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Activate your Warrior Forum Account Hello billyalexis0, Congratulations, billyalexis0. You're now only one step away from being part of the #1 Internet Marketing Community. Hit the activation button below to get started or contact us here if you need further support. medications that can help in case of a heart attack. • In many locations, emergency personnel are linked to the hospital. They can send information about a patient’s condition to the emergency department before the patient arrives at the hospital. • Heart attack patients who are brought by ambulance receive faster treatment than patients who have someone drive them to the hospital. • Your heart may stop beating during a heart attack. Emergency personnel carry equipment to restart the heart if that happens. Session 2. Act in Time to Heart Attack Signs 30 Note: Most communities have the 9â€"1â€"1 system. However, if your community does not, ♥ say: The best way to get the care you need is to call the local emergency medical number. In our community, that number is _____________________. ■ Say: It is a good idea to plan ahead for who will take care of your family in an emergency. Emergency personnel will usually contact a relative or friend to make arrangements, if necessary. ■ Ask: What would you plan to do if you suddenly had to go to the hospital in an ambulance? Note: Allow about 5 minutes for group members to discuss their answers. ♥ 7. How To Plan Ahead ■ Say: We have learned a lot today about heart attacks and what to do if one happens. Here’s the good news: Planning ahead with your family can help you survive a heart attack. Here are things you can do now to prepare for a possible heart attack. ■ Show picture card 2.4. ■ Say: You now know the warning signs for a heart attack. Talk to your family and friends about these signs and the importance of calling 9â€"1â€"1 right away. ■ Show picture card 2.5. ■ Say: You and other adults in your family should talk to your doctor about your risk of a heart attack and how to lower it. Your Heart, Your Life: A Community Health Worker’s Manual 31 ■ Show picture card 2.6, and give each group member the “My Emergency Card” handout (page 41). ■ Say: You and your family should have a plan of action in case of an emergency. This plan should include an emergency card. This card gives health care providers the information they need to know about you in case of an emergency. Let’s look at your emergency card. The emergency card includes the following information: • Name, relationship, and phone number of emergency contacts who should be called if you have to go to the hospital • Emergency numbers in your area • Name and phone number of your doctor or clinic • Your health conditions • Current medicines • Known allergies • Any other important information Make a copy for all adults in your family and encourage them to fill it out. ■ Ask for volunteers to tell you how they would explain the importance of making a survival plan to their family members. ■ Ask group members to tell you how they would make sure that all of their family members (such as a grandparent, spouse, or uncle) know what to do in case of a heart attack. Note: Allow 2 or 3 minutes for group members to respond. ♥ Session 2. Act in Time to Heart Attack Signs 32 Mor e Infor mation Aspirin: Take With Caution A person who is thinking about using aspirin to treat or prevent heart problems should talk to a doctor first. If the doctor thinks that aspirin is a good choice, it is important to take the correct dose. If a person has had a heart attack or stroke, aspirin can help lower the risk of a second one. It can also help keep arteries open in persons who have had heart surgery. It has also been shown that healthy women who take a low dose of aspirin every other day may prevent a first stroke. Aspirin may also prevent a first heart attack in women over the age of 65. 8. Tender Care for a Happy Heart ■ Say: After you finish preparing your emergency card, try some of these actions to lift up your heart. ■ Give group members the “Tender Care for a Happy Heart” handout (page 42). Note: Allow 2 to 3 minutes for group members to read the handout. ♥ ■ Ask: Which of these things would you like to do first? Note: Allow about 3 minutes for group members to answer. ♥ ■ Say: Choose one or two action items from this handout that you would like to do during each week of the training. Then, write down the date that you complete each action. Your Heart, Your Life: A Community Health Worker’s Manual 33 Review of Today’s Key Points ■ Say: Let’s review the main points that we learned today. What is a heart attack? • A heart attack occurs when a coronary artery becomes blocked and blood flow is closed off. • If the blood flow is stopped, parts of the heart muscle start to die. What stops a heart attack? • Quick action and medical treatment restore blood flow and save heart muscle. Why is it important to get treatment quickly? • Quick treatment can prevent the heart muscle from dying. • It is best to receive treatment within 1 hour after warning signs start. This will improve chances of survival and will help save the heart muscle. • “Clot-busting” and other medicines open up the artery and restore blood flow. • Angioplasty opens the artery and restores blood flow. What are the warning signs of a heart attack? • Your chest may hurt or feel squeezed. • One or both of your arms, your back, or your stomach may hurt. • You may feel pain in your neck or jaw. • You may feel like you cannot breathe. • You may feel light-headed or break out in a cold sweat. • You may feel sick to your stomach. Session 2. Act in Time to Heart Attack Signs 34 What should you do if you experience these warning signs? • Call 9â€"1â€"1 in 5 minutes or less, even if you are not sure you are having a heart attack. Calling 9â€"1â€"1 gets you treated more quickly. • Do not drive yourself to the hospital. Weekly Pledge ■ Say: You have learned a lot today about how to be prepared if a heart attack happens. Now let’s think about how you can practice what you have learned. Please think of one change you can make. This will be your pledge for the week. ■ Say: Be specific about what you plan to do, how you plan to do it, and when you will start. Here are some examples: • Within the next week, I will think about what to do if a heart attack happens at home, at work, in the middle of the night, or in other situations. • I will talk with family and friends within the next week about the heart attack warning signs and the need to call 9â€"1â€"1 right away. • I will make an appointment within the next month to talk to my doctor about my heart attack risk. ♥ Note: Allow 5 minutes for group members to think of a pledge. ■ Say: Would anyone like to share his or her pledge with the group? ♥ Note: Write down pledge ideas on the blackboard or on a large piece of paper taped to the wall. Your Heart, Your Life: A Community Health Worker’s Manual 35 ■ (Optional) Say: A personal value is a quality that you consider valuable or important. Personal values can help you make changes in your everyday life to improve your health. Today, the value is serenity. Serenity helps you stay calm, even when you face problems or worries. It can help you manage stress and anger, which are two things that can bring about a heart attack. Note: Ask the group members to share how serenity, or another personal value, can help ♥ them keep their pledge. Allow 3 minutes for group members to share their ideas. ■ Say: We will talk about how you did with your pledge at the next session. Closing ■ Say: Thank you for coming today. What did you think of today’s session? Note: Allow a moment for group members to respond. ♥ ■ Say: The next session is about physical activity. Please wear comfortable clothing and walking shoes. Learn What a Heart Attack Feels Like Act fast. Call 9â€"1â€"1. It could save your life. Clot-busting medicines and other treatments can stop a heart attack as it is happening. These treatments work best if given within 1 hour of when heart attack signs begin. If you think you are having a heart attack, call 9â€"1â€"1 right away. KnOW THE HEART ATTACK WARnIng SIgnS: Your chest may feel pressure. You may feel discomfort in one or both arms, or the back or stomach. You may feel discomfort in your neck or jaw. You may feel like you can’t breathe. You may feel light-headed or break out in a cold sweat. You may feel sick to your stomach. â€" HAnDOuTâ€"SESSIOn 2 37 Fast Action Saves Lives YOu MAY nOT BE SuRE IT IS A HEART ATTACK. A heart attack may not be sudden or very painful. You may not be sure what is wrong. But it is important to check it out right away. ACT FAST. CALL 9â€"1â€"1. Call 9â€"1â€"1 in 5 minutes or less. Do not drive yourself to the hospital. When you call 9â€"1â€"1, an emergency vehicle arrives right away. Medicines can be given at once. TO HELP SuRvIvE A HEART ATTACK, TAKE THESE STEPS: ■ Learn the warning signs of a heart attack, and act fast if you feel them. ■ Talk with family and friends about the warning signs and the need to call 9â€"1â€"1 right away. ■ Ask your doctor about your heart attack risk and how to lower it. ■ Complete the “My Emergency Card” handout (page 41). 38 HAnDOuTâ€"SESSIOn 2 Fast Action Saves Lives: Role Plays (continued) Role Play 1: At Home Actor 1 You are at home having breakfast with your spouse. You tell your spouse that you woke up not feeling well. You have a variety of warning signs, including the following: ■ You feel some pressure and discomfort in your chest. ■ Your arm hurts. ■ You feel short of breath. ■ You feel a little light-headed. Actor 2 You look worriedâ€"you are not sure what is wrong, but your spouse looks sick. You tell your spouse you have recently heard about the signs of a heart attack and are worried that this may be the problem. You say that maybe it is best if you call 9â€"1â€"1. Actor 1 You insist it is nothing, probably just indigestion. It will pass; you will be fine. Actor 2 You reply by telling your spouse why it is important to call 9â€"1â€"1 right away: ■ Even if you are not sure it is a heart attack, it is best to check it out. ■ If it is a heart attack, fast treatment can prevent damage to the heart. ■ Getting to the hospital quickly means that treatment can start right away and maybe save your life. You call 9â€"1â€"1. HAnDOuTâ€"SESSIOn 2 39 Fast Action Saves Lives: Role Plays (continued) Role Play 2: At Work Actor 1 You are at work one afternoon, and you see that your coworker does not look well. You ask if anything is wrong. Actor 2 You reply that you came to work this morning not feeling quite right. You describe the warning signs: ■ A heavy feeling in the center of the chest ■ Difficulty catching your breath ■ Feeling sick to your stomach ■ Feeling light-headed ■ Some pain going down the left arm Actor 1 You say you have heard that these signs may mean a heart attack. If so, it is best to get it checked out right away at the hospital. You offer to call 9â€"1â€"1. Actor 2 You give your coworker many reasons why this is not necessary. ■ You ate a big lunch, and it’s just indigestion, nothing serious. ■ You don’t want to cause a scene at work and get everybody worried. ■ You want to wait and see if the pain goes away in a little while. ■ If you went to the hospital, no one would be there to pick up your grandson from daycare. Actor 1 You tell your coworker why it is important to call 9â€"1â€"1 right away. You make the call. 40 HAnDOuTâ€"SESSIOn 2 Fast Action Saves Lives: Role Plays (continued) Role Play 3: At Night Actor 1 You are at home one night reading a magazine when you suddenly start to feel very sick. You call your neighbor on the phone to say you are not feeling well. You describe the signs. ■ You suddenly feel a very bad pain in the center of your chest. ■ You are out of breath, and you are breaking out in a cold sweat. You feel it is something bad, and you think you should drive yourself to the hospital. Will your neighbor go with you? Actor 2 You tell your neighbor you are worried because these symptoms sound like the warning signs of a heart attack. You say in this case it is best to call 9â€"1â€"1, not to drive yourself, so you will get to the hospital safely and be treated right away. Actor 1 You protest that you don’t want to wake up the neighborhood and cause a big scene with the siren and all the lights; it’s easier to drive. Actor 2 You tell your neighbor why it is better to call the emergency service. ■ Emergency personnel can start medical care right away. ■ If your heart stops beating, emergency personnel can revive you. ■ Heart attack patients who arrive by ambulance tend to receive faster treatment when they get to the hospital. Actor 1 You agree that this makes sense. You ask your neighbor to call 9â€"1â€"1 for you right away and then come over to be with you. HAnDOuT SESSIOn 2 41 ____________________________________________________ ____________________________________________________ " " Cut along dotted lines. Fold card in half and paste with a glue stick (Fold 1). (fold 2) Fold in half again to make your own personal wallet card (Fold 2). " Family Doctor: _____________________________________ My Emergency Card Phone: ___________________________________________ Name: ______________________________________________ Local Clinic/Hospital: ________________________________ Date of Birth: _____________ Home Phone: ________________ Phone: ___________________________________________ Emergency Contacts: Emergency numbers Fire Department: ___________________________________ Local Police Department: ____________________________ Name Relationship Phone Current Medications: ___________________________________ Known Allergies: ______________________________________ Other Information: _____________________________________ q No q No q No q No Heart Disease ___________________ Do you have any of the following conditions? q Yes Previous Heart Attack _____________ q Yes High Blood Pressure ______________ q Yes Diabetes _______________________ q Yes Other ____________________________ My Emergency Card " (fold 1) â€" 42 HAnDOuTâ€"SESSIOn 2 Tender Care for a Happy Heart Choose one or two action items from this handout that you would like to do during each week of the training. Then, write down the date that you completed each action. Action q Say something nice, positive, or uplifting to someone. q Allow additional time to do things and get to places without rushing. q Try a new hobby such as arts and crafts. q Look for an activity that will allow you to make new friends. q Show gratitude to at least five people. q Tell your loved ones that you love them. q Do something nice for someone. q Think about three things that make you happy. q Value what you have, and try to see the positive side of things. q Do something special for yourself. q Laugh and be positive. If you like jokes, tell one. Date Action q Call a friend you have not seen for a long time. q Look at yourself in the mirror and say, “I am special and unique.” q Write down how you feel. q At the end of the day, think about the things that were good and the things you can improve. q Rest. Go to bed 1 hour earlier than usual. q Listen to soft music to relax. q Help someone in need. q Plant a garden. q Be thankful for your family. q Seek support in your faith community. q Speak calmly. Do not yell or scream. q Take 15 minutes to breathe deeply and relax. q Be kind to someone with whom you have differences. Date 43 session 3 Take Heart: Say YES to Physical Activity Objectives By the end of this session, group members will learn that: ■ Physical activity is good for the heart and overall health. ■ Adults should be physically active for 30 to 60 minutes on most days. ■ Children and adolescents should be physically active for about 60 minutes on most days, preferably daily. ■ Brisk walking is a simple activity nearly everyone can do. ■ There are ways to fit more activity into a busy schedule. Materials and Supplies To conduct this session, you will need: ■ “Your Heart, Your Life” manual and picture cards ■ Blackboard and chalk or several large pieces of paper, a marker, and tape ■ (Optional) Index cards for physical activity guessing game* ■ (Optional) VCR or DVD and TV * Prepare before the session. Session 3. Take Heart: Say YES to Physical Activity 44 ■ (Optional) “The New Health Machine: Exercise” telenovela or fotonovela (pages 412 and 413) Note: The telenovela is available in Spanish only. ♥ ■ Cool drinking water and cups ■ (Optional) Music for walking activity and tape player or CD player Handouts Give group members these handouts during this session: ■ “Getting Started With Physical Activity” (page 65) ■ “Getting Started With Physical Activity: Doña Fela’s Answers” (page 66) ■ “Take Heartâ€"Say Yes to Physical Activity” (pages 67â€"68) ■ “Stretching Activities” (page 69) ■ “How To Be Physically Active” (page 70) ■ “Make Physical Activity a Habitâ€"My Personal Record” (page 71) ■ “Sample Walking Program” (page 72) Session Outline Introducing the Session 1. Welcome 2. Review of Last Week’s Session 3. About This Session Your Heart, Your Life: A Community Health Worker’s Manual 45 Conducting the Session 1. Facts About Physical Activity 2. (Optional) “The New Health Machine: Exercise” Telenovela or Fotonovela (pages 412â€"413) 3. Benefits of Physical Activity 4. Types of Physical Activity (Optional) Physical Activity Guessing Game 5. Getting Started: Important Things To Know 6. Finding Time To Be Physically Active 7. Walking: An Activity for Almost Everyone* A. Discussion and Stretching B. Walking Activity Review of Today’s Key Points Weekly Pledge Closing Note: If you have time, include a 30-minute activity, such as walking, at the beginning ♥ or end of the remaining sessions. * Prepare for the walking activity by reading the box with tips on page 58. Session 3. Take Heart: Say YES to Physical Activity 46 Introducing the Session 1. Welcome ■ Welcome group members to the session. 2. Review of Last Week’s Session ■ Say: At the last session we talked about the heart attack warning signs. Who remembers the warning signs of a heart attack? Note: Allow about 3 minutes for group members to answer. Write their answers on the ♥ blackboard or on a large piece of paper taped to the wall. ■ Add these signs if they are not mentioned: • Your chest may hurt or feel squeezed. • You may feel pain in your neck or jaw. • One or both of your arms, your back, or your stomach may hurt. • You may feel like you can’t breathe. • You may break out in a cold sweat. • You may feel sick to your stomach. • You may feel light-headed. ■ Ask: Who remembers what you should do if you feel these symptoms? Your Heart, Your Life: A Community Health Worker’s Manual 47 ■ Say: The answers are: • Call 9â€"1â€"1 in 5 minutes or less, even if you are not sure you are having a heart attack. Calling 9â€"1â€"1 gets you treated more quickly. • Do not drive yourself to the hospital. ■ Say: At the end of the session, we pledged to do one thing to be prepared if a heart attack happens. Please share with the group what you did. ♥ Note: Allow 2 to 3 minutes for group members to respond. 3. About This Session ■ Say: During today’s session, we will discuss physical activity and how important it is to your heart health. When the session ends, you will know: • How physical activity can help you and your family • What kind of activities are good for you and for your heart • How much activity you should do • How you can find time to be active Note: “Physical activity” and “exercise” mean the same thing. ♥ Session 3. Take Heart: Say YES to Physical Activity 48 Conducting the Session 1. Facts About Physical Activity ■ Say: Not getting enough physical activity is a major health risk for people today. • Being physically inactive puts you at risk for heart disease. The good news is that you can do something about this risk factor. • Latinos, especially women and children, are not getting enough physical activity. • As a person gets older, having little or no physical activity can lead to health problems. 2. (Optional) “The New Health Machine: Exercise” Telenovela or Fotonovela ■ If you choose, show the telenovela on physical activity, “The New Health Machine: Exercise,” or have volunteers read the fotonovela (pages 412â€"413). ♥ Note: The telenovela is available in Spanish only. 3. Benefits of Physical Activity ■ Ask: How do you think physical activity can help you? Note: Allow about 5 minutes for group members to answer. Write their answers on the ♥ blackboard or on a large piece of paper taped to the wall. ■ Show picture card 3.1. Your Heart, Your Life: A Community Health Worker’s Manual 49 ■ Say: Physical activity can help you: • Strengthen your heart and lungs. • Feel better about yourself. • Build and maintain healthy bones, • Lower your stress. muscles, and joints. • Reduce feelings of depression • Control your weight. and anxiety. • Have more energy. • Sleep better. ■ Show picture card 3.2. ■ Say: Physical activity can also help you: • Lower your blood pressure. • Control your blood cholesterol. • Lower your risk of getting heart disease, diabetes, and some cancers. ■ Show picture card 3.3. ■ Say: People feel better when they are active. Physical activity may help you lose weight. 4. Types of Physical Activity ■ Ask: What do you do to be physically active? Note: Allow about 5 minutes for group members to respond. Write their answers on the ♥ blackboard or on a large piece of paper taped to the wall. Session 3. Take Heart: Say YES to Physical Activity 50 ■ Say: There are different types of physical activity. Physical activity includes some of the things that you probably do each day, like walking, climbing stairs, or doing household chores. ■ Show picture card 3.4. ■ Say: You may want to start with moderate (medium-level) activities. Moderate activities should require you to make some physical effort, but you should be able to have a conversation comfortably while doing them. Examples of moderate activities include: • Walking at a brisk pace • Gardening (mowing, raking) • Dancing (salsa, merengue) • Making home repairs (painting) • Washing and waxing a car ■ Show picture card 3.5. ■ Say: • Scrubbing floors and washing windows • Weightlifting • Playing softball • Doing floor exercises (pushups, situps) After a while, you will be able to do more vigorous (high-level) activities. Vigorous activities require hard physical effort and make your heart rate and breathing much faster. You usually can’t carry on a conversation comfortably while you are doing vigorous activities. Vigorous activities that you might enjoy include: • Playing soccer, basketball, or baseball • Running or jogging • Bicycling fast or uphill • Doing aerobics • Swimming laps • Jumping rope • Skating • Performing heavy construction work Your Heart, Your Life: A Community Health Worker’s Manual 51 A. (Optional) Physical Activity Guessing Game Note: You can play a physical activity guessing game. Ahead of time, write the names ♥ of the 8 medium-level physical activities on index cards of one color and the 10 high-level activities on index cards of a different color (listed on page 68). ■ Divide participants into two groups, and give each person a card. ■ Ask the medium-level activity group to go first. One by one, each person will act out the physical activity on his or her card. Ask the rest of the participants to guess the activity. ■ Follow the same process for the high-level activity group. ■ Say: All types of physical activity are good for you. Aerobic activities, such as brisk walking that speeds your heart rate and breathing, help your heart. Other activities such as weightlifting and stretching can help improve strength and flexibility. ■ Say: Start slowly. Then move on to higher-level activities. For example, when you are comfortable walking, gradually begin to jog. You’ll feel great! ■ Ask: How much physical activity do you think you need to do each day to improve your health? ■ Say: • Adults should have at least 30 minutes of moderate physical activity daily to lower their chances of getting heart disease. • Some adults need up to 60 minutes of moderate physical activity on most days to prevent unhealthy weight gain. • Adults who used to be overweight need 60 to 90 minutes of moderate physical activity every day to avoid regaining weight. • Children and adolescents need at least 60 minutes of moderate to vigorous physical activity on most days, preferably daily. Session 3. Take Heart: Say YES to Physical Activity 52 ■ Show picture card 3.6. ■ Say: If you can’t set aside 30 or 60 minutes at one time to be active, you can break your activity into shorter periods of 10 minutes or longer. It’s the total time of physical activity that is important. Just make sure that the total time adds up to 30 or 60 minutes on most days. ■ Say: For example, if you can only do 30 minutes of physical activity a day: • Ride your stationary bike for 10 minutes before you go to work.............+10 • Take a 10-minute walk with your kids after work....................................+10 • Do aerobic exercises for 10 minutes later in the day................................+10 30 minutes ■ Show picture card 3.7. ■ Say: If you have more time, you can build up to 60 minutes a day with activities like these: • Use your stationary bike for 10 minutes before you go to work..............+10 • Take a 15-minute walk with coworkers during your lunch break. ...........+15 • Lift weights (dumbbells) while dinner is baking ......................................+10 • Dance with your family to your favorite music........................................+15 • Do aerobic exercises for 10 minutes later in the day................................+10 60 minutes Your Heart, Your Life: A Community Health Worker’s Manual 53 More Information Just Move It ■ Physical activity is important in weight control. ■ Try to be physically active for 30 to 60 minutes on most days. Here are some examples of how many calories you can burn from various activities for 30 minutes. Activity Calories burned per 30 minutes* Weightlifting 110 Walking (briskly), 31/2 miles per hour 140 Gardening 165 Raking leaves 165 Dancing 240 Bicycling (slowly), 10 miles per hour 145 Swimming laps 255 Jogging, 5 miles per hour 295 * These calories are for a healthy 154-pound person. A lighter person burns fewer calories; a heavier person burns more. Source: “The Compendium of Physical Activities Tracking Guide,” University of South Carolina, 2000 Session 3. Take Heart: Say YES to Physical Activity 54 5. Getting Started: Important Things To Know Note: This session gives information for people who are just starting to be active. It also ♥ helps people add more activity to what they already do. ■ Say: There are a few things you should know before starting to be physically active. ■ Give each group member the “Getting Started With Physical Activity” handout (page 65). ■ Say: It’s very important to know when to talk with a doctor before starting a physical activity program. In the list on your handout, check which people should see a doctor before they begin physical activity. ■ Read the passages below while the participants check off the boxes. ❏ Carlos is 65 years old and had a heart attack 10 years ago, but he is fully recovered. ❏ Maria is 32 years old and had a healthy baby 8 months ago. ❏ Arturo is 38 years old and has diabetes, but he controls his condition very well with medication. ❏ Carmen is 35 years old and wants to start being more physically active to lower her high blood pressure and help herself to quit smoking. ❏ Gloria is 27 years old and in good health, and she wants to start running. ❏ Hector is 57 years old and broke his leg 2 years ago, but it healed very well. He walks every day but wants to start jogging. Note: Allow a few minutes for group members to discuss. ♥ ■ Give each group member the “Getting Started With Physical Activity: Doña Fela’s Answers” handout (page 66). Your Heart, Your Life: A Community Health Worker’s Manual 55 ■ Say: Let’s look at the handout to see what Doña Fela has to say about this. ♥ Note: Go over the answers with the group. ■ Say: These are Doña Fela’s answers: ❏ âœ" Carlos should see a doctor before starting a physical activity program, because he has had a heart attack. Even though he is fully recovered, he should still check with his doctor. ❏ Maria does not need to see a doctor before starting a physical activity program. Having a baby is not a risk factor, and she is young. ❏ âœ" Arturo should see a doctor before starting a physical activity program, because he has diabetes. Even though he is young and he controls his condition very well with medication, he should still check with his doctor. ❏ âœ" Carmen should see a doctor before starting a physical activity program because she has two risk factors: high blood pressure and smoking. ❏ Gloria does not need to see a doctor before starting a physical activity program. Even though she wants to start a harder activity, such as running, she is young and in good health. ❏ âœ" Hector should see a doctor before starting a physical activity program. His broken leg is not a factor, but he should check with the doctor first, because he wants to start a harder physical activity program, and he is more than 45 years old. ■ Say: Here are some other things you should know before starting a physical activity program: 1. Start slowly. Build up the time and effort that you put into any activity. You should not be tired the next day. Session 3. Take Heart: Say YES to Physical Activity 56 2. Drink plenty of fluids before, during, and after physical activity, even if you are not thirsty. Drink water. Water has no calories and will prevent you from becoming dehydrated. Special sports drinks are not needed. 3. Wear shoes and socks that give your feet support. Shoes with thick soles will cushion your feet and absorb shock. 4. Wear comfortable clothing. You do not need to buy fancy outfits. 5. Never wrap your body in plastic or wear clothing that is too heavy. This will not help you lose fat, but it can: • Make you sweat too much. • Make your body temperature rise. • Make your heart beat too fast. • Make you sick to your stomach. • Cause you to pass out. • Cause damage to your organs. ■ Say: You should also know that some people who are very overweight may face special challenges in trying to be physically active, but they too have good options. Start with these activities: • Weight-bearing activities, such as walking, involve lifting or pushing your own body weight. • Nonweight-bearing activities, such as swimming and water workouts, put less stress on your joints because you do not have to lift or push your own weight. If your feet or joints hurt when you stand, nonweight-bearing activities may be best for you. • Lifestyle activities, such as gardening, do not have to be planned. Your Heart, Your Life: A Community Health Worker’s Manual 57 Note: For more information on being active at any size, visit the Weight-control ♥ Information Network at http://win.niddk.nih.gov or call 1â€"877â€"946â€"4627 (toll free). ■ Ask: Does anyone have any questions? Note: Allow 2 or 3 minutes for questions. ♥ 6. Finding Time To Be Physically Active ■ Say: I know that all of you have busy lives. You may be wondering how you will ever find time to be physically active. Let’s look at some ways. ■ Give each group member the “Take Heartâ€"Say Yes to Physical Activity” handout (pages 67â€"68). Read the handout aloud. ■ Ask: What are some other ways to become more active even when you don’t have time? Note: Allow about 5 minutes for group members to answer. Write their answers on the ♥ blackboard or on a large piece of paper taped to the wall. ■ Add these ways if group members do not mention them. • Take a 15- to 20-minute walk during your lunch break at work or after dinner with your family. • Jump rope a few minutes each day. Work up to jumping for 10 minutes. • Dance with your children. You’ll burn calories and have fun together. ■ Say: Spend more time being active, and cut back on watching TV, videos, or DVDs; using the computer; or playing video games. Session 3. Take Heart: Say YES to Physical Activity 58 7. Walking: An Activity for Almost Everyone Tips for Preparing for the Walking Activity Before the start of this session: ■ Review the “Stretching Activities” handout (page 69). ■ Practice until you know each part well enough to teach it to the group members. ■ Practice a brisk walk. Take long strides, and swing your arms. When leading this activity, remember: ■ Music can get people in the mood for being active. Use a lively song for the warmup exercises, a faster beat for the walking, and a relaxing song for the cooldown period. Make sure that no one objects to the music. ■ Be enthusiastic. Group members will pick up on your enthusiasm and feel good about exercising. ■ Lead the walk in a circle if you have to do the walking indoors or if space is limited. ■ Have plenty of cool drinking water available before and after the activity. A. Discussion and Stretching ■ Say: Brisk walking is an excellent form of physical activity. It’s easy to do, and you do not need special equipment. All you need are shoes for support and socks for cushioning. Your Heart, Your Life: A Community Health Worker’s Manual ■ Say: Walking can be done outdoors or indoors. If you do not feel safe walking in your neighborhood, a school or churchyard may be a safer place to walk. Walk in well-lit areas at night. Many shopping malls let people walk inside the mall before the stores open. Some malls even have walking clubs that meet every day. ■ Say: It’s important to spend time warming up and cooling down each time you are physically active. Although the risk of injury from walking is low, the warmup gets your leg muscles ready for the activity. The cooldown lets your heart rate slowly return to normal. This also keeps your leg muscles from getting stiff. Note: Ask the group members to stand up and spread out, with at least 3 feet between ♥ them and other group members. ■ Start the music. ■ Say: It is important to warm up your muscles and stretch before you begin physical activity. First, we will warm up our muscles, and then we will stretch. Let’s walk in place slowly for 3 minutes. ■ Say: Now, I am going to show you some stretching activities. Watch me, and then try doing them yourselves. Some are easier to do than others. With time and practice, you will be able to do them all. If you have a bit of trouble at first, just do your best. You will get a handout that tells you how to do these stretching activities. Use the handout to help you do them at home. B. Walking Activity ■ After the stretching activities, lead the group members on a 15- to ACTIVITY 20- minute walk. Walk slowly for the first 5 minutes. Then show them how to do a brisk walk for 5 to 10 minutes. ■ During the last 5 minutes, slow your pace. Session 3. Take Heart: Say YES to Physical Activity 59 60 ■ Say: We are slowing down now so that our bodies can gradually relax. This important part is called the cooldown period. It’s usually recommended that you gradually slow your pace during the last 5 minutes of an activity. Doing a few stretching exercises to loosen the muscles should also be part of your cooldown. ■ Say: For example, runners or joggers may cool down by walking for a few minutes and then stretching their leg muscles before they stop entirely. ■ Ask: How do you feel? Do you think you could continue to walk like this? Why or why not? Note: Allow 3 to 5 minutes for group members to answer. ♥ ■ Say: If you already walk three or more times a week, add other activities to become more fit. Try running, jumping rope, or doing aerobics. ■ Say: One of the hardest parts of being more active is staying motivated. Many people find that having a partner helps them stay active. A partner can be a family member, neighbor, or friend. The benefits of having a partner are: • You can motivate each other. You can set goals together and help each other meet them. • It makes the time go by faster. You focus on talking rather than on the activity. ■ Say: Walking clubs are a great way to enjoy physical activity and make friends. Your Heart, Your Life: A Community Health Worker’s Manual 61 ♥ Note: See page 424 for tips on how to organize a walking club, so you can share the tips with group members. ■ Ask: • What would help you stay motivated to continue being physically active? • Where are some safe places in your neighborhood to be active? ♥ Note: Allow about 3 minutes for group members to answer. Write their answers on the blackboard or on a large piece of paper taped to the wall. ■ Give each group member the following handouts: “Stretching Activities” (page 69), “How To Be Physically Active” (page 70), “Make Physical Activity a Habitâ€"My Personal Record” (page 71), and “Sample Walking Program” (page 72). ■ Say: Use the “Make Physical Activity a Habitâ€"My Personal Record” handout to track your daily progress. Review of Today’s Key Points ■ Say: Let’s review what we have learned today. What are some of the benefits of regular physical activity? • Regular physical activity can: â€" Strengthen your heart and lungs. â€" Build and maintain healthy bones, muscles, and joints. â€" Help you lose excess weight and prevent weight gain. â€" Control blood cholesterol and lower blood pressure. Session 3. Take Heart: Say YES to Physical Activity 62 â€" Help you sleep better, reduce stress, increase energy, and reduce feelings of depression. â€" Lower your chance for heart disease, diabetes, and cancer. What is an activity that just about everyone can do? • Brisk walking What are simple ways to become more active throughout the day? • Take a walk. • Get off the bus early and walk. • Dance to your favorite music. What is the minimum amount of physical activity recommended for you to do every day? • Adults need at least 30 minutes, and children and adolescents need at least 60 minutes daily. Weekly Pledge ■ Say: You have learned a lot today about how you can become more physically active. Now let’s think about how you can apply what you have learned. Please think of one change you can make in your everyday life to increase your level of physical activity. This will be your pledge for the week. ■ Say: Be specific about what you plan to do, how you plan to do it, and when you will start. Examples include: • I will talk to family members and friends this weekend about taking regular walks together. Your Heart, Your Life: A Community Health Worker’s Manual 63 • I will start walking for at least 20 minutes during my lunch break at work, starting tomorrow. ■ Say: Write your pledge on the “Take Heartâ€"Say Yes to Physical Activity” handout on page 68. Keep this handout in a special place so you can review your pledges and keep your goal in mind. ♥ Note: Allow 5 minutes for group members to think of a pledge and write it down. ■ Say: Would anyone like to share his or her pledge with the group? Note: Write down pledge ideas on the blackboard or on a large piece of paper taped to ♥ the wall. ■ (Optional) Say: Keeping a personal value in mind can help you make changes in your everyday life to become more physically active. Remember that a personal value is a quality that you consider important. Today the value is perseverance. Perseverance helps you have the willpower to keep your pledge, even if it means starting again after a slip. It helps you set a routine to keep you focused on your goal to improve your health. ■ Ask: How could you use perseverance or another value to help you keep your pledge? Note: Allow 3 minutes for group members to share their thoughts. ♥ ■ Say: We will talk about how you did with your pledge at the next session. Remember to keep working on your pledge to be prepared if a heart attack happens. Session 3. Take Heart: Say YES to Physical Activity 64 Closing ■ Say: Thank you for coming today. What did you think of today’s session? ♥ Note: Allow a moment for group members to respond. ■ Say: I am looking forward to seeing you at the next session. The next session will be about how to cut back on salt and sodium to prevent and control high blood pressure. Note: Think about today’s class. What worked? What didn’t work? Have you made ♥ any changes in your own life that were covered in today’s session? Your Heart, Your Life: A Community Health Worker’s Manual HANDOuTâ€"SESSION 3 65 Getting Started With Physical Activity It’s very important to know when to talk with a doctor before starting a physical activity program. In the list below, check which people should see a doctor before they begin a physical activity program. ❏ Carlos is 65 years old and had a heart attack 10 years ago, but he is fully recovered. ❏ Maria is 32 years old and had a healthy baby 8 months ago. ❏ Arturo is 38 years old and has diabetes, but he controls his condition very well with medication. ❏ Carmen is 35 years old and wants to start being more physically active to lower her high blood pressure and help her to quit smoking. ❏ Gloria is 27 years old and in good health, and she wants to start running. ❏ Hector is 57 years old and broke his leg 2 years ago, but it healed very well. He walks every day, but wants to start jogging. 66 HANDOuTâ€"SESSION 3 Getting Started With Physical Activity: Doña Fela’s Answers ❏ âœ" Carlos should see a doctor before starting a physical activity program because he has had a heart attack. Even though he is fully recovered, he should still check with his doctor. ❏ Maria does not need to see a doctor before starting a physical activity program. Having a baby is not a risk factor, and she is young. ❏ âœ" Arturo should see a doctor before starting a physical activity program, because he has diabetes. Even though he is young and he controls his condition very well with medication, he should still check with his doctor. ❏ âœ" Carmen should see a doctor before starting a physical activity program, because she has two risk factors: high blood pressure and smoking. ❏ Gloria does not need to see a doctor before starting a physical activity program. Even though she wants to start a harder activity, such as running, she is young and in good health. ❏ âœ" Hector should see a doctor before starting a physical activity program. His broken leg is not a factor, but he should check with the doctor first, because he wants to start a harder physical activity program, and he is more than 45 years old. 67 Take Heartâ€"Say Yes to Physical Activity Regular physical activity can help your heart and lungs work better; lower your blood pressure, blood cholesterol, and blood glucose (blood sugar); and help you control your weight. It can also help you relax, feel less tense, sleep better, have more energy, and feel better about yourself. Physical activity can also reduce your risk for diabetes and some types of cancer. Make staying active 68 HANDOuTâ€"SESSION 3 Take Heartâ€"Say Yes to Physical Activity (continued) Keep moving. Start slowly, and work your way up! Strive to do at least 30 minutes of activity every day. If you’re short on time, try three or more 10-minute periods. Start with light activities • Slow walking • Watering the lawn or garden • Vacuuming Move to moderate activities • Walking at a brisk pace • Gardening (mowing, raking) • Dancing • Doing home repairs • Washing and waxing a car • Washing windows and scrubbing floors • Playing softball • Weightlifting Increase to vigorous activities • Playing soccer • Playing basketball • Playing baseball • Running or jogging • Bicycling fast or uphill • Doing aerobics • Swimming laps • Jumping rope • Skating • Doing heavy construction work Other things to do to help you and your family get started: • Leave a pair of walking shoes in your car. • Set a date and time with a coworker to begin walking. Carmencita, Virginia, and Néstor Ramírez have all increased their physical activity. They now dance and use their stationary bike almost every day. And Mariano Ramírez jogs in place each day. Make your personal pledge to exercise like the Ramírez family does! Look at these examples: Morning Park the car a few blocks away and walk for 10 minutes. Noon During lunch, take a walk with a coworker. Evening After dinner, take a walk with your family. Write the changes you will make this week. Your health and your family’s health are priceless. Make an investment in it! HANDOuTâ€"SESSION 3 69 Stretching Activities Do these stretches gently and slowly. Do not bounce. 1. Deep breathing 2. Neck Stretching 3. Shoulder Stretches 4. Side Stretches Arms up, breathe in. Side to side two times. Up and down five times Up and down five times Arms down, breathe out. on each side. in each direction. Two times each. 5. Waist Stretches 6. Twists 7. Back and Leg 8. Back Stretch Side to side three times Side to side three times Stretches Arms through legs six in each direction. in each direction. Down and up five times. times. 11. Leg Stretch 3 Move heels up and down six times. 9. Leg Stretch 1 10. Leg Stretch 2 Hold onto ankle, four Down and up five times. times on each side. Developed by the California Diabetes Program, California Department of Health Services. 70 HANDOuTâ€"SESSION 3 How To Be Physically Active 1. Walk slowly for 5 minutes. Then do stretching exercises. (See handout on stretching exercises.) 3. Walk slowly for 5 minutes. 4. Relax! 2. Walk briskly for 20 minutes. 71 Make Physical Activity a Habitâ€"My Personal Record Name: _____________________________________________ Track your progress every day. Start out slowly. Aim to reach 60 minutes or more each day! Write down the number of minutes you are active each day. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Example 5 min. 5 10 10 15 15 15 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 HANDOuTâ€"SESSION 3 Sample Walking Program* Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Warm Up Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk Walk briskly 5 minutes Walk briskly 10 minutes Walk briskly 15 minutes Walk briskly 20 minutes Walk briskly 25 minutes Walk briskly 30 minutes Walk briskly 35 minutes Walk briskly 40 minutes Cool Down Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Walk slowly 5 minutes Total Time 15 minutes 20 minutes 25 minutes 30 minutes 35 minutes 40 minutes 45 minutes 50 minutes * Walk every day of the week. 72 HANDOuTâ€"SESSION 3 73 session 4 Help Your Heart: Control Your High Blood Pressure Objectives By the end of this session, group members will learn: n What blood pressure is n That it is best to have a blood pressure below 120/80 mmHg (millimeters of mercury) n That blood pressure between 120/80 and 139/89 mmHg is prehypertension n That a blood pressure of 140/90 mmHg or greater is high n What a stroke is and what the warning signs are n That eating less salt and sodium can lower the risk of developing high blood pressure n That they can take steps to lower the amount of salt and sodium in their diet Materials and Supplies To conduct this session, you will need: n “Your Heart, Your Life” manual and picture cards n Blackboard and chalk or several large pieces of paper, a marker, and tape n Measuring spoons (1 teaspoon) n Small amount of salt Session 4. Help Your Heart: Control Your High Blood Pressure 74 n Colored plate or plastic test tube n Doña Fela’s Seasoning Mixture (page 105). Prepare enough to give a small sample to each group member in a plastic bag or cup. n (Optional) The “They’ll Learn To Like Him” and “An Unsettling Surprise: Prevent High Blood Pressure” telenovelas. The “An Unsettling Surprise: Prevent High Blood Pressure” fotonovela can be found on pages 414â€"415. ♥ Note: The telenovela is available in Spanish only. n (Optional) VCR or DVD and TV monitor ♥ (Optional) Note: Arrange for a health professional to come to the session to take blood pressure readings. Handouts Give these handouts to each group member during this session: n List of places where group members can get their blood pressure checked* n “Know the Stroke Signs. Act Quickly.” (page 98) n “My Healthy Heart Wallet Card” (page 99) n “Take Stepsâ€"Healthy Habits To Lower High Blood Pressure!” (page 100) n “Read the Food Label for Sodium!” (page 101) n “Mariano’s Food Choices” (pages 102â€"103) n “Sodium in Foods” (page 104) n “Keep Your Heart in Mind: Eat Less Salt and Sodium” (pages 105â€"106) n “Tips for Taking Medicine for High Blood Pressure” (page 107) * Prepare this list before the session. You may find information at your local health department, a hospital, or a clinic. Your Heart, Your Life: A Community Health Worker’s Manual 75 n “Turkey Meatloaf Recipe” (page 108) n “Use Herbs and Spices Instead of Salt” (page 109) Session Outline Introducing the Session 1. Welcome 2. Review of Last Week’s Session 3. About This Session Conducting the Session 1. The Facts Don’t Lie 2. (Optional) “An Unsettling Surprise: Prevent High Blood Pressure” Telenovela or Fotonovela 3. Facts About Blood Pressure and Stroke 4. Lowering High Blood Pressure 5. (Optional) “They’ll Learn To Like Him” Telenovela 6. Salt and Sodiumâ€"How Much Do We Need? 7. Food Label Activityâ€"Sodium 8. Shake the Salt and Sodium Habit 9. Easy on the Alcohol 10. Manage Your High Blood Pressure With Medicine 11. Turkey Meatloaf Recipe Review of Today’s Key Points Weekly Pledge Session 4. Help Your Heart: Control Your High Blood Pressure 76 (Optional) Blood Pressure Check Closing Introducing the Session 1. Welcome n Welcome group members to the session. 2. Review of Last Week’s Session n Say: Last week, we talked about why you should be physically active. What do you remember about the benefits of being physically active? Note: Allow about 3 minutes for group members to answer. Write responses on the ♥ blackboard or on a large piece of paper taped to the wall. n Add the following benefits if they are not mentioned. Physical activity: • Strengthens your heart and lungs. • Builds and maintains healthy bones, muscles, and joints. • Helps you feel better about yourself. • Helps you control your weight. • Helps you lower your high blood pressure. • Helps you control your blood cholesterol. • Helps you sleep better. • Helps you reduce stress and feelings of depression and anxiety. Your Heart, Your Life: A Community Health Worker’s Manual 77 • Helps you have more energy. • Helps lower your chances of developing diabetes (high blood sugar), heart disease, and some cancers. n Say: At the end of our last session, everyone made a pledge to be more active. Note: Share with the group what you did and what barriers you faced. ♥ n Ask: Would any of you like to share with the group what you did? What problems did you face (such as not having time or not getting family support)? How did you solve them? Note: Allow about 5 minutes for responses. ♥ 3. About This Session n Say: Today’s session is about blood pressure and the steps you can take to lower your blood pressure or keep it from rising. Conducting the Session 1. The Facts Don’t Lie n Say: • More than 65 million people (one in three) in the United States have high blood pressure, which is also called hypertension. Nearly a third of these people don’t know they have high blood pressure. Session 4. Help Your Heart: Control Your High Blood Pressure 78 • Another 59 million Americans have prehypertension, which means they are at risk for developing high blood pressure. • Nearly one in five Latinos has high blood pressure. • Only one in five Mexican Americans with high blood pressure have their blood pressure under control. 2. (Optional) “An Unsettling Surprise” Telenovela or Fotonovela n Show the telenovela, “An Unsettling Surprise: Prevent High Blood Pressure,” or have volunteers read the fotonovela (pages 414â€"415). 3. Facts About Blood Pressure and Stroke n Show picture card 4.1. n Say: Blood pressure is the force of blood against the walls of your arteries. Blood pressure is needed to move the blood through your body. n Show picture card 4.2. n Say: Blood pressure is recorded as two numbersâ€"â€"the systolic pressure (as the heart beats) over the diastolic pressure (as the heart relaxes between beats). n Say: The measurement is written one above the other, with the systolic number on top and the diastolic number on the bottom. For example, a blood pressure measurement of 120/80 mmHg is expressed verbally as “120 over 80.” Your Heart, Your Life: A Community Health Worker’s Manual 79 n Say: It is important to keep track of your blood pressure numbers. Write down your numbers every time you have your blood pressure checked. n Ask: Do you know your blood pressure numbers? Note: Allow about 2 minutes for responses. ♥ Note: Copy this chart on the blackboard or on a large piece of paper taped to the wall. ♥ Your Blood Pressure Numbers Level First number (mmHg) Second number (mmHg) Results Normal Below 120 Below 80 Good for you! Prehypertension 120â€"139 80â€"89 Keep an eye on your blood pressure. It is time to make changes in your eating and physical activity habits. Visit the doctor if you have diabetes. High blood pressure 140 or greater 90 or greater Ask your doctor or nurse how to control it. n Say: A normal blood pressure is less than 120/80 mmHg. Blood pressure of 120/80 to 139/89 mmHg is prehypertension. This means that you don’t have high blood pressure yet, but are likely to develop it in the future, unless you make changes in your health habits. Blood pressure is high when it is 140/90 mmHg or greater. n Show picture card 4.3. Session 4. Help Your Heart: Control Your High Blood Pressure 80 n Say: If you have high blood pressure, or hypertension, it means your heart has to pump harder than it should to get blood to all parts of your body. High blood pressure raises your chances of having a stroke, heart attack, or kidney problems or becoming blind. n Say: High blood pressure is known as the “silent killer” because it often has no symptoms. Most people who have it don’t feel sick until they have a stroke, heart attack, or some other problem caused by high blood pressure. n Say: High blood pressure is a major risk factor for stroke. Other risk factors that increase your chances of having a stroke include heart disease, smoking, diabetes, and high blood cholesterol. n Ask: Do you know anyone who has had a stroke? Note: Allow a few minutes for group members to answer. ♥ n Give group members the “Know the Stroke Signs. Act Quickly.” handout (page 98). n Show picture card 4.4. n Say: A stroke is also called a brain attack. A stroke happens when blood suddenly stops going to the brain and brain cells die. A stroke is very serious and can lead to disability and death. Your Heart, Your Life: A Community Health Worker’s Manual 81 n Say: The warning signs of a stroke happen suddenly. A person may have one or more warning signs. The warning signs of a stroke include: • Numbness of the face, arm, or leg (especially on one side of the body) • Confusion, trouble talking, and difficulty understanding others • Trouble seeing in one or both eyes • Trouble walking, dizziness, and loss of balance or coordination • Severe headache n Say: Ministrokesâ€"or transient ischemic attacks (TIAs)â€"have the same symptoms as a stroke, but they do not last as long and usually do not cause brain damage. A ministroke is a warning that a stroke may happen in the future. n Say: Ministrokes may last a few seconds or an entire day and then go away. These signs should not be ignored. As with a heart attack, act immediately if you or someone you know has stroke symptoms. Calling 9â€"1â€"1 right away will help prevent serious problems. n Show picture card 4.5. n Say: Measuring blood pressure is easy and does not hurt. The best way to find out if you have high blood pressure is to have it checked at least once a year. Check it more often if you already have high blood pressure. n Give group members: • A list of places (such as clinics and hospitals) to get blood pressure checked • The “My Healthy Heart Wallet Card” handout (page 99) Session 4. Help Your Heart: Control Your High Blood Pressure 82 n Say: Ask for your numbers each time you have your blood pressure checked. Keep a record of each reading on the wallet card. 4. Lowering High Blood Pressure n Ask group members to raise their hands if someone in their families has high blood pressure. n Say: If a member of your family has high blood pressure, you are at greater risk for getting it, too. Even if you do not have high blood pressure now, you are still at greater risk if a family member has it. n Say: The good news is that you can take steps now to lower your blood pressure or keep it from rising. Let’s find out how. n Give each group member the “Take Stepsâ€"Healthy Habits To Lower High Blood Pressure!” handout (page 100). n Read aloud the steps to lower high blood pressure or keep it from rising. n Ask: Which steps could you and your family take to prevent or lower high blood pressure? Note: Allow 3 minutes for group members to respond. ♥ Your Heart, Your Life: A Community Health Worker’s Manual 83 5. (Optional) “They’ll Learn To Like Him” Telenovela n Say: Let’s see what the Ramírez family has to say about eating less salt and sodium. n Show the “They’ll Learn To Like Him” telenovela. 6. Salt and Sodiumâ€"How Much Do We Need? Note: For this activity, you will need a 1 ♥ /4 teaspoon measuring spoon, a 1 teaspoon measuring spoon, and some salt. Use a colored plate or a plastic test tube to show the sodium levels. n Say: Eating less salt and sodium can help you prevent or lower high blood pressure. You probably know what salt is, but you may wonder what sodium is. Sodium is a part of salt. It is also part of mixtures used to flavor and preserve foods. n Say: You should cut back the amount of sodium you get from all foods and beverages to less than 2,300 milligrams of sodium, or about 1 teaspoon of salt per day. Note: Now show 1 teaspoon of salt. ♥ n Say: Most people in the United States eat about 4,000 to 6,000 milligrams of sodium each day, or about 2½ teaspoons. Note: Now show 2½ teaspoons of salt. Session 4. Help Your Heart: Control Your High Blood Pressure 84 ♥n Say: This is about 8 to 12 times more sodium than the body needs. Eating this much salt and sodium may lead to high blood pressure. n Show picture card 4.6. n Say: Let’s talk about what foods are high in sodium. • Most of the sodium that we eat comes from packaged foods, and from restaurants and fast foods. Examples of packaged foods are regular canned soups, canned vegetables, frozen dinners, salty chips, and meats high in sodium such as hotdogs. • When you eat out, most of the food will be high in sodium. If you have high blood pressure, you should eat out less often. • Sodium also comes from salt added during cooking or at the table. 7. Food Label Activityâ€"Sodium n Show picture card 4.7. n Say: The food label found on packaged foods is one of the best tools we have for choosing foods for a healthy diet. In this session, we will learn how to use the food label to choose foods that are lower in sodium. n Give group members the “Read the Food Label for Sodium!” handout (page 101). n Say: Your Heart, Your Life: A Community Health Worker’s Manual 85 The food label lists the serving size and number of servings in the container. It also gives the amount of calories, sodium, saturated fat, trans fat, cholesterol, and sugar in one serving of the food. We will talk about calories, saturated fat, trans fat, and cholesterol in the next two sessions. Today we will concentrate on sodium. n Point to where the Percent Daily Value is located on the food label. n Say: The Percent Daily Value helps you compare products. It tells you if a food is high or low in various nutrients. Rememberâ€"it is easy to take in more than 2,300 milligrams of sodium. Choose foods with a lower Percent Daily Value for sodium. A Percent Daily Value of 5 or less is low, and a Percent Daily Value of 20 or more is high. Once you get into the habit of looking at food labels, it will be easy. n Say: Let’s take a close look at the Nutrition Facts on an actual label to find the amount of sodium. Let’s go back to the “Read the Food Label for Sodium!” handout. n Point again to picture card 4.7. n Say: The Percent Daily Value for sodium in a packaged noodle soup is circled on the food label. n Say: The sodium content of the same food can vary, depending on how it is packaged or what brand it is. Compare food labels to choose foods that are lower in sodium. n Say: Look at the bottom of the handout. Look at the Percent Daily Value for lowsodium soup and for packaged noodle soup. Which soup is lower in sodium? n Say: Session 4. Help Your Heart: Control Your High Blood Pressure 86 Low-sodium soup is lower in sodium. One serving of low-sodium soup has only 9 percent of the Daily Value for sodium. One serving of packaged noodle soup has 34 percent of the Daily Value for sodium. The oriental soup has four times more sodium than low-sodium soup. n Say: You can also think of the Percent Daily Value like a budget. For example, you have a daily budget of $100 for all of your sodium needs for 1 day. If, from that daily budget, you spend $34 (Percent Daily Value) on the packaged noodle soup, that serving has cost you almost a third of your daily budget. That’s not too bad if it is for a whole meal, but it is for one food item. You now have only $66 left. You could easily go over your sodium budget for that day if the sodium content of the rest of your foods is also “expensive.” n Say: More Information: Potassium, Calcium, and Magnesium The latest research shows that foods rich in potassium are important in protecting against high blood pressure. Foods rich in calcium and magnesium may help, too. Eat foods that are a good source of these nutrients: • Potassium: bananas, plantains, tomatoes, potatoes, oranges, prunes, spinach, and dry beans • Calcium: low-fat milk; low-fat, reduced-sodium cheese; low-fat yogurt; calcium-fortified orange juice; leafy greens; and fresh or rinsed canned fish • Magnesium: whole-grain breads and cereals, beans, nuts, seeds, okra, and spinach Your Heart, Your Life: A Community Health Worker’s Manual More Information: The DASH Eating Plan To Lower Your Blood Pressure One eating plan that can lower blood pressure is Dietary Approaches to Stop Hypertension (DASH). By using the DASH plan, you can lower blood pressure by eating: • Lots of fruits and vegetables • Fat-free or low-fat milk products • Whole-grain products • Fish, poultry, and lean meats • Nuts, seeds, and dry beans The DASH eating plan also includes: • Less salt and sodium • Small amounts of fats and oils • Small amounts of sweets and beverages that are high in added sugar People with high blood pressure will get extra benefits from following the DASH eating plan and eating foods low in salt and sodium. This combination also is heart healthy for people who don’t have high blood pressure. Choosing and preparing foods that are lower in salt and sodium may help prevent or lower high blood pressure. Eating more fruits and vegetables, wholegrain breads and cereals, and fat-free or low-fat milk products also may help lower blood pressure. n Say: Let’s try an activity that will help us choose foods that are low in salt and sodium. First, I am going to describe a situation that may apply to you or to a member of your family. Then, using food labels, we are going to learn how to choose lower-sodium foods. ACTIVITY n Give each group member the “Mariano’s Food Choices” handout (pages 102â€"103). Read or ask a volunteer to read the story below. Session 4. Help Your Heart: Control Your High Blood Pressure 87 88 n Say: Let’s go over some questions. Use the food labels to choose the food Mariano’s Food Choices Mariano’s blood pressure was slightly higher the last time he visited his doctor. The doctor told Mariano to cut back on the amount of sodium he eats. Use the food labels to help his wife Virginia choose foods that will help Mariano follow his doctor’s advice. that is lower in sodium. n Ask these questions. Give the correct answer after group members guess. 8. Shake the Salt and Sodium Habit Questions Correct Answers When buying juice, should Virginia choose tomato juice or orange juice? Orange juice Should she serve corn tortillas or flour tortillas? Corn tortillas Is there less sodium in canned chicken or roasted chicken? Roasted chicken To cut back on sodium, should Mariano eat thin pretzels or baked tortilla chips? Baked tortilla chips Your Heart, Your Life: A Community Health Worker’s Manual 89 Note: Prepare Do ˜na Fela’s Seasoning Mixture (page 105) before the session. n Give group members the “Sodium in Foods” handout (page 104). ♥ n Ask: Does anyone see a food on the right side of the page that you eat often? n Ask the person to name a lower-sodium food on the left side that he or she could eat instead. n Say: Let’s now review some practical tips that will help you cut back on salt and sodium. n Give each group member a copy of the “Keep Your Heart in Mind: Eat Less Salt and Sodium” handout (pages 105â€"106). Review the tips on how to cut back on salt and sodium when you are shopping, cooking, and eating. n Say: Here is a sample of Doña Fela’s secret recipe from the bottom of the “Keep Your Heart in Mind” handout. Fill an empty saltshaker with the seasoning mixture, and put it on your table. Tell your family to try this instead of salt. n Give each group member a sample of Doña Fela’s seasoning mixture. n Ask: Why is it hard for you to cut back on salt and sodium? Note: Write their responses on the blackboard or on a large piece of paper taped to the wall. Then write down some possible solutions. See the “Examples” box for some ♥ problems and solutions. 9. Easy on the Alcohol Session 4. Help Your Heart: Control Your High Blood Pressure 90 Examples Problems You May Encounter The food has no flavor. Family members will get upset. Adding salt is a habit that is hard to break. Solutions Use herbs or spices to add flavor to foods. See the “Use Herbs and Spices Instead of Salt” handout (page 109). Cut back on salt slowly. Use less salt each time you cook, so family members can get used to the taste. Give yourself time to get used to using less salt. Choose brands that are lower in salt. Take the saltshaker off the table. n Say: Drinking too much alcohol can raise your blood pressure. It can also harm the liver, brain, and heart. Alcoholic drinks also contain calories. The extra calories can make it hard to control your weight. If you don’t drink alcohol, don’t start. If you drink alcohol, drink only a moderate amount. That means: • Men should have no more than two drinks a day. • Women should have no more than one drink a day. • Pregnant women should not drink any alcohol. n Ask: What do you think counts as one drink? Note: Allow a few minutes for group members to respond. n Say: ♥ Your Heart, Your Life: A Community Health Worker’s Manual 91 One drink is: • 12 ounces of beer (regularâ€"150 calories; lightâ€"100 calories) • 5 ounces of wine (100 calories) • 1½ ounces of liquor (100 calories) Manage Your Blood Pressure With Medicine n One drink is: 12 ounces of beer 5 ounces of wine Say: 10. If you have high blood pressure, making the lifestyle changes we just discussed may not be enough to lower your blood pressure. Medications are available to lower blood pressure. They work in different ways. n Give group members the “Tips for Taking Medicine for High Blood Pressure” handout (page 107). n Ask: Do any of you take medicine for high blood pressure? n Ask: Session 4. Help Your Heart: Control Your High Blood Pressure 92 If you are taking medication for high blood pressure, what are some things you can do to help your medicines work better? Note: Allow a few minutes for group members to respond. n Add the following suggestions if they are not mentioned: ♥ • Ask your doctor the name of your medicine and how to take it. • Take your medicine the way the doctor tells you. • Tell your doctor the names of all other medicines, home remedies, herbs, or supplements you take. • Tell your doctor if the medicine makes you feel strange or sick. • Refill your prescription before you run out of medicine. • Have your blood pressure checked to see if the medicine is working for you. • Keep taking the medicine as your doctor tells you, even if your blood pressure is okay. Turkey Meatloaf Recipe More Information: Medicine for High Blood Pressure • Many people with high blood pressure may take more than one medicine to keep their blood pressure low. • Some medicines can cause side effects or reactions. If this happens, talk to your doctor. • Eating more fruits and vegetables, cutting back on salt and sodium, losing weight, and being physically active can help your medicines work better. Your Heart, Your Life: A Community Health Worker’s Manual 11.n Give group members the “Use Herbs and Spices Instead of Salt” handout (page 109). Ask them to use some of the herbs and spices in place of salt when they cook this week. n Give group members the “Turkey Meatloaf Recipe” handout (page 108). Ask them to prepare it during the coming week. Tell them that using this recipe will give them a chance to practice some of the ideas from the session. RECIPE Review of Today’s Key Points n Say: Let’s review what we learned today. What is blood pressure? • Blood pressure is the force of blood against the walls of your arteries. Blood pressure is needed to move blood through your body. What is a normal blood pressure? • A normal blood pressure is below 120/80 mmHg. What is prehypertension? • Blood pressure of 120/80 to 139/89 mmHg is prehypertension. This means that you don’t have high blood pressure yet, but you’re likely to develop it in the future unless you make changes in your health habits. What is high blood pressure? • High blood pressure is 140/90 mmHg or greater. Have your blood pressure checked. If it is 140/90 mmHg or greater, see your doctor. Why is high blood pressure dangerous? Session 4. Help Your Heart: Control Your High Blood Pressure 93 94 • High blood pressure can lead to a heart attack, stroke, kidney problems, eye problems, and death. What can you do to help make your blood pressure medicine work better? • Eat more fruits and vegetables, cut back on salt and sodium, lose weight, and be more physically active. Take your medicine as your doctor tells you. Talk to your doctor about side effects. Why should you cut back on salt and sodium in your food? • You should cut back on salt and sodium to help prevent or lower high blood pressure. What are some ways to cut back on salt and sodium? • Use herbs and spices to season foods. Be careful! Some seasonings such as garlic salt and onion salt are high in sodium. Check the food label to choose foods lower in sodium. Eat more fruits and vegetables for snacks instead of salty snacks such as nuts, pretzels, or chips. How can drinking alcohol affect your blood pressure? • Drinking too much alcohol can raise blood pressure. What is a stroke? • A stroke happens when blood suddenly stops going to the brain. This can happen for different reasons. One example is that a blood vessel bursts. Another way is that a clot blocks the arteries. Either way, the result is the same: blood stops going to the brain, and brain cells die. Both types of stroke are very serious and can lead to disability and death. What is another name for a stroke? • A stroke is also called a brain attack. Your Heart, Your Life: A Community Health Worker’s Manual 95 Weekly Pledge n Say: You have learned a lot today about how to prevent and control high blood pressure. You also learned how to cut back on salt and sodium. Now let’s think about how you can practice what you have learned. Please think of one change you can make in your everyday life. This will be your pledge for the week. n Say: Be specific about what you plan to do, how you plan to do it, and when you will start. Here are some examples: • I will get my blood pressure checked within the next month. • I will read food labels the next time I go to the store to help me choose canned soups that are lower in sodium, or I will prepare homemade soup without adding salt. • I will rinse canned foods with water before I cook or eat them, starting tomorrow. • I will take the saltshaker off the table, starting tomorrow. n Say: Write your pledge on the back of the “Keep Your Heart in Mind: Eat Less Salt and Sodium” handout on page 106. Keep this handout in a special place so you can review your pledge and keep your goals in mind. ♥ Note: Allow 5 minutes for group members to think of a pledge and write it down. n Say: Would anyone like to share his or her pledge with the group? Note: Write down pledge ideas on the blackboard or on a large piece of paper taped to ♥ the wall. Session 4. Help Your Heart: Control Your High Blood Pressure 96 n (Optional) Say: Keeping a personal value in mind can help you make changes in your everyday life to prevent and control high blood pressure. Remember that a personal value is a quality that you consider important. Today’s value is openness. Being open means you are willing to consider making changes to improve your health, such as cutting back on foods high in salt and sodium. n Ask: How can you enlist the quality of openness, or another value, to help you keep your pledge? ♥ Note: Allow 3 minutes for group members to share their thoughts. n Say: We will talk about how you did with your pledge at the next session. Remember to keep working on your pledge to be more physically active. Blood Pressure Check (Optionalâ€"Try to get a health professional to come to your session.) n Tell group members that a health professional will now check everyone’s blood pressure. n Ask group members to write their blood pressure numbers on the “My Healthy Heart Wallet Card” handout. Your Heart, Your Life: A Community Health Worker’s Manual 97 Closing n Say: Thank you for coming today. What did you think of today’s session? Note: Wait to see if group members have a response. ♥ n Say: I am looking forward to seeing you at the next session. The next session will be about how to prevent and control high blood cholesterol. Note: Think about today’s session. What worked and what didn’t work? Have you ♥ decided to make any changes in your own life based on what was covered in today’s session? Session 4. Help Your Heart: Control Your High Blood Pressure 98 HANDOUTâ€"SESSION 4 Know the Stroke Signs. Act Quickly. A stroke happens when blood suddenly stops going to the brain and brain cells die. A stroke is very Eyes serious and can lead to disability and death. Face Signs of a stroke: Arm n Numbness of the face, arm, or leg (especially on one side of the body) n Confusion, trouble talking, and difficulty understanding others n Trouble seeing in one or both eyes Leg n Trouble walking, dizziness, and loss of balance or coordination n Severe headache Brain A Stroke Is Serious. Every Second Counts. • Learn the stroke signs and teach them to your family and friends. • Call 9â€"1â€"1 immediately if you have any of these stroke warning signs. • Treatment can reduce the risk of damage from a stroke. You must get help within 3 hours of your first symptoms. Adapted from the American Stroke Association, “Let’s Talk About Risk Factors for Stroke.” 1999â€"2003. A division of the American Heart Association. HANDOUT SESSION 4 99 Cut along dotted lines. Fold the card in half and paste with a glue stick (fold 1). Fold in half again to make your own personal wallet card (fold 2). (fold 2) My Healthy Heart Wallet Card MiFID II â€" Keynote Speech, PwC Breakfast Briefing “MiFID II â€" Are you Ready?” 28.06.17. Denise Murray, Head of Asset Management: Authorisation and Inspection Division Introduction Good morning Ladies and Gentlemen. It is a pleasure to be here this morning and I would like to thank PwC for the opportunity to speak with you on the challenges and opportunities that MiFID II presents. As we move into the final 6 months of preparations, the Central Bank maintains its commitment to engage with industry, outline our expectations and gauge preparedness for business in the MiFID II world. Today I would like to focus on four areas:  An update on the Central Bank’s own approach to MiFID II implementation;  Industry’s preparedness;  A brief summary of some of the relevant European Security Markets Authority’s (ESMA) initiatives; and  Finally, I will mention the potential impact of MiFID II on Irish Firms which do not currently need but which may require authorisation as a result of MiFID II. As I begin I’d like to reflect for one moment on what MiFID II/MiFIR seek to achieve â€" the changes proposed are fundamentally rooted in common sense. They look to achieve more stable, transparent financial markets; to protect investors and to improve client outcomes. Few of us here today would disagree with these objectives. As you are all no doubt very much aware, MiFID II represents the most substantial overhaul of EU legislation for markets in financial instruments in more than a decade. It presents a major implementation challenge for firms and Competent Authorities across Europe. 2 The ‘go live’ date of 3 January 2018 is fast approaching and as the, the Chair of ESMA1 , Steven Maijoor has recently again confirmed there will be no further extensions to the implementation deadline. The last 10 years have been unprecedented in the history of financial markets. The world initially faced a financial crisis, followed by an economic crisis, and since then there has been considerable focus to bring our economies back on a sustainable growth path. MiFID II/MiFIR are key reform measures, and the most significant piece of level 2 regulation that has ever been undertaken by ESMA. Since 2014, ESMA has been delivering technical advice to the European Commission. In addition, it has issued 47 level two texts covering issues ranging from market microstructure, pre and post-trade transparency, commodity derivatives to authorisations procedures and investor protection. The level two texts were drafted following consultations with stakeholders and with the input of Competent Authority experts, including many colleagues from the Central Bank. The impact that MiFID II will have on the asset management industry cannot be understated. Firms should fully understand the effect this legislation will have both on their businesses and on the industry as a whole. The landscape is set to change and our asset management industry must stand ready to adapt. As, Michael Hodson, the Central Bank’s Director of the Asset Management Supervision2 , has previously stated, firms that proactively manage regulatory amendments tend to create opportunities that elude firms who view implementation as merely a compliance task. Furthermore, firms who willingly engage and adapt are those who benefit most. 1 Steven Maijoor speech at Futures Industry Association IDX Conference, London, 7 June 2017 2 KPMG Seminar - Michael Hodson, Director of Asset Management Supervision 7 February 2017 3 ___________________________________________________________________________ Topic One: An update on the preparations of the Central Bank ___________________________________________________________________________ Now I would like to discuss the first of the four areas I want to focus on today, the Central Bank’s preparedness for MiFID II. As I mentioned earlier, the implementation of MiFID II is a major challenge for industry and Competent Authorities. I would like to share with you some of the initiative 4 I will address the general findings of the heat-mapping exercise in a few moments. Engagement with industry was a key priority for our implementation programme. We are and will continue to participate in industry engagements like this one today, and Central Bank representatives have been speaking at a number of MiFID II round tables and conferences since 2015. At an EU level, our ESMA representatives are engaged in the negotiation and finalisation of various ESMA measures and we continue to provide technical advice to the Department of Finance as it enters final preparations for the transposition of MiFID II into Irish Law. Another area, which will see significant change, is Transaction Reporting. As you know, a standardised reporting regime is provided for across Europe, with new standards and formats prescribed in legislation. To that end, the Central Bank is building and enhancing its systems to receive, validate, store, and exchange transaction reports with other Competent Authorities. We have a number of projects in train to manage these significant IT developments. The Central Bank has issued communications (which are available on our website) regarding the operational and technical arrangements, for submitting transaction reports and the proposed testing timeframes. Under MiFID II, Competent and European Supervisory Authorities will have the power to prohibit or restrict the sale of any financial instrument or structured deposit that causes serious concerns regarding investor protection, orderly functioning of the market or the stability of the financial system. Interventions may take the form of restricting how products can be marketed, distributed or sold to certain client groups. The powers also allow Competent Authorities and the European Supervisory Authorities to prohibit or restrict ‘types of financial activities or practices’ carried out by those firms within the scope of the legislation. 5 The Central Bank recently published a Consultation Paper on the protection of retail investors in relation to the distribution of Contracts for Difference. The Central Bank has engaged extensively with industry on this topic, and we are participating at European level, where there has been an ever-increasing focus on this matter with many Competent Authorities taking action. We are the first Competent Authority in Europe to consult on the potential use of this new product intervention supervisory power. The Consultation closed on 29 May and we received a number of responses, which we are currently considering. ___________________________________________________________________________ Topic Two: Firms’ preparedness ___________________________________________________________________________ Having discussed with you how the Central Bank has prepared and continues to prepare for MiFID II implementation, I would now like to move closer to home and speak to firms’ preparedness. The Central Bank expects that firms are now well advanced in their MiFID II implementation projects; in particular, we expect that there has been considerable advances by those firms, which did not have a project plan in place when we issued our industry questionnaire in March. As I mentioned previously our supervisory teams are using heat-maps to inform their engagement with firms, we have focused on the potential impact of MiFID II on business models. We have initially prioritised meetings with the compliance officers of the higher impact firms. One of the most notable outputs from this exercise was that firms and the Central Bank were very much aligned in terms of the key impacts of MiFID II. Additionally, it is clear that industry is working hard to be compliant on the implementation deadline, by for example, increasing dedicated MiFID II resources. It may be worth flagging some of the general themes, which emerged from this exercise: 6  Some firms noted that despite the fact that they have significant MIFID II budgets, they shall face time pressures to ensure that all systems and processes are fully compliant by the implementation deadline.  Some firms, which are part of wider international groups, have broader group-wide MiFID II projects and have the additional challenge of ensuring that the Irish firms take appropriate steps to implement and ultimately own MiFID II initiatives at a local level.  The majority of the firms we engaged with have indicated that they will provide nonindependent advice only. The firms that have indicated that they intend to provide both, independent and non-independent advice have outlined that they will have the required processes in place for implementation.  MiFID II also introduced product governance requirements for firms who manufacture or distribute financial products. Throughout the heat-map engagements, questions arose as to the practicalities of the manufacturer’s responsibility to perform a target market assessment. However, the recent publication of ESMA’s guidelines on 2 June, which are focussed on this assessment process, should address these queries.  Supervisors had a lot of discussions with firms on the new rules in relation to investment research. On the Buy-side, the issues, which we discussed, included whether firms will pay for research directly or establish Research Payment Accounts (RPAs). Whilst on the Sell-side firms have advised that they still need to determine whether they will pay for research or if the cost shall be passed on to their clients.  Firms through the heat mapping exercise also drew attention to the changes MiFID II brings to the concept of the Systematic Internaliser and the new Organised Trading Facility or “OTF”.  In the market infrastructure space, firms are coming to terms with for example pretrade transparency requirements, waivers and the Double Volume Cap. Firms that operate such venues are currently having their waiver applications assessed by ESMA.  As the scope of transaction reporting requirements has been extended to include firms who receive and transmit orders. Some firms have highlighted uncertainty in 7 relation to the extent of their responsibilities and whether or not they can avail of exemptions outlined in the level 2 texts.  Other challenges that firms are facing include uncertainty as to whether or not brokers will transaction report on their behalf, or whether they will need to engage the services of an Approved Reporting Mechanism (ARM). Some firms were not as advanced in their decision-making as we would have expected, in relation to how the enhanced transaction and indeed trade reporting responsibilities are going to be managed. In terms of our next steps, having completed the first phase of the MiFID II heat-map project, supervisors will utilise the outputs from these meetings, to further frame engagement with firms throughout the second half of 2017 and into 2018. The heat-map project will also continue for the remainder of the year, with supervisors meeting with firms not as heavily impacted by the new legislation as those included in the initial phase. Topic Three: Brief summary of some of the relevant European Security Markets Authority’s initiatives ___________________________________________________________________________ Turning to the third topic, which centres on updates from ESMA. As the Central Bank remains fully committed to the principle of supervisory convergence, we engage with and rely on ESMA to produce the level 2 and level 3 guidance on all aspects of MiFID. The Central Bank will therefore not be issuing guidance on particular areas of MiFID II over and above what is provided by ESMA. ESMA has made significant progress over the last number of months, undertaking a broad range of activities aimed at supporting market participants and competent authorities in their preparations for implementation. This has included work on providing Q&As across a broad range of issues related to transparency requirements, commodity derivatives, data reporting and market structures topics. 8 14 Q&As were recently added covering ‘information on costs and charges’, ‘post-sale reporting’, and ‘appropriateness.’ I also want to remind firms that ESMA has launched its Q&A tool 9 ___________________________________________________________________________ Topic Four: Unauthorised Business ___________________________________________________________________________ Before I conclude, I would like to spend a few moments speaking about the expanded scope of MiFID II and in doing so draw industry’s attention to the possibility that this may necessitate some firms requiring the Central Bank’s authorisation on the implementation deadline. The Central Bank is responsible for preventing unauthorised financial services business. It is a criminal offence for an unauthorised firm or person to provide financial services in Ireland that require authorisation under legislation. MiFID II removes and narrows certain exemptions from authorisation that were available under MiFID. A full discussion of this is outside the scope of today’s speech but I would like to draw the wider market’s attention and in particular those proprietary traders and other businesses that deal in financial instruments on their own account in the course of an otherwise unregulated business model. If you are unsure as to whether or not your firm’s activities fall within the scope of MiFID II, you should consult legal representatives who are familiar with the regime. The Central Bank expects firms who require authorisation from the implementation deadline to apply in sufficient time so that applications can be assessed and a determination made prior to 3 January 2018. Additionally, under MiFID II, the Ancillary Activity Exemption continues to apply for firms whose investment services and activities are ancillary to the business of the main group; but this exemption has significantly narrowed. MiFID II places an obligation on all firms who wish to take advantage of the Ancillary Activity Exemption to notify the Central Bank that they make use of the exemption. Notification forms are available on the Central Bank’s website as are all MiFID application forms. 10 We are asking all firms who come within the scope of this exemption to submit this notification in good time. I want to urge all firms who currently engage in investment services or activities but who, because of the exemptions under MiFID, have not applied for authorisation, to review their activities in light of MiFID II. For those firms operating in this space, the Central Bank is warning that firms must have a valid authorisation or completed the notification process to comply with MiFID II. 11 __________________________________________________________________________________ Conclusion â€" Key Messages ___________________________________________________________________________ To conclude, I want to reiterate that, yes MiFID II represents the most substantial overhaul of EU legislation for markets in financial instruments in more than a decade. But at its core is the key objective of making financial markets more stable, transparent and cognisant of investor protection obligations, which will ultimately benefit all of us; regulators, firms and clients alike. The key messages, which I hope you all take away from my remarks this morning, are: We understand the challenge that MiFID II has presented to your businesses, as competent authorities have had similar challenges to overcome. However, as I stated earlier there will be no further extensions to the implementation date. We expect Irish firms to:  Be fully resourced to meet their regulatory obligations;  Be advanced in terms of implementing their project plans, with key decisions made at this point; and  Have fully considered the implications of MiFID II on their businesses and have made the changes to their systems, policies and procedures. It is currently not our intention to issue guidance to industry beyond what is produced by ESMA. This aligns with the Central Bank’s approach to supervisory convergence. We strongly urge firms, which may not currently require a MiFID authorisation to consider the impact of MiFID II. Firms, which require authorisation or to complete the notification process, should apply in good time to the Central Bank so that we may review applications by 3 January 2018. Finally, I would like to thank you for your attention this morning and your continued engagement on this topic. MiFID II will bring momentous and positive change to financial 12 services â€" taking advantage of this change will bring opportunities and give the best chance of success in the new regulatory regime.