1. Lifestyle Medicine Curriculum – a method for training about behavioral change Pam Webber September 2011 Fort Collins Family Medicine Residency Program Fort Collins, Colorado

2. Goals and Objectives  Learn more about Lifestyle medicine as a discipline related to Family Medicine  Understand how a Lifestyle Medicine curriculum can promote learning about behavioral change  Apply some of the techniques used in lifestyle medicine teaching of behavioral change

3. Outline of presentation  Introduction to Lifestyle Medicine  Lifestyle Medicine at the Fort Collins Family Medicine Residency  History  Current curriculum  Practice with teaching tool  Discussion

4. “ Excellent health is much more than the simple absence of disease; it is an integral state of well-being achieved through a lifestyle of self- responsibility and balance, a lifestyle that encourages continuous exploration of one’s potential in all areas.”

5. “Lifestyle medicine is simply the use of therapeutic lifestyle interventions in the treatment and prevention of human disease. We are practicing lifestyle medicine when we tell a patient to get plenty of fluids and rest; it is lifestyle medicine when we tell patients to stop smoking; and it is lifestyle medicine when we tell a patient to begin an exercise program. Most clinicians commonly use lifestyle medicine without even realizing it. In fact, lifestyle medicine is so ubiquitous that its importance is often underestimated. Too often we give little attention to the foundational role lifestyle factors play in the cause, and the cure, of disease.” John Kelly, MD, MP Past President, and Co-founder American College of Lifestyle Medicine

6. 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

7. 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

8. Actual Causes of Death 1.Tobacco: 435,000 2.Poor diet and physical inactivity: 400,000 3.Alcohol consumption: 85,000 4.Microbial agents: 75,000 5.Toxic agents: 55,000 6.Motor vehicle: 43,000 7.Firearms: 29,000 8.Sexual behavior: 20,000 9.Illicit Drug use: 17,000 * Mokdad, Actual Causes of Death in the US, 2000. JAMA 2004 *Leading causes of death similar to 2007

9. Causes of Death in US Tobacco (smoking) Poor diet & inactivity Alcohol (drinking) CDC Burden of Chronic Disease Report, 2000.

10. 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 BEHAVIORDISEASE Tobacco Use Physical Activity Diet Preventive Services Heart Disease Stroke Cancers Diabetes

11. Health Care, Not Sick Care “In the U.S., we spend approximately $1.8 trillion a year on health care. Fully 75% of that total is accounted for by chronic diseases — things like heart disease, cancer, and diabetes—all of which, in large measure, are preventable. Meanwhile, only 2% of all health care spending is on prevention. What is wrong with this picture?” Senator Tom Harkin, AJHP 2004 Sep/Oct;19:1-2.

13. The Treatment Triangle Lifestyle Medicine Diet, Exercise, Sleep, Temperance, Meditation, etc. Physiologic Therapies PT, Counseling, Alternative Medicine, etc. Medications Pharmacologic, Supplements Surgery

14. Lifestyle Interventions  Nutrition  Physical Activity  Stress Management  Rest/Sleep  Substance Use  Smoking cessation  Other non-drug modalities  Sunshine/Light  Social and spiritual supports

15. 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!

16. Special Requirements for Residency Training in Family Practice Effective July 1, 1989 Prevention of disease and disability, health promotion, health maintenance and health screening are important aspects of family practice. Preventive medicine must include training in immunizations and in appropriate behaviors which protect the individual and families from illness or injury. Residents should be given the opportunity to acquire specific knowledge, skills, and attitudes which provide special competence in these areas. Residents should be instructed in the general principles of health promotion and appropriate intervention based upon the needs of the individual patient and the community.

17. Evolution of Lifestyle Medicine Curriculum   1987 – part time health promotion/disease prevention coordinator/faculty hired   2000 – Behavioral faculty trained in MI introduced to residency   Grants to support Obesity training   2005 – Community CAN DO grant   2007 – Community Lifestyle conference as part of 30 th anniversary of residency

18.   GOAL: The goal of the lifestyle medicine curriculum is to prepare family medicine residents to skillfully integrate lifestyle medicine with patient care and utilize appropriate clinical and/or community resources

19. Objectives: By the completion of this rotation the resident will be able to integrate lifestyle medicine with patient care, demonstrating the following competencies:   Assessment of such behaviors as diet, activity, sleep, substance use and stress management, assessment of risk, and assessment of the patient’s readiness for and ability to make needed changes. This core competency may include the use of tools such as a health risk appraisals or fitness assessment.   Identification of the impact of lifestyle factors on health/well-being and identification of evidenced-based lifestyle interventions shown to be effective in the treatment of disease. This competency will require information mastery abilities and use of point-of-care and other electronic tools.

20. Application of lifestyle medicine interventions conveying the importance and relevance of lifestyle; writing a lifestyle medicine prescription; demonstrating motivational interviewing; and using lifestyle intervention tools and resources Coordination of care with team members and community partners such as a dietitian or tobacco cessation specialist

21. Documentation of lifestyle medicine interventions, including tracking patient progress over time Appropriate and effective billing for lifestyle medicine services

22. Teaching Methods   Block Rotation Year 1: This block rotation will include an overview of lifestyle medicine and evidence base (didactic and reading), information on behavior change, brief interventions, and motivational interviewing (lecture/discussion), self-care and personal well-being (experiential), shadowing physician faculty (observation), integration of lifestyle recommendations into patient care (case presentation/ discussion), resources (dialogue, observation, participation, written materials), Self-Directed Learning Activities (i.e., on- line training modules, site visits)

23. Longitudinal Curriculum: Will include didactic conferences (two hours/year), precepting encounters (ongoing interactions with physician & lifestyle medicine faculty), shadowing of individual residents (once/year), small group learning sessions (three hours/year for each resident class).

24. First year one week block rotation   Content areas   Personal reflection   How lifestyle fits practice/personal life   What areas of Lifestyle least comfortable with   Yoga experience   Knowledge and Skills   Exercise as medicine   Nutrition   24 hour recall   Stress Management   Breathing

25. Content continued   Motivational Interviewing   Introduced in group session with all R1s   During week   Follow-up on personal goals   Work on skills   Reflective listening   Role plays

26. More content   Patient encounters   Shadow lifestyle visits   Look at patients scheduled in clinic for lifestyle issues   By end of rotation lead a lifestyle visit

27. TOOLS AND RESOURCES Professional Resources The American College of Lifestyle Medicine The Harvard Institute of Lifestyle Medicine The American Academy of Family Physicians: AIM to Change toolkit, CME Monographs on Exercise and Nutrition, Obesity, Well Older Adult, and Sleep Colorado Clinical Guidelines Collaborative: Guideline for Tobacco Cessation and Guideline for Obesity Lifestyle Medicine, James Rippe, MD The Spectrum, Dean Ornish, MD Exercise is Medicine, Steven Jonas, MD, MPH, MS and Edward Phillips, MD Overdosed America, John Abramson, MD Professional Journals: The American Journal of Lifestyle Medicine and Obesity Management

28. Questions?