lifestyle medicine: redefining “health” care
TRANSCRIPT
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Lifestyle
Medicine:
Redefining
“HEALTH” care Brian Asbill, MD, FACC
October 6, 2017
Lifestyle Medicine Symposium
Outline
• State of the Union
• What is Lifestyle Medicine?
•The Evidence of Benefit
• Our Experience in Asheville
• Where Do We Go From Here?
Obesity, the common denominator of chronic
disease Overweight – 32%
Obese - 34%
Morbidly Obese - 6%
Obese men use 5.9 sick days
Obese women use 9.4 sick days
Obese men cost an extra $1152 in medical cost
Obese women cost an extra $3613 in medical costs
Source: Begley, Sharon. As America’s Waistline Expands, Costs Soar, Reuters, 2012
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1945 1965 2005 1985
25%
20%
15%
10%
5%
900% age 60+
age 40-59
cdc.gov/diabetes/stats
Diabetes Trend (US 1945 to 2010)
“You can expect one heart attack per year in an average
hospital in an average sized town”. Prevalence of Coronary Heart Disease in North America, 1928
Medical Textbook by Sir William Osler, MD
Today, the number of heart attacks in the US is
1,460,000 a year!
Heart Disease… Less Than 100 Years Ago
• Bypass Surgery
• 400,000/year
• Averaging $60,000+ each
• 37-46% of vein grafts failed (75% narrowing) within 12
to 18 months
NEJM 2009, 361 (3) 235
• Angioplasties & Stents
• 1,000,000/year
• Averaging $35,000 each
Heart Disease Today…
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Let food by thy medicine
and medicine be thy food-
-Not Hippocrates?
180,000* serious or fatal adverse drug reactions
reported to the FDA,
making drugs a significant % of US deaths
*Properly or improperly prescribed
FDA, reported in 2011
Prescription Drugs
Are NOT the Answer
Which of the following statements is
true about adverse drug reactions?
a) Total cost for ADRs ranks 6th on annual national health
care expenditures
b) Total costs for hospital patients with an ADR are 5
times those of patients without an ADR
c) ADRs are responsible for 1 in 25 injuries or deaths per
year in the hospital
d) Hospitalized patients with an ADR have the same
mortality as those without an ADR
e) The annual costs for ADRs are greater than total costs
for cardiovascular or diabetic care
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Which of the following statements is
true?
a) ADRs are responsible for fewer deaths than pulmonary
disease, DM, and pneumonia
b) There are enough prescriptions filled yearly in the US
to average 10 prescriptions for every person in the US
c) On average, an increase in the number of concomitant
drugs does not increase the risk of an interaction until
6 are given at the same time
d) 47% of patient visits result in a prescription
e) In general, patients have little concern about potential
drug interactions
Someone has to stand up and say
that the answer isn’t another pill.
The answer is spinach
-Bill Maher
A Solution For Today’s Health Care
Dilemma
Lifestyle Medicine:
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Lifestyle Medicine Definition
• Lifestyle medicine is the evidence based practice of helping individuals and families adopt and sustain (natural) healthy behaviors that affect health and quality of life…
Lifestyle Medicine Pioneers
Dean Ornish, MD *Ornish Lifestyle Medicine
Prevent and Reverse Heart Disease
Lifestyle Interventions
1) Nutrition
2) Physical Activity
3) Stress Management
Rest/Sleep/Meditation
4) Social supports
* Environmental Exposures
Smoking cessation/Toxicology
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Lifestyle
Medicine
Growth
- Growth Numbers
- Growth Drivers
132
152
303
448
565
698
1116
0
200
400
600
800
1000
1200
2010 2011 2012 2013 2014 2015 2016
Annual Membership Growth
19%
38%
1531
Physician 56%
Doctoral 8%
Executive 1%
Professional 15%
Affiliate 4%
Retired 4%
Trainee 12%
ACLM Membership 2016
7
0
100
200
300
400
500
600
700
800
Physician/Doctoral Executive Professional/Affiliate Retired Trainee
Me
mb
ers
Membership Growth by Category (2015 – 2016)
Four Lifestyle Medicine
Growth Drivers
1) The Chronic Disease Epidemic
fueled by… food processing/preserving/shipping
modern transportation/communication tech
Four Lifestyle Medicine
Growth Drivers
1) The Chronic Disease Epidemic
fueled by… food processing/preserving/shipping
modern transportation/communication tech
2) Increasing Health Care Costs
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Four Lifestyle Medicine
Growth Drivers
1) The Chronic Disease Epidemic
fueled by… food processing/preserving/shipping
modern transportation/communication tech
2) Increasing Health Care Costs
3) Dissatisfaction with the Status Quo patients
physicians/providers
Discontent is the first necessity of
progress.
-Thomas Edison
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Four Lifestyle Medicine
Growth Drivers
1) The Chronic Disease Epidemic fueled by… food processing/preserving/shipping modern transportation/communication tech
2) Increasing Health Care Costs 3) Dissatisfaction with the Status Quo patients physicians/providers
4) Science epidemiology, basic science, clinical trials
Data for Lifestyle Efficacy JACC 9/5/14 Akesson et al
• 20,721 men ages 45-79 followed for 11 years
• 5 lifestyle factors:
• Healthy diet
• Smoking
• Moderate etoh consumption
• Physical activity
• Abdominal adiposity
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Data for Lifestyle Efficacy JACC 9/5/14 Akesson et al
• 79% lower risk if met all lifestyle factors
• Only 1% of the study population
Data for Lifestyle Efficacy JACC 1/5/15 (Chomistek et al)
*88,940 women in NHS2 ages 27-44 with no h/o
cancer, CVD or DM
*6 lifestyle factors defined healthy living:
-no smoking
-diet in top 40% of healthy eating index
-physical activity at least 2.5 hrs/week
-TV watching <7 hrs/week
-BMI <25
-Alcohol not more than 1/day
Data for Lifestyle Efficacy JACC 1/5/15 (Chomistek et al)
*At 20 yrs f/u, those who adhered to all 6 lifestyle
factors had 92% lower CVD risk vs those with zero
*Only 4.6% of the study population were optimal
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Overview
Lifestyle intervention education program
100% evidence based
community based (not residential)
Regular group sessions over several weeks
Blood draws and Health Risk Assessments
Education, practical experience, reinforcement
“Whole of Health” approach
60,000+ participants over 25 years and counting…
25+ peer reviewed articles in medical journals
25 – 45 minutes of content delivery
25 - 45 minutes of facilitated group discussion,
based on these recurring questions:
• What was new to me?
• What did I like?
• What did I not like?
• What will I change from now on?
Food Sampling/cooking demos/
exercise (some lectures)
A typical CHIP session
CHIP Efficacy
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Asheville CHIP 1
30 day results (N=22)
DAY 1 DAY 30 Decrease
Average weight 228 lbs 218 lbs 4.4%
Ave. total chol 187 mg/dl 161 mg/dl 13.9%
Ave. LDL-C 110 mg/dl 93 mg/dl 16.1%
Ave TG 186 mg/dl 139 mg/dl 25.3%
Ave glucose 121 mg/dl 112 mg/dl 7.5%
Ave SBP 132 mmHg 122 mmHg 7.6%
Asheville CHIP 2
12 week results
• Weight Loss
– 27 participants lost a total of 363.5 lbs
– Average weight loss 13.5 lbs/person
– 61.5 inches on waist circumference lost (2.25 in/pt).
One man lost 8 inches
• Glucose
– 17 people had a fasting glucose >100. 8 of the 17 lowered
their glucose to <100 at 12 weeks
Asheville CHIP 2
results
• Lipids
– Only 6 had a total cholesterol >200 at the start with
an average TC of 242 mg/dl
• At 30 days it dropped 20% to 194 mg/dl
– 16 pts had an LDL >100 mg/dl with ave 134 mg/dl
• At 30 days it dropped 24% to 102 mg/dl
– 8 had TGs >150 mg/dl with ave 235 mg/dl
• At 90 days 17% decrease to 195 mg/dl
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Copyright © 2014 Healthways, Inc. All rights reserved. Copyright © 2014 Healthways, Inc. All rights reserved.
Dr. Ornish’s Program for Reversing Heart Disease™
Copyright © 2014 Healthways, Inc. All rights reserved. Copyright © 2014 Healthways, Inc. All rights reserved.
Experimental group (Ornish participants) had more regression after 5 years than after 1 year.
Proven Regression
Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001-2007.
27.7% relative worsening in the control group.
7.9% relative improvement in the Ornish group.
91% decrease in angina
vs
165% increase
5y: 2.5 x increased
event rate
in control group
20% LDL reduction
in both groups
60% on statins vs 0%
99% stopped or reversed their CHD
with average 300% increase
in myocardial perfusion by PET scan
Copyright © 2014 Healthways, Inc. All rights reserved. Copyright © 2014 Healthways, Inc. All rights reserved.
Long term regression
0%
10%
20%
30%
40%
50%
60%
70%
3 months 1 year 2 years 3 years
% Reporting No Angina
of intervention patients avoided revascularization,
with no increased frequency of cardiac events.
77% At three years
Ornish D, for the Multicenter Lifestyle Demonstration Project Research Group. Avoiding revascularization with lifestyle changes: The Multicenter lifestyle demonstration project. Am J Cardio 1998;82:72T-76T.
47% lower cost with $3.1 M savings
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Copyright © 2014 Healthways, Inc. All rights reserved. Copyright © 2014 Healthways, Inc. All rights reserved.
Recent Results | Mission Health
The information below represents sample outcomes from the most recent Healthways clinical outcomes report.
Baseline 9 weeks Change
Weight Loss 199.7 192.1 -3.8%
BMI 29.8 28.6 -3.9%
Total Cholesterol 167.6 136.0 -18.9%
LDL Cholesterol 94.8 71.1 -25%
Triglycerides 164.7 141.1 -14.3%
Systolic Blood Pressure 121.3 119.5 -1.5%
Diastolic Blood Pressure 73.4 67.8 -7.7%
Exercise capacity (METS) 4.3 5.5 27.9%
HbA1c 6.7 6.4 -4.7%
Depression Score (CESD) 14.6 6.2 -57.7%
Copyright © 2014 Healthways, Inc. All rights reserved. Copyright © 2014 Healthways, Inc. All rights reserved.
Quarterly Results – Q2 2017
Baseline 9 weeks Change
Weight Loss 200.0 188.4 -5.8%
BMI 31.5 29.7 -5.7%
Total Cholesterol 168.9 142.0 -16.0%
LDL Cholesterol 92.4 72.5 -21.5%
HDL Cholesterol 48.0 43.4 -9.5%
Triglycerides 152.6 133.6 -12.5%
Systolic Blood Pressure 129.6 121.5 -6.2%
Diastolic Blood Pressure 76.0 70.9 -6.7%
HbA1c 6.7 6.2 -7.4%
Depression Score (CESD) 11.4 5.6 -51.2%
Exercise Capacity (Mets) 3.7 5.5 47.5% Data is based off participants in Q2 2017 quarterly report. N-2786 participants.
Physical and Dietary Behavior Adherence Over 18
Months Physical and Dietary Behavior Mean change
at 18 mo
% of participants who
improved over 18 mo
Physical Activity
(steps/wk)
5,596
63
Kcal/day
-391
75
Vegetables servings/day
2.6
59
Dietary saturated fat g/day
-8
83
Dietary fiber g/day
4
67
Sweets kcal/day %
-3
69
Merrill RM, Aldana SG, Greenlaw RL, et al. Can Newly Acquired
Healthy Behaviors Persist? An Analysis of Health Behavior Decay.
Prev Chronic Disease. 2008 5:1;1-13.
Average
about 70%
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Medication continuation after myocardial infarction
in the community
Shah ND, Dunlay SM, Ting HH et al. Long-term Medication Adherence after
Myocardial Infarction: Experience of a Community. The Amer J of Med. 2009:122:10.
About 70%
at 18 mo
What are we to do?
• Barriers to success • Most providers are used to guideline driven
medicine.
• They don’t have time
• Lifestyle medicine data is not widely known
• Not trained in behavioral medicine techniques
• The whole world is against us?
What are we to do?
• Possible solutions • Educate providers about the power of lifestyle
medicine
• Development of wellness referral programs
employing team based care
• Hospital
• Business
• Local government
• Advocacy at local, state and national level
• Start to talk about this!
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The doctor of the future will give no
medicine, but will instruct his patient
in the care of the human frame, in
diet and in the cause and prevention
of disease.
-Thomas Edison
What is CHIP?
Overview
Lifestyle intervention education program
100% evidence based
community based (not residential)
Regular group sessions over several weeks
Blood draws and Health Risk Assessments
Education, practical experience, reinforcement
“Whole of Health” approach
60,000+ participants over 25 years and counting…
25+ peer reviewed articles in medical journals
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25 – 45 minutes of content delivery
25 - 45 minutes of facilitated group discussion,
based on these recurring questions:
• What was new to me?
• What did I like?
• What did I not like?
• What will I change from now on?
Food Sampling/cooking demos/
exercise (some lectures)
A typical CHIP session
Program Content
Phase 1 Lifestyle is the best medicine
Session 1 The rise and rise of chronic disease
Session 2 Lifestyle is the best medicine
Session 3 The common denominator of chronic disease
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Are Programs like CHIP Covered by
Insurance Plans? • Considered licensed “clinicians” that are capable of billing- M.D., D.O., NNPP,
PA, or RD are the most common clinicians who are able to bill using Medical
Nutritional Therapy (MNT) using CPT codes 97802-4
• Clinicians must be in their network or system
• Those providers use the proper CPT codes and have a referral for the
therapy, and a diagnosis, or reason for the referral, from the participant’s
primary care physician on file. At this point all insurance plans do require a
“diagnosis code” for reimbursement to be possible. Most common diagnoses:
obesity counseling, any diet related chronic disease state, and/or any
cardiovascular risk factor like hyperlipidemia, hypertension, or diabetes (all
great reasons for being in CHIP!)
ITLC Billing
Source Average Payment
Insurance $1483.68 / participant
Self Pay $699.00 / participant
(minus $350) = $349.00
16 classes were billed 99214
4 classes were billed 99213
2 Lab draws/assessments billed 99211
Labs billed through insurance Participants bought own textbooks
Self-Pay $699
Textbooks $250/ person
Labs $50/ person
$21.81 revenue/ session
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Phase 2 Optimal Lifestyle
Session 4 Optimal Lifestyle
Session 5 Eat more, weigh less
Session 6 Fiber, your new best friend
Session 7 Disarming Diabetes
Session 8 The heart of the matter – heart healthy
Session 9 Blood Pressure and & discovering protein
Session 10 Bone health essentials
Session 11 Cancer Prevention
Phase 3 Pause & Reflect
Session 12 Understand your results & take action
Asheville CHIP 1
30 day results (N=22)
DAY 1 DAY 30 Decrease
Average weight 228 lbs 213 lbs 6.6%
Ave. total chol 187 mg/dl 167 mg/dl 10.7%
Ave. LDL-C 110 mg/dl 94 mg/dl 14.6%
Ave TG 186 mg/dl 158 mg/dl 15.1%
Ave glucose 121 mg/dl 109 mg/dl 10.0%
Ave SBP 132 mmHg 124 mmHg 6.1%
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Asheville CHIP 3
30 day results (N=20)
DAY 1 DAY 30 Decrease
Ave total chol 188 mg/dl 167 mg/dl 11%
17 pts had TC >150
Avg = 199mg/dl
177 mg/dl 11%
9 pts had TC >200
Avg 225 mg/dl
198 mg/dl 12%
Waist circ 42.6 inches
40.1 in 2.5 in
11 pts had SBP >135
Avg 145 mmHg
128 mmHg 12%
7 pts had glc >100
Avg 176 mg/dl
132 mg/dl 25%
Asheville CHIP 3
30 day results (N=20)
DAY 1 DAY 30 Decrease
4 pts had TG >150
Avg 241 mg/dl
184 mg/dl 24%
12 pts had LDL-C >100
Avg 131 mg.dl
110 mg/dl 16%
5 had LDL-C >130
Avg 152 mg/dl
127 mg/dl 17%
Asheville CHIP 3 and 4
80 day results (N=37)
• Weight loss 13.8 lbs/person. 509 lb total
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Asheville CHIP
(N=86)
• Total 1185 lbs weight loss = 13.8 lb/person
Phase 4 Get Set for Success
Session 13 Become what you believe
Your DNA is NOT your destiny
Session 14 Anger Management – practicing forgiveness
Session 15 Re-engineer your environment
Phase 5 From Health to Happiness
Session 16 Stress relieving strategies
Session 17 Fix how you feel
Session 18 From surviving to thriving
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Text Book
Work Book
Cook Book
Pedometer
Water Bottle
Live More
Learn More
Eat More
Walk More
Drink More
The Participant Tool Kit
CHIP Food Philosophy
CHIP is not a vegan program! It is about making good choices.
It seeks to help people move from the left side of the spectrum to the right side.
NOTE: The science indicates that for disease reversal, plant based eating gives the best outcomes.
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Live Healthy Asheville
…and please refer patients to
CHIP
Lifestyle
Medicine
Opportunities
- Educational
- Professional
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Asheville CHIP 1
12 week results
• Weight Loss – 22 participants lost a total of 312 lbs
– Average weight loss 14.2 lbs/person
– 5 participants lost at least 10% of their body weight
• Blood Pressure – 6 people had SBP >140 at day 1
– Only 1 person had SBP >140 at 12 weeks
– Of those with BP >140 on day 1, the average SBP was 161. After 12 weeks their average was 130 (20% decrease)
Asheville CHIP 1
12 week results
• Glucose
– Insulin requirements dropped by >50% in insulin
requiring diabetics
– 12 had glucose >100 at day 1 (diabetic or “pre-
diabetic”)
– Those 12 pts had an 18.5% decrease in fasting blood
sugar
– Only 7 had glucose >100 after 12 weeks
Asheville CHIP 1
12 week results
• LDL cholesterol
– 8 people had LDL >130 on day 1 (US 50th percentile)
– 3 people had LDL >130 after 12 weeks
– The 12 pts with an LDL >100 at baseline had an average
reduction in LDL of 22.9% over 12 weeks
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Asheville CHIP 1
12 week results
• Health age
– Average 3.5 years gained per participant