Sage Journals: Discover world-class research

Abstract

Introduction

The relevance of lifestyle medicine in diabetes treatment is now incorporated in clinical practice guidelines but finding an exemplar for the creation of a Lifestyle Medicine Program (LMP) is a difficult task.

Aim

To use Lifedoc Health (LDH) as a LMP exemplar by describing their multidisciplinary team (MDT) approach to diabetes care along with tactics to address sustainability challenges.

Results

The LDH model facilitates early activation of patients with diabetes and other cardiometabolic risk factors, MDT approaches, and protocols/policies that are able to overcome barriers to equitable healthcare in the community. Specific programmatic targets are clinical outcomes, effective dissemination, economic viability, and sustainability. Infrastructure centers on patient-driven problem-based visits, shared medical appointments, telemedicine, and patient tracking. Further discussions on program conceptualization and operationalization are provided.

Conclusion

Even though strategic plans for LMPs that specialize in diabetes care are well represented in the literature, implementation protocols, and performance metrics are lacking. The LDH experience provides a starting point for those healthcare professionals interested in translating ideas into action.

Keywords

lifestyle medicine center lifedoc health lifestyle medicine program dysglycemia-based chronic disease multidisciplinary team

“The description of the LDH LMP offers a comprehensive illustration of tactical planning and execution.”

Introduction

The prevalence of diabetes has increased in the U.S. from 7.7% to 13.3% from 1999–2000 to 2015–2016 (90–95% are type 2 diabetes [T2D]) following the same trend as other regions in the Americas.¹ Effective and sustainable actions are required to mitigate the burden and consequences of diabetes. However, successful preventive strategies to reduce T2D incidence and progression, such as the National Diabetes Prevention Program (DPP)² and the Diabetes Self-Management Education and Support Program³ are not easy to implement into practice. Most patients with T2D present with other cardiometabolic risk factors and comorbid conditions, including abnormal adiposity, hypertension, and dyslipidemia. Additionally, T2D progression and management are deeply influenced by social determinants of health (SDOH), as well as ethnocultural and behavioral factors,⁴ which are elements that must be taken into consideration for successful implementation of preventive strategies.

In clinical practice guidelines, lifestyle medicine strategies in T2D care focus on the incorporation of nutrition, physical activity, smoking cessation, alcohol moderation, sleep hygiene, and behavioral support,⁵ with levels of intensification depending on disease severity. The implementation of these strategies (long-term goals) begins with translation into a tactical plan (short-term actions), which is followed by a materialization process. Conceptualization is the first materialization step, followed by operationalization. These 2 steps define the targeted population, develop diagnostic and management protocols based on the population’s ethnocultural risk profile, and then set realistic financial projections to ensure sustainability and growth.^6,7 Lifestyle medicine programs (LMPs; including Centers and Clinical Service Lines) play a critical role in narrowing practice gaps. However, descriptions of this process to enable large scale implementation are scarce.⁸

Lifedoc Health (LDH) was designed according to a practice model that can address the glaring barriers compromising care for patients with cardiometabolic-based chronic disease (CMBCD) in the Greater Memphis Area. Since 2005, this translational-research center has been dedicated to building a self-sustained and outcome-oriented resource that detects and manages populations at high risk for T2D, obesity, and associated complications. The key feature of LDH is a primary framework focused on characterization of a particular patient’s cohort in order to better understand the complexity and real-life evolution of cardiometabolic drivers in the population. Data collection platforms and protocols for systematic capture are the central provision of this dynamic model.

The objective of this review is to present the Lifedoc Health model as an exemplar of a LMP for diabetes and cardiometabolic care. A multidisciplinary team (MDT) approach will be described, and the process of implementation outlined. In addition, sustainability challenges especially from the standpoint of ethnocultural factors and SDOH will be discussed.

LDH Care Model

Lifedoc health is a multidisciplinary and data-driven healthcare organization committed to preventing and treating dysglycemia (insulin resistance, prediabetes, and T2D), abnormal adiposity (including overweight/obesity), and their adverse consequences. The LDH programs have received state and National Committee for Quality Assurance (NCQA) recognition and accreditation for over 10 years.⁹ Within LDH, there are various clinical service lines that encompass primary and specialty care, acute and chronic conditions, as well as care coordination, pharmacy, patient education, and lifestyle medicine into a unified dynamic approach to patient care. Healthcare professionals (HCPs) undergo protocol training and reinforcement, and primary care providers (PCP) are coached to achieve early activation of patients, with or at risk of cardiometabolic conditions, for co-management by the multidisciplinary team.

The LDH model was designed under the Family-Centered Medical Home (FCMH) model with 3 main aims: MDT approach, validation of outcomes, and building systems based on data collection and analysis to refine the model. The LDH model includes 5 components. The first is risk screening through the LDH’s Diabetes and Cardiovascular Risk Stratification Program, eye exam, cardiology tests, and collecting information about SDOH, ethnocultural factors, lifestyle, and risk behaviors. The second is activation of those patients with at least 1 risk factor to interventions. The third is clinical intervention applying an evidence-based MDT protocol that includes visits provided by nurse practitioners supervised by an endocrinologist, lifestyle medicine, care coordination, shared medical appointments, cardiometabolic-related drug-curriculum, and psychological intervention when needed. The fourth is to reduce inequities by implementing an affiliation program that increases access to healthcare to uninsured patients (e.g., Vida Plus program) via culturally competent services. The bulk of the assigned and referred patients are under some type of governmental healthcare plan (e.g., Medicare or Medicaid) or uninsured. In essence, the LDH model has an inclusive protocol in which any patient could benefit from it regardless of their socio-cultural strata, racial background, or insurance coverage. The last and fifth component of the FCMH model is the inclusion of community-based programs that include nutrition education and healthcare in schools (e.g., Wave for Health Program) and the healthy prepared meal program to reduce food insecurity. Also, within the LDH model is a monthly patient newsletter with educational content about health, lifestyle, nutrition, and exercise. Also, as part of ongoing medical education for HCPs and staff members, an educational meeting (i.e., inservice meeting) is delivered every month. This includes lectures to update the current knowledge about strategic and operational topics. Population characterization, risk stratification and efforts validating interventions has been reported to optimize the LDH model.^7,10-22

An analysis of the LDH patient population showed that over 70% of the children, adolescents, and young adults with obesity exhibited 3 or more cardiovascular disease risk factors. Additionally, 13% of patients with overweight or obesity undergoing risk stratification had either prediabetes or unknown T2D, and close to one-third of them have either elevated blood pressure or established hypertension. Data from 2018 showed that 68% of the patients having at least 1 cardiometabolic condition (overweight/obesity, prediabetes/T2D, or hypertension) and 97% of the patients with a glycated hemoglobin A1C (A1C) ≥ 6.5% began the MDT protocol,²³ reflecting the PCP’s awareness regarding the importance of the MDT approach.

The LDH protocol has resulted in a decreased number of cardiovascular disease risk factors among patients and demonstrable financial sustainability, in part because patient activation is associated with those codes and procedures that are covered by insurance companies. The LDH clinics serve between 8000 and 10 000 active patients per year, of which 83% are African American or Hispanic, 44% younger than 21 years of age, and 85% under government insurance or cash coverage, with a 3-year patient retention rate close to 70% and a sustained growth of 11% year over year.²⁴

LDH Implementation Modalities

Implementation modalities in the LDH model span clinical practice, research, and education. The LDH relies primarily on clinical practice, with research conducted through Lifedoc Research PLLC, a sister company dedicated to clinical trials, investigator-initiated studies, and both translational and population-based research. Evidence generated from research studies can optimize intervention protocols, specify transcultural components, generate novel hypotheses, and lead to publications in peer-review journals. Education to HCPs and staff is an ongoing process. For example, contacts have been established with local universities to formalize a training program in chronic cardiometabolic diseases for nurse practitioners. Lifedoc health members are also involved in continuing medical education, such as lectures, research training programs, and other activities associated with research grants.

Clinical Intervention Protocols

Within the LDH model, there is an emphasis on diabetes and cardiovascular risk stratification that fosters preventive interventions and dynamic insulin algorithms. In this type of protocol, patients are activated through involvement with an MDT when ≥1 cardiometabolic condition (overweight/obesity, prediabetes/diabetes, or hypertension) is detected. Once activated, a visit is scheduled to collect blood samples following a ≥8 h overnight fast for a cardiometabolic laboratory profile, including a 75 g oral glucose tolerance test (OGTT) with serum glucose and insulin samples at 0, 30, 60, 90, and 120 minutes. Lifestyle recommendations are provided by an exercise physiologist. If needed, patients then undergo protocolized pharmacotherapy. Specifically, those with overweight/obesity are treated with topiramate (25 mg po BID) and low dose phentermine (18.5 mg po QD) unless contraindicated or otherwise not tolerated. Those with insulin resistance are treated with metformin (1500 mg po daily in split doses initially and then uptitrated to 2000 mg a day). Patients with T2D are treated with anti-diabetic drugs clinically proven to promote weight loss, primarily metformin and either incretin-based (e.g., glucagon-like peptide 1 receptor agonist [GLP1ra] or dipeptidyl-peptidase 4 inhibitor [DPP4i]) or sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapies. Specific medications are selected according to individual clinical conditions and insurance coverage. Additional follow-up and engagement protocols are tailored according to individual needs (Figure 1).

Figure 1.

Lifedoc Health clinical intervention protocol. Abbreviations: BID: twice a day, BMI: Body mass index, CVD: Cardiovascular disease, DBP: Diastolic blood pressure, DM: Diabetes, DPP-4: Dipeptidyl-peptidase 4 inhibitors, Echo: Echocardiography, GLP-1: Glucagon-like peptide 1, ICD-10: International Classification of Diseases 10, LDH: Lifedoc Health, OGTT: Oral glucose tolerance test, QD: Once a day, SGLT-2: Sodium-Glucose Cotransporter-2 inhibitors, SBP: Systolic blood pressure, T2D: Type 2 diabetes.

LDH MDT Outcomes

A 1-year retrospective review in 2018 of 598 adults (African American 59%, Hispanic 35%, and Caucasian 6%) with a mean age of 43.8 years ±14.0 was performed. Activated patients (≥1 cardiometabolic risk factors of overweight/obesity, prediabetes/diabetes, or hypertension) who were treated under an MDT protocol were compared to patients who qualified for MDT but instead were treated solely by a PCP. After 1 year of intervention, patients treated by the MDT had a greater reduction (β, 95% CI) in weight (− 4.29 kg, −7.62, −.97), body mass index (−1.43 kg/m2, −2.68, −.18), systolic blood pressure (− 2.18 mmHg, −4.09, −.26), and diastolic blood pressure (− 1.97 mmHg, −3.34, −.60). They also had 77% higher odds of reducing their initial weight by ≥ 5%, 83% higher odds of reducing their body mass index by ≥ 1 point, and 59% higher odds of reducing their diastolic blood pressure by ≥2 mmHg. The number of encounters was an important factor in these positive results. The average number of visits for the total sample was 10.5 but was 2 times higher in the MDT group (12.3) compared to the PCP group (6.6). Among those engaged with the MDT, 30.9% of their visits were for lifestyle intervention.²³

Lifestyle Medicine at LDH

The Implementation Process

For 15 years, the LDH model has provided lifestyle medicine recommendations to patients with obesity and diabetes within an MDT approach. Before the COVID-19 pandemic, group exercise classes, especially in youth, were part of the usual routine of lifestyle interventions. This approach has now been updated by incorporating rigorous standardization to expand the program, replicate outcomes, facilitate personnel training for new satellites centers, and optimize lifestyle interventions. The purpose is to decrease the risk and progression of cardiometabolic chronic diseases in at-risk populations, while investing in new expert leadership and organizational infrastructure. This update of LDH operations adhered with the methodology proposed by Mechanick and Kushner²⁵ (Figure 2).

Figure 2.

Conceptual framework for the implementation of the Lifestyle Medicine Program at Lifedoc Health. Adapted from reference 57. Abbreviations: FCMH: Family Center Medical Home; HCPs: Health Care providers; LDH: Lifedoc Health; tCMBCD: Transcultural cardiometabolic-based chronic disease.

Implementation science involves well-designed multilevel processes that apply evidence-based actions into routine healthcare.²⁶ However, barriers or “determinants of practice,” including financial and human resources, time constraints, ethnocultural factors, and SDOH, must be used to adapt these interventions to achieve necessary changes.²⁷ Implementation of the LDH program began with the characterization of the population based on cardiometabolic risk profile, then definition of lifestyle interventional protocols addressing SDOH and transcultural factors, redistribution of existing physical spaces, and eventually “translation” of both evidence-based theoretical frameworks and clinical outcomes expressed in the real-world environment. The subsequent “materialization” process began with “conceptualization” of the care model, followed by “operationalization” (planning, building, and managing), including a process for continuous clinical and financial “optimization” to achieve sustainability. At a later point, the LDH program was scaled up by opening a third location with plans to open 4 more centers in the next 2 years to cover a larger geographic area in Memphis (Figure 2). Codification of these various sequential processes facilitates implementation with the materialization step being the most critical.

The first materialization step is a detailed conceptualization of the idea to be built-out

Interventions to prevent, treat and reverse the progression of diabetes and other cardiometabolic chronic conditions should focus on identifying the most prevalent risk factors in the target population.^6,28 The LDH programs are based on overcoming the barriers to access healthcare in the community served and therefore must meet 4 established LDH premises: (1) Can patients be helped? (Clinical outcomes) (2) Can whole populations be helped? (dissemination), (3) Can the program be financially advantageous? (economics), and (4) Can these positive results be sustained? (sustainability). The LDH program leadership continuously adapts to changing environmental pressures optimize resource allocation in this conceptualization process.

Specifically, the LDH programs merged the Family-Centered Medical Home (FCMH) and transcultural CMBCD (tCMBCD) concepts into a structured model. The main objectives of this new model are applicability, actionability, and sustainability for early intervention (e.g., during childhood).^29,30 The tCMBCD comprises 3 dimensions: stages, drivers, and SDOH. In the first dimension, the 4 stages are mapped to specific prevention modalities: 1 (Risk—primordial prevention of risk development and progression), 2 (Predisease—primary prevention of disease), 3 (Disease—secondary prevention of complications), and 4 (Complications—tertiary prevention of suffering and mortality); each stage is also subject to quaternary prevention (the avoidance of overmedicalization and unethical behavior).^29,31,32 In the second dimension, individual metabolic drivers are considered as progressing along these 4 stages. For example, the dysglycemia-based chronic disease (DBCD) model constitutes a new way to approach diabetes prevention and management: stage 1 is insulin resistance, stage 2 prediabetes, stage 3 T2D, and stage 4 cardiovascular complications. By adopting this paradigm, culturally adapted preventive care is applied at earlier stages .^33,34 The DBCD model aims to resolve the controversy around insulin resistance and the diagnosis of prediabetes incorporating them as specific DBCD stages in the progression of dysglycemia and incorporating them as an actionable entity for early prevention. When other metabolic drivers (e.g., abnormal adiposity [adiposity-based chronic disease; ABCD], hypertension [hypertension-based chronic disease; HBCD], and dyslipidemia [lipid-based chronic disease; LBCD] are configured along the 4 stages, a 2 × 2 matrix arises and depicts the 2-dimensional CMBCD framework.^29,32 In the third dimension, each stage and driver (represented by each cell of the 2 × 2 CMBCD matrix) is populated by SDOH and other ethnocultural factors to improve precision of preventive actions and optimize outcomes (Figure 3). Implementing this model in the daily routine clinical practice implies the staging of the patient’s individual risk for each biological driver (adiposity, dysglycemia, hypertension, dyslipidemia) and the incorporation of social determinants to specify the lifestyle recommendations.

Figure 3.

The transcultural Cardiometabolic-Based Chronic Disease (tCMBCD) model. The tCMBCD model describes the natural history of the cardiometabolic disease continuum, its drivers, preventive interventions, and opportunity for transculturalization at each stage. Abbreviations: ABCD: Adiposity-Based Chronic Disease; CMBCD: Cardiometabolic-Based Chronic Disease; DBCD: Dysglycemia-Based Chronic Disease; MetS: Metabolic Syndrome.

The second materialization step is operationalization of the new LDH programmatic concept

Lifestyle medicine was framed within the mission (To build healthier communities by preventing diabetes and obesity through healthcare and research) and vision (A healthier community with equitable access to healthcare) statement of the institution, followed by a strategic plan are created and included the design of a core academic curriculum consisting of 6 segments, each with specific objectives and actions: CMBCD; lifestyle medicine; translation of strategies into clinical practice; resources management; community expansion; education and research, and business plan. At a more granular level, these segments contain policies and protocols that are audited, vetted, adapted over time, and consequently evolve to allow for success and sustainability.

Resources

The LDH programs need physical resources to perform anthropometry, laboratory evaluations, cardiometabolic risk screening (e.g., intima-media thickness, ambulatory blood pressure monitoring), diagnostic cardiology (e.g., echocardiography and exercise stress testing), and consultative services (e.g., eye clinic to diagnose/manage diabetic retinopathy), pharmacy, exercise physiology and gym, and educational spaces/activities (Table 1). Human resources were based on materialization processes, which centered on an MDT protocol. In particular, dedicated lifestyle medicine specialists were identified and utilized as part of the programs’ core services. Additionally, wearable technologies to provide patients with lifestyle information, questionnaires/surveys, and nudges (to prompt a predictable response while preserving choice) were incorporated through a shared link on their mobile phones. The content includes health coach’s Facebook and Instagram links, exercise videos, general recommendations on physical activity, healthy dietary patterns, recipes, glycemic index/load of carbohydrates, and culturally adapted food exchange lists, available in English and Spanish. Telemedicine patient encounters were increased, especially after with social distancing mandates with the Covid-19 pandemic. Body composition measurements by bioimpedance and muscular strength by handgrip to estimate sarcopenia were also incorporated, and patients were provided with tools and education to monitor both nutritional intake and physical activity using manual records or apps according to the patient’s health literacy.

Table 1.

Lifedoc Health Physical Setting and Resources.

Resources	Description
Physical setting	- Physical examination room - Exercise training room - Conference/Exercise room for education and/or exercise classes - 2 offices (Lifestyle providers)
Existing equipment and facilities	- Exercise testing facility - Eye clinic - ER diversion unit - Metabolic testing unit - Echocardiography - Spirometry - Ankle-brachial index for arterial stiffness index - 24 h ambulatory BP monitoring - LifeDoc research (clinical trials and research grants) - Laboratory (LabCorp) - In-house A1c and blood glucose monitoring - LifeDoc Pharmacy - Audio-visual material
New resources incorporated	- Handgrip strength (Jamar®) - Bioimpedance (Body composition analyzer Tanita: 1. Segmental Ironman RD 545 IM®. 2. Tanita UM 81®)
Operation manual	- Operation manual. LMP program. V1
Electronic medical record	- EMR eClinicalworks V11
Human resources	- Internal medicine - Family practitioner - Cardiologist - Nurse practitioners (adults and pediatric) - Exercise physiologist - Nutrition and lifestyle provider - Data managers - Medical assistants - Front office personnel - Care coordination unit - Information technology support

Initial Structure and Subsequent Adaptations

The LDH programs were designed based on analysis of DPP lifestyle recommendations for diabetes prevention and clinical outcomes,³⁵ American Association of Clinical Endocrinology guidelines for cardiometabolic risk management,⁵ various diabetes self-management education and support programs,³ general reviews of lifestyle medicine in T2D,³⁶ and guidelines on creating a lifestyle medicine center and/or clinical service line.³⁷ The initial LDH protocol consisted of establishing a sequence of visits per year based on the patient’s needs and evolution. On average, patients attend 11 flexible-scheduled visits per year (3 for lifestyle education, 4 with providers, and the rest are shared medical appointments). During this process, an interesting opportunity for adaptation emerged: diabetes and obesity were recognized as independent interventions prompting even more structured patient encounters. However, the program had a >50% dropout that could potentially compromise sustainability. Subsequently, compensatory strategies were formulated to integrate more personalized lifestyle medicine infrastructure for those patients with a higher level of complexity. In contrast, less complex cases are referred to group educational sessions (Figure 4). Thus, risk-stratification protocols became part of conceptualization and operationalization steps. These adjustments have produced an increase in the number of visits with better integration among MDT members.

Figure 4.

Lifestyle Medicine Program at Lifedoc Health: flow chart of visits. Abbreviations: MDT: Multidisciplinary team, MNT: Medical Nutrition Therapy, SDOH: Social determinants of Health, SMA: Share medical appointment.

Operationally, the first patient encounter in the LDH program aim to motivate and engage the patient and increased the knowledge-based and understanding of their conditions and potential risks. The next visits include a lifestyle medicine diagnosis and then general recommendations centered on the Mediterranean and low glycemic index dietary patterns. During the in-person visits, patients were given personalized, culturally adapted lifestyle medicine prescriptions adapted to their routines. Tactically, medical nutrition therapy (MNT) was adapted to patients’ preferences and comorbidities offering different strategies. Of the initial 604 MNT prescriptions, 76.6% were healthy culturally adapted meal plans based on Mediterranean diet pattern including low glycemic index options, 16.7% had meal replacements, 4.0% intermittent fasting, 1.5% vegetarian diets, and 1.2% special requirements (hyperlipidemia, athletes, among others). Physical activity prescriptions included exercises for stretching, flexibility, balancing, aerobic conditioning, and muscle strength. For the aerobic component, intensity based on heart rate, duration, and frequency were specified. There were also goals set for the number of steps using pedometers and active pauses at the workplace. Physical activity plans were prescribed according to the patient’s preferences, sports activities that the patient had practiced, and available resources (gym, treadmill, weights, bands, swimming pool, parks, or sports fields nearby). In patients with diabetes, MNT included carbohydrate counting when appropriate, education about insulin adjustments, strategies to overcome the resistance both from patient and provider to initiate insulin treatment,³⁸ tailored physical activity goals, and education. Most patients with severe hyperglycemia were managed in the protocol-based outpatient emergency room-diversion unit. Those patients demonstrating a willingness for significant lifestyle change, in a behavioral state somewhere between the preparation and action stages,³⁹ were referred to the in-person visit program. Reinforcement and tracking with telemedicine visits were added when in-person visits were not feasible or as otherwise needed.

The MDT approach allows for more interaction among HCPs, facilitates intensive pharmacological management, and improves access to cardiometabolic risk factors screening tools and lifestyle counseling. In the MDT approach, patients are co-managed by their PCP. Most visits are scheduled as shared medical appointments (SMA) to maximize patient convenience, and involves personnel that can provide logistical support, education, and medical care culminating in a comprehensive care plan.⁴⁰ As part of the optimization process, 1 survey data indicated that 95% of the patients reported being satisfied with the care received, and 91% reported that the recommendations were adequate. Other components of the implementation framework informed by HCPs (e.g., adoption and fidelity) and the organization (e.g., cost, feasibility, penetration, and sustainability) are being currently evaluated.⁴¹ These LMP features are summarized in Table 2.

Table 2.

Lifestyle Medicine Program Content and Strategies for Cardiometabolic-Based Chronic Disease Management.

Visit*	Visit content	Provided by	Lifestyle questionnaires	Physical and lab evaluation	Prescription and education content/deliverables
Initial engagement and referral visit
SMA	Detection of individual patient needs, barriers, and gaps in cardiometabolic chronic disease	MDT member: PCP/diabetes educator/MA	None	A/BC, CBG, A1C	- Wearable LMP content (flow code) - MNT: Exchange list and portions - Medication’s adherence - LDH protocols compliance
Group visits options
1	Nutrition and physical activity recommendations	Lifestyle provider	None	A/BC, CBG, A1C When are scheduled as SMA	- LMP overview and aims. General recommendations: (1) MNT based on Mediterranean Diet pattern and glycemic index, (2) Physical activity
2	Exercise classes				- Exercise sessions in the gym led by lifestyle provider (exercise physiologist)
3	Behavioral support and other lifestyle components				- Behavioral support, stress management, sleep hygiene, smoke, and alcohol use
4	Diabetes self-management education	Diabetes educator			- CBG monitoring, diabetes self-management, adjusting insulin dose, hypoglycaemia management. Carbohydrate counting
In-person visits options
1	Individual MNT and physical activity evaluation and prescription	Lifestyle medicine provider	To be applied in the first in-person visit: Current questionnaires - Lifestyle questionnaire (nutrition and physical activity preferences and available facilities, individual routines shifting) - SDOH using PRAPARE⁵⁸ Proposed additional questionnaires - Cardiovascular health AHA score⁵⁹ - Sleep apnea screening (no SAS score)⁶⁰ - Sleep quality score⁶¹ - Smoking and alcohol - General anxiety Disorder 7 (GAD-7)⁶² - Patient health 9 Depression (PHQ-9)⁶³	A/BC, HS, CBG, A1C	- Physical activity recommendations - Individual culturally adapted meal and physical activity plan
2	Nutritional and exercise tactics				Nutrition: - Meal replacement to foster weight loss - Very low-calorie diets for diabetes remission - Reading labels, eating out, smart shopping, healthy snacks. - Use of apps for tracking caloric intake Exercise: - Prescription based on exercise test, advanced exercise plan - Use of app for tracking physical activity
3	Behavioral support and other lifestyle components evaluation and management				- Individual approach to behavioral support, stress management, sleep hygiene, smoking, and alcohol use - Long-term success, prevention of relapse, copy with psychosocial factors
4	Diabetes education	Diabetes educator or Lifestyle medicine provider			- Diabetes self-management, CBG monitoring - Hypoglycaemia prevention and management - Overcoming barriers to using insulin - Adjusting basal insulin dose based on FBG and prandial insulin based on I: CHO and ISF. Carbohydrate counting

*Preferred scheduled a SMA. Extra appointments are scheduled for exercise testing, 2-h oral glucose tolerance test, ankle-brachial index, ambulatory blood pressure monitoring, and phone visits.

Abbreviations: A/BC: Anthropometrics/Body composition, AHA: American Heart Association, A1C: Glycated Hemoglobin, CBG: Capillary blood glucose, FBG: Fasting blood glucose, HS: Handgrip strength, I: CHO: Insulin/carbohydrate ratio, ISF: Insulin sensitivity factor, LMP: Lifestyle Medicine Program; MA: Medical Assistant, MDT: Multidisciplinary team, MNT: Medical Nutrition Therapy, PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences, SDOH: Social Determinants of Health, SMA: Share Medical Appointment, PCP: Primary Care Provider.

Transcultural Components

Among African Americans, compared with the general American population, there are disproportionately high morbidity and mortality rates, lower quality and accessibility to health care, less representative randomized controlled study data, more ketosis-prone diabetes, and more associated metabolic syndrome traits.^4,42 Among Latino/Hispanics, abdominal obesity, prediabetes, high triglycerides, and fatty liver disease⁴³ are important drivers, and unhealthy food preferences, physical inactivity, diabetes complications, insulin resistance,⁴⁴ and poor adherence to diabetes treatment are more prevalent compared with other U.S. ethnicities.⁴ Moreover, language barriers are significant among Latino/Hispanics with 21% not speaking English and only 5% of physicians and 2% of nurses being Latino/Hispanics.⁴ In the LDH population, although the majority of their children speak English, more than 80% of their parent adult Hispanic are not fluent in English.

Cultural competency describes a set of behaviors, attitudes, and policies that enable a healthcare system to work more effectively within a transcultural context.⁴⁵ In other words, to better incorporate transcultural components so the precision of screening and lifestyle interventions can be maximized.³⁴ The LDH programs are culturally competent and therefore recognize and include cultural aspects to improve the interactions between patients and HCPs, and consequently the effectiveness of healthcare delivery.⁴⁵ Considering that the Hispanic and African American populations represent 83% of adults and 95% of youth patients, 90% of the LDH personnel is bilingual (i.e., English and Spanish speaking). Also, key LDH personnel are trained to improve (1) knowledge about community demographics and the relevant SDOH, (2) attitudes toward ethnocultural diversity, health inequities, and respect for cultural differences, and (3) skills related to transcultural communication and patient-centered healthcare.

One of the major limiting factors for treatment adherence and program engagement is the lack of affordable patient transportation to the Center. At LDH, approximately 35% of scheduled patients are under simultaneous clinical visits including, education, procedures, laboratory, eye clinic, specialty, or primary care; these are arranged based on patients’ needs or gaps in care. In addition, LDH’s pharmacists are part of the MDT approach, and they work in close collaboration with HCPs and patients to educate, synchronize, and consolidate prescriptions. Likewise, LDH’s Medical Treatment Management (MTM) program provides extra support for patient treatment adherence, education, and monitoring. On average, 700 MTM visits a month are implemented and close to 3000 prescriptions every month are delivered to patients during the clinical visits or sent at home without additional charges. These elements enhance the relationship between the patient and healthcare team, overcoming barriers and gaps in the healthcare process, increasing access to care, activating the patient for change, and finally improving outcomes.⁴⁵

In the LMP, MNT and physical activity are prescribed based on individual needs, routines, health literacy, willingness, and ability for behavioral change. A survey to explore food preferences (e.g., fruits, vegetables, and protein source) and nutrition behaviors (e.g., meal timing, accessibility, affordability, culinary aspects, and social contexts) among African American patients was performed to tailor MNT recommendations. Patients preferred grapes (68%) and banana (62%) as fruits, broccoli (71%) and green beans (65%) as vegetables, pizza (71%) and chicken (65%) as meals, and chicken (96%) and fish (73%) as meat (protein) sources. Likewise, 87% ate 2 to 3 meals a day, 85% ate 2 to 5 snacks a day, 21% do not cook, and only 20% cook at least 7 times per week (Table 3). Transcultural-specific food exchange lists (i.e., African American and Mexican) were provided to educate patients in designing their meal plans. Recently, LDH partnered with insurance companies to implement a SDOH Pilot project focused on the screening and detection of those patients with unmet social determinants captured through the Protocol for Responding to and Assessing Patient’s Assets, Risk, and Experiences (PRAPARE) tool,⁴⁶ referring them to community-based resources, and ultimately closing the loop to confirm if the patients’ needs were met.

Table 3.

Food Preferences and Nutrition Behaviors in Lifedoc Health African American Patients (n = 94).

Preference or behavior	Answer	Frequency (%)	Preference or behavior	Answer	Frequency (%)
Fruits you eat the most	Grapes	66	How many meals do you usually eat per day	1 Meal	6
	Banana	62		2 Meals	40
	Orange	60		3 Meals	47
	Strawberry	50		4 Meals	6
	Watermelon	39

Vegetables you eat the most	Broccoli	71	How many snacks do you usually eat per day?	0–1 Snack	9
	Green Beans	65		2 Snacks	22
	Carrots	65		3 Snacks	27
	Corn	42		4 Snacks	19
	Spinach	30		5 Snacks	17
				6-7 Snacks	7

Meal that you enjoy the most	Pizza	71	Do you cook?	Yes	79
	Chicken	65		No	21
	Burger	65
	Spaghetti	42
	Salad	30

Protein source you like	Chicken	96	Cooking (times per week)	1-2	12
	Fish	73		3	13
	Shrimp	66		4	10
	Beef	64		5	26
	Pork	54		6	20
				7	20

Source: Structured questionnaire applied by LDH personnel.

Outcomes During the LMP Updating Period

In the first 14 months after update, 2809 visits were performed in the LDH programs applying lifestyle medicine, with a mean of 200 visits/month (12.5 visits/day). Of these, 800 visits (28.5%) focused on diabetes care, 623 (77.9%) were in-person, and 177 (22.1%) occurred through phone visits. Measurements of A1C and random capillary blood glucose were performed in 59% and 97% of the diabetes visits, respectively. Physical activity and MNT prescriptions were delivered to 77.3% and 99.4% of patients, respectively, at the first visit; these proportions were similar in patients with diabetes (Table 4). Among first visit patients, 37.3% performed a sub-maximal stress test to estimate exercise tolerance, fitness level, and better categorize exercise intensity and modalities according to patient’s performance and mechanical limitations.

Table 4.

Lifestyle Medicine Program Visits and Prescriptions in the first 14 months After the Updating Process.

	Total patients		Diabetes patients
	n	%	n	%
# Total visits	2809	100	800	100
# In-person visits	2072	73.8	623	77.9
# Phone visits	737	26.2	177	22.1
# LMP in-person visit 1	906	43.7*	250	40.1
# LMP in-person visit 2	503	24.3*	151	24.2
# LMP in-person visits 3 - 8	663	32.0*	222	35.6
Mean # visits/month	200.6		57.1
Mean # visits/day	12.5		3.6
MNT prescriptions delivered	901	99.4**	249	99.6
Physical activity prescriptions delivered	700	77.3**	193	77.2
# Glycated hemoglobin A1C measurements			370	59.4 ***
# Capillary blood glucose measurements			604	97.0 ***

*% of the total in-person visits (n = 2072), ** % of the total LMP visit 1 (n = 906), *** % of the total LMP diabetes visit 1 (n = 623). Abbreviations: LMP: Lifestyle Medicine Program, MNT: Medical nutrition therapy.

Cardiometabolic risk changes in the first patients who entered in the LMP and had available data in the last quarter within the 1-year of follow-up were evaluated. In total, 223 patients (Hispanic 51.1%, AA 42.2%, Whites 5.8%; and adults 65.9%, adolescents 21.5%, children 12.6%) were included in the analysis. Improvements in weight, body mass index, diastolic blood pressure (DBP), and A1C in adults, reduction of DBP in adolescents, and no significant changes in children were observed (Table 5).

Table 5.

Changes in Cardiometabolic Lifestyle Medicine Program Outcomes by Age Groups

	Baseline	Final *	Change	p
Total sample
n (%)	223 (100)
Age, years
Hispanic (%)	51.1 (44.6–57.6)
AA (%)	42.2 (35.8–48.7)
White (%)	5.8 (3.4–9.7)
Weight (Kg)	88.8 ± 28.5	88.8 ± 27.8	0	.96
BMI (Kg/m²)	33.6 ± 8,8	33.2 ± 8.6	−0.4	.04
SBP (mmHg)	118.9 ± 13.8	119.9 ± 14.8	+1.0	.26
DBP (mmHg)	76.8 ± 10.7	74.5 ± 9.2	−2.3	.002
Random capillary BG (mg/dl)	135.1 ± 61.0	129.1 ± 62.9	−6.0	.171
A1C (%)	7.5 ± 2.4	6.9 ± 1.9	−0.6	.002
Children (6–11 y)
n (%)	28 (12.6)
Age, years	9.21 ± 28.5
Hispanic (%)	92.9 (77.4–98.0)
AA (%)	7.1 (2.0–22.6)
White (%)	0.0
Weight (Kg)	54.2 ± 20.0	58.7 ± 21.1	+4.5	.0001
BMI (Kg/m²)	26.5 ± 4.9	26.9 ± 5.3	+0.3	.194
SBP (mmHg)	101.8 ± 9.5	103.0 ± 10.6	+1.2	.457
DBP (mmHg)	65.0 ± 9.7	66.3 ± 7.9	+1.3	.461
Random capillary BG (mg/dl)	105.1 ± 12.7	97.3 ± 23.1	−7.8	.146
A1C (%)	5.9 ± 1.0	5.7 ± 0.4	−0.2	.443
Adolescents (12–19 y)
n (%)	48 (21.5)
Age, years
Hispanic (%)	77.1 (63.5–86.7)
AA (%)	22.9 (13.3–36.5)
White (%)	0.0
Weight (Kg)	91.3 ± 21.6	93.3 ± 21.9	+2.0	.07
BMI (Kg/m²)	33.4 ± 6.8	33.3 ± 6.5	−0.1	.81
SBP (mmHg)	117.7 ± 10.3	115.5 ± 9.8	−2.2	.13
DBP (mmHg)	73.9 ± 9.0	71.4 ± 7.8	−2.5	.04
Random capillary BG (mg/dl)	113.1 ± 34.4	107.1± 38.3	−6.0	.15
A1C (%)	6.6 ± 2.7	6.1 ± 1.8	−0.5	.37
Adults (≥ 20 y)
n (%)	147 (65.9)
Age, years
Hispanic (%)	55.1 (47.0–62.9)
AA (%)	34.7 (27.5–42.7)
White (%)	8.8 (5.2–14.5)
Weight (Kg)	94.6 ± 27.3	93.1 ± 27.2	−1.5	.009
BMI (Kg/m²)	35.0 ± 9.3	34.4 ± 9.3	−0.6	.006
SBP (mmHg)	122.7 ± 12.8	124.8 ± 14.0	+2.1	.08
DBP (mmHg)	80.2 ± 9.4	77.6 ± 8.4	−3.6	.003
Random capillary BG (mg/dl)	145.5 ± 67.7	139.7 ± 69.2	−5.8	.343
A1C (%)	7.8 ± 2.3	7.2 ± 2.0	−0.6	.001

*Available data in the last quarter within the 1-y of follow-up. Abbreviations: AA: African American, A1C: Glycated hemoglobin A1C, BG: blood glucose, BMI: Body mass index, DBP: Diastolic blood pressure, SBP: Systolic blood pressure.

Business Model and Economic Sustainability

Economic factors pose the greatest challenge to achieving the LMP mission and vision, which only have a pragmatic impact if sustainable. 82% of the revenue from LDH programs results from third-party payments: public (Medicaid/Medicaid) in 64%; and private in 18%. Patients without insurance (18%) are served through VidaPlus membership (12%) or self-pay (6%). VidaPlus is a discount membership program launched in 2011 offering access to all outpatient services at 50%–90% off the cash price regardless of pre-existing chronic conditions. VidaPlus has reached over 3000 patients with approximately 400 active members at any given moment and a mean enrollment duration of 18 months. Exceptions and adjustments to out-of-pocket requirements are analyzed on a case-by-case basis to assure delivery of care to all patients despite socioeconomic status. Lifestyle program billing codes are summarized in Table 6.

Table 6.

Procedures Codes Related with the Lifestyle Medicine Program.

Procedure code	Procedures
Counselling
G0447	Obesity, behavioral counseling, face-to-face, individual (also applicable for phone visits)
G0108	Diabetes outpatient self-management (also applicable for phone visits)
G0473	Behavioral counseling obesity, face-to-face, group (2–10), 30 minutes
Diagnosis test
36 416	Capillary blood collection
82 962	Capillary blood glucose test
83 037	Hemoglobin A1C
0358T	Bioimpedance whole body. Body composition by bioimpedance
97 750	Physical performance test. Hand-grip strength
97 750	Physical performance test. Sub-maximal treadmill test
93 922	Ankle Brachial Index
96 784 Recording only (96 786)	Ambulatory blood pressure monitoring
94 010	Spirometry
G0399	Obstructive sleep apnea screening. Home sleep test
94 681	Indirect calorimetry Oxygen uptake, expired gas analysis, rest, and exercise, direct, simple, including CO2 output
Social determinants of health
96 160 Modifier 32	Patient-focused health risk assessment. PRAPARE assessment completed
96 160 Modifier U1	Patient-focused health risk assessment. Referred
96 160 Modifier U2	Patient-focused health risk assessment. Follow-up or Close loop

Long-term sustainability implies both clinical and economic success. In the process of evaluation, LDH programs target all clinical outcomes required for the program to be recognized by the Diabetes Recognition Program of the NCQA. This includes:

• having an A1C over 9% in <15% of patients, with A1C <8% in at least 60% and <7% in at least 40%;

• having a blood pressure >140/90 mmHg in <35% of patients and <130/80 mmHg in >24% of patients;

• having an LDL-cholesterol > 130 mg/dl in <37% of patients and an LDL-cholesterol <100 mg/dl in >36% of patients;

• having a documented eye exam in >60% of patients;

• having a documented nephropathy assessment in >80% of patients;

• having a documented foot examination in >80% of patients;

• and having documented smoking status and cessation advice or treatment in >80% of patients.⁹

Economic targets to achieve self-sustainability for all LDH programs and their various clinical service lines (clinical practice, LMP, cardiology diagnosis services, education, research, etc.) are considered in aggregate. As new clinical services are proposed during scale-up discussions, they are analyzed using unit economics and reviewed with LDH finance personnel with respect to marketability and sustainability. For example, vibration perception threshold test and arterial stiffness evaluation were useful tools to determine early the end organ impact. However, both were considered experimental procedures and no reimbursable code could be signed. During the LMP update period, an initial financial evaluation of obstructive sleep apnea screening using home sleep testing and indirect calorimetry to assess resting metabolic rate and substrate oxidation for precision MNT counseling did not support self-sustainability when considering third-party reimbursements.

Limitations and Challenges

T2D is a complex disease that must be treated with a combination of personalized lifestyle and medications using advancements in behavioral change technologies, eHealth, health literacy, and personal health data valorization. Lifedoc health is a regional “ecosystem” that combines some of the necessary instruments (education, diagnostics, medication, most of these trying to be personalized and integrated) reducing healthcare costs but is immersed in a healthcare system dominated by industry and insurance companies which only hinders the sustainability of the LMP.⁴⁷

Barriers to the LDH LMP’s success include factors from patients, HCPs, health system, and environment. Among patients’ barriers are non-physical contextual factors, such as ethnocultural factors and structural conflict—society’s tendency to change and develop due to perpetual conflict between classes—(e.g., discrimination⁴⁸/oppression)⁴⁹ and deterioration (e.g., housing/amenities).⁵⁰ Many adverse myths and false beliefs about insulin among African Americans with uncontrolled T2D compromise diabetes care and outcomes and are based on fears, fatalism, self-blame, stigma, frustration, self-care fatigue, and misconceptions among family, friends, co-workers, and HCPs.⁴ In the Hispanic population, fears of insulin derive from concerns about hypoglycemia, weight gain, pain, efforts adhering to single or multiple injections, the association of insulin with complications such as amputation and blindness, trust in HCPs, and the positive belief in folk remedies, also compromising treatment adherence and diabetes control.⁵¹ The SDOHs are crucial factors in diabetes management.⁵² According to the LDH experience, these SDOHs include lack of transportation or insurance, low income, low health literacy, and work-related constraints for appointments, which contribute to the high proportion of no-shows.

Barriers that are related to HCPs, mainly the PCPs, include clinical inertia and under-recognition of early DBCD and CMBCD stages and obesity stigma. In addition, both time constraints on HCPs and multimorbidities frequently can impose barriers to better outcomes in PCP-driven interventions. Finding qualified HCPs has been a permanent challenge; stiff learning curve about the protocol and outcome-oriented approach, limited understanding of the early risk stratification and the need of intensive intervention, several gaps in their practice skills and evidence-based intervention, poor understanding of the disease mechanism has been significant limitations.

Healthcare system and institutional variables, such as costs, staff turnover, high demand of patients that exceeds the capacity of attention, low third-party reimbursements, and onerous paperwork imposed by payers can influence implementation and effectiveness. Economical aspects also pose challenges since payers generally prefer a fee-for-service reimbursement model, which contributes to the implementation of a volume-driven practice restricting the visit duration and making it difficult for management of patients with multiple competing chronic conditions. The environment is also an important determinant. The LDH LMP began operations during the COVID-19 pandemic and mandated social distancing protocols, which disrupted patients' routines by decreasing the quality of food, reducing physical activity, and adversely affecting other lifestyle behaviors,⁵³ promoting weight increase,⁵⁴ worsening diabetes control,⁵⁵ and exacerbating other cardiometabolic risk factors.⁵⁶ Moreover, pre-COVID-19 group exercise activities became restricted and in-person appointments were reduced. Lastly, a poorly resolved challenge for any healthcare initiative that has also influenced implementation tactic for LDH programs is striking an optimal balance between massification of lifestyle medicine practices and individualization of recommendations.

From a macro perspective, the mid-term goals of the LDH LMP are to (1) progressively incorporate all lifestyle components; (2) adapt business plans to scale up and out Centers to better serve communities; and (3) continually perform environmental scans to locate realistic funding sources. Under current practice and reimbursement scenarios, an independent, free-standing, self-sustaining LMP is unrealistic. So, for now, the LMP is conceptualized as a clinical service line to support LDH preventive and clinical functions while generating favorable economic outcomes.

Conclusion

Lifestyle medicine is now explicitly part of guidelines in diabetes care. Detailed descriptions of the implementation of lifestyle centers including diabetes care in the U.S. are scarce, so finding a role model for the creation of a Lifestyle Medicine Center, program, or clinical service line is difficult. The description of the LDH LMP offers a comprehensive illustration of tactical planning and execution. Knowledge acquisition, strategics, translation into action, and implementation was accomplished, but LMP has been effective and sustainable only by the integration into LDH clinical model. The creation and optimization of existing formal lifestyle medicine endeavors, especially in cardiometabolic-based chronic disease, is encouraged to foment a transformative healthcare culture that emphasizes prevention.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: JIM reports receiving honoraria from Abbott Nutrition for lectures and is on Advisory Board of Twin Health.

ORCID iDs

Ramfis Nieto-Martinez

Juan P. González-Rivas

References

NCD Risk Factor Collaboration (NCD-RisC)—Americas Working Group . Trends in cardiometabolic risk factors in the Americas between 1980 and 2014: a pooled analysis of population-based surveys. Lancet Glob Health. 2020;8(1):e123-e133.

Ritchie

Baucom

Sauder

. Current Perspectives on the impact of the national diabetes prevention program: building on successes and overcoming challenges. , 2020;13:2949-2957. doi:10.2147/dmso.s218334

Beck

Greenwood

Blanton

, et al. National standards for diabetes self-management education and support. Sci Diabetes Self-Manag Care. 2017;47(1):14-29. (In eng). doi:10.1177/0145721720987926

Mechanick

Adams

Davidson

, et al. Transcultural diabetes care in the United States - a position statement by the American association of clinical endocrinologists. Endocr Pract. 2019;25(7):729-765. (In eng). doi:10.4158/ps-2019-0080

Garber

Handelsman

Grunberger

, et al. Consensus statement by the American association of clinical endocrinologists and American college of endocrinology on the comprehensive type 2 diabetes management algorithm - 2020 executive summary. Endocr Pract. 2020;26(1):107-139. (In eng). doi:10.4158/cs-2019-0472

Mechanick

JIKRF

. Translating knowledge and implementing a successful lifestyle medicine center. In: Mechanick

Kushner

, eds Creating a Lifestyle Medicine Center. Cham2020: Springer.

Velasquez-Mieyer

Neira

Velasquez

Velasquez Rodriguez

. Evaluating the Impact of a multi-professional, outcome-oriented model on clinical and financial performance metrics. COSEHC Quality Impact Practice Transformation Network Collaborative Meeting Poster Presentation March 2018 2018.

Nieto-Martínez

RG-RJP

Mechanick

. Survey of international centers that incorporate lifestyle medicine. In: Mechanick

Kushner

, eds Creating a Lifestyle Medicine Center. Cham2020: Springer.

Diabetes Recognition Program . National committee for quality assurance. Accessed 01/15/2022. https://www.ncqa.org/programs/health-care-providers-practices/diabetes-recognition-program-drp/

10.

Harden

Cowan

Velasquez-Mieyer

Patton

. Effects of lifestyle intervention and metformin on weight management and markers of metabolic syndrome in obese adolescents. J Am Acad Nurse Pract. 2007;19(7):368-377.

11.

Hitt

Velasquez-Mieyer

Neira

Cowan

. Factors affecting hemoglobin A1C in the diagnosis of diabetes and prediabetes in youth. J Pediatr Nurs. 2016;31(5):511-518. (In eng). doi:10.1016/j.pedn.2016.03.020

12.

Neira

Hartig

Cowan

Velasquez-Mieyer

. The prevalence of impaired glucose metabolism in Hispanics with two or more risk factors for metabolic syndrome in the primary care setting. J Am Acad Nurse Pract. 2009;21(3):173-178. (In English). doi:10.1111/j.1745-7599.2008.00380.x

. Efficacy of glycosylated hemoglobin vs. OGTT in diagnosing a sample of at-risk children and adolescents: a comparison study. Poster presentation at the American Association of Clinical Endocrinologists 24th Annual Scientific and Clinical Congress. Nashville, TN; 2015.

. Comparison of cardiovascular risk factors in children and adults stratified by age and severity of overweight. American association of clinical endocrinologists 24th annual scientific and clinical congress. Late Breaking. Endocrine Practice. 2015;21(No. suppl 2):294-295.

. Obesity and cardiometabolic syndrome in children. Ther Adv Cardiovasc Dis. 2007;1(1):61-81. (In eng).

. Predicting impaired glucose tolerance in severely obese adolescents. Proc Int Congress Endocrinol. 2004:1433-1437.

, et al. Fitness capacity is the major predictor of the number of cardiovascular risk factors in obese adolescents. Atherosclerosis. 2006;7(suppl l):381.

. Assessing the risk of impaired glucose metabolism in overweight adolescents in a clinical setting. J Nutr Health Aging. 2008;12(10):750s-757s. (In eng). doi:10.1007/bf03028625

, et al. Racial disparity in glucagon-like peptide 1 and inflammation markers among severely obese adolescents. Diabetes Care. 2008;31(4):770-775. (In eng).

. Identifying children at risk for obesity, type 2 diabetes and cardiovascular disease. Diabetes Spectr. 2005;18:213-220.

21.

PAea

V-M

. Can OGTT-derived indices uncover an overweight threshold for deterioration in adolescent glucose metabolism? Diabetologia. 2003;46(suppl l):A26.

22.

Quality Care Quarterly . Your Guide to Programs and Rewards Featuring. DarSalud Delivers Cost-Effective Care by Focusing on Prevention Spring 2018 - Volume 4. BlueCross BlueShield of Tennessee, Inc. and BlueCare Tennessee Available online Accesses 03/27/2020. https://www.bcbst.com/docs/providers/PQ_QualityCareQuarterlyNewsletter_Spring_2018.pdf. 2018.

23.

Nieto-Martínez

Velásquez-Rodríguez

Neira

, et al. The impact of lifedoc health’s multidisciplinary team approach on cardiometabolic risk profile in a multiracial cohort of adults with obesity: a 1-year Yy. unpublished results.

24.

Velásquez-Mieyer

Neira

Velásquez-Rodriguez

Velasquez Rodriguez

. Evaluating the impact of a multi-professional, outcome-oriented model on clinical and financial performance metrics. Consortium for Southeastern Hypertension Control Meeting 2018; 2018.

25.

Mechanick

Synthesis

. Deriving a core set of recommendations for planning, building, and operating a lifestyle medicine center. In: Mechanick

JKR

, ed. Creating a Lifestyle Medicine Center: From Concept to Clinical Practice. Cham.: Springer; 2020.

26.

Eccles

Foy

Sales

Wensing

Mittman

. Implementation science six years on—our evolving scope and common reasons for rejection without review. Implement Sci. 2012;7(1):71. doi:10.1186/1748-5908-7-71

27.

Nieto-Martínez

González-Rivas

Florez

Mechanick

. Transcultural endocrinology: adapting type-2 diabetes guidelines on a global scale. Endocrinol Metab Clin North Am. 2016;45(4):967-1009. (In Eng). doi:10.1016/j.ecl.2016.06.002

28.

Uusitupa

Khan

Viguiliouk

, et al. Prevention of type 2 diabetes by lifestyle changes: a systematic review and meta-analysis. Nutrients. 2019;11(11):2611. (In eng). doi:10.3390/nu11112611

29.

Mechanick

Farkouh

Newman

Garvey

. Cardiometabolic-based chronic disease, addressing knowledge and clinical practice gaps: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(5):539-555. (In eng). doi:10.1016/j.jacc.2019.11.046

30.

Mechanick

Farkouh

Newman

Garvey

. Cardiometabolic-based chronic disease, adiposity and dysglycemia drivers: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(5):525-538. (In eng). doi:10.1016/j.jacc.2019.11.044

31.

Nieto-Martinez

Gonzalez-Rivas

Mechanick

. Cardiometabolic-Based Chronic Disease (CMBCD): A New Framework for Early and Sustainable Preventive Care. Delhi: Jaypee Brothers Medical Publishers.

32.

Nieto‐Martínez

González‐Rivas

Mechanick

. Cardiometabolic risk: new chronic care models. JPEN J Parenter Enteral Nutr. 2021;45(S2):85-92. (In eng). doi:10.1002/jpen.2264

33.

Mechanick

Garber

Grunberger

Handelsman

Garvey

. Dysglycemia-based chronic disease: an American association of clinical endocrinologists position statement. Endocr Pract. 2018;24(11):995-1011. (In eng). doi:10.4158/ps-2018-0139

34.

Nieto-Martínez

González-Rivas

. Transcultural lifestyle medicine. In: Mechanick

Kushner

, eds Creating a lifestyle medicine center: From concept to clinical practice. Cham, Switzerland: Springer Nature Switzerland AG; 2020:233-248.

35.

The diabetes prevention program (DPP): description of lifestyle intervention. Diabetes Care 2002;25(12):2165-2171. (In eng). doi:10.2337/diacare.25.12.2165

36.

Timothy Garvey

Arathuzik

. Lifestyle therapy for diabetes mellitus. In: Mechanick

Kushner

, eds Lifestyle medicine: a manual for clinical practice. Cham: Springer; 2016.

37.

Mechanick

JIKRF

. Synthesis: deriving a core set of recommendations for planning, building, and operating a lifestyle medicine center. In: Mechanick

Kushner

, eds, Creating a Lifestyle Medicine Center. Cham. Springer; 2020:355-361.

38.

Polonsky

Fisher

Guzman

Villa-Caballero

Edelman

. Psychological insulin resistance in patients with type 2 diabetes. Diabetes Care. 2005;28(10):2543-2545. doi:10.2337/diacare.28.10.2543

39.

Prochaska

Velicer

. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):38-48. (In eng). doi:10.4278/0890-1171-12.1.38

40.

Edelman

Gierisch

McDuffie

Oddone

Williams

Jr . Shared medical appointments for patients with diabetes mellitus: a systematic review. J Gen Intern Med. 2015;30(1):99-106. (In eng). doi:10.1007/s11606-014-2978-7

41.

Proctor

Silmere

Raghavan

, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65-76. (In eng). doi:10.1007/s10488-010-0319-7

42.

Marshall

Jr.

Diabetes in African Americans. Postgrad Med J. 2005;81(962):734-740. (In eng). doi:10.1136/pgmj.2004.028274

43.

Saab

Manne

Nieto

Schwimmer

Chalasani

. Nonalcoholic fatty liver disease in latinos. Clin Gastroenterol Hepatol. 2016;14(1):5-12. quiz e9-10. (In eng). doi:10.1016/j.cgh.2015.05.001

44.

Chiu

Cohan

Lee

Chuang

. Insulin sensitivity differs among ethnic groups with a compensatory response in beta-cell function. Diabetes Care. 2000;23(9):1353-1358. (In eng). doi:10.2337/diacare.23.9.1353

45.

Watt

Abbott

Reath

. Developing cultural competence in general practitioners: an integrative review of the literature. BMC Fam Pract. 2016;17(1):158. (In eng). doi:10.1186/s12875-016-0560-6

46.

Protocol for Responding to and Assessing Patient’s Assets, Risk, and Experiences (PRAPARE) Implementation and Action Toolkit National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, and Institute for Alternative Futures March 2019 Available online: http://wwwnachcorg/wp-content/uploads/2019/04/NACHC_PRAPARE_Full-Toolkitpdf (last accessed January 17, 2022).

47.

van Ommen

Wopereis

van Empelen

, et al. From diabetes care to diabetes cure-the integration of systems biology, ehealth, and behavioral change. Front Endocrinol. 2017;8:381. (In eng). doi:10.3389/fendo.2017.00381

48.

Hornbuckle

. Running while Black: a distinctive safety concern and barrier to exercise in White neighborhoods. Prev Med Rep. 2021;22:101378. (In eng). doi:10.1016/j.pmedr.2021.101378

49.

Lloyd-Jones

Lewis

Schreiner

Shikany

Sidney

Reis

. The coronary artery risk development in young adults (CARDIA) study: JACC focus seminar 8/8. J Am Coll Cardiol. 2021;78(3):260-277. (In eng). doi:10.1016/j.jacc.2021.05.022

50.

Sims

Kershaw

Breathett

, et al. Importance of housing and cardiovascular health and well-being: a scientific statement from the American heart association. Circ Cardiovasc Qual Outcomes. 2020;13(8):e000089. (In eng). doi:10.1161/hcq.0000000000000089

51.

Bermeo-Cabrera

Almeda-Valdes

Riofrios-Palacios

Aguilar-Salinas

Mehta

. Insulin adherence in type 2 diabetes in Mexico: behaviors and barriers. J Diabetes Res. 2018;2018:3190849. (In eng). doi:10.1155/2018/3190849

52.

Haire-Joshu

Hill-Briggs

. The next generation of diabetes translation: a path to health equity. Annu Rev Publ Health. 2019;40:391-410. (In eng). doi:10.1146/annurev-publhealth-040218-044158

53.

Ammar

Brach

Trabelsi

, et al. Effects of COVID-19 home confinement on eating behaviour and physical activity: results of the ECLB-COVID19. Int Online Survey. 2020;12(6):1583. doi:10.3390/nu12061583

54.

Zachary

Brianna

, et al. Self-quarantine and weight gain related risk factors during the COVID-19 pandemic. Obes Res Clin Pract. 2020;14(3):210-216. (In eng). doi:10.1016/j.orcp.2020.05.004

55.

Abed Alah

Abdeen

Kehyayan

Bougmiza

. Impact of COVID-19 related home confinement measures on the lifestyle, body weight, and perceived glycemic control of diabetics. Metabolism Open. 2021;12:100144. (In eng). doi:10.1016/j.metop.2021.100144

56.

Marçal

Fernandes

Viana

Ciolac

. The urgent need for recommending physical activity for the management of diabetes during and beyond COVID-19 outbreak. Front Endocrinol. 2020;11(849):11. (Review) (In English). doi:10.3389/fendo.2020.584642

57.

Mechanick

Kushner

. Translating knowledge and implementing a successful lifestyle medicine center. In: Mechanick

JKR

, ed. Creating a Lifestyle Medicine Center. Cham: Springer; 2020.

58.

Weir

Proser

Jester

Hood-Ronick

Gurewich

. Collecting social determinants of health data in the clinical setting: findings from national PRAPARE implementation. J Health Care Poor Underserved. 2020;31(2):1018-1035. (In eng). doi:10.1353/hpu.2020.0075

59.

Lloyd-Jones

Hong

Labarthe

, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American heart association's strategic impact goal through 2020 and beyond. Circulation. 2010;121(4):586-613. (In eng). doi:10.1161/circulationaha.109.192703

60.

Marti-Soler

Hirotsu

Marques-Vidal

, et al. The NoSAS score for screening of sleep-disordered breathing: a derivation and validation study. Lancet Respir Med. 2016;4(9):742-748. (In eng). doi:10.1016/s2213-2600(16)30075-3

61.

Snyder

Cai

DeMuro

Morrison

Ball

. A new single-item sleep quality scale: results of psychometric evaluation in patients with chronic primary insomnia and depression. J Clin Sleep Med. 2018;14(11):1849-1857. (In eng). doi:10.5664/jcsm.7478

62.

Spitzer

Kroenke

Williams

JBW

Löwe

. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. (In eng). doi:10.1001/archinte.166.10.1092

63.

Kroenke

Spitzer

Williams

JBW

Löwe

. The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345-359. (In eng). doi:10.1016/j.genhosppsych.2010.03.006

Lifestyle Medicine in Diabetes Care: The Lifedoc Health Model

Abstract

Introduction

Aim

Results

Conclusion

Keywords

Introduction

LDH Care Model

LDH Implementation Modalities

Clinical Intervention Protocols

LDH MDT Outcomes

Lifestyle Medicine at LDH

The Implementation Process

The first materialization step is a detailed conceptualization of the idea to be built-out

The second materialization step is operationalization of the new LDH programmatic concept

Resources

Initial Structure and Subsequent Adaptations

Transcultural Components

Outcomes During the LMP Updating Period

Business Model and Economic Sustainability

Limitations and Challenges

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

References