weight loss due to a metabolic interference, which is also the case with medications such as sulfonylureas, beta-blocking agents, some antipsychotics, antidepressants, antiepileptics, hormones including anti-conceptive agents and corticosteroids.
\nWhereas exercise contributes rather little—but sometimes the important part—to weight loss, it plays an important role in maintaining reduced weight. It confers other benefits. It improves insulin sensitivity and blood pressure, redistributes fat and improves mood and well-being. It should, therefore, be part of any lifestyle intervention. However, some patients may be relieved to hear that they do not have to focus so much on exercise. Non-exercise activity thermogenesis is performed by standing more than sitting, doing more little walks by parking the car farther away from a store or the work site and so on. These activities may contribute to a modest increase in energy expenditure and are a way to gradually add in exercise [49].
\nProbably the most important aim is the normalisation of the physical and the psychosocial situations. In many patients’ situations, this means that normalisation of weight should be the aim of weight reduction.
\nHowever, a weight reduction into a range of much better physical performance, of normalisation of actual disease such as pre-diabetes, can sometimes be a compromise. In a considerable proportion of patients, the compromise occurs itself, as it is where the patient arrives within months or years of follow-up with his weight and fitness. We still then have to keep in mind that the whole psychosexual aspect of obesity can highly impact the person’s life, relational and social functioning.
\nThere are recommendations that if people wish to have a sustained successful weight loss that then not 10,000 steps but 12,000–15,000 steps would be wise [62]. Note that this is a lot, as the 30 minutes of moderate exercise is only about 3100–4000 steps [63]. In order to build aerobic fitness, the recommendation would be to do 3000 of the daily steps fast. Note that for a 75–80 kg person, 10,000 steps are roughly 500 calories of energy. However many variables contribute in this fact, for example, speed, denivellation and so on, 10,000 steps more per day would be 3500 calories difference and thus about the burning of 0.5 kg of fat per week (1 kg equals about 7000 calories). In 20 weeks, there would be a potential of 10 kg weight loss (that had then to be stabilized as the second challenge). Note that walking is easier for most overweight persons and is also clearly more recommended than jogging by the associations like the American College of Sports Medicine; walking is less leg joint distressing than jogging, that is, it halves maximum forces for a knee from the equivalent force of about 7 to 3.5 times the own body weight. Beginning with jogging is more difficult, as any activity will give muscle soreness, and initial “overactivity” can thus lead to pain and sufferance, frustration and potentially impede an excellent intention. Nordic walking clearly further reduces those forces; it gives further a more integral muscular training integrating virtually the whole body musculature [64]. Novel data on 40-minutes per day by an electrobicycle to go to work suggest important health profit in sedentary persons.
\nThe surgeon general advises for an increase in physical activity, for example, to increase the steps per day by 20% each week and to get to 10,000 (or 15,000) steps [62]. Apart from Amish and from Tsimane populations, we might derive that more than 15,000 or even more than about 17,000 steps a day might be ideal in terms of health, possibly reflecting that we are not meant to sit around and that for hundred thousands of years we have been on our feet for 8 hours or more. As we all cannot necessarily hit that number, we should aim to reduce sedentary behaviour by interrupting prolonged periods of sitting with walking or standing and reflect our working, transportation and spare time procedures.
\nAs professional life is an important integrating factor and an important axis of self-fulfilment, it may be important, especially in young persons, to best integrate or help to integrate the patient/client in professional life, to manage that the person has fulfilled adequate schools and works, that is, appropriately to her or his professional educational level in the first-job market (see the discussion earlier on inequities of employment) and to help to keep in a long-term stable and good professional life. Workload reduction may sometimes be a solution for physical activity or training in severely obese patients.
\nSleep is rather frequently affected in obese and severely obese patients, either by obstructive sleep apnoea hypopnoea syndrome or by adiposity-hypoventilation. As sleep is a huge resource for any physical, mental or intellectual activity, it is of key importance to solve relevant concomitant sleep problems. Patient history and sleep screening tests should in many instances be performed, and arterial hypertension, pre-diabetes or diabetes mellitus should be diagnosed and treated.
\nBesides nutrition and exercise, sleep is the probably most underestimated physiological resource for a healthy life. It is of central importance for physical functioning as well as for emotional and intellectual integrity. Deep sleep and rapid eye movement sleep, for example, are the key to learning, be it memorizing facts or be it movements, and thus the key to any good functioning in a society.
\nSleep is necessary to be performant. However there are untoward restrictions of sleep for many peoples, whether in school and student life, at weekends, or during the working week. Its consequences are manifold and probably more complex than long time assumed.
\nSleep deprivation is one of the most prevalent problems of Western society beginning usually in adolescence. Within a 5-day week, there are a huge proportion of people who have a sleep deprivation of about one night in total. We all need individual sleep time that may bit and rarely considerably differ from about adults 7½–7¾ hours as a rule of thumb. Retired persons usually sleep 20 minutes per night longer and with better sleep quality probably due to less psychological distress [65]. Also, midlife sleep problems are probably associated with cognitive decline [66].
\nSleep deprivation has many consequences. Sleep is important for any cerebral process and therefore for any functioning of our physical systems. For example, sleep influences how our bodies recovering and restoration and includes metabolic links, it influences how we learn and memorize facts or movements and it influences our psychic stability. It is also linked to weight gain. Data suggest that 30-minutes less sleeping lead to weight gain: Logically, it is practically impossible to stay committed to a healthy lifestyle if we do not have the energy for it. If we go late to bed or have a restless night, we are more likely to both skip exercise and eat less healthily.Sleep deprivation is thus linked to car and work accidents, relationship troubles, poor job performance, job-related injuries, memory problems and mood disorders. Short sleep duration, obstructive sleep apnoea and overnight shift work are underrecognized as predictors of adverse outcomes after acute coronary syndrome. Increased efforts should be made to identify, treat and educate patients about the importance of sleep for the potential prevention of cardiovascular events [67].
\nThere may clearly be huge and in part vital impacts for any other substance addictions including alcohol, cannabis, oral, sniffable and inhalable or injectable drugs. There is some basis in common that makes the situation rather similar to counselling like for smoking cessation. It is of note that we know from heroin addicted persons who frequently are also smokers that heroin addiction is not more difficult to stop than smoking, but rather similar. For all those substances, there are peculiarities, for example, the limited evidence of chronic cannabis use and less employment, which is not so clearcut as cannabis is more frequently chronically used in socially less privileged persons. This also seems similar to cannabis and social functioning or the engagement in the developmentally appropriate social roles [68].
\nShopping has become one of the most popular leisure activities. Shopping centres are increasingly replacing green areas on which people used to play, walk and breathe clean and healthy air. Complex and subtle advertising measures influence our consumer behaviour [69]. In the 1990s, it was highly controversial to realize that buying, like playing or working, can take on the character of an addiction. Looking at the surface, the compulsive buying is actually lacking some characteristics of other addictions; it is a “clean” addiction, and the people affected are active, successful and performance-oriented and seem to have a perfect grip on their lives, while alcoholics or other addicts are regarded as unstable, weak-willed and externally controlled [70]. It is a rather discreet addiction that is difficult to recognise for outsiders. Compulsive buying rarely changes the personality at least not at an early stage [71].
\nCompulsive buying can be described as a persistent and recurring, and maladaptive buying of consumer products that disturbs personal, family and professional goals often even burdens them very heavily. People concerned often negate the serious psychological, social and economic consequences [72]. It is not the products purchased that constitute addiction, but rather the experience of buying itself. This alienated behaviour is characterised by increasing internal pressure, which can only be reduced by purchasing the goods. Short-term relief and the resulting feeling of happiness after the purchase are associated with long-term consequences such as financial and social problems in addition to feelings of guilt. Other features are the futile attempts to resist the impulse and the loss of control over buying behaviour [73].
\nPrevalence rates of 2–8%, and 80–95% of those affected are female. The disorder usually starts at the age of 20 ± 5 years. The course of the disease is generally chronic, although most patients do not receive treatment until two decades later. Systematic studies on therapy are missing [73].
\nTreatment of compulsive buying is much developing. Pharmacotherapeutic approaches play an important role in the USA [74], whereas the focus in Germany is on behavioural therapy [75]. “Immediate measures” for the establishment of controlled purchasing behaviour include the immediate return of credit and debit cards and the return to cash payments, the targeted analysis of the triggering situations, the avoidance of periods of high seasonal consumption (e.g., the pre-Christmas period), the inventory of one\'s own possessions and the permanent keeping of this inventory and the regular keeping of budget books. The therapy aims to process and modify situations that trigger compulsive buying and to strengthen the resources in order to prevent unwanted and damaging behaviour in the future [76]. Key behavioural interventions include graduated exposition with reaction prevention, self-regulation techniques and stimulus control as well as cognitive restructuring techniques.Leite et al. examined a number of cognitive-behavioural therapies [77], including cognitive-behavioural model, identifying buying problem behaviours and learning to identify the normal buying, assessment of pros and cons of compulsive buying, financial planning including putting limits or getting rid of credit cards, assessing the “pleasure of buying” behaviour that includes emotional regulation of impulsive feelings, restructuring thoughts; working with exposure; response prevention, work on self-esteem and training in social skills, stress management and problem solving. Relapse prevention and the elaboration of a relapse plan are further key elements ([77], p. 419). Affected persons can also benefit from self-help groups and self-help books.
\nTheoretically, unresolved addictive behaviour like compulsive behaviour can shift to other compulsive behaviour, for example, to compulsive Internet use or gambling.
\nPathological gambling is a common disorder associated with social and family costs. Much is in common to substance addictions, and much less with impulse control disorders and high comorbidity exists especially with alcohol problems. According to DSM-V, an individual must have at least four of the following symptoms within 12 months [78]:
Needs to gamble with increased amount of money in order to achieve the desired excitement;
Being restless or irritable when attempting to cut down or stop gambling;
Having made repeated unsuccessful force to control, cut back or stop gambling;
Being of preoccupied with gambling (e.g., having persistent thoughts of relieving past gambling experiences, handicapping or planning the next venture and thinking of ways to get money with which to gamble);
Often gambling when feeling distressed (e.g., helpless, guilty, anxious and depressed);
After losing money gambling, of returning another day to get even (“chasing” one’s losses);
Lies to conceal the extent of involvement with gambling;
Having jeopardized or lost a significant relationship, job, education or career opportunity because of gambling;
Relying on others to provide money or relieve desperate financial situations caused by gambling.
The lifetime suicide risk seems rather high especially in the early onset of problem gambling, and comorbid substance use and comorbid mental disorders increase its risks. Reports that are up to one in five pathological gamblers attempt suicide underline that the rate is higher than in any other addictive disorder [79]. Treatments involve counselling, step-based programs, self-help, support, medication or a combination; however, no treatment is considered to be most efficacious, and no medications have been approved for this specific addictive disorder. The SSRI paroxetin or the opioid antagonist nalmefene or in comorbid bipolar person lithium seems to have some effect [80, 81]. Similar to “Alcoholics Anonymous”, “Gamblers Anonymous” exists and is in the USA, a commonly used resource. Cognitive behavioural therapy has been shown to reduce symptoms and gambling-related urges.
\nCultural achievements and processes in economic and social life are based on the work of people, so that work can be understood as a central foundation of human life. Diligence, efficiency and success are considered virtues and foundations of the modern performance society [82]. Through work, people can satisfy many basic needs, such as social contact and self-realization. As a result, the work fulfils numerous functions in addition to merely securing one\'s livelihood [83]. However, if a person becomes addicted to work, cannot determine the amount and duration of work, cannot be inactive and develops withdrawal symptoms, if he or she does not work [84], then work behaviour becomes pathological, problematic and is defined as workaholism. This is an uncontrollable, inner compulsion to become active not only in the world of work but also in leisure time and private life, while at the same time, other possibilities of behaviour that are subordinated to working and addictive behaviour similar to substance-related dependencies are shown [85].
\nThe workaholic is mentally and physically addicted to work. He can no longer control his work behaviour (loss of control). He works longer than he intended or in situations in which he cannot or should not work, for example, in the event of illness or in social situations outside the workplace. It is impossible for him not to work (abstinence incapacity), so that he suffers from withdrawal symptoms when he is not working. Workaholics report that in such situations they experience feelings of pressure and tightness, deep sadness or massive states of inner restlessness. However, physical symptoms can also occur during periods of non-work, for example, nausea, headaches or sleep disorders. Due to the development of tolerance, the workaholic has to work much more to achieve the desired effects, for example, a feeling of performance, a feeling of raison d\'être, the suppression of feelings of fear or displeasure, hinting to a dose increase. The working behaviour is not only extended quantitatively in the sense of more working hours, but there are also qualitative changes in the working behaviour. For example, many workaholics tend to take care of jobs for which they are not or too well qualified. Psychosocial and/or psychoreactive disorders also occur [86]. The characteristics of workaholism are summarized in \nTable 3\n.
\nCharacteristics of workaholism [84].
Results show that workaholics complain significantly more about physical complaints than non-workaholics. In a group of workaholics, 40% report heart pain, 54% report aching limbs, 43% of workaholics suffer from stomach complaints and 58% from general exhaustion such as fatigue or feeling weak. In all aspects, the workaholics can be classified into a greater extent in the group with severe health problems [87].
\nWorkaholics often lack the insight to be ill. Normally those affected do not take help because of excessive work, but the pressure of suffering and the desire for change grow due to the numerous negative consequences that occur [88].
\nThe focus of therapy is on concrete instructions for future everyday life. They include meditation, relaxation, better daily schedule, flexibility and balance. Regular participation in meetings with other workaholics to talk about one\'s own problems, which could help to overcome conflict situations, also plays an important role. Fundamental is that the addict shows an insight into the disease and thus sees a need for action due to the pressure of suffering. The addict should analyse his or her work behaviour more closely, set new goals and refrain from all unnecessary activities. Finally, a detailed schedule is drawn up, which precisely regulates the daily schedule—in particular breaks and leisure time [89].
\nCox et al. [90] described the concept that workaholism is an endogenous addiction. In their leisure time, workaholics should be led to activities that give them pleasure. This would bring the joy itself and then the new experience of leisure activities. This could act as a stimulus for endogenous opiate secretion in a more stress free and therefore healthier way [90].
\nSpecific individual measures are [91] a consistent time management; read and edit emails only 1–2 times a day; set up smartphone-free times, if necessary via an app; set up regular rest periods, for example, with a block as an appointment in the calendar; follow a hobby regularly, for example, minimally 2 times per week; spend time with friends and family on a regular basis; learn passive relaxation techniques, for example, autogenic training, MBSR and meditation and if required, support in individual coaching by business coach.
\nBasis for any more profound professional relationship is, however, a symmetrical communication basis at the same level as the patient or client. The good relationship is essential, and its authentic emotional basis is the only way to be able to put together in question things: The patient or client accepts confrontation only when a symmetry is present and he or she feels a huge quality of relationship. Relationship that functions gives the patients or clients “moments of truth” and the authenticity of feeling and thinking that help him/her to find and believe in his/her own resources to try a novel way with a life change. Therapy is completely oriented at the patient’s or client’s resources. This is contrary to physician’s assessment of pathologic findings as a deficiency-oriented thought. As therapists, we have to support self-efficacy, that is, the patient’s or client’s self-belief in his ability to change, for example, focusing on past successes, skills and strengths and promoting self-esteem and confidence. Briefly, therapists can only help to modulate a life change when they have this sound relationship. The necessary skills and attitude for counselling can be learnt and trained, intervised or supervised, with elements from different techniques, including motivational interviewing, as shown earlier.
\nAs soon as a therapist “lives” or communicates non-verbally or verbally a bias, for example, devalorises smoking or overweight, an emotional barrier between therapist and client or patient results that may block emotional openness to address important personal problems in an ensuing discussion. Therapeutic persons should therefore be very open-minded and supportive towards any problem that interferes with the health of a patient or client. Carl Rogers with his humanistic person-centred approach defines three essential basic elements for an optimal conversation: congruence, empathy and unconditional appreciation. Congruence means authenticity, genuineness and transparency on the part of the therapist/consultant. Empathy is the empathetic understanding, the non-valuing approach, that is, the real understanding of a person. Unconditional appreciation is the therapist/consultant\'s acceptance and sympathy for the feelings and statements of his patient or client. This does not mean that the therapist must necessarily agree with these feelings. But it means that he accepts his patient or client without judgement and prejudice. This attitude should be adopted by every good therapist/consultant [92]. And we should be aware of interfering central roles of relationship and sexuality, of working or occupational situation and of the patient’s home situation.
\nOne of the key questions is which aim to propose to a patient or a client. The aim should have a rational background and should be realistic to obtain in a shorter period of time as well as in long term. There might be a mixture of “tailored” aim that not only includes the assumed patient or client resources, but also some ideal should probably be included. This seems important as we sometimes overestimate patients and, especially, also sometimes underestimate their faculties: if a heroin- and nicotine-dependent persons achieve to stop smoking or to stop the heroin consumption, then it is a huge achievement that should also be reflected with the patient or client and highly valorised. In areas like overweight management or physical activity management especially, intermediate aims could also be iteratively adapted, for example, in terms of a shared decision.
\nIn the perspective that patient and client care have changed due to a novel insight into the major role of lifestyle aspects, as discussed, that can tremendously interfere with health status and survival, we are obliged to integrate those in therapeutic situations and to improve communication on them also between different therapists. Setting together aims (e.g., stopping smoking) and defining milestones (e.g., at 3-month re-assessing smoke stop, in case of smoke stop empowerment and 3-month follow-ups, in case of continuous smoking beginning with varenicline and weekly therapist visits for smoking cessation during 2 months, then monthly follow-ups) when to re-assess patient or client situations and defining the adequate algorithms for patient or client care would probably improve the patient or client outcome.
\nIn a short, a 4-hour course could give 87 medical students a wide array of knowledge, skills and attitude towards smoking cessation and evidenced with a vast spectrum of measurements including blinded analyses of conversations with a figured patient. However, as many other areas are of major importance in terms of prevention, the most important question arises whether or not such gain of experience can be derived to other subjects as obesity counselling or exercise counselling in our patient and client care. While many parallels exist between the different areas of counselling on habits and lifestyles, we can only assume that counselling competencies can be deduced to such areas but cannot answer this by data. In common, for any important therapeutic effect, some bases for effective communication and a therapeutic attitude most probably exist. One common denominator is also that there is no way to make people like a lifestyle change. By means of thoughtful and empathic communication and an adequate attitude, we most probably can help for a lifestyle change, ultimately always to make the patient or client feel less threatened by performing this change.
\nThe authors acknowledge Sarah-Lea Hipp, Graphics & Typography, www.sarahleahipp.ch, for designing and providing the figures. The authors also acknowledge the financial support of the Lungen-und Atmungsstiftung, Bern. The authors highly acknowledge the interactions with patients, clients, students and colleagues including interdisciplinary colleagues for all the discussions, contributions, style and culture that are tried to be presented in this chapter.
\nThe authors declare no conflict of interest.
This book chapter is intended to develop ideas on increasing knowledge, skills and attitude in different therapeutic settings. It is far from perfect and is aimed to lead to discussion and interaction. The authors highly welcome feedback and criticism to improve this presented work in progress.
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