“I can manage my health!”

How one health system is eliminating barriers to diabetes treatment using lifestyle medicine to educate health care providers and patients.

“We want patients to improve their self-efficacy by reducing their social determinants of health (SDOH) barriers and having them work toward addressing diabetes through nutrition awareness and education.” – Hugo Ortega, MD

Sean Hashmi

Dr. Ortega (far left) joins Dr. Dexter Shurney (center)  and Janet Calhoun (right) at the LM2022 conference this past November.

Serving on the American College of Lifestyle Medicine Board of Directors as Young Director is a full-circle achievement for Hugo Ortega, MD.

Hugo Ortega, MD, an internist at Northwell Health, was recently elected to the ACLM Board of Directors as Young Director. Serving in this leadership role is a full-circle moment. While working on his own health and weight loss journey, Dr. Ortega tapped into the nutritional resources being offered to patients at Montefiore Medical Center, where he was a resident at the time. Dr. Robert Ostfeld, director of preventive cardiology, was a huge advocate of whole food plant-based nutrition and introduced many of his patients to the “Forks Over Knives” documentary.

“I was slowly transitioning, but I wanted to fully commit [to a whole food, plant-based diet],” he said. At the recommendation of his nutritionist, he participated in Plant Powered Metro New York, a program for health care providers to do a two-week intensive meal-plan diet that is whole-food, plant-based. The results were promising.

“I was almost diabetic in terms of my A1C levels,” Dr. Ortega said. “Those numbers went down to 5.8%, in just two weeks. But more importantly, for me, in those two weeks, I lost eight pounds. It was then that I realized that lifestyle changes work. I wanted to teach this to my patients.”

The Eliminating Barriers Initiative

After being awarded $15,000 by an in-house Northwell Health grant, Dr. Ortega and his team sought to create a program that would improve patient self-efficacy and diabetes, which was impacting about 60% of Medical Specialties at Glen Oaks patients. “We had to fix that somehow,” said Dr. Ortega before explaining the initiative’s two-pronged approach. “We want them [patients] to improve their self-efficacy by reducing their social determinants of health (SDOH) barriers and having them work toward addressing diabetes through nutrition awareness and education.” Any patient with an A1C level of 9% or above is automatically eligible to participate in the Eliminating Barriers Initiative. Forty-five patients are enrolled in the program, which was launched in July 2022.

Northwell Health is on a “mission to serve and care for the entire community regardless of the ability to pay.” An ACLM Health Systems Council partner, Northwell Health is the largest health system in New York providing health services to patients with Medicaid, Medicare, or no insurance at all.

“We have a high patient population of Blacks, Hispanics, and Southeast Asians,” said Dr. Ortega. These groups are historically medically underserved and typically have challenges finding physicians who look like them due to the lack of diversity in the medical workforce. However, Dr. Ortega, who is an underrepresented in medicine (UIM) physician, says that his ethnicity alone helps him positively reach patients. “It’s extremely easy to form a relationship with the Spanish-speaking patients because I’m able to immediately address the language barrier by speaking Spanish to them.”

Social Determinants of Health

In addition to tracking the patients’ A1C levels, the program’s team leads also assess the patients’ social determinants of health and self-efficacy to ensure that the initiative’s interventions are making a lasting impact. The social determinants of health model was adopted by Montefiore Medical Center in which each patient is screened to better understand barriers that may impede their ability to access health care, housing, nutritious food, and many other factors that are part of one’s environment.

“After gathering all this information, we refer the patients to specialists and experts who can help them better navigate these issues by providing wrap-around services,” said Dr. Ortega. “If the patient is housing insecure or struggling with getting access to medication, our social worker can assist for example.” At the end of the program, all patients are reassessed with the hope that they can now answer “no” instead of “yes” in response to questions about SDOH barriers.

Diabetes awareness and education

Addressing each patient’s diabetes is more in-depth than a standard diagnosis. Instead, residents and attending physicians educate patients about evidence-based lifestyle medicine that, if prescribed intensively, could reverse their diagnosis. Dr. Ortega considers himself “frank” and admits to some patients that medication may have to be the first course of treatment. However, he also reassures them that if they commit to the program and are able to operate in a “maintenance stage” that coming off of medication is a realistic goal.

“We haven’t had any failures,” he said. “Everyone has improved to some degree. We have some patients who have come down on their insulin. I take that as a big win.”

While some patients are referred to on-site pharmacists to learn more about the medications they’re prescribed, patients who identify as food insecure have access to “health bucks” that they can use at the Queens County farmers’ market, a Northwell Health partner that supports the clinic’s patients with fresh produce. In addition, patients’ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) dollars and Supplemental Nutrition Assistance Program (SNAP) benefits count double at the farmers’ market, meaning they can get 50% more fresh produce.

Other lifestyle medicine pillars emerging as part of the Initiative

Nutrition is the most defined lifestyle medicine pillar informing the Eliminating Barriers Initiative. Dr. Ortega does hope to incorporate other pillars of lifestyle medicine as the program evolves. Currently, patients in the program have one-on-one visits with providers. However, Dr. Ortega is gearing up to co-host bi-weekly group sessions alongside the program’s diabetes educator and nutritionist in which participants can forge social connections with class members to help them stay encouraged and on-track. Lifestyle medicine is largely successful when patients are able to master behavior change, which has been proven to occur when patients see physicians during shared medical appointments or group visits.

“I think the group visits are good for two reasons,” said Dr. Ortega. “One, people are more trusting of people who they think are like them. Secondly, it gives them accountability.” These two reasons align with lifestyle medicine’s positive social connections pillar, a pillar Dr. Ortega strives to teach his residents along with sleep and stress management.

Lifestyle Medicine Residency Curriculum at Northwell Health

Dr. Ortega has done a significant amount of front-end work to ensure that residents at Northwell Health can learn about lifestyle medicine and its benefits for preventing, treating, and reversing chronic disease. When he first learned about ACLM’s Lifestyle Medicine Residency Curriculum (LMRC), he was a third-year resident at Montefiore Medical Center. He wasted no time promoting it to his co-resident and upcoming chief resident who pitched the idea to the program director, but by the time the LMRC was implemented, Dr. Ortega had already finished his primary care and social internal medicine residency. He didn’t give up and worked diligently to bring the LMRC to Northwell Health, which has been delivering the comprehensive, applicable, and flexible curriculum to residents since July 2022.

Dr. Ortega recently took ACLM’s “Remission of T2 Diabetes & Reversal of Insulin Resistance” course, which he says aligned nicely with the Eliminating Barriers Initiative. Of the 11 patients that Dr. Ortega referred to the program, five are doing exceptionally well. One patient was weaned completely off of insulin and is now only taking metformin. His A1C, which started at 12.8%, is now at a 6%, which is considered pre-diabetic. In the next two months, Dr. Ortega plans to take him off of metformin if his repeat A1C levels show a controlled range.

The Eliminating Barriers Initiative is another full-circle career moment for Dr. Ortega, who has a few patients who are trending toward complete remission. “I’ve never had someone go into remission so that would be nice.”

As he made changes to his own lifestyle habits, Dr. Turner started talking to a nutritionist colleague at the Mayo Clinic who mentioned ACLM, the nation’s medical professional society representing clinicians dedicated to a lifestyle medicine. ACLM defines lifestyle medicine as the evidence-based use of a predominantly whole food, plant-based diet, physical activity, restorative sleep, social connection, avoidance of risky substances and stress management. ACLM, which represents more than 7,000 physicians and other clinicians, is the only organization that educates, equips, and supports certification of physicians and other clinicians in lifestyle medicine.

Dr. Turner began talking to patients about their lifestyle habits and explaining the evidence that supported how changes could improve their whole health. During clinical rounds, he visited patients with lifestyle-health related books that could benefit their specific health ailment. Resident doctors accompanying him on rounds would say afterward “I’ve never seen anyone do that before. Can you show me the books you’re using?”

For patients who committed to lifestyle behavior changes, the results were at times astonishing. Patients suffering from severe hypertension enjoyed dramatic decreases in blood pressure and, subsequently significantly reduced the antihypertension medication they required. Patients with chronic kidney disease, diabetes or advanced atherosclerotic vascular disease stabilized their kidney function and did not progress to the point of needing dialysis. Patients with a history of kidney stones were able to prevent stone growth and new stone formation.

At times, Dr. Turner took good-natured ribbing from colleagues — “Here comes Turner with his veggies.” But as health care spending soared, the pandemic raised awareness of the risks of chronic lifestyle-related disease and the evidence grew proving the therapeutic power of lifestyle medicine, interest in the field exploded. ACLM, which had 500 members in 2014, has grown to more than 9,000 practicing in the field. Large health systems are increasingly integrating a therapeutic dose of lifestyle medicine into patient care, employee health and their broader communities.

“Interest in lifestyle medicine is growing not just among clinicians and health systems but among patients who are increasingly understanding that they can make a big difference in their health with small lifestyle changes,” said ACLM President Dr. Cate Collings, MD, MS, FACC, DipABLM. “Dr. Turner’s generous gift to ACLM will help more clinicians gain the knowledge and skills to practice lifestyle medicine and partner with their patients take control of their heath.”

The time is now for lifestyle medicine to become the foundation of health and health care, Dr. Turner said. He hopes his gift to ACLM can help build that foundation.

“ACLM has really become my intellectual home,” Dr. Turner said. “I truly believe lifestyle medicine is the most positive thing happening in the medical space. I am excited to do my part to keep that positive momentum going.”

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