Lifestyle Medicine: Evidence,Education,and Practical Applications

‘National guidelines for virtually every major entity dealing with metabolic-based disease emphasize the importance of lifestyle medicine either for prevention of disease or its treatment.’

We at the American Journal of Lifestyle Medicine (AJLM) are delighted to, once again, devote an entire issue to the national meeting of the American College of Lifestyle Medicine (ACLM), which took place on October 23-26, 2016, in Naples, Florida. This is our fourth entire issue devoted to selected presentations from ACLM national meetings. It has been a great pleasure to focus our attention on the important work being done at ACLM by devoting entire issues to their national conferences.

As articulated in our first issue 9 years ago, our goal at AJLM, which remains just as true today, is to provide a forum for evidence-based information in the emerging medical specialty of lifestyle medicine. This vision involves bringing together information not only from practitioners of lifestyle medicine but also from the diverse disciplines that provide evidence in how daily habits and actions affect short-term and long-term health and quality of life. In the past, this information had only been provided in journals specifically focused on each discipline. Our goal at AJLM has always been to bring key articles and concepts related to lifestyle medicine together in one platform and in a single publication.

Based on my participation in the 2016 national meeting of the ACLM, I am pleased to report that the field of lifestyle medicine continues to grow and evolve in positive directions! When we first started devoting an entire issue of AJLM to the national meeting of the ACLM, the theme of the conference was “The Treat the Cause Movement” (2013). In 2014, the emphasis for the conference had evolved to “Treat the Cause: Evidence-Based Practice.” In 2015, the conference theme changed slightly to “Integrating Evidence into Practice.” In 2016, the theme of the ACLM national conference was “Healthy People, Healthy Planet.” The Expert Panel discussion that I was honored to moderate at the 2016 conference was titled “Implementing Intensive Therapeutic Lifestyle Change Programs.”

This evolution over the past 4 years shows that while evidence remains the core of lifestyle medicine, issues related to education and practical applications, as well as the overall impact on our planet, are now part of the purview of this important conference.

This evolution also shows that the tasks for the lifestyle medicine movement have become broader and deeper over the past 4 years. Sound evidence on the efficacy of lifestyle measures to promote good health remains the core, but the emphasis has now broadened to include the emerging role of education and the recognition and development of practical strategies to successfully incorporate lifestyle principles and practices into modern health care.

The evidence for the importance of lifestyle medicine in modern health care has never been greater. As I have articulated in previous editorials, national guidelines for virtually every major entity dealing with metabolic-based disease emphasize the importance of lifestyle medicine either for prevention of disease or its treatment. These include guidelines from the American Heart Association, ¹ the American Diabetes Association, ² the Institute of Medicine, ³ and many others. ⁴

Lifestyle medicine practitioners are very familiar with this broad understanding of the importance of daily habits and actions on health. The larger medical community, however, is only now beginning to understand its importance. To give one of many examples, at one medical grand rounds I delivered, I was cautioned to be careful since the audience was deeply versed in evidence-based medicine. There was concern that lifestyle medicine was not evidence based. Yet when I asked audience members if they were familiar with the JNC 7 Guidelines for treating hypertension, ⁵ and the imperative to include lifestyle measures for the first 6 months in stage 1 hypertension before starting pharmacologic therapy, not a single individual was familiar with these evidence-based guidelines. It turns out that the audience was familiar with certain types of evidence but oblivious to others. As careful as we are to use evidence in lifestyle medicine, we must also be cognizant of bringing this evidence into the mainstream of modern medicine and not operate on a parallel path.

Recent summaries published in the Journal of the American Medical Association ⁶ and the New England Journal of Medicine, ⁷ as well as the 20/20 Strategic Guidelines from the American Heart Association, ⁸ have all emphasized the primacy of daily lifestyle practices in preventing disease as well as preserving good health and as components of treatment for various metabolic diseases such as cardiovascular disease, diabetes, and obesity.

The current issue of AJLM focuses on many of the insights articulated by various presenters at the 2016 ACLM conference. The Expert Panel Discussion that occurred on the first full day of the ALCM conference provided multiple exciting models of how lifestyle medicine is branching out across the United States. A transcript of this Expert Panel Discussion, which is the first article in this issue, includes multiple different initiatives, all of which show how intensive therapy with lifestyle changes is making progress throughout diverse channels. ⁹ Cummins, Inc, for example, has begun to utilize lifestyle medicine principles across its human resources platform throughout the world. The YMCA of the USA is delivering the Diabetes Prevention Program based on the National Institutes of Health landmark Study ¹⁰ in more than 250 cities utilizing hundreds of branches of the YMCA. The Complete Health Improvement Program (CHIP), developed by Hans Diehl and colleagues, is now being delivered in multiple health care and community settings. The Ornish Intensive Cardiac Rehabilitation Program is expanding to multiple hospitals and, importantly, is covered by insurance. The Live Healthy Appalachia model utilizes CHIP and also provides a sophisticated understanding of how lifestyle medicine can be supported within the current insurance system. All of these initiatives provide models and guidance for individuals hoping to expand lifestyle medicine programs in their own practices, communities, or in broader geographic areas.

The article by Gardner and Hauser, “Food Revolution,” provides a compelling look at how and why we need to change nutritional habits in our country. ¹¹ Importantly, the authors emphasize that healthy food must also be delicious if we are ever going to change the way Americans consume it. The increasing number of chefs involved in this area is a most welcome addition to this initiative. One example that I personally participated in involved a presentation in December 2016 where I had the pleasure of conducting a seminar and press briefing at the famous Bouley Restaurant in New York City. Celebrity Chef David Bouley is so committed to the health aspects of food that he will be taking a year off from his restaurant business to immerse himself deeply in this area. What will emerge, I am confident, will be a great leap forward in the interface between food and health. I had an opportunity to have an hour dialogue with Chef Bouley that evening and left impressed with his deep commitment to creating great tasting food while delivering the highest level of dietary quality.

Many of the principles of lifestyle medicine will require individuals to make changes in their lives. Not enough attention has been paid to key questions such as “Why Do People Change?” and “What Can I Do to Help?” Mark Faries and Alyssa Abreu in their article in this issue, titled “Medical Adherence: When Lifestyle Is the Medicine,” provide an in-depth, practical exploration of these questions. ¹²

Practical considerations involving how to actually start a lifestyle medicine practice are the key concepts of the article by Braman and Edison, titled “How to Create a Successful Lifestyle Practice.” ¹³ Certainly the wealth of practical information provided in this article will guide individuals who want to either convert their entire practice to lifestyle medicine or expand the use of lifestyle medicine principles in their broader health care practices.

One practical solution to make lifestyle medicine more cost-efficient is to offer group visits. The article by Frates et al, “The Art and Science of Group Visits in Lifestyle Medicine,” provides a detailed, evidence-based review of group visits including the evidence to support their efficacy. ¹⁴

As the field of lifestyle medicine continues to move forward, education will also be a key. It is encouraging to see that the first certification in lifestyle medicine will be offered through the American Board of Lifestyle Medicine and ACLM in conjunction with the 2017 national ACLM meeting. In addition, a Lifestyle Medicine Core Competencies program is being offered online by ACLM and the American College of Preventive Medicine and carries 30 hours of CME credits. ¹⁵

There will also be a need for fellowship-trained lifestyle medicine specialists to lead the field in the future. Dr John Kelly, the Founder of the American College of Lifestyle Medicine, is a leader in this field. His article, along with this first lifestyle medicine fellow, Dr Jeni Shull, titled “A Comprehensive Clinical Lifestyle Medicine Specialty Fellowship Program: What Intensive Lifestyle Treatment Can Do,” provides guideposts and a framework for establishing fellowships in lifestyle medicine. ¹⁶

The articles contained in this issue of AJLM are only a sampling of the many interesting and valuable presentations conducted at the national meeting of the ACLM. Many of the presentations involved practical, hands-on workshops as well as inspiring talks showing how the lifestyle medicine movement is spreading worldwide. Thus, the emphasis on lifestyle medicine is not only for healthy individuals but also a healthy planet!

I am also pleased that this issue of AJLM also contains the thought-provoking opinion piece by ACLM President George Guthrie, titled “Money Talks,” ¹⁷ where he provides a clarion call for the economic imperative to incorporate more lifestyle medicine into modern health care—both to achieve superior outcomes and also to control costs.

My research organization, Rippe Lifestyle Institute, continues to be active in providing evidence and practical applications in the area of lifestyle medicine. A new book that I edited, titled Nutrition in Lifestyle Medicine, was published in early 2017. ¹⁸ The third edition of the comprehensive textbook that I edit involving more than 150 authors with expertise in various aspects of lifestyle medicine, Lifestyle Medicine, will be published by CRC Press in 2018. ¹⁹ An expanded direction for this book includes not only evidence in the multiple fields that comprise lifestyle medicine but an entire section devoted to the key components of a lifestyle medicine practice. A number of members of the ACLM leadership team are involved throughout this third edition.

Finally, I would be remiss if I did not give a shout out to the guest editor for this issue of AJLM, Dr Jonathan Bonnet. Jon did an exemplary job of assembling and editing the multiple articles in this issue. He is an outstanding writer and editor and will undoubtedly assume increasing leadership positions in ACLM. His editorial “Lifestyle Medicine 2016: Emerging Opportunities and Continuing Challenges” ²⁰ provides an excellent summary and perspective on the 2016 ACLM conference.

It is a particular pleasure for me as one of the “elder statesmen” of lifestyle medicine to see the positive evolution in lifestyle medicine achieved by blending evidence, education, and practical applications. We are at an important “tipping point” in the lifestyle medicine movement. I am confident that the principles and practices of lifestyle will continue to play an increasingly and important role in modern health care not only in the United States but around the world.