The Time is Now For Lifestyle Medicine: Lesson From Lifestyle Medicine Leaders

Abstract

The time is NOW for Lifestyle Medicine. In this review based on a presentation at the American College of Lifestyle Medicine (ACLM) 2021 annual conference, ACLM Current President Cate Collings, MD, Immediate Past-President Dexter Shurney, MD, and President Elect Beth Frates, MD, share insights on the current state of lifestyle medicine (LM). Interest in LM has greatly advanced in the face of disruptions from the COVID-19 pandemic, expanded educational opportunities in the field, and a rapidly changing healthcare landscape. With growing access to virtual care, advancing technologies, growing emphasis on home-based chronic care, continuing corporate healthcare mergers and acquisitions, and widening adoption of personalized, patient-empowered treatments, the time is ripe for LM interventions to move to the mainstream. As health investments and costs skyrocket, and new players enter the scene, traditional models of payments, reimbursements, and incentives are slowly being upended. Companies and healthcare systems are finally recognizing the scientific evidence and powerful but undervalued potential of LM to accelerate healthy outcomes while controlling costs. Taken together, the lessons from the COVID-19 pandemic, the growth in LM educational opportunities, and the evolving “business of medicine landscape” signal that the time for lifestyle medicine is NOW.

‘As one observes life before and after COVID-19, massive growth in educational opportunities, and evolving business in the medicine, lifestyle medicine’s time is now’

Introduction

In a rapidly evolving healthcare landscape, as leaders in the field of lifestyle medicine, we believe that the TIME IS NOW for lifestyle medicine. In this review, we offer our perspective about how an LM approach is the healthcare intervention most needed at this moment. LM is the patient-centered approach needed to bridge the divide between public health guidance and healthcare delivery, a critical lesson learned from the COVID-19 pandemic. Critical to this endeavor is education. We believe the strength of our organization rests with our ability to help teach future generations of health professionals and the public about the health benefits of an LM approach both in the clinic and outside of it, in our communities and schools. In this review, we also share the breadth of educational opportunities offered though the work of ACLM members. We end by discussing current trends in healthcare innovation, trends that will allow us to grow the field and deliver the highest quality care to patients within a reimbursement model that is shifting to reward value-based care.

Lifestyle Medicine: The Time Is Now

The case for lifestyle medicine has become urgent in the syndemic arising from the COVID-19 pandemic and concurrent lifestyle-related chronic disease pandemics. This global infectious pandemic has exposed numerous gaps that have obstructed a controlled response and solution. Some failures of control have been related to the virus’s ability to develop new variants and evade vaccination efforts, but also by co-existing sociopolitical forces, co-existing lifestyle-related chronic disease at pandemic global levels, and vast health inequities. Of these, appropriate attention to health inequities in COVID-19 testing, vaccine distribution, and the provision of clinical care have risen in priority. Much has also been considered about co-existing sociopolitical forces that continue to seed COVID-19 spread. What has been largely disregarded is attention to mitigation of co-existing lifestyle-related chronic diseases that portends the gravest COVID-19 impact.

Efforts to improve population-level responses to COVID-19 such as quarantines, physical distancing, and vaccination have been assigned to the public health sector through educational and campaign efforts. Lifestyle recommendations such as dietary and physical activity guidelines have likewise been provided through public health guidelines for decades. And yet, the percentage of adults meeting lifestyle public health recommendations remains low and without significant change over the past decade. For example, despite the well-known advantageous effects of regular physical activity on cardiovascular and all-cause mortality, immune function, long-term mental health, and on the particular morbidities considered as risk factors for severe COVID-19 disease outcomes, physical activity recommendations are poorly met. According to recent data, only 23.2% of US adults 18 years of age and over meet the aerobic and weight resistance guidelines in 2018. This is a percentage that has not changed in magnitude over the past decade. ¹

Dietary guidelines have also been a mainstay of public health recommendations, and yet the recommended fruit and vegetable intake has not been achieved. Only 1 in 10 US adults eat the recommended amounts of fruit and vegetables, based on data as recent as 2019. ² The prevalence of obesity, which is often the sequelae of nutritional and physical activity mismatch, has risen from 26.4% in 2006 to 31.7% in 2018. ¹ These statistics demonstrate that public health recommendations and the imparting of knowledge, while important, are not sufficient to change lifestyle behaviors. Early efforts to integrate lifestyle variables such as BMI into electronic medical records add knowledge but provide insufficient workflow and infrastructure support for patients to make lifestyle behavior change.

We now see that the gap between public health guidelines and their intended aim can be achieved through the implementation of lifestyle medicine models of care at the individual practice, health-system level, and community-health level. The exponential growth of lifestyle medicine physicians and other lifestyle medicine health professionals certified through the American Board of Lifestyle Medicine and American College of Lifestyle Medicine (ACLM) provides the clinical human capital to achieve public health and population health goals through implementation of clinical lifestyle medicine.^3,4

Other initiatives to bridge the gap between current public health recommendations and their equitable implementation include the emergence of health systems who are sharing best practices for integration of lifestyle medicine at a systems level through ACLM’s Health Systems Council and prioritization of Health Equity Achieved Through Lifestyle Medicine (HEAL) scholarships for LM-certified diplomates serving through safety net clinics. ACLM curation and certification of evidence-based intensive lifestyle medicine programs is another building block to add systemization and structure for lifestyle program implementation, whether in the healthcare or community setting.

After decades of supporting pharmaceutical and procedural research to manage chronic conditions rooted in lifestyle behaviors, a pivot to support research on the most scalable and cost-effective models of lifestyle medicine that will support widespread implementation and the management of chronic conditions at their root cause is slowly unfolding. Whether approaching the current syndemic or those in our future, the time is now for an accelerated approach to support public health through the adoption of clinical lifestyle medicine.

Lifestyle Medicine Education for Health Professionals and the Public

In order to engage and educate health professionals and the public, ACLM has developed a variety of initiatives. As an organization, ACLM continues to provide educational materials that are engaging and impactful. Every year, the organization adds more educational options to support growing membership. The offerings range from CME courses, both live and online, to resources for specialties such as pediatricians and healthcare workers serving teenagers. There has never been a better time to learn about and seek certification in the field.

Currently, board certification in lifestyle medicine is available for physicians, healthcare professionals, and practitioners. The more healthcare providers spend the time to master the core material of lifestyle medicine, the better off the field. When physicians, nurses, therapists, physician assistants, nurse practitioners, nutritionists, exercise physiologists, and other allied healthcare providers are all well-educated in the science of lifestyle medicine, ultimately, patients benefit. As lifestyle medicine is optimally practiced with a team of individuals all working to support the patient when the team has the same foundation of knowledge, the patient receives consistent up-to-date information.

Since 2017, the number of physicians in the United States taking and passing the American Board of Lifestyle Medicine exam has almost doubled each year with 221 passing in 2017, 440 passing in 2018, 761 passing in 2019, and 1586 passing in 2020. A similar trend is noted among healthcare professionals and providers with a total of 441 professionals passing in 2020 and 154 providers passing in 2020. Certification is available for physicians, professionals, and providers across the globe, and there are 887 international board certified physicians through ABLM as of 2020. In order to maintain an active license, physicians complete continuing medical education (CME) hours. Again, ACLM helps physicians meet this requirement. There are more than 100 hours of CME available through ACLM.

The LM field continues to grow with a Lifestyle Medicine Specialist Fellowship at Loma Linda University Health. In the future, the plan is to develop more fellowship training opportunities building from the sites that implement the Lifestyle Medicine Residency Curriculum (LMRC). Currently, there are 82 sites offering the LMRC. The curriculum is comprehensive, applicable, and flexible. It is designed for integrated implementation into medical residency programs. There are 40 hours of didactic material and 60 hours of independent application activities included in the program. Upon completion, residents qualify to sit for the ABLM certification exam.

ACLM also has a Medical School Education Task Force that has been working to create ways to help medical school faculty include lifestyle medicine guidelines, practice, principles, and research into the undergraduate medical curriculum. The committee created a cardiovascular case study that will be available for all members to utilize. The ACLM members on this committee also collaborated to advance knowledge about medical education transformation and lifestyle medicine curriculum education standards.^5,6

One of the most powerful and widespread efforts that ACLM has put forward in the medical school education space is the development of the Lifestyle Medicine Interest Groups (LMIGs). In 2009, the first lifestyle medicine interest groups started. At that time, there were two. Twelve years later, there are over 60 official LMIGs. The goal is to reach all 192 medical schools in the next five years. ACLM is available to help guide students and faculty in creating and sustaining LMIGs. There is a supportive community of LMIG members that meet regularly throughout the year. To start an LMIG, there needs to be an interested student and an interested faculty member at a minimum. The paper, “A Parallel Curriculum,” outlines the steps involved in starting an LMIG. ⁷ Additionally, the American Journal of Lifestyle Medicine publishes an education column each year, authored by leaders in lifestyle medicine.^8-10

To make lifestyle medicine education mainstream, LM needs to become part of the public school education system. ACLM members have been working to make this a reality throughout the United States for the past four years.^11,12 ACLM has a full teen curriculum available to members that can be used in middle school or high school. A Teen Lifestyle Medicine Handbook, 12 decks of PowerPoint Slides, and a Teacher’s manual to help empower teachers to use the curriculum.

With the vast array of educational resources, the time to learn about and practice the pillars of lifestyle medicine is now. As interest in learning more about LM is mounting, so are the resources are available through ACLM. Health professionals must continue to engage in LM education to meet the moment.

The Business Case for Lifestyle Medicine

By training the next generation of health professionals, LM-trained healthcare workers will be poised to take advantage of the latest trends in healthcare financing and innovation.

The financial footing is always a good place to start to spot trends or to examine the emergence and staying power of anything that pops up in the constant 360-degree social, economic, environmental, governance, and industry scanning. This is particularly true when we look at the state of lifestyle medicine (LM)—who is or should be financing it? Where are the dollars flowing?

According to health technology investment trends identified in the 2020 Deloitte publication, “The Future of Health,” $34.7 billion dollars were invested in more than 1500 healthcare deals, with digital startups representing about 40% of both the number of deals and the funding. ¹³ In fact, the investments in digital health solutions more than doubled over those of prior years.

During 2021, according to the Mercom Capital Group, these investment trends have continued. ¹⁴ Virtual care, in particular, is accelerating faster than anticipated, and dollars are being directed at companies in the chronic-care management arena. The theme is not only consumer and patient access to primary and urgent care, but also chronic care, which is starting to expand into specialties.

Consumers are taking more control of their own health, and more diagnostics being deployed for use in the home outside of clinical settings. Strategic mergers and acquisitions remain popular, a trend started pre-pandemic and still changing the healthcare landscape. In addition, an influx of new, nontraditional healthcare investors, organizations, and companies have entered the healthcare market. What was big business before is even bigger business now.

Deloitte notes that of the $4 trillion spent on health within the Gross Domestic Product of 2019, $1.5 trillion (18.5%) was spent “on waste.” ¹³ Today, the company predicts deceleration in health spending as a percentage of GDP by 2040, creating a $3.5-trillion “well-being dividend” and thus, a potential revenue opportunity for providers and vendors working in well-being and possibly, LM. ¹³ Put another way, traditional healthcare revenues that were projected to grow to a breathtaking $11.8 trillion (26.15% of the nation’s estimated GDP in less than 20 years) will only reach $8.3 trillion due to a predicted $3.5-trillion well-being dividend. ¹³

These general health trends also apply to LM or versions of it. Each transformation seeks ways to improve chronic-care management at scale, direct to consumers, and virtually. The nation is at a crossroads—continue “sick care” unabetted or commit to more ways to improve and support “well care.” While chatter and pilots abound, little has truly been enacted or achieved.

What is critical and clear, though, is that lifestyle medicine must play a material role in realizing that “well care”—and the financial incentives, reimbursements, and models to support this evolution—is the only sustainable path to a healthier American public. It is encouraging that in some circles, LM is already being thought of as an essential component of well care, but more advocates, research, and practitioners for this to become a common reality are needed.

Why Now for Lifestyle Medicine?

One key burgeoning opportunity for LM is that it is synonymous with value-based care (VBC), a developing payment trend whose importance will be elevated by the transition to this model by the Centers for Medicare & Medicaid Services (CMS) and across America’s healthcare system. Because LM addresses the root cause of disease rather than medicating and managing symptoms, it is a highly cost-effective, efficient way to tackle near- and long-term chronic care. This positions LM in a good place to help organizations achieve the quadruple aim of enhanced patient experience, improved population health, reduced costs, and better work lives for healthcare providers. LM reignites the passion for why most healthcare providers even went into medicine—to become true healers, a potential antidote to the epidemic levels of provider burnout.

Is LM gaining traction? Yes, but again—follow the money. In 2021, investors were showing the most interest in chronic conditions, behavioral change, patient empowerment, and convenience.

Companies focusing on behavior change and on understanding what drives individual habits and behaviors related to weight reduction are leaders in terms of attracting the most dollars. Other companies that have successfully wooed investor attention with promises to manage care better and even reverse conditions such as type-2 diabetes. What is missing is substantial investment in what physician colleagues would call the “practice” of LM.

Growing the “Food as Medicine” Movement

Many companies also are very interested in the Food as Medicine (FAM) movement. Although medically tailored meals have been available for some time, next-generation FAM advocates and investors view it with a twist—convenience. Kroger Health, for example, has not only made a major splash delivering care within its parent grocery stores, it also has launched an initiative called OptUP, a nutrition rating system to simplify choices around nourishing foods.

Kroger Health calculates nutrition ratings by “leveraging data science, evidence-based nutrition information, and machine learning to rate foods on a simple scale from 1 to 100. Consumers can check nutrition ratings as they grocery shop, looking for the information on each product page.” The tactic empowers shoppers to “use nutrition ratings to quickly compare similar products and add better-for-you items,” so they can “understand how healthy they are eating.”

Kroger relies on a different app to help power its programs for diabetes prevention and control. The technology connects patients to a coach to assist them with tracking and control of their condition. Patients also receive daily text messages with educational content, personalized exercise and nutrition plans, progress reports, social support from a small group of peers, and monthly phone calls from wellness professionals to ensure they are getting guidance and encouragement from coaches and other available providers. The app automatically tracks other LM elements such as sleep, stress, and weight data to optimize and personalize the program.

Diet ID, an LM company led by another LM leader, David Katz, MD, also doubles down on innovation and personalization. The company is growing in prominence due to its groundbreaking technology that will enable nutrition to become a vital sign, an emerging standard of care. The importance of diet and health, and diet in the treatment of disease is recognized. However, due to the lack of a quick, convenient way to assess nutritional status at scale, it has not been a part of general practice to include nutrition as a vital sign. Now, consumers have an accurate way to assess nutrition quickly (within a couple of minutes) and correlate it to the validated Healthy Eating Index. In the future, nutritional assessments can be performed in the clinic setting for each patient in a fashion similar to checking blood pressure. Since blood pressure is used to assess, track, and monitor patients’ improvement and risk, developing a customizable diet can be done the same way using this new technology.

In addition, organizations such as The University of Mississippi, for example, are using LM to improve outcomes of traditional treatments. The university incorporates LM into its total joint replacement program for hips and knees prior to patients receiving joint arthroplasty if they are overweight or have issues with hemoglobin, A1C, body mass index, or poor nutritional status. Patients are referred to LM to improve their condition by losing weight or bringing blood glucose into control prior to surgery. More widely, there is greater appreciation for how LM can work in conjunction with surgical programs to reduce complications and speed recovery, and how it can be applied practically into greater care scenarios.

LM has even drawn the interest of real estate developers. One is working with Blue Zones, LLC, to develop a mixed-retail space in Miami, Florida, that will be a Blue Zones micro-immersion for people living there as resident owners or staying as hotel guests. Called “The Center for Health + Performance,” the innovative care system aims to seamlessly incorporate wellness, prevention, and LM services in response to “patients’ desire for more transparent and holistic care.” Developers are relying on smart, integrated technology and design to optimize clinical efficiency to help carry out the mission.

Given the tremendous interest in FAM, the 2021 launch of the Blue Zones Well-Being Institute (BZWI) has decided to conduct clinical trials in this research area. The FAM clinical study is a randomized controlled l trial that will compare a whole-foods, plant-based (WFPB) to a more traditional Mediterranean diet for several chronic conditions such as type-2 diabetes. Patients with disease states of interest will be followed longitudinally through an induction phase of 3 to 6 months that includes education, coaching, and meals, followed by a sustainability phase of ongoing education and access to community and other resources to ensure self-sufficiency and continued success for up to 24 months.

The BZWI is not alone in the pursuit of expanding the scientific evidence underpinning FAM. Although more payers are open to the concept of FAM and ways to pay for these services, often through CMS’s “in-lieu” provisions, many FAM initiatives are still funded through grants and charities.

Some have pondered that if “food” can truly be used as a medicine, then how might it fit into the standard drug benefits design? Placing prescribed diets for a given disease on the “formulary” as a specific therapy, perhaps a new Tier 1 intervention as a component of a well–thought-out step-therapy.

More broadly, LM also has reimbursement challenges with physicians often trying to work around a CPT coding system that was not originally intended for LM. To a large extent, this approach has proven to be inefficient and unsustainable. Thus, the BZWI will endeavor to leverage promising discoveries into meaningful changes to policies and reimbursement to create sustainability.

Innovative thinking and these types of initiatives could become the basis for acceptable alternative payment models for LM practitioners. Disease reversal should ideally trigger the provision of “residuals payments,” whereby providers receive reimbursement credit for reversing the disease for a number of years into the future from the first year the condition was reversed or sent into remission. As we look at the status of life medicine today, despite continued challenges, we have made progress and opportunity has never been greater.

Lifestyle Medicine Leaders Call to Action

As we look at what has come before and life after COVID-19, the massive growth in educational opportunities, and the evolving “business of medicine landscape,” as LM leaders, we firmly believe the time for lifestyle medicine is NOW.

The urgency of the current syndemic is a call to join and expand the reach of lifestyle medicine.