Slides adapted with permission from: Liana Lianov MD, MPH, FACPM

1. 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, FACPM Eleanor Loomis, UC Davis Public Health Program Michael D Parkinson MD, MPH, FACPM

2. 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

3. 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

4. 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?

5. 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

6. 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 Heart Disease Physical Activity Stroke Diet Cancers Preventive Services Diabetes

7. 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

8. USPSTF Recommendations I- still need further studies in this area

9. 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

10. 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)

11. 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

12. 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

13. CPTs Covered By Affordable Care Act USPSTF Services Grade B

14. HPCS Codes Covered By Affordable Care Act

15. 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…

16. How we raise the bar… Lifestyle Medicine Competencies Blue Ribbon Panel American 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

17. 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.

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

26. 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.

27. 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