Lifestyle Medicine:
Campaign by American College of Preventive
Medicine and
American College of
Lifestyle Medicine to Inspire Local
Champions to Action
Slides adapted with permission from:
Liana Lianov MD, MPH, FACPM
Eleanor Loomis, UC Davis Public Health Program
Michael D Parkinson MD, MPH, FACPM
American College of
Medicine
Preventive
• Evidence based disease prevention and health
promotion research policies, practice programs.
• 2400 members engaged in preventive medicine practice,
teaching, and research
• General preventive medicine, public health, occupational
and environmental medicine, aerospace medicine
• For more information: www.acpm.org
American College of
Medicine
Lifestyle
• The American College of Lifestyle Medicine serves its
members by advancing the field of lifestyle medicine,
promoting excellence in clinical practice and advocating on
behalf of medical and public policy issues related to the
practice and promotion of lifestyle
• For more information: www.lifestylemedicine.org
Overview
• What is the role of lifestyle change in preventing and
treating disease?
• Do physician interventions lead to lifestyle change?
• What is lifestyle medicine?
• What are the core LM competencies?
• What are the next steps and how can you help?
• What are options for enhancing LM in your practice?
Leading Causes of Death
1. Heart disease: 616,067
2. Cancer: 562,875
3. Stroke (cerebrovascular diseases): 135, 952
4. Chronic lower respiratory diseases: 127, 924
5. Accidents (unintentional injuries): 123,706
6. Alzheimer’s disease: 74,632
7. Diabetes: 71,382
8. Influenza and Pneumonia: 52,717
9. Nephritis, nephrotic syndrome, nephrosis: 46,448
10. Septicemia: 34, 828
*Data for 2007 National Vital Statistics Report- US Adults
Actual Causes of Death
1.
2.
3.
4.
5.
6.
7.
8.
9.
Tobacco: 435,000
Poor diet and physical inactivity: 400,000
Alcohol consumption: 85,000
Microbial agents: 75,000
Toxic agents: 55,000
Motor vehicle: 43,000
Firearms: 29,000
Sexual behavior: 20,000
Illicit Drug use: 17,000
*Mokdad, Actual Causes of Death in the US, 2000. JAMA 2004
*Leading causes of death similar to 2007
Behavioral Determinants
• Virtually ALL of the top 10 leading causes of death in US
adults are moderately to STRONGLY influenced by lifestyle
patters and behavioral factors
BEHAVIOR
DISEASE
Tobacco Use
Heart Disease
Physical Activity
Stroke
Diet
Cancers
Preventive Services
Diabetes
Leading Health Indicators
Healthy People 2020
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Physical activity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and Violence
Environmental quality
Immunization
Access to health care
The current challenges for
patients: Unhealthy Lifestyles
• Only 11% of patients with diabetes follow accepted
dietary recommendations for saturated fat intake (EilatAdar)
• 8% of patients with heart disease continue to smoke
(Soni)
Can you say yes to all?
Only 8% of Americans can
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I am within 5 pounds of my ideal body weight
I exercise 30 minutes or more most days of the week
I eat a healthy diet with 5 fruits/vegetables most days
I don’t use tobacco products
I have 2 or fewer alcoholic drinks per day
These are the drivers of health care costs!
Optimism for Action
• Decline in tobacco use prevalence from 42.4% to 20.6%
of American adults between 1965 and 2009 (CDC)
• Lifestyle change that is an important example of success
• How did we do it?...
Health Behavior Change:
Model
Ecologic
Societal/Public Policy
Community
Organizational
Interpersonal
Individual
Physician Counseling
• Evidence is mixed about impact of physician counseling
on health behavior change (Cochrane)
• May be artifact of study design
• Varity of health behaviors, interventions, application of
approaches, length and intensity, statistical power
• US Preventive Service Task Force (USPSTF)
• In general, the recommendations are in favor of
physician counseling
• Recommendations vary for specific health behaviors
USPSTF Recommendations
Behavior
Recommendation for
Screening and Behavioral
Counseling
Tobacco Use
A
Physical Activity
I
Healthy Diet
B (for at-risk patients)
Alcohol Misuse
B
I- still need further studies in this area
Examples of the Impact of
Physician Counseling
• Patients who make behavior change often cite that the
physician’s advice influenced them (Galuska)
• Sedentary patients increased weekly walking exercises by
5 times when counseled by physician and received health
educator booster call (vs. standard of care) (Calfas)
• Patients who were counseled to lose weight more likely
to (Huang):
• Understand risks of obesity
• Understand benefits of weight loss
• Higher stage of change of readiness for weight loss
Current rates of Health
Behavior Advice/Counseling
• Physicians often do not offer lifestyle as first line
prevention and treatment (Stafford)
• Only 36% of obese patients are advised to lose weight
during regular exams
• Only 52% of patients who already have obesity-related
co-morbidities are advised to lose weight
• Only 28% of smokers reported that health care
professionals had offered them assistance to quit
smoking in the past year (Partnership for Prevention)
Physician Barriers to
Counseling
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Lack of time
Reimbursement issues
Insufficient confidence
Insufficient knowledge
Insufficient skills
Others?
• From previous examples
• Patient’s note counseling has significant effect of
understanding and motivation
• BUT physicians often provide insufficient guidance
Time & Reimbursement
• Affordable Care Act and prevention:
• $15 billion over 10 years to “expand and sustain the
necessary infrastructure to prevent disease, detect it
early, and manage conditions before they become
severe.”
• Private carriers and Medicare required to cover
preventive screenings (USPSTF “A” and “B” & future
guidelines for women, children, adolescents, to be
developed by HRSA)
Time & Reimbursement cont.
• State Medicaid matching funds enhanced for following
USPSTF recommendations
• Medicare Annual Wellness visit
• Numerous employer and worksite incentives and
grants to improve health promotion programs
• Individualized prevention plans in Medicare
• Incentives for chronic disease patients in Medicaid
“McLipitor Syndrome”*
• "I call it the McLipitor Syndrome. Patients feel they can
eat whatever they want as long as they take a statin drug
to lower cholesterol. Because of time constraints,
physicians may spend little time counseling lifestyle
change, which can work as well as or better than the best
drugs for heart disease, obesity, diabetes and high blood
pressure."
*Mark Goldstein, MD, NY Times Magazine Letter to Editor
Feb 11, 2007
Tools for Physicians
• 5 A’s- Assess, Advise, Agree, Assist, Arrange
• Americans in Motion (American Academy of Family
Physicians)
• Healthier Life Steps (American Medical Association)
• Screening, Brief Intervention, Referral and Treatment
(Substance Abuse and Mental Health Services
Administration)
• BUT THIS ISN’T ENOUGH!
What Works to
Improve Health Behaviors
Create sense of self-efficacy, address barriers
Perceived
Severity
Perceived
Benefit
Perceived
Susceptibility
Self- efficacy
Behavior
Change
Cues to
Action
What Works….Goal Setting
• Listen . . choose
ONE behavior &
reasonable goal
• Patient should rate
confidence of
completing the goal
at 7/10
What works…Stages of Change
• Identify stage, and move patient along the continuum
• Not every patient will enter every stage
• Not every stage is the same length
How we raise the bar…Lifestyle
Medicine Competencies
Blue Ribbon Panel
American College of
Preventive Medicine
American College of
Lifestyle Medicine
American Academy of
Family Physicians
American Medical
Association
American College of
Physicians
American College of Sports
Medicine
American Osteopathic
Association
Panel-Developed Definition of
Lifestyle Medicine
LM is the evidence-based practice of helping
individuals and families adopt and sustain
healthy behaviors that affect health and quality
of life.
Examples of target patient behaviors include but
are not limited to eliminating tobacco use,
improving diet, increasing physical activity, and
moderating alcohol consumption.
Field of Lifestyle Medicine
• LM recognizes the link between lifestyle medicine and
health outcomes
• Uses science behind health behavior change
• Emphasizes value of lifestyle medicine prescriptions by
physicians
• Emphasizes value of support of those prescriptions by
other health professionals
LM Competencies- Summary
• Perform comprehensive lifestyle assessments
• Risk assessments
• Patient’s readiness to change modifiable risk factors
• Establish effective relationships and use national
guidelines
• Use team approach
• Make referrals
• Use medical information technology to maximize lifestyle
medicine care
• Promote healthy behaviors as foundation of health
promotion and medical care
• Physician should personally practice a healthy lifestyle
LM competencies
(for reference only)
• Leadership
• Promote healthy behaviors as foundational to medical care,
disease prevention, and health promotion.
• Seek to practice healthy behaviors and create school, work and
home environments that support healthy behaviors.
• Knowledge
• Demonstrate knowledge of the evidence that specific lifestyle
changes can have a positive effect on patients’ health outcomes.
• Describe ways that physician engagement with patients and
families can have a positive effect on patients’ health behaviors.
LM competencies cont.
• Assessment Skills
• Assess the social, psychological, and biological predispositions of
patients’ behaviors and the resulting health outcomes.
• Assess patient and family readiness, willingness, and ability to
make health behavior changes.
• Perform a history and physical examination specific to lifestylerelated health status, including lifestyle “vital signs” such as
tobacco use, alcohol consumption, diet, physical activity, body
mass index, stress level, sleep, and emotional well-being. Based
on this assessment, obtain and interpret appropriate tests to
screen, diagnose, and monitor lifestyle-related diseases.
LM competencies cont.
• Management Skills
• Use nationally recognized practice guidelines (such as those for
hypertension and smoking cessation) to assist patients in selfmanaging their health behaviors and lifestyles.
• Establish effective relationships with patients and their families
to effect and sustain behavioral change using evidence-based
counseling methods and tools and follow-up.
• Collaborate with patients and their families to develop evidencebased, achievable, specific, written action plans such as lifestyle
prescriptions. – Help patients manage and sustain healthy
lifestyle practices, and refer patients to other health care
professionals as needed for lifestyle-related conditions.
LM competencies cont.
• Use of Office and Community Support
• Have the ability to practice as an interdisciplinary team of health
care professionals and support a team approach.
• Develop and apply office systems and practices to support
lifestyle medical care including decision support technology
• Measure processes and outcomes to improve quality of lifestyle
interventions in individuals and groups of patients.
• Use appropriate community referral resources that support the
implementation of healthy lifestyles.
Next steps for competencies
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Increase awareness
Develop training programs
Adapt LMCs to other health professionals
Advocate for wide implementation and integration into
practice
• Integrate lifestyle medicine into your practice with easy
first steps
With Every Patient
• Make a point of addressing lifestyle issues with every
patient, even briefly
• Prescribe lifestyle as the first-line treatment for most
chronic illnesses
Some Options to Consider
Your Practice
for
• All patients need their lifestyles addressed in the health
maintenance section of the plan
• Include a health assessment and readiness assessment
for patients to complete in advance or in the waiting
room; you may need to verbally address key questions
with patients who have low literacy levels
• Identify and/or adapt questionnaires to your patient
population—in terms of literacy level and cultural
background
• Review responses in advance of visit, if possible, or
during the visit to prioritize lifestyle areas which the
patient is most ready to address
• Make sure support staff routinely collect lifestyle vital
signs: waist circumference, BMI, physical activity level
Some Options to Consider
Your Practice
for
• Consider lifestyle as first line therapy (rather than a
supplement to the treatment plan) for patients with chronic
diseases and include it in the treatment plan
• Use patient registries to identify and prioritize patients in
need of intensive lifestyle interventions
• Refer to other health professionals and community resources
whenever these are available and financially feasible or
covered by insurance
• Leverage worksite wellness and other programs
If you only have 30 seconds…
• Tell the patient that you believe lifestyle issues are important
and would like to address them at the next visit
• Schedule a follow-up visit for the current condition and carve
out at least 2 minutes for addressing lifestyle at that visit
• Schedule a prevention visit (Medicare)
If you only have a couple of minutes…
• Review lifestyle vital signs (that should be listed in the
chart)
• Choose one area to address
• Ask patient to consider what he/she might be ready/able
to do
• State that you will follow-up at next visit
If you have 5 minutes…
• Choose one area of concern that patient is ready to
address
• Ask patient about what specific steps he/she could do
• Develop a brief action plan—one small step
• Check patient’s confidence level
• If patient is not ready for an action plan, offer a brief
message appropriate to the patient’s stage of readiness.
For example, if the patient is in precontemplation about
an becoming more physically active, review how physical
activity can treat a current condition or decrease his risk
of a condition of concern.
If you can carve out 10 minutes
or
more…
• Briefly address two or more lifestyle areas appropriate to
the patient’s readiness to make a change; for example
with motivational interviewing or developing a brief,
specific action plan
References
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Behavioral Counseling in Primary Care to Promote a Health Diet, Topic Page. December 2010. U.S. Preventive
Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiet.htm
Behavioral Counseling in Primary Care to Promote Physical Activity, Topic Page. December 2010. U.S. Preventive
Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsphys.htm
Brunner E, Rees K, Ward K, Burke M, Thorogood M. Dietary advice for reducing cardiovascular risk. Cochrane
Database of Systematic Reviews 2007, Issue 4. Art. No.:CD002128.DOI:10.1002/14651858.CD002128.pub3
Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counseling to promote the
adoption of physical activity. Prev. Med. 1996 May-Jun; 25(3):225-33
Counseling to Prevent Tobacco Use and Tobacco-Caused Disease, Topic Page. Novenmber 2003. U.S. Preventive
Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac.htm
Ebrahim S, Beswick A, Burke M, Davey Smith G. Multiple risk factor interventions for primary prevention of
coronary heart disease. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.:
CD001561.DOI10.1002/14651858.CD001561.pub2
Eilat-Adar S, Xu J, Zephier E, O’Leary V, Howard BV, Resnick HE. Adherence to dietary recommendations for
saturated fat, fiber, and sodium is low in American Indians and other US adults with diabetes. J Nutr. 2008;
138(9):1699-1704.
Flodgren G, Deane K, Kickinson HO, Kirk S, Alberti H, Beyer FR, Brown JG, Penney TL, Summerbell CD, Eccles MP.
Interventions to change the behavior of health professionals and the organisation of care to promote weight
reduciton in overweight and obese adults. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.:
CD000984.DOI:10.1002/14651858.CD000984.pub2
References
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Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising ovese patients to lose weight?
JAMA. 1999;282(16):1576-1578.
Healthy People 2020. Determinants of Health, ed. USDHHS. Washington DC: US Department of Health and Human
Services.
Huange J, Yu H, Marin E, Brock S, Carden D, Davis T. Physicans’ weight loss counseling in two public hospital
primary care clinicas. Acad Med.2004;79(2):156-161
Interventions to Promote Physical Activity and Dietary Lifestyle Cahnges for Cardiovascular Risk Factor Reduction in
Adults, A Scientific Statement From the American Heart Association, Circulation. 2010;122:406-441
Leading Health Indicators. www.health.gov/healthypeople/ (last accessed 2 December 2010).
Lianov L, Johnson M, Physician Competencies for Prescribing Lifestyle Medicine, JAMA. 2010;304(2):202-203
Mokdad Ah, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA.
2004:291(10):1238-1245
Partnership for Prevention. Preventive Care: A National Profile on Use, Disparities, and Health Benefits.
Washington, D.C.: Partnership for Prevention. August 2007.
Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, Topic Page. April
2004. U.S. Preventive Services Task Force. http://www.uspreentiveservicestaskforce.org/uspstf/uspsdrin.htm
Soni A. Personal Health Behaviors for heart Disease Prevention Among the US Adult Civilian Noninstitutionalized
Population, 2004. Rockville, Md: Agency for Healthcare Research and Quality; March 2007. MEPS statistical brief
165.
Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physican actvities related to obesity
management. Arch Fam Med. 2000;9(7):631-638.
Webinars:
-
Webinars:
Dr. Michael Parkinson: Healthcare Reform, Preventive Medicine
and the Future of Patient Care.http://www.acpm.org/MSSwebinars.htm
Dr. Liana Lianov: Lifestyle Medicine Approaches to Effective
Employer Health ad Wellness Initiatives.
https://live.blueskybroadcast.com/bsb/client/CL_DEFAUL
T.asp?Client=446569&PCAT=2719&CAT=2719