The Clinical Nature of Lifestyle Medicine

Lifestyle medicine clinicians emphasize the use of lifestyle intervention in the treatment of disease. While the practice of Lifestyle Medicine (LM) incorporates many public health principles and approaches, it remains primarily a clinical discipline.

Recent clinical research provides a strong evidential basis for the preferential use of lifestyle interventions as first-line therapy. (e.g. The Lifestyle Heart Trial, the Lyon Diet Heart Study and the Dietary Portfolio study) This research is moving lifestyle from prevention only to include treatment--from an intervention used to prevent disease to an intervention used to treat disease. This represents a fundamental change in the way medicine views lifestyle medicine, but one not yet well understood or appreciated.

Preventive services are generally not recommended or adopted unless they are cost-effective in the population in which they are to be implemented. Since preventive services accrue their benefit primarily by reducing costs from morbidity and mortality, this cost-effectiveness criteria is reasonable.

Treatment services, on the other hand, are recommended and adopted when there is an evidence-based medical indication for treatment. The presence of morbidity constitutes a sufficient medical indication for applying an intervention proven to improve, reverse or ameliorate the disease or its symptoms. Costs play a very different role in determining treatment services as opposed to preventive services. This difference is poorly understood as it pertains to the practice of clinical lifestyle medicine, and the confusion is inappropriately limiting the application of proven lifestyle interventions in the treatment of patients with existing disease.

We do not ask whether a multi-vessel CABG (coronary artery bypass graft) is cost-effective before performing open-heart surgery, so why do we ask whether smoking-cessation or diet-modification and weight-loss are cost-effective before applying them? Part of the cause is the confusion existing over the difference between using lifestyle modifications to reduce risk of future disease versus the use of lifestyle intervention to treat existing disease. LM can be highly effective in both applications, but the basis for deciding whether to treat existing disease is quite different from the basis for whether to treat not-yet-existing disease (primary prevention services). Education is needed to end this confusion and stop the unfortunate denial of first-line therapy for patients with diagnosed disease.