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Transitioning from Acute Care to Lifestyle Medicine

Don Bovell

Presenter

Don Bovell

Emergency physician in Central Florida

Conference

Recorded

  • October 29, 2013
    4:30 PM
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R has a prayer please family father we thank you for this wonderful day we thank you for the conversations about health that we've had today new we need practical applications from these talks a man right so all my name is Don both valve and emergency medicine physician practicing here in the state of Florida and I'm board-certified by the American Board of emergency medicine I've been practicing for twenty years I graduated from Angie's University with a BS in biochemistry graduated from the University of Michigan article school and in my residency in Detroit receiving Hospital from nineteen eighty nine to nineteen ninety two which I was a level one trauma center and currently I work in a large community Hospital in Ocala Florida we see about a hundred and six thousand patients through all her departments we have a main emergency department we have a freestanding ER which is a first of its kind in the state of Florida and the busiest in the state of Florida we have a pediatric emergency department cell that's my background that's my training now my experience with the current healthcare system as expensive as it is is I would say it's disappointing in the sense that we really don't address the underlying cause of our patient's condition when we see them in the emergency room now don't get me wrong if you have a fire in your house you want a fireman okay so if I have a heart attack at six a.m. I want Doctor to come take care of me as the fireman aspect of it but our emphasis in healthcare healthcare will unquote is the firemen approach rather than what I would probably turn the Smokey the bear approach can we prevent these forest fires and that's where we should have questions in the emergency room as an emergency room physician and as acute care clinicians when he worked in the intensive care unit whether you are a family practice physician with your nurse practitioner practitioner or physician assistant I mean the current research shows past research shows how initially very graphically that back in the nineteen hundreds what really addressed the problem with a mortality from infectious diseases was not a future medicine what address the major problem was preventive measures of this is really a U-turn for me because my life is busy fast-paced emergency department but really have to think about these things so healthcare is really a misnomer because what we actually do in the hospital 's disaster management or disease management okay it's you know the house is burning down we have to put it out all of us have had numerous patients who fan multiple bypasses in order on the third bypass on behalf of multiple stands acting to revision at thirteen stents still smoke in and I've talked to some of these people many of them no one has ever talked to them about preventive health measures so watch doing gap for health care dollar is two thousand and ten thirty percent went to hospitals and what are we doing hospitals we pharmaceuticals and procedures right this particular hospital twenty percent with the physicians more and more on seeing patients who tell me I spend more time with them in a busy ER than their pick than their physician spends with them their busy utilities charting so we have to I hate those things ten percent prescription drugs again were talking pharmaceutical so were talking about majority of our healthcare dollar goes to pharmaceutical and on prescriptions what though still like public health or prevention minimal amount was the cost of you without healthcare in ninth in two thousand nine we spent two five trillion dollars on health care sentences six five billion was due to waste that's thirty percent of the total and .net waste was due to inefficiently delivered services prices that are too high and missed prevention opportunities now what result do we get for this extremely expensive system we are a society plagued with chronic diseases of the West as some people call all in two thousand ten the top cause of of death was heart disease cancer was number two I put heart disease and cerebrovascular disease together since the etiology is very similar they got noninfectious airway diseases like COPD emphysema let's look at something really interesting look at the diseases that were the cause of death in nineteen hundred you got everything was before pneumonia influenza was the top top cause tuberculosis was number two in fact many years tuberculosis is actually higher than pneumonia or influenza and then you have gastrointestinal infections like you know Colorado and those types of things and heart disease number for now decline in mortality from infectious diseases from nineteen hundred and nineteen ninety six you'll notice that the death the death rate for infectious diseases was eight hundred per one hundred thousand in nineteen hundred others included pneumonia influenza can see the results of the pandemic this was in nineteen eighteen the other major spike but notice very carefully that this graft steadily climbs as urea and the first use of penicillin every have the first use of vaccinations and this is when vaccinations were used on a very on in a public way to villainous before the first use of penicillin infectious diseases were dropping by it begs the question the penicillin actually improve the the decrease of of of that death rate was in a come down anyway okay now don't get me wrong I'm I'm I'm I'm living in in the era of vaccinations I actually took care of the patient with at the black Titus a little kid when I was a resident at Detroit receiving Hospital and I don't see if the buckeyes anymore it's amazing to me that the HIV vaccine as coming virtually or I take it with you in the ER about the white looks like the Google okay well not really depends on the age so so naturally she was amazing decline and so what did we do what did we do back there are achievements in public health nineteen hundred and nineteen ninety nine control of infectious diseases what was going on at that time was people were reluctant realizing there's a connection between contaminated water and health okay was they noted at that time we had teeny sanitarium 's anybody ever heard of that very these big buildings where people would rest they would get fresh air and sunlight and if you'll notice TBB client one hundred and ninety four per one hundred thousand persons in life or death of forty six before antibiotics and this was due to improve housing and TV control programs so I got this from a CDC website it's in the patient handout is with their televisions today and Mrs. Howard probably treating patients mainly back in nineteen hundred teenagers can sometimes stay alive in the air for a few hours especially in small places with no fresh air fresh air and sunlight make it harder for teenagers to stay alive the fresh air scatters adjourns in the sunlight kills them so we solved that problem back then we can solve it again we just need to go back to public health measures we go back to this graph and to forget anything else only does look at this graph and study it because this was very perfunctorily if you did you look at this you have forty states have health departments now health departments came about back then because people wanted to get a sure water supply on there is interest in solid and liquid waste disposal and so because the community was interested in having a virtual water supply people started to and be active in that area and I got forty states have having health departments have people interested in the clip of chilled water together first continues Nick municipal use of chlorine warning United States Om and so these simple interventions that were preventive at a power looked powerful effect right cell ligand S six hundred and twenty soldiers died in the Civil War it's estimated that two thirds of them died from disease rather than from their loans what difference would it with that of native who knew about the antiseptic procedures back then you can see that there were a bunch of yellow fever at the let's all there was transmission of cholera on and after the adoption of sewage systems in Great Britain in the US received amazing drops in these infectious diseases so up your water supply was not just a convenience but a necessity for good health other than Doctor Ignatz so why similar to recognize him aging eighteenth eighteen sixty five he was a assistant in midwifery I guess that's an OB/GYN back in those days and began in the eighteen forties and he took upon himself the task of finding out what was killing the women in Europe and America from this disease called corporal fever or childbed fever what would happen mothers would deliver their babies and very soon afterwards they would die of this they would get high femurs and get sick they would get confused and essentially they were all dying from sepsis rates at his hospital were extremely high and there was a difference depending on where you had your delivery there was the first division where the doctors and medical students delivered him women and it was the second division where nurses delivered delivered women and she noted that on average it was a rate that was three times higher in the first division with doctors and medical students delivered women you can read about that in the doctor 's plague sure what Sherwin knew what was actually a surgeon voted extremely interesting book about it so she actually after observing and doing autopsies and and really looking into it discovered that uncle came up with the theory that physicians were actually carrying the disease from tainted hats it was no germ theory back then so we call this these things out of their particles what would happen as you would do an autopsy on the woman who died of peripheral fever in the morning I was back then and then he would build the the bimanual vaginal exam on a woman who's about to deliver that afternoon directly transmitting the germs to that woman and so rates of disease and death would get as high as thirty percent can you imagine going to the hospital to deliver your baby and you got a three out of ten chance of not coming out alive and often your baby would also die from that disease goes coming down the birth canal that could be transmitted so she instituted something extremely simple handwashing with chloride why in many of eighteen forty seven so the Om the death rate which on physician side which I think was about nine eight went down one two percent and the death rate on the nurse 's side which is around three percent when done one three percent so both markedly dropped from something very simple again a simple intervention that emphasize prevention yet Doctor Joseph Lister was a surgeon in England he actually came up with the uncertain methods of five Senate certain sanitary measures during surgery on his coin the term antisepsis in his mortality rates dropped by two thirds now you are in my recognizes God 's Moses they said nothing in three thousand years before these guys were alive you've got the laws of purification handling a corpse and you have the ritual after childbirth now think about this if we had these laws this was an epidemic that would've been totally would not happen the law purification states that if you're exposed to a corpse isolated for seven days and then you wash yourself on wash her clothes and then you can come back into the community the ritual after childbirth for sports specific amount of time you are isolated from the community if we had these laws on or if you're in America for following these simple laws be simple that it measures would've been a totally different story this is Doctor Theodore Cooper M.D. PhD brilliant man he was a cardiac surgeon published more than two hundred scientific articles director of the NIH was President Ford's assistant Secretary of health she was chairman and CEO of Upjohn which was either the or one of the largest pharmaceutical companies that danced no longer in existence at version merchant merchants of different now so I got was an expert at procedures and pharmaceuticals when you say so let's see what he said addressing some physicians he said is one of the great and sobering truths of our profession that modern healthcare probably has less impact on the health of the population and economic status education housing nutrition and sanitation yet knowing that I think their foster the idea that abundant readily available high-quality health care subsidy disease management or disaster management there would be some kind of panacea for the ills of society and the individual that is a fiction a hoax so waiting cause of death in two thousand heart disease malignant neoplasms cancer is cancer through cerebrovascular disease and stroke chronicler rhetoric tract disease COPD emphysema unintentional engine injuries diabetes right nine nine to start seeing likes the infectious diseases there so these are leading causes of disease but some retrieve the researchers actually wanted to look at what they call the actual causes of disease the underlying behaviors that result in these top causes of disease so if you smoke tobacco that's a risk factor for heart disease risk factor for him single lung cancer okay they estimated and always estimate is a conservative feasibility and guys and I'm I'm not a academic either Doctor Gaughan so not the I am at a friend is a sociologist and dozens of the papers I agree with them so anyway so tobacco forms and thirty five thousand people in two thousand tobacco smoking tobacco on four hundred thousand died from poor diet and physical inactivity eighty five thousand from alcohol use so it's at that's that's you know what it was probably switch back in two thousand but yeah it's definitely send that paper that this was good to be the number one so someone comes in with a heart attack symptoms of diabetes symptoms and with a chronic of Lord of lower respiratory condition should we do a bypass on someone having a heart attack yes but should we address the tobacco the poor diet and physical inactivity and alcohol that underlies condition guess should we do it like episodically no singular consistently yes should it be something that the nurses talk about yesterday so that the physicians talk about yes their family doctors yes members medicine physician yes our churches yes our health and temperance leaders yes everyone should be talking about okay moving let's see how much time do I have so this is a prospective cohort study seventy over seventy thousand US women age thirty five fifty nine in starting in nineteen eighty they follow them for twenty four years and these are five risk factors low quality of diet excessive alcohol intake up for in inactivity and there's smoother to others that's a smoking okay smoking and there's there's something else accompany a regular five risk factors on my cell risk factors and as you increase your lifestyle risk factors your deaths per one hundred thousand person years goes up markedly different two hundred if you have zero risk factors the one thousand if you have all five so this is a major study that showed a direct correlation between all physical activity diet and on and on decreased mortality as the running via Disney Marathon physical activity affecting all notice maintain weight reduce blood pressure reduce risk for type two diabetes heart attack stroke several forms of cancer reduce arthritis pain and associated disability reduce risk for osteoporosis and falls so when something comes in and they say my knees hurt in the morning cars and actually do some walking reduce or do something where they're moving around a little bit do some exercise it reduces symptoms of depression and anxiety obesity effects as you get overweight to obese you increase your risk of Corning heart disease stroke type two diabetes hypertension cancers liver and gallbladder disease sleep apnea and respiratory problems osteoarthritis gynecological problems abnormal menses and infertility for Excel this shows a small study that shows the phenomenal impacted by the study was a study of twenty lean diabetic patients who receive daily insulin injections they were placed on a high carbohydrate high-fiber diet for sixteen days after they were out of control diaper seventeen for seven days so the controlled I consisted of twenty percent protein forty three percent carbohydrate thirty seven percent fat that's really high-fat and twenty six grams of fiber no unfortunately is probably high-fiber in our day I was was the average American intake of fiber the average person eight four well so I guess this would be high-fiber but look at what on in our date blew my a true high carbohydrate high fiber diet twenty one percent protein seventy percent carbohydrate nine percent fat sixty five grams of fiber on the daily dose of insulin was lower for all patients on the high carbohydrate high-fat diet I'm high-fiber sorry high-fiber diet the average insulin dose was reduced from twenty six to eleven units a day insulin therapy was completely discontinued for fifty five percent of the patient's cholesterol dropped by fifty nine from two oh six one forty seven so this shows up in an they did not even examine the it was an exercise on this this was just early diagnosis from nineteen seventy nine this is not any new data this date 's been there but the diabetes prevention program New England Journal of Medicine on this is oh two two thousand and two if I'm reading it you know it's all an emergency medicine physician so this was a randomized clinical trial to prevent type two diabetes and persons at high risk heat they had their eligible participants randomized everyone got standard lifestyle recommendations everyone all of these people but then they were placed into an intensive lifestyle program or metformin which is medication that treats type two diabetes or placebo now the interesting thing to me was this lifestyle intervention structure was pretty intense there were sixteen session quark with curriculum over twenty four weeks with a long-term maintenance program was supervised by case manager there is access to lifestyle support staff there was a dietitian is a behavior counselor it was an exercise specialist annual notice from this graph that became one of the incidence of diabetes was much lower than those who were in the lifestyle arm than those within the foreman arm placebo arm so they are so the way of life prevention program now has a symbol of the diet their diet was that their goal was less than twenty five percent fat their goal was just above a hundred and fifty minutes of exercise on a week and they had to maintain a seven about a seven percent weight loss okay so your conclusions reduce the development of diabetes by thirty one percent so and by intensive lifestyle intervention reduced the development of diabetes by fifty eight percent lifestyle was more effective than metformin my summary was on a subpar diet with a less than optimal exercise plan but with a consistent message and greatly great support they got good results and in iPod that I held in temperance leader at the church and I think this is why sometimes her health intemperance outreach in the church doesn't work because their haphazard and episodic you will have like a health day one day a year NAB health program a weekend and sometimes we kind of beat up on the people about what they're eating etc. and that now and why do I want to know what I want to go today and I'm adjusted and health self so this shows that if you have you know we have all these wonderful churches that we only like go to like maybe once a week most of us should go twice a week maybe more I mean these can be here is where we can get this consistent message and great support that people need to make a change and if they're sharing it in the emergency room after hearing it from other physicians if they are hearing it at the church you know what people are filing a start believing that maybe it's true so businesses and I read the advocate nine servings a day by the National Cancer Institute what's a serving people often ask the question itself that's a large RNs incised banana two cups of salad a medium-size apple oh Sarah and Neil for food group this is by Doctor Neal Barnard reversing diabetes talks about whole grains legumes festivals fruits and I put in there some some hold on hole we call it down notes on what you say not on your walnuts almonds but not not roasted a raw nuts that's what I want to say that a little GIA there so this is a friend of mine who's a forty nine -year-old man sits with two starts she called me at least is a dog gullible they'll actually is my fresco will now I went to my doctor I got diabetes into leaders nothing I can do about it I said don't believe them to get this book he's an engineer to get this book by Neil Barnard and read it so starts exercising preservers and diabetes over the next year loses thirty five pounds his hemoglobin A-1 C increased from ten two to six three and he notes an astonishing increase in his energy and libido pretty much within a few weeks of starting is whole foods plant -based diet he explained to me happily this is our health message or a Windows guy Caldwell BS is the physician is a fellow of the American College of surgeons is also gold medalists who was a growing momentum rolling in nineteen fifty six Re: interview review article that he wrote to the optimal diet consists of grains legumes vegetables and fruit with less than ten to fifty percent of its calories coming from fat this diet minimizes the likelihood of stroke obesity hypertension type two diabetes and cancers of the breast prostate colon rectum uterus and ovaries there are no known adverse effects of such a diet when mineral and vitamin contents are adequate not the new laws concerning dieting and eating diet you got Genesis one twenty nine two 's sixteen and seventeen that is a whole food plant based diet begun and the World Bank licorice candy plants in the classroom so then you got some rules about what kind of the flesh who usually get the Exodus diet and don't let anyone forget is a merely wholesome plant -based diet read Exodus sixteen every numbers eleven and again the exiled by Daniel one feet to sixteen again a whole food plant based diet nothing new so you're a physician and you have an office only people her nurse practitioners PAs physicians who work out of their office to write anybody anybody is a sentence of the herbal therapy for obesity goes I know I don't use in the ER so that you can go to this website no tell you off on the things you can do for preventive care but on Medicare will pay you twenty five dollars and fifty two cents for a fifteen minute visit to counsel someone who is obese versus seventy two eighty one further quibbling time for the time spent with an established visit okay how a physician should thank her data on counsel patients new intensive behavioral therapy for obesity when they can make almost three times as much with an established patient doing something else but I say ill with our perspective we need to do it anyway okay it's because they are the rewards as you know other than monetary rewards this is a gentleman who was involved in RB Smart program MMI collies come up in two minutes and talk about that and she lost forty three pounds his blood pressure went from one fifty four over eighty eight one seventeen over seventy one his total cholesterol decreased from two oh five to one seventy three and hit a venous stasis ulcers that completely resolve and this is over of four months and some other people who are engaged who involved in RB smart program which is a church -based on nutrition and exercise program that all my calling to talk to you about him after one year on we've got a thirty six -year-old five foot six Hispanic woman was twenty nine pounds August two thousand thirteen she's currently two hundred forty seven pounds as of probably yesterday because that's when we had class she lost forty three pounds borderline hypertension is now normal now what's interesting to me is what people say quality of qualitatively about how they feel she reports that she could not see her feet and that her legs were very painful those issues have resolved we had a fifty seven -year-old five percent African-American woman who was a medical spot from May to July two thousand thirteen over ten weeks just a total of one thousand twenty seventy seven dollars for exercise nutrition counseling injections and pills she lost nine pounds the receptionist said hey that was great to start on the Smart program August two thousand thirteen at set with that two months ago weighing two hundred forty one pounds and is not too urgent eighteen pounds twenty two pounds weight loss free to rejoice that our arthritic knee pain has improved to the point where she can now clean her own bathroom rather than hiring someone to do sell so how do you make a therapeutic alliance with the patient well basically the question that I often ask my colleagues is to some wasn't involved with us is really like people maybe don't like people each of your own people set simple self cell that's a person feel like people the next thing is if you like people need to have a conversation about change this is an approach to counseling called motivational interviewing on those developed by two clinical psychologist as to promote self confrontation there's several on principles that they use I encourage you to read the book of them running out of time but listen to your patient look at your patient you know near their emotions except anger here the words and decode the meaning reflect what the patient says in a guiding fashion try not dictate if I don't try not to take up the process of engaging the client the patient should should feel respected patient the patient should feel that she's listened to and understood the patient should feel like you're someone that she can trust the patient should be given options rather than a one-size-fits-all approach and it should be a negotiation rather than you dictating what's good happen Christ method alone will give true success in reaching the people the Savior mingled with men is one whose are they good show sympathy for them minister to their needs and won their confidence then he bade them follow me so I did ER when someone comes and was wheezing and her saturations are down to about ninety ninety two percent in this process in our hospital now where everyone has to talk to talk to the patient about putting smoking I think it's a good thing but I see the nurses asking them about their tobacco use when they're huffing and puffing once that so what I do is I wait until they've stabilize our better and I go in because you either have to discharge and remit them to the hospital when you have to tell them what the plan is in and I say a word about your smoker that's all I have to say nine times out of ten they'll say yeah I know I need to quiet and then you can engage in a conversation and that try to move them along the path toward change writers or be smart program under the ask my colleagues to come up this is a program that we do through the church and I have three colleagues here with me grace daily she is a former WNBA basketball player she's her exercise and strength coach we have an Burnett who is a certified exercise instructor and she's also my wife so she's my boss and he also have pastor Matthew Christo who was a of a pastor in the Florida conference fees we actually do a a lot of the programs and work with them in in his church self every everyone are these people are to come up and started talk about their experience with what redoing all case on medical leave Mark will hand it very simple program that is for new start I'm sure the ever-increasing health of our span on the age old order time with Doctor Dennis had health principles the guy gave a thought because I believe in God believe also put this program into the public school system where that really wouldn't float so we came to be to rush if you could be and I'm currently delivered teacher that is more relevant than you can imagine and the ears were eating fruits and vegetables drinking water for encouraging seven servings a day and activists on site near Emily Donna's been the past emissions Re: why these principles is not just believing God your mission is number one secondary prayer number two how Collymore and devotion number three entity referred pretty for combustible your mission is to get seven servings of vegetables over rainbow and to drink water and were saying half your body weight in ounces and while you are taking water know so that the reason that you all know and to choose different advantages the only thing even for the whole throat nothing with it sometime near replicating fifteen minutes a day for lighter skin more than our present and his electability checklist that we give articles that can abuse my classes exercises and I get my kindergarten is very an amateur moderation is a Christian definition which is self-control in blood things and that something is bad avoided completely so your mission for moderation as to exercise self-control and good things and to avoid the all-knowing junk food we got it right that is fast foods and sugary snacks and treats a distraction for children's hour days Fred Dalton thirty one centimeters I decide we often find the commandment that says thou shall exercise in your Bible Exodus twenty residual eleven numbers are particularly six days shalt thou rest right I remember having to keep it holy six days shalt thou labor okay Natalie Murray Beemer Word abides which means heavy like vigorous work physical exercise like tilling a field of the law so he was I specifically direct wondering and many aren't harassed and arrested me in bed by ten o'clock p.m. per adult every children getting on the downgrade my aunt walked him and achieve ritual others and that is shrinking at some point during the day that your mission should be very simple to live the Christian life every children and adults he also attached television time delimiter to be kind to one hour left of quality television and what we learn the program is when you get evil missions guilty missions to accomplish and hold them accountable by meeting together often consistently we see amazing results and his wife with remarkable showing what being a disregard teacher I know one thing works really well so I don't everyone loved it and it makes dramatic changes are given the dental dimension I change itself one thing we don't talk about moderation and elect people to be what were saying right the average American consumes seven and seventy nine days consumes as much sugar as if I come back to sugar okay a five pound bag of sugar and seventy nine days everyone seems that needs a wilder possible well Cheryl shall Intel has had to got a few things each of these packets of sugar represents fifty okay so in a simple bag of Italy to talk about one two three four very big number five p.m. this but we save face any more food connections right and certainly more skills and their simple their simple changes that we can make something like this juice it says from ponds so we actually from Friday if you want that kind allowed religious leader again and so it's a world of hurt this is one of the problems beside the gain your ball moving she and we also show that Cedric Fox at the Krispy Kreme box in the then living in my garage for over two years and everything perfectly exact okay I should ultimately also fell over backwards right Dempsey afterward was notable for needed although it looks as good as new there is no mold no self-respecting bacteria nothing like this okay ha ha as you women should give us that Hannibal was due to your cheeseburger from McDonald's is over five years old annually and means now parts of the bread is broken off is not the peak is granted I'm okay with it but no accident is the long multiyear England the back of a pickup job in child on America and got was when they were expelled together again and we have mom school and staunchly encouraged to bring a lunch this would be a really good weapon for Goliath Orford even if you want to react that story but there's there's a simple think we can do in public in this table afterwards and they are playing this find sugar everywhere frosted flicks of Boston with sinners thinkers evidently satisfy his advisors fighting up and crashing down and it triggers rapid Dagny Unger need more civil one of encouraging people to make smart choices and practicing the Christian definition moderation which is thought controlling the things I love bananas but quite funny banana today that's trouble right and things like that they really don't have a lot of nutritional value you want to avoid them completely but these my program and for developing more effective are you hello and can hear me okay yes good class I'm following and graces for the kindergarten teacher are I doubt they regards the Bismarck program you're probably wondering how do we implement this right all I really have incorporated in our day-to-day daily lives or in our ministries well we have five exercise class is every week in three different Adventist churches in two different conferences pretty impressive how quickly time to time if it's important to you you will carve out time for the people for these classes now on it is attended by approximately eighty percent non- Adventist pretty impressive praise Jesus is always right now our observation in this is our second perjury doing these classes is that we see bodies changing blood pressure is being lowered you know hypertension you get the idea bookmarklet changes being made in their health and their bodies they removed all their spiritual lives additionally their former relationships will get to that later writing the next thing is as they are young people in the community we have dodgeball other physical activities and that is done at has a crystal search you I'll bring up in a moments and what it was we played dodge ball in different games and then we have time and that's where we do a particular activity and then from that activity the young people they huddled together in groups and they find this virtual applications they pulled out the spiritual lessons from the activity that we did when they come up in the present they preach and deliver the services again that is eighty percent non- Adventist young people pretty amazing they also practice praying that he can imagine young men come in the comparison you know by the time they enter the door writing Excel on the end of the you are changing after Christo is right there in the midst of it he also teaches them table tennis like I said we have no gains for them and he facilitates me so he is also building bridges the gap conforming that relationship so now they're thinking passes are critical is that cool I don't now the next thing that we do oh by the way in all our program to be smart programs principles are being reinforced and introducing me reinforce it in some way we are and make it have helped me to make the connections so that they start to think about making smart choices by the way that while they're playing you really exercising down you realize that right the next thing I want to share with you is that Mister Pitts and his school in the town where we live Ocala Florida they've never had PE so what did we do two years ago over like a school principal physical education priest and all you will be a teacher cannot even cost you time business introduced to be smart program and that's what I was so scared we had fun doing PE off course and we have these more charts which you have in your possession you should see the pictures of us on that hand out you have okay they have to fill out shards and on the left-hand side you see all the principles they have to check them out make sure that the accomplished everything they do this and then the one that they always get is the eighth action because I am very taken them outside and making sure that they play this kindergarten through eighth grade together sunshine is the Christian schools that have their devotion to the idea we're reinforcing the health principle of independent school also building renovations share this observation in the insurance and the students they were they formed a connection they are helping each other holding each other accountable not through the smart not always in the smartcards but they've essentially is not if they brought in from findings will that's not smart the teacher started having smart parties like the Valentine's Day no longer brought Asia's China junk it was now bringing fruits and telling their parents and kids to do that is this so far as it is here out at Bethel which is this year 's infrastructure mentioned that we gave the kids on the accidents Doctor Smart chart you can go to the back of my vehicle and pick up a toy the whole schools will so cool this year the event to do that there is no thing outfitting out their charts even though it wasn't incentivized can you imagine why because now it's a learned behavior is not part of their scholastic lifestyle we together yes we are okay now the cool thing is that in account where we made married here in Florida there are thirty five elementary schools public schools and graceful start of entryway into that because she was not school system so we wanted to introduce them these my programs through them of course these not believing that it is Russian-made exactly and through the extended day program we were able to get into all elementary schools and praise Jesus rebels may change itself how do we do that you wonder if there was something called moody and depressed looking at Echo but you break our four-minute long videos that we offer on YouTube and also DVD so we did not disclose the teachers where one minute and down on those who the teachers after he was in classrooms because there is only now Cousineau one plus one equals two who cares or it's too much about digital minute we popped anybody break again they do one of the activities for Mac launch contender to refocus come to find out because we can track those are hitting our websites from all across America teachers are using this to also get feedback is helping them to refocus Mister getting action and there is the health principles because all the videos tab up top top of these on different health principle voting upon completion check out okay you know I mentioned to you really quickly every summer now we offered the smart camps so we have made progress to be out of school for Cisco security Stoic and so with whatever church invites as we go to their church a printer we can't be smart can't afford dark for the young people it's not just an enrichment and outreach because when people have anything to do some thinking about nothing when given Christ to the one given health message but we do it in a fun way health snack that the snacks are healthy on the phone requirements they have to be be smart compliant kids who have never heard of the health message are now introduced to it and they now learned that this kind of food is junk they don't have anything to do with they take the information home to their parents and the word goes on and off of our rights and of course churches invite us to host the open on this program for them and share with them and am excited about in mission work without going overseas but in their community but also Cyrus in your church and that's all we do message from the churches and encourage them to start exercising of the Internet for them we jumpstart it never can we do praise Jesus is free all right the one thing I wanted to mention cute how we train session because we know that it was a tender exercise classes they day out and they change their bodies change them they form relationships the transition from that to now doing more Christ centered lashes across the transition and then sue like a church program for church service so thanks to Pastor Christo and inviting invite them opinion in the Midlands I share this with him and he's not just a pastor he's also a D Smart for two class participants as you share his own personal story about the own mind about how nutrition can improve your health and but yet so we had the idea okay and used he said Sabbath afternoon program for those in come out to exercise classes and to get an idea were talking and yet if everyone were to come to class I want to be over two hundred and fifty people but on average is about eighty seventy to eighty people at the law is the three preseason so Sabbath afternoon once per month about six p.m. we have found family and family Fellowship and and not any praise food and fellowship and repressing praise songs we do an activity does spiritual lesson is is extricated the pastor ties it all together and so they are being introduced to Christ now can I just mention we had Hindus Muslims Hispanics Asians on Caucasians and African Americans with stadiums all together in one room a man so we use Christ methodology of reaching them through the shelves and then introduce them to the gospel any questions for any of the parts that you sir the question was him how do you get your people to come I decide you advertise right well initially be the own from care fires and just flooded the neighborhood with an door hangers and hung them on the door we also met with people in the streets seen on shopping centers close to our pastor crystals charge because they would know where the church is an personally invited them and the connection that we made we were either funny or we try to connect with them if they're older person displaying some common ground that we can connect with them anyway once once those individuals came and they had so much on me I didn't have to do anything else we went out and handed out flyers just once and it grew to what it is right now so if the product is going and Christ centered people that absolutely so they do the work forest and every single class this is our second year every class we have an average three new people on average absolutely every Tuesday and everyone's of the same is true for Wednesday Wednesday night dodgeball we never advertise that the young people they go and tell their friends and some on high schoolers for high schoolers to invite their high school friends you know it has to be cool I also spent one think in addition to the exercise classes we also provide nutritional information and education and every class and behavioral modification instruction or counseling every class we pray at every class we ask for prayer requests or take praise reports publicly so they share you know what God has done for them publicly so they encourage each other in the Lord and even the Hindus do the same things that you pray for my son he's in jail right and some of the songs of course on the you know has all the sons of God in Jesus but sometimes the sum of mistake on you know if you're not Jesus say say say my fiancée my name since it was said items you try for something I say I know Jesus and he will seek here everyone even Muslims either Jesus and pretty amazing the power of Christ he and people like things that are free I mean young quality service are providing and begin our best ever working for we always do our best to providing a quality service back in demand in the fitness industry makes billions of dollars here we are providing this for free no strings attached us come as you are and we change that's it only we go to Sunday churches to do it they call the answer and the message is the same for everyone we want to make it available to everyone let's close with a prayer utterly fun we thank you for this wonderful day and all the seminars that we had and what we learn premium that will give us the power to spirit that said gifts that you and us to utilize them in practice and a media with broad audio nurse a website dedicated to spreading God 's word through reading sermon audio and much more we would like to know more about hothouse the more certain and www. done on universal .org

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