1. 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

2. American College of Preventive Medicine
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:

3. American College of Lifestyle Medicine
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:

4. 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?

5. Leading Causes of Death
Heart disease: 616,067
Cancer: 562,875
Stroke (cerebrovascular diseases): 135, 952
Chronic lower respiratory diseases: 127, 924
Accidents (unintentional injuries): 123,706
Alzheimer’s disease: 74,632
Diabetes: 71,382
Influenza and Pneumonia: 52,717
Nephritis, nephrotic syndrome, nephrosis: 46,448
Septicemia: 34, 828
*Data for 2007 National Vital Statistics Report- US Adults

6. Actual Causes of Death 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, JAMA 2004
*Leading causes of death similar to 2007

7. 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
Figure adapted from:
Physical Activity
Stroke
Diet
Cancers
Preventive Services
Diabetes

8. Leading Health Indicators Healthy People 2020
Physical activity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and Violence
Environmental quality
Immunization
Access to health care
Healthy People provides science-based, 10-year national objectives for improving the health of all Americans.
These are the underlying root causes of the leading causes of death seen before.
There is an increasing amount of evidence-based data that supports these changes to decrease morbidity and mortality.

9. The current challenges for patients: Unhealthy Lifestyles
Only 11% of patients with diabetes follow accepted dietary recommendations for saturated fat intake (Eilat-Adar)
8% of patients with heart disease continue to smoke (Soni)
There are significant challenges with patients today, even with those patients who have current disease.

10. Can you say yes to all? Only 8% of Americans can
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!

11. 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?...

12. Health Behavior Change: Ecologic Model
Societal/Public Policy
Community
Organizational
Interpersonal
Individual
HEALTH PROVIDERS

13. 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

14. 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
Clearly a role for physician counseling on health behaviors
I- still need further studies in this area

15. 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
Even if patients do not fully achieve the behavior change, physician counseling can move them along the continuum of the stage of change. Stages of change: Pre-contemplation > Contemplation> Preparation>Action>Maintenance

16. 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)
Physicians need help in offering this type of health behavior counseling

17. Physician Barriers to Counseling
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

18. 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)
First looking at time and reimbursement barriers

19. 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

20. “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
Short visit, lack of community involvement, need drugs, too busy working or taking care of home

21. 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!
Addressing Insufficient knowledge, skills, confidence:

22. What Works to Improve Health Behaviors
Create sense of self-efficacy, address barriers
Behavior Change
Perceived Susceptibility
Perceived Benefit
Perceived Severity
Self- efficacy
Cues to Action
HEALTH BELIEF MODEL

23. What Works….Goal Setting
Listen . . choose ONE behavior & reasonable goal
Patient should rate confidence of completing the goal at 7/10
Image from:

24. 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

25. 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

26. 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.

27. 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

28. 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

29. 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.
FOR REFERENCE ONLY

30. 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 lifestyle-related 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.
FOR REFERENCE ONLY

31. LM competencies cont. Management Skills
Use nationally recognized practice guidelines (such as those for hypertension and smoking cessation) to assist patients in self-managing 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 evidence-based, 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.
FOR REFERENCE ONLY

32. 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.
FOR REFERENCE ONLY

33. Next steps for competencies
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

34. 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

35. Some Options to Consider for Your Practice
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 35

36. Some Options to Consider for Your Practice
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

37. 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) 37

38. 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 38

39. 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. 39

40. 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 40

41. References
Behavioral Counseling in Primary Care to Promote a Health Diet, Topic Page. December U.S. Preventive Services Task Force.
Behavioral Counseling in Primary Care to Promote Physical Activity, Topic Page. December U.S. Preventive Services Task Force.
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.:CD DOI: / CD 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 May-Jun; 25(3):225-33
Counseling to Prevent Tobacco Use and Tobacco-Caused Disease, Topic Page. Novenmber U.S. Preventive Services Task Force.
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.: CD DOI / CD 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):
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.: CD DOI: / CD pub2

42. References
Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising ovese patients to lose weight? JAMA. 1999;282(16):
Healthy People 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):
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:
Leading Health Indicators. (last accessed 2 December 2010).
Lianov L, Johnson M, Physician Competencies for Prescribing Lifestyle Medicine, JAMA. 2010;304(2):
Mokdad Ah, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, JAMA. 2004:291(10):
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 U.S. Preventive Services Task Force.
Soni A. Personal Health Behaviors for heart Disease Prevention Among the US Adult Civilian Noninstitutionalized Population, Rockville, Md: Agency for Healthcare Research and Quality; March 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):
Webinars: -

43. Webinars:
Dr. Michael Parkinson: Healthcare Reform, Preventive Medicine and the Future of Patient Care.
Dr. Liana Lianov: Lifestyle Medicine Approaches to Effective Employer Health ad Wellness Initiatives.
Much of the information in these slides were adapted from these webinars: