The root of disease
Lifestyle interventions take aim at chronic ailments
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.