President's Desk, August 2014
For any medicine, timing and dose matter. For lifestyle medicine, with our national conference coming up fast, a double dose of high-profile commentaries about the medicine we have versus the medicine we need is a timely opportunity for reorientation.
The initial provocation was delivered by the British Medical Journal in June. A commentary published on the BMJ blog site asserted, in essence, that lifestyle medicine is ineffective. Specifically, it said that screening for chronic disease risk factors in the general population, and addressing them with lifestyle counseling in the clinical setting, is of no value. The commentary was in response to a paper published in the BMJ that reached essentially the same conclusion. An accompanying editorial was entitled: “General health checks don’t work” and began with “it’s time to let them go.”
The trial that provoked these responses randomized a large sample of Danish adults either to screening for chronic disease risk factors with tailored lifestyle counseling, or usual care. After 10 years, the two groups did not differ for the rate of heart disease or all-cause mortality.
The “intervention” consisted of 3 individualized lifestyle counseling sessions of 15-45 minutes each, spread over the first 3 years of the 10-year study period. If you will, the intervention was itself a tidbit of lifestyle counseling. An additional 6 group sessions were available, but that means even for the rare participants who took advantage of all offerings, less than one counseling session per year of observation. The sessions were made available to those study participants with overt chronic disease risk factors, including smoking, high alcohol intake, poor diet, and/or lack of physical activity.
I invite you to pause and consider whether you would expect that between 45 minutes and two hours of clinical counseling over 3 years would meaningfully change health outcomes over 10 years for people who potentially smoke, drink, eat badly, and avoid exercise.
As we reflect on that, we may note the other relevant provocation. A recent New York Times editorial suggested that the high-profile shortcomings at the VA hospital system may be the tip of a national iceberg. There is an established and growing shortage of physicians relative to the needs of the population. That shortage is especially acute in the area of primary care, where it is expected to grow as ever more young physicians, saddled with educational debt, turn to specialty training that will make that debt easier to repay.
The problem of inadequate primary care person power is much compounded by the perverse incentives of modern medical practice, as elucidated by yet another piece in the New York Times. Cardiologist Sandeep Jauhar pointed out that declining per-patient compensation for primary care physicians has them seeing more patients each day, in less time. With less time to work through the subtleties of patient care, the primary care provider is more likely to refer any real challenges on to a specialist- where costs, of course, are higher. So declining compensation for good primary care may be driving overall costs up, not down.
The plot gets at least one degree thicker than that. Not addressed in either of these commentaries is the high rate of complications resulting from even good medical care. That issue was addressed recently in the journal Injury Prevention. Fully one in five Medicare beneficiaries- basically anyone in the U.S. age 65 or older- suffers an ‘adverse medical event’ during any given year. These events occur routinely with both inpatient and outpatient care, and are enormously costly in both human and dollar terms.
To some extent, these AMEs may be the result of the rushed care referenced by Jauhar. But to some extent, they are inevitable. When people get sick, they need treatment. When they get sicker, they need more treatment. The more drugs people take, the more drug side effects to which they are subject. The more operations people need, the more post-operative complications they have a chance to encounter. The more side effects and complications people experience, the sicker they get, and the more treatment they need. I trust you see the drain down which this spiral potentially leads. We have a shortage of the doctors we most need; perverse financial incentives; stunning inefficiencies; pervasive dissatisfaction with the system among doctors and patients alike; and a rising burden of chronic disease calling for ever more care, beginning at ever younger age.
That last one- the chronic disease burden- is the darkest of these clouds. It also harbors the silver lining. While it is true that a society this sick needs more doctors to provide more medical care, it is equally true that a society need not be nearly this sick. Fully 80% of the extant chronic disease burden could be eliminated by means already well known, reliably established, and accessible to us. Fully 80% of the chronic disease burden could be eliminated with the effective application of lifestyle as medicine.
Which leads us back to the questionable conclusions propagated by the BMJ. I would not expect a few lifestyle counseling sessions over a span of years, potentially delivered by non-experts, to exert much of an effect. Concluding on the basis of so feeble an intervention that lifestyle medicine is ineffective is analogous to concluding from a study of postage-stamp size parachutes that parachutes don’t work. The profound potential benefits of lifestyle medicine cannot be surrendered to the parable of the tiny parachute.
Eliminating 80% of all chronic disease- the aggregate toll of heart disease, cancer, stroke, diabetes, dementia, and so on- would be a stunning public health advance. It would be a stunning personal advance as well, since there really is no public- there is just you, and me, and everybody else. When 8 times in 10, heart attacks, strokes, diabetes, and cancer don’t happen- we will all feel it, because we have skin in this game- our own, and the skin of the people we love, laid low by these invaders. Keeping them out of our homes and families 8 times in 10 is not a ‘remote’ public health advance; it is up close, and intensely personal.
And, of course, it would have profound implications for the volume of care we all need. An 80% reduction in the prevalence of the most prevalent diseases of modern society is already a stunning improvement. But these conditions are, as the name suggests, chronic. They don’t require treatment once- they require on-going treatment. So an 80% reduction in “chronic” disease means a multiplied reduction in the number of clinic visits and hospitalizations: the number of people with the conditions, multiplied by the number of such events per person over time.
And that reduction in disease resulting in a much reduced need for care would, of course, slash the rate of complications of care. Complications of care, or AMEs, are the unintended consequence of clinical care. People who don’t need medication don’t get side effects from medication. People who don’t require surgery are immune to post-operative complications. Reduce disease, and the need for care falls. Reduce care, and the complications of care go away.
So I contend that the right response to these conjoined provocations is more and better lifestyle medicine.
The power of lifestyle medicine is best revealed where lifestyle is working as medicine throughout the expanse of culture, rather than delivered in medicine as an antidote to cultural misdeeds. The world’s Blue Zones exemplify this. The longest-lived, healthiest, happiest people on the planet do not attribute these blessings to high quality clinical counseling; they attribute them to a culture that puts health on the path of lesser resistance, and to prevailing norms.
That said, high quality clinical counseling can make a difference, and is most needed where culture is least salutary. But it must be high quality counseling, and most of what is provided by non-experts falls well short of that bar.
Models exist that adapt the best behavior modification techniques into the primary care setting; my colleagues and I have developed one such, available for free. Intensive skill-building programs can do far more to help people lose weight and find health than a few sessions with a clinician spread over years. And when the problem is advanced, such as severe obesity in teens, the evidence favors truly immersive therapy to offer an adequate dose of the lifestyle remedy.
Clinicians can and should play an important role in delivering lifestyle as medicine. For that to happen, the standards of such counseling, and affiliated programming, need to rise. The American College of Lifestyle Medicine is devoted to this very proposition- and to the propagation of programs that empower clinicians to provide better help, and empower patients to put good guidance to better use. We have sister organizations around the world, helping us turn lifestyle medicine into the global movement it should be. Our upcoming conference is an excellent opportunity to advance this mission, so please consider joining us if not already registered.
We need more doctors than we have to treat the disease burden we have because the disease burden we have is far greater than it needs to be.
Fully 80% of all chronic disease is preventable by means at our disposal, and the application of lifestyle as medicine. It would take a lot fewer doctors to care for us all if we were empowered to take better care of ourselves in the first place. Good lifestyle counseling can function like a good parachute; it can make a meaningful difference. We simply don’t see such benefit when we do too little, or intervene too late.
Lifestyle medicine has the potential to be stunningly effective - but too little is too little, and too late is too late. Only timely administration is effective, only expert delivery is appropriate, and only enough- is enough. It’s our job to make it so.