A Call to Action for Intermediate and Secondary School Lifestyle Medicine Education: Instating Healthy Teen Behaviors

Abstract

Chronic diseases, previously thought to require decades of risk factors, have become increasingly prevalent in America’s youth. National Health Education Standards have been published since 1995, and yet nearly a fifth of schools fail to follow any state or national health education guidelines. Utilizing the phrase “lifestyle medicine” in childhood would elevate the importance and standardization of the core health guidelines. Several independent pilot programs taught by undergraduate and medical student volunteers have successfully demonstrated lifestyle medicine education models at intermediate and secondary schools. Preliminary feedback demonstrates that student interest in and consideration of behavioral change is possible within this age group. As with any life stage, significant behavior change in youth requires strategic planning of authentic learning practices and culturally competent lessons. We argue for the interdisciplinary development and implementation of community-engaged lifestyle medicine education for intermediate and secondary schools as a promising intervention to address and reverse the chronic disease trend in our youth.

‘When students understand the authority and control that they hold over their current and future health through personal lifestyle choices, they are more likely to take these choices seriously.’

Today’s children and teens are met with the burgeoning reality of potentially becoming chronically ill adults of the future. The Centers for Disease Control and Prevention (CDC) findings from 2015 to 2016 indicated that among US youth aged 2 to 19 years, a staggering 13.7 million or 18.5% were obese. ¹ Data collected by the CDC National Youth Risk Behavior Survey indicated that in 2017, among the national high school student population, 15.6% were overweight and 14.8% were obese. ² Dietary behaviors among survey respondents showed that within the previous 7 days, 7.2% had not consumed vegetables, 5.6% had consumed neither fresh fruit nor 100% fruit juice, and 18.7% had consumed at least 1 serving of soda per day. Additionally, 15.4% of surveyed high school students had failed to accumulate at least 60 minutes of physical activity in the past week, 48.3% had not attended at least 1 day of physical education class, and 43% engaged in video gaming for 3 or more hours per day. ²

From 1999 to 2017, the prevalence of overweight and obese children increased significantly, ³ whereas from 2015 to 2017, US life expectancy at birth has declined by approximately 1.2 months. This marks the first 3-year decline since 1916 to 1918, which notably marked the worst flu pandemic in recent history. ⁴

In all, 60% of middle school students and 70% of high school students do not get adequate sleep, which over time increases a child’s future risk of diabetes, obesity, injury, poor mental health, and attention and/or behavioral problems. ⁵ Additionally, prolonged psychological stress experienced in childhood can lead to negative short-term and long-term health effects such as an increased risk of alcohol abuse, eating disorders, and heart disease. ⁶

The National Health Education Standards, first published in 1995, included 8 written expectation standards for “what students should know and be able to do by grades 2, 5, 8, and 12 to promote personal, family, and community health.” ⁷ These standards include the following:

• “(1) Students will comprehend concepts related to health promotion and disease prevention to enhance health; (2) students will analyze the influence of family, peers, culture, media, technology, and other factors on health behaviors; (3) students will demonstrate the ability to access valid information, products, and services to enhance health; (4) students will demonstrate the ability to use interpersonal communication skills to enhance health and avoid or reduce health risks; (5) students will demonstrate the ability to use decision-making skills to enhance health; (6) students will demonstrate the ability to use goal-setting skills to enhance health; and (7) students will demonstrate the ability to practice health-enhancing behaviors and avoid or reduce health risks.” ⁷

Whereas these standards provide admirable objectives, results from the School Health Policies and Practices Study, which collected a nationally representative sample of public school districts, found that 18.3% of school districts do not follow any national, state, or district health education standards, and only 63% of school districts follow the National Health Education Standards. ⁸ Meanwhile, a mere 42.2% of districts had requirements in place for representational oversight of health education, and only 58.6% had reviewed or updated their existing health education curricula. ⁸

Lifestyle medicine is relatively new at the associate’s and bachelor’s level; however, education at these levels is increasing in popularity at a rapid pace. Intermediate and secondary school lifestyle medicine education is the most logical next step to confront the growing issues previously discussed. Lifestyle as medicine principles are already being taught in schools throughout the United States; however, it is often not referred to formally as lifestyle medicine but generically as “health class.” Utilizing the phrase “lifestyle medicine” in childhood education would elevate the importance and standardization of the core healthy lifestyle behaviors. When students understand the authority and control that they hold over their current and future health through personal lifestyle choices, they are more likely to take these choices seriously. Lifestyle medicine has the capacity to arm these students with the decision-making power over their food choices, how they will engage in physical activity, and how they cope with daily stressors. With empowerment, education, and support, behavior change at any age is feasible and allows students to become the catalysts of change in their current and future health, families, broader community, and even future generations.

Lifestyle medicine education for middle and high school students should focus on authentic-learning practices that are rooted in evidence-based approaches. As opposed to teaching for a graded exam, lifestyle medicine education should focus on establishing and implementing personal healthy lifestyle behaviors that will persist for a lifetime. Teaching lifestyle medicine through PowerPoint lectures alone would not do any justice, especially when considering the target age group. Rather, lifestyle medicine is most powerful when it is experienced and implemented firsthand and enhanced through personal goal setting. Encouraging various forms and intensities of physical activity throughout the day; teaching students how to prepare delicious and easy whole-food, plant-based meals; and demonstrating how yoga prior to an exam may help students excel in the classroom takes the educational components of lifestyle medicine and puts them into active practice.

Physical activity should be presented as a powerful tool that reaches far beyond physical education class. Therefore, physical activity should be integrated throughout the day with activity encouragement. Classroom teachers can have students stand in a circle and throw a soft object while conducting a discussion, have students take turns leading movement breaks, and use technological platforms such as Go Noodle to encourage movement in the classroom. Wobble chairs, standing desks, and other adaptive seating options give students more opportunities to move while learning. Physical education teachers often have ideas for incorporating physical activity in a variety of classroom settings and should be utilized for their expertise when promoting school physical activity.

In the idealized view of middle school experiential lifestyle medicine learning, students could have access to healthy foods not only during lunch, but also in vending machines and for snacks. The adventurous nature of adolescents can be harnessed to encourage students to try whole-food, plant-based meals. Having students learn about traditional healthy eating patterns of other cultures, cooking plant-predominant dishes, researching food policy topics, or exploring food marketing are great ways to advance discussions about health in schools. Students can take turns researching and teaching their classmates about healthy stress management techniques. Classrooms can be equipped with calm kits containing fidget toys, de-stress squeeze balls, mindfulness galaxy jars, and weighted lap blankets to encourage relaxation. Although more often utilized in primary schools, middle and high school students are also eager to incorporate stress management practices when education and resources are supplied.

Lifestyle medicine education should be culturally competent, with the knowledge that students come from a variety of socioeconomic and cultural backgrounds that could influence how they perceive health and lifestyle behaviors. Teachers will likely have students in the classroom who have significant healthy lifestyle knowledge, practice healthy lifestyle behaviors, and have family and peers who already support these behaviors. Likewise, teachers will likely have students whose health views are not evidence based, who do not currently practice healthy lifestyle behaviors, and who are surrounded by family and peers who do not support healthy lifestyle changes.

Current efforts are underway to implement a curriculum rooted in lifestyle medicine into intermediate and secondary education throughout the country. A recent pilot program implemented at a private middle school in the Boston area demonstrated the ease and effectiveness of bringing lifestyle medicine to middle school students. Through weekly discussions led by an undergraduate student, middle school students learned the power of healthy behaviors. For example, students learned to use sleep as a tool for boosting performance in the classroom. Most important, students learned why proper sleeping habits improve cognitive functioning by exploring up-to-date scientific literature. When provided evidence-based approaches to healthy lifestyle habits, students are able to gain a more robust understanding of the power of lifestyle medicine. This pilot program emphasized the growing need for such a curriculum within this age group.

Parallel efforts are afoot at an urban school district in northern New Jersey. An after-school lifestyle medicine curriculum is taught by current medical students to small groups of 7th to 11th graders. The session topics range from core topics of exercise and nutrition to adolescent-focused activities on stress management and healthy relationships. The medical students lead short didactic introductions followed by the main focus of each session: an activity that requires students to leave their seats. This activity incorporates combinations of visual, auditory, and tactile learning, reflective of the holistic sensory approach of lifestyle medicine and a means to improve the students’ engagement and retention of the material. The activities go on to provide practical methods of implementing lecture examples and encourage behavior modification within the constraints of their urban environments. Throughout the year, students get a chance to design and participate in high-intensity interval workouts, create well-balanced meal plans, act out conflict resolution scenarios, and learn to critically read primary research literature. All lessons conclude with current events that place the health topic and skills in the context of the students’ daily and community lives. The intent of such efforts to develop comprehensive curricula by these students is to publish a model program with the hope that it can be easily replicated by other undergraduate and medical student groups and inserted into communities around the country.

These successful efforts have demonstrated that students want to learn the power of lifestyle medicine, and educators must provide them the tools necessary to embrace this curiosity. However, to understand the best teaching practices for lifestyle medicine at the middle and high school levels and how to motivate students to engage with and maintain healthy behavior change, further research efforts are required. For example, does understanding health disparities and connecting lifestyle behaviors with health activism encourage teens to change their behavior? How are the values and priorities of these students connected with lifestyle medicine and behavior change? Students may be motivated to improve their sleep habits if they understand how sleep hygiene can be used to optimize their recall for an exam or to improve their athletic performance in competitive team sports. What learning tools exist or need to be developed to best support teachers and students? The lifestyle medicine pillars of healthful eating, increasing physical activity, stress management, healthy relationships, sleep hygiene, and substance abuse avoidance ⁹ affect many areas of the lives of students now and offer an opportunity to be improved on through lifestyle medicine education in intermediate and secondary schools. We can utilize experiential learning, authentic learning, technology, and student focus groups to develop quality lifestyle medicine education that will maximize the chances of long-term healthy behavior practices.

One important teaching challenge can be the controversial or sensitive nature of some lifestyle medicine topics, such as whole-food, plant-based nutrition and/or childhood obesity as a long-term risk for comorbid chronic diseases once thought to only affect adult demographics. Although these issues complicate the teaching of lifestyle medicine, they do not garner abandonment. As educators and health experts, we have the knowledge and the innate responsibility to empower and equip students and future generations with this knowledge. However, knowledge and intention are not enough. We need to work together from an interdisciplinary standpoint that includes educators, health professionals, physicians, lifestyle medicine undergraduate students, medical students, community leaders, parents, middle and high school student-driven advocacy, and policy makers to educate instructors on the best practices in the field of lifestyle medicine health promotion. This includes identifying the steps to address the needs of the students; to successfully plan, implement, and evaluate health promotion programs; and to translate these efforts and research into practice. The health of our children, teens, and our nation at large is at stake, and we are the stakeholders who can facilitate a better future endorsed by the change we wish to see.

Please consider joining the American College of Lifestyle Medicine, joining the Lifestyle Medicine Pre-Professional Education Member Interest Group, and/or the Pediatric Lifestyle Medicine Interest Group, working with other educators, sharing resources, downloading the free Lifestyle Medicine Syllabus, and reading the Lifestyle Medicine Handbook. ¹⁰ Infuse lifestyle medicine and American College of Lifestyle Medicine resources into your current curriculum, perhaps develop new curricula, and advocate for the transformational power of lifestyle medicine to be part of policy. Many educators are already invested in groundbreaking lifestyle medicine activities. Educators, clinicians, and other stakeholders are ready to join together to amplify the health-promoting work that is already occurring. The time has come to work together to translate the power of current and future research into practice. The time for change is now, and it requires a coordinated effort that involves us all!