The Use of Reframing: Increasing the Importance of Lifestyle Medicine

Abstract

Lifestyle behavior modification is an essential component to prevention and treatment of non-communicable diseases worldwide. For the last 40 years, studies have recognized that there is suboptimal training of physicians in lifestyle medicine and its implementation in clinical settings. The lack of nutrition and exercise counseling occurring in the medical office does not reflect the high level of evidence supporting its use. Lifestyle behavior counseling is complex; as are the individualized needs of patients. Therefore, we suspect that the lack of knowledge in nutrition and exercise prescriptions are not the only barriers to providing optimal care. Reframing lifestyle medicine interventions like nutrition and exercise from adjunctive to central to treatment and reframing the role of the physician therein may be necessary to address important barriers to overall lifestyle behavioral counseling.

Nutrition and exercise is not opinion but a science translated into practice via behavioral modification and individualized counseling to promote optimal health.

Non-communicable diseases account for the majority (74%) of all deaths globally. ¹ Cardiovascular disease alone results in nearly half (45%) of all deaths annually. ¹ The need to address lifestyle early in these instances are clear; ² however, lifestyle modifications such as exercise and nutrition interventions are often absent in patient-physician encounters. Lifestyle interventions are a first-line defense and treatment for maintaining normal health and development but are often considered adjunctive therapy in the medical setting.^3-7 To address this issue, Sugimoto and colleagues ⁸ evaluated the knowledge, self-efficacy, and education of cooking and nutrition in medical students and found that many felt knowledgeable about nutrition, were often self-taught but were interested in more nutrition education. ⁸ This is important as nutrition education in medical school has been largely inadequate for decades despite consensus that healthy diets are essential components to the overall care of all patients. ⁹

In recent years, increased nutrition training has been offered in medical school; ⁸ however, the translation from education in medical schools to application in clinical practice remains elusive.^9-12 This is not only true for nutrition but for lifestyle behaviors in general.^11,12 Continued reports of limited knowledge, understanding or comfort in providing nutrition or physical activity recommendations by physicians and many other healthcare providers hinders their ability to have meaningful lifestyle modification conversations with their patients.^13,14 Although the value of behavioral modifications on improving population health and reducing resource utilization has been clearly demonstrated,^6,15-17 the lack of adoption of these interventions in the medical setting is a serious concern.

Barriers in Prescribing Behavioral Interventions in Nutrition and Exercise

Physicians face a variety of barriers to implementation of lifestyle interventions. Physicians often feel ill equipped to prescribe physical activity and nutrition interventions for primary treatment and prevention, but there is also an even higher degree of uncertainty and efficacy for patients with medically complex conditions. Despite evidence that these populations would greatly benefit from physical activity and nutrition interventions,^6,18 recommendations in the area of lifestyle medicine for individuals with other, perhaps more concerning, medical conditions are lacking in the physician-patient encounter. In these instances, patients report receiving inconsistent and even contradictory advice regarding the prescription of lifestyle modifications from physicians.^19-21

Individualized counseling is a crucial component of achieving behavioral change. ²² Lifestyle behavioral counseling requires consistent, long-term support, and it is frequently a process that takes considerable time. Physicians spend less than 5 minutes giving nutrition or physical activity information during patient visits.^3,23,24 Clearly, the time provided for healthcare appointments is a significant barrier ²³ to delivering physical activity recommendations in primary care visits even though it is a bedrock to cardiovascular and metabolic health.^5,12 Lifestyle behavioral counseling is time intensive and non-linear in practice. Translation of scientific information into usable everyday recommendations that fit an individual's age, sex, disease, health status, goals, and social, cultural, and environmental needs requires significant training and time.^22,25

Physician’s personal lifestyle habits have also been reported as a barrier to prescription of lifestyle medicine interventions (e.g., those who eat healthy or exercise regularly are more likely to address these topics with their patients).^3,26 However, it also imbues an interesting bias within lifestyle medicine not elucidated in traditional medicine. Is the expectation that only those with personal experience give information? Interestingly, this bias is not reported with the prescription of medication. Nutrition and exercise is not opinion but a science translated into practice via behavioral modification and individualized counseling to promote optimal health.

Limited availability of qualified lifestyle medicine professionals (e.g., Registered Dietitian Nutritionists (RDNs), Exercise Physiologists) within the clinic space are an additional barrier to lifestyle medicine modification.^14,23 Collaboration and referrals to qualified professionals do not occur routinely ²⁷ despite reported benefits of interdisciplinary members improving patient health and well-being. ²⁸ Integration of a multidisciplinary team to aid physicians with the prevention and treatment of lifestyle behavioral modification is an integral solution but further investigation is required to identify why routine involvement of multidisciplinary teams does not occur. ²³ Investigations into access barriers of qualified lifestyle medicine professional networks for referrals or hiring practices within medical offices to support the multidisciplinary approach should be performed. ²²

Cognitive Reframing with Healthcare Professionals

Cognitive reframing is a valuable tool in counseling. In essence, the goal of reframing is to allow a patient to spend time considering an entrenched belief and learn to look at the problem in a different light. ²⁹ For example, a patient may only believe that behavioral changes need to occur on a large scale (e.g., weight loss will only be meaningful if they lose 20% of their body weight). In these cases, it is critical to evaluate this assumption with a patient. Once the patient is able to understand their belief behind this goal, it is possible to reframe these thoughts into something more productive. In order for cognitive reframing to be beneficial, patients must be aware of the belief and then challenge the belief with one that is more accurate and helpful.

It is plausible that cognitive reframing is needed with healthcare professionals in terms of understanding the critical role of lifestyle medicine. Although it appears that many healthcare professionals understand that lifestyle intervention is important, it is likely that disease management is viewed as their primary responsibility while issues such as diet or inactivity, although important, are not as necessary for treatment. For example, the medical model that most healthcare professionals are trained under is likely to emphasize the importance of medication and issues that can be addressed during a short clinic visit. ³⁰ If it is correct that individuals do not place nutrition or physical activity as a central tenant to the treatment of many diseases, cognitive reframing may be an important tool used in lifestyle medicine education for healthcare professionals to allow for full integration into lifestyle medicine treatment planning.

Too often in lifestyle medicine (e.g., physical activity and nutrition), the responsibility is placed primarily on the physician to implement the lifestyle intervention plan. Effective delivery and counseling of lifestyle interventions require individualized adaptation to a patient's social determinants of health, culture, and knowledge base.^31,32 The idea that limited training alone in medical school can effectively solve how to address modifiable factors downplays the biopsychosocial nuances inherent to every patient population.^13,25 These biopsychosocial nuances point to the existence of additional barriers for physicians and may help answer why they are not well prepared and unable to effectively translate their patients' nutritional and physical activity needs into practice.^10,25,33 Similarly, the training that a physician receives in medical school will not provide the level of training of an RDN or exercise physiologist who has expertise and ongoing practical experience.

Although physicians can significantly reduce the health impact of poor diets and inactivity, they are not necessarily providers of specialized lifestyle medicine counseling. In fact, physicians continue to have mixed views on their role in lifestyle medicine, with some describing nutrition education competence as knowing when to refer to an RDN. ¹⁴ Continued emphasis on lifestyle medicine in medical school can provide a great value in understanding and recognizing basic concepts (e.g., when and how to triage). Perhaps a part of educating health practitioners should include training that helps providers to recognize the limitations of their knowledge in lifestyle and the appropriateness of enhancing other team members’ involvement (e.g., exercise physiologists and RDNs).

Conclusion

Difficulties in the implementation of lifestyle behavior modifications in the physician office are due to multiple factors. Increasing comfort and knowledge in healthcare professionals who are not trained in lifestyle behaviors is important as discussed by Sugimoto and colleagues ⁸ in this issue. Multiple other factors also play large roles. For example, barriers to physician-led interventions in nutrition and physical activity include time, behavioral traits, and resource availability. Although lifestyle medicine education is important for healthcare professionals, the dilemma of substandard lifestyle behavioral interventions has been present for decades and is unlikely to be solved by increasing knowledge and comfort in the subject area alone during training. The more probable solution likely rests in additionally reframing the importance of lifestyle behaviors. As the issues of nutrition and physical activity are reframed from “important” to “central” in obtaining healthier outcomes, it is likely that these behaviors are more likely to be addressed in a way that is meaningful to patients. Finally, ensuring that all healthcare professionals understand that they may not be, nor are they expected to be, experts in nutrition or exercise therapy, rather, they should support individuals who are experts is critical to keeping patients healthy.