Presentation on theme: "Lifestyle Medicine: Campaign by American College of Preventive Medicine and American College of Lifestyle Medicine to Inspire Local."— Presentation transcript:
1Lifestyle Medicine: Campaign by American College of Preventive Medicine and American College of Lifestyle Medicine to Inspire Local Champions to ActionSlides adapted with permission from:Liana Lianov MD, MPH, FACPMEleanor Loomis, UC Davis Public Health ProgramMichael D Parkinson MD, MPH, FACPM
2American College of Preventive Medicine Evidence based disease prevention and health promotion research policies, practice programs.2400 members engaged in preventive medicine practice, teaching, and researchGeneral preventive medicine, public health, occupational and environmental medicine, aerospace medicineFor more information:
3American 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 lifestyleFor more information:
4OverviewWhat 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?
5Leading Causes of Death Heart disease: 616,067Cancer: 562,875Stroke (cerebrovascular diseases): 135, 952Chronic lower respiratory diseases: 127, 924Accidents (unintentional injuries): 123,706Alzheimer’s disease: 74,632Diabetes: 71,382Influenza and Pneumonia: 52,717Nephritis, nephrotic syndrome, nephrosis: 46,448Septicemia: 34, 828*Data for 2007 National Vital Statistics Report- US Adults
6Actual Causes of Death Tobacco: 435,000 Poor diet and physical inactivity: 400,000Alcohol consumption: 85,000Microbial agents: 75,000Toxic agents: 55,000Motor vehicle: 43,000Firearms: 29,000Sexual behavior: 20,000Illicit Drug use: 17,000*Mokdad, Actual Causes of Death in the US, JAMA 2004*Leading causes of death similar to 2007
7Behavioral Determinants Virtually ALL of the top 10 leading causes of death in US adults are moderately to STRONGLY influenced by lifestyle patters and behavioral factorsBEHAVIORDISEASETobacco UseHeart DiseaseFigure adapted from:Physical ActivityStrokeDietCancersPreventive ServicesDiabetes
8Leading Health Indicators Healthy People 2020 Physical activityOverweight and obesityTobacco useSubstance abuseResponsible sexual behaviorMental healthInjury and ViolenceEnvironmental qualityImmunizationAccess to health careHealthy 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.
9The 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.
10Can you say yes to all? Only 8% of Americans can I am within 5 pounds of my ideal body weightI exercise 30 minutes or more most days of the weekI eat a healthy diet with 5 fruits/vegetables most daysI don’t use tobacco productsI have 2 or fewer alcoholic drinks per dayThese are the drivers of health care costs!
11Optimism for ActionDecline 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 successHow did we do it?...
12Health Behavior Change: Ecologic Model Societal/Public PolicyCommunityOrganizationalInterpersonalIndividualHEALTH PROVIDERS
13Physician CounselingEvidence is mixed about impact of physician counseling on health behavior change (Cochrane)May be artifact of study designVarity of health behaviors, interventions, application of approaches, length and intensity, statistical powerUS Preventive Service Task Force (USPSTF)In general, the recommendations are in favor of physician counselingRecommendations vary for specific health behaviors
14USPSTF Recommendations BehaviorRecommendation for Screening and Behavioral CounselingTobacco UseAPhysical ActivityIHealthy DietB (for at-risk patients)Alcohol MisuseBClearly a role for physician counseling on health behaviorsI- still need further studies in this area
15Examples 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 obesityUnderstand benefits of weight lossHigher stage of change of readiness for weight lossEven 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
16Current 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 examsOnly 52% of patients who already have obesity-related co-morbidities are advised to lose weightOnly 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
17Physician Barriers to Counseling Lack of timeReimbursement issuesInsufficient confidenceInsufficient knowledgeInsufficient skillsOthers?From previous examplesPatient’s note counseling has significant effect of understanding and motivationBUT physicians often provide insufficient guidance
18Time & 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
19Time & Reimbursement cont. State Medicaid matching funds enhanced for following USPSTF recommendationsMedicare Annual Wellness visitNumerous employer and worksite incentives and grants to improve health promotion programsIndividualized prevention plans in MedicareIncentives 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, 2007Short visit, lack of community involvement, need drugs, too busy working or taking care of home
21Tools 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:
22What Works to Improve Health Behaviors Create sense of self-efficacy, address barriersBehavior ChangePerceived SusceptibilityPerceived BenefitPerceived SeveritySelf- efficacyCues to ActionHEALTH BELIEF MODEL
23What Works….Goal Setting Listen . . choose ONE behavior & reasonable goalPatient should rate confidence of completing the goal at 7/10Image from:
24What works…Stages of Change Identify stage, and move patient along the continuumNot every patient will enter every stageNot every stage is the same length
25How we raise the bar…Lifestyle Medicine Competencies Blue Ribbon PanelAmerican College of Preventive MedicineAmerican College of Lifestyle MedicineAmerican Academy of Family PhysiciansAmerican Medical AssociationAmerican College of PhysiciansAmerican College of Sports MedicineAmerican Osteopathic Association
26Panel-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.
27Field of Lifestyle Medicine LM recognizes the link between lifestyle medicine and health outcomesUses science behind health behavior changeEmphasizes value of lifestyle medicine prescriptions by physiciansEmphasizes value of support of those prescriptions by other health professionals
28LM Competencies- Summary Perform comprehensive lifestyle assessmentsRisk assessmentsPatient’s readiness to change modifiable risk factorsEstablish effective relationships and use national guidelinesUse team approachMake referralsUse medical information technology to maximize lifestyle medicine carePromote healthy behaviors as foundation of health promotion and medical carePhysician should personally practice a healthy lifestyle
29LM competencies (for reference only) LeadershipPromote 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.KnowledgeDemonstrate 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
30LM 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
31LM 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
32LM 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 technologyMeasure 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
33Next steps for competencies Increase awarenessDevelop training programsAdapt LMCs to other health professionalsAdvocate for wide implementation and integration into practiceIntegrate lifestyle medicine into your practice with easy first steps
34With Every PatientMake a point of addressing lifestyle issues with every patient, even brieflyPrescribe lifestyle as the first-line treatment for most chronic illnesses
35Some Options to Consider for Your Practice All patients need their lifestyles addressed in the health maintenance section of the planInclude 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 levelsIdentify and/or adapt questionnaires to your patient population—in terms of literacy level and cultural backgroundReview responses in advance of visit, if possible, or during the visit to prioritize lifestyle areas which the patient is most ready to addressMake sure support staff routinely collect lifestyle vital signs: waist circumference, BMI, physical activity level35
36Some 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 planUse patient registries to identify and prioritize patients in need of intensive lifestyle interventionsRefer to other health professionals and community resources whenever these are available and financially feasible or covered by insuranceLeverage worksite wellness and other programs
37If you only have 30 seconds… Tell the patient that you believe lifestyle issues are important and would like to address them at the next visitSchedule a follow-up visit for the current condition and carve out at least 2 minutes for addressing lifestyle at that visitSchedule a prevention visit (Medicare)37
38If you only have a couple of minutes… Review lifestyle vital signs (that should be listed in the chart)Choose one area to addressAsk patient to consider what he/she might be ready/able to doState that you will follow-up at next visit38
39If you have 5 minutes…Choose one area of concern that patient is ready to addressAsk patient about what specific steps he/she could doDevelop a brief action plan—one small stepCheck patient’s confidence levelIf 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
40If 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 plan40
41ReferencesBehavioral 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 pub3Calfas 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):225-33Counseling 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 pub2Eilat-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
42ReferencesGaluska 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:-
43Webinars:Dr. Michael Parkinson: Healthcare Reform, Preventive Medicine and the Future of Patient Care.http://www.acpm.org/MSS-webinars.htmDr. Liana Lianov: Lifestyle Medicine Approaches to Effective Employer Health ad Wellness Initiatives. https://live.blueskybroadcast.com/bsb/client/CL_DEFAULT.asp?Client=446569&PCAT=2719&CAT=2719Much of the information in these slides were adapted from these webinars: