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Lifestyle Medicine: Campaign by American College of Preventive Medicine and American College of Lifestyle Medicine to Inspire Local Champions to Action

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Title: Lifestyle Medicine: Campaign by American College of Preventive Medicine and American College of Lifestyle Medicine to Inspire Local Champions to Action


1
Lifestyle MedicineCampaign 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

2
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

3
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

4
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?

5
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
  • Alzheimers 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

6
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

7
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
Physical Activity
Stroke
Diet
Cancers
Preventive Services
Diabetes
8
Leading Health IndicatorsHealthy 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

9
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)

10
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 dont use tobacco products
  • I have 2 or fewer alcoholic drinks per day
  • These are the drivers of health care costs!

11
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?...

12
Health Behavior Change Ecologic Model
  • HEALTH PROVIDERS

13
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

14
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
I- still need further studies in this area
15
Examples of the Impact of Physician Counseling
  • Patients who make behavior change often cite that
    the physicians 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

16
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)

17
Physician Barriers to Counseling
  • Lack of time
  • Reimbursement issues
  • Insufficient confidence
  • Insufficient knowledge
  • Insufficient skills
  • Others?
  • From previous examples
  • Patients note counseling has significant effect
    of understanding and motivation
  • BUT physicians often provide insufficient guidance

18
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)

19
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

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, 2007

21
Tools for Physicians
  • 5 As- 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 ISNT ENOUGH!

22
What Works to Improve Health Behaviors
  • Create sense of self-efficacy, address barriers

23
What Works.Goal Setting
  • Listen . . choose ONE behavior reasonable goal
  • Patient should rate confidence of completing the
    goal at 7/10

24
What worksStages of Change
  • Identify stage, and move patient along the
    continuum
  • Not every patient will enter every stage
  • Not every stage is the same length

25
How we raise the barLifestyle 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

26
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.

27
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

28
LM Competencies- Summary
  • Perform comprehensive lifestyle assessments
  • Risk assessments
  • Patients 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

29
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.

30
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.

31
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.

32
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.

33
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

34
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

35
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 populationin 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

36
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

37
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)

38
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

39
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 planone small step
  • Check patients confidence level
  • If patient is not ready for an action plan, offer
    a brief message appropriate to the patients
    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.

40
If you can carve out 10 minutes
or more
  • Briefly address two or more lifestyle areas
    appropriate to the patients readiness to make a
    change for example with motivational
    interviewing or developing a brief, specific
    action plan

41
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/uspst
    f/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/uspst
    f/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.DOI10.1002/14651858.CD
    002128.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/uspst
    f/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.pu
    b2
  • Eilat-Adar S, Xu J, Zephier E, OLeary 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.DOI10.1002/14651858.CD000984.p
    ub2

42
References
  • Galuska DA, Will JC, Serdula MK, Ford ES. Are
    health care professionals advising ovese patients
    to lose weight? JAMA. 1999282(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.200479(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. 2010122406-441
  • Leading Health Indicators. www.health.gov/healthyp
    eople/ (last accessed 2 December 2010).
  • Lianov L, Johnson M, Physician Competencies for
    Prescribing Lifestyle Medicine, JAMA.
    2010304(2)202-203
  • Mokdad Ah, Marks JS, Stroup DF, Gerberding JL.
    Actual causes of death in the United States,
    2000. JAMA. 2004291(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.
    20009(7)631-638.
  • Webinars
  • -

43
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?Client446569PCAT2719CAT
    2719
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