Lifestyle Medicine: An Overview
The recent debate on health care reform has highlighted the increasing burden of the cost of chronic disease and the lack of effective means to address these challenges. Lifestyle medicine traditionally has been embraced by primary care physicians, but until recently there have been obstacles for dissemination due to poor or absent reimbursement, questions regarding the efficacy of interventions, and the sheer volume of acute episodic medical care that squeezes our time with patients.
Lifestyle medicine is an evolving approach to patient care that focuses on comprehensive, evidence-based health assessment and natural treatment approaches. Although the use of the term "lifestyle medicine" is new, in many ways the practice of lifestyle medicine returns the health care provider to core health care concepts that have been in existence for years, but have recently gained increasingly large bodies of scientific evidence supporting their practice.
There are many definitions of lifestyle medicine. The broadest-based denotation states, "Lifestyle medicine 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."1 Lifestyle medicine includes a thorough assessment of an individual's current health habits, development of individualized treatment plans, and implementation of individual, group, and community resources that assist in health behavior change. Lifestyle medicine approaches can be used in primary, secondary, and tertiary prevention arenas it can prevent the development of disease risk factors, modify risk factors when they are already present, and treat disease if risk factors have progressed to that level. Lifestyle medicine focuses on recognizing and treating the causes of disease, not just the symptoms.2
Most lifestyle medicine definitions refer to the use of lifestyle interventions in the prevention and treatment of chronic disease. Lifestyle interventions are generally considered to be activities that are a common part of the human condition but are frequently not practiced in the manner that is known to maximize health. The most common of these lifestyle interventions is the proper use of food and nutrition. How an individual eats and takes in nutrients can greatly affect his or her health both on a short- and long-term basis. Interventions by health care providers that improve diet and nutrition should be foundational to much of both acute and chronic care. The second most frequently mentioned lifestyle intervention is physical activity. Evidence that increased physical activity improves health and well being is strong. Health care providers can influence participation in physical activity, thereby strengthening an individual's health status. Other lifestyle factors that are frequently mentioned include rest and proper sleep as well as the development of stress management tools including balanced social, emotional, and spiritual support systems. Finally, at times individuals make choices that are detrimental to their health, such as smoking or drinking too much alcohol. In these cases, lifestyle interventions are focused on assisting individuals in removing these exposures. Classic examples of these types of interventions are smoking cessation counseling and limiting alcohol use to moderate levels.
Lifestyle medicine is not complementary or alternative medicine. It is based on strong evidence for the value of lifestyle interventions in a variety of disease states. It does not bring experimental or unproven approaches to health and is, in fact, core to most nationally recognized protocols for the treatment of diabetes, hyperlipidemia, hypertension, and a variety of other disease states. While lifestyle medicine supports the proper use of other preventive measures like immunizations and chemoprophylaxis or integrative therapies such as judicious herbals, massage, and energy techniques, these are not considered lifestyle medicine because they go beyond the simple, natural approaches discussed above that form the core of lifestyle medicine. The relationship of lifestyle medicine to other aspects of health care can be seen in the context of a hierarchal treatment triangle. (See Figure 1.)
Currently, the majority of our health care resources go toward the top ends of this triangle. Lifestyle medicine practitioners believe that it should be the other way. Lifestyle practices and health habits are among the nation's most important health determinants. Changing unhealthy behaviors is foundational to medical care, disease prevention, and health promotion. While lifestyle medicine does require a certain knowledge base and skill set, it is much more than that it is really a philosophy and approach to care that is rooted in the science of conventional medicine but goes beyond traditional medical training.
Lifestyle medicine adjusting nutrition, physical activity, and rest to maximize health has existed since the first time a human felt unwell. Around 400 B.C., Hippocrates summarized health and healing, stating, "the natural force within each one of us is the greatest force in getting well. Our food should be our medicine, our medicine should be our food ... food and exercise ... work together to produce health."3 More than 2000 years later, these concepts were still dominant when Thomas Edison hypothesized, "the doctor of the future will give no medicine, but will instruct his patient in the care of the human frame, in diet and the cause and prevention of disease."
The modern age of lifestyle medicine really began with the publication of a lifestyle medicine text in 1999.4 A Medline search for articles mentioning lifestyle medicine in 1998, the year prior to the text publication, found 669 articles. By 2008, the number of articles mentioning lifestyle medicine had almost quadrupled to 2284 articles. In 2004, a lifestyle medicine professional association, the American College of Lifestyle Medicine, was formed.5 The first formal lifestyle medicine training program was started by Loma Linda University in 2006.6 This was followed in 2007 by the first peer-reviewed professional journal dedicated to lifestyle medicine, the American Journal of Lifestyle Medicine.7 In 2008, a second Lifestyle Medicine text was published.8 In 2009, a consensus conference on lifestyle medicine was facilitated by the American College of Preventive Medicine. This important meeting brought together physicians from the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and several other specialty societies with the express purpose of developing a set of lifestyle medicine competencies that should be adopted by all primary care physicians. Institutes for lifestyle medicine now exist at Harvard Medical School and Loma Linda University.
The greatest force behind this rapid expansion of interest in and resources for lifestyle medicine has been the epidemic of chronic disease, especially diabetes mellitus type 2 and obesity. In the past 100 years new methods for growing, processing, shipping, and storing food has led to a dramatically different set of nutritional choices. At the same time, the development of modern transportation and communication systems has disincentivized physical activity. These environmental changes have dramatically affected caloric balance, sparking a crippling wave of morbidity and early mortality first in the developed world, and now increasingly in the developing world. Modern technologies and environmental changes have not only reduced activity and led to the consumption of more food that is less healthy, they have also led to a more rushed and stressed society that is less able to find adequate rest, sleep, and social and spiritual support systems.
Currently, the average American does not practice what is known to be healthy. Eighty percent need to significantly improve their nutritional status,9,10 and three-quarters don't get adequate physical activity.11 Close to one-third get significantly less sleep than is ideal,12 and only one in 33 achieve ideal nutrition, physical activity, weight, and smoking status.13 The inability to practice healthy lifestyles has led to a well-documented epidemic of chronic disease. Two-thirds of the American population are either overweight or obese.14 One-third are pre-diabetic and more than one-eighth have a diagnosis of diabetes.15 More than half of individuals older than age 60 have metabolic syndrome,16 and two-thirds of those older than 65 have hypertension.17 Many individuals who have these diseases don't realize they have them,18 and even those who do recognize it frequently do not implement the lifestyle choices that are available to achieve adequate disease control and/or reversal.
The burden of chronic disease has placed an enormous strain on the American health care system. It is now estimated that up to 80% of the care provided by primary care physicians involves treatment of diseases that should first be addressed by improving lifestyle choices. The overall cost to the U.S. health care system of unhealthy lifestyles is difficult to quantify but has been estimated at $1.3 trillion each year.19 Assisting the average American in implementing healthier lifestyle choices is recognized as a major challenge by both the medical community and policy makers. Exactly how to do this is more controversial. Population-based interventions such as food labeling and changing the built environment are important and discussed elsewhere.20 There is also a place, however, for improved individualized counseling by physicians and other health care professionals. Both population and individual approaches to improving lifestyles have been incentivized in the Patient Protection and Affordable Care Act of 2010.
The body of evidence for the value of lifestyle change is enormous and, for the most part, not disputed. A high-level overview of this literature is provided in the effectiveness section of this paper. An understanding of the efficacy of health behavior change and the ability for a physician or other health care provider to successfully implement clinically significant changes for individual patients is more controversial. The evidence for the value of this is nonetheless still strong and is reviewed in the health behavior change and approaches sections of this paper. Most physicians would not argue against the value of lifestyle change, the ability of individuals to change, or the importance of their role in facilitating this change. When studied, however, the majority of health care providers do not routinely screen nor adequately assist patients in modifying their health-damaging behaviors.21-23 The current challenge for the health care delivery system is no longer proving that lifestyle interventions work, but rather in enhancing clinicians' and the health care system's commitment to learning how to incorporate the interventions into their practices and to deliver specific, compelling messages and strategies to patients.24
The reasons why inadequate implementation of individualized therapeutic lifestyle changes occurs are multi-factorial but fall into two major categories. The first is logistical: time constraints and lack of reimbursement incentives. This will be discussed in the practice section of this paper. The second major reason solid lifestyle medicine is poorly implement is directly connected to inadequate medical education and the resulting poor self-efficacy in this area.25 It is common for physicians to admit to poor training and lack of confidence in implementing lifestyle changes.26,27 This is especially true when it comes to obesity care.28 Addressing the education and self-efficacy issues is the major thrust of this paper.
From a lifestyle medicine perspective, there are three significant concerns around how the typical physician approaches chronic disease care. The first is initial identification of the value of a therapeutic lifestyle change for a particular patient with a diagnosed disease. The majority of physicians do not routinely screen for lifestyle activities and change opportunities in patients who have ongoing disease states. Despite the prevalence of chronic maladies, the National Health Interview Survey (NHIS) has found that less than one-fourth of patients report having ever received any nutrition or physical activity counseling from their physician.29 Especially problematic is the under-recognition by physicians of the importance of weight loss in disease prevention and treatment. Only two in five obese patients receive any advice to lose weight, even when they have chronic diseases that are clearly worsened by their obesity.30,31 So, the first problem the typical physician deals with is consistently recognizing that therapeutic lifestyle change is the treatment of choice for the patient in front of him or her.
The second improvement opportunity for the typical primary care physician relates to the fact that even when the average health care provider clearly recognizes that a particular patient would benefit from a significant change in lifestyle, he or she frequently doesn't fully advise the patient on either medical issues or specific concerns. Even those with known lifestyle-related diseases such as diabetes, hypertension, and hyperlipidemia received counseling only 30-45% of the time. The likelihood of receiving lifestyle modification advice decreases with age, for women, and for established patients.32,33 No more than 25% of patients who do receive counseling around weight loss are provided specific advice on dietary fat or physical activity.34,35 Patients are especially unsatisfied with what and how the health care provider approaches weight loss compared to health care in general.36 In one study, only half of those with weight problems reported receiving specific weight-loss strategies, and three-quarters of these had little confidence in the ability of their physician to give useful advice.37
The third lifestyle medicine concern is that even when patients who could benefit from a therapeutic lifestyle change are adequately screened, identified, and given focused advice on health behavior change, they are not given adequate tools with which to implement their healthy behavior goals. Physicians must move beyond the tendency to give simple advice. A brief educational exchange is most commonly not enough to produce sustained behavior change.38 Development of a personalized lifestyle change plan that includes specific lifestyle medicine prescriptions, team support, and the use of community resources needs to be incorporated into all chronic disease care.
Physicians need to: 1) recognize that the health issues faced by the average person with chronic disease are lifestyle related; 2) consistently address these lifestyle issues as a foundational component to their patient care encounters; and 3) provide their patients with not just advice but a whole tool kit that will maximize their resources as they go about instituting healthier lifestyles.
Lifestyle Medicine Competencies
The health care provider can and should have a strong and positive role in addressing and implementing lifestyle change. The knowledge and skill required to do this includes a lifestyle assessment, adequate understanding of behavior change, and implementation of both individual and team or community resources to assist in behavior change. Although many health care providers do not feel well trained, the value of physician counseling and interventions for health behavior change is well documented. This has been most broadly seen in smoking cessation,39 but is also clearly important in nutrition and physical activity counseling.40
The United States Preventive Services Task Force (USPSTF) recommends that physicians screen all adults for obesity, tobacco, and alcohol use. They also advocate intensive counseling and behavioral change interventions for weight loss for those who are obese, and dietary changes for all who have hyperlipidemia or other known risk factors for cardiovascular and other chronic diseases that are affected by nutritional status.41 The American Medical Association (AMA) has stated that physicians have a key responsibility to promote preventive measures and encourage positive lifestyle behaviors for those who are obese. This includes counseling and work with effective weight management programs.42
The consensus conference on lifestyle medicine has recommended 15 lifestyle medicine competencies that all primary care physicians should have.1 These competencies include recognition of the literature documenting the connection between lifestyle change and health outcomes and the science behind health behavior change, as well as the ability to perform comprehensive lifestyle assessments including predispositions and readiness to change. To implement lifestyle change, physicians should know how to establish effective relationships and use national guidelines. They also need to understand the value of lifestyle medicine prescriptions and be able to use team approaches, referrals, and medical information technology to maximize lifestyle medicine care. Physicians should promote healthy behaviors as the foundation of health promotion and medical care as well as personally practice a healthy lifestyle.
Health Behavior Change
Successful health behavior change is the cornerstone to implementing lifestyle medicine in the individual or group patient care encounter. Changing a health behavior requires an understanding of current status including patient readiness to change; a patient encounter that leads to positive patient motivation for change; and implementation of ongoing support resources for sustained healthier lifestyles. The 5As (ask, advise, agree, assist, arrange) health behavior change framework has been successfully implemented in smoking cessation and, with modifications, holds promise for multiple facets of lifestyle medicine.43
Health behavior change will not occur unless the physician knows the patient well. Knowing a patient well includes understanding his or her current health habits. This includes a clear understanding of existing nutrition, physical activity, and rest patterns; a trends analysis reviewing previous lifestyle change efforts focusing on successes and failures; a specific readiness to change analysis; an assessment of core patient beliefs and efficacies, including likes and dislikes; and an overview of barriers and resources the patient will encounter and/or need in the path toward a healthier lifestyle.44 (See Table 1.)
Much of this information gathering is best accomplished in a longer initial patient encounter. Incorporation of a "health habits" section to the medical record that is completed by either the patient, provider, or a trained staff member is crucial. Implementation of a computerized health risk assessment tool also can be very valuable.
A positive patient encounter that sets a motivated foundation for change is also critical for development of improved health behaviors. For this to occur, each and every provider-patient interaction must be based on an underpinning of respect and curiosity. Such encounters begin by developing the ability to listen to the patient from an empathetic perspective45 and continue with appreciating a clear understanding of what motivates, inspires, and creates meaning for that individual. This requires the ability to roll with the resistance that commonly occurs with initial exposures to recommended change and resist the desire to force patients down the "right" or provider-preferred change path. In this process, patients must be helped to see the discrepancies that exist between their stated or envisioned life goals and their actual current life situation. Throughout the patient encounter, the provider must consciously seek to empower the patient by infusing hope and optimism. These concepts, referred to as motivational interviewing, can be developed through training and practice.46
There are two important support resources, one from the medical community and one from the behavioral health community, that are important for successful early and sustained lifestyle change. For early lifestyle change, implementation of a lifestyle medicine prescription system encourages small, concrete health behavior change steps. A lifestyle medicine prescription, or lifescription, begins with medical prescription concepts that require written medication guidelines from the health care provider to the pharmacist (and on to the patient). These prescriptions are highlighted by three characteristics: individuality, clarity, and brevity. The details of these prescriptions for particular interventions are discussed in the next section of this paper. They have been documented as valuable primarily in the physical activity realm,47 but show great promise for nutrition, rest, and other lifestyle medicine interventions.
Another important lifestyle medicine resource for ensuring sustained lifestyle change is the support group. The value of an open, honest group of caring and empathetic individuals who encourage accountability and positive change has been most clearly demonstrated in the addiction world. Alcoholics Anonymous is perhaps the most successful health behavior change program ever. Since it is common to the point of being considered the norm for people to choose an unhealthy behavior even in the face of negative consequences, all patients dealing with lifestyle-related chronic disease should be encouraged to develop a support system, ideally a small group but minimally an individual. The use of interactive technologies as a support system is a growing field that also shows tremendous potential for supporting healthy lifestyle choices.
Lifestyle Medicine Interventions
Lifestyle medicine interventions can be disease-focused or risk factor-focused. This paper provides a brief overview of both approaches. As a general rule, however, a risk factor-focused approach to changing lifestyle is encouraged. There is good evidence that the same healthy behaviors positively affect the majority of chronic diseases. The same small, incremental change can improve obesity, diabetes, hyperlipidemia, hypertension, arthritis, and a host of other disease processes. For the primary care practitioner, developing knowledge, skills, and tools for assisting patients in healthier nutrition, increased physical activity, balanced rest, and other improved lifestyles can be used in multiple disease states and settings. As discussed above, implementing a comprehensive health habits assessment is the critical first step in all risk factor focused approaches to lifestyle change. Once the assessment data are obtained, there are some key considerations for each of the core lifestyle interventions.
Nutrition. An understanding of nutrition is foundational for the health care provider who practices lifestyle medicine. The scope of this article does not allow a detailed review of nutritional principles as they relate to improved health. Instead, we will briefly touch on two basic nutrition themes and then review some key guidelines for approaching patients who could benefit from an improved nutritional status.
What appears to be the greatest challenge in the area of nutrition is clarity on what is the optimal diet. When a high-level overview is taken, however, recommendations from numerous national organizations create a common set of themes.48-50 The first is an emphasis on whole foods. Whole foods are best described as food that is consumed fresh, in its natural state. Any movement toward slicing, grinding, or preserving starts food down the processing pathway. Further, processing may include extracting certain portions of the food or adding manufactured coloring, flavoring, or texturizing. These steps change the context with which nutrients enter the body, decreasing their biochemical value. Classic whole foods that are readily available, economical, and clearly beneficial to health include all varieties of vegetables, fruits, and legumes. The average American does not get even the minimum recommendation of 5 servings of fruits and vegetables per day,51 and the value of the fiber and plant protein content of legumes is highly under-recognized and under-utilized.
The corollary to increasing whole foods is decreasing processed foods. There are four food components that are frequently highly processed and dramatically overused in the standard American diet. These are salt, sugar, saturated fats, and grains.52 There are three primary sources of extra salt: snack and fast foods, canned foods, and added salt. Unneeded sugar also is commonly found in snack and fast foods as well as desserts. Sugar is the most common ingredient in liquid calories from sodas to juices to coffee and tea. It also is frequently connected to grain products such as cereals, muffins, and certain breads. Extra saturated fat tends to come from animal products. The saturated fat content of red meats has been highly publicized. What is less known is how much saturated fat is in cheese. (A cheeseburger has 50% more saturated fat than a hamburger the difference being the cheese.) Processed wheat, corn, and rice account for more than 50% of the calories in the standard American diet. These show up in many types of packages in convenience and grocery stores in forms such as pastries, cereals, crackers, breads, and many types of chips.
It is difficult to find a patient who consumes enough whole food, and even harder to find one who doesn't use any type of processed food. This makes a lifestyle nutritional intervention beneficial for close to every patient encounter. Assuming the proper lifestyle assessment and motivational interviewing techniques are applied, the next step in a nutritional intervention should be to provide brief counseling and create a customized nutrition prescription for the patient. One formula for creating a nutrition prescription focuses on reversing fat by using TAF (type, amount, and frequency) as a guideline. Nutrition prescriptions can be positive (i.e., eat more of) or negative (eat less of), should be small steps forward, and must be seen as attainable by the patient.
There are many opportunities for support groups around nutrition. A partial list is given in Table 2.
Physical Activity. The ideal standards for physical activity recommendations are clearer than the ideals for nutrition. The basic guidelines are listed in Table 3.53
Moderate-intensity physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. This recommendation is for the average healthy adult to maintain health and reduce the risk for chronic disease.
Like nutrition, there is much room for improvement in physical activity for the average American. Exercise prescriptions frequently follow the FITT (frequency, intensity, time, type) formula. A more exact way to calculate intensity is by calculating a training heart rate using the following formula: Training heart rate = Maximum heart rate (220 - age) x 0.6 to 0.85.
The value of physical activity goes beyond traditional exercise programs. Incorporating movement such as walking and stair climbing into activities of daily living and involvement in recreational pursuits that require exertion also provide long-term health benefits. Patients who have negative perceptions of exercise may be more open to physical activity prescriptions that incorporate atypical movement endeavors. A key physical activity resource is the Exercise Is Medicine web site and associated resources.54 Physical activity support systems can be found among friends and co-workers, in exercise groups such as running clubs, and in commercial programs such as Curves.
Rest. The core rest recommendation is 7-8 hours of sleep each night.55 Individuals who are able to incorporate naps or siestas into their daily life56 as well as meditation and relaxation techniques have decreased morbidity and mortality.57 Inclusion of sleep and self-care as a component of a health habit questionnaire brings significant insights into a patient's stress and coping mechanisms. Because stress reactions are so closely related to sleep patterns, lifestyle prescriptions for increased meditation and relaxation techniques are the initial treatment of choice for insomnia.58 Incorporation of rest and renewal into a patient's daily life frequently requires an understanding of a patient's spiritual resources and perspective on life.
Other Lifestyle Interventions. Nutrition, physical activity, and rest prescriptions are the most common lifestyle interventions. Modifications of numerous other basic approaches to living also can be beneficial. Elimination of substance abuse is an important area. Cigarette smoking continues to be one of the greatest killers in the United States. Simple office-based interventions can be very helpful in smoking cessation. Abuse of alcohol and prescription and illegal drugs also can lead to serious health consequences. Treatment of these issues frequently requires a more intensive therapeutic intervention. Fully exploring the value of social and spiritual support systems and prescriptions for improving these is beyond the scope of this paper. A holistic approach to health care, however, requires a recognition of the need for balance in all aspects of life.
The Effectiveness of Lifestyle Medicine in Treating Chronic Disease
Healthy lifestyles are recommended in virtually every practice guideline for chronic disease prevention and treatment. Key examples of the evidence supporting these approaches is summarized in core recommended approaches to obesity59 and metabolic syndrome60 as well as guidelines for the treatment of diabetes,61 hyperlipidemia,62 and hypertension.63 Further details of these recommendations follow.
Obesity. Although there is a place for medications and surgery in obesity treatment, the most important component of all weight loss, and the portion applicable to a typical primary care office, is lifestyle based. Weight loss is best achieved with a combination of improved nutrition and increased physical activity. Moderate and well-balanced calorie restriction is more effective than any specific diet. A caloric deficit of about 500 kcals per day is equivalent to one pound of weight loss per week and is the optimal goal for most.64 Movement toward a moderate, well-balanced eating pattern can be facilitated by focused, small-step improvements. One of the best tools for successful adoption of these small steps is the nutrition prescription. Considerations when creating nutrition prescriptions for those who are obese include a recognition of the value of increasing fiber and legumes and decreasing refined grain products and fats.65 Encouraging smaller, more frequent meals also is effective.66 Exercise is not as effective as diet in producing caloric deficits, but is valuable in weight loss maintenance.67 The most successful lifestyle interventions for obesity incorporate not only improved nutrition and increased physical activity, but also address emotional and social issues, taking advantage of counseling and support systems.68
Diabetes. Diabetes type 1 and type 2 are distinctly different physiologic processes. Lifestyle interventions can assist with both but are the core treatment for type 2 diabetes mellitus. Patients at risk for diabetes and those with early issues with hyperglycemia should know that their risks, and in fact the whole disease process, can not only be stopped but actually reversed by adopting healthier lifestyles.69 There is no other viable treatment alternative.70 The current epidemic of diabetes, pre-diabetes, and metabolic syndrome should by itself be enough of a stimulus for the primary care practitioner to ensure his or her practice has adequate lifestyle medicine resources. The lifestyle interventions that are most successful in diabetes type 2 prevention and treatment are similar to those already reviewed above. Core guidelines include an emphasis on caloric deficit to promote weight loss, generous use of whole foods especially legumes and other high-fiber plant products, and decreased total protein intake ensured by decreased use of animal products.71
Hyperlipidemia. Lifestyle interventions are recommended as the first-line treatment for elevated cholesterol and dyslipidemia. Specific lifestyle improvements that work include decreased saturated and trans fats, decreased cholesterol, and increased dietary fiber and physical activity.72 Primary care practitioners anxious to assist hyperlipidemic patients with lifestyle interventions prior to or in addition to medications should be comfortable in prescribing specific nutrition prescriptions that either dramatically decrease or eliminate trans fats, saturated fats, and cholesterol in the diet. Since cholesterol is an animal product, an easy although sometimes poorly tolerated prescription is to eliminate the intake of animal products. The more important food component to focus on in reversing hyperlipidemia is saturated fats.73 A low saturated fat diet combined with increased fiber can lower cholesterol levels as much as a statin.74 In studies where dyslipidemia and actual atherosclerosis have been successfully treated and in fact reversed using aggressive lifestyle interventions, saturated fats were eliminated and total fat intake was lowered to 10% of all calories.75 A community-based intervention, the Coronary Health Improvement Project (CHIP), is the best documented support group for treating hyperlipidemia and reversing heart disease.76
Hypertension. Therapeutic lifestyle interventions are recommended as the first-line treatment, prior to medications, for patients with hypertension. Again, implemented properly, they can be as powerful as medication. The core lifestyle interventions discussed above work to decrease high blood pressure; however, there are some specific focus areas to consider when applying lifestyle medicine approaches to the hypertensive patient. The first is salt restriction. Sodium intake should be lowered to no more than 100 mmol/day and ideally to 50 mmol/day.77 (Mmol x 23 = mg, so this is equivalent to a 1-2 g sodium/day diet.) The second lifestyle intervention that has more evidence for hypertension than other chronic diseases is stress reduction. Prescribing specific meditation techniques and/or relaxation therapies statistically lowers both systolic and diastolic pressures at a level equivalent to many medications.78 A third area for evidence-based lifestyle medicine approaches to hypertension is substance abuse. There are clear correlations between both cigarette smoking79 and alcohol abuse80 and high blood pressure.
Other Chronic Diseases. The scope of this paper does not allow a review of the literature for lifestyle medicine approaches to other chronic diseases. There is a solid evidence base available, however, for the value of lifestyle interventions in a wide variety of disease states. These include stroke, heart failure, chronic obstructive pulmonary disease, osteoarthritis, rheumatoid arthritis, low back pain, prostate cancer, breast cancer, fibromyalgia, chronic fatigue syndrome, and depression. The type and dosing of the beneficial lifestyle interventions vary somewhat from disease state to disease state, but the core principles of increasing whole foods, decreasing processed foods, increasing aerobic and strength-building physical activity, increasing rest and relaxation techniques, and decreasing smoking and substance abuse consistently hold true.
Lifestyle Medicine Reimbursement
Currently, the majority of lifestyle medicine practice is reimbursed using typical office visit billing procedures. Patients present with a symptom set or one or more chronic disease diagnoses. They are evaluated and treated as any typical patient, but instead of a medication prescription they are given a lifestyle prescription and/or other lifestyle intervention. Because lifestyle medicine incorporates large amounts of health behavior change, and this frequently requires counseling and education, providers should consider billing using time instead of trying to meet the typical requirements around history, physical exam, and visit complexity. Time codes are listed in Table 4.
Specific lifestyle-related billing codes do exist for particular disease or risk states as well as for certain defined treatment activities. Examples include nutrition counseling for diabetics, nicotine cessation counseling for smokers, and exercise and nutrition therapies for patients undergoing cardiac rehabilitation. Despite these reimbursable treatment opportunities, the majority of primary care offices will find that billing using more traditional techniques and codes is simpler and economically smarter in the long term.
The health care system reform legislation signed in to law in March 2010 includes several specific supports to lifestyle medicine. An annual wellness exam that is exempt from co-payments and deductibles is encouraged. These will include coverage for all preventive services recommended by the United States Preventive Services Taskforce. The wellness exam is covered by Medicare beginning in January 2011, is incentivized for Medicaid, and is also required for private insurers. Individuals seeking preventive care services are well positioned for lifestyle interventions. Other provisions include demonstration programs to develop the concept of the individual wellness plan for at-risk individuals in federally qualified health centers, and support for employer-based wellness programs.
The real reimbursement incentives for lifestyle medicine will come as outcomes-based reimbursement is implemented. Although they may require a significant time and support system investment, when compared to most pharamacologic and interventional treatments, lifestyle medicine approaches to health care are inexpensive and cost effective. The concept of reimbursing health care providers for patient outcomes rather than for specific visits and/or procedures will reinforce the value of low-cost lifestyle interventions.
Lifestyle Medicine Challenges
As the national health care system evolves, lifestyle medicine will continue to play an increasingly important role. For lifestyle medicine to be fully implemented in primary care practices at the evidence-based levels currently recommended by national guidelines, several important steps must be taken. First, physicians must be convinced that they are adequately reimbursed for the lifestyle interventions they institute for their patients. No matter how strong the idealism and education of the provider, eventually reimbursement drives physician behavior.
Second, health care providers must be educated to feel competent and efficacious in facilitating health behavior change. Physicians must know the science behind lifestyle interventions and the steps that lead to improved health choices that are sustained. They must be confident in their ability to listen to and assess the patient and to successfully motivate them toward healthier behaviors. Providers must have teams and community resources that will support their lifestyle prescriptions for better nutrition, physical activity, rest, and the other core lifestyle interventions. Both office-based and interactive technologies must continue to evolve as part of the support systems for both providers and patients outside of the typical office visit.
Third, the research base behind the application of lifestyle medicine must be strengthened. The science is strong regarding what constitutes a healthy lifestyle. It is apparent that health behaviors can change; lifestyle prescriptions do have value. What is not clear are the methods that need to be applied in the typical primary care office. Brief individual counseling works, but there is scant literature on lifestyle prescriptions, especially in the area of nutrition. The role of group visits appears promising, but again this format is not well studied for initiating and sustaining healthier lifestyles. Intensive therapeutic lifestyle change has been shown to be effective in a variety of institutional and community-based settings,81,82 but when and how it is best applied to typical patient care is still to be defined.
Fourth, the roles of the lifestyle medicine team need to be clarified. Lifestyle interventions are likely best accomplished by physicians working with nutritionists, exercise physiologists, behavioral therapists, and a variety of other health care professionals. The ideal roles and ratios of various providers have not been discussed in the literature. The place of a lifestyle medicine specialist is also unclear. While the majority of lifestyle interventions will take place facilitated by primary care physicians in a medical home-type setting, it is likely that there is a place for specialists with more extensive training in health behavior change and lifestyle interventions who can facilitate intensive therapeutic lifestyle change for very high-risk patients in a variety of settings.
Finally, the public consciousness and desire for healthier lifestyles must outweigh the natural societal tendency to migrate to that which in the short term is easier and more enjoyable but in the long term leads to higher morbidity, mortality, and health care costs. It will really only be when we as a people demand healthier systems around food, physical activity, and medical care that the political, financial, and scientific communities will work together to fully implement a culture of wellness and healthy lifestyles.
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