Hello, and welcome to the topic of lifestyle medicine. My name is Dr. Seema Sareen, and together we'll talk about lifestyle modification, wellbeing programs, and lifestyle approaches to the prevention of disease. After this lecture, you'll be able to define lifestyle medicine and its six pillars, which are nutrition, exercise, sleep, stress management, cultivating positive relationships, and avoidance of risky substance use. You will be able to use the fundamental principles of behavior change, as well as assessments and interventions that are required when supporting your patients to adapt to positive change. We will discuss how and where lifestyle medicine fits into practice, with evidence supporting its use through major national guidelines for prevention, treatment, and even reversal of chronic disease, such as cardiovascular disease, hypertension, obesity, type 2 diabetes, and cancer, which we know are the top killers in the US. Lastly, we'll cover how it not only improves population health, but also supports provider wellbeing, enhances patient experience, addresses health disparities, and reduces cost. So let's get started. What is lifestyle medicine and why is it important? Chronic disease is the leading cause of death and disability in the US. Rates of chronic disease have never been higher. In fact, it is so common that more than one half of US adults have at least one chronic disease, and these diseases count for 90% of healthcare spending. According to the World Health Organization, 80% of chronic diseases like stroke and type 2 diabetes, and 40% of cancers could be avoided primarily with improvements to diet and lifestyle. That is why lifestyle medicine is so critical to our current and future health. As defined by the American College of Lifestyle Medicine, lifestyle medicine is a medical specialty that uses therapeutic lifestyle interventions as a primary modality to prevent, treat, and potentially reverse chronic conditions, including, but not limited to, the diseases we talked about, cardiovascular disease, type 2 diabetes, obesity, and the like. Lifestyle medicine certified clinicians are trained to provide and apply evidence-based whole person prescriptive lifestyle change to treat patients, and when used intensively, often even reverse these conditions. There's six basic pillars of lifestyle medicine that impact mental, emotional, and social health, which improve optimal health and wellbeing. They are a whole food plant-based diet, which is a predominant eating pattern, regular movement and physical activity, getting restorative sleep, controlling and managing our stress, avoidance of risky substances that include smoking, vaping, eliminating or limiting alcohol, and other substances like marijuana and drug use, and lastly, cultivating positive social connection. There are six core principles that help individuals be healthy. It's simple, powerful therapy. However, it does take work and dedication to incorporate these pillars effectively into daily life. So let's break down some key strategies for incorporating behavior change into your patient's lifestyle. The first one here is to listen, understand a patient's current state and what has worked with them in the past. You can think about how to capitalize their strengths, and you can help patients link healthy behavior with positive emotions and help find the patient's why, or the main reason for adopting positive changes. A great way to do this is through motivational interviewing. Motivational interviewing, or MI, is a patient-centered collaborative counseling approach. It helps strengthen patient's motivation to improve behaviorally influenced health problems. It improves treatment adherence and helps to optimize medical interventions to help improve patient quality of life. Using motivational techniques such as empathy, asking open-ended questions, reflective listening and affirmations can effectively guide patients towards that positive behavior change that we would like them to attain. This helps them explore the benefits and the challenges and develop a plan that works for them that aligns with their motivations and goals. It involves engaging patients with a collaborative conversation, helping them explore their own motivations for change and how they best can achieve them. For example, you can help link getting a good night's sleep with improved mood the following day, or exercise with an improved night's sleep. You can also use motivational interviewing for a multitude of things. Some reasons why that I found in practice patients may wanna play with their grandchildren or they wanna be fit enough to take that vacation overseas. They may wanna avoid complications of chronic disease. All are wonderful reasons to make those behavior change. You can go back to that patient's why throughout their health journey and address specific changes to reach that overarching goal that they have. Sometimes it's important to understand that a strict diet or an exercise program is not sustainable. For example, when a person feels deprived or hungry, they may overindulge and actually eat more calories than necessary or eat more calories that they normally don't eat. So it's important to consider focusing on more, not less. So what they should eat, for example, such as more nutrient dense foods that are whole and plant-based. Exercising more, for example, incorporating more movement throughout the day rather than focusing on not eating that piece of cake. You wanna provide a complimentary environment for patients to understand your goals as a practitioner providing handouts, tools, resources along their journey. You can set your office up to really support lifestyle change with resources and education that they can check out, create classes and other learning opportunities and collaboration opportunities with yourself and your staff depending on what the patient population you serve's needs are. Be prepared to provide that evidence that supports their goals, whether it be a healthy and nutrition diet, exercising more or developing social relationships. You also wanna make sure that you provide prescriptions that are smart, S-M-A-R-T. Those are specific, measurable, attainable, realistic and time-sensitive. For example, if a person wants to move more, you don't wanna just say, hey, I think you need to move more, let's do that and then move on to the next piece that you wanna talk about. Instead, you wanna guide them to a smart prescription such as I'll walk 30 minutes on Tuesdays, Wednesdays and Saturdays after lunch for the next two weeks. You also wanna manage expectations. Make patients' choices about what to eat. Patients make choices about what to eat every time they sit down at the table, for example. So there will be challenges, but it's important to celebrate progress and not aim for perfection. You also wanna understand their social determinants of health their limitations, challenges and strengths. So these are just the general guidelines and pillars for all the behavior changes that we'll discuss today. The first lifestyle medicine pillar is nutrition. There has been extensive scientific evidence supporting the use of full predominantly plant-based diets. It is an important strategy in the prevention of chronic disease, treatment of chronic condition and in intensive therapeutic doses, a plant-based whole food diet can actually even reverse chronic illness. Nutrient dense foods are ones that are high and under consumed calories and low and over consumed calories. The recommendation is to eat minimally processed nutrient rich foods that meet recommendations for protein, fiber, vitamins and minerals, but are low in saturated fats, added sugars and sodiums. And those foods are the whole food plant-based items which we'll talk about in just a moment. So the gold standard as agreed upon by lifestyle medicine practitioners is a whole food plant-based diet which provides the greatest health, promotion and disease risk reduction. Among the benefits of a healthy eating pattern, it's low cost, it's low risk, it leads to lower morbidity and mortality. It may allow for reduction in doses and types of medications such as the ones for hypertension and obesity. Oftentimes we'll have to scale back diabetes medications or hypertension medications as they adapt these positive lifestyle changes. It also may lead to the avoidance of procedures like coronary catheterization procedures because their risk of cardiovascular disease goes down and we'll see later the evidence behind their arteries becoming more patent. It's also good news for the environment requiring lower greenhouse gases, fresh water and land use. Thus an assessment and education on nutrition should be done at every preventive visit. So what does this diet entail? We all know that an unhelpful diet is a leading cause of disability and death globally. But there's some confusion, however, in popular media regarding which dietary intervention is most appropriate. And I'm sure you all are familiar with the multitude of diets out there between Atkins and dash diets and the like. But when you look at major medical professional organizations and governmental bodies, you see that they're all in alignment. They emphasize unrefined plant foods for the prevention and treatment of chronic disease and health promotion. In fact, the American College of Lifestyle Medicine published a paper in the journal Advances in Nutrition that reviewed dietary recommendations worldwide from clinical practice guidelines over the past 10 years. It included 78 clinical practice guidelines published between 2010 and 2021 that address nutrition for a variety of health conditions as well as for general health promotion. The guidelines most frequently encourage the intake of three food groups, vegetables, fruit and whole grains. They also encourage the intake of legumes, pulses, any nuts and seeds, low-fat dairy, and any fish or seafood. For food groups that were discouraged, the guidelines most frequently included red meat, processed meat, refined grains, and fatty meats. So now that we know what a healthy diet entails, how do we address and assess patients to get them to adapt healthier eating habits to promote health in practice? So the first thing is we wanna understand the current state of our population. We understand that three out of four Americans, unfortunately, do not eat a single piece of fruit in the day. Nearly nine in 10 Americans do not eat the minimum daily intake of vegetables that's needed. More than half of Americans are over consuming calories, added sugars, sodium, saturated fats, and in turn, we're not eating enough nutrient dense foods, like foods that contain calcium, fiber, magnesium, potassium, and vitamins A, C, D, E, and K. So even though about 73% of Americans report that they're fairly focused on healthy eating, they actually are not as evidenced by the data. So it's important to know it's not just about choice and change. There's a lot of social determinants to keep in mind and environmental factors that create barriers to nutrition, exercise, and adapting the rest of the lifestyle medicine pillars as well. One of the major challenges that lifestyle medicine practitioners face is how to talk to patients about these pillars, including healthy eating. We have to talk to them to support them in creating truly healthy choices, especially if they think they're already eating healthy. The solution is assessment, education, and creation of a program that works within your individual practice with your individual patients. You wanna address ideal eating patterns, understanding, collective strengths, and challenges. So you wanna obtain a nutrition history. Options include questionnaires on how many fruits and vegetables do you eat a day? How much fast food are you eating? How many processed foods do you take or package foods? How much are you eating out? What kind of sugary sweetened beverages are you taking in daily? To a 24-hour food blog. Once you assess the patient and understand how well or where opportunities lie to improve their nutrition status, you wanna use lifestyle and evidence-based treatments to improve what they're doing. You can use the social determinants of health as well and understand their biometrics, their labs, their cholesterol levels, as well as their blood sugar, their body mass index, and their waist circumference. After you do the nutrition-based health history and dietary assessment, that individualized, personalized plan is important. And to do so, you can write a prescription. And that is something that we, as practitioners, are pretty well-versed in, writing a prescription for a medication or a referral for a specialist. But we wanna provide a prescription for nutrition and all the lifestyle medicine pillars, for example. You wanna include the type, amount, and frequency, or TAF, to be as specific as possible. You wanna include things like ways to incorporate cognitive behavioral therapy, team approaches, and referral to specialists if needed. You wanna make the intervention smart, so specific, measurable, attainable, realistic, and time-sensitive. And you wanna understand the patient's preferences, what their limitations are, what their budgets are. So, for example, if they hate broccoli, it may not be a great idea to come up with a solution that incorporates broccoli. Or if they are on food stamps, for example, you want to think about foods that are easily accessible, that are less expensive. A good solution may be to provide a list of healthy items from the dollar store, along with recipes, put them together for a simple plant-based dinner that they could start with once a week. At our practice, sometimes we'll incorporate and coordinate with patient groups and provide education through webinars. There's also programs like Walk with a Dog or programs where you can talk and do field trips to grocery stores, for example. And that way you're partnering with the patient, you're partnering with the community as well, and you're providing those interventions and ongoing support and motivation that is needed. That's why step three is so critical, to provide those ongoing assessments, see how they're doing, and then troubleshoot as needed. The next pillar is exercise. The benefits of exercise are numerous, from reducing mortality risks from cardiovascular disease to improving quality of life across the entire lifespan. It's estimated that only one half of American adults engage in regular physical activity. What we really need to be doing is light or moderate intensity activity. So when you're thinking about light or moderate activity, that is when, if you're exercising, you could talk to a friend, but you can't sing. And you wanna do this for at least 150 minutes a week. Examples include walking, jogging, gardening, biking, or you could do vigorous intensity exercise where you wouldn't even able to be talking to a friend, you can't even maybe say a few words if you're moving that fast. And the good thing about vigorous intensity exercise is you need to do that at least only 75 minutes per week. Unfortunately, physicians and healthcare professionals have not frequently leveraged their important influencing powers when it comes to advancing regular physical activity in their patient population. So you can get issues that arise such as loss of muscle mass, increased weight gain, increased susceptibility to chronic disease. Exercise also has an impact on our immune system as well. In fact, there's data to support a clear inverse relationship between moderate exercise training and illness rates. So it's important to talk to your patients about exercise and not only the aerobic component, but include strength training or resistance activities at least two times a week and flexibility and balance. That is key to ensure that we're not hurting ourselves, we're able to do multiple things, like reach that picture up on the top shelf or that legume jar on the top shelf and be able to put it down, raise our grandchildren and move through life without hurting ourselves, maintaining flexibility and stamina. So how do we do this? How do we assess exercise? We wanna assess it at every visit. You can do something called exercise vital signs which can be a part of your electronic medical record. And if not, you can keep that as part of your daily intake for patients. A great 10 second assessment is to simply ask people how many minutes of exercise do you do a week? When evaluating your patient population you wanna include a full objective assessment, include biometrics, labs, health history, for example, low HDL cholesterol which are the good cholesterol levels are strong predictor of cardiovascular disease risk and can be improved with regular exercise. You also wanna create a personalized intervention plan next. Once you understand what their strengths, limitations and current state of movement is, you can keep in mind their environment, their beliefs and their social determinants of health and think about their own health goals when creating a plan to encourage movement throughout the day. Walking is of course a great intervention and is often very accessible. There's also stationary cycling, jogging, swimming involving large muscle groups that can be sustained over time as needed. When thinking about writing a prescription for exercise, you want to establish a progressive plan for each variable of exercise, type of exercise, frequency, how long they'll do the exercise and how many times per week. You can also use readiness to change models as they progress. So if they're in the pre-contemplation stage, maybe they're not ready to start exercising yet, you can start with an education program or they are thinking about starting exercising but haven't gotten around to that yet, you can give them options for free classes in the area using things like weights like water bottles, for example or books is a great way to do weight bearing exercises. When they're in the action stage, they're probably currently acting or they may need to maintain it if they're already on an exercise program over the last six months to a year. So you really want to tailor that prescription to their individual needs. You also want to take inventory of their environmental conditions, their facility and equipment access, safe streets, for example and you want to provide them with appropriate follow-up and ongoing assessments asking at every visit how many minutes of exercise they do per week. You can also determine recommended referrals such as do they need a cardiovascular risk assessment prior to starting an exercise program or they may need coaching or behavioral services for exercise specialists. They may need physical therapy or other adjunctive specialists that involving the other pillars of lifestyle medicine like a dietician for metabolic issues, mental health professionals as determined by appropriate screening as well. A great way is to have them start in terms of follow-up and tracking their progress through a fitness diary. There's also all kinds of wearable smartphone apps and other non-wearable technology for them to log exercise and movement throughout the day. So throughout the journey, you want to talk about primary barriers as they go along, celebrate successes and strategize tactics to address over time. Be sure to provide teaching resources, intensity measurements. There's one great resource on the American College of Sports Medicine website which has templates and other items you can use when adapting exercise and movement into your daily intake and into your daily routine when seeing patients. The next pillar is sleep. We all know that sleep is necessary for human life and high quality restorative sleep is essential for health and wellbeing. Unhealthy sleep is associated with the most common causes of premature death and disability and in many cases can be directly responsible. Thinking about when you're sleep deprived, how well you function. Lifestyle medicine practitioners support the American Academy of Sleep Medicine recommendations for about seven to nine hours per night for optimal health. Excessive sleep is associated with poor health outcomes including stroke and other conditions. And of course, children require more sleep depending on their age. When optimizing sleep, you want to think about establishing a regular sleep schedule avoiding food right before bedtime, especially high sodium foods, minimizing light, including blue light from devices and getting into a good sleep hygiene routine. So how do we address sleep in practice? Step one includes checking for primary sleep issues and their onset, frequency, duration, severity and exacerbating factors. You want to think about previous treatments. For example, if they've had symptoms of a sleep disorder like obstructive sleep apnea, restless leg syndrome, other factors that can affect sleep like mental health, medical conditions, current medications and supplements as well as substance abuse and use. These all can affect and disrupt sleep a great deal. You want to look at sleep hygiene practices as well and daytime problems. For example, are they falling asleep during the day? Step two, you want to personalize their plan. When you go back to doing their sleep history, you want to think about specific questions for sleep like what is their typical bedtime and wake up time? What type of work do they do? Is it shift work? For example, do they take the night shift often? What's the quality of their sleep? Are they refreshed when they wake up? Do they experience symptoms of chronic insomnia or restless leg syndrome? Do they nap throughout the day? What type of medications and supplements do they take? And when do they take their medications? For example, diuretics can cause people to have to get up at night several times to urinate. These focused queries can help you develop a true lifestyle medicine effective intervention. You want to provide prescriptions that are smart, of course, using behavioral interventions such as relaxation therapy, sleep restriction as needed, really optimizing the time that they're in bed to sleep. Stimulus control and cognitive therapy can also provide excellent adjuncts to a sleep intervention. You can refer to specialists as needed, especially if they have comorbidities. For example, if they need a sleep study for obstructive sleep apnea, you want to continue to partner with the patient, providing those brief interventions and long support and motivation as needed, just like the rest of the pillars and supporting them with their progress. Some referral criteria you can use if a patient has uncontrolled or poorly controlled comorbid psychiatric disorders, substance use disorders, dementia, neurocognitive disorders, or traumatic brain injury, they may need referral to a specialist. The next lifestyle medicine pillar is stress management. Stress, when appropriate, can help us improve health and productivity. For example, the stress of doing a presentation or making it on time to enjoy a picnic with friends. But the chronic stress of modern society has really made it more difficult to practice healthy lifestyle habits, and it can exacerbate health issues, such as cardiovascular disease, insulin resistance, sleep deprivation, depression, anxiety, weight gain, and more. Chronic stress can cause poor overall quality of life, decreased job and school performance, and lead to mental and physical health issues. Communities of color are often disproportionately affected by stress, and this is caused by many different factors, including bias and discrimination, in addition to the social drivers of health. And that's why we must, when we're looking at stress management, be aware of those items and conditions in the places where people live, work, and play. Understanding that landscape is critical for each person, and partnering with each individual patient to recognize negative stress responses, identify coping mechanisms, and using stress reduction techniques is really important. As you can see on the right side of the screen, there are some things that you can do to promote wellbeing, and we'll discuss that right now. Positive psychology is a great model of wellbeing that can promote great stress management. The acronym that you see on the screen is called PERMA. It contains five elements that contribute and encapsulate the experience of thriving and flourishing. Number one is P, positive emotion. Cultivating this positive emotion, such as happiness when one attains a goal, when danger has been avoided, for example, or the contentment when someone's satisfied with the state of present affairs. Number two is engagement. That brings a positive outlook on life that is associated with longevity as well. So being fully absorbed in the present moment with blissful immersion, that strengthens intelligence, skill, and emotional capacity like, for example, when you're learning a new dance move. Relationships are next. Relationships are one of the most important aspects of life. It is the development of positive social connections with other humans, both emotionally and physically, and it's even part of its own pillar, which we'll discuss shortly. Meaning is connecting one's daily life to a broader, larger narrative, which can be facilitated through a sense of belonging and purpose. The last is accomplishment. That is having the ambition to and accomplishing realistic goals, which produces a sense of efficacy, satisfaction, and the experience of difficulty and challenge on the path to accomplishment. On the right-hand side of the screen, you will see positive psychology interventions that are supported by evidence, and these are my favorite ones to go through when working with patients. You want to help them find and improve their signature strengths, expressing gratitude, counting blessings, savoring the pleasing things in life. For example, what I ask patients to do is write down how they want to be remembered. If they can't figure out what their strengths are in improving those signature strengths, they can ask friends and family to describe what they think that are their greatest strengths. Thinking about one's happy state frequently is a great one. For example, you can encourage patients to look back through their photos of great memories or celebrations, vacations, and special occasions. Also doing activities that they feel meaningful is key. Volunteering in a food kitchen, for example, or helping in a community garden. Lastly, connecting and interacting with others is key, not mainly through social media, and you want to help patients identify ways they can spend time within their social networks that matter, their family, their social groups, their sport groups, their spiritual groups. But these are some top ways you can help your patient population optimize their stress. So how do you systematically incorporate these stress management techniques into practice? It's the same principles we've talked through for the previous pillars. For assessment, you can use these measurement tools such as a psychological stress measure series. There's also the brief resiliency scale score. There's trans-theoretical models for change to see where they are and try to find patients that are most ready for certain tactics and strategies. In summary, you really want to tailor interventions to the specific needs of your population and your individual. So sometimes patients may not be ready for change. For example, if they're not ready for change, it's a great opportunity to talk about awareness of the issues at hand and education. You can teach them how to uncover motivational internal motivations. Listing pros versus cons lists as well can help them. And it can also help them move someone along the spectrum of change to get them to that action point of addressing stress management. Using a patient-centered approach and listening carefully to their sources of stress is key. You can talk about how they've displayed any levels of resiliency in the past and what role social connectivity has had and helped in their situations, in their past and present situations. To manage stress is important. You want to think about how they self-monitor and through motivational interviewing, you can use practical examples to create smart goals for themselves. You can use things like mind and body practices, meditation and breathing. There are several apps that patients can use to optimize stress management as well. Thinking about those lists that we discussed in the previous slide and writing a prescription for one of those. I like to prescribe breathing twice a day for patients and it only can take 30 seconds at the beginning, at the end of their week for the next two weeks before and after work, for example. Another goal is to have them thank a person in their life each day by text or in person right before they get lunch every day for the next two weeks. Spending time in nature is also great for stress management and combines the pillar of exercise as well. So when devising lifestyle medicine interventions, you want to think about the pillars together. Exercise helps with stress management. Avoiding risky substances can help with sleep. Social connections can be used to help patients get into an exercise routine or eat healthier. And then at each follow-up visit, you can lead with accountability, following up using that variety of communication techniques and then provider referrals as needed, especially when you uncover something like depression or anxiety and you need to refer to appropriate specialists. The next pillar is social connection. We touched about it when discussing stress management, but it's important to note that loneliness and social isolation pose a serious public health risk and affects a significant number of people in the U.S., putting them at risk for dementia and other serious medical conditions. In fact, a report from the National Academies of Sciences, Engineering, and Medicine points out that one third of adults ages 45 years and older feel lonely. Nearly one quarter of adults ages 65 years and older are considered to be socially isolated. So that's really important to remember. And according to the CDC, social isolation actually increases a person's risk for developing premature death from all causes that may rival the risks of smoking, obesity, and physical inactivity. It actually increases dementia risk by about 50% and is associated with higher rates of depression, anxiety, and suicide. On the other hand, research shows that having social connection is a key factor in human happiness and longevity. Social connections and relationships affect our physical, mental, and emotional health, including prevention of dementia, as we discussed earlier, and getting them more active and to older ages. In addition, people who are likely to adapt healthy behaviors of others and their immediate social networks also live longer. So if you have a healthy social group, you'll adapt their habits, including, for example, maybe moderate or eliminating alcohol consumption or optimizing exercise levels and optimizing diet, which just becomes a snowball effect to adapt more and more healthy living habits. Thus, it's important to address social connection with each one of our patients. And here's a great guideline to think about how much you should aim for. You should aim for at least one interaction per day with a meaningful person. There was actually a large study done to create a potential national health guideline for social connections where we could think who were at risk for social isolation. Ideally, you want to have social connections with six or more people a day, or at least four to five social times. That reduces the risk of abdominal obesity by 61%, hypertension by 41%. That's even adjusting for age, sex, race, body mass index, as well as other social and behavioral analysis factors in a study done by Yang in 2012. Having fewer than six close friends was linked to inflammation, metabolic and cardiovascular disregulation, which is pretty significant to think about according to this evidence. So really thinking about getting a diversity of relationships, roles, and closeness with mixed types of contacts from inside and outside the home is really key to optimizing social connection. You want to start with just one social connection a day and build that to the ideal level. So there's a number of different ways to do this. It's very important to quantify for social connection and loneliness when assessing patients. There's something called the Berkman-Sein Social Connection Network Index. That's a great resource. You can ask patients directly, making sure you ask open-ended questions using those motivational interviewing techniques, and making sure that it's patient-centered and culturally appropriate as well. In terms of evidence-based lifestyle intervention, formulate those SMART goals. And the CDC actually published some great tips for spending more quality time and creating opportunities to make more friends and spend time with family. That includes spending time with others in nature, expressing gratitude when you are with friends, colleagues, and even acquaintances, volunteering within a group or organization, getting involved in the community, and establishing connections, both big and small, for those around you. For example, thanking the person who makes your coffee in the morning. That counts as a social interaction. So those big and small connections really do mean a great deal and add to our longevity. What you can do today is perhaps text someone as you're going through studying for these boards and listening to these lectures, expressing your gratitude on how they helped to support you. Then there's step three. From a practitioner standpoint, you want to follow up appropriately, provide referrals and resources. There's many free classes, clubs, organizations, and volunteer places that could use extra help. These are excellent ways to cultivate deep, rich, varied social connections that are so key in health. The last pillar we'll talk about is the avoidance of risky substances. And this is something in medicine we definitely understand. Of course, tobacco, alcohol, and non-prescription medications have been shown to increase the risk of chronic disease and death. So it's very important as part of the lifestyle medicine pillars to address these chronic substance use issues for all of your patients. Lifestyle Medicine supports the National Institute on Drug Abuse's position on utilizing effective treatment models. That means mental health treatment to solve and resolve underlying triggers that may include counseling, medication-assisted therapies, and the use of other lifestyle medicine pillars, such as decreasing stress through exercise, healthy eating, and improved sleep, rather through risky substances. You can decrease stress through meditation and mindfulness that we discussed earlier, improving relationships. And it's important to note combination of treatments with multiple modalities, including support with medication, is actually shown to be more effective. For example, when you're looking at alcohol use, it's important to understand if your population does drink, drinking in moderation with one to two drinks or less per day for men, or one drink or less a day for women on days when alcohol is consumed. Even the American College of Lifestyle Medicine recognizes that for cancer prevention, it's best not to drink alcohol. And the research does show that the level of alcohol consumption that really minimized harm across all health outcomes is a zero amount of alcohol. So the less, the better for alcohol use, for example, and that goes with smoking and all risky substances as well. So how do we assess patients? As we know, alcohol and tobacco use are the most commonly used drugs in the world and do carry significant health risks. They are among the top causes of preventable deaths in the U.S. So we want to educate and assess for risky substance use and abuse. For substance use and for every pillar, you want to make your environment conducive to adapting healthy habits by supplying materials, resources, finding signs, and explaining that changing these habits can affect health greatly. And that's an important part of your visit and your philosophy as a provider. You want to designate a specific person, for example, to assess patients and health goals, flagging charts for at-risk patients, performing assessments as part of the intake process, providing resources, follow-up appointments, checking in with patients, and really standardize the process across all pillars, including risky substances use assessment. You want to have support and community. You want to have support and referrals as needed to detox and rehab units, for example. I'll have a slide on specific resources that you can share with your patients in just a moment, as well as a brief intervention called the two A's or five A's. Another important piece to think about with substance use and abuse is counseling. There are many different types of counseling available, including individual, group, and even telephone counseling, and there are medications needed to support abstinence and relapse to consider. Combining techniques really is best. For example, using counseling plus medication is more effective, according to the research. And at follow-up, you want to ensure accountability, record-keeping, and troubleshooting as well. These are the five A's and the two A's of smoking cessation. You can use this for all risky substances, as well as the other pillars. The five A's, which are on the right panel, is well-known, commonly used in clinical practice, and takes about three minutes to complete. It's ask, advise, assess, assist, and arrange for help. The American Academy of Physicians endorsed a two-step approach, which is the two A's, ask and act, and which only takes about 30 seconds. It involves asking patients about smoking behavior and acting to help them quit. It's the minimum strategy that can be considered for every patient who smokes, for example. Here is a list of helpful resources specific to risky substances and use and abuse that can help people of all ages and help them navigate the system. So, in sum, the time is now. You have the power to help your patients implement these six pillars and techniques to improve the health of each person, each community, and the population you serve. We know that six in 10 of American adults have a chronic disease, four in 10 have two or more chronic diseases, and that costs us $4.1 trillion a year in annual health care costs. So we can't afford not to address these pillars. The evidence shows us that the lifestyle behavioral counseling that we discussed at length throughout this presentation is a cornerstone for a variety of top conditions. According to the gold standard, the U.S. Preventive Services Task Force Guideline and the American College of Cardiology or the American Heart Association, they all recommend lifestyle changes to prevent disease. And you can see the list here from the U.S. Preventive Services Task Force. This is the 2019 ACC, American College of Cardiology, American Heart Association guidelines. They were released in 2019 and shows that it's critical to adapt lifestyle change as a part of primary prevention of heart attacks and other cardiovascular diseases. The JNC or the Joint National Community Guidelines for Hypertension also recommend lifestyle changes as an important component of therapy for treatment of hypertension. The American Association of Clinical Endocrinologists and the American College of Endocrinology also state that lifestyle optimization is essential for all patients with diabetes. They note that lifestyle optimization is multifaceted, ongoing, and should engage the entire treatment team. And here is one from the current guidelines for the American College of Cardiology, the Obesity Society, as well as the guidelines from the American Association of Clinical Endocrinologists. As you can see, lifestyle therapy is listed. This one is from the American Diabetes Association, which recommends, again, lifestyle behavior change using diet and physical activity to prevent type 2 diabetes for anyone at risk. So you're seeing the trends here with all major societies pointing to these essential lifestyle changes. For many chronic conditions, you'll find that lifestyle modifications are listed as the first line of treatment. This is from diabetes standards of care, for example. The American Institute for Cancer Research offers recommendations for cancer prevention that includes dietary and physical activity guidelines. And again, this sounds very familiar to the six pillars, particularly for nutrition and exercise that we discussed. This is from the World Health Organization. The six pillars of lifestyle medicine can reduce cognitive decline and dementia as well. In addition to prevention, treatment, and potential remission of a variety of chronic diseases, lifestyle is an important adjunct for many other therapies, such as the GLP-1 medications that are used for diabetes and weight loss. You also need behavior change in order for these therapies to work over the long term and potentially get rid of some of the medications that people are taking, including for weight loss medications, diabetes medications, hypertension medications, and the like. It also can assist surgery readiness, like orthopedic surgery, bariatric surgery, and heart surgery. Lifestyle medicine can also reverse disease. Dean Ornish's seminal study, which is a study that proved lifestyle intervention can not only halt progression of disease, but also reverse symptoms and damage from cardiovascular disease, was a key study. It showed that a low-fat vegetarian diet, ensuring appropriate exercise, avoidance of tobacco, and stress management techniques and exercises can reverse coronary artery disease. We say that a picture says a thousand words, and on the left-hand side, in 1996, you see this distal left anterior descending artery, which is moth-ridden and has very poor flow at the beginning of the study. By 1999, this is the same patient, and in doing those lifestyle changes, you can see the same angiogram showing beautiful flow without the use of a stent or any medical intervention. It was lifestyle intervention that created this dramatic effect. So, as you can see here, lifestyle medicine gives you greater health benefits. There's improvements in all of the following, hypertension, blood lipids, mental health, depression, reduced risk of Alzheimer's disease, musculoskeletal condition, certain forms of cancer like colon cancer and breast cancer, prostate cancer, to name a few, and even remission of type 2 diabetes. So, using lifestyle medicine in addition to practice, to your practice, you can really optimize and speed up positive outcomes, and that can be positive for your patient population. It can also improve provider health as well. A study found that practitioners who implement more lifestyle medicine in their clinical practice actually experience less burnout. It's also cost effective as well. These are just two types of cost savings that resulted from lifestyle medicine interventions. The study on the left is a summary of the CHIP lifestyle program at Vanderbilt University, which demonstrated an early return on investment for a diabetic cohort in the workplace setting. They saw a reduction of healthcare costs to the system for patients that was equated to a net savings of about $70,000. In the second long-term study, a health plan was used, and it was looked at cardiovascular disease and diabetes risk. They found that after five years of the program, there was decreased cholesterol levels, decreased blood sugar and blood pressure levels, and improvement in overall general health. They combined healthcare and productivity return on investment for the program at five years to be about $10 for every $1 invested. That's pretty significant right there. We all may know about the diabetes prevention program. This was a major multicenter clinical research study that was now adapted across the U.S., and that intervention involved a lifestyle change. A program focused on calorie reduction, increasing physical activity, and providing patients with a structured lifestyle change program. You can see that lifestyle actually reduced the incidence of type 2 diabetes more effectively than metformin or traditional therapy alone. In fact, it was a 58% reduction in incidence of type 2 diabetes. That's incredible, and that's a real-life example of lifestyle medicine in practice. Not only improving population health, which is what we want to do, but also reducing cost. Lifestyle medicine achieves that quintuple aim. It improves not only population health, but supports care team well-being. It enhances the care experience and provides great patient satisfaction and provider satisfaction. It reduces costs and advances health equity because we're looking at the holistic view of the patient, the social determinants of health, and determining appropriate interventions based on the patient's individual needs within their community. Today, we've explored the transformative potential of lifestyle medicine in patient care. We've seen how guiding our patients towards healthier life-child change can prevent chronic disease, enhance their well-being, and ultimately transform our healthcare system. As we conclude, remember this, each patient interaction is an opportunity to empower and inspire change. The path to better health not only lies in our prescriptions, but our everyday choices that patients make. So integrating these lifestyle medicine principles into practice is critical, not just as an adjunct, but as a foundational approach to patient care. By doing so, we can lead our patients towards healthier, more fulfilling lives and set the new standard in medicine. Together, we have the power to reshape the future of healthcare, one patient, one conversation, and one lifestyle change at a time. Thank you so much for your time, attention, and dedication. www.cdc.gov

lifestyle medicine

well-being programs

disease prevention

nutrition

exercise

stress management

chronic conditions

behavior change

motivational interviewing