A Note From the Founding President of ACLM
John Kelly, MD, MPH
Lifestyle Medicine (LM) is gaining ever more traction in healthcare as the focus turns away from fee-for-service to pay-for-performance. The transition will happen even faster as healthcare payment focuses on outcomes performance and not merely on excellence in delivering conventional care. Why should payers settle for excellence and efficiency in providing disease management when disease reversal is possible, available, and even predictable with evidence-based Lifestyle Medicine? As basic science advances modern medicine, particularly in the field of epigenetics, revealing the power of lifestyle change to alter human metabolism and reverse the ill effects of poor lifestyle choices, Lifestyle Medicine is destined to become a top priority in clinical care.
I well recall my frustration when, upon finishing medical school and matching to a residency, there was no residency training in Lifestyle Medicine available. In fact, there still is none as I write this, over a decade later, but I am happy to say there are far more opportunities to get a Lifestyle Medicine-friendly residency training than there was, though there still is no “specialty” in Lifestyle Medicine and no true residencies in Lifestyle Medicine—yet.
Nonetheless, it is exciting to be able to say there are an increasing number of LM education and training opportunities available now. It is my distinct honor and privilege to serve as medical director for one of them—a Lifestyle Medicine Fellowship specialty training program in the Black Hills near Mount Rushmore in South Dakota (BHHEC.org). The fellowship prepares physicians to practice as a LM specialist using a brief, intensive lifestyle intervention program followed by ongoing coaching support. Our first fellow graduates in early 2016 and already has a position waiting in a LM Clinic for a large self-insured international corporation.
Some of the best opportunities to practice specialty LM are found at forward-thinking companies who understand the value of treating causes rather than symptoms, and who are determined to no longer accept the ever-increasing cost of employee healthcare as inevitable. Such companies are looking for physicians and other professionals to form effective LM teams that will maximize wellness and human performance. In this setting the perverse incentives and constraints of conventional healthcare are no longer present. LM clinicians can practice their specialty without the limitations of billing and having to fit LM visits and interventions into E&M guidelines designed for acute disease and fee-for-service care.
Nevertheless, rosy as this assessment of future and existing opportunities may be, the future of Lifestyle Medicine is not without its threats and potential risks. One of the greatest threats to any paradigm shift of this magnitude is the likelihood of dilution, or substitution—the good often becomes the worst enemy of the best! All of us are subject to the fallacy of grasping for the good while letting the best escape our reach. It is tempting to be content with slowing the steady death march of chronic disease instead of taking on the more difficult task of truly stopping and reversing it. Both physicians and patients are inclined to make this mistake, especially when they do not grasp the power of sufficiently dramatic lifestyle change to alter metabolism, change gene expression, and slow cell aging, etc. While no one would suggest that slowing disease and delaying death a few years or months is a bad thing, we must not miss the point that doing merely that when arrest and reversal is possible and achievable IS a bad thing. As clinicians we are responsible and accountable to inform patients of all of their treatment options, and I believe we are morally obligated to recommend the option that provides the best possible medical outcome. If reversal is possible I must make it my treatment priority and seek to make it the priority of my patients.
If there is one thing that has put LM “on the map” more than anything else, it is disease reversal. While it is not surprising that adopting a healthy lifestyle can prevent or delay the onset of disease, when intensive lifestyle changes were shown to reverse disease, LM grabbed our attention. It is now well-proven that sufficiently intensive lifestyle change can arrest and reverse a growing number of diseases, including hypertension, heart disease and type 2 diabetes. Interestingly, the experimental treatment in these paradigm-changing studies did not consist of incremental change and motivational interviewing—it was intensive, dramatic lifestyle intervention that produced major lifestyle change. Actually, it was the control group that typically received only lifestyle change advice and support.
A perhaps unexpected threat to the fledgling LM movement is the present emphasis on incremental change and motivational interviewing. Lifestyle coaching and motivational interviewing have not been shown to produce disease reversal without an initiating intensive lifestyle intervention. Motivational interviewing emphasizes facilitating patient-selected changes rather than coach-prescribed change, thus by itself it is unable to produce the degree of change required for disease reversal. Before patients can choose to make the dramatic changes necessary to reverse disease, they need a personal demonstration in their own bodies of what it can do. They need to experience how effective it can be in improving the way they feel and reducing their risk factors. Before experiencing such a personal demonstration, most patients have no idea what is possible, or how dramatic are the changes required to overcome the threshold and achieve dramatic outcomes. Once they see what intensive lifestyle changes can do, they are ready for lifestyle coaching support with motivational interviewing. Without the personal demonstration they will seldom choose to make sufficiently intensive changes and, as a result, LM is considered not to work. This is similar to a patient taking a sub-therapeutic dose of a medication and then saying it doesn’t work.
Lifestyle change does NOT work until it reaches therapeutic levels of dosing. Studies like the Dansinger trial (Dansinger, et al, JAMA 2005) have shown that there is a “threshold effect” with lifestyle change—unless dosing exceeds the threshold there is no change in risk. Each of the four diets studied in the trial exhibited this “threshold effect.” (figure 3, p. 51) Biometric improvements were only seen in those with adherence above four on a scale of 10, with the most improvement occurring in those with the greatest adherence. The dose-response effect is seen only above the threshold.
There is a very real danger in substituting small, incremental lifestyle changes for the dramatic lifestyle changes shown to reverse disease. Unless sufficiently intensive changes are made, LM will be ineffective and inevitably lose its appeal. This threat is clearly evident in the growing use of motivational interviewing by primary care LM physicians and clinicians, and lifestyle coaches. Without the induction phase of LM treatment (typically provided by LM specialists), motivational interviewing will at best merely slow disease progression. Only intensive lifestyle changes have been shown to arrest and reverse disease. To prescribe incremental lifestyle changes and lifestyle coaching before prescribing or providing intensive lifestyle interventions is like starting a patient on rehabilitation before doing the surgery or starting chemotherapy before staging and excising the tumor. And, just as the treatment would be in these examples, LM treatment without the intensive induction phase is ineffective and liable to cause LM to be abandoned as the preferred treatment.
What ACLM needs to do for the emerging LM movement is to develop and promote the specialty of LM so we do not end up with the cart before the horse. Important as LM is in primary care, it can only be fully potentiated by the use of LM specialists expert in producing dramatic disease reversal in a short time, thus motivating patients to set their goals sufficiently high. The published evidence supports this model and clinical experience confirms its validity. As the specialty society for Lifestyle Medicine, I encourage ACLM to step up to the plate and lead this vital aspect of evidence-based LM. This is why I and the others who were part of the founding group established the College, and why I am happy to once again be serving on the Board. We must be careful to follow evidence-based LM and not settle for less-effective substitutes.