Abstract
“The behavior of the economy, at the aggregate, macro-level, is built up from the individual equations at the micro-level” Paul Ormerod, Behavioral Economist
Early thinkers in lifestyle medicine observed that the cumulative micro-level behaviors of their patients; what they ate or didn’t eat, how they moved, their mindsets or mood, and how they slept added up at the macro-level to their health or disease outcomes. In an earlier column, I wrote about the vision of merging lifestyle medicine into the main healthcare highway. I’m glad to report that vision is being actualized through the efforts of members and partners of the American College of Lifestyle Medicine (ACLM) and World Lifestyle Medicine Council, formerly known as the Global Lifestyle Medicine Alliance, and increasingly at US health policy and health systems levels. But if that vision implies that effectiveness is only at the macro-level, it would be short sighted. The field of lifestyle medicine must be built and directed to each crossroad of a patients’ health and healthcare experience: at the individual office visit level, through coordination at the multispecialty or network level, at the health system level and on to the macro population health level.
At the individual office visit level, practitioners who have long enjoyed close relationships with their patients can be tremendously successful in prescribing lifestyle treatments and achieving excellent health outcomes. These practitioners treat individual human beings, tailoring their messaging and methods to the intimate details of their patients’ lives. As they actively influence and treat one individual, they take to heart the impact on and of that individual’s family and friends. The early trailblazers in lifestyle medicine had office “test kitchens” where they prescribed micro-level lifestyle behaviors and researched outcomes to steer the early development of our field. Stepping aside the common belief that only evidence achieved through large-scale randomized controlled trials could inform treatment, the quantitative and qualitative health outcomes they witnessed through lifestyle prescriptions gave them the courage to continue in what was often dubiously described as alternative medicine. I am grateful to their courage and to those who still practice at a small practice level, testing different methods and achieving outcomes that stand on their own merit while informing research for larger scale trials.
The practice of lifestyle medicine at the mid-size group or multispecialty practice level is another crossroad for application in the field. Lifestyle treatments standardized and coordinated into referral and workflows for chronic disease patients can optimize quality outcome metrics such as HgbA1c and blood pressure which in turn can be tied to reimbursements, competitive contracting, and success in capitated contracts. Using a team approach with integration of team members such as nutritionists, exercise specialists, and health coaches working collaboratively under board-certified LM providers is essential for scalability and success at this level. In the setting of capitated care and financial at-risk models, self-care achieved through behavior change lifestyle programs can be more cost effective than procedures and hospitalizations, particularly when scaled with digital health as an extender of in-person care.
Application of lifestyle medicine to scale at a health systems or population health level requires advanced infrastructure including that which recognizes the large role of the social and cultural determinants of life and lifestyle. A recent ACLM-sponsored Health Equity Achieved through Lifestyle Medicine (HEAL) Summit provided a strong first step in addressing this topic and two research protocols in communities of color are in final planning stage through the ACLM research department. Equal in scale of impact is the formation of the ACLM Health Systems Council. This council, formed by 19 founding member institutions, will become the wellspring to share best practices for provider education and infrastructure to leverage lifestyle medicine at the health system level. During a recent Lifestyle Medicine in Health Systems symposium, active-duty Air Force division leaders shared that training initiatives in Lifestyle and Performance Medicine have been launched with an aim to formulate best practices for other active-duty military branches as a means of optimizing national security. Organization at the scale of health systems or population health is when we will realize the Quadruple Aim: better health outcomes, lower costs, improved patient experience, and improved provider experience.
While I am often most excited about large scale initiatives that aim at macro-level impact, I have found my most rewarding moments face to face with patients in my office visits and you may too. These micro-level interactions centered on eating patterns, activity habits, and how patients sleep and socialize are the essential building blocks of a successful clinical encounter. In recent times, the Covid pandemic has amplified the compounding risk of health care inequities, lifestyle related co-morbidities, and infrastructure fault lines. As our field is merging onto the mainstream healthcare highway at this time, we have a unique opening to intensify the message that lifestyle medicine must be built throughout the micro, intermediate, and macro-level of a redesigned and transformed healthcare system.