Physician Education and Lifestyle Medicine: A Key to the Future

“It is shocking that only 9% of medical schools have any academic offerings in physical activity.”

There is no longer any serious doubt that daily habits and actions profoundly impact on short and long-term health and quality of life. This contention is supported by literally thousands of studies and is incorporated into the evidence-based guidelines of virtually every metabolic expert panel both for children and adults. In addition, the World Health Organization (WHO) has focused on daily habits and actions as key components of their initiative on non-communicable diseases (NCDs). The WHO states that 71% of all mortality each year comes from NCDs. ¹

With all this as background, it remains a source of deep chagrin for me that so few physicians have fully embraced the evidence that supports the major components of lifestyle medicine. Physicians take pride in feeling that they practice “evidence-based medicine” yet, the enormous evidence that supports lifestyle medicine habits and actions, and their positive impact on health, remains sadly underappreciated and utilized within mainstream medicine.

While we have made enormous progress in this area, we need to do more! Physicians generally agree with the premise that healthy nutrition, regular physical activity, weight management, avoidance of addictive products such as cigarettes and alcohol, stress reduction, and connection with others all contribute to good health. Yet, putting this predisposition into clinical practice has remained frustratingly difficult.

For example, in the area of nutrition, studies have indicated that only 21% of patients feel that they receive adequate nutritional advice from their physicians. This is not surprising given that only 20% of medical schools have a nutrition course and only 14% of individuals who graduate from medical school feel they have adequate nutritional knowledge. ² In my own discipline of cardiology, it is shocking that 90% of cardiologists feel they do not have adequate nutritional knowledge. ³ It is somewhat comforting to me, however, that 95% of cardiologists feel that nutrition counseling is important and try to do it.

The area of physical activity shows similar results. It is shocking that only 9% of medical schools have any academic offerings in physical activity. It is, thus, not surprising that a recent survey of 175 primary care physicians reveal that only 12% were aware of recommendations from the American College of Sports Medicine (ACSM) related to physical activity. ⁴ An evaluation of 51 internal medicine residents reported that 88% felt confident in their knowledge of the benefits of exercise but only 25% demonstrated adequate knowledge that would be useful for patient counseling. ⁵

The low levels of education in the important pillars of nutrition and physical activity do not reflect a lack of interest on the part of medical students and physicians. For example, in a recent survey of 1000 physicians, only 13.5% agreed or strongly agreed that they were adequately trained to discuss nutrition with their patients. ⁶ A significant majority (78.4%), however, thought additional training in nutrition would help them provide better clinical care in the prevention of cardiovascular disease. When physicians were asked to rate the importance of various therapies in CVD on a scale 1-10 (with 10 being the most important), respondents rated nutrition at 8.1 ± 2.05 and physical activity at 8.2 ± 1.56. Both of these were higher than statins (7.8 ± 2.11).

Amongst medical students, it is clear that the 4 years spent in medical school discourages many students from pursuing their initial interest in nutrition. In 1 survey 72% of students reported nutritional counseling to be highly relevant during their first year of medical school but only 46% did in their final year. ⁷

I have been proud to say that in my own particular area of subspecialty of cardiovascular medicine, there has been real interest in the relationship between nutrition and physical activity and health. In fact, the Council of the AHA that I helped establish is now called the “Council on Lifestyle Medicine and Cardiovascular Health.”

Despite general interest in this area amongst cardiologists the actual educational training remains dismal. Over 90% of cardiologists report receiving minimal education during fellowship training in nutrition and only 8% describe themselves as having “expert” knowledge in nutrition. ³ This despite the fact that 2013 practice guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC) recommend nutritional counseling as a key component of the practice of cardiology. ⁸ In addition, the evidence-based guidelines for lipid management ⁹ and detection and treatment of high blood pressure ¹⁰ from the AHA and ACC, both strongly recommend dietary intervention as a key component of managing the CVD risk factors.

In this otherwise dismal picture, there are some emerging glimmers of hope. The American College of Lifestyle Medicine (ACLM) has been a leader in developing educational materials for physicians at all levels of training from medical school through residency and fellowship and into clinical private practice. In response to the recently completed White House Conference on Hunger, Nutrition, and Health, ¹¹ ACLM committed to sponsoring the CME courses for thousands of physicians in the area of healthy nutrition. In the area of physical activity, in addition to ACLM, the American Academy of Geriatrics, American College of Preventive Medicine, the American Academy of Pediatrics and the American Academy of Orthopedic Surgeons all issued statements encouraging their members to address physical activity with patients. ¹² As a lifelong exerciser I strongly support these efforts!

National efforts such as the Food is Medicine initiative, ¹³ sponsored by the NIH, Robert Wood Foundation and other organizations offers hope that more physicians will embrace nutrition education as part of their training. The Exercise is Medicine initiative sponsored by the American College of Sports Medicine offers user-friendly tools to assist physicians in the process of recommended physical activity. ¹⁴

With these initiatives in progress, I am hopeful that we will continue to advance various aspects of lifestyle medicine as part of the physician education. One prominent factor that remains as an impediment is that undergraduate and graduate medical boards currently do not contain questions related to either physical activity or nutrition. Passing these Boards is essential for physicians in training and the lack of questions on physical activity and nutrition needs to be urgently addressed!

Over the 25 years that I have been involved in the area of lifestyle medicine, I have been committed to spreading the word concerning the vast evidence that supports the power of daily habits and actions to enhance both short and long-term health and quality of life. My team and I at Rippe Lifestyle Institute have pursued these activities both through the publication of our major academic textbook, Lifestyle Medicine, which has now entered its fourth edition. ¹⁵ We also coordinate the Lifestyle Medicine Series ¹⁶ and I serve as Editor in Chief of the American Journal of Lifestyle Medicine. ACLM has been a wonderful partner and truly visionary in the area of advancing medical education in lifestyle medicine.

While we have made great progress, we still are falling short of our goal of having all physicians understand why it is so important to counsel every patient in the area of lifestyle medicine. At the current time, only 40% of physicians speak about lifestyle issues when counseling patients. ¹⁷ The average physician spends less than 3 minutes counseling patients in these areas if they counsel them at all. This is a sadly wasted opportunity since 70% of adults see their personal physician on an annual basis.

We have made great progress, but we need to do more!

James M. Rippe, MD

Editor in Chief, AJLM

Professor of Medicine, UMass Chan

Medical School, Worcester, MA