Lifestyle Medicine:Campaign by American College of Preventive Medicine and American College of Lifestyle Medicine to Inspire Local Champions to Action

Slides adapted with permission from: Liana Lianov MD, MPH, FACPMEleanor Loomis, UC Davis Public Health ProgramMichael D Parkinson MD, MPH, FACPM

American College of Preventive Medicine

• Evidence based disease prevention and health promotion research policies, practice programs

• 2400 physician members engaged in preventive medicine practice, teaching, and research

• General preventive medicine, public health, occupational and environmental medicine, aerospace medicine

• For more information: www.acpm.org

American College of Lifestyle Medicine

• Advancing the field of lifestyle medicine, promoting excellence in clinical practice and advocating on behalf of medical and public policy issues related to the practice and promotion of lifestyle

• Physician and non-physician members

• An academy of ACPM

• For more information: www.lifestylemedicine.org

Overview• What is the role of physician interventions to promote

lifestyle change?

• What are the barriers and facilitators for integrating lifestyle medicine into primary care?

• What is lifestyle medicine?

• What are the core LM competencies?

• What are the next steps and how can you help?

• What are options for enhancing LM in your practice?

Leading Health IndicatorsHealthy People 2020

• Physical activity• Overweight and obesity• Tobacco use• Substance abuse• Responsible sexual behavior• Mental health• Injury and Violence• Environmental quality• Immunization• Access to health care

Behavioral Determinants• Virtually ALL of the top 10 leading causes of death in US

adults are moderately to STRONGLY influenced by lifestyle patters and behavioral factors

BEHAVIOR DISEASE

Tobacco Use

Physical Activity

Diet

Preventive Services

Heart Disease

Stroke

Cancers

Diabetes

Physician Counseling

• Evidence is mixed about impact of physician counseling on health behavior change (Cochrane)

• May be due to study design: Variety of health behaviors, interventions, application of approaches, length and intensity, statistical power

• US Preventive Service Task Force (USPSTF)

• In general, the recommendations are in favor of physician counseling

• Recommendations vary for specific health behaviors

USPSTF Recommendations

Behavior Recommendation for Screening and Behavioral Counseling

Tobacco Use A

Physical Activity I

Healthy Diet B (for at-risk patients)

Alcohol Misuse B

I- still need further studies in this area

Examples of the Impact of Physician Counseling

• Patients who make behavior change often cite that the physician’s advice influenced them (Galuska)

• Sedentary patients increased weekly walking exercises by 5 times when counseled by physician and received health educator booster call (vs. standard of care) (Calfas)

• Patients who were counseled to lose weight more likely to (Huang):

• Understand risks of obesity

• Understand benefits of weight loss

• Higher stage of change of readiness for weight loss

Current Rates of Health Behavior Advice/Counseling• Physicians often do not offer lifestyle as first line

prevention and treatment (Stafford)• Only 36% of obese patients are advised to lose weight

during regular exams• Only 52% of patients who already have obesity-related

co-morbidities are advised to lose weight

• Only 28% of smokers reported that health care professionals had offered them assistance to quit smoking in the past year (Partnership for Prevention)

Physician Barriers to Counseling

• Lack of time• Reimbursement issues• Insufficient confidence• Insufficient knowledge• Insufficient skills• Others?

• From previous examples• Patient’s note counseling has significant effect of

understanding and motivation• BUT physicians often provide insufficient guidance

Reimbursement• Private carriers and Medicare required to cover

preventive services given USPSTF “A” and “B” grades

• State Medicaid matching funds enhanced for following USPSTF recommendations

• Medicare Annual Wellness visit

• Numerous employer and worksite incentives and grants to improve health promotion programs

• Individualized prevention plans in Medicare

• Incentives for chronic disease patients in Medicaid

• Ornish and Pritikin lifestyle programs for eligible patients

CPTs Covered By CPTs Covered By Affordable Care Act Affordable Care Act

USPSTF Services Grade BUSPSTF Services Grade B97802 Initial 15 minute therapy to include initial assessment

and intervention, individual, face-to-face

97803 Reassessment and intervention, individual, face-to-face, 15 minutes

97804 Group (2 or more) counseling on obesity or healthy diet for 30 minutes

HPCS Codes Covered HPCS Codes Covered By Affordable Care Act By Affordable Care Act

G0270 Initial 15 minute therapy to include initial assessment and intervention, individual, face-to-face for Medicare patients

G0271 Reassessment and intervention, individual, face-to-face, 15 minutes, for Medicare patient

Examples of Tools for Physicians

• 5 A’s- Assess, Advise, Agree, Assist, Arrange

• Americans in Motion—Healthy Interventions (American Academy of Family Physicians)

• Healthier Life Steps (American Medical Association)

• Screening, Brief Intervention, Referral and Treatment (Substance Abuse and Mental Health Services Administration)

• Others

BUT WE NEED ADDITIONAL HELP…

Blue Ribbon PanelAmerican College of Preventive Medicine

American College of Lifestyle Medicine

American Academy of Family Physicians

American Medical Association

American College of Physicians

American College of Sports Medicine

American Osteopathic Association

How we raise the bar… Lifestyle Medicine

Competencies

Panel-Developed Definition of Lifestyle Medicine

LM is the evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life.

Examples of target patient behaviors include but are not limited to eliminating tobacco use, improving diet, increasing physical activity, and moderating alcohol consumption.

Field of Lifestyle Medicine

• LM recognizes the link between lifestyle medicine and health outcomes

• Uses science behind health behavior change

• Emphasizes value of lifestyle medicine prescriptions by physicians

• Emphasizes value of support of those prescriptions by other health professionals

LM Competencies- Summary

• Perform comprehensive lifestyle assessments

• Risk assessments

• Patient’s readiness to change modifiable risk factors

• Establish effective relationships and use national guidelines

• Use team approach

• Make referrals

• Use medical information technology to maximize lifestyle medicine care

• Promote healthy behaviors as foundation of health promotion and medical care

• Physician should personally practice a healthy lifestyle

Next Steps for Integrating Lifestyle Medicine

• Increase awareness about lifestyle medicine and the competencies

• Develop training programs• Adapt lifestyle medicine competencies to other health

professionals• Advocate for wide implementation into practice

Your Role• Integrate lifestyle medicine into your practice with easy first

steps• Serve as a local champion and advocate for integration of LM

services in settings such as your hospital, local medical society, and academic center

Act Now By…• Contact Liana Lianov, MD, MPH to be added to the group

webpage• Download LM advocacy materials• Give a talk focused on lifestyle medicine at a local grand

rounds or medial society meeting• Include a few slides about lifestyle medicine in your existing or

planned presentations• Enter your events on the tracking sheet (found on the group

webpage)

In Your Clinical Practice: With Every Patient

• Address lifestyle issues with every patient

• Remember that less than 10% of your patients are adhering to recommended healthy lifestyles and can be at-risk for several chronic diseases

• Prescribe lifestyle change as the first-line treatment for patients with chronic disease

Some Options to Consider for Your Practice

• Update lifestyle issues in the health maintenance section of the plan in your medical record notes for every patient

• Include a health assessment and readiness assessment for patients to complete in advance or in the waiting room

• Verbally address key questions with patients who have low literacy levels

• Identify and/or adapt questionnaires to your patient population—in terms of literacy level and cultural background

• Review responses in advance of visit, if possible, or during the visit to prioritize lifestyle areas which the patient is most ready to address

• Make sure support staff routinely collect lifestyle vital signs: waist circumference, BMI, physical activity level

Some Options to Consider for Your Practice

• Prescribe lifestyle change as first line therapy (rather than a supplement) for patients with chronic diseases and include it in the treatment plan

• Use patient registries to identify and prioritize patients in need of intensive lifestyle interventions

• Refer to other health professionals and community resources whenever these are available, financially feasible or covered by insurance

• Leverage worksite wellness and other community health promotion programs

References• Behavioral Counseling in Primary Care to Promote a Health Diet, Topic Page. December 2010. U.S. Preventive

Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiet.htm• Behavioral Counseling in Primary Care to Promote Physical Activity, Topic Page. December 2010. U.S. Preventive

Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsphys.htm• Brunner E, Rees K, Ward K, Burke M, Thorogood M. Dietary advice for reducing cardiovascular risk. Cochrane

Database of Systematic Reviews 2007, Issue 4. Art. No.:CD002128.DOI:10.1002/14651858.CD002128.pub3• Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counseling to promote

the adoption of physical activity. Prev. Med. 1996 May-Jun; 25(3):225-33• Counseling to Prevent Tobacco Use and Tobacco-Caused Disease, Topic Page. Novenmber 2003. U.S. Preventive

Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac.htm• Ebrahim S, Beswick A, Burke M, Davey Smith G. Multiple risk factor interventions for primary prevention of

coronary heart disease. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001561.DOI10.1002/14651858.CD001561.pub2

• Eilat-Adar S, Xu J, Zephier E, O’Leary V, Howard BV, Resnick HE. Adherence to dietary recommendations for saturated fat, fiber, and sodium is low in American Indians and other US adults with diabetes. J Nutr. 2008; 138(9):1699-1704.

• Flodgren G, Deane K, Kickinson HO, Kirk S, Alberti H, Beyer FR, Brown JG, Penney TL, Summerbell CD, Eccles MP. Interventions to change the behavior of health professionals and the organisation of care to promote weight reduciton in overweight and obese adults. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD000984.DOI:10.1002/14651858.CD000984.pub2

References• Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising ovese patients to lose weight?

JAMA. 1999;282(16):1576-1578.• Healthy People 2020. Determinants of Health, ed. USDHHS. Washington DC: US Department of Health and Human

Services.• Huange J, Yu H, Marin E, Brock S, Carden D, Davis T. Physicans’ weight loss counseling in two public hospital

primary care clinicas. Acad Med.2004;79(2):156-161• Interventions to Promote Physical Activity and Dietary Lifestyle Cahnges for Cardiovascular Risk Factor Reduction

in Adults, A Scientific Statement From the American Heart Association, Circulation. 2010;122:406-441• Leading Health Indicators. www.health.gov/healthypeople/ (last accessed 2 December 2010).• Lianov L, Johnson M, Physician Competencies for Prescribing Lifestyle Medicine, JAMA. 2010;304(2):202-203• Mokdad Ah, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA.

2004:291(10):1238-1245• Partnership for Prevention. Preventive Care: A National Profile on Use, Disparities, and Health Benefits.

Washington, D.C.: Partnership for Prevention. August 2007.• Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, Topic Page. April

2004. U.S. Preventive Services Task Force. http://www.uspreentiveservicestaskforce.org/uspstf/uspsdrin.htm• Soni A. Personal Health Behaviors for heart Disease Prevention Among the US Adult Civilian Noninstitutionalized

Population, 2004. Rockville, Md: Agency for Healthcare Research and Quality; March 2007. MEPS statistical brief 165.

• Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physican actvities related to obesity management. Arch Fam Med. 2000;9(7):631-638.

Web Resources:Michael Parkinson: Healthcare Reform, Preventive Medicine and the Future of Patient Care.http://www.acpm.org/MSS-webinars.htm

Liana Lianov: Lifestyle Medicine Approaches to Effective Employer Health ad Wellness Initiatives.https://live.blueskybroadcast.com/bsb/client/CL_DEFAULT.asp?Client=446569&PCAT=2719&CAT=2719

Liana Lianov: Prescribing Lifestyle Medicine http://www.medscape.com/viewarticle/747743