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 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: www.acpm.org

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: 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 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

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, 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 Figure adapted from: www.balancedweightmanagement.com/TheSocio-EcologicalModel.htm Physical Activity Stroke Diet Cancers Preventive Services Diabetes

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.

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.

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!

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: Ecologic Model Societal/Public Policy Community Organizational Interpersonal Individual http://www.balancedweightmanagement.com/TheSocio-EcologicalModel.htm HEALTH PROVIDERS

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 Clearly a role for physician counseling on health behaviors 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 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

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

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

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

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

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:

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

What Works….Goal Setting Listen . . choose ONE behavior & reasonable goal Patient should rate confidence of completing the goal at 7/10 Image from: http://purelifewellness.wordpress.com/2011/04/12/s-m-a-r-t-goal-setting/

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. FOR REFERENCE ONLY

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

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

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

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

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 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

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

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

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

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

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

References 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 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/MSS-webinars.htm Dr. 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=2719 Much of the information in these slides were adapted from these webinars: