Lifestyle Medicine Course Syllabus

Creator: Beth Pegg Frates, MD Contributors: Jonathan Bonnet Merlica Coriolan Yasamina McBride Gia Merlo Irena Metanovic Kate Simeon Shannon Worthman; Vision A world in which all physicians and allied health professionals have been trained in evidence-based lifestyle medicine, integrating healthful behaviors into their own lives and incorporating a lifestyle medicine-first approach into clinical practice.

lifestylemedicine.org This syllabus is based on the foundational work of Beth Pegg Frates, MD who created a lifestyle medicine course at the Harvard Extension School in 2014, available to undergraduate, master, and other professional students interested in health and wellness. It has consistently been one of the most popular courses at the Harvard Extension School and has been attended by physicians, lawyers, engineers, nurses, wellness coordinators, social workers, business owners, religious leaders, stay at home moms, and retirees. The success of the course and increasing demand for the information inspired Dr. Frates to partner with the American College of Lifestyle Medicine to craft a syllabus that could be widely distributed and used in many different health care institutions, organizations, and schools. This curriculum represents the work of an entire team whose goal is to supply a foundation for a lifestyle medicine course on which instructors and professors can build and personalize it for their own individual needs. It is adaptable to a variety of educational environments, including undergraduate studies, master level courses, nursing school, physical therapy programs, occupational therapy programs, nutrition education courses, health and wellness coaching, or in the exercise and fitness space. We hope that you find the material useful and would love to hear your feedback on ways in which we can improve the syllabus for others.

© 2021 American College of Lifestyle Medicine. Introduction to Lifestyle Medicine Syllabus Creator: Beth Pegg Frates, MD, @BethFratesMD Contributors: Jonathan Bonnet MD; Merlica Coriolan; Yasamina McBride; Gia Merlo MD, MBA, DipABLM; Irena Metanovic; Kate Simeon; and Shannon Worthman, NBC-HWC Course Syllabus 4.1.2021

2 Lifestyle Medicine Course Syllabus Author

Beth Pegg Frates, MD, is trained as a physiatrist as Dr. Frates is currently working on writing her next book. well as a health and wellness coach. Dr. Frates is a She is passionate about developing programs focused Magna Cum Laude graduate of Harvard College where on lifestyle medicine and wellness. she majored in psychology and biology. She then As a member of the Board of Directors of the American graduated from Stanford Medical School and did her College of Lifestyle Medicine, Dr. Frates established the internal medicine internship at Massachusetts General Donald A. Pegg Student Leadership Award in 2016, in Hospital, after which she completed her physiatry honor of her late father, a New York City businessman, residency at Harvard’s Department of Physical Medicine Donald Pegg, who suffered a heart attack and a stroke and Rehabilitation. Dr. Frates has held a faculty in 1986 when he was 52. In response to this health appointment at Harvard Medical School (HMS) since set back, he went on a mission and searched for ways 2000, and she is now an Assistant Professor, Part Time. to prevent it from happening again. He participated in She is an award-winning teacher at HMS. In 2008, residential intensive lifestyle change programs, added she started the first Lifestyle Medicine Interest Group fruits, vegetables, more whole grains, and healthy (LMIG) at HMS and has worked with ACLM to help protein to his diet as well as started riding a stationary other institutions develop LMIGs in her role as Board bike religiously five days a week. Liaison to the ACLM Trainees. Two years ago, Dr. Frates developed and taught a college lifestyle medicine With this regimen and his medical care, Dr. Frates’ curriculum at the Harvard Extension School, which is father was able to live the best years of his life after his one of the most popular courses offered at the school. heart attack and stroke, enjoying 27 additional years In addition to her academic work, Dr. Frates runs her with family and friends. Donald served as an inspiration own private practice, helping people adopt healthy to many, especially his daughter, Beth who has spent habits, through Wellness Synergy, LLC. As the Director the past 30 years researching, studying, teaching, and of Wellness Programming at the Stroke Institute for practicing lifestyle medicine. Research and Recovery at Spaulding Rehabilitation Dr. Frates and her family believe in the power of lifestyle Hospital, Dr. Frates has created and implemented a medicine to transform lives and help individuals be twelve-month wellness program for stroke survivors healthier and more productive. She is now dedicated and their caregivers. Co Author of the book, Life After to working with young aspiring healthcare students, Stroke: The Guide to Recovering Your Health and understanding that our nation and world need a Preventing Another Stroke, co-author of three chapters transformed and sustainable system of healthcare on behavior change in different medical textbooks, and delivery, built on the foundation of evidence-based author of multiple journal articles on lifestyle medicine, lifestyle medicine.

Lifestyle Medicine Course Syllabus 3 Founded in 2004, the American College of Lifestyle Medicine (ACLM) is the only medical professional association for physicians, allied health professionals, health care executives, medical students and residents, and those in professions devoted to advancing the cause of lifestyle medicine. ACLM supports its members by educating, equipping and empowering them to provide an evidence-based lifestyle medicine-first treatment option for chronic disease, as opposed to prescribing ever-increasing quantities of pills and procedures. ACLM provides live and online CME- and CE-accredited events and educational offerings across the medical education continuum, Board and professional certification opportunities, clinical practice tools, patient education resources, networking opportunities, and advocacy—all designed to manifest the vision of lifestyle medicine becoming the foundation of health and all health care. ACLM has a rapidly expanding membership base of more than 4,500 across the United States and around the globe. Its members represent the broad diversity of the medical profession, reflecting the interdisciplinary “team- based” approach of lifestyle medicine clinical practice: primary care physicians, physician assistants, nurses, allied health professionals, researchers, educators, students, lifestyle medicine thought leaders, health care executives and health coaches. Medical students and residents are encouraged to join the American College of Lifestyle Medicine, taking an active role in ACLM’s Trainees . In the true spirit of the Hippocratic Oath, Trainee members are committed to ‘first, do no harm’ as they immerse themselves in specialized lifestyle medicine training, so they are equipped to be on the forefront of an emerging value and outcome-based system of healthcare delivery. As young trainees, they hope to develop the skills and knowledge to effectively prevent, treat, and reverse chronic disease using evidence-based practices.

What is Lifestyle Medicine? Lifestyle Medicine is the use of evidence-based lifestyle therapeutic intervention—including a whole-food, plant-predominant eating pattern, regular physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connection—as a primary modality, delivered by clinicians trained and certified in this specialty,to prevent, treat, and often reverse chronic disease.

It is one of the fastest growing specialty career fields in medicine and holds the promise of real value-based care and true health reform as it addresses the root-cause of most chronic illness.

Education Offerings

Bachelor Level Masters Doctorate Residency Fellowship CMECEMOC Certification

Professional Education Professional Experience

Learn more about other Lifestyle Medicine educational offerings at lifestylemedicine.org. Questions? Contact [email protected]

4 Lifestyle Medicine Course Syllabus Table of Contents

Week 1: Understanding Lifestyle Medicine 6 Week 2: Empowering People to Change 8 Week 3: Collaborating, Motivating, Goal-Setting, and Tracking 10 Week 4: Improving Health Through Exercise 12 Week 5A: The Nutrition-Health Connection 14 Week 5B: Weight Management 17 Week 6: Sleep Matters 19 Week 7: Stress and Resilience 21 Week 8: Peace of Mind With Meditation, Mindfulness, and Relaxation 23 Week 9: The Power of Connection 25 Week 10: Positively Positive 27 Week 11: Substance Use Disorder 29 Week 12: Staying the Course - Self Care 31 Week 13: Education Reform around Lifestyle Medicine Current State of Practice for Lifestyle Medicine 33 Week 14: Review Week 35

Lifestyle Medicine Course Syllabus 5 Week 1: Understanding Lifestyle Medicine

The introductory week provides students with a framework from which to build. Starting from Hippocrates and moving forward, the work and research performed by lifestyle medicine pioneers is highlighted. We explore how the development of vaccines and antibiotics changed the landscape of medicine, and how the Industrial Revolution played a part in the spread of lifestyle-related diseases. In addition, the economics of lifestyle medicine are addressed, looking at the cost and burden of chronic diseases such as diabetes, obesity, cardiac disease, and metabolic disorder. As lifestyle medicine is an evidenced-based specialty, we review research basics including the value of randomized, controlled studies, observational studies, longitudinal studies, and prospective and retrospective studies, as well as case studies. Weekly Goals for Instructors: 1. Introduce the field of lifestyle medicine. 2. Encourage students to consider their own healthy habits. 3. Provide a road map for the next 13 classes. 4. Take care of housekeeping items for the course (such as reviewing logistics, the grading scheme, and discussing the value of section sessions). Learning Objectives: By the end of the module, the participant will be able to: 1. Define lifestyle medicine. 2. Explain the concept of evidence-based lifestyle medicine. 3. Summarize the importance of lifestyle medicine for individuals, society, and healthcare. 4. Describe the history, economics, and competencies attendant to lifestyle medicine. Guiding Questions for Students: 1. What are some of the lifestyle-related problems patients, providers, and healthcare systems are facing today? 2. How is lifestyle medicine meeting the needs of patients, providers, and healthcare systems in the 21st century? 3. How can patients and providers acquire the necessary knowledge, skills, and tools required to treat and prevent lifestyle-related chronic diseases such as cancer, diabetes, obesity, cardiac disease, stroke, metabolic syndrome, and other chronic diseases? 4. What is the evidence supporting lifestyle medicine (e.g., how do we know it works)?

Lecture Topic: Overview and Introduction to Lifestyle Medicine Section Information: Section sessions are run by teaching assistants (TAs). The TAs can use the section time to review logistics for weekly assignments, quizzes or other requirements for the course. The sections run for an hour, and they provide an opportunity for students to ask questions and to learn more information on the topic of the week. If there is a recent article from the medical literature or the popular press related to the weekly topic, the section session is a great forum for discussing it. In addition, students will be asked to consider how the weekly topic pertains to their own lives, at times taking self-assessments. These smaller sessions encourage greater student participation and help to foster connections among students and between student and teaching faculty.

6 Lifestyle Medicine Course Syllabus Section Activities: Pre-assignment: Lifestyle Evaluation on page 25 of Fahey Chapter 1 Logistics Topic: Discuss overall course logistics and address students’ questions and concerns. Overall Goal: Define evidence-based practice Application Goal: Determine how students feel about their own healthy habits and evaluate students’ Fahey Lifestyle Evaluation results. Discussion Board Topic(s): General Discussion Board Assignment Instructions (same for each week): This is a group discussion that should be completed after the lecture. It is graded out of 5 points: 1. Include information from Weekly Lecture, Weekly Section, or Weekly Reading (1p). 2. Supply at least one reference at the end of your discussion (1p). It is strongly recommended that you use APA format, but you are not required to do so. 3. Respond to a classmate’s post (1p). 4. Limit your response to a 1-2 paragraphs (5 to 7 sentences, no more) answer (1p). 5. Submit on time (1p). An online “coffee house” discussion board is available for students who would like to share more than the allocated 1-2 paragraphs to answer the question. The coffee house discussions are lively and invite students to discuss topics of interest amongst themselves while a teaching assistant monitors the group. Discussion Board Topic(s): Prior to the readings and lecture for this week, what did you think lifestyle medicine was? What do you think it is now? Be sure to cite what influenced your prior thinking on the topic and your current thinking.

Required Readings: Fitness and Wellness. 9th ed. New York: McGraw Hill Higher Education;2010: 1-26 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Understanding lifestyle medicine. In: Frates B, ed. Lifestyle Medicine 8. Diabetes Prevention Research Group. Reduction in Handbook: An Introduction to the Power of Healthy Habits. the incidence of type 2 diabetes with lifestyle intervention Monterey, CA: Healthy Learning; 2021:17-44. or Metformin. New England Journal of Medicine. 2002;346(6):393–403. doi:10.1056/nejmoa012512. 2. Egger G, Binns A, Rossner S. Chapter 1 Introduction to lifestyle medicine. In: Egger G, Binns A, Rossner S.Lifestyle 9. Subramanyam R. Art of reading a journal article: Medicine: Managing Diseases of Lifestyle in the 21st Century. Methodically and effectively. Journal of Oral and 2nd ed. North Ryde, Australia: McGraw-Hill; 2010:1–10. Maxillofacial Pathology : JOMFP. 2013;17(1):65-70. doi:10.4103/0973-029X.110733. 3. DeCourten M, Egger G. Chapter 2 The epidemiology of chronic disease. In: Egger G, Binns A, Rossner S.Lifestyle Optional Readings: Medicine: Managing Diseases of Lifestyle in the 21st Century. 2nd ed. North Ryde, Australia: McGraw-Hill; 2010:11–24. 1. Rippe J, Angelopoulos. Chapter 1 Rationale for Intervention to Reduce the Risk of Coronary Artery Disease. In 4. Frates EP. Interview With Award Winners From ACLM Rippe J Lifestyle Medicine, 2nd Ed. Boca Raton, FL, CRC Press; 2015: Dean Ornish and John Kelly, Nashville, Tennessee. Am J 2013:3-17. Lifestyle Med. 2016. 2. Rippe J, Angelopoulos. Chapter 2 Lifestyle Strategies for 5. Dysinger WS. Lifestyle medicine competencies for primary Risk Factor Reduction, Prevention, and Treatment of Coronary care physicians. Virtual Mentor. 2013;15(4):306–310. Artery Disease. In Rippe J Lifestyle Medicine, 2nd Ed. Boca doi:10.1001/virtualmentor.2013.15.4.medu1-1304. Raton, FL, CRC Press; 2013:19-34. 6. Katz D. Lifestyle is medicine. Virtual 3. How to read a paper. rhttps://ebm.bmj.com/ Mentor. 2013;15(4):286–292. doi:10.1001/ vir content/6/5/135. Accessed June 22nd, 2020. tualmentor.2013.15.4.ecas1-1304. 4. How to read and understand a scientific paper: A step by 7. Fahey TD, Insel PM, Roth WT. Introduction to Wellness, step guide for non-scientists by Jennifer Raf for the Huffington Fitness, and Lifestyle Management In: Fahey TD, Insel PM, Post http://www.huffingtonpost.com/jennifer-raff/how-to-read- Roth WT. Fit and Well: Core Concepts and Labs in Physical and-understand-a-scientific-paper_b_5501628.html

Lifestyle Medicine Course Syllabus 7 Week 2: Empowering People to Change

Behavior change is a critical component of lifestyle medicine. Learning to use the coach approach is important. There are distinct differences between being a coach and being an expert, which we explore in depth, looking at both “doing” and “being” skills. Empowering lasting behavior change requires the lifestyle medicine practitioner to fill up his or her toolbox with effective, research-based tools, skills and theories, including the Transtheoretical Model of Change, Motivational Interviewing techniques, Appreciative Inquiry, Goal Setting Theory, Acceptance and Commitment Therapy, and the Social Ecological Model. Equally important are the “being” skills necessary to partner with patients, support them, collaborate with them, and to co-create goals and plans that are specific to each patient. The five As of counseling (assess, ask, agree, assist, arrange) and its evolution are reviewed. In this week, we consider the Coach Approach and the Expert Approach in theory as well as from a patient’s perspective. In addition, we take a look at the medical literature and review the latest studies on behavior change, coaching, and Motivational Interviewing. Weekly Goals for Instructors: 1. Challenge students to think differently about how to empower people to change. 2. Invite students to consider the pros and cons of direct advice vs. negotiation in the area of behavior change 3. Consider the role of education in behavior change. 4. Demonstrate how to be a coach by highlighting the “being” and “doing” characteristics/attributes of a coach through patient examples and case studies. 5. Explain the five As of behavior change counseling. 6. Introduce the Transtheoretical Model of Change. Learning Objectives: By the end of this module, participants will be able to: 1. Outline health and wellness coaching strategies. 2. Describe the differences in the coach-like approach vs. the expert-like approach. 3. Discuss the essential elements of being a coach. 4. Summarize the five As of behavior change counseling. 5. Recognize the six stages of change in the Transtheoretical Model of Change. 6. Describe the concept of the Frates COACH approach. Guiding Questions for Students: 1. What are the attributes of an effective health and wellness coach? 2. How does the coach-like approach differ from the expert-like approach? 3. What is the Frates COACH Approach? 4. How could the Transtheoretical Model of Change help both patients and providers? 5. How can a clinical environment be created that facilitates lasting behavior change? 6. What are the key factors involved in behavior change counseling?

8 Lifestyle Medicine Course Syllabus Lecture Topic: Behavior Change as a Critical Component in Lifestyle Medicine Section Activities: Logistics Topic: Introduce Case Study assignment and address students’ questions and concerns. Overall Goal: The Coach Approach helps clients/patients to find their vision, motivation, to determine their goals, and to work toward those goals in a non-judgmental manner. Application Goal: Help students learn why and how to use the Coach Approach with themselves or a friend/family member. ● The Coach Approach: • When have you experienced counseling with the Expert Approach (e.g., doctor’s visit, school education, parents giving advice, a sports coach)? • When have you experienced the Coach Approach (e.g., collaborating with a friend or colleague, at a yoga studio, during a wellness coaching session)? • How do you feel when people tell you what to do? • How do you feel when people ask you your opinion on different topics? • Can one healthcare practitioner work with both hats? ● Readiness for Change Scale – Review with students what it is and how to use it. Discussion Board Topic(s): How could you incorporate the Coach Approach into your practice when working with a client/patient and what are the benefits for utilizing the Coach Approach vs. the Expert Approach?

Required Readings: Optional Readings: 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Empowering 1. Frates EP, Moore MA, Lopez CN, McMahon GT. Coaching people to change. In: Frates B, ed. Lifestyle Medicine for behavior change in physiatry. American Journal of Physical Handbook: An Introduction to the Power of Healthy Habits. Medicine & Rehabilitation. 2011;90(12):1074–1082. Monterey, CA: Healthy Learning; 2021:45-88. doi:10.1097/ phm.0b013e31822dea9a. 2. Egger G, Coutts R, Litt J. Chapter 4 Everything You Wanted 2. Ghorob A, Willard-Grace R, Bodenheimer T. State of to Know About Motivation. In: Egger G, Binns A, Rossner the art and science: Health coaching. American Medical S.Lifestyle Medicine: Managing Diseases of Lifestyle in the Association Journal of Ethics. 2013;15(4):319–326. http:// 21st Century. 2nd ed. North Ryde, Australia: McGraw-Hill; journalofethics.ama-assn.org/2013/04/pdf/stas2-1304.pdf. 2010:33–47. Accessed June 10, 2020. 3. Boehmer KR, Barakat S, Ahn S, Prockop L, Erwin P, 3. Frates EP, Moore M. Chapter 27 Health and Wellness Murad MH. Health Coaching Interventions for persons with Coaching Skills for Lasting Change. In: Rippe JM, ed. Lifestyle chronic conditions: a systematic review and meta-analysis Medicine. 2nd ed. Boca Raton, FL CRC Press. 2013: 343-360. protocol. BioMed Central Systematic Reviews. 2016:5:146. 4. Linke SE, Pekmezi D. Chapter 17 Applying Psychological https://systematicreviewsjournal.biomedcentral.com/ Theories to Promote Healthy Lifestyles. In Rippe JM Lifestyle articles/10.1186/s13643-016-0316-3. Accessed June 10, Medicine, 2nd Ed. Boca Raton, FL, CRC Press; 2013:223-232. 2020. 5. Stoltzfus T. Coaching questions: A coach’s guide to 4. Frates EP, Bonnet J. Collaboration and negotiation: powerful asking skills. Virginia Beach, VA: Pegasus Creative The Key to therapeutic lifestyle change. American Arts; April 1, 2008. Journal of Lifestyle Medicine. 2016;10(5):302–312. doi:10.1177/1559827616638013. 6. Kent K, Johnson JD, Simeon K, Frates EP. Case series in Lifestyle Medicine: A Team approach to behavior changes. 5. Frates EP, Bonnet J Behavior Change and Nutrition American Journal of Lifestyle Medicine. 2016;10(6):388–397. Counseling. In: Rippe JM, ed Nutrition in Lifestyle Medicine. doi:10.1177/1559827616638288. Humana Press 2017

Lifestyle Medicine Course Syllabus 9 Week 3: Collaborating, Motivating, Goal-Setting, and Tracking

To practice lifestyle medicine, one must practice setting goals that are appropriate for the patient and that patient’s stage of change for that particular behavior. Patients can be in different stages of change for different behaviors, and thus the goals they set for the behavior will be different. Building self-efficacy—the feeling of confidence that a person can complete a task—is critical in lifestyle medicine. Co-creating SMART goals is essential. SMART stands for Specific, Measureable, Action-oriented, Realistic, and Time-sensitive. It is important to practice setting SMART goals so that patients can enjoy small successes and feel motivated to continue with their lifestyle changes. The best goal is the one that the patient feels is important, the one the patient feels confident that he or she can complete, and the one that is SMART. The provider or the patient’s caregiver might feel that the patient should complete a goal that the provider or caregiver feels is very important, but if the patient does not view that particular goal as worthy or interesting, then the patient is not going to work towards that goal with any sustained effort. Setting the goal is one piece of the puzzle and keeping the patient accountable for the goal is another. If no one is checking on the patient, then the patient might forget or just ignore the goal. We explore effective strategies for holding people accountable for their goals. Motivational Interviewing techniques, Appreciative Inquiry, Goal Setting Theory, Acceptance and Commitment Therapy, and the Social Ecological Model are covered in detail this week. Weekly Goals for Instructors: 1. Introduce techniques that practitioners can use to empower patients, including change talk with motivational interviewing and finding the positive with appreciative inquiry. 2. Provide a history of goal setting with relation to organizational behavior. 3. Review the 5-Step Model for creating a collaborative relationship. Learning Objectives: By the end of the module, the participant will be able to: 1. Describe goal-setting theory. 2. Integrate motivational interviewing, appreciative inquiry, and the social-ecological model of change into practice. 3. Describe SMART goals. 4. Discuss the 5-step model for collaboration and coaching conversations. 5. Demonstrate collaboration as the key piece of goal-setting. 6. Acknowledge the importance of respecting autonomy when setting goals. 7. Outline strategies for accountability and monitoring. Guiding Questions for Module: 1. Why is it important for a health care provider to set goals with patients? 2. What is the difference between a healthcare provider setting a goal for a patient and a healthcare provider co- creating a goal with a patient? 3. What types of goals motivate people? 4. What is the difference between setting a goal and holding a person responsible for a goal? 5. How does tracking progress add value to the behavior change process?

10 Lifestyle Medicine Course Syllabus Lecture Topic: Goal Setting, Accountability, and Tracking for Lifestyle Medicine Section Activities: Logistics Topic: Introduce the Personal Change Project. Address students’ questions and concerns Overall Goal: Review goal setting for different stages of change, motivational interviewing, appreciative inquiry, and ACT therapy. Application Goal: Practice setting SMART goals. (Show students how to effectively use Goal Setting Worksheet) Discussion Board Topic(s): Imagine yourself speaking to another healthcare professional/colleague. How would you explain to your colleague the importance of goal setting in the practice of lifestyle medicine? And what does empathy have to do with it anyway?!

Required Readings: Optional Readings: 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Collaborating, 1. Frates EP. The Five step collaboration cycle: A tool for the Motivating, Goal-Setting and Tracking. In: Frates B, ed. doctor’s office. International Journal of School and Cognitive Lifestyle Medicine Handbook: An Introduction to the Power of Psychology. 2015;2(3). doi:10.4172/2469-9837.1000144. Healthy Habits. Monterey, CA: Healthy Learning; 2021:89-118. 2. Battersby M, Egger G, Litt J. Chapter 5 Self-Management in Lifestyle Medicine. In: Egger G, Binns A, Rossner S.Lifestyle Medicine: Managing Diseases of Lifestyle in the 21st Century. 2nd ed. North Ryde, Australia: McGraw-Hill; 2010:48–58. 3. Newton P, Bristoll H. Effective Goal Setting: Productivity Skills. Team FME: Free Management ebooks; 2013:8:29 http://www.free-management-ebooks.com/dldebk-pdf/fme- effective-goal-setting.pdf Accessed June 10, 2020. 4. Donnachie C, Wyke S, Mutrie N, Hunt K. “It's like a personal motivator that you carried around wi’ you’: utilising self-determination theory to understand men’s experiences of using pedometers to increase physical activity in a weight management programme. The International Journal of Behavioral Nutrition and Physical Activity. 2017;14:61. doi:10.1186/s12966-017- 0505-z. 5. Samdal GB, Eide GE, Barth T, Williams G, Meland E. Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses. The International Journal of Behavioral Nutrition and Physical Activity. 2017;14:42. doi:10.1186/s12966-017-0494-y.

Lifestyle Medicine Course Syllabus 11 Week 4: Improving Health Through Exercise

Starting from suggestions provided by Hippocrates about walking, we examine physical activity recommendations over the years. The most recent government guidelines provided by the Department of Health and Human Services in 2008 are reviewed. Understanding the definitions and differences between types of physical activity is stressed with a special appreciation for lifestyle exercise. The four parts of the exercise prescription (FITT= frequency, intensity, time, and type) are introduced as a framework for exercise counseling, to be used along with the Coach Approach for behavior change. Lastly, the risks of exercise are discussed with a focus on the American College of Sports Medicine’s algorithm for risk stratification, which categorizes patients as high, moderate, or low risk for exercise. Updated recommendations for pre- screening patients are included. We examine specific exercise prescriptions for diseases and conditions including heart disease, diabetes, obesity, arthritis, osteoporosis, and multiple sclerosis. Weekly Goals for Instructors: 1. Emphasize the health benefits of physical activity to the body and the brain. 2. Review the evidence-based guidelines for physical activity levels. 3. Consider ways to present physical activity as doable and enjoyable. Learning Objectives: By the end of this module, participants will be able to: 1. List the definitions of exercise. 2. Recall the physical activity guidelines. 3. Utilize a framework to make exercise prescriptions. 4. Discuss the benefits and risks of exercise and review the risk stratification system developed by the American College of Sports Medicine. Guiding Questions for Students: 1. What are the primary benefits of exercise? 2. What are some less commonly known benefits of exercise? 3. How does exercise affect the 11 systems of the body? 4. What are the risks of exercise? 5. Why don’t people exercise? 6. How can physical activity become part of daily life in the twenty-first century? 7. What is the evidence that physical activity affects health?

Lecture Topic: Value of Physical Activity and Physical Activity Guidelines Section Activities: Pre-assignment: Physical Activity Readiness Questionnaire – PAR-Q Logistics Topic: Discuss a Personal Behavioral Change assignment – monitoring behavior without change. Address students’ questions and concerns. Overall Goal: Provide an overview of benefits of physical activities and different forms it can take. Introduce students to different physical activity-promoting initiatives (government and NGO) Application Goal: Practice with students how to make an Exercise Prescription and review PAR-Q with them.

12 Lifestyle Medicine Course Syllabus Discussion Board Topic(s): Why is physical activity promotion important to the health of individuals and what steps can we take to change our culture around physical activity?

Required Readings: 2. Stetson BA, Cooper JM, Dubbert PM. Chapter 18 Cognitive and Behavioral Approaches to Enhancing Exercise 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Improving Prescription. In Rippe JM Lifestyle Medicine, 2nd Ed. Boca health through exercise. In: Frates B, ed. Lifestyle Medicine Raton, FL, CRC Press; 2013:233-243. Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy Learning; 2021:119-175. 3. Kokkinos PF, Myers J. Chapter 15 Physical Fitness Evaluation. In Rippe JM Lifestyle Medicine, 2nd Ed. Boca 2. Egger G, Climstein M. Chapter 8 Physical Activity: Raton, FL, CRC Press; 2013:199-208. Generic Prescription for Health. In: Egger G, Binns A, Rossner S.Lifestyle Medicine: Managing Diseases of Lifestyle in the 4. David PG. Chapter 16 Exercise Prescription for Apparently 21st Century. 2nd ed. North Ryde, Australia: McGraw-Hill; Healthy Individuals and for Special Populations. In Rippe 2010:91–110. JM Lifestyle Medicine, 2nd Ed. Boca Raton, FL, CRC Press; 2013:209-222. 3. Egger G, Climstein M. Chapter 9 Physical Activity:Specific Prescriptions for Disease Management and Rehabilitation. 5. Dunstan DW, Barr ELM, Healy GN, et al. Television viewing In: Egger G, Binns A, Rossner S.Lifestyle Medicine: Managing time and mortality: The Australian diabetes, obesity and Diseases of Lifestyle in the 21st Century. 2nd ed. North Ryde, lifestyle study (AusDiab). Circulation. 2010;121(3):384–391. Australia: McGraw-Hill; 2010:111–126. doi:10.1161/circulationaha.109.894824. 4. 2008 Physical Activity Guidelines. Office of Disease 6. van der Ploeg HP, Chey T, Korda RJ, Banks E, Bauman Prevention and Health Promotion. http://www.health.gov/ A. Sitting Time and All-Cause Mortality Risk in 222 497 paguidelines/guidelines/. Accessed June 10, 2020. Australian Adults. Arch Intern Med. 2012;172(6):494-500. doi:10.1001/ archinternmed.2011.2174. 5. The Executive Summary of the Advisory Report and selected passages of interest to the student-- for the student 7. Segar M, Guerin E, Phillips E, Fortier M. From a Vital Sign to decide. to Vitality: Selling Exercise So Patients Want to Buy It. Current Sports Medicine Reports. 2016;15(4):276–281. doi:DOI: 6. Naci H, Ioannidis JPA. Comparative effectiveness of 10.1249/ JSR.0000000000000284. exercise and drug interventions on mortality outcomes: Metaepidemiological study. BMJ. 2013;347(oct01 1):f5577. 8. Reynolds G. The scientific 7-Minute workout. Well. http:// doi:10.1136/bmj.f5577. well.blogs.nytimes.com/2013/05/09/the-scientific-7-minute- workout/?_r=0. Published May 2013. Updated October 7. Hallowell E, Frates EP. Mini Distraction #20: Why 24, 2014. Accessed June 10, 2020. The New York Times walking is powerful medicine. 2016. Distraction. Available Magazine. at: http://www.distractionpodcast.com/2016/08/03/mini- distraction-20- why-walking-is-powerful-medicine/ Published 9. Riebe D, Franklin B, Thompson P, et al. Updating August 3, 2016. ACSM’s recommendations for exercise Preparticipation health screening. Medicine & Science in Sports & 8. Frates E, McBride Y, Bonnet J. It’s fun: A Practical Exercise. 2015;47(11):2473– 2479. doi:10.1249/ algorithm for counseling on the exercise prescriptions: A mss.0000000000000664. method to mitigate the symptoms of depression, anxiety, and stress- related illness. Clinical and Experimental Psychology. 10. Ratey JJ, Hagerman E. Spark: The revolutionary new 2016;02(116). doi:10.4172/2471- 2701.1000116. science of exercise and the brain. New York, NY: Little Brown and Company; 2013. 9. Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM's recommendations for exercise preparticipation health 11. American College of Sports Medicine. ACSM’s guidelines screening. 2015. https://www.acsm.org/docs/default-source/ for exercise testing and prescription. 9th ed. Pescatello L, files-for-resource-library/updating_acsm_s_recommendations_ Arena R, Riebe D, Thompson P, eds. Philadelphia: Wolters for_exercise-28-(1).pdf?sfvrsn=3aa47c01_4. Accessed July 6, Kluwer/ Lippincott Williams & Wilkins Health; February 1, 2020. 2013. 10. DocMikeEvans. 23 and 1/2 hours: What is the single best 12. American College of Sports Medicine. ACSM’s exercise thing we can do for our health? [Video]. Youtube. https://www. management for persons with chronic diseases and youtube.com/watch?v=aUaInS6HIGo Published December 2, disabilities. 4th ed. Moore G, Durstine J, Painter P, eds. United 2011. Accessed June 10, 2020. States: Human Kinetics; May 3, 2016. Optional Readings: 13. Office of Disease Prevention and Health Promotion. 2008 Physical Activity Guidelines for Americans Summary. https:// 1. Frates EP, Crane ME. Lifestyle medicine consulting walking health.gov/paguidelines/guidelines/summary.aspx. Accessed meetings for sustained weight loss. BMJ Case Reports. June 10, 2020. February 2016. doi:10.1136/bcr-2015-213218. Lifestyle Medicine Course Syllabus 13 Week 5A: The Nutrition-Health Connection

Eating patterns and guidelines have changed over the years, and with new research, comes new evidence based recommendations. We explore the history and evolution of the dietary guidelines in order to better understand how we have arrived at the current dietary recommendations. We review the spectrum of diets and common eating patterns from the Standard American Diet (SAD), to the American Heart Association Diet, the DASH Diet, the Mediterranean Diet, the vegan diet, and the raw food diet. The concept of a whole foods, plant-based diet (WFPB) is highlighted. The issue of how our food choices affect not just our bodies but also the planet are considered as well. Individual nutrients, vitamins, and minerals are addressed, but the focus is on consuming healthful meals and snacks on a regular basis as part of an overall healthy eating pattern. Research on how a healthy WFPB diet can prevent, treat, and reverse disease is emphasized. The notion that more intensive dietary changes (specifically, following WFPB diet) can potentially offer superior health outcomes (i.e., disease reversal) is discussed. Weekly Goals for Instructors: 1. Challenge students to evaluate different diets. 2. Invite students to consider the pros and cons of eating plants. 3. Consider the why, what, and how of a healthy diet. 4. Consider the role of digestion, metabolism and energy balance. 5. Review basic strategies for effective weight management. 6. Consider the role of digestion, metabolism and energy balance. Learning Objectives: By the end of this module, participants will be able to: 1. Identify the role that nutrition plays in lifestyle medicine. 2. Describe the key factors associated with a healthy eating pattern. 3. Evaluate the diet spectrum, ranging from the standard American diet (SAD) to the whole food, plant-based (WFPB) diet. 4. Compute the power of plants. 5. Discuss the need to focus on behavior change, with regard to weight management. Guiding Questions for Students: 1. Why is it important to consume a nutritious diet? 2. What can people do to adopt and maintain healthy eating habits? 3. What is the role of energy balance in body weight maintenance? 4. How can food be medicine? 5. What would it take to change the Standard American diet (S.A.D.) to a more healthful one? 6. What are the roles of government, workplace, healthcare system, and food industry in creating, changing, and maintaining the diet of a society? 7. What is the evidence that diet affects health? 8. What is the evidence that our eating patterns influence the health of the planet?

14 Lifestyle Medicine Course Syllabus Lecture Topic: Value of Healthy Nutrition and Overview of Nutritional Guidelines Patient Testimonials are available through the following programs: Dean Ornish, John McDougall, and Pritikin. May be helpful in actualizing the change required and the benefits achieved with a plant based diet. Section Activities: Logistics Topic: Discuss a second Personal Behavioral Change assignment – submitting a behavior change goal for approval and developing a SMART goal. Address students’ questions and concerns. Overall Goal: Review with students what the healthy nutritional guidelines are and the key recommendations to consider when evaluating different diets. Discuss the question, “What is a healthy eating pattern?” Application Goal: Review with students some of the current diet trends and fads and discuss why they might or might not be healthy. Discuss the idea of how to make healthful nutrition a lifestyle rather than just a diet. Discussion Board Topic(s): What patterns and similarities do you see among the USDA MyPlate, Harvard’s Healthy plate, the USDA and USHHS Dietary Guidelines, the American Heart Association and American Diabetes Association guidelines, and a whole foods, plant-based diet? What foods are stressed and what conclusions do you make from these patterns?

Required Readings: 8. Martindale W. Is a vegetarian diet really more environmentally friendly than eating meat? CNN The 1. Frates B, Bonnet JP, Joseph R, Peterson JA. The nutrition- Conversation on February 6, 2017. http://www.cnn. health connection. In: Frates B, ed. Lifestyle Medicine com/2017/02/06/health/vegetarian- diet-conversation/. Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy Learning; 2021:173-228. 9. How Not To Die: The Role of Diet in Preventing, Arresting and Reversing our Top 15 Killers NutritionFacts.Org https:// 2. Price JM, Egger G. Chapter 10 Nutrition for the Non- nutritionfacts.org/video/how-not-to-die/. Accessed June 10, Dietitian. In: Egger G, Binns A, Rossner S.Lifestyle Medicine: 2020. Managing Diseases of Lifestyle in the 21st Century. 2nd ed. North Ryde, Australia: McGraw-Hill; 2010:127–139. Optional Readings: 3. Egger G, Pearson S. Chapter 11 Fluid, Fitness, and 1. Dwyer J. Chapter 8 Nutrition 101: The Concept of Fatness. In: Egger G, Binns A, Rossner S.Lifestyle Medicine: Nutritional Status and Guides for Nutrient Intakes, Eating Managing Diseases of Lifestyle in the 21st Century. 2nd ed. Patterns, and Nutrition. In Rippe JM Lifestyle Medicine, 2nd North Ryde, Australia: McGraw-Hill; 2010:140–150. Ed. Boca Raton, FL, CRC Press; 2013:103-118. 4. King N, Egger G. Chapter 12 Behavioral Aspects of 2. Starke-Reed P, McDade-Ngutter C. Hubbard VS. Chapter Nutrition. In: Egger G, Binns A, Rossner S.Lifestyle Medicine: 9 Healthy People 2020: Highlights in the Nutrition and Weight Managing Diseases of Lifestyle in the 21st Century. 2nd ed. Status Focus Area. In Rippe JM Lifestyle Medicine, 2nd Ed. North Ryde, Australia: McGraw-Hill; 2010:151–164. Boca Raton, FL, CRC Press; 2013:119-130. 5. U.S. Departments of Health and Human Services, U.S. 3. U.S. Department of Health and Human Services, U.S. Departments of Agriculture. Dietary Guidelines for Americans Department of Agriculture. 2015 – 2020 Dietary Guidelines 2015-2020, Executive Summary, (2015). https://health.gov/ for Americans. 8th ed. December 2015. http://health.gov/ dietaryguidelines/2015/guidelines/executive-summary/. dietaryguidelines/2015/guidelines/. Accessed June 10, 2020. Accessed June 10, 2020. 4. Sofi F, Cesari F, Abbate R, Gensini GF, Casini A. Adherence 6. Katz DL, Meller S. Can we say what diet is best for to Mediterranean diet and health status: Meta-analysis. BMJ. health? Annual Review of Public Health. 2014;35(1):83–103. 2008;337:a1344. doi:10.1136/bmj.a1344. doi:10.1146/annurev-publhealth-032013-182351. 5. Frates EP. Interview with award winners from ACLM 7. Herrero M, Havlík P, Valin H, et al. Biomass use, 2015, Nashville, Tennessee - Dean Ornish. American production, feed efficiencies, and greenhouse gas Journal of Lifestyle Medicine. 2016;10(5):341–344. emissions from global livestock systems. Proceedings of doi:10.1177/1559827616642399. the National Academy of Sciences of the United States 6. Public Broadcasting Service. How the sugar industry paid of America. 2013;110(52):20888-20893. doi:10.1073/ experts to downplay health risks [PBS Video]. http://www.pbs. pnas.1308149110. org/video/2365841210/: PBS; 2016.

Lifestyle Medicine Course Syllabus 15 7. Nestle M. Corporate funding of food and nutrition [Video]. https://youtu. be/8mF0U546084: YouTube; research. JAMA Internal Medicine. 2016;176(1):13–14. November 2009. doi:10.1001/jamainternmed.2015.6667. 23. The Endocrine Society. Cooking for pleasure, healthy for 8. American College of Lifestyle Medicine, Turn the Tide life: Type 2 diabetes cooking demonstration[Video]. https:// Foundation. True Health Initiative. A global consensus on youtu.be/oSBX2HLzIH8: YouTube; September 21, 2012. lifestyle as medicine. http://TrueHealthInitiative.org. Accessed 24. The Aspen Institute. Foods for protecting the body & mind: June 10, 2020. Dr. Neal Barnard [Video]. https:// youtu.be/BnHYHjchn6w: 9. Willett WC, Stampfer MJ. Current evidence of healthy YouTube; August 19, 2015. eating. Annual Review of Public Health. 2013;34(1):77–95. 25. Fulkerson L. Forks Over Knives. [DVD]. New York, NY: Virgil doi:10.1146/annurev-publhealth-031811-124646. Films & Entertainment; 2011. 10. Campbell TC, Campbell TM. The China Study: The most 26. Ornish D, Brown SE, Billings J, et al. Can lifestyle changes comprehensive study of nutrition ever conducted and the reverse coronary heart disease?: The Lifestyle Heart Trial. The startling implications for diet, weight loss, and long-term Lancet. 1990;336:129-33. health. Revised ed. United States: BenBella Books; December 27, 2016. 27. Ornish D, Lin J, Daubenmier J, et al. Increased telomerase activity and comprehensive lifestyle changes: a pilot study. The 11. Ornish D, Smith A. The spectrum: A scientifically proven lancet oncology. 2008;9:1048-57. program to feel better, live longer, lose weight, and gain health. New York: Random House Publishing Group; December 28. Ornish D, Scherwitz LW, Billings JH, et al. Intensive 2008. lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001-7. 12. Katz DL, Colino S. Disease-proof: Slash your risk of heart disease, cancer, diabetes, and more - by 80 percent. United 29. McDougall J, Litzau K, Haver E, Saunders V, Spiller G. States: Plume; September 18, 2014. Rapid reduction of serum cholesterol and blood pressure by a twelve-day, very low fat, strictly vegetarian diet. J Am Coll Nutr. 13. Barnard ND, Grogan BC. Dr. Neal Barnard’s program 1995;14:491-6. for reversing diabetes: The scientifically proven system for reversing diabetes without drugs. 1st ed. New York: Rodale 30. Esposito K, Giugliano F, Di Palo C, et al. Effect of lifestyle Books; April 1, 2008. changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA. 2004;291:2978-84. 14. Harvard Health Publications, Naidoo U. Learn about hidden sugar in foods [Video].https://youtu. be/fVAEgzXXLVs 31. Jenkins DJ, Kendall CW, Marchie A, et al. Effects of a YouTube; May 23, 2016. dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. JAMA. 2003;290:502-10. 15. BBC Productions. The Truth about sugar. [Video].https:// youtu.be/K4LzSH9qU_QYouTube; October 16, 2015. 32. Barnard RJ, DiLauro SC, Inkeles SB. Effects of intensive diet and exercise intervention in patients taking cholesterol- 16. NWO BBC Horizon. The truth about vitamins supplements lowering drugs. Am J Cardiol. 1997;79:1112-4. [Video]. https://youtu. be/7i7gPyDZZv4: YouTube; May 13, 2013. 33. Esselstyn CB, Jr. Resolving the Coronary Artery Disease Epidemic Through Plant-Based Nutrition. Prev Cardiol. 17. Killoran E. Healthy grocery shopping scavenger hunt. 2001;4:171-7. Pritikin Longevity Center + Spa. https://www.pritikin.com/ learn-healthy-grocery-shopping-skills. Accessed June 10, 34. Barnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan 2020. diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial. Am J 18. Whole Foods Market. Healthy Cooking Techniques Videos Clin Nutr. 2009:ajcn. 26736H. [Video]. http://www.wholefoodsmarket.com/healthy-eating/ healthy-cooking-videos: Whole Foods Market; December 2015. 35. Trapp CB, Barnard ND. Usefulness of vegetarian and vegan diets for treating type 2 diabetes. Current diabetes 19. U.S. Department of Health and Human Services and U.S. reports. 2010;10:152-8. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http:// 36. Barnard RJ, Hong Gonzalez J, Liva ME, Ngo TH. Effects health.gov/dietaryguidelines/2015/guidelines/. of a low-fat, high-fiber diet and exercise program on breast cancer risk factors in vivo and tumor cell growth and apoptosis 20. U.S. Department of Agriculture and U.S. Department of in vitro. Nutrition and Cancer. 2006;55:28-34. Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing 37. Kahleova H, Matoulek M, Malinska H, et al. Vegetarian Office, December 2010. diet improves insulin resistance and oxidative stress markers more than conventional diet in subjects with Type 2 diabetes. 21. Dietary Guidelines Advisory Committee. Dietary guidelines Diabetic Medicine 2011;28:549-59. for Americans 2015-2020. Government Printing Office; 2015. 38. Frattaroli J, Weidner G, Dnistrian AM, et al. Clinical events 22. LifespanHealth. Healthy recipes cooking demonstration in prostate cancer lifestyle trial: results from two years of follow-up. Urology. 2008;72:1319-23. 16 Lifestyle Medicine Course Syllabus Week 5B: Weight Management

Discuss that weight is a sensitive topic and that many factors come into play beyond simply calories in and calories out. Encourage sensitive dialogue, the important nature of this topic, and that over 2/3 of American adults are outside of the healthy BMI. Weekly Goals for Instructors: 1. Review the essential factors involved in weight management. 2. Develop an understanding of why it can be difficult for a person to lose weight and maintain that loss. 3. Explore the role that diet plays in weight management. 4. Examine the strategies for modifying a person’s behavior with regard to their efforts to manage their weight. 5. Detail the benefits of adhering to a healthy eating pattern for weight management. 6. Review basic strategies for effective weight management. 7. Consider the role of metabolism and energy balance. Learning Objectives: By the end of this module, participants will be able to: 1. Understand the key factors involved in weight management. 2. Be aware of the impact of a healthy eating pattern and physical activity/exercise on weight management. 3. Grasp the advantages and disadvantages of various diets. 4. Identify the factors that affect how much a person weighs. 5. Recognize the need for behavioral change in achieving weight management goals. 6. Discuss the need to focus on behavior change, with regard to weight management. Guiding Questions for Students: 1. How much should a person weigh? 2. How do psychological factors affect a person’s ability to manage their weight? 3. What are the two most important factors in keeping an individual’s weight at a desired level? 4. What factors should a person consider when selecting an eating plan? 5. How should a lifestyle medicine professional assess an individual’s weight status? 6. What is the role of energy balance in body weight maintenance?

17 Lifestyle Medicine Course Syllabus Lecture Topic: Importance of Healthy Weight Management Section Activities: Pre-assignment: Have students research the strengths and limitations of BMI. Why is it an important tool? What limitations does it have? Also have them reflect upon their personal views of weight and what shaped these views. Weight is more than a number on a scale. It is also about how comfortable you feel moving around day to day and your functional abilities. How can you convey these concepts to others? Logistics Topic: Discuss how they can talk about healthy weight to potential patients or clients, in a way that does not shame them if they do have an unhealthy body weight, but that motivates them to work toward achieving a healthy weight. Discuss how they can use the COACH approach when discussing weight with a patient. Overall Goal: Students should understand the complex nature of weight, factors that influence it, society’s perceptions, and the health benefits of a healthy BMI. Application Goal: Students should be able to talk with others about the importance of healthy weight and why it matters, while supporting people who struggle with being underweight, overweight or obese.

Required Readings: 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Weight Management. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy Learning; 2021:229-260.

18 Lifestyle Medicine Course Syllabus Week 6: Sleep Matters

Sleep is often ignored and taken for granted. While people boast about how they only need 3 hours of sleep a night, researchers are demonstrating that sleep is connected to satiety hormones, mood, productivity, learning, memory, and weight. We review the basics of sleep and sleep cycles, how poor sleep affects the human body, and how proper sleep enhances the functioning of the human body. We identify the factors that promote healthy sleep and those factors that steal sleep. After stressing the importance of sleep for a healthy body, we explore possible sleep prescriptions and strategies. Weekly Goals for Instructors: 1. Invite students to consider the importance of sleep and the dangers of the lack of sleep. 2. Teach the updated stages of sleep. 3. Discuss healthy sleep habits. 4. Challenge students to identify the connection between sleep and health. 5. Share tips for falling asleep. Learning Objectives: By the end of this module, participants will be able to: 1. Describe the basics of sleep. 2. Identify the key factors that inhibit sleep. 3. Recognize the importance of evidence-based information concerning sleep. 4. Demonstrate the connection between sleep and health. 5. Recognize how to improve sleep through behavior change. Guiding Questions for Students: 1. How can people get more sleep? 2. How much sleep do people need? 3. What are healthy sleep habits? 4. What are the stages of sleep? 5. How does a lack of sleep affect the body?

Lecture Topic: Benefits of Healthy Sleep and How to Achieve It Section Activities: Pre-assignment: Sleep Questionnaire available at http://internalmedicine.med.sc.edu/forms/Sleep%20 questionnaire2.pdf Logistics Topic: Review Case Studies and Behavior Change Project progress. Address students’ questions and concerns. Overall Goal: Review with students healthy sleeping recommendations and discuss solutions for possible sleep disruptors. Application Goal: Discuss with students their results on the sleep questionnaire. Practice with students the Coach Approach way of addressing some of their sleep disruption issues, and utilize the Epworth Sleepiness scale (available at: http://healthysleep.med.harvard.edu/narcolepsy/diagnosing- narcolepsy/epworth-sleepiness-scale) as a tool.

19 Lifestyle Medicine Course Syllabus Discussion Board Topic(s): Your friend is driving you home from the library late one evening. You both live 30 minutes from school and need to take the highway. It is midterm time, and you are both exhausted. Although you begin the drive talking about organic chemistry, soon things quiet down and you fall asleep. You wake up after your friend swerves and hits the brakes. She then continues driving. What do you do next? How could you help to inform your friend about the dangers of sleep deprivation and, specifically, driving while drowsy?

Required Readings: 3. Division of Sleep Medicine at Harvard Medical School, WGBH Educational Foundation. Finding your sleep/wake 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Sleep rhythm. Healthy Sleep. http://healthysleep.med.harvard.edu/ Matters. In: Frates B, ed. Lifestyle Medicine Handbook: An interactive/circadian. Accessed June 10, 2020. Introduction to the Power of Healthy Habits. Monterey, CA: Healthy Learning; 2021:261-272. 4. University of South Carolina School of Medicine. Sleep Questionaire, Department of Internal Medicine, (2006). 2. West C, Egger G. Chapter 18 To Sleep Perchance...To Get http://internalmedicine.med.sc.edu/forms/Sleep%20 Everything Else Right. In: Egger G, Binns A, Rossner S.Lifestyle questionnaire2.pdf. Accessed June 10, 2020. Medicine: Managing Diseases of Lifestyle in the 21st Century. 2nd ed. North Ryde, Australia: McGraw-Hill; 2010:226–241. 5. Stevenson S. Sleep smarter: 21 essential strategies to sleep your way to a better body, better health, and bigger 3. Division of Sleep Medicine at Harvard Medical School, success. United States: Rodale Books; March 15, 2016. WGBH Educational Foundation. Assess your sleep needs. Get Sleep. http://healthysleep.med.harvard.edu/need-sleep/ 6. Foster RG, Lockley SW. Sleep: A very short introduction. what-can-you-do/assess-needs. Updated December 15, 2008. Oxford: Oxford University Press; March 22, 2012. Accessed June 10, 2020. 7. Lewis PA. The secret world of sleep: The surprising 4. Buysse DJ. Sleep Health: Can We Define It? Does It science of the mind at rest. New York, NY, United States: Matter? Sleep. 2014;37(1):9-17. doi:10.5665/sleep.3298. Palgrave MacMillan Trade; November 11, 2014. 5. Havekes R, Park AJ, Tudor JC, et al. Sleep deprivation 8. Dement WC, Vaughan C, Vaughn C. The promise of sleep: causes memory deficits by negatively impacting neuronal A pioneer in sleep medicine explores the vital connection connectivity in hippocampal area CA1. Takahashi JS, ed. eLife. between health, happiness, and a good night’s sleep. New 2016;5:e13424. doi:10.7554/eLife.13424. York: Random House Publishing Group; March 7, 2000. 5. Touitou Y, Reinberg A, Touitou D. Association between 9. Rath T. Eat move sleep: How small choices lead to big light at night, melatonin secretion, sleep deprivation, and the changes-. New York: Missionday; May 14, 2014. internal clock: Health Impacts and mechanisms of circadian 10. Cappuccio FP, Cooper D, D’Elia L, Strazzullo P, Miller MA. disruption. Life Sciences 2017: 173: 94-106. Sleep duration predicts cardiovascular outcomes: A systematic 6. Kahn MS, Aouad R. The effects of insomnia and sleep review and meta-analysis of prospective studies. European loss on cardiovascular disease. Sleep Medicine Clinics. Heart Journal. 2011;32(12):1484–1492. doi:10.1093/ 2017:12(2): 167-177. eurheartj/ehr007. Optional Readings: 11. Asarnow LD, McGlinchey E, Harvey AG. The effects of bedtime and sleep duration on academic and emotional 1. Division of Sleep Medicine at Harvard Medical School. outcomes in a nationally representative sample of Epworth Sleepiness scale. Narcolepsy. http://healthysleep. adolescents. Journal of Adolescent Health. 2014;54(3):350– med.harvard.edu/narcolepsy/diagnosing-narcolepsy/epworth- 356. doi:10.1016/j.jadohealth.2013.09.004. sleepiness-scale. Published 1997. Updated October 16, 2013. 12. Araghi MH, Chen Y-F, Jagielski A, et al. Effectiveness Accessed June 10, 2020. of lifestyle interventions on obstructive sleep Apnea 2. National Sleep Foundation. National sleep foundation (OSA): Systematic review and Meta-Analysis. Sleep. Sleepiness test. https://sleepfoundation.org/quiz/national- 2013;36(10):1553–1562. doi:10.5665/sleep.3056. sleep-foundation-sleepiness-test. Accessed June 10, 2020.

20 Lifestyle Medicine Course Syllabus Week 7: Stress and Resilience

We discuss a variety of definitions for stress. The negative impact that stress has on the body is identified, and the positive aspects of stress are considered. Stress has been the topic of scientific experimentation for many years; therefore, we review the literature around stress, looking at specific clinical trials from 25 years ago as well as the most recent studies. People cope with stress in a myriad of ways, and we examine both the unhealthy coping strategies as well as the healthy ones. Finally, we discuss the concept of stress resiliency and consider ways to counsel towards this goal. Weekly Goals for Instructors: 1. Invite students to consider physiological and psychological effects of stress. 2. Review the scientific literature on the topic of stress and coping with stress. 3. Discuss the concept of stress resilience and introduce several stress-coping techniques. Learning Objectives: By the end of this module, participants will be able to: 1. Describe the connection between stress and health. 2. Recognize inappropriate methods for coping with stress. 3. Identify the factors that contribute to stress. 4. Discuss the fight-or-flight response. Guiding Questions for Students: 1. What is stress? 2. What are the basic signs and symptoms of stress? 3. How can stress, depending on the circumstance, be either bad or good for a person? 4. How does the fight-or-flight response work in the modern era? 5. How does chronic stress affect the mind and the body? 6. How does chronic stress affect the mind and the body? 7. What types of behaviors contribute to stress overload? 8. How can chronic stress be relieved?

Lecture Topic: Effects of Stress, the Stress Resilience Concept, and Coping Skills Section Activities: Pre-assignment: Perceived Stress Scale (PSS) available at http://www.mindgarden.com/docs/PerceivedStressScale.pdf Logistics Topic: Discuss a third Personal Behavioral Change assignment – integrate suggested changes to SMART goals and start behavior change. Address students’ questions and concerns. Overall Goal: Introduce different types of stress and coping strategies. Address Automatic Negative Thoughts processes and techniques for dealing with them. Application Goal: Discuss with students sources of stress in their lives and ways they might be able to deal with it. Discussion Board Topic(s): A friend of yours says that whenever she goes to French class and the teacher calls on her, she feels her heart racing and her palms get sweaty. She knows you are taking a class on Lifestyle Medicine, so she asks you, “What is happening? Could this mental stress be affecting my body and health?”

Lifestyle Medicine Course Syllabus 21 Required Readings: Optional Readings: 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Stress and 1. Csikszentmihalyi M. Flow: The psychology of optimal Resilience. In: Frates B, ed. Lifestyle Medicine Handbook: An experience. New York: Harper Perennial Modern Classics; Introduction to the Power of Healthy Habits. Monterey, CA: August 1, 2008. Healthy Learning; 2021:295-318. 2. Fernandez A, Goldberg E, Michelon P. Chapter 7. In: 2. Egger G, Reznik R. Chapter 13 Stress: Its Role in the Fernandez A, Goldberg E, Michelon P. The Sharpbrains guide S-AD Phenomenon. In: Egger G, Binns A, Rossner S.Lifestyle to brain fitness: How to optimize brain health and performance Medicine: Managing Diseases of Lifestyle in the 21st Century. at any age. 2nd ed. San Francisco, CA: SharpBrains Inc; April 2nd ed. North Ryde, Australia: McGraw-Hill; 2010:165–175. 4, 2013. 3. CDC. Stress...At Work, DHHS: NIOSH No. Publication 3. Goleman D. Emotional intelligence: Why it can matter Number 99-101, (1999). http://www.cdc. gov/niosh/docs/99- more than IQ. London: Bloomsbury Publishing PLC; July 20, 101/. Published Online June 6, 2014. 2009. 4. van der Ploeg MM, Brosschot JF, Verkuil B, et al. Inducing 4. Sapolsky RM. Why zebras don’t get ulcers. 3rd ed. New unconscious stress: Cardiovascular activity in response to York: Henry Hold and Co./Owl Books; September 23, 2004. subliminal presentation of threatening and neutral words. 5. Cohen S. Perceived Stress Scale. Mind Garden. https:// Psychophysiology. 2017;00:1–14. https://doi.org/10.1111/ www.mindgarden.com/documents/PerceivedStressScale.pdf. psyp.12891. Published 1994. Accessed June 10, 2020. 5. Kronenberg, G., Schöner, J., Nolte, C. et al. Eur Arch 6. Seligman ME. Learned optimism: How to change your Psychiatry Clin Neurosci Charting the perfect storm: emerging mind and your life. New York: Knopf Doubleday Publishing biological interfaces between stress and stroke. April 9, 2017: Group; January 3, 2006. pp1-8 doi:10.1007/s00406-017-0794-x https://link.springer. com/article/10.1007%2Fs00406-017-0794-x. Accessed June 7. Dweck CS. Mindset: The new psychology of success. New 10,2020. York: Random House Publishing Group; February 1, 2008. 8. Frankl VE. Man’s search for meaning. Boston: Beacon Press; June 14, 2006. 9. drbrianpsych. Selye [Video]. https://youtu.be/YJCeDtNh_ Aw: YouTube; May 20, 2007. 10. Brooks R, Richman D. The Charismatic Advisor: Becoming a Source of Strength in the Life of Your Clients. Charismatic Advisor Publishing; 2010. 11. Brooks RB, Goldstein S. The power of resilience: Achieving balance, confidence, and personal strength in your life. New York: McGraw-Hill Companies, The; November 1, 2004. 12. Rosengren, Annika et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11 119 cases and 13 648 controls from 52 countries (the INTERHEART study): case-control study. The Lancet. 2004:364(9438):953 -962.

22 Lifestyle Medicine Course Syllabus Week 8: Peace of Mind With Meditation, Mindfulness, and Relaxation

Relaxation, mindfulness, and meditation have all been used to enhance health and well-being. We briefly examine the history of these three tools and then explore each one separately. Starting with Dr. Herbert Benson’s Relaxation Response, which is the bedrock of his mind-body medicine program at MGH, we identify how to elicit the Relaxation Response and what happens to the body during this process. The concept of mindfulness is also introduced and compared to its opposite, mindlessness. Mindfulness-based Stress Reduction programs from UMass and Professor Jon Kabat-Zin are reviewed. The ancient practice of meditation and its effect on the body is described and demonstrated. We examine the latest research on mediation and yoga. Weekly Goals for Instructors: 1. Introduce relaxation, mindfulness, and meditation practices and their health benefits. 2. Challenge students to explore different mindfulness and meditation practices. 3. Review the literature demonstrating changes to the brain after meditation. Learning Objectives: By the end of this module, participants will be able to: 1. Describe the connection between peace of mind and health. 2. Compare and contrast mindfulness, meditation, and relaxation. 3. Demonstrate familiarity with the Relaxation Response. 4. Recognize the barriers to having peace of mind. Guiding Questions for Students: 1. What is meditation? 2. What is Mindfulness-Based Stress Reduction? 3. What is the Relaxation Response? 4. How does meditation affect the mind and body? 5. What is the evidence that relaxation, mindfulness, and meditation have positive effects on the body?

Lecture Topic: Relaxation, Mindfulness, and Meditation Techniques and Their Benefits Section Activities: Pre-assignment: Five Facet Mindfulness Scale available at: http://awakemind.org/quiz.php & https://goamra.org/ wp-content/uploads/2014/06/FFMQ_full.pdf. Other scales to consider on mindfulness outlined by Dr. Vago at HMS available at: http://davidvago.bwh.harvard.edu/measures-of-mindfulness/ Logistics Topic: Check on students’ progress with their Behavior Change Project. Address students’ questions and concerns. Overall Goal: Explore different ways of relaxation and a place it takes in students’ life Application Goal: Discuss with students what they do to relax and what evidenced-based techniques might they try in the future. What seems like a good first step for making mindfulness and meditation part of one’s life and daily routine? Discussion Board Topic(s): Meditation, mindfulness, and relaxation have been around for thousands of years and recently have been hot topics for research. Name 1-2 concepts in this field that intrigue you. Please share how you will further explore them and/or apply them to yourself and/or others.

Lifestyle Medicine Course Syllabus 23 Required Readings: Optional Readings: 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of 1. Body Scan. Jon Kabat-Zinn, PhD Guided Mindfulness Mind with Meditation, Mindfulness, and Relaxation. In: Frates Meditation Series 1 – (Excerpt from Track 2). Youtube Web B, ed. Lifestyle Medicine Handbook: An Introduction to the site. Available by clicking on this Link (Links to an external Power of Healthy Habits. Monterey, CA: Healthy Learning; site.) 2021:319-347. 2. Jon Kabat-Zinn – Mindfulness Guided Meditation: The 2. Stahl JE, Dossett ML, LaJoie AS, Denninger JW, Mehta DH, Power of Now. Youtube Web site. Available by clicking on this Goldman R, et al. (2015) Relaxation Response and Resiliency link: https://www.youtube.com/watch?v=422n7tzAxEI. Training and Its Effect on Healthcare Resource Utilization. 3. Kabat-Zinn J. Wherever You Go, There You Are. New York, PLoS ONE 10(10): e0140212. https://doi.org/10.1371/ NY: Hyperion, 1994. journal.pone.0140212. 4. Fernandez A. Goldberg E, Michelon P. Chapter 7. In: The 3. Galla, BM, O’Reilly GA, Kitil, MJ, Smalley SL Black SharpBrains Guide to Brain Fitness. San DS, Community-Based Mindfulness Program for Disease Prevention and Health Promotion: Targeting Stress Reduction Francisco, CA: SharpBrains Inc, 2013. American Journal of Health Promotion 2015:30(1):36 -41. 5. Stahl B, Goldstein E, Santorelli S, Kabat-Zinn J. A 4. Laneri, D., Krach, S., Paulus, F. M., Kanske, P., Schuster, Mindfulness-Based Stress Reduction Workbook. Oakland, CA: V., Sommer, J. and Müller-Pinzler, L. Mindfulness meditation New Harbinger Publications, Inc, 2010. regulates anterior insula activity during empathy for social 6. Teasdale JD, Williams MG, Segal ZV, Kabat-Zinn J. The pain. Hum. Brain Mapping. 2017:. doi:10.1002/hbm.23646. Mindful Way Workbook: An 8-Week Program to Free Yourself 5. Haines J, Spadaro KC, Choi J, Hoffman LA, Blazeck AM. from Depression and Emotional Distress. New York, NY: The Reducing stress and anxiety in caregivers of lung transplant Guiliford Press, 2014. patients: benefits of mindfulness meditation. Int J Organ 7. Hayes S. Get Out of Your Mind and Into Your Life: The Transplant Med 2014;5:50-6. New Acceptance and Commitment Therapy. Oakland, CA: New 6. Jon Kabat-Zinn, PhD Guided Mindfulness Meditation Harbinger Publications, Inc, 2005. Series 3 – (Excerpt from Introduction). Youtube Web site. 8. Borreli L. A Life Hack for Sleep: The 4-7-8 Breathing Exercise Will Supposedly Put You To Sleep In Just 60 Seconds. Medical Daily Web site. Available at: http://www.medicaldaily. com/life-hack-sleep-4-7-8-breathing-exercise-will-supposedly- put-you-sleep-just-60-332122. 9. van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil 2005;12:193- 202. 10. Seligman ME. Flourish: A Visionary New Understanding of Happiness and Well-being. New York, NY: Free Press, 2011. 11. Ben-Shahar T. Choose the Life You Want: The Mindful Way to Happiness. New York, NY: The Experiment, LLC, 2012. 12. VIA Character Survey. VIA Institute on Character Web site. Available at: https://www.viacharacter.org 13. Frederickson B. The Positivity Self Test. Positivity Ratio Web site. Available at: https://www.positivityratio.com/single. php.

24 Lifestyle Medicine Course Syllabus Week 9: The Power of Connection

There has been evidence of the power of human connection ever since the bond between mother and baby was first acknowledged. There is a deep-rooted need for humans to connect with each other. In addition, connection to pets, especially dogs, has been researched in the medical literature and is so clearly beneficial that dogs are used as therapeutic agents in the hospital, in medical schools, and in elderly care facilities. We review the medical literature and identify the benefits of connection for the body and the mind. Connecting with nature and one’s faith are other ways to enrich life and to improve one’s state of well-being. One of the most important connections and perhaps the most often overlooked, is a persons connection with his or her personal self. After examining a variety of connections, we determine how to counsel patients in this important area of their lives.

Weekly Goals for Instructors: 1. Invite the students to consider the power of human connection and connection to other living beings. 2. Challenge students to consider the impact of loneliness and social isolation on health. 3. Summarize the literature on the benefits of connection for health and well being. 4. Describe effective ways to counsel patients on the importance of connections and how connections can enhance health. Learning Objectives: By the end of this module, participants will be able to: 1. Analyze the impact of being socially connected on a person’s health. 2. Recall the factors that contribute to social connection. 3. Identify the obstacles to being socially connected. 4. Compare and contrast the differences between loneliness and social isolation. Guiding Questions for Students: 1. What is social connection? 2. What is the impact of a strong social connection on health? 3. What factors affect how connected a person is to others? 4. What barriers exist to social connection? 5. What is social isolation? 6. Why does social isolation occur? 7. What are the perils of social isolation? 8. How can social connection be developed?

Lecture Topic: The Power of Social Connections and Ways to Improve Them and Utilize Them to Promote Health and Well-being Section Activities: Pre-assignment: Lubben Social Connection Score available at: http://www.brandeis.edu/roybal/docs/LSNS_ website_PDF.pdf Revised UCLS Loneliness Scale available at: http://psychology.uchicago.edu/people/faculty/cacioppo/jtcreprints/ hwhc04.pdf

Lifestyle Medicine Course Syllabus 25 Logistics Topic: Check on students’ progress with their Behavior Change Project. Address students’ questions and concerns. Overall Goal: Discuss the benefits of high-quality connections and problems with low-quality connections (Jane Dutton work) and ways to improve both the level of connectedness and the quality of connections. Application Goal: Explore with students how socially connected they feel, the quality of their connections in their lives, and what they think they can do to improve their current connections and establish new ones. Discussion Board Topic(s): We would like you to create an “aha! moment” post this week. Share with the group a time when a piece of the material in the class resonated with you and led you to deeper thinking or understanding on the topic. Please select a time when you truly “connected” with the material.

Required Readings: Optional Readings: 1. Connection. In: Frates B, ed. Lifestyle Medicine Handbook: 1. Berkman Syme SL Social networks, host resistance, An Introduction to the Power of Healthy Habits. Monterey, CA: and mortality: a nine-year follow-up study of Alameda County Healthy Learning; 2021:349-370. residents. 1979;109(2):186-204. 2. TED Talk: The Hidden Influence of Social Network by 2. Hallowell EM. Connect: 12 Vital Ties that Open your Heart, Nicholas Christakis: Available at: http://www.ted.com/ Lengthen your Life, and Deepen your Soul. New York, NY: talks/nicholas_christakis_the_hidden_influence_of_social_ Pocket Books, 1999. networks 3. Hallowell EM. The Childhood Roots of Adult Happiness: 3. Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Five Steps to Help Kids Create and Sustain Lifelong Joy. New Bodenheimer TA. Impact of Peer Health Coaching on Glycemic Your, NY: The Ballantine Publishing Group, 2002. Control in Low-Income Patients with Diabetes: A Randomized 4. Hallowell EM, Ratey JJ. Driven to Distraction (Revised): Controlled Trial. Ann Fam Med 2013;11:137-144. Recognizing and Coping with Attention Deficit Disorder. New 4. Stephens JP, Heaphy ED, Carmeli A, Spreitzer GM, Dutton York, NY: Anchor Books, 2011. JE. Individual and Team Resilience Relationship Quality and 5. Christakis NA, Fowler JH. Connected: The Surprising Power Virtuousness: Source of Emotional Carrying Capacity. J Appl of Our Social Networks and How They Shape Our Lives – How Behav Sci 2013; 49:13. Your Friends’ Friends’ Friends Affect Everything You Feel, 5. Martino J, Pegg J, Frates EP. The Connection Prescription: Think, and Do. New York, NY: Little, Brown and Company, Using the Power of Social Interactions and the Deep Desire for 2009. Connectedness to Empower Health and Wellness. American 6. Dutton JE. Energize Your Workplace to Create and Sustain Journal of Lifestyle Medicine. 2016. High-Quality Connections at Work. San Francisco, CA: Jossey- 6. Su SF, Chang MY, HE CP, Social Support, Unstable Angina, Bass, 2003. and Stroke as Predictors of Depression in Patients With Coronary Heart Disease. J Cardiovasc Nurs. 2017 May 9. doi: 10.1097/JCN.0000000000000419. 7. Georgousopoulou EN, Mellor DD, Naumovski N, et al. Mediterranean lifestyle and cardiovascular disease prevention. Cardiovascular Diagnosis and Therapy. 2017;7(Suppl 1):S39-S47. doi:10.21037/cdt.2017.03.11.

26 Lifestyle Medicine Course Syllabus Week 10: Positively Positive

Positive emotions play a central role in well-being. The relatively new field of Positive Psychology has demonstrated this through research, writing, and teaching. This week we focus on laughter, optimism, and gratitude as gateways to positivity. The “laughter prescription” is explored with an emphasis on research demonstrating the physiologic effects of laughter, whether it be in response to humor or forced as in laughter yoga. We define optimism and demonstrate its power to help transform lives. In addition, we consider gratitude as a healing agent and demonstrate how it affects the mind and body of the person giving as well as the person receiving the gratitude. Weekly Goals for Instructors: 1. Challenge students to consider the power of positive emotions. 2. Demonstrate the benefits of laughter, optimism, and gratitude for human well-being. 3. Invite the students to explore the differences between appropriate and inappropriate humor. 4. Explain different positive psychology interventions and research supporting their benefits. Learning Objectives: By the end of this module, participants will be able to: 1. Distinguish the basic forms of positivity. 2. Recall the evidence-based information on laughter. 3. Recognize the benefits of having an attitude of gratitude. 4. Identify the attributes of happy people. 5. Formulate an understanding of the barriers to feeling joy. Guiding Questions for Students: 1. What is positive psychology? 2. Why is it important that people develop a more positive attitude toward life? 3. What are appropriate ways to cultivate an attitude of gratitude? 4. What are the obstacles to being happy? 5. How can people find more joy in their lives? 6. How can laughter have a positive impact on health?

Lecture Topic: Benefits and Research on the Power of Positive Emotions: Laughter, Optimism, and Gratitude Section Activities: Pre-assignment: Positivity Self-Test by Barbara Fredrickson, PhD available at: https://www.positivityratio.com/ single.php; The Positivity Scale-Available through Research Gate available at: https://www.researchgate.net/ publication/221752656_The_Positivity_Scale Learned Optimism Scale, Marin Seligman, PhD available at: https:// web.stanford.edu/class/msande271/onlinetools/LearnedOpt.html Logistics Topic: Check on students’ progress with their Behavior Change Project. Discuss what tracking and logging methods they are using to track progress on their project goals. Address students’ questions and concerns. Overall Goal: Review a few definitions and benefits of Positive Psychology concepts and interventions. Application Goal: Show Authentic Happiness site (www.authentichappiness.sas.upenn.edu/) and discuss some of the personal assessments they can take there. Practice with students expressing positive emotions in a group setting and create a plausible plan for fitting this into their daily routines.

Lifestyle Medicine Course Syllabus 27 Discussion Board Topic(s): A client comes to you saying she has recently decided she is going to change her career path (unexpectedly and she has not yet taken any steps to do so) and would like your help in navigating this change. Using what you have learned about Positive Psychology and the Coach Approach, please respond with 4 or 5 questions/tactics* you would use to begin a relationship with this client. * This week’s topic could lead to long discussions: please keep your submission within the 2-paragraph limit in order to get full points.

Required Readings: Optional Readings: 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Positively 1. Goodin BR, Bulls HW. Optimism and the Experience of Positive. In: Frates B, ed. Lifestyle Medicine Handbook: An Pain: Benefits of Seeing the Glass as Half Full. Current Pain Introduction to the Power of Healthy Habits. Monterey, CA: and Headache Reports. 2013;17(5), 329-338. Healthy Learning; 2021:371-396. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/ 2. Egger G, Binns A, Rossner, S. Chapter 16. In: Lifestyle PMC3935764/ Medicine. 2nd ed. North Ryde, Australia: McGraw-Hill; 2010. 2. Breuning LG. Habits of a Happy Brain: Retrain Your Brain 3. Louie D, Brook K, Frates E. The Laughter Prescription: A to Boost Your Serotonin, Dopamine, Oxytocin, & Endorphin Tool for Lifestyle Medicine. AJLM, 2014. Levels. Avon, MA: Adams Media; 2016. 4. Shifren K, Anzaldi K Optimism, well-being, depressive 3. Seligman MEP. Authentic Happiness: Using the New symptoms, and perceived physical health: a study among Positive Psychology to Realize Your Potential for Lasting Stroke survivors. Psychol Health Med. 2017 May 5:1-12. doi: Fulfillment. New York, NY: Atria Paperback; 2002. 10.1080/13548506.2017.1325505. [Epub ahead of print]. 4. Ben-Shahar T. Happier: Learn the Secrets to Daily Joy and 5. Emmons RA, McCullough ME. Counting blessings Lasting Fulfillment. New York, NY: McGraw-Hill; 2007. versus burdens: An experimental investigation of 5. Frederickson BL. Positivity: Top Notch Research Reveals gratitude and subjective well-being in daily life. Journal of the 3-to-1 Ratio That Will Change Your Life. New York, NY: Personality & Social Psychology. 2003;84(2):377–389. Three Rivers Press; 2009. doi:10.1037//0022-3514.84.2.377. 6. Seligman ME. Flourish: A Visionary New Understanding of 5. Yazdani M, Esmaeilzadeh M, Pahlavanzadeh S, Khaledi F. Happiness and Well-being. New York, NY: Free Press; 2011. The effect of laughter Yoga on 7. Frankl VE. Man’s Search for Meaning. Boston, MA: Beacon general health among nursing students. Iranian Journal of Press; 1959. Nursing and Midwifery Research. 2014;1014;19(1):36-40. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/ 8. 8 Things Happy People Do Differently. YouTube Web site. PMC3917183/ Available at https://www.youtube.com/watch?v=3OQDI-BZdnI. 6. Laughter Yoga on the Discovery Channel. YouTube Web site. Available at http://www.youtube.com/ watch?v=ahhN3Ryw4O4. 7. Baby Laughing Hysterically at Ripping Paper (Original). YouTube Web site. Available at http://www.youtube.com/ watch?v=RP4abiHdQpc.

28 Lifestyle Medicine Course Syllabus Week 11: Substance Use Disorder

Many people in America struggle with addiction. Although rates of smoking are decreasing, it still represents a major lifestyle risk factor causing significant morbidity and mortality. Despite the advances made by pharmaceutical companies to discover drugs that can ease the pain of withdrawal for some patients, smoking continues to plague both patients and practitioners. Smoking cessation programs have evolved over the years and counseling strategies taught in medical schools have also changed. We discuss the use of Motivational Interviewing techniques for smoking cessation. Next, we address alcohol consumption, which in moderation has health benefits, but in excess can cause distress, disease, and death. We explore the recommendations released by the American Heart Association and review effective counseling strategies around alcohol consumption. Given that addiction to smoking and alcohol are major problems for the healthcare system, we determine what it means to be addicted, and what we can be done about it. Given the opioid crisis in the United States and worldwide, we examine the root causes of the opioid crisis in the worldwide and discuss possible solutions. Lastly, we explore the concept of food addiction. Weekly Goals for Instructors: 1. Challenge students to explore the meaning and impact of substance use disorders. 2. Address controversies in defining addiction and discuss under what circumstances a certain behavior may move from healthy to unhealthy. 3. Discuss the signs and symptoms of various substance use. 4. Invite the students to consider the negative effects of smoking, alcohol consumption, and the use of other drugs. 5. Review different ways in which the Coach Approach may help patients with substance use disorder. Learning Objectives: By the end of this module, participants will be able to: 1. Define and categorize substance use disorders. 2. Identify the importance of substance use disorders. 3. Recognize the impact of substance use disorders on health. 4. Explain treatment options for various forms of substance use disorders. 5. Formulate possible lifestyle interventions for substance use disorders. Guiding Questions for Students: 1. What is substance use disorder? 2. What are the signs and symptoms of substance use? 3. What is the impact of substance use on society? 4. What is the impact of substance use on health? 5. What are common ways of treating substance use? 6. What are barriers to treating substance use? 7. What techniques can lifestyle medicine practitioners use when dealing with patients who use substances?

Lecture Topic: The Dangers of Addictions and Ways to Address Addictive Behaviors Section Activities: Pre-assignment: Alcohol and Drugs available at: http://www.addictionsandrecovery.org/addiction-self-test.htm Yale Food Addiction Score available at: http://www.midss.org/content/yale-food-addiction-scale-yfas Logistics Topic: Check on students’ progress with their Behavior Change Project. Address students’ questions and concerns.

Lifestyle Medicine Course Syllabus 29 Overall Goal: Understand what constitutes addiction and how it is different from just unhealthy behaviors. Application Goal: Practice the Coaching Approach with students when dealing with a person with addiction utilizing a real-life example brought up by a student or a fictional case. Differentiate how you approach a person with addiction in different stages of change and how to deal with sustaining the motivation for change. Discussion Board Topic(s): A friend of yours approaches you and says that he is considering quitting smoking. How do you respond?

Required Readings: Optional Readings: 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Substance 1. Ciccolo JT, Jennings EG, Busch AM. Chapter 19 Behavioral Abuse. In: Frates B, ed. Lifestyle Medicine Handbook: An Approaches to Enhancing Smoking Cessation. In Rippe JM Introduction to the Power of Healthy Habits. Monterey, CA: Lifestyle Medicine, 2nd Ed. Boca Raton, FL, CRC Press; Healthy Learning; 2021:397-430. 2013:245-254. 2. Egger G, Binns A, Rossner, S. Chapter 17. In: Lifestyle 2. Blum K et al. Hatching the behavioral addiction egg: Medicine. 2nd ed. North Ryde, Australia:McGraw-Hill; 2010. Reward Deficiency Solution System (RDSS) as a function of 3. Dwyer-Clonts M, Frates E. Suzuki J. Managing Problem dopaminergic neurogenetics and brain functional connectivity Drinking: Screening Tools and Brief Interventions for Primary linking all addictions under a common rubric. J Behav Addic, Care Physicians. Am J Lifestyle Med, 2016. Available 2014;3(3):149-156. Available here Link (Links to an external here: Week 11 - AJLM-ManagingProblemDrinking-Dwyer- site.). Clonts+Frates.pdf. 3. Prochaska JO. Norcross J, DiClemente C. Changing for 4. Alcohol Screening Tools available at National Institute of Good: A Revolutionary Six-Stage Program for Overcoming Bad Alcohol Abuse and Alcoholism Web site. Available at http:// Habits and Moving Your Life Positively Forward. New York, NY; pubs.niaaa.nih.gov/publications/arh28-2/78-79.htm HarperCollins Publisher; 1994. 5. Gearhardt, A, Corbin W, Brownell KD. Preliminary 4. Foote J, Wilkens C, Kosanke N, Higgs S. Beyond Addiction: Validation of the Yale Food Addiction Scale. Appetite, How Science and Kindness Help People Change. New York, 2009;52:430-436. NY: Simon & Schuster, Inc; 2014. 6. Yale Food Addiction Scale. Available at: http://abcnews. 5. Stein J, Silver JK, Frates EP. Life After Stroke: The Guide go.com/Health/quiz-addicted-food/ story?id=14406763. to Recovering Your Health and Preventing Another Stroke. Baltimore, MD: Johns Hopkins University Press; 2006. 7. Nicotine Addiction and Assessment. Fagerstrom Test for Nicotine Dependence, first published in: Fagerstrom 6. Hari J. Everything you think you know about addiction is K, Heatherton T, Kozlowski L. Nicotine Addiction and wrong. TED. Available at: https:// www.ted.com/talks/johann_ its Assessment. Ear, Nose, and Throat Journal, 1990; hari_ever ything_you_think_you_know_about_addiction_is_ 69(11):763-765. Available at: http://www.dartmouth. wrong?language=en. edu/~thlab/ pubs/90_Fagerstrom_etal_ENTJ.pdf. 7. Nuggets. YouTube Web site. Available at: https://www. 8. Various substance/area-specific addiction scales: Global youtube.com/watch?v=HUngLgGRJpo. Addiction Conference for alcohol, smoking, drugs, food, sex 8. Kaplan R. Carrot addiction. Aust N Z J Psychiatry, 1996; and more. Available at http://www.globaladdiction.org/scales. 30(5):698-700. Available at: https://www.ncbi.nlm.nih.gov/ php. pubmed/8902181. 9. Griffiths MD. Grasp a Carrot: A brief look at compulsive carrot eating. Psychology Today Website. July 1, 2013. Available at: https://www.psychologytoday.com/blog/ in-excess/201307/grasp-carrot. 10. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America:The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016. Available at: https:// addiction.surgeongeneral.gov/surgeon-generals-report.pdf. 11. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, Executive Summary. Washington, DC: HHS, November 2016. Available at: https://addiction.surgeongeneral.gov/executive- summary.pdf. 30 Lifestyle Medicine Course Syllabus Week 12: Staying the Course - Self Care

Ralph Waldo Emerson said, “The first wealth is health.” This concept has been around for years, but it has not been a priority for many. We review cases of people and patients who did not take care of themselves and find take- home messages from them. We review the basics for self-care at any age and discuss how self-care can improve well-being, creativity, and productivity, even though it seems like it takes time away from accomplishing the tasks of the day. There is ample literature that reveals that physicians who exercise themselves counsel their patients on exercise, and conversely that physicians who do not exercise do not counsel on exercise. Change agents of any kind must walk the walk and not only talk the talk. We explore the importance of cognitive stimulation throughout the lifespan and the value of exercise, a healthy diet, social connection, good sleep, and effective stress management and how they apply to the lives of healthcare providers and patients alike. We address simple strategies to use to stay accountable for goals around healthy living, and we discuss them in relation to their applicability as well as their efficacy.

Weekly Goals for Instructors: 1. Challenge the students to consider the importance of self-care and obstacles to practicing it. 2. Review the literature on the power of modeling healthy behaviors rather than just talking about them. 3. Invite the students identity self-care practices and how to integrate them into daily routines. 4. Describe the importance of lifelong learning and the power of “live and learns.” Learning Objectives: By the end of this module, participants will be able to: 1. Recognize the need for self-care. 2. Review key aspects of self-care including routine activity, healthy eating, stress management, sleep hygiene, connection, and positive emotions. 3. Review the literature showing that physicians counsel on the behaviors that they do routinely.

4. Explore strategies for enhancing self-care as a student, a parent, a teacher, a physician, a grandparent, and a worker of any type. Guiding Questions for Students: 1. What steps should physicians and allied healthcare professionals take concerning their own personal self-care? 2. What can lifestyle medicine practitioners do to avoid burning out professionally? 3. What does lifelong learning entail? 4. What can physicians and allied healthcare professionals do to continue to thrive and be passionate about the impact that they have on others?

Lecture Topic: Importance of Self-Care and Overcoming Obstacles to Self-Care Section Activities: Pre-assignment: Self-Care Assessment Worksheet, available at: https://www.ecu.edu/cs-dhs/rehb/upload/ Wellness_Assessment.pdf. Self-Assessment Tool available at: http://peer.hdwg.org/sites/default/files/7b%20 SelfAssessmentToolSelfCare-PeerRole- Peer_Training.pdf Logistics Topic: Discuss wrap-up of students’ behavior change projects and how to document the change process in a final paper. Address students’ questions and concerns. Overall Goal: Explore students’ self-care assessments and discuss areas and ways of improvement Application Goal:

Lifestyle Medicine Course Syllabus 31 Discuss with students their self-care practices and areas where they want to improve. Have students share what worked for them. Discussion Board Topic(s): How do you plan to use the information from this class to support yourself in your practice of self-care this week and throughout the upcoming year?

Required Readings: Optional Readings: 1. Frates B, Bonnet JP, Joseph R, Peterson JA. Staying the 1. Abramson S, Stein J, Schaufele M, Frates E, Rogan Course. In: Frates B, ed. Lifestyle Medicine Handbook: An S. Personal Exercise Habits And Counseling Practices Of Introduction to the Power of Healthy Habits. Monterey, CA: Primary Care Physicians: A National Survey. Clin J Sport Med. Healthy Learning; 2021:431-458. 2000;10(1): 40-48. 2. Sanchez-Reilly S, Morrison LJ, Carey E, et al. Caring for 2. Lewis CE, Wells KB, Ware J. A model for predicting the oneself to care for others: physicians and their self-care. The counseling practices of physicians. J Gen Intern Med, 1986; journal of supportive oncology. 2013;11(2):75-81. 1(1): 14-19. 3. Cho J. Healing The Healer: Why Physicians and Medical 3. Frank E, Breyan J, Elon L. Physician Disclosure of Healthy Professionals Must Practice Self-Care. Forbes (Pharma and Personal Behaviors Improves Credibility and Ability to Motivate. Healthcare). May 30, 2016. Accessed on June 10, 2020 Arch Fam Med. 2000; 9(3): 287-290. at https://www.forbes.com/sites/jeenacho/2016/03/30/ healing-the-healer-why-physicians-and-medical- professionals- must-practice-self-care/#353efe43797a. 4. Troy Parks. Report reveals severity of burnout by specialty. AMA Wire. January 31, 2017. Accessed on June 10, 2020 at https://wire.ama-assn.org/life-career/ report-reveals-severity-burnout-specialty. 5. Fung, B. Is your Doctor Healthier Than You? The Atlantic Web site. Available at: http://www. theatlantic.com/health/ archive/2012/08/is-your-doctor-healthier-than-you/260706/. Published on August 6, 2012. 6. Bass K, McGeeney K. US Physicians Set Good Health Example. Gallup Well-Being Web site. Available at: http://www. gallup.com/poll/157859/physicians-set-good-health-example. aspx. Published on October 3, 2012. 7. Oberg EB and Frank E. Physicians’ health practices strongly influence patient health practices. J R Coll Physicians Ednib. 2009; 39(4): 290-291. Available at: https://www.ncbi. nlm.nih.gov/pmc/ ar ticles/PMC3058599/. 8. Voltmer E, Frank E, Spahn C. Personal Health Practices and Patient Counseling of German Physicians in Private Practice. ISRN Epidemiol. 2013; 2013: Article ID 1760202, 10 pages. Available at: https://www.hindawi.com/journals/ isrn/2013/176020/abs/.

32 Lifestyle Medicine Course Syllabus Week 13: Education Reform around Lifestyle Medicine and Current State of Practice for Lifestyle Medicine

More than ever before, medical schools are starting to focus on lifestyle medicine and behavior change. Although Hippocrates described the benefits of a healthy lifestyle centuries ago, it was not until recently— when the research base became robust—that medical professionals began taking exercise, diet, stress reduction, and sleep seriously. The change in the MCATs to include more behavior change questions helped to alter the pre-med focus. The Harvard Extension School course which gives psychology and biology credits to undergraduates also gives graduate school credits to psychology masters students. Continuing Medical Education courses on lifestyle medicine topics are offered in the US and around the world. With the creation of the American Board of Lifestyle Medicine, there is a lifestyle medicine certification process in place for physicians, PhDs, and masters-level practitioners in the healthcare field. Lifestyle medicine education has come a long way in the past 10 years, and more and more medical schools are adopting nutrition and exercise courses. Several medical schools and allied health professional schools have created a parallel curriculum in lifestyle medicine in the form of Lifestyle Medicine Interest Groups (LMIGs) modeled after the one at Harvard Medical School, which has been running since 2008. These LMIGS are a way to expose medical students and students in the healthcare profession to lifestyle medicine information, research, and tools— even when school administrators are not yet ready to include the material in the core curriculum. Dr. James Rippe’s textbook Lifestyle Medicine is now in its 3rd edition and there is an academic journal dedicated to research and education in this field titled the American Journal of Lifestyle Medicine. Much progress has been made, and much more progress needs to be made. Weekly Goals for Instructors: 1. Consider the current state of lifestyle medicine education. 2. Invite the students to identify the gaps in the current education curriculum and where education needs to go in order to achieve better patient and self-care. 3. Challenge the students to evaluate what can be done by organizations and individuals to improve lifestyle medicine education and application in practice. Learning Objectives: 1. Analyze the state of education around lifestyle medicine with regard to medical schools. 2. Discuss the importance of offering lifestyle medicine programs to college students, medical students, law students, and other graduate students. 3. Formulate ideas on moving education reform form in hometowns, schools, and cities. 4. Describe the components of a successful lifestyle medicine practice. 5. Formulate a plan to access lifestyle medicine resources for future use. Guiding Questions for Students: 1. When and why did medical educators express interest in teaching lifestyle medicine principles to students? 2. What would it take to require exercise and nutrition prescription counseling to all medical students? 3. How would the health of America be different if all healthcare professionals were trained in lifestyle medicine? 4. What would it take to open a lifestyle medicine clinic?

Lifestyle Medicine Course Syllabus 33 Lecture Topic: The Current State and Future of Lifestyle Medicine Education Section Activities: Logistics Topic: Discuss with students what they need to do in their final assignments and final due dates. Address students’ questions and concerns. Overall Goal: Introduce some government and NGO initiatives and programs that help promote education about health behaviors, as well as awareness and practice of lifestyle medicine topics. Application Goal: Discuss with students programs they are aware of or have experience with. Explore what the students have been inspired to do while taking this class in promoting lifestyle medicine goals in their lives, the lives of their friends and family members, and in their community. Discussion Board Topic(s): After this course ends, how will you apply the information you’ve learned to your career, your education, your family, or your life in general going forward?

Required Readings: 3. Connaughton AV, Weiler RM, & Connaughton DP. Graduating medical students’ exercise prescription 1. Egger G, Binns A, Rossner, S. Making Lifestyle Medicine competence as perceived by deans and directors of medical Work and Pay in General Practice. Appendix page 323-331. In: education in the United States: Implications for Healthy Lifestyle Medicine. 2nd ed. North Ryde, Australia:McGraw-Hill; People. Public Health Reports. 2001;116(3), 226-234. 2010. 4. Garry JP, Diamond JJ, Whitley TW. Physical Activity 2. Dacey ML, Kennedy MA, Polak R, and Phillips EM. Physical Curricula in Medical Schools. Academic Medicine. 2002; activity counseling in medical school education: a systematic 77(8):818-820. review. Med Educ Online. 2014; 19: 24325. Available at: http://med-ed-online.net/index.php/meo/ar ticle/ 5. Vallance JK, Wylie, M, Macdonald R. Medical students’ view/24325. self-perceived competence and prescription of patient- centered physical activity. Preventive Medicine. 2009; 3. Walsh CO, Ziniel SI, Delichatsios HK, Ludwig DS. 48(2):164-166. Nutrition attitudes and knowledge in medical students after completion of an integrated nutrition curriculum 6. Rogers LQ, Bailey JE, Gutin, B, Johnson, KC, Levine MA, compared to a dedicated nutrition curriculum: a quasi- Milan F, et al. Teaching Resident Physicians to Provide Exercise experimental study. BMC Medical Education. 2011; Counseling. Academic Medicine. 2002;77(8):841-844. 11:58. Available at: http://download.springer.com/static/ 7. Rogers LQ, Bailey JE, Gutin B, Johnson KC, Levine pdf/965/art%25 3A10.1186%252F1472-6920-11-58. MA, Milan, F, et al. Teaching Resident Physicians to pdf?originUrl=http%3A%2F%2Fbmcmededuc. Provide Exercise Counseling. Academic Medicine. 2002; biomedcentral.com%2Far ticle%2F10.1186%2F1472- 77(8):841-844. 6920-11-58&token2=exp=1480462 8. Conroy M, Delichatsios H, Halfler J, & Rigotti N. Impact of 981~acl=%2Fstatic%2Fpdf%2F965%2Far t% a preventive medicine and nutrition curriculum for medical 25253A10.1186%25252F1472-6920-11-58. students. American Journal of Preventative Medicine. 2004; pdf*~hmac=a35cfb8573a9a0cbbbefc60905f26d4b51f 27(1): 77-80. f364553bb7f3d67699f75a84b168b. 9. Lifestyle Medicine Core Competencies Program. American 4. Marbury D. Making dollars and sense of Lifestyle College of Preventive Medicine Web site. Available at: http:// Medicine. Medical Economics Website. August 23, 2013. www.acpm.org/page/lmprogram. Available at: http://medicaleconomics.modernmedicine. com/medical-economics/ content/tags/cme/ 10. Lifestyle Medicine Board Certification. American Board of making-dollars-and-sense-lifestyle-medicine?page=full. Lifestyle Medicine Web site. Available at: https://ablm.co/. Optional Readings: 11. Kent K, Johnson JD, Simeon K, Frates EP. Case Series in Lifestyle Medicine: Approach to Behavior Changes. Am J 1. Ángyán L. Promoting physical activity in medical Lifestyle Med. 2016. education. Acta physiologica Hungarica, 2004; 91(2):157- 166. Available at: http://www.akademiai.com/content/ 12. Frates EP. Xiao RC, Simeon K, McCargo T, Guo M, Stern TA. m262m62305514227/fulltext.pdf. Increasing Knowledge and Confidence in Behavioral Change: A Pilot Study. Prim Care Companion CNS Discord. 2016;18(6). 2. Burke, E. J., & Hultgren, P. B. (1975). Will physicians of Available here: http://www-psychiatrist-com.ezp-prod1.hul. the future be able to prescribe exercise? Journal of Medical harvard.edu/PCC/article/Pages/2016/ v18n06/16m01962. Education. 1975; 50(6):624-6. aspx.

34 Lifestyle Medicine Course Syllabus Week 14: Review Week

After spending 13 weeks together, in the final class we take time to pause and reflect on what we have learned. We ask how this course has changed our perspectives, our behaviors, and our thoughts and feelings about exercise, nutrition, sleep, stress, laughter, smoking, self-care, and more. Together, we find commonalities among the weeks and guiding principles to follow for leading a healthy lifestyle. We explore possible research opportunities and identify research projects that would be valuable to complete. In addition, we review case studies of lifestyle medicine patients. Time is given to ask questions and gain clarity around any concepts that were covered during the semester. Weekly Goals for Instructors: 1. Review major topics of lifestyle medicine, overreaching messages of the course, and the most important take- away points. Learning Objectives: 1. Students have the opportunity to present questions to the class. 2. Review the 13 main topics covered in the semester in brief fashion. 3. Formulate commonalities among weeks. 4. Recall guiding principles for moving forward in personal wellness journeys as well as in general health promotion for lifestyle medicine. 5. Explore the direction of future research in lifestyle medicine. Guiding Questions for Students: 1. How have your attitudes and beliefs changed throughout this course? 2. What behaviors, if any, have you changed for yourself and why? 3. How will you make these changes stick? 4. How will you continue your study of lifestyle medicine? 5. What are some potential future areas of research in lifestyle medicine?

Lecture Topic: Global Overview of the Course and Guiding Principles

Required Readings: 1. Egger G, Binns A, Rossner, S. Chapter 26. In: Lifestyle Medicine. 2nd ed. North Ryde, Australia:McGraw-Hill; 2010. 2. Look through the articles and find one that you missed or one that resonated with you. Reread it. 3. Find an article in a topic from these past 13 weeks that interests you--behavior change, physical activity, nutrition, stress management, meditation, sleep, relaxation, stress resilience, positive emotions, laughter, gratitude, addictions, self care or something else that calls to you.

Lifestyle Medicine Course Syllabus 35 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, FACLM