Q&A: How to integrate lifestyle medicine in primary care

Key takeaways:

• A new consensus statement provides a roadmap for integrating lifestyle medicine into primary care settings.
• The first step to integration is learning about the pillars of lifestyle medicine.

The American College of Lifestyle Medicine has recently published an expert consensus statement outlining best practices for implementing lifestyle medicine in primary care.

The expert panel that developed these practices define lifestyle medicine as “a medical specialty that prevents, treats and, in some cases, reverses chronic disease by utilizing six pillars of active intervention that promote a predominantly whole food, plant-based dietary pattern, adequate physical activity, restorative sleep, stress management, positive social connections and avoidance of risky substances,” Meagan Grega, MD, DipABLM, FACLM, first author of the consensus statement and co-founder and chief medical officer of the Kellyn Foundation, told Healio.

The panel is the first to describe how to integrate lifestyle medicine into primary care, according to a press release. The diverse group of health professionals who practice lifestyle medicine reached consensus on 65 statements across categories like provider education, delivery models, vital signs and the evidence base for lifestyle medicine.

Healio spoke with Grega to learn more about the consensus statement, what primary care physicians should know about lifestyle medicine and more.

Healio: How did this consensus statement come to be?

Grega: The impetus for the expert consensus statement (ECS) “Lifestyle Medicine for Optimal Outcomes in Primary Care” originated from perceived gaps identified by the leadership of the American College of Lifestyle Medicine. Those gaps were in the literature pertaining to lifestyle medicine in primary care, and the practical challenges encountered by primary care clinicians while exploring ways to implement lifestyle medicine as a foundational component of their patient care. The goal of the ECS was to identify best practices for clinicians integrating lifestyle medicine into the primary care setting to achieve improved outcomes. The anticipated audience for the ECS includes primary care clinicians, but also health care executives, payors and policymakers, with the goal of accelerating lifestyle medicine implementation into primary care at scale.

Healio: What were some of the most important points the experts agreed on?

Grega: The expert consensus panel reached consensus on 65 statements relating to lifestyle medicine in primary care. Some of the fundamental areas of consensus include both the importance and the feasibility of integrating lifestyle medicine approaches into primary care settings; the critical requirement of incorporating lifestyle medicine concepts into all aspects of health care clinician education, including undergraduate/graduate medical education, allied health provider training and continuing education opportunities for practicing clinicians; and the vital role played by a multidisciplinary team in successful implementation of lifestyle medicine services.

Additional areas of consensus involved the agreement that lifestyle medicine can identify and address the root causes of chronic disease, leading to improved patient outcomes and satisfaction and reduced clinician burnout; that clinicians should utilize strategies such as motivational interviewing and assessment of the patient’s readiness to change as part of shared decision-making around health behavior goals while encouraging patients to be active participants in their care; and acknowledgement that social determinants of health can lead to unhealthy behavior choices and health disparities, making it absolutely essential that lifestyle medicine recommendations are in alignment with and respectful of a patient’s cultural background and lived experience.

Another significant area of consensus concerned the importance of the patient’s social support system — family, friends and community — in the success of lifestyle medicine interventions and endorsed the availability of lifestyle medicine programs in community locations in addition to conventional health care facilities to make participation as convenient and experiential as possible for patients and their families.

Healio: What does implementing lifestyle medicine in primary care look like? Would PCPs need to restructure their practices?

Grega: There are many varied approaches to implementing lifestyle medicine in primary care, including basic assessment and counseling about health behaviors, which is primarily intended to raise awareness and educate patients regarding how their lifestyle choices may be impacting their risk of chronic disease; therapeutic lifestyle medicine interventions, which are intended to address the root cause of chronic disease through behavior change; and intensive lifestyle medicine interventions, which are intended to reverse or promote remission of chronic disease.

One of the strengths of primary care is the longitudinal and coordinated nature of the relationship between the patient and the clinician, which is the ideal situation for implementing a lifestyle medicine approach that is focused on long-term behavior change to prevent, treat and even potentially reverse chronic disease. Current clinical practice guidelines for management of cardiovascular disease, type 2 diabetes, hypertension and other chronic conditions list healthy lifestyle behaviors as part of the recommended treatment strategy. Implementing lifestyle medicine into primary care involves the use of screening tools to assess the patient’s current health behaviors in the areas of nutrition, physical activity, sleep, stress management, social connection and harmful substance exposure and then working together to identify achievable steps toward optimizing those lifestyle choices.

Motivational interviewing and SMART goals (Specific, Measurable, Achievable, Relevant and Time-bound) are excellent strategies to utilize while pursuing health behavior change. Providing patients with “homework assignments” that encourage them to learn about each of the pillars of lifestyle medicine between appointments with their clinician is an efficient and impactful adjunct to goal-setting discussions during patient visits. Frequent follow-up with the patient by a member of the health care team during the beginning stages of the behavior change journey is beneficial, providing ongoing guidance and accountability. The follow-up contact can be in person or virtual and can be asynchronous in the form of text/email/patient portal messages. Shared medical appointments where a group of patients with similar diagnoses gather with the health care team for education, goal-setting and group support are also an effective way to integrate lifestyle medicine into the clinic workflow. Having access to a multidisciplinary team, either within the practice itself or as a referral network, is an important component of successful lifestyle medicine implementation.

Healio: What resources would PCPs require to implement lifestyle medicine into their practice?

Grega: The first step is skill-building and training on the competencies of the pillars of lifestyle medicine, which can be accessed through the American College of Lifestyle Medicine (ACLM) educational resources and attending conferences on the topic of lifestyle medicine. For physicians, it is also beneficial to pursue board certification in lifestyle medicine through the American Board of Lifestyle Medicine certification exam. ACLM has an excellent board review course that provides a deep dive into the fundamentals of lifestyle medicine. Other health professionals can also achieve certification in lifestyle medicine. Additionally, ACLM offers 5.5 hours of complimentary lifestyle and food as medicine continuing education courses in partnership with the White House Conference on Hunger, Nutrition and Health.

The next step is to create your library of lifestyle medicine patient resources (handouts, recipes, recommended books/movies/websites/TEDx talks, etc) and build your multidisciplinary team. The composition of the team is flexible depending on the capacity of the practice, but can include dietitians, behavioral counselors, exercise physiologists, health coaches, physical therapy/occupational therapy, nurses, pharmacists and medical assistants. The multidisciplinary team can be a referral network, or it can consist of professionals within the practice. ACLM member resources are a great place to look for patient-facing handouts and other tools to utilize in your practice.

Choosing screening/assessment tools for each of the pillars of lifestyle medicine is another component of the process of implementing lifestyle medicine in practice. There are several validated tools mentioned as part of the ECS, and there are additional options available.

Healio: How does this benefit patients and their providers?

Grega: Lifestyle medicine is intended to complement, not replace, conventional medical approaches. When implemented with an appropriate therapeutic dose, lifestyle medicine can prevent, treat and often reverse many of the chronic diseases that primary care clinicians confront every day in their practice. It aligns with the recommendations of many clinical practice guidelines regarding best practices for treating chronic disease. Lifestyle medicine interventions can lead to improved patient outcomes and satisfaction, medication deprescribing, increased patient longevity and vitality and decreased clinician burnout. Assisting patients to improve their health and well-being, rather than primarily managing the symptoms of chronic disease, can reinvigorate clinicians with the joy of practicing medicine, leading to increased professional satisfaction.

Healio: What should PCPs take from this statement? What can they learn from lifestyle medicine?

Grega: Our current health care trajectory is unsustainable. In 2021, the U.S. spent nearly $13,000 per person in annual per capita health care expenditures, far exceeding the amount spent by our reference countries analyzed by the Organization for Economic Cooperation and Development that demonstrate superior health outcomes for their citizens. Our chronic disease epidemic, including cardiovascular disease, type 2 diabetes, obesity, chronic kidney disease and mental health disorders, continues to accelerate. Approximately 90% of the health care expenditure in our country is due to chronic disease and mental health conditions, of which the majority are strongly influenced by our lifestyle choices. Integrating lifestyle medicine as the foundation of our health care toolkit will change the paradigm to a health and longevity-promoting focus from a disease-management approach. It is time to embrace the power of supporting health behavior change as the first-line therapy for preventing, treating and reversing chronic disease. Lifestyle medicine provides the evidence-based roadmap to transition to an improved model of health care for patients and clinicians.

References:

• Expert consensus statement defines best practices for integration of lifestyle medicine into primary care settings. https://www.prweb.com/releases/expert-consensus-statement-defines-best-practices-for-integration-of-lifestyle-medicine-into-primary-care-settings-301981868.html. Published Nov. 8, 2023. Accessed Nov. 14, 2023.
• Grega ML, et al. Am J Lifestyle Med. 2023;doi:10.1177/15598276231202970.