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Teaching Doctors to Teach Patients about Lifestyle
by Kate Murphy
The New York Times
April 17, 2007
Everybody knows that diet,
exercise and other aspects of lifestyle play a significant role in health. But
the specifics are less well understood.
To what extent does lifestyle cause or contribute to disease and disability?
And what exactly is a healthy lifestyle anyway? There is much confusion about
what type of diet or exercise is best, not to mention how much sleep, stress or
sex is ideal. Nor is it clear how best to motivate people to change their
habits.
This lack of clarity has inspired a growing movement to inform health
professionals and patients about the importance of lifestyle in preventing and
treating disease. Its aims are to disseminate scientific research about what it
means to live well and to encourage doctors and other providers to incorporate
this knowledge into their practices.
Two years ago, a group of doctors founded an organization with the goal of
making lifestyle medicine a credentialed clinical specialty and a part of basic
medical training. Symptomatically treating disease without assessing patients’
lifestyles or offering them guidance on how to change is “irresponsible and
bordering on neglect,” said Dr. John H. Kelly Jr., president of the fledgling
organization, the American College of Lifestyle Medicine.
A professor of preventive medicine at the Loma Linda University School of
Medicine in California, Dr. Kelly said the group was formed because of people
like his uncle.
Given a diagnosis of heart
disease, the uncle had a stent surgically implanted to open a clogged artery
but received no advice on how he might change his lifestyle, even though
research shows that diet, exercise and stress management could greatly improve
his condition.
Dr. Kelly says lifestyle medicine is essential in fighting the national
epidemics of obesity,
diabetes
The Centers
for Disease Control and Prevention reports that 1.7 million Americans die
and 25 million are disabled each year by chronic diseases caused or made worse
by unhealthy lifestyles. And a 2005 study in The New England Journal of Medicine
predicted that average life expectancy in the United States would decline in the
next 20 years as a result of unhealthy lifestyles, reversing a trend dating to
the 1850s. The American College of Lifestyle Medicine has 150 members in a wide
array of specialties — nutritionists, ophthalmologists, gastroenterologists and
oncologists, among others. Helping their cause is a new publication, The
American Journal of Lifestyle Medicine, which appears every other month with
peer-reviewed research on the way daily habits affect health.
“Bottom line is we want to promote the science, education and practice of
lifestyle medicine,” Dr. Kelly said.
Lifestyle medicine proponents include researchers and clinicians from the
fields of medicine and public health. While they agree on the importance of
questioning patients about their lifestyles and giving tailored advice on how to
make improvements, there remains disagreement about who should provide such
counseling and with what sort of training. Nor is there a widely accepted
prescriptive approach for encouraging patient compliance.
“We know lifestyle interventions can be very powerful,” often more effective
than drugs or surgery, said Dr. JoAnn Manson, a professor of epidemiology at Harvard’s
School of Public Health and a member of the editorial board of the new journal.
“But we need to provide the scientific evidence on how to incorporate that
knowledge into practice.”
Doctors may vaguely recommend that patients lose weight or get more sleep,
for example, but they do not necessarily know how to help them do it.
Moreover, many physicians themselves have unhealthy habits that may prevent
them from offering advice.
Sleep-deprived doctors who scarf candy bars for lunch “tend to feel inhibited
in counseling others when they aren’t exactly setting an example,” said Dr.
Walter Willett, chairman of the department of nutrition at the Harvard School of
Public Health and a member of the lifestyle medicine college’s board of
advisers.
“Primary caregivers at least should have extensive training in lifestyle
medicine,” Dr. Willett said. “And it’s reasonable for there to be a medical
specialty” so patients can consult a trained practitioner who is certified as an
expert in the field.
Others say lifestyle medicine should be incorporated into every facet of
health care.
“I don’t think it’s appropriate to segment it off,” said Dr. Thomas W.
Rowland, chief of pediatric cardiology at Baystate Medical Center in
Springfield, Mass., who routinely counsels children and parents on how to adopt
healthy lifestyles. “It needs to be a fundamental part of every doctor’s
practice” and therefore a part of every medical school’s core curriculum.
Still, he acknowledges that there are significant obstacles, because
lifestyle counseling is time-consuming and is seldom compensated by Medicare or
health insurers.
Reimbursement is a chief concern of the American College of Lifestyle
Medicine. The group plans to lobby Congress to that end. And it wants Congress
to require that patients be informed about the relative effectiveness of
lifestyle changes before receiving certain medications — including blood
pressure, acid reflux and cholesterol
drugs — and before undergoing procedures like back surgery, bypass surgery and
stent placement.
But first, Dr. Kelly said, patients and insurers need to be assured of the
professionalism of lifestyle medicine providers.
Some doctors say the movement suffers from fringe elements that advocate
unproven strategies like strict vegan diets and daily saunas.
“Lifestyle medicine has to be scientifically based to distinguish it from all
the quackery out there,” said David R. Brown, senior behavioral scientist in the
division of nutrition and physical activity at the disease control center.
Dr. Kelly agreed. “We need to have a certification process in place with
rigorous, evidence-based standards,” he said.
Proponents of lifestyle medicine are quick to distinguish it from alternative
medicine. “This is mainstream medicine supported by mainstream medical
research,” said Dr. James M. Rippe, associate professor of cardiology at Tufts
University School of Medicine and the editor of The American Journal of
Lifestyle Medicine. “The lifestyle medicine movement is not an anti-procedure,
anti-medication movement.”
Rather, he said, it advocates that lifestyle interventions become part of the
doctor’s arsenal in fighting disease: “For too long we’ve ignored our most
powerful weapon when it should be our first line of defense.”
and cardiovascular disease. “We cannot solve the health problems of society
unless we change our focus from acute, episodic care to health promotion and
wellness — lifestyle medicine,” he said.
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