Abstract
In the reductionist approach in science, there is a tendency to study just one aspect of lifestyle.
As Editor of the American Journal of Lifestyle Medicine (AJLM) I am delighted to, once again, serve as moderator of the Expert Panel discussion to open the Annual Meeting of the American College of Lifestyle Medicine (ACLM). AJLM is the official journal of the ACLM. I am particularly pleased that ACLM continues to grow and thrive. The attendance at this conference has doubled each year for the past 2 years. I take particular personal pride in this since the textbook that I edited many years ago (Lifestyle Medicine, Blackwell Publishing, 1999) named the field of lifestyle medicine (LM). Of course, there were many other researchers working in the areas of exercise, nutrition, weight management, and other behaviors with particular emphasis on the health-related benefits of adopting positive practices and habits in daily lives. This textbook was, however, the first to call this discipline “lifestyle medicine.” It certainly has grown and prospered in the ensuing years! The format today will involve me asking several general questions to all members of the Expert Panel who will each be given a turn to answer. Let me start with the first question: “What is Evidence-based Practice in Lifestyle Medicine and why is it important?”
Thank you Dr Rippe. This question is fraught with some degree of peril. I wrote a recent column for the ACLM newsletter on the parable of the tiny parachute. If we conducted a randomized controlled trial (RCT) of parachutes that were way too small, we would conclude that parachutes were ineffective. There have actually been some studies lately suggesting that lifestyle interventions are ineffective. For example, we tend to perform badly in the treatment of obesity with lifestyle measures as compared to bariatric surgery. But is that really evidence of ineffectiveness or is it simply a demonstration that too little, too late, isn’t enough and isn’t timely? So there is peril both in the definition of “evidence” and in the definition of “lifestyle.” In the reductionist approach in science, there is a tendency to study just one aspect of lifestyle. When you attempt to study models of care, it is very hard to get them funded. It is much easier to get funding to do an intervention trial for just one thing as opposed to the comprehensive array of changes in behavior, circumstance, social interactions, and environment that are all conducive to a truly comprehensive change in lifestyle. So I don’t know that we have a decisive answer.
We really need to rally around the definition of lifestyle. How much is enough? What is timely? How reductionistic can we afford to be, and what kinds of evidence are we talking about? For instance, the Diabetes Prevention Program (DPP) was a $174 million dollar clinical trial in which about 3500 adults at risk for type 2 diabetes were randomly assigned to 1 of 3 groups: usual care, metformin, and lifestyle intervention. Metformin is a good drug. It prevented the incidence of diabetes 30% of the time, but lifestyle is still the best medicine. It prevented incident diabetes 58% of the time. In other words, lifestyle intervention was twice as good as the best drug we have. But ever since the DPP was conducted, the NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) and the rest of us have struggled with how to make it work for real people in the real world. How can we operationalize it? There is a lot of research that simply has not been done. In conclusion, I believe we have to be very careful. Absence of evidence is not evidence of absence. Consider ethnographic evidence. The Blue Zones, for example—we know what lifestyle can do. If we look back to the seminal paper by McGinnis and Foege in 1993, 1 we know what lifestyle can do. Lifestyle interventions can prevent 80% or more of all chronic disease. If we could eliminate 80% of premature deaths, it would add years to life and life to years. Doing the studies to show that though is fraught with peril because if we do too little, too late, we’ll get negative results and that may dissuade people from following what really ought to be the trend in medicine. Lifestyle is medicine.
I think the fact that there is a concept called “evidence-based medicine” says a lot about the field of medicine. You don’t hear people clamoring for evidence based engineering or chemistry. In this field, evidence is basically assumed. We have to demand robust evidence, proof of efficacy, and then do what works best. In many instances these are lifestyle interventions. I think, for many, they have no trouble understanding that LM can be cheaper and safer. But what they often fail to understand is that it can work better. I think one of the reasons that the specialty of LM is marginalized is that people tend to wildly overestimate the efficacy of traditional medical interventions and the power they have to treat or prevent chronic disease. Whether we are talking about mammography, colonoscopy, angioplasty, or bisphosphonates to prevent hip fractures—the actual risk reduction for such pharmaceutical agents as blood thinners, antihypertensives, or statins is on the order of about 5% over 5 years. If patients actually understood how small the chance they might benefit from traditional interventions, they might say “wait a second, there’s got to be something better.” If you survey cardiac patients at high risk (post MI, unstable angina) and ask them, “What will it take for you to start a statin drug?” most of them demand at least kind of a 1 in 5 chance that it will actually help them over the next couple of years, whereas the actual risk reduction is about 3.1% over 6 years. So if we are actually honest with patients about how small the chance is that they would benefit, many patients would not take pills. So we have to oversell them. In a sense, to practice traditional medicine is often to practice deceptive medicine. In contrast, we undersell lifestyle interventions. In many cases, they may be able to actually reverse the progression of the disease because we are actually treating the cause of disease. When it comes to patients given the choice of diet versus drugs, it is not a choice between eating a healthy diet to prevent a heart attack or taking a pill to prevent a heart attack because for 97% of patients that pill is not going to work for them, whereas they may be able to reverse heart disease, open up their arteries without drugs or without surgery. So the answer to the question, “What is lifestyle evidence based practice?” for me involves offering the choices and really being honest about the risks and benefits of each of them. To me, evidence-based practice means truly informed consent.
I appreciate the point made by Dr Katz about the hypothetical randomized study of parachutes that are too small to support a human being. Of course, we know the result is going to show that they are ineffective. I also agree with the point that Dr Greger is adding to this, so I want to pull them together. I believe that the evidence-based factors of LM have 3 dimensions. One dimension is truly science based. It is formed by science, guided by science, and science driven, but avoids the extremes of dogma and favorite fads. These 2 aspects are essential but we also have to realize that there is probably more we do not understand about nutrition and health than what we do. I believe that in the future, as we continue to measure outcomes and measure carefully the treatment effect of various diet and lifestyle patterns, we are going to ferret out the answers. Right now, however, we know enough that even the LM skeptics agree that we can prevent 70% of disease with what we know. I personally believe it is closer to 95% but I’ll take 70%!
Published data analyses reveal that contraindicated percutaneous coronary intervention (PCIs) are reimbursed just like the indicated ones, while proven LM interventions are not reimbursed. Furthermore, the consent process does not inform patients about LM treatment options or the fact many PCIs are contraindicated. So here is my question: “Is it evidence-based practice of any kind of medicine to pay for procedures that the American College of Cardiology Expert Guidelines say are contraindicated, while we refuse to pay for procedures that are clearly shown to be effective? Even at not only managing disease, but reversing it?” So I would argue that evidence-based LM is something we need, but we also need to realize that the failure to practice evidence-based medicine in other disciplines is largely hindering the acceptance and the practice of LM. I want to share this comment by the way. I own a copy of the first edition of Dr Rippe’s Lifestyle Medicine textbook. I deeply appreciate the presence of that book. It is extremely comprehensive, and it was instructive to me about evidence-based LM by emphasizing that it is more complex and more comprehensive than I had any ability to master. I may not be able to master all of LM, but I will tell you what we can do. We need to measure all that we do. Evidence-based LM is measuring what we do as well as we are able and being prepared to use our findings to bring constant quality improvement—not only for my own practice but for others. I think evidence-based LM practice is impacted by the failure of other disciplines to practice evidence-based medicine and that we should raise the standard and make LM set the pace for real evidence-based medicine. By the way, the DPP was stopped by the ethics committee because it was considered unethical to deny the patients access to the lifestyle changes, which we are still not paying for patients to receive!
Developing the evidence base for LM that would support broad-based reimbursement is a huge challenge. My perspective is informed by what it takes to develop and launch new medicines. I grew up in the biotechnology industry, over 17 years in 4 countries, and led multiple R&D teams. I was focused on developing evidence for new medicines and vaccines. Bringing a new medicine to the market is a simpler undertaking than implementing LM. When testing the biological effects of a new medicine in humans, researchers focus on 1 bio/chemical compound used in narrowly defined populations with narrow inclusion/exclusion criteria, thus aiming to show the benefit of a single medicine at 1 dose in 1 homogeneous population. Clinical development through phase 3 studies to market launch and reimbursement proceeds on this narrow basis. Only after a decade or more does a medicine get tested more widely.
LM on the other hand is in fact many diverse medicines mixed together in a variety of ways, with broad application across all demographics and health situations. The evidence needed to support financial reimbursement for a complex mix of LMs on a broad basis is a heroic, long-lasting undertaking.
We face another challenge, which is to enable people to use these medicines day in day out, in sustainable ways. I left the biotech industry 15 years ago, because I saw that people weren’t taking good care of their health by engaging in healthy lifestyles. This gap seemed critical to the health of all. I thought that if we could help people take good care of their health and improve their behaviors for good we could make much more impact than many of the biotech medicines that I might help develop. So I asked “what can I do to support engagement in healthy lifestyles?”
My first step was to identify coaching skills and develop coaching protocols that could help people change their lifestyles, particularly when change is hard. Evidence was emerging on the aspects of human nature that are vital to the change process, that coaching could address. The scientific foundation of health and wellness coaching competencies and tools has strengthened considerably in recent years as evidence for the value of particular aspects of human nature has mounted. For example, empathy and self-compassion for negative emotions, and harvesting and amplifying of positive emotions, have gained recognition as interventions that improve health and support learning and positive change.
But like LM, coaches integrate numerous small interventions into a whole, with a wide range of skill mastery, which makes for a complex mix to implement and study. We then find ourselves with multifaceted coaching interventions of widely varying quality that deliver multifaceted LMs to people who live diverse and multifaceted lifestyles. The path to widely applicable evidence becomes even more challenging.
The way the biotech industry looks at medical research is to focus first on the most advanced and difficult cases. For example, researchers start with stage IV cancer, not stage I, and certainly not cancer prevention. That strategy makes for a long, long road to wide dissemination across many lifestyle-related diseases, where early intervention is ideal.
Following this strategy, I am fostering clinical evaluation of coaching for fibromyalgia, for which there is no good treatment other than exercise. However, it has taken 10 years to get to the place where we have enough coaches who are skilled enough to handle well the challenges of fibromyalgia on a large scale. So a focus on the toughest health challenges has not exactly offered low-hanging fruit from the perspective of evidence and reimbursement.
Thankfully, developing an evidence basis for coaching and LM is not hopeless! I was inspired recently by Jeff Dusek who is an integrative medicine researcher at Allina, a hospital system in Minneapolis. He recommended that the health and wellness coaching field look to “practice effectiveness” studies, now more respected by the NIH (National Institutes of Health), as a better way forward than the pursuit of many randomized controlled studies in many clinical populations. Rather than conducting lots of narrow, randomized studies on narrow homogeneous populations, data are gathered and analyzed on tens of thousands of patients that all together create a picture of real-world application and improved outcomes. This may be a better way to build an evidence base than pursuing a large number of narrow, randomized studies that could take decades to accumulate.
The health and wellness coaching field is serving tens of thousands of coaching clients now. Even if there is too much diversity today to develop a strong case for evidence and wide reimbursement now, there is an opportunity to orient many groups using similar coaching protocols to measure and collect similar data, so we can generate outcomes data on a large scale going forward. If we started today, a few years from now, we could have a compelling evidence base.
My last point is on the state of evidence-based medicine today. Dan Friedland, a physician in San Diego, teaches physicians, medical schools, and other organizations how to practice evidence-based medicine. He has developed a practical protocol, starting with an online medical textbook and then drills down to find the randomized studies relevant to one’s circumstances. It turns out frequently that if you look for the evidence specific to your profile, you will drill down to find only 1 relevant study. One randomized study with may be 150 people. That was a real eye opener for me.
In summary, given the challenges we face in developing an evidence base for LM, I agree with Dr Kelly. We must lead and get out in front, by defining and declaring sensible principles for evidence-based LM that enable early and wide dissemination. The world is waiting. Many people are suffering.
Allow me to share a story. The owner of a certain company suspected that employees were stealing company property, so he posted a security guard at the exit. As the security guard watched the employees file past at the end of the shift, he noticed Kowalski pushing a very suspicious looking sack in a wheelbarrow. The security guard called out, “Hey, Kowalski, what’s in the sack?” Kowalski sheepishly replied, “Nothing. Just sawdust.” “I wasn’t born yesterday,” came the security guard, “Open it up. Let’s see inside.” Kowalski reluctantly opened the sack, but after being forced to empty the entire contents, nothing but sawdust was found. Puzzled, the security guard told him to take his sawdust and be on his way. The same scenario played out the next day, and the next, and the days after that, but on all occasions, there was nothing but sawdust. After 1 week, the security guard took Kowalski aside. “This is driving me crazy,” he said. “I know you are up to something and I can’t sleep at night thinking about it. Just tell what it is you are stealing and I will let it go. I just have to know!” Kowalski pondered for a moment and then replied, “OK, I’ll tell you. Wheelbarrows. I’ve been stealing wheelbarrows.”
The point is, distractions can powerfully draw our attention away from that which is blatantly obvious—an analogy that is pertinent to our current health care, or should I say “disease care,” system. While modern medicine is absolutely incredible and remarkably innovative, we have been distracted into thinking that drugs and surgery are the way to address the epidemic of chronic diseases that constitute the major cause of death and disability today. We keep peering deeper into the sack of sawdust and overlook the wheelbarrow, which is LM that treats the causes.
As a researcher in the LM space, I see evidence-based medicine as lending a voice to help the medical community and others see the wheelbarrow. There needs to be compelling evidence for the efficacy and cost-effectiveness of LM to help overcome the pervading distraction. However, this can be problematic. As accurately described by Dr Katz, “too little too late” can lead to conclusions that LM is not effective. Furthermore, as argued by Laurie Thomas 2 recently in Medical Hypotheses, the emphasis of the “gold standard” in research being the double-blind RCT (the corollary being that every other type of study is inferior) often biases against nutrition and lifestyle interventions because it is virtually impossible to perform these studies. How do you “blind” people to what they are eating and how they are moving?
Unfortunately, this often results in compelling “evidence” for LM being understated and delegated to lower-impact journals. For example, Dr Esselstyn took 18 individuals considered hopeless cases—they had 49 cardiac events between them in the 8 years before entering his study—and applied aggressive therapeutic lifestyle change. 3 Twelve years later they were all still alive and not one had suffered another cardiac event. More recently, he has published similarly impressive outcomes in a cohort of nearly 200 individuals. 4 To my mind, this is compelling evidence, but unfortunately, these studies do not get published in the Lancet or New England Journal of Medicine because they are “only” cohort studies.
I have encountered similar biases in our studies of the LM intervention called the Complete Health Improvement Program (CHIP). I recall one paper in which we documented a 16% average cholesterol reduction in 30 days of over 500 participants with high cholesterol levels, but the reviewers of the paper dismissed the results because there was no control group. One reviewer argued that the improvement was likely just “regression to the mean” (because over 500 people can spontaneously in unison improve their cholesterol profile to this magnitude!).
There are impressive RCTs showing the effectiveness of LM, such as those led by Dr Ornish, but the overemphasis on this methodology can undermine the evidence base for LM.
If I might be so bold to summarize responses to the question of evidence-based LM, I believe the panelists have offered insightful comments. This question actually raises more questions. It doesn’t mean we shouldn’t be struggling to find the answers, but it may be a somewhat different answer and different approach than how traditional medicine approaches evidence-based medicine. This will be a constant struggle and one that our panel has really helped clarify that will take a lot of hard work. It is worth the challenge, but it is not going to be easy.
Here is the second question for all of the panelists. “How can LM specialists be best utilized in treating lifestyle disease?”
LM specialists can serve as “tip of the spear” basically. This is an important theme in LM. Very little else that we do in medicine is actively sabotaged throughout our culture. The way that lifestyle measures are currently treated in our society, it’s as if everywhere you went messages were delivered by credible individuals, groups, and entities telling you not to take the medication prescribed to you, not to do what your doctor told you, undermine every clinical intervention, ignore that coach, and so on, because they are really trying to kill you. If you think about the key elements of LM, which I refer to routinely as “feet, forks, and fingers,” along with sleep, stress, and love, our society actively conspires against all of them. We peddle tobacco and bad diets. We peddle technology to dissuade people from doing anything other than moving their thumbs and devise schedules that make it impossible to get enough sleep. We stress everybody out. We are so busy looking at cell phones that we never make eye contact any more, let alone hug anybody. This is active cultural sabotage. In light of that, generating the evidence for LM becomes an uphill battle. Whether it is a RCT or not, you are measuring the residual effect of what you can do while working against the major streams of our culture. That’s a hard task. In light of that, the role for clinicians in LM should be to become the tip of the spear. In other words, LM specialists need to lead the way. How can we accomplish this? First, the passion for this cause must be disseminated. We have got to pay it forward. One of the things we need to do is work to convert the rest of medicine to appreciate the evidence that we do have—many studies that have been done, which have been mentioned here, and many others. There have been RCTs to prove that lifestyle is twice as good as a drug. As a group of clinicians who understand the need to do all we can to share this information with our fellow clinicians, we have a particular task and responsibility. We need to share this with our patients, as I suspect most of us are already doing. The other thing we need to do is be agents of culture change. It cannot work to give people good advice about lifestyle and send them out into a world that makes it nearly impossible to act on that advice. The choices our patients make, no matter how good our counseling, are subordinate to the choices they have. They live in a world of bad choices.
We need to be the tip of the spear and cut through the noise and the clutter with good, effective clinical counseling. Think about where LM reaches its pinnacle. Think about those populations around the world who routinely use lifestyle as medicine and have the most years in life and have the most life in years. They do not say, “This is because my clinician does such a great job of lifestyle counseling.” What they say is, “I don’t know, I just live here.” Their culture carries them along in a current that takes them toward health. We have got to propagate that current. These are the dual tasks before us. To provide good guidance, so that people can acquire the skillpower to overcome the world as it is. We need to be agents of change, so that we make a better world, so that getting to help and improved lifestyle is the path of lesser resistance and not the road so seldom taken.
With regard to the role of LM specialists, it almost goes without saying that all clinicians need to have this basis since three-fourths of our resources are going now toward chronic disease. Much effort should go into medical school requirements for the boards, CMEs, and so on. I imagine specialists in LM being particularly useful to very motivated patients. So being in primary care, like I am, when someone comes to me and says, “I’m not ready to die; I will do whatever you tell me,” maybe they just had a diagnosis. Now these people I could see referring to a LM specialist who would be willing to really exploit that willingness to maximize their health and longevity.
Let me suggest that the answer to this question should be driven by the answers to the first question. I find it surprising that many people seem to have the concept that LM is the treatment we use for the control group in the LM studies that we do. There are studies that have actually looked at group interventions compared to interventions done one-on-one with the physician and the nurse in the office setting. One study showed that the same people could deliver the intervention more effectively and achieve greater treatment effectiveness, when it was done with a group dynamic. We are social people. Christakis and Fowler5 have shown some very interesting findings from the Framingham Study about making lifestyle changes. They report that among friends, if one becomes obese the other is almost 4 times as likely to become obese as when a person’s spouse becomes obese. We tend to ignore this when we are trying to get people to make change in individual office visits and return to clinic in 3 months, 6 weeks, or whatever. I am not saying we don’t need to do that, but I believe that every medical practice should incorporate lifestyle changes in their treatment plan. If you look at surgeons, isn’t it common practice to ask smokers to stop smoking? There are things, such as that, involving lifestyle interventions in nonlifestyle medical practices.
I want to focus in this question not on whether all doctors should be using evidence-based lifestyle interventions; but whether they are or not, doesn’t the best evidence indicate there is a place for and a need for intensivists who are LM specialists that narrow their scope of practice, so they can deepen the impact of the point of the spear? The point of the spear is where you have the most cutting power. What I am surprised at is that even the ACLM so far seems more focused on LM as part of primary care practice, whereas there has not been a focus on what the evidence shows in published studies. Most published studies have used LM specialists providing treatment in a group setting. We don’t have what I would call “seminal studies” of the effectiveness of a specialist in providing lifestyle intervention. I believe the reason is that motivation for lifestyle change is often fear, and fear is not a good long-term motivator. Think about your kids for a minute—is fear the best motivator? Fear can be a useful motivator, but my approach is to use the window of opportunity fear provides to produce a dramatic enough change that motivation switches to enjoyment. That happens when the patient realizes, “I had no idea it was this doable! I did not realize I could make this much change in my lifestyle.” Everyone has had an “ah-ha” moment—that moment where you realize it works—it works in my own life! I had my “ah-ha” moment decades ago with regard to LM. So, I am just saying that we are not being ultimate evidence-based practitioners if we are ignoring the fact that the evidence indicates there is a need for an intensivist to make intensive lifestyle changes. There is an induction phase, a consolidation phase, and a maintenance phase. Intensivists are more effective during the induction phase. Think about how surgeons work and apply it to LM practitioners. Surgeons take a patient that needs a specific intervention that they are expert at, and they accomplish it. They specialize in that procedure and they are good at it. I am not a primary care doctor. About 25% to 30% of my patients come from referrals from primary care doctors who would not refer to me if I were a competing primary care doctor. I am a LM specialist. They are happy to refer their patients to me for intensive lifestyle treatments.
I agree that the most skilled people in any helping profession will deliver the best results. That is a great starting point.
Here’s another angle to consider. If you think about the fundamental principles of the motivational interviewing, the 2 questions to ask are, “How do we build confidence in the delivery of LM?” and “How do we build desire and motivation for improved health and well-being via LM?” On the first question, I think the world is now at a rock-bottom level of confidence about our collective ability to help people adopt healthy lifestyles. Motivation goes to sleep when confidence is low, so if we don’t build confidence levels, motivation will also not come alive.
Often I have conversations with physicians who say, “I don’t see a lot of hope.” Even if we had a larger evidence base, we might still face the viewpoint that large-scale change is difficult if not hopeless. So the question really becomes, “How do we build collective confidence in the delivery of LM?”
Perhaps we need more storytelling, not just evidence. I think we need to find ways to tell the many, many good stories that already exist to help build hope. For example, what Kaiser Permanente has done to move the needle for healthy lifestyles and health improvements.
In my experience, having talked about wellness over many years, I have found that people are not jumping out of bed in the morning to engage in personal wellness. I understand Medicare’s reimbursement for the wellness visits hasn’t taken off like a rocket. So, then, we must ask, “Are we giving people what they really want? Is there a different way to present this opportunity?”
The lack of urgent interest has led me to think about 2 different directions. One relates to our country’s competitive advantage and economic potential. We are leaving a billion of dollars on the table because people don’t have the physical and mental energy to work hard and innovate. It would boost the economy significantly if everybody was really well and really healthy.
The second thing, which may offer another avenue, relates to brain function. I find that people are significantly more interested and worried about their brain function than they are about their heart and limbs. I wonder if we added to our agenda the concept of brain health and brain performance, whether people would come running to the offices of the LM practitioners who could potentially offer an approach to reduce dementia risk. This is something all of us—especially the baby boomers—are really frightened about.
To summarize, let’s think about how to build confidence in the delivery of LM and what would bring patients to LM practitioners because they want what we have.
In Australia, the LM movement arguably attracts more allied health professionals, such as dieticians, exercise physiologists, and practice nurses, than physicians. Furthermore, the Australian health care system provides supported access (albeit limited) to these allied health professionals. Hence, there is the opportunity within the Australian context to progress LM through these personnel. However, physicians remain the gatekeepers of health care in Australia, and so to champion LM it is necessary to influence physicians and create opportunities for those who catch the vision to implement it in their practice. The model that is being promoted in Australia by Professor Garry Egger—a leader in the LM space—is for shared medical appointments in which physicians, supported by other health professionals, conduct consults in a group setting. Shared medical appointments can be cost-effective while allowing more time to educate patients and support behavior change. They are currently being met with great success, which is not surprising, as we people often need others to do our best and be our best.
Without underplaying the value of physicians who are LM specialists, we have collected substantial data examining the effectiveness of the CHIP lifestyle intervention when it is administered by nonhealth trained volunteers in community settings. Interestingly, participants in these volunteer-facilitated programs achieve comparable outcomes to participants in programs delivered by health professionals. Provided with a professionally developed resource, volunteers may, therefore, represent tremendous social capital by serving as champions of LM.
In conclusion, physicians with LM specialization have a lead role to play in the LM movement, gaining traction and moving ahead, but let’s not fail to recognize that there are many nonphysicians who have a tremendous amount to contribute.
Several people on the panel have mentioned that obesity behaves somewhat like an infectious disease. I think at this conference, we may have a case study that LM is also behaving like a positive infectious disease since this conference has doubled in size each year for the past 2 years? So don’t dismiss the power of being here and positively “infecting” other people.
I have one final question that I would like to ask all of the panelists to briefly respond to: Given the preponderance of unhealthy food options, strong advertising and sales tactics by the food industry, the pharma-healthcare industrial complex, lack of health literacy, a broken health care system, and more, how long do you think it will take for us as a nation to change our ways and make real strides in LM?
I believe this type of change can happen very quickly. What we have to do is to change the question. It is not about disease management, it is about disease reversal. It is not about ameliorating the symptoms of a toxic lifestyle, it is about changing that toxic lifestyle. I don’t think there is anything to change except the perception. I believe that it can change quickly. The single greatest disincentive for any treatment is lack of reimbursement. How many times have you altered what you thought was the best treatment for a patient because of reimbursement? So you get my point. I believe that we must change our mindset to ensure that health care is not costing money but saving money to make lifestyle change the first line of treatment.
The best way to bring about change is to create it. To some extent, the answer to your question is contingent upon us all. What do we do with what we know? Who do we influence? What do we change? I believe we own the answer collectively. We can also invoke Malcom Gladwell when he writes about tipping points. The status quo is unsustainable. It is unsustainable in terms of human capital and unsustainable in terms of the economy. We had a recent bit of good news about diabetes slightly going down, but up until then, it had been a steady drumbeat of ever-worse news. A third of us will be diabetic by midcentury, 40% prediabetic by midcentury—that’s basically a formula for financial insolvency at the level of the federal government. We have to change things. The question is, will we own that future that we want to create for our children and grandchildren? Will we be the change agents for what we want to see in the world? In that case, I believe it probably can happen pretty quickly. It is very hard to predict the future. We are talking about a future that we want to create. One final comment. I am a little concerned that we might oversell the notion of treating and reversing disease through LM. One of the things I ask my patients is what they think health is for. The presumption when patients and clinicians interact is that the prize is health. The prize is not health. Health is currency that we all get to spend on living. Living the way we want to live is the prize. I think the message we fail to convey effectively is, yes, it can fix the economy. Perhaps a better question is how can people have more fun? People taking lots of medications are not having more fun. Healthy people have more fun. We are in the business of making life fun. Who doesn’t want that?
I think cost containment may really be the saving grace. The irony of the corporate boogie men who put unhealthy food in our school districts is that they are also bleeding red ink by paying for employee health benefits. Prevent a few cases of diabetes, and you can switch your whole bottom line. So, ironically, the push toward LM involves striving toward cheaper ways to achieve better outcomes. In the end, no one can beat that!
One of the benefits of all that we went through last year with the launch of the Affordable Care Act is that people got a wake-up call and started thinking more about their health. I agree with Dr Katz, we have to make this cool. Just like it is not cool to smoke, whereas 40 years ago it was. When I started my career 30 years ago, it wasn’t all that cool to exercise. I worked with a lot of MDs and PhDs who thought, “My, my brain works so well I don’t really need to exercise.”
Let’s think about specific ways to make positive lifestyle decisions cool. How do we get celebrities on board? I think you’re starting to see that. Hip hop videos, and so on. That’s the future. It is about selling and marketing and emphasizing the fun about making positive lifestyle decisions.
Nobody likes being sick, but survey after survey has shown that people don’t know they are sick because they associate health with the absence of disease rather than a platform for being happier and having a fuller life. In short, a platform for better performance in life and more enjoyment.
Dr Kelly suggested that change can happen quickly, and I would assert that it must. Imagine a world where bypass and other surgeries that we presently rely upon as stop-gap measures for managing chronic disease were no longer available. In the wake of antibiotic resistance, forecast to be only a couple of decades away, this is a likely reality. Perhaps the application of LM for combating chronic disease will come to the fore when the other options are no longer viable.
I would like to thank the panelists for their thought-provoking comments. I would also like to thank this large audience for your passion and commitment to LM. It was Margaret Meade, the famous sociologist who said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” The people in this audience are the change agents. It is clear from what the panelists have articulated that the core concept of LM, that daily habits and actions profoundly impact on both short- and long-term health and quality of life, must be placed front and center in our health care agenda. I would like to say one further thing. My wife and I put a quote on t-shirts for our children because we thought it was so impactful. The quote was “Without a dream there is no reason to work. Without work, there is no reason to dream.” So I challenge members of the LM movement that to make this happen, we already have the dream, but now, we are going to have to work harder than we ever have worked before to make it happen. The world is waiting for our message. Are we ready to answer the call?
Footnotes
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This article is based on an Expert Panel Discussion delivered at the American College of Lifestyle Medicine 2014 Annual Meeting, October 2014.