LIFESTYLE IS MEDICINE Jennifer T. Shalz, M.D. Medical Director , St. Luke's Department of Lifestyle Medicine Outline
1. Review the scientific evidence that demonstrates the connection between individual health behaviors and chronic disease
2. Describe the new sub specialty of Lifestyle Medicine
3. Give ideas on how to incorporate lifestyle medicine principles in your current practice and offer resources to help you make any desired future practice change
4. Describe a consultative Lifestyle Medicine practice within a community hospital health system
Health Care Costs
•Since 2010, nearly 18% of the US gross product is spent on healthcare
•Chronic diseases: heart disease, cancer, and diabetes •Responsible for 7 of every 10 deaths among Americans each year •Account for 75% of the nation’s health spending
National Center for Health Statistics. Fast Stats. CDC 2016 and 2017 at cdc.gov
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Life Expectancy
•Life expectancy in the United States has dropped again •78.6 years in 2016 •Increased mortality from •Unintentional injuries (opioid overdoses) • Alzheimer's disease •Suicide •Combined with substantial slowdown in the rate of decline for cardiovascular mortality. Mortality in the United States, 2016; CDC Dec 21, 2107; cdc.gov
The World Health Organization estimated that ≈80% of NCDs (non-communicable diseases) could be prevented if 4 key lifestyle practices were followed A healthy diet Being physically active Avoidance of tobacco Alcohol intake in moderation.
Noncommunicable diseases and mental health. World Health Organization website. http://www.who.int/nmh/en/ Accessed October 16, 2015 3% of Americans Practice all 4 of these Health Behaviors Non smoking Healthy weight Regular Physical activity 5 Fruits and Vegetables a day
Reeves & Rafferty, Arch Intern Med, 2005
Interheart Study 52 countries, prospective case control Yusuf Lancet 2004
9 Modifiable Risk Factors for Acute MI Smoking, lipids, hypertension, diabetes, obesity, diet, physical activity, alcohol consumption, and psychosocial factors (stress, mental illness, isolation, addiction)
5 factors accounted for 80% of the risk for Acute MI: Smoking Lipids Hypertension Diabetes (T2DM) Obesity
InterSTROKE 32 countries prospective case control O’Donnell, Lancet 2016 Ten Lifestyle Related Risk Factors associated with 90% of all Strokes • Hypertension • Current smoking • Abdominal obesity • Unhealthy diet • Physical inactivity • Diabetes • Alcohol intake • Psychological stress • Depression • Cardiac causes • Lipids
The China Study • Major findings • Degenerative diseases more common in Western countries occurred clustered together • Heart Disease, Diabetes, Cancer • Higher death rates from these diseases in counties with a high consumption of animal based foods • Disease outcomes related to routine amount of intake of plant vs animal based foods •Conclusion The closer people came to an all plant-based diet, the lower their risk for chronic disease Lowering Number of Lifestyle Risks: Improves Life Expectancy and Lifetime Risk of Atherosclerotic Cardiovascular Disease (CVD)
• Framingham Heart Study Lloyd-Jones Circulation 2006 • In those free of CVD at age 50 • Both men and women at optimal risk median life expectancy ~10 years longer than those with >2 risk factors at age 50
• Nurses Health Study Stampfer NEJM 2000 • If all 5 factors then 82% lower lifetime risk of CVD • Absence of smoking • BMI<25 kg/m2 • Physically active 30 min a day • Moderate alcohol consumption (5-30 gm/day) • Top 40% of a healthy diet score
90% of Malignancies Rooted in Lifestyle and Environmental Exposures
Tobacco and alcohol
Physical Inactivity
Dietary Factors
Obesity
World Cancer Research Fund/American Institute for Cancer Research McMichael Public Health Nutr. 2008
Colorectal Cancer Associated with Modifiable Lifestyle Issues (Diet and Activity) more than other Malignancies •Dietary Factors • Large consumption of red meats, highly processed foods • Low amounts of fruit, vegetables, legumes, fiber intake •More co morbidities at time of diagnosis than patients with other malignancies • T2DM 26% increased risk of colorectal ca • 30% increased risk of dying vs. those without T2DM
Breast Cancer Survivor Data
• American Institute for Cancer Research in 2014: • Diet, physical activity, and weight control major contributors to long term survival after breast cancer diagnosis
• Meta analysis in 2011 of 12,000 patients performing post diagnosis exercise Irwin Med Oncol 2011 • 34% decreased risk of death by breast ca • 24% decrease in recurrence • 41% decrease in risk of all cause mortality
Proposed Mechanisms for Health Behaviors causing Disease • Epigenetics • DNA sequences (genes) explain 10% of variance in health status • Epigenetics refers to gene switches that modulate gene expression and account for 70-90% variance in health • Favorable lifestyle in patients with a high genetic risk profile associated with 50% decreased risk of CVD Khera NEJM 2016 • Prostate oncogene expression was beneficially changed after 3 months on a low fat plant based diet with daily 30 minutes of exercise and stress reduction program Ornish Proc Nat Acad Sci 2008 • Epigenetics being studied in pregnancy and preconception
Proposed Mechanisms for Health Behaviors causing Disease • Gut Microbiome • Recent advances in molecular tools like gene sequencing resulted in more understanding
• An endocrine organ that manufactures possibly thousands of chemicals that influence the regulation of multiple distant organs • “Leaky gut” can occur where toxins enter the bloodstream and result in increased inflammation, alterations in lipid metabolism and insulin signaling Marchesi Gut 2016, Rajendhran Int J Cardiol 2013
• “Dysbiosis”: different bacteria in meat eaters vs plant eaters • Meats are high in L-carnitine are metabolized by the gut microbes to trimethylamine that is hepatically converted to trimethylamine oxide or TMAO which cause macrophage uptake of oxidation of low density lipoproteins • High TMAO production in meat eaters but low levels of TMAO in an anti inflammatory diet pattern even when they are given meat to eat Koeth Nat Med 2013
Proposed Mechanisms for Health Behaviors causing Disease •Oxidative Stress
• Caused by free radicals that are not balanced effectively by anti oxidants • Food, toxins (tobacco), radiation
• Atherosclerosis result of oxidative damage to the endothelial cells then oxidation of low density lipoproteins energized to penetrate the endothelial layer leading to plaques
Proposed Mechanisms for Health Behaviors causing Disease Chronic Inflammation • Causative factor in nearly all chronic diseases • Activation and recruitment of immune cells • 4 pathophysiologic mechanisms • Increases insulin resistance • Increases thrombosis • Causes endothelial dysfunction • Direct cell and tissue injury
Emotional Stress Causes Disease through Inflammation Depression • Association between obesity and depression Lupino Arch Gen Psychiatry 2010 • Risk factor for development of CVD and prognostic indicator for poorer outcomes in those with CVD with 3x increase in mortality if depression present after an acute MI Hare Eur Heart J 2014 • Shortening of telomere caplets at the ends of chromosomes associated with process of aging and onset of malignancies • Chronic emotional stress can result in shortening damage to telomeres Epel Proc Natl Acad Sci 2004
Determinants of Health and Relative Impact on Health Outcomes The Leadership Role of Nonprofit Health Systems in Community Health, American Hospital Association, 2017
Impact on Health Outcomes
Determinants of Health 7% Behaviors Use of tobacco, alcohol, drugs; diet; physical activity; 11% overweight/obesity 36% Social Circumstances Economic stability, education, housing, transportation, access to healthy food, social support, community engagement and safety, discrimination Genetics Sex, inherited conditions and genes 22% Health and Medical Care Insurance coverage, access and quality of care, providers’ clinical competency and linguistic/cultural proficiency Physical Environment Air pollution, water sanitation, exposure to toxic and microbial agents 24%
26 European Prospective Investigation into Cancer and Nutrition-Potsdam study 23,000 participants
• 4 simple recommendations • No tobacco use • 30 min of exercise 5xweek • Maintain a bmi <30 kg/m2 • Eat a healthy diet
• 9% (2070) adhered to all 4 • 78% decreased risk of developing a chronic condition during an 8 yr follow up with 93% reduced risk of diabetes, 81% reduced risk of myocardial infarction, 36% reduction in risk of developing cancer Ford Arch Intern Med 2009 Dean Ornish, MD The Lifestyle Heart Trial Intensive lifestyle changes caused regression of coronary atherosclerosis after 1 year
• 10% fat whole foods vegetarian diet, aerobic exercise, stress management training, smoking cessation, group psychosocial support for 5 years • 20/28 (71%) patients completed 5 yr follow up maintained lifestyle changes for 5 yrs vs controls 15/20 patients made more moderate changes
Experimental group average percent diameter stenosis decreased 1 year 1.75% (absolute%) 5 years 3.1 %
Control group percent diameter stenosis increased 1 year 2.3% (absolute%) 5 years 11.8%
25 cardiac events in 28 experimental subjects vs 45 in 20 control subjects Ornish JAMA 1998 Caldwell Esselstyn, MD from the Cleveland Clinic
• Demonstrated reversal of coronary plaques in 18 people eating a very low fat 10-15% whole food plant based diet without oils, dairy, meat, poultry, fish
• 12 year study in 18 patients who had CAD and failed earlier intervention of bypass surgery or angioplasty
• All who maintained the diet achieved cholesterol goal <150 and no recurrent coronary events over 12 years. They had 49 coronary events the 8 years prior to the study
• At 5 years, angiography repeated and showed none had progression and 70% had selective regression
“Heart disease is a foodborne illness. A plant based diet is the most powerful medicine.”
“The truth be known coronary artery disease is a toothless paper tiger that need never exist and if it does exist, it need never progress.” Esselstyn J Fam Pract 1995 and Am J Cardiol 1998 The Diabetes Prevention Program study
• Lifestyle intervention (low fat low calorie diet and 15 min of moderate intensity exercise daily) more effective at preventing or delaying onset of type 2 diabetes than usual care • 3000 subjects followed until 2014 with metformin 850 mg twice daily vs lifestyle alone vs placebo controlled • Lifestyle decreased risk of developing diabetes by 27% compared to 18% in metformin group Diabetes Prevention Program Research Group. Lancet Diabetes Endocrinol 2015
Complete Health Improvement Program (CHIP)
• 5070 participants with a 30 day program encouraging a whole food plant based diet pattern and physical activity • All statistically and clinically significant decreases • Body mass -3.2% • Systolic and diastolic BP -4.9%, -5.3% • Total cholesterol -11% • LDL cholesterol -13% • Triglycerides -7.7% • Fasting plasma glucose -6.1%
Rankin American Journal of Cardiology 2012
The Adventist Health Study-2
“Vegetarian dietary patterns were associated with lower: Body Mass Index Prevalence and incidence of Diabetes Mellitus Prevalence of the Metabolic Syndrome and its component factors Prevalence of Hypertension All-cause Mortality Risk of Cancer.”
Adventist Health Study-2 Orlich JAMA 2013, and Am J Clin Nutri 2014
In 2015: The International Agency for Research on Cancer (IARC) classified processed meat as a carcinogen and classified red meat as a probable carcinogen Twenty-two experts from 10 countries reviewed more than 800 studies • Eating 50 grams of processed meat (hot dogs, ham, bacon, sausage, and some deli meats) every day increased the risk of colorectal cancer by 18% • Eating red meat (beef, pork, lamb, goat) showed some evidence of increased risk of colorectal, pancreatic and prostate cancer Bouvard Lancet Oncol 2015
Breaking News June 14, 2017 American Medical Association Annual Meeting Policy Statement “The AMA hereby calls on U.S. hospitals to improve the health of patients, staff, and visitors by 1) providing a variety of healthful foods, including plant based meals and meals that are low in fat, sodium, and added sugars, 2) eliminating processed meats from menus, and 3) providing and promoting healthful beverages.”
Healthy Plants good. Unhealthy Plants bad. 3,710 women in NHS (Nurses’ Health Study) (1984 to 2012), 92,329 women in NHS2 (1991 to 2013), and 43,259 d men in Health Professionals Follow-up Study (1986 to 2012), free of chronic diseases at baseline Healthy plant foods = whole grains, fruits/vegetables, nuts/legumes, oils, tea/coffee Unhealthy plant foods= juices/sweetened beverages, refined grains, potatoes/fries, sweets CONCLUSIONS Higher intake of healthier plant foods is associated with substantially lower CHD risk, whereas a plant-based diet that emphasizes less-healthy plant foods is associated with higher CHD risk Satija J Am Coll Cardiol 2017
Type 2 Diabetes and Effects of Diet • Each daily serving of sugar sweetened beverages associated with 25% increased risk Imamura BMJ 2015
• Meta analysis of processed meats showed each serving daily associated with 51% increased risk of T2DM Micha Curr Atheroscler Rep 2012
• Nurses and Physicians Health Studies combined showed substituting just 5% of calories from animal to plant reduced the risk of T2DM by 23% Malik Am J Epidemiol 2016
• Randomized controlled trial compared whole foods plant based diet (WFPBD) vs ADA diet showed both dietary patterns improved glycemic control but WFPBD was superior Barnard Diabetes Care 2006
Food is Medicine: Whole Food Plant Based Diet “Eat Food, Not too Much, Mostly Plants.” Michael Pollan Journalist
“There are two kinds of cardiologists: vegans and those who haven’t read the data.” Kim Williams, MD Recent Past President of the American College of Cardiology Nov 2017 Optimal Health Behaviors
• Consume Whole, Plant based Foods ie. anti inflammatory diet
• Moderate level of Exercise for 150-300 minutes weekly as goal
• Develop Emotional Resilience • Depression and anxiety negatively affect • Gratitude practice and mindfulness promote well being which builds resilience
• Sleep 7-8 hours nightly
• No Tobacco use or Illicit Drug use
• Moderate to no Alcohol use
• Maintain a BMI <25 and a Waist Circumference <40 in (men), <35 in (women)
• Maintain >2-3 strong Social Connections
• Develop and maintain a Sense of Purpose
Guidelines recommend using Lifestyle as the Primary Approach to Chronic Disease Management and Prevention • The 2015-2020 USDA Dietary Guidelines for Americans “A healthy dietary pattern is high in vegetables, fruit, whole grains, seafood, legumes, and nuts; moderate in low- and non-fat dairy products; lower in red and processed meat; and low in sugar-sweetened foods and beverages and refined grains.”
• AHA/ACC 2017 Hypertension Guidelines “Many nonpharmacological interventions that are effective in lowering BP are recommended for people with elevated BP or hypertension (strong recommendation; high-quality evidence). These interventions include weight loss in patients who are overweight or obese; a heart- healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet; sodium reduction; potassium supplementation; increased physical activity; and moderation of alcohol consumption…Weight loss has been shown to decrease BP by about 1 mm Hg per 1 kg of weight loss. Adoption of the DASH diet yielded an 11-mm Hg decrease in SBP.”
• ADA Standards of Medical Care in Diabetes-2017 • Lifestyle management is a fundamental aspect of diabetes care and includes diabetes self- management education (DSME), diabetes self-management support (DSMS), nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care. More Guidelines • American College of Gastroenterology Practice Guideline for Non alcoholic Fatty Liver Disease 2012 “Weight loss generally reduces hepatic steatosis, achieved either by hypocaloric diet alone or in conjunction with increased physical activity.”
• 2013 ACC/AHA Guideline on Lifestyle Management to reduce Cardiovascular Risk “Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats.”
• The USPSTF in 2011 recommended screening all adults for obesity. “Refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.”
• The USPSTF in 2014 recommended offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors “Intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention.”
• The USPSTF recommended in 2015 that clinicians ask all adults about tobacco use “Advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to adults who use tobacco.”
• American Academy of Neurology Practice Guideline Update for Mild Cognitive Impairment 2017 “Recommend regular exercise to manage symptoms. Twice weekly exercise for 6 months at least shown to improve memory.” Barriers to Medical Providers Helping Patients Change their Lifestyle Behavior • No incentive in the fee for service health care model • Inadequate medical education and training on specifics of prescribing lifestyle behavior and how to effectively activate behavior change • No easy way to refer patients to effective programs. Programs may not be available, not known or not trusted by the provider • Scientific evidence is available to guide practice but not widely known or consistently propagated by mainstream providers • Requires a different care model of a coordinated team of allied health professionals led by a physician or APP • Sustainable behavior change is best supported by the culture and environment in which a patient lives as well as social determinants of health so relies on a strong tie with community health
Founded in 2004 Definition of Lifestyle Medicine
The use of lifestyle interventions in the treatment and management of disease. American College of Lifestyle Medicine Physician Competencies for Prescribing Lifestyle Medicine Liana Lianov, MD, MPH & Mark Johnson, MD, MPH JAMA, July 14, 2010—Vol 304, No. 2
15 competencies in 5 main areas Leadership Knowledge Assessment Skills Management Skills Use of Office and community support
Inaugural Exam October 2017 Conventional vs Lifestyle Medicine
• Treats Individual Risk Factors • Treats Lifestyle Root Cause
• Patient passive recipient • Patient active partner
• Patient not required to make big • Patient must make substantial changes transitions
• Responsibility mostly on clinician • Responsibility mostly on patient
• Medication is the end treatment • Medication added as adjunct to lifestyle behavior change
Egger, LM 2008
Lifestyle Medicine compared to other Disciplines
• Complementary and Alternative Medicine CAM • Diverse medical and health care systems, practices and products not part of mainstream conventional medical practice
• Integrative Medicine • Combines treatments from conventional medicine and CAM with a personalized approach that is holistic and includes spiritual health
• Functional • Holistic model to balance core functional processes in the body like cellular metabolism, digestive function, detoxification, control of oxidative stress with focus on biochemical and physiologic function: cellular to organ level • Mind body Medicine • Interactions on mind, body, brain, behavior • Emotional, mental, social, spiritual, behavioral ways you can directly impact health • Incudes tai chi, yoga, meditation, hypnosis, biofeedback, visual imagery
• Preventative Medicine • All aspects of medical care that seeks to prevent disease • Screening, public health, immunizations, population based • Health promotion • Maintain healthy behaviors • Control chronic diseases with monitoring and self management Lifestyle Medicine Defining Characteristics
• Focuses on lifestyle behavior as the root cause of disease • Applies to every patient, every practice: prevention to palliative care with a spectrum of intensity depending on individual’s risks and needs • Emphasizes collaborative care model • Allied health professionals do most of the counseling
• Uses prescriptive lifestyle interventions for specific disease or risk conditions • Recommended in most national guidelines for prevention and treatment • Successful outcomes contingent on patient participation • Can be done through outpatient pcp office with individual visits focused on lifestyle or shared medical visits or group appointments for established patients to focus on lifestyle issues • Other settings • Consulting practices where entire focus is on LM • Telemedicine • Inpatient rehab or residential lifestyle medicine programs
Main Interventions in Lifestyle Medicine • Personally model healthy lifestyle behaviors • Provide recommendations related to health behavior habits • Perform comprehensive lifestyle assessments including risk factors and readiness for change for modifiable risk factors • Prescribe lifestyle change for treatment, prevention or even cure; use medications as adjunct • Coach patients to improve personal lifestyle choices • Prohaska’s Stages of Change • Pre-contemplative, contemplative, planning, action, maintenance • Motivational Interviewing • Cognitive Behavioral Therapy • Positive Psychology
• Team based care • Always Follow up The Gaps in Lifestyle Medicine Literature Right Now • Which interventions best for sustainable change? • What sort of practice models lead to higher rate of change in the general population?
Current Approach • Offer intense interventions to rising risk or high risk patients only • Less intense interventions to less high risk patients • Offer to targeted populations and track outcomes • Refer patients to resources and support beyond the clinical setting
Incorporate Lifestyle Medicine into your Practice • Establish lifestyle vital signs as part of your routine • Example for physical activity • On average how many days per week do you exercise? • How many minutes per week? • BMI, waist circumference, #of sleep hours , #fruits and veg daily
• Attend a lifestyle medicine related CME conference, online CME including for specific behavior activation skills • Give specific advice and prescribe change: it works! • Establish a team: partner with RD, health coach, trainer Patients Lose More Weight with a Team
• General Practitioner alone giving educational advice to patients to lose weight • 1.2 Kg lost over 1 year
• Registered dietitian alone giving advice • 5.6 kg lost over 1 year
• Registered dietitian with MD • 6.0 kg lost over 1 year
Flodgren Cochrane Data Syst Rev 2010
Physician Personal Health Impacts Patient Care • Poor physician health habits impact counseling physicians provide to patients • Oberg JAMA Internal Medicine 2013
• Doctors who exercise are more likely to counsel patients on exercise than those who don’t exercise • Abramson Clin J Sport Med 2000
• Physicians more likely to record obesity diagnosis and initiate a conversation if they perceive the patient’s weight to be more than their own body weight • Bleich Obesity 2012
• Female physicians who consumed a vegetarian diet more likely to counsel on weight loss and nutrition at least once a year • Frank Am J Clin Nutr 2002
• Nonsmoking physicians more likely to emphasize risks of smoking • Frank Arch Fam Med 2000 Incorporate Lifestyle Medicine into your Practice
• Use established calculators to motivate your patients • Framingham or 2013 Prevention Guidelines tool
• Screen with hga1c as per guidelines to diagnose pre diabetes and diabetes • >25 yo with a risk factor • Everyone >45 yo • repeat every 3 yrs if normal • Repeat annually if pre diabetic (5.7-6.4)
• Don’t forget to make obesity and depression as diagnoses • Discuss lifestyle interventions as an initial treatment option unless contradicted like emergency/urgency: subtle shift in messaging • Tell patients prescribing lifestyle as first line therapy to treat the root cause of the problem and supplementing that approach with medication Incorporate Lifestyle Medicine into your Practice • Enhance link between your clinical care and community resources • Assign a team member to amass the available resources and keep it updated
• Use EMR to document patient goals, create flowsheets for specific outcome measures for follow up and to track outcomes • Example: Physical activity minutes per week
• Consider doing group appointments to focus on lifestyle as the root cause of a variety of diseases • Have a series and invite patients with chronic disease • Use RN or MA (someone needs to scribe, get vitals), RD, behaviorist
• Encourage patients to use devices like pedometers or apps like myfitnesspal.com • Get involved in Community Advocacy for public health and policy
A Consultative Lifestyle Medicine Practice: St. Luke’s Department of Lifestyle Medicine Secondary Prevention • Cardiac Rehab • Pulmonary Rehab • Peripheral Arterial Disease Rehab (coming in March 2018)
Primary Prevention • Tobacco Treatment Program • Complete Health Improvement Program (CHIP)
Our Interdisciplinary Team • Lifestyle Medicine and Hospice and Palliative Medicine certified Internal Medicine Physician
• Lifestyle Medicine certified Nurse Practitioner
• Nurses
• Exercise Physiologists
• Diabetic Educator
• Licensed Clinical Social Workers
• Registered Dieticians
• Physical Therapists
• Occupational Therapist
• Respiratory Therapists
• Certified Tobacco Counselors (RN, LCSW) Cardiac Rehab Treasure Valley and Magic Valley
• National data supports decreases overall mortality (literature cites 20-45%) over the 10 years following completion of the program compared to those who don’t participate
• Outcomes tracked pre and post program: bp, lipids, hga1c, smoking status, improvement in exercise capacity, weight loss, phq9 results, Dartmouth quality of life
• 36 session program with supervised exercise, education, biometrics, lifestyle assessment with a provider, internal referrals to one of our many team members or group sessions
• Patient Criteria for Participation • Acute cardiac event (PCI, acute MI) or surgery (CABG, valve surgery, TAVR, heart transplant) within the last 12 months • Stable angina • Systolic heart failure with LVEF<35%, stable on meds for 6 weeks
Pulmonary Rehab Treasure Valley and Magic Valley
• National data and our data show improved function and quality of life post program for participants • Early outpatient pulmonary rehab within 4 weeks of discharge for an acute exacerbation of COPD hospital admission may decrease risk of readmission • Patient Criteria for Participation • Symptomatic COPD with pulmonary function test supporting the diagnosis • Any symptomatic lung disease • Pulmonary hypertension
Peripheral Arterial Disease Supervised Exercise March 2018 tentative start date
• Walking exercise and tobacco treatment should improve intermittent claudication symptoms and improve function, quality of life and decrease risk of complications like wounds and amputations • CMS recently approved reimbursement • Patent Criteria for Participation • Symptomatic intermittent claudication
Tobacco Treatment Program since October 2014 Treasure Valley
• Certified Tobacco Counselors give Intensive Behavioral Support and help develop a Pharmacotherapy Plan with patients • PCP prescribes the medications if they agree with the treatment plan • Patients seen face to face and telephonically supported as well during quit attempt • Followed for one year post quit by telephone
• 100% telephonic care is being offered currently to employees and dependents on St. Luke’s Health Plan • Average quit rates in the literature for similar intervention • ~25% 6 months • ~20% 12 months
• Outcomes of all patients who have had at least one appointment with our counselors • 31% 6 month quit rate • 24% 12 month quit rate
Complete Health Improvement Program (CHIP) since Feb 2017 • 18 session facilitated group based program teaching patients about optimal lifestyle including importance of eating a more whole foods plant based pattern, exercising, reducing stress, etc. • Biometrics and labs done pre and post program • Outcomes on (N=62) participants • Weight loss average 4.57 kg (10 pounds): -4.8% • Waist Circumference average inches lost: 2.81 • HgA1C -0.13 • Systolic BP -9 mmHg • LDL cholesterol -9% • Triglycerides -10%
• Classes available now in Wood River, McCall, Magic Valley, Boise, and Meridian • Will start a new class in the Treasure Valley approximately every month • St. Luke’s Health Plan will cover for all employees and/or adult dependents with a BMI >30 kg/m2 as of April 1, 2018
The St. Luke’s Department of Lifestyle Medicine in the new South Meridian YMCA “The Hill” Opens June 2018
• Based on new health care economic model of value based care • Sharing risk with payers such that when patient sick, we lose money, when patient healthy, we save money • Patients on risk based contract insurance plans should have this as an added service in their plan • Fee for service plan individuals will be cash pay if not covered by insurance company
• Considering cohorts of patients who don’t traditionally have lifestyle interventions covered in the fee for service world • Prehab for total knee or hip joint replacements • Rising risk Diabetics • Metabolic Syndrome • Preconception/early prenatal program for higher risk women with hypertension, obesity, prediabetes/diabetes
A Consultative Service for Providers to Refer Patients for Lifestyle Interventions
• Triage service by a Nurse Health Coach • Low risk-warm hand off to YMCA community programs with follow up and loop back info to referring provider • Moderate risk-establish in any of the offered classes ala carte or a cohort • High risk-Lifestyle Medicine provider individual appointment for assessment and treatment plan and enrollment in one of our supervised interventions or cohorts • Group insomnia cognitive behavioral training • Tobacco treatment • Supervised exercise • Group and/or individualized dietician support • Group and or individualized behavioral support and positive psychology • Addressing psychosocial barriers to change
Lifestyle as medicine has the potential to prevent up to 80% of chronic disease; no other medicine can match “ that. In addition, it is potentially inexpensive and even cost-saving; free of all but good side effects; safe and appropriate for children and octogenarians alike. It is, quite simply, the best medicine we’ve got.” David Katz, MD, MPH Past President American College of Lifestyle Medicine
Provider Education Resources • American College of Lifestyle Medicine certification, conferences, online core competency CME
• The Institute of Lifestyle Medicine at Harvard conferences
• The Plantrician Project conference
• Plant based nutrition certification, Cornell University
• T Colin Campbell Center for Nutrition Studies
• Healthy Kitchens, Healthy Lives conference
• Rouxbe online Culinary School: Culinary RX 60 day program for patients/lay people and other courses for health professionals
• Wellcoaches online or in person training
• Motivational Interviewing training suggested
• Physicians Committee for Responsible Medicine (PCRM) Food for Life Program Patient and Provider Resources
• Books • Cookbooks • The China Study by T. Colin Campbell • Forks over Knives • Blue Zones by Dan Buettner • Thug Kitchen • How Not to Die by Michael Greger • Chloe’s Vegan Italian • Disease Proof by David Katz • Minimalist Baker • No Sweat by Michelle Segar • Plant Pure Nation • Proteinaholic by Garth Davis • How Not to Die • Power Foods to the Brain by Neil Barnard • Vegan under Pressure (pressure cooker recipes) • Prevent and Reverse Heart Disease by Caldwell Esselstyn • Herbivore • The Spectrum By Dean Ornish • The Plantpower Way • Salt, Sugar, Fat by Michael Moss • Becoming Vegan by Brenda Davis • Websites • Nutritionfacts.org • Documentaries • Lifestylefacts.org • What the Health • brendadavisrd.com • Eating You Alive • Bluezones.com • Forks over Knives • Chiphealth.com • Plant Pure Nation • Forksoverknives.com • Vegucated Patient Resources • Diabetes Prevention Program at the YMCA
• Complete Health Improvement Program (CHIP) at St. Luke’s various sites (McCall, Magic Valley, Wood River, Boise, Meridian)
• Cooking Matters cooking classes by ID Food Bank
• Idaho Quitline for tobacco treatment and free 2 months supply of nicotine replacement products
• St. Luke’s Tobacco Treatment Program in Boise and Meridian
• Quit with Nancy in the Treasure Valley