On Your Mark,Get Set,Go! It’s Time to Elevate All Six Pillars of Lifestyle Medicine . . . Starting With Physical Activity!

Peak VO₂ independently predicts overall mortality, overall cardiovascular mortality, and even health care costs . . .

What a perfectly timed issue of the American Journal of Lifestyle Medicine (AJLM) with a focus on cardiovascular and exercise topics to welcome in my term as the new President of American College of Lifestyle Medicine (ACLM) and reflect on my journey from Exercise Physiology to Cardiology to Lifestyle Medicine.

Whereas I suspect many ACLM members come to lifestyle medicine through the perspective of food as medicine, I came to lifestyle medicine through the perspective of exercise as medicine. Before medical school and while a graduate student at the University of Wisconsin Human Performance Lab, my responsibilities included performing peak VO₂ testing on Olympic athletes and staffing one of the earliest cardiac rehabilitation programs by running alongside heart failure patients on the shores of Lake Mendota. While I loved understanding the intricacies of how the human body achieves Olympian-level physical endeavors, it was working with cardiac patients that inspired me toward a clinical career in cardiology and cardiac rehabilitation, and eventually into lifestyle medicine where I developed a deeper understanding of nutritional sciences and the other pillars of lifestyle care.

Since joining ACLM in 2014, I have often been approached by members expressing interest that lifestyle pillars beyond nutrition become more developed within our organization and at our national conferences. I could not agree more and so I was delighted to see the article by Lamonte in this AJLM issue focused on physical activity and heart failure, a condition I treated daily over the past 30 years. The severity of heart failure and need for cardiac transplantation has long been measured by the level of peak VO₂. Lamonte describes that the level of peak VO₂ is a risk independent of physical activity level for patients with heart failure. We also know that peak VO₂ independently predicts overall mortality, overall cardiovascular mortality, and even health care costs in multiple patient populations. And yet peak VO₂, more simply referred to as cardiovascular fitness, is not often talked about to patients, nor among practitioners of lifestyle medicine.

This brings me to a question and a challenge to our members. Can we do better for our patients by expanding our exercise prescriptions beyond general exercise guidelines to exercise training prescriptions? Can we further leverage the exercise sciences to provide precision prescriptions for specific chronic disease conditions? Just as a generally healthy diet may not provide a sufficient dose to accomplish regression or remission of disease activity, a general activity prescription may not be sufficiently dosed to yield an improvement in cardiovascular fitness or appropriately targeted to a particular patient’s health condition. I encourage members to work with certified clinical exercise specialists and fitness trainers to create precision prescriptions to dose and tailor exercise for a particular patients’ medical condition. Talk to your patients about the importance of cardiorespiratory fitness above and beyond general physical activity and help them see the connection between your precision prescription and their disease activity.

Over the past year, ACLM has forged partnerships to build the pillar of physical activity including a partnership with the American College of Sports Medicine (ACSM) and the new Physical Activity Alliance (PAA) comprised of multiple national stakeholder organizations in the physical activity area. Advocacy for exercise as a lifestyle medicine intervention promises to be that much more successful through these affiliations. If you have a passion and expertise in exercise sciences, please contribute to the Fitness and Rehab (PT) and Medicine Member Interest Group to help us elevate our physical activity pillar. I also encourage members to join ACSM and receive their journal, Medicine & Science in Sports & Exercise. You will discover fascinating exercise science to expand and optimize treatment of your patients with diabetes, cancer, and hypertension, and many other conditions. As examples, stay current on the evidence for when high-intensity interval training may give superior results to moderate intensity training for your least fit patients and or what the science says about exercise parameters for diabetic or cancer patients. And if you are athletic-minded, you will pick up some amazing science to support your own exercise goals. Just as I developed a deeper understanding of nutritional sciences after joining ACLM, our members must embrace a deeper understanding of the exercise sciences.

And now back to heart failure, the other topic of Lamonte’s article. I have no doubt that most of our members have treated heart failure in their training days or in their current practices. However, not all of you may know that heart failure is the leading cause of hospitalization after age 65 years, has a 50% 5-year mortality rate, and that the prevalence of heart failure is dipping into younger age groups, particularly patients who are obese, hypertensive, or diabetic. With the exception of viral and unusual genetic etiologies, all of heart failure may now be considered a lifestyle-related condition and is optimally managed through coordinated efforts between cardiologists and lifestyle medicine–proficient physicians. Heart failure is such a costly condition that it has become a diagnosis to address in the CMS (Centers for Medicare and Medicaid Services) Model 2 of Bundled Payments for Care Improvement (BPCI). Stay tuned for some ideas on how lifestyle medicine physicians may participate in that program.

While at a heart transplant center during my cardiology fellowship, I saw many patients with heart failure with reduced ejection fraction (HFrEF) and over the decades, watched amazing pharmacologic and device therapies advance for this condition. In 2018, CMS even expanded coverage for lifestyle services for these patients through participation in cardiac rehabilitation programs. Most of us practicing outside a tertiary center care for patients in the category of heart failure with preserved ejection fraction (HFpEF), a still poorly understood and complex condition without effective pharmacological or device treatment, and without cardiac rehabilitation coverage. These patients with normal or hyperdynamic left ventricular ejection fraction represent 50% of heart failure patients. My HFpEF patients were often older women and their quality of life was terribly impacted with exercise intolerance and fatigue after even light activities of daily living. I knew they would thrive and best survive with comprehensive lifestyle medicine services but without cardiac rehabilitation, resources are scarce for this population. Despite my appeals and seeming inspiration for them to increase physical activity on their own, these patients did not experience an endorphin rush with exercise, and rarely could exercise long or frequently enough to experience a positive training effect and improved quality of life.

Lifestyle medicine providers can fill an enormous gap in care for these HFpEF patients through several means. The first is to encourage cardiovascular colleagues to refer to your Intensive Therapeutic Lifestyle Change programs or your Shared Medical Appointment models of care where patients gain additional support for comprehensive lifestyle care to target hypertension, diabetes, and obesity, the root causes of their condition. The second is to have these patients, despite or because of their chief complain of exercise intolerance, work under the guidance of a clinical exercise specialist. They may require more individualized, nuanced approaches but even small increases of cardiorespiratory fitness will go the distance in improving quality of life for these patients.

The last way lifestyle medicine providers can optimize care for all types of heart failure patients is through the CMS BPCI program. This program operates on a total cost-of-care concept with a goal to reduce rehospitalization and skilled nursing facility costs for 90 days after an index heart failure hospitalization. Lifestyle medicine providers may be able to provide wrap-around lifestyle medicine services or participate in gain sharing through convener organizations for the program. Explore community practices or hospitals in your community who may be participating in this program.

If you, like myself, opened the door to lifestyle medicine mainly though one pillar of lifestyle, now is the time to get out of your lane and nourish yourself with a deeper understanding of all the pillars of lifestyle medicine. Starting with the pillar of physical activity, amplify its importance and be prescriptive and individualized when you counsel your patients. Help them understand peak VO₂ is just as important for them as for admired Olympic athletes. Look for ways to expand the reach of your lifestyle medicine services by approaching cardiovascular colleagues or your hospital and help solve for the excess morbidity, hospitalizations, and costs associated with all patients even those so markedly affected by heart failure. On your mark, get set, go!