Professionals in Training

Author:
Elizabeth Pegg Frates, MD
Assistant Professor, Part Time, Harvard Medical School (HMS)
Faculty, Psych E 1037-Introduction to Lifestyle Medicine
Harvard Extension School
Founder and Faculty Advisor, Lifestyle Medicine Interest Group at HMS
Board Liaison for Professionals in Training (PiT),
American College of Lifestyle Medicine (ACLM)
Editors:
Jonathan Bonnet, MD
Sports Medicine Fellow
University of Florida
ACLM Board Member, Young Physician Director
ACLM PiT Co-President
Kate Simeon
Teaching Assistant
Harvard Extension School
Pysch E 1037-
Introduction to Lifestyle Medicine

“The evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life.” http://www.lifestylemedicine.org/core

• 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 http://www.lifestylemedicine.org/core

• Industrial Revolution-(1760-1850)
– Steam Engine-James Watt- 1755
– Cotton Gin-Eli Whitney- 1793
– Telegraph-Samuel Morse- 1836
– Sewing Machine-Elisa Howe- 1844
– Telephone-Alexander Graham Bell- 1876
– Light Bulb-Thomas Edison- 1879
• Digital Revolution-Information Age

• Vaccinations
• Surgical Anesthesia and anti-sepsis
• Clean water and improved sanitation
• Antibiotics and Antivirals
• The Birth Control Pill
• Improvements in heart surgery and cardiac care
• Randomized Controlled Trials
• Radiologic imaging
• Advances in childbirth
• Organ transplantation http://abcnews.go.com/Health/TenWays/story?id=3605442&page=3

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm

Major Causes of Death in U.S.: 2011
Statistics
• Heart disease: 596,577
• Cancer: 576,691
• Chronic lower respiratory diseases: 142,943
• Stroke (cerebrovascular diseases): 128,932
• Accidents (unintentional injuries): 126,438
• Alzheimer's disease: 84,974
• Diabetes: 73,831
• Influenza and Pneumonia: 53,826
• Nephritis, nephrotic syndrome, and nephrosis: 45,591
• Intentional self-harm (suicide): 39,518 http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
(Of note: Fahey Chapter 1 page 5 has stats from 2007)

Summary of Articles Published Between
1977-1993: Major Non-genetic Factors
Contributing to Death in the U.S.
Ovid: McGinnis and Foege. Actual Causes of Death in the United States.
JAMA, Volume 270(18).Nov 10, 1993.2207-2212

This information is broken down into # deaths per year and % of total deaths for Mokdad study
Fahey Chapter 1, Table 1.3 page 6

http://www.who.int/mediacentre/factsheets/fs310/en/

• No Smoking
• BMI < 25kg/m2
• Eat > 5 servings of fruits and vegetables/day
• Alcohol ~ 1 drink/day
• Physical Activity/Exercise > 150 minutes/week

Comparison of Adherence to Healthy
Lifestyle Habits in US Adults 1988-1994 and 2001-2006
Diana King, MD, MS and colleagues at Medical University of So Carolina
The American Journal of Medicine (2009) 122, 528-534.

Conclusions and Highlights of Data in
US Adults: 1988-1994 and 2001-2006
• Obesity has increased from 28% to 36%.
• Regular physical activity has decreased from 53% to 43%.
• Eating 5 or more fruits and vegetables a day has decreased from 42% to 26%.
• Adherence to all 5 healthy habits has gone from
15.8 % to 8.2% .
• Adherence to healthy habits is no more likely in people with cardiovascular disease, hypertension, diabetes, or hypercholesterolemia.
The American Journal of Medicine (2009) 122, 528-534.

Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI  30, or about 30 lbs. overweight for 5’4” person)
1990 2000
2010
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% www.cdc.gov/obesity/downloads/obesity_trends_2010.ppt

Lifestyle Habits and Mortality in
Overweight Individuals
Eating 5 or more fruits and vegetables daily, exercising regularly (at least 12 times in a month), alcohol in moderation, not smoking
J Am Board Fam Med 2012;25:9 –15

Figure 1. Healthy Behavior Impact on
Incidence of MI in Men http://content.onlinejacc.org/article.aspx?articleID=1909605

Coronary Artery Disease Risk Factors
• High blood cholesterol and triglyceride
• High blood pressure
• Diabetes
• Overweight and obesity
• Smoking
• Lack of physical activity
• Unhealthy diet
• Stress http://www.nhlbi.nih.gov/health/health-topics/topics/hd

County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years:
United States 2009
Age-adjusted percent
0 - 6.3
6.4 - 7.5
7.6 - 8.8
8.9 - 10.5
> 10.6

• Landmark Study funded by NIH, published in
2002 in the New England Journal of Medicine
• Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin
• 3234 non diabetic patients with elevated fasting and post-load plasma glucose levels
• Randomly assigned to placebo, Metformin, or lifestyle intervention

• Lose 7% of initial body weight
– Low calorie, low fat diet
• 150 minutes of moderate intensity physical activity per week
• 16 lesson curriculum covering diet, exercise, and behavior modification
– Taught by case managers
– Flexible
– Individualized
– Subsequent- individual (monthly) and group sessions

Lifestyle Counseling: Does It Work?
Diabetes Prevention Program
31% 58%
DPP Research Group NEJM (2002): 346 (6): 393

Prevalence for CV Risk Factors in US
Adults http://circ.ahajournals.org/content/123/4/e18.full.pdf+html

Adequate Physical Activity Levels in US

• What % of cardiovascular disease can be prevented or delayed with dietary choices and lifestyle modifications?
Forman D, Bulwer BE. Cardiovascular disease: optimal approaches to risk factor modifications of diet and lifestyle. Curr Treat Options
CardiovascMed 2006;8:47–57.

• What % of cardiovascular disease can be prevented or delayed with dietary choices and lifestyle modifications?
• 70%
Forman D, Bulwer BE. Cardiovascular disease: optimal approaches to risk factor modifications of diet and lifestyle. Curr Treat Options
CardiovascMed 2006;8:47–57.

• $2.8 trillion overall
• $8,915 per
• Top five most expensive conditions:
– heart disease, cancer, trauma, mental disorders, and pulmonary conditions
• Top 5% of spenders responsible for 50% of healthcare costs:
– Most suffering from chronic diseases http://archive.ahrq.gov/research/findings/factsheets/costs/expriach/index.html#MostExpensive http://www.cms.gov/Research-Statistics-Data-….

• What percentage of health care dollars are spent on prevention?
– 3%
• What percent of our healthcare costs are related to preventable conditions?
– 75%
• Institute of Medicine recommended we increase federal funding for public health and prevention by
– $12 billion annually http://www.apha.org/NR/rdonlyres…..

CDC Reports on Benefits of Physical
Activity to the National Bottom Line
• Active people have significantly lower annual direct medical costs than inactive people.
• In 2000, it suggested that by getting more people to be active, we could cut annual medical costs:
– By over $70 billion http://www.hsph.harvard.edu/nutritionsource/staying-active-full-story/

• In a 2008 study of hypertensive patients, what
% received counseling to engage in physical activity as a way to manage their hypertension?
– 1/3
• Of the patients who were counseled, what % followed the recommendations to exercise and reduced their blood pressure?
– 71%
Halm J, Amoako E. Physical activity recommendation for hypertension management: Does healthcare provider advice make a difference?
Ethnicity and Disease 2008 Summer; 18(3): 278-82.

• According to a 2008 study,
• Diabetic patients received counseling/referral for nutrition:
– only 36% of the time,
• And for exercise:
– only 18% of the time.
Peek ME, Tang H, Alexander GC, Chin MH. National prevalence of lifestyle counseling or referral among African-Americans and Whites with diabetes.
Journal Gen Intern Med, November 2008;23(11):1858-1864

There is Minimal Training on Exercise &
Nutrition Counseling in Medical School
1975- “Will Physicians of the Future be Able to
Prescribe Exercise?”
– 74 medical school participated in questionnaire
– 16% offered a course geared to exercise as preventive medicine
Burke EJ, Hultgren PB. Will Physicians of the Future Be Able to
Prescribe Exercise? J Med Educ. 1975;50:624-6.

2001-Medical school leaders including Deans and Directors of Medical Education reported
– 72 out of 128 medial schools participated in questionnaire
– 6% of medical schools polled reported having a core course addressing the exercise prescription
Connaughton AV,Weiler RM, Connaughton D. Graduating Medical Students’ Exercise Prescription
Competence as Perceived by Deans and Directors of Medical Education in the United States:
Implications for Healthy People 2010. Public Health Reports. 2001;116:226-234.

Relative lack of education in formal training at undergraduate, graduate and post-graduate
(CME) levels in:
1. Tobacco/smoking cessation
2. Exercise/physical activity and inactivity
3. Nutrition/Overweight/Obesity Weight management
4. Stress management

• Increase awareness
• Develop training programs
• Adapt LMCs to other health professionals
• Advocate for wide implementation and integration into practice
• Integrate lifestyle medicine into clinical practice with simple first steps http://www.lifestylemedicine.org/core

• Join the American College of Lifestyle Medicine
(ACLM) and connect with others passionate about LM!
– Plus, tons of additional membership benefits !
• For trainees, we encourage you to become a
Professional in Training (PiT) member and get involved in spreading LM to campuses nationwide!
– Lifestyle Medicine Interest Group (LMIG) Starter Kit and Introductory Video available online www.lifestylemedicine.org

What is a Lifestyle Medicine Interest
Group?
• An organized group of students with a faculty advisor that meets regularly to discuss and learn about how healthy habits affect the body.
• Students can be from college, master’s program, graduate school, medical school, residency, fellowship, nursing school, pharmacy, occupational therapy, physical therapy, and other allied health care professionals.
www.lifestylemedicine.org

Interested in Diving Deeper into LM and Advancing the Field?
There is a special award for Professionals in Training.
The Donald Anderson Pegg Award for innovative research and inspiring projects in LM.
Please go to the ACLM website for further information.
Teams of students can apply and attendings/mentors are encouraged to get involved, as well.
www.lifestylemedicine.org

Lifestyle Medicine 2016, the annual conference of
ACLM, will be held at the Naples Grande Resort in
Naples, FL from October 23-26.
Come connect with colleagues and hear from LM visionaries to learn about current, evidence-based
LM practices.
Details coming soon!
www.lifestylemedicine.org/Lifestyle-Medicine-Conference

…to the American College of Lifestyle
Medicine and to ACLM’s Professionals in
Training (PiT) for their support.

• American Heart Association 2011 Update : A Report From the −− Heart Disease and Stroke Statistics. Circulation. February1, 2011.
• Matteson, EM et al. Healthy Lifestyle Habits and Mortality in Overweight and
Obese Individuals. J Am Board Fam Med 2012;25:9 –15
• Lianov, L and Johnson, M. Physician Competencies for Prescribing Lifestyle
Medicine. JAMA. 2010;304(2):202-203
• Diabetes Prevention Program research Group. Reduction in incidence of Type 2
Diabetes with Lifestyle Intervenions or Metformin. NEJM 2002;346:393-403.
• Barnard RJ, Massey MR, Cherny S, O'Brien LT, Pritikin N. Long-term use of a highcomplex-carbohydrate, high-fiber, low-fat diet and exercise in the treatment of
NIDDM patients. Diabetes Care. 1983 May-June;6(3):268-273.
• Reddy BS, Engle A, Simi B, O’Brien LT, Barnard RJ, Pritikin N, Wynder EL. Effect of low-fat, high-carbohydrate, high-fiber diet on fecal bile acids and neutral sterols.
Prev. Med. 1988 Jul;17(4):432-9.
• Sullivan S, Samuel S. Effect of Short term Pritikin Diet Therapy on the Metabolic
Syndrome. J Cardiometab Syndr. 2006 Fall;1(5):308-12.

• Ornish D et al. Can Lifestyle Changes Reverse Coronary Heart Disease?
Lancet 1990;336(8708);129-133.
• Ornish D et al. Intensive Lifestyle Changes for Reversal of Coronary Heart
Disease. JAMA 1998;280(23);2001-2007.
• Fratarroli J, Weidner G, Merritt-Wardon T, Frenda S, Ornish D. Angina
Pectoris and Atherosclerotic Risk Factors in the Multisite Cardiac Lifestyle
Intervention Program. AM J Card 2008;101(7);911-918.
• The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. Am J Health Promot. 2010 Mar-Apr;24(4):260-6.
• Frates, EP, Moore, M. et al. Coaching for behavior change in physiatry. Am.
J. Phys. Med. Rehabil. & Vol. 90, No. 12, December 2011
• Burke EJ, Hultgren PB. Will Physicians of the Future Be Able to Prescribe
Exercise? J Med Educ. 1975;50:624-6.
• Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and counseling practices of primary care physicians: a national survey. Clinical Journal of Sports Medicine. 2000;10(1):40-8.

• 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
http://www.lifestylemedicine.org/

• 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.
http://www.lifestylemedicine.org/