Abstract
Since the COVID-19 pandemic, health equity has been placed front and center in the conversations surrounding healthcare as well other fields. This conversation has also been occurring in the field of lifestyle medicine with an intentional focus on developing solutions at the intersection of lifestyle medicine and health equity. Initiated by a call to action by ACLM Past President Dexter Shurney at the 2019 Lifestyle Medicine conference, the HEAL Initiative was created with that intention, to address health disparities and advance health equity through lifestyle medicine. Since 2019, the HEAL initiative has grown considerably in its work and impact, creating solutions aligned with the AMA strategic planning recommendations as well developing projects that are examples of community engaged-lifestyle medicine. The work of the HEAL initiative culminated in a full circle moment at the 2023 Lifestyle Medicine Conference which featured an interview (facilitated by Dr. Dexter Shurney) with former US Surgeon General Dr. Jerome Adams and review of HEAL’s work over the past 3 years. This article will capture the key highlights of the HEALing our Nation opening session and the cumulative work of HEAL Initiative.
“Focus group feedback was optimistic and encouraging with plans to the program to more multiple cohorts moving forward.”
Introduction
In November 2022, the American College of Lifestyle Medicine kicked off its annual Lifestyle Medicine conference with an opening session dedicated to discussing and showcasing the health equity efforts that the college had undertaken through the HEAL initiative. The session started with an interview of Dr. Jerome Adams sharing his thoughts on the health equity conversation which are highlighted in the following section.
Lifestyle Medicine, Health Equity, and the Challenge - Key Highlights from the LM 2022 conversation with Dr. Jerome Adams
Former U.S. Surgeon General Jerome Adams has advocated for health equity and lifestyle medicine (LM) his entire life. As far back as age eight, when he suffered a life-threatening asthma attack, he understood his healthcare opportunities differed from most other people.
Raised in an environment unfavorable to healthy living, Adams says his lifestyle and that of his family contributed to poor health. Today, his entire family has various forms of cardiovascular disease, and he himself has hypertension. For Adams, LM is personal.
In his opening session interview with former ACLM President Dexter Shurney, MD, MPH, Adams explained, “I’ve been at this for 22 years, since I got my MD and my MPH, and we need different results. We can’t keep doing the same thing over and over in healthcare-and what I call a ‘sick reimbursement system’.”
This is especially true when tackling health disparities and racism in healthcare. Adams points to maternal mortality as “the clearest, most glaring example of structural racism that I’ve ever encountered in medicine.” Forty-nine percent of U.S. births are to BIPOC women, 1 but “we need to be horrified and ashamed that in this country, a black woman with a PhD is still twice as likely to die while giving birth as a white woman who dropped out of high school-and that’s after controlling (adjusting) for every known risk factor,” including socio-economic status (education, geography, and income).
For other disparities, we see the inequity gaps shrink significantly when adjusted for SES, but not for maternal mortality. Almost 700 women and birthing individuals die 2 of complications during childbirth or pregnancy annually in the United States. Indeed, America remains the only industrialized country with rising maternal mortality rates, 2 and it ranks nearly the highest among high-income nations. 3
“There is still something going on here,” Adams said.
In response, during his tenure as Surgeon General from September 2017 to January 2021, he emphasized the “community aspects of maternal mortality” in his maternal health call to action. This strategy included hospital-based actions such as recognizing and controlling mothers’ hemorrhages and blood pressure. But it also addressed the two-thirds of maternal deaths occurring outside of a hospital and in the community.
The plan acknowledged the critical role and realities of lifestyle behaviors that birthing individuals are practicing, ranging from living with domestic violence to their inability to eat healthy whole foods to other ongoing stressors. Adams acknowledged that he “very intentionally” moved public attention beyond traditional medical components in the hope of accelerated positive change.
“We’re never going to change our negative outcomes in this country by focusing on only 20% of the problem,” he said. “And, clinical care is only about 20% of what makes you healthy. It’s where we live, learn, work, play, and pray that ultimately determines whether or not we’re going to be healthy.”
Too often, though, health providers and researchers point only to social determinants, as if dealing with those alone would level the playing field, cautioned Adams. Data points suggest it’s not that simple. He urged LM supporters to “broaden our lens,” saying this is critical to widespread adoption of a lifestyle medicine approach to health equity, healthcare and general environments in which people live.
Along those lines, Shurney and Adams discussed another disturbing data point about disproportionate BIPOC mortality rates: At Yale University, Black graduates in 1970 experienced a premature mortality rate at three times the level of other non-Black cohorts of that class. 3 These graduates are educated, employed, well-insured, and with access to good healthcare, but they still are more likely to die or have their newborn die.
For far too many people of color, that environment includes overt and implicit racism, which wears on you over the years. He points to singer Beyoncé, Olympian Alison Felix, and tennis world champion Serena Williams-all of whom almost died giving birth. “We’ve got to ask ourselves then, ‘What’s going on in the environment that people of color are existing in where, no matter how much money you have, they suffer these negative health outcomes?’”
Indeed, CDC estimates that at least 60% of maternal and infant deaths are preventable. 3
Adams challenged conference attendees to think intentionally about capturing and showcasing the abundance of strong evidence for policy makers to decree racism as a public health crisis. That declaration brings politics front and center, and Adams advised lifestyle medicine and health equity advocates to show lawmakers hard data and to build fact-based arguments, if they wish to succeed in bringing about meaningful change.
Citing his former experience as Indiana health commissioner for a deeply conservative state, he acknowledged that “talk of health disparities can set up a stubborn wall of resistance, so I’m not overtly out there screaming racism. I’m trying to show people that while we can’t be false or afraid to call out explicit racism, we do have to put together data and evidence, and build the case to show them that they have to care about racism.”
Surprisingly, Adams believes this task is fairly easy. As an anesthesiologist, he looks at disparities through the lens of quality. Race aside, if different groups of patients have differential outcomes, he believes that’s a quality issue. If government and health providers want to deliver efficient, effective care to citizens and patients, everyone “must have the courage to say people are having differential outcomes and to ask why.”
Adams closed his remarks by calling for LM practitioners and advocates to be introspective. His call to action was a directive statement that included a rhetorical question, “Have the courage to ask yourselves, ‘Are we providing opportunities for a healthier, better lifestyle to people equitably?’ We must work to dispel the myth that LM is a privilege and a luxury for the few. It’s incumbent upon us to take it from that space to a place where … we make it equitably available to everyone.”
HEAL in Action - A Review of HEAL’s Accomplishments Since 2019
In line with Dr. Jerome Adam’s admonitions, the HEAL initiative
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has been working over the last three years to make advancing health equity a priority and reality of the American College of Lifestyle Medicine and more closely examining the intersection of health equity and lifestyle medicine. Since the first meeting of the inaugural vision team with Drs. Dexter Shurney, Jasmol Sardana, Terri Stone and Marsha-Gail Davis in 2019, HEAL has made significant progress in a short amount of time. In just three years, HEAL leadership (Inaugural leaders: Dr. Terri Stone - Co-chair, Dr. Marsha-Gail Davis-Co-chair, Dr. Erin Sinnave - Secretary) advocated for health equity to hold a central role in the American College of Lifestyle Medicine (ACLM), HEAL has been established as an organization wide initiative outlining three key priorities to advance health equity, a scholarship fund has been established to support URM providers working to advance equity, ACLM has acquired a Director of Health Equity and Advocacy, a successful virtual webinar series titled, “A Seat at the Table” was co-sponsored with Big Picture Learning as a part of the Community Conversations priority, a social media campaign has been launched to expand HEAL’s reach into the wider community and Community-Engaged Lifestyle Medicine (CELM) has been realized with the launch of the Friendly Temple’s
The HEAL Initiative is the realization of the intersection of Lifestyle Medicine and Health Equity. Oftentimes, the discourse around lifestyle medicine and systemic barriers are at extremes. On one hand, lifestyle medicine can overcome systemic barriers once an individual decides to take personal responsibility while on the other hand, systemic barriers are so gigantic that individual choices have no power to resist or dismantle them. HEAL has found that place of intersection between the two perspectives through the power of community to activate agency in every individual and multiply that agency in community to begin to break down systemic barriers, eventually resulting in healing of both individual and community. Three key priorities were identified to activate this HEALing process initially through a focus on Practice Materials, Community Conversations and HBCUs. With Practice Materials, HEAL was able to create a useful cost comparison chart to highlight affordability of whole plant-based foods in comparison to the Standard American Diet (SAD) and the Mediterranean Diet and continues to work on resources that can be used to practice lifestyle medicine with a health equity lens. With Community Conversations, HEAL was able to open the door to community engagement in conversations around the application of lifestyle medicine in the context of social determinants of health with the education and faith communities. With HBCUs, HEAL has begun to establish relationships with historically black colleges (starting with medical schools) to begin meaningful conversations around lifestyle medicine and to establish lifestyle medicine interest groups LMIGs on campuses. There has been great progress made and with transitions to new leadership, HEAL will continue to expand these priorities and further this work.
The HEAL initiative is an organization-wide effort to embed health equity in ACLM’s work at large with an affiliated member interest group. As a member interest group, we have established a community of HEALers who are committed to not only advancing health equity but dismantling the barriers that create health disparate experiences among marginalized groups through community engagement and community activation. Several HEALers have taken inspiration from HEAL and begun creating change in their respective communities. Two exceptional HEALers are Jacque Salomon and Nivi Jaswal. Jacque Salomon, an intersectional activist, speaker and Trauma-Informed Lifestyle Wellness Mentor and Coach, who founded her non-profit, Seeds to Inspire, 6 during her own journey of health transformation through lifestyle medicine. She developed an extensive community network and works with diverse communities including native/indigenous, incarcerated and the Black communities to bring the healing power of lifestyle medicine to communities and activate agency around taking control of their health. Prior to joining HEAL, Nivi Jaswal founded her non-profit, the Virsa Foundation, 7 after experiencing her own health transformation through lifestyle medicine. In this work, she blends the fields of anthropology, psychology, animal rights, social work, lifestyle medicine, health coaching, filmmaking, and creative problem solving “to design and deliver Climate Conscious Plant Powered Community projects, with a focus on addressing Chronic Illness, encouraging Emotional Wellbeing, Immune Resiliency and ultimately, fostering enhanced Creative and Artistic Expression-amongst Women of Color in Underserved Communities.” After joining HEAL, her most recent work is in the development of the GAIA research project 8 that explores the connection between nutrition and COVID-19 to connect the dots between public and planetary health and the pandemic.
The creation of the HEAL initiative has had many ripple effects. The following review is an aggregate of all the amazing accomplishments that the HEAL initiative has realized with the effort and dedication of HEALers.
The Health Disparities Solutions Summit (HDSS)
This summit was a successful convening of ACLM leaders, physicians, academics, community organizers, food justice advocates and faith-based leaders to discuss how lifestyle medicine could be an important part of the work of advancing health equity. At the end of three 3-hour sessions, an expert consensus 9 was developed and four key action steps were recommended to address health equity through the lens of lifestyle medicine. The first recommendation was to educate clinicians and promote URM clinician representation. The second recommendation was to empower patients to self-advocate to increase agency in making lifestyle changes that would improve their health. The third recommendation was to build community engagement as the first step to building momentum for greater positive societal change. The fourth recommendation was to advocate for policy changes that focus on social determinants of health to improve the overall health of the population and address the societal and environmental factors that largely contribute to chronic preventable diseases. In conclusion, it was made clear that lifestyle medicine is the foundation needed to achieving optimal health for all.
The HEAL Scholarship
The HEAL Scholarship 10 has been one of the most exciting and successful projects launched through the HEAL Initiative. The mission of this scholarship program is to support a diverse healthcare workforce with particular focus on those working in marginalized communities: a realization of the first recommendation from the HDSS White paper as well as one of the key areas of focus outlined by the AMA to advance health equity and the fourth guiding principle of Commission to End Health Care Disparities. Since the inaugural HEAL scholarship created in 2021, ACLM has awarded over $120,000 to a diverse group of 46 lifestyle medicine practitioners with varying healthcare backgrounds (physician, nurse practitioner, registered nurse, physician assistant, therapist, etc.). To offer one example of the impact of the HEAL scholarship, a recent article published on the American College of Lifestyle Medicine blog and written by Dr. Jamal Wallace, a 2022 HEAL Scholarship recipient, highlights how the HEAL scholarship has enriched his practice and work to advance health equity in his community in Savannah, GA. 11
Director of Health Equity and Advocacy
In May 2022, ACLM was privileged to welcome Stacia Johnston, MSC to the ACLM staff team as the Director of Health Equity and Advocacy. Ms Johnston’s prior work leading the diversity, equity and inclusion efforts at the American Academy of Dermatology and her expertise in communications have allowed her to be an excellent asset to HEAL’s work to advance advocacy priorities including lifestyle medicine in medical education, reimbursement for lifestyle medicine practice, the opportunity to implement lifestyle medicine in the prevention, treatment and reversal lifestyle-related chronic disease health disparities and lifestyle medicine in the U.S. Military. ACLM’s most recent and unprecedented advocacy work has included involvement in the White House Conference on Hunger, Nutrition and Health resulting in a recent pledge to improve nutrition training of medical professionals specifically through offering 5.5 hours of Continuing Medical Education course credits on nutrition and “food is medicine” topics. 12 The $24.1 million in donated CME would help to train 100 000 healthcare providers in regions with high chronic disease burden in the practice of lifestyle medicine. Additionally, ACLM has also pledged to cover half the cost of lifestyle medicine training and certification for 1400 primary care providers from Federally Qualified Health Centers across the nation (one from each FQHC).
A Seat at the Table Community Conversation Series and Big Picture Living
One of the key principles of health equity is community engagement, which has been outlined as one of HEAL’s key priorities through Community Conversations. The aim of community conversations is bridging the gap between the medical/healthcare sector and the other societal sectors that influence social determinants of health such as education and faith and engaging in conversations that identify key barriers to health. The identification of these barriers through the lens of the community then allows for the development of practical and community-led solutions. During the pandemic, ACLM, Big Picture Learning and FableVision partnered to create Big Picture Living, a student-led health campaign “to build meaningful relationships that empower our communities - starting with our youth build, adapt and share a culture of health.” Big Picture Living is dedicated to equipping students with lifestyle medicine tools at a young age to support a thriving health trajectory in the future. During the month of January 2022, HEAL and Big Picture Living 13 (an entity of Big Picture Learning, an educational organization dedicated to helping students live lives of their own design) jointly sponsored a three-part virtual webinar series on health and education titled, “A Seat at the Table,” 14 outlining the importance of lifestyle medicine as an expanded understanding of the integral elements of social and emotional learning in educational to optimize educational experience for today’s young people. The series covered the state of health of the young people in America, health disparities as it pertains to school-aged children and the solutions being created and led by students of the Big Picture Learning community in their respective schools to engage their peers in living healthy lifestyles.
HEAL Social Media
Upon the creation of HEAL, it was important to utilize social media as a means to create awareness of HEAL’s work in the general public. An IG channel was created to share HEAL’s work and facilitate conversations through IG Live sessions around lifestyle medicine and health equity. In addition, the HEAL website officially launched during the annual Lifestyle Medicine conference in November 2022. Most recently, the IG channel has launched some efforts to engage the public including hosting a conversation on Childhood Obesity with Dr. Qadira Huff in 2022 and starting an IG live series in 2023 titled, “Brunch with HEALers” with Jacque Salomona and Dr. Marsha-Gail Davis to create a space of meaningful conversation to highlight where lifestyle medicine and health equity intersect to offer solutions to health inequity.
The Health and Faith Project-Community-Engaged Lifestyle Medicine at Friendly Temple
The Health and Faith Project sprouted from a partnership with the HDSS summit participant, Bishop Michael Jones and his congregation, Friendly Temple, and will be discussed in more detail below.
New Leadership to Continue the Work of HEAL
The HEAL initiative will officially transition leadership from Drs. Terri Stone, Marsha-Gail Davis and Erin Sinnave to our new leaders, Drs. Qadira Huff, David Bowman, and Daphne Bascom at the end of the first quarter of 2023.
The Friendly Temple (FT) Project - HEALing Communities Through Community-Engaged Lifestyle Medicine (CELM)
As culmination of HEAL’s work, we would like to highlight the Friendly Temple’s
As a result of Summit recommendations and Bishop Jones’ vision to bring health, hope, and healing to his congregation, the Logo for the Friendly temple “Health and Faith” project
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Through the
FT has a long standing reputation in the St Louis community as a faith-based force of good motivated by its desire to serve. Additionally, the church, in the Black community in particular, has a long tradition of being a force of change where lives are transformed for the better. The church, as a connected community supporting spiritual journeys, is in a unique position to guide and support personal health journeys as well. The
The vision and mission statements of the
Vision
A nation wherein all people are equipped with the knowledge and resources necessary to eliminate lifestyle-related chronic disease health disparities.
Mission
Working in collaboration with Friendly Temple (FT) leadership, develop a scalable, replicable church-based intervention to educate, equip and empower the church and those it serves to address lifestyle-related chronic disease health disparities.
The Health and Faith community prepared tools, centered around an eight -week lifestyle program,
In addition to 1. A Health Self-Assessment Survey to capture biometrics and health goals. 2. Curated presentations by lifestyle medicine leaders sharing their personal health journeys, faith and insight into the intersection of the two. 3. Fifty two weekly scriptures to guide and support participants on their healthy transformation journey to health and weight management. 4. Theology in Health by Mark Faries, PhD to reinforce the intersection of scripture and optimal health of mind body and spirit 5. Printable educational tools and resources from the ACLM library 6. Body and Soul curriculum wellness program 7. Films and documentaries that provide supporting evidence for lifestyle medicine, forks over knives, GameChangers 8. A Partnership with St Louis community businesses, local grocers and BJC HealthCare to provide food and biometric measurements.
ACLM hosted a celebratory and supportive kick off meeting with FT members. FT wellness champions were identified by health ministry members led by RN Jackie Ewell. These enthusiastic volunteers received virtual Full Plate living facilitator training. Over one hundred FT members successfully completed the Health and Faith health transformation journey. Focus group feedback was optimistic and encouraging with plans to the program to more multiple cohorts moving forward. Facilitators and participants discussed feeling empowered to manage their wellbeing, enjoying shopping in the produce section, sharing delicious nutritious dishes with family, resolution of joint pain, adding beautiful whole grains, vegetables, fruits, to dishes. Health minister, leader Jackie Ewell commented “Our members are empowered to... ‘
In the future, FT would like to expand the scalable sustainable program to FT youth members. ACLM and Ardmore Institute of Health envision sharing the Health and Faith program with interdenominational faith-based communities across the nation.
HEALing Our Nation - The Power of Lifestyle Medicine to Buffer Downstream Effects of Social Determinants of Health
HEALing our Nation begins with addressing underlying factors, both social, political, economic and environmental that create health disparities. Healthy People 2030 defines a
Using the African American community as an area of focus, African American health disparities are notable in that they are: • 30% more likely to die from heart disease.
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• More likely to have hypertension.
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• 60% more likely to be diagnosed with diabetes.
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• 2x more likely to die from diabetes than non-Hispanic Whites.
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• More likely to have 2-3 times more kidney problems or limb amputations from diabetes.
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• More likely to die from cancer than other groups.
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In April 2020, Dr. Anthony Fauci stated that Blacks and people with chronic disease are dying fastest from COVID-19.17,19 The underlying commonality between non-Blacks with chronic disease and Blacks is oxidative stress.18,19 The underlying cause of oxidative stress for most people with chronic disease includes the standard American diet, stress, poor sleep, a sedentary life, amongst others.20,21 For Blacks, those same causes exist, along with health inequities and other social determinants of health that increase their oxidative stress.
Using the analogy of an iceberg, the diseases that we see at the tip of the iceberg are hypertension, diabetes, heart disease, cancer and severe COVID (Figure 2). For African Americans and other diverse and marginalized populations (low income, Latino, Indigenous, LGTBQ and rural) that face health disparities, the social determinants of health and the health inequities include systemic racism, discrimination, unequal healthcare access and treatment, biased policing and justice system, an unhealthy food environment, gentrification, gerrymandering, voter suppression and unequal education.
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It may appear that those social determinants of health (outside of unequal healthcare access and treatment) are factors that health care providers cannot control. However, those social determinants do lead to the physiological effects of immune dysfunction, oxidative stress, inflammation and gut microbiome dysbiosis, and those factors increase the risk of the cardiometabolic, neoplastic and inflammatory diseases as well as severe COVID. These physiologic effects of oxidative stress and inflammation are addressed by the six pillars of lifestyle medicine-a whole food, plant-predominant diet, physical activity, stress management, adequate sleep, avoidance of risky substances, and positive social connections. This lifestyle reduces oxidative stress and chronic inflammation, with dietary antioxidants and an anti-inflammatory diet. It is by these mechanisms that we can start to achieve health equity, by having the lifestyle medicine principles address the physiologic effects of the adverse social determinants of health and act essential as a buffer to prevent disease burden and suffering created by downstream effects (Figure 3). Infographic describing the link between social determinants of health and the pathophysiology of common chronic disease using the analogy of an iceberg. Infographic describing the link between social determinants of health and the pathophysiology of common chronic disease using the analogy of an iceberg and the role of lifestyle medicine pillars in addressing the underlying pathophysiology.
The following real case scenario illuminates how to impact one lifestyle pillar, stress management, on an individual level. A 16-year-old African American female comes to a health center for a physical exam. She is accompanied by her 8-month-old child and her social worker. The teen lives in foster care with her aunt and uncle, who are unable to come because of work. The medical student takes the history and notes that the girl is smoking marijuana twice a day. Her diet consists of a Wendy’s bacon burger with cheese fries, and waffles and a Lunchable for dinner. The teen’s mother had been incarcerated and died while in jail, just 3 days before the baby was born. There are some adverse childhood experiences that are definitely present, and the predictable, almost certain future of her health is not good.
Regarding adverse childhood experiences, one of the goals of anticipatory guidance should include decreasing blame and shame. 23 It is important to note that patients and caregivers are exhibiting normal physiologic and biological reactions to abnormal, traumatic situations. If they didn’t have those traumatic experiences, perhaps they wouldn’t have the physical and behavioral problems that they do. Trauma-informed care shifts the focus from “what’s wrong with you?” to “what happened to you?” 24
Applying that mentality to the case study above led to a changed approach. Empathy was exhibited in understanding with her choice of ways to relieve stress. Other opportunities for constructive ways to relieve stress were discussed, including physical activity and helping her understand that certain foods would increase or decrease the physiological effects of stress. A vision for a better future for her and her child was presented to her, and she believed in the vision and was excited to make the changes. Her health destiny (and that of her son) potentially transformed dramatically in a few minutes, by focusing not on what was wrong with her, but rather how to constructively deal with stress and apply lifestyle medicine principles. In this example, it is important to note that a change in narrative was the first step to practicing lifestyle medicine with a health equity lens, which then allowed for the practical application of lifestyle medicine at the specific level of needs for this patient.
In summary, to achieve health equity through lifestyle medicine, it is important to start first with the correcting narrative as outlined by the AMA’s Narrative Guide 3 and clearly illustrated in the closing case study of this article. Secondly, it is critical to examine lifestyle medicine and health equity principles separately to identify the most effective strategies and then observing where practical solutions can emerge at this intersection. This will in turn allow for opportunities on the macro and micro levels to address health disparities which describes the extensive work accomplished by the HEAL Initiative over the past 3 years. Lastly, the hope of health equity achieved through lifestyle medicine is that promoting lifestyle medicine principles in an equitable and culturally relevant way can help buffer the downstream physiological effects of health inequities and create resilience and activate agency that can result in individual and community wide change.
Footnotes
Acknowledgments
The authors wish to acknowledge the generous support provided by the Ardmore Institute of Health to support the HEAL initiative in addressing lifestyle-related chronic disease health disparities through community engaged lifestyle-medicine and organization-level health equity efforts.
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) received no financial support for the research, authorship, and/or publication of this article.
