The root of dis­ease

Life­style in­ter­ven­tions take aim at chronic ail­ments

Modern Healthcare - - PHYSICIAN|AFFAIRS - Lola Butcher is a free­lance health­care writer in Spring­field, Mo. Contact Butcher at lola@lo­

When the Amer­i­can Col­lege of Life­style Medicine con­venes its an­nual meet­ing in Septem­ber, quacks are not in­vited. As they work to be­come a sig­nif­i­cant force in Amer­i­can medicine, ACLM mem­bers, which num­ber about 250, are de­ter­mined not to let the term “life­style medicine” go the way of al­ter­na­tive medicine, com­ple­men­tary medicine or in­te­grated medicine.

“Each of those terms were kind of pop­u­lar, kind of hip for a while, but ev­ery­body started do­ing ev­ery­thing un­der the sun un­der those la­bels, in­clud­ing a lot of non-ev­i­dence-based stuff that wasn’t good health­care,” says Dr. Marc Bra­man, the ACLM’s ex­ec­u­tive di­rec­tor.

Life­style medicine is the name for life­style in­ter­ven­tions—diet and nu­tri­tion, ex­er­cise, stress man­age­ment, smok­ing ces­sa­tion and oth­ers—to pre­vent and treat Type 2 di­a­betes, coro­nary heart dis­ease, hy­per­ten­sion and other chronic dis­eases that clog Amer­ica’s health­care sys­tem.

“It’s also a term that we in­tend to de­velop and pro­tect as be­ing a cred­i­ble, sci­en­tif­i­cally sound, ev­i­dence-based field of health­care prac­tice,” he says.

Fo­cus on root causes of dis­ease

Dr. Dex­ter Shur­ney, med­i­cal di­rec­tor of the em­ployee health plan for Van­der­bilt Univer­sity and Van­der­bilt Univer­sity Med­i­cal Cen­ter, Nashville, con­sid­ers life­style medicine to be the an­ti­dote to Amer­ica’s health­care cost cri­sis. Chronic dis­eases drive about two-thirds of a plan’s costs, he says, and at least 75% of chronic dis­eases are pre­ventable.

“If you can get peo­ple to fo­cus on the root cause, you can ac­tu­ally pre­vent a lot of those dis­eases, and you can ac­tu­ally re­verse some,” says Shur­ney, a mem­ber of the ACLM’s board of di­rec­tors.

What dis­tin­guishes life­style medicine physi­cians is their ap­proach to the root causes of chronic dis­ease. Bra­man says telling an over­weight pa­tient to lose weight is not suf­fi­cient be­cause it is un­likely to pro­duce re­sults. Physi­cians must un­der­stand how to iden­tify a pa­tient’s readi­ness to change un­healthy habits and mo­ti­vate them to adopt new be­hav­iors, he adds.

“There’s a whole sci­ence on health be­hav­ior change and why we do what we do,” he says. “And physi­cians have zero train­ing in it, and they are typ­i­cally ter­ri­ble at it. And the (health­care) sys­tem makes them ter­ri­ble at it in giv­ing them only five or 10 min­utes with a pa­tient. You can’t do any­thing sig­nif­i­cantly pro­duc­tive in five or 10 min­utes.”

Life­style medicine prac­tice varies widely. At Cleve­land Clinic’s Cen­ter for Life­style Medicine, chronic dis­ease pa­tients can sign up for 12-month physi­cian-led pro­grams to de­velop healthy habits and week­end work­shops that prom­ise “life­style trans­for­ma­tion” while the physi­cians at North­west­ern Univer­sity’s Cen­ter for Life­style Medicine fo­cus pri­mar­ily on weight man­age­ment.

When a pa­tient has an ap­point­ment with Dr. Wayne Dysinger, co-di­rec­tor of the Life­style Medicine In­sti­tute at Loma Linda (Calif.) Univer­sity, the ex­am­i­na­tion will in­clude ques­tions about nu­tri­tion, ex­er­cise and sleep habits, as well as so­cial sup­ports. A body fat anal­y­sis or tread­mill test may be used to mea­sure a pa­tient’s health sta­tus.

Al­though he may pre­scribe phar­ma­ceu­ti­cals in some sit­u­a­tions, the more typ­i­cal pre­scrip­tion or­ders up spe­cific life­style changes.

For ex­am­ple, an arthri­tis pa­tient is likely to leave with in­struc­tions to eat cru­cif­er­ous veg­eta­bles be­cause of their anti-in­flam­ma­tory prop­er­ties.

“I’m go­ing to ac­tu­ally write a pre­scrip­tion that says you need to eat broc­coli three times a week, or some­thing like that,” he says. “I’m go­ing to be in­ter­act­ing with you dif­fer­ently that way.”

‘Edge of a wave’

Life­style medicine has been gain­ing trac­tion since car­di­ol­o­gist Dr. James Rippe pub­lished a text­book on the topic in 1999. Rippe, founder of the Rippe Life­style In­sti­tute in Florida, is a pro­fes­sor of bio­med­i­cal sciences at the Univer­sity of Cen­tral Florida.

Its prac­ti­tion­ers be­lieve chang­ing pri­or­i­ties of pay­ers, pol­i­cy­mak­ers and pa­tients will cre­ate a huge de­mand for their ex­per­tise in the years ahead. To be suc­cess­ful in the pa­tient-cen­tered med­i­cal home and ac­count­able care or­ga­ni­za­tion mod­els, physi­cians must learn how to help their pa­tients adopt healthy habits, says Dr. Ed­ward Phillips, the Har­vard Med­i­cal School as­sis­tant pro­fes­sor who heads the In­sti­tute of Life­style Medicine in Bos­ton.

“All of a sud­den doc­tors are be­ing told, ‘We’re think­ing that if you could ac­tu­ally get (pa­tients) to lose weight and get ac­tive and man­age their stress, all the lit­er­a­ture shows that that’s go­ing to save our or­ga­ni­za­tion money,’ ” he says. “We’re see­ing folks that two years ago weren’t ready to take a trip to Bos­ton to learn about this, and now their liveli­hood may de­pend on it. So we are re­ally at the edge of a wave.”

Bra­man con­sid­ers life­style medicine to be the clin­i­cal ap­proach that sup­ports the med­i­cal-home de­liv­ery model.

“The chal­lenge with the pa­tient-cen­tered med­i­cal home is that (prac­ti­tion­ers) are all fo­cused on process ef­fi­ciency,” he says. “If your sys­tem is just pills and pro­ce­dures to treat con­se­quences and never treat the causes (of chronic dis­ease), it’s never go­ing to work—I don’t care how ef­fi­cient you get.”

Life­style medicine has no cre­den­tial­ing process for prac­ti­tion­ers and it is not rec­og­nized by the Amer­i­can Board of Med­i­cal Spe­cial­ties. But its ad­her­ents are pre­par­ing to jump the hur­dles needed to be rec­og­nized by the med­i­cal es­tab­lish­ment.

A few physi­cians started the ACLM in 2004 as the first step to­ward cre­at­ing an of­fi­cial dis­ci­pline. Af­ter a few years of all-vol­un­teer lead­er­ship, Bra­man be­came ex­ec­u­tive di­rec­tor, as­signed to build the or­ga­ni­za­tional in­fra­struc­ture—from pro­fes­sional stan­dards to re­im­burse­ment mod­els—that are needed for life­style medicine to ad­vance.

“The sci­ence clearly shows this is the big­gest, most im­por­tant, most pow­er­ful stuff you can do,” Bra­man says. “We’re re­ally out to make this ac­cepted health­care.”

To that end, the ACLM has as­sem­bled an ad­vi­sory board that in­cludes for­mer U.S. Sur­geon Gen­eral Dr. Richard Car­mona; best-sell­ing au­thor Dr. Dean Or­nish, pres­i­dent of the Pre­ven­tive Medicine Re­search In­sti­tute; T. Colin Camp­bell, co-di­rec­tor of the Cor­nel­lOx­ford-China Diet and Health Project at Cor­nell Univer­sity; and Dr. David Jenk­ins, di­rec­tor of the Risk Fac­tor Mod­i­fi­ca­tion Cen­tre at the Univer­sity of Toronto.

The field took a step for­ward in 2010 when the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion pub­lished “Physi­cian com­pe­ten­cies for pre­scrib­ing life­style medicine,” the first pub­lished stan­dards for the emerg­ing field. The com­pe­ten­cies were iden­ti­fied by a panel of rep­re­sen­ta­tives from the Amer­i­can Med­i­cal As­so­ci­a­tion, the Amer­i­can Academy of Fam­ily Physi­cians, the Amer­i­can Col­lege of Physi­cians, the Amer­i­can Col­lege of Pre­ven­tive Medicine, the ACLM and other or­ga­ni­za­tions.

The ACLM’s of­fi­cial pub­li­ca­tion—the Amer­i­can Jour­nal of Life­style Medicine—dis­sem­i­nates re­search find­ings. Mean­while, ACLM lead­ers are work­ing with the MGMAACMPE on a prac­tice model ini­tia­tive de­signed to help pay­ers un­der­stand how life­style medicine prac­ti­tion­ers should be paid.

Too many spe­cial­ties?

While the ACLM’s goal is to be rec­og­nized as a med­i­cal spe­cialty, Bra­man says the group’s lead­ers re­al­ize they are in for a long slog be­cause es­tab­lished med­i­cal spe­cial­ties will have to sup­port their goal.

“There’s this sense that there are al­ready too many and it is al­ready con­fus­ing to peo­ple,” he says. “Ba­si­cally, the med­i­cal pro­fes­sion does not want any new med­i­cal spe­cial­ties.”

Phillips, as­sis­tant pro­fes­sor of phys­i­cal medicine and re­ha­bil­i­ta­tion at Har­vard Med­i­cal School, launched Har­vard’s first on­line course on life­style medicine in 2005. The next

year, he taught life­style medicine in four cities in In­dia and, in 2007, he started the In­sti­tute of Life­style Medicine in Mas­sachusetts.

Through a grant from the Health Re­sources and Ser­vices Ad­min­is­tra­tion, the in­sti­tute pro­vides train­ing in life­style medicine for in­ter­nal medicine/pre­ven­tive medicine res­i­dents at Yale School of Medicine. They spon­sor con­tin­u­ing med­i­cal ed­u­ca­tion cour­ses avail­able to clin­i­cians around the world.

For the past three years, the in­sti­tute has of­fered a life­style medicine “in­ter­est group” for Har­vard Med­i­cal School students and fac­ulty who want to learn how to mo­ti­vate peo­ple to stop smok­ing, in­crease their ex­er­cise and adopt other healthy habits.

“It’s set up sort of as a par­al­lel cur­ricu­lum” to stan­dard course­work, Phillips says.

Stan­ford Univer­sity School of Medicine, Weill Cor­nell Med­i­cal Col­lege and Philadel­phia Col­lege of Os­teo­pathic Medicine have all fol­lowed suit with in­ter­est groups of their own. Har­vard trained the Stan­ford and Cor- nell lead­ers; it is pro­vid­ing on­line lec­tures via Skype to sup­port the Philadel­phia group.

Phillips says life­style medicine pro­po­nents are still pri­mar­ily “preach­ing to the choir,” but the con­gre­ga­tion of en­thu­si­asts is grow­ing.

“I’m the guy at the front of the room, see­ing more and more seats filled up,” he says. “And I’m see­ing more and more ex­cited peo­ple send­ing e-mails to me about how they are con­vinc­ing their hos­pi­tals to be­gin to make the nec­es­sary changes to re­di­rect the way we de­liver health­care.”

Mean­while, Loma Linda Univer­sity has been mar­ket­ing its com­bined fam­ily medicine/pre­ven­tive medicine res­i­dency un­der the “life­style medicine” ban­ner since 2006. Dysinger says the qual­ity of ap­pli­cants, about 450 a year for four slots, has im­proved be­cause the pro­gram at­tracts trainees who want to fo­cus on pop­u­la­tion health and sys­tem­atic ap­proaches to im­prov­ing the health of in­di­vid­ual pa­tients.

“The peo­ple that are in­ter­ested in it are the peo­ple who are vi­sion­ar­ies and peo­ple who want to do more than just plain clin­i­cal medicine,” he says.

Life­style medicine spe­cial­ist Dr. Ed­ward Phillips, far right, was joined by U.S. Sur­geon Gen­eral Regina Ben­jamin in the White Coats, White Sneak­ers walk as part of Har­vard Med­i­cal School’s Ac­tive Doc­tors, Ac­tive Pa­tients con­fer­ence in 2009.

Life­style medicine prac­ti­tioner Dr. John Principe uses a “healthy teach­ing kitchen” at his prac­tice in Pa­los Heights, Ill., to ed­u­cate pa­tients about nu­tri­tion.

In his solo prac­tice in Chelms­ford, Mass., Dr. Damian Folch pro­vides preven­tion, dis­ease man­age­ment, episodic care, life­style medicine and pa­tient ed­u­ca­tion.

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