Doctors Who Actually Tackle Your Unhealthy Lifestyle

“You should lose weight and exercise, but in the meantime, take these pills.”

That’s the sort of prescription Dr. Damian Folch, a general practitioner in the working-class Massachusetts town of Chelmsford, might have given a typical patient in the old days.

But Dr. Folch has changed, radically, under the influence of an emerging movement called Lifestyle Medicine, centered in part here at Harvard Medical School. And if health reform goes as expected at both the national and the state level, many more doctors may undergo similar transformations, in keeping with strong new incentives to keep patients well rather than just treating them when they’re sick.

Dr. Folch doesn’t just tell patients to eat better and get moving, he coaches them using proven motivational techniques. He records the amount they exercise as a vital sign, along with blood pressure and pulse. He writes out prescriptions for exercise on his pad. He shows them his office treadmill desk and shares his own fitness efforts, which include his first-ever half-marathon this fall at the age of 58.

‘Medicine’s past was dominated by fighting infectious disease; its future is dealing with chronic disease influenced by lifestyle.’

A national survey by the CDC just reported that more than ever, doctors are advising their patients to exercise: In 2010, 32% of adult patients reported being told to exercise, up from about 22% a decade earlier.

But it’s not enough to just say, “You need to exercise.” Or “Please eat less.” Lifestyle Medicine teaches doctors how to actually get their patients to do it — as part of an evolving science of healthy behaviors.

The evidence is mounting that a doctor’s guidance can have dramatic effects. A Brigham and Women’s Hospital study of more than 30,000 patients with diabetes found that “lifestyle counseling” helped them improve their glucose scores, blood pressure and cholesterol far more rapidly than usual care, this month’s “Diabetes Care” journal reports.

Similarly, two recent New England Journal of Medicine papers found that “lifestyle coaching” significantly helped patients lose weight.


A no-brainer, but revolutionary

It seems like a no-brainer, acknowledges Dr. Edward Phillips, director of the Institute for Lifestyle Medicine at Harvard Medical School. Doctors and patients alike know they should eat right, exercise, stay trim, quit smoking. At the same time, what Lifestyle Medicine proposes is downright revolutionary:

“We’re seeking nothing short of transforming the practice of primary care,” he recently told a lunch-time meeting of interested Harvard medical students.

Harvard Medical students at a Lifestyle Medicine lunch talk” credit=”Anna Rubin/ILM

His argument: More than half of deaths involve poor lifestyle behaviors like unhealthy diet and inactivity. The World Health Organization predicts that by 2020, two-thirds of disease will stem from lifestyle choices.

Medicine’s past was dominated by fighting infectious disease, he says; its future is dealing with chronic disease influenced by lifestyle.

Yet the current model of medicine amounts to only “taking care of something once it’s broken” — and that, he argues, “is not sustainable anymore.” Medicine must be “redirected.” Doctors have to actively help keep people well instead of just treating them when sick.

How? Dr. Phillips distilled what the Lifestyle Medicine movement aims to do to change the practice of medicine:

  • Teach students of health care much more about exercise, nutrition, stress and other lifestyle topics.
  • Give doctors better tools for helping patients change, such as exercise prescriptions.
  • Help doctors improve their own lifestyle behaviors so they can better motivate patients. (The institute offers an annual course called “Active doctors, active patients” that even includes gym time for doctors.)
  • Emphasize training for doctors on how to coach their patients rather than just issue commands.

The advent of Lifestyle Medicine couldn’t be more timely, he notes: “Accountable care organizations” that are financially responsible for keeping patients healthy are on the rise, particularly since new federal health reform rules that kicked in January 1. “Yet doctors and hospitals need training in how to promote healthy behaviors.”


Barriers and challenges

Lifestyle Medicine is a whole newborn discipline already, with an American College of Lifestyle Medicine and its own journal and a landmark paper in the Journal of American Medical Association in 2010 defining its “core competencies.”

‘Time and payment, that combination is the big elephant in the room.’

But in some ways, it is still struggling uphill.

First, American medicine is notoriously conservative and slow to change. Enough said.

Second, at a recent Lifestyle Medicine conference at Harvard, one speaker referred to an “elephant in the room”: The threat of lawsuits. Doctors may fear that a patient might start exercising on their advice and then have a heart attack or other complication, and sue. (Dr. Phillips responds that he, instead, ponders the possibility of a physician who ignores nearly 10,000 articles on the benefits of exercise being sued for not prescribing exercise.)

In fact, even Lifestyle Medicine enthusiasts see two far bigger obstacles than fear of litigation: Money and time.

Michael Barry, executive director of the American College of Preventive Medicine, applauds Lifestyle Medicine as a growing movement, but says that one of its central challenges is what it lacks: “A core economic driver like other treatments. The pharmaceutical industry and the device industry, they’re economic drivers. We don’t see that with Lifestyle Medicine.”

Sigh. And then there is that ugly word: reimbursement. Health insurers don’t tend to pay for many of the processes of Lifestyle Medicine. How do you code for “discussed eating fruit instead of chips while watching television”?

Then there’s the eternal office time crunch. “A lot of physicians will push back and say, “We’re being squeezed so much within the current health care system,” Mr. Barry said. “We’ve got 10 minutes with a patient, and the patient comes in with ailments.” Adding a Lifestyle Medicine component, they may argue, “puts more on our plate.”

Actually, he said, “it’s really not that overwhelming in terms of building it into your practice. A lot of it is mindset, and how you think: You think to prevent.”

But time is a tough one, even Dr. Folch of Chelmsford allows. The elephant in the room is not fear of lawsuits, he said. “Time and payment, that combination is the big elephant in the room. And that should get better with health reform.”


The coming waves

Indeed, health care reform and Lifestyle Medicine fit together neatly. A central tenet of reform, particularly here in Massachusetts, is that instead of “fee for service,” in which doctors are paid for each bit of care they provide, the system should focus on overarching care that is paid for in a big “bundle” — with bonuses for good results.

‘You’re going to get paid based on your patients’ blood sugar measurements or body mass index.’

As Dr. Phillips warned the Harvard students, the federal health overhaul includes a provision under which “you guys may, in the near future, get paid based on the health behaviors and outcomes of your patients. When that day comes, and the metric shifts 180 degrees, I would just say to be ready. You’re going to get paid based on your patients’ A1Cs [a blood sugar measurement] or BMIs.”

Another tenet of reform is that doctors must become less like lone cowboys and more like good team players. Lifestyle Medicine fits into that perfectly. Take the study on 30,000 diabetics. Dr. Alexander Turchin of Brigham and Women’s Hospital said that it’s clear that there are not always enough “physician resources” in the system to perform the counseling that the study found was so helpful.

“So we do need to be more creative to implement findings like this,” he said. “We may need to engage more nurse practitioners or physicians assistants, more dietitians. Or maybe do group counseling, which is more cost-effective.”

But something must be done. “Lifestyle is the cause of many of these diseases,” Dr. Turchin said. “So lifestyle really does need to play a role in dealing with it as well.


What a practice looks like

Dr. Damian Folch

Back to Dr. Folch’s office in Chelmsford. He’s so busy — a solo practitioner with a roster of 3500 patients — that he has recently expanded and added two new staffers to his team, a physician’s asssitant and a nurse practitioner, who can help with Lifestyle Medicine-based care.

The office has expanded physically as well, which let him put in a shower for after lunchtime workouts. “You lead by example,” he says. Lifestyle Medicine conferences influenced him to ramp up his exercise to the point that he’s in the best shape of his life. He went from size 34 to size 30 pants, and he gets comments from patients like “Wow, you look great! What have you been doing?”

During a recent morning of office hours, he saw a broad gamut of patients, from a generally healthy fortyish blonde seeking more holistic care to a developmentally disabled man with diabetes to an elderly man with congestive heart failure.

He shared exercise guidelines and recommendations on books about healthy eating with the fortyish woman, explaining how to lift weights to the point of muscle failure. She complained of having the hips of a 70-year-old, and he suggested Vitamin D to help her bones absorb calcium. (His practice has recently added a website with a compendium of Lifestyle Medicine resources.)

A young man who works in a warehouse had recently gained five pounds despite more than a week of diarrhea, and Dr. Folch told him straight that the extra weight was driving up his high blood pressure. “Do you exercise?”

“I play ball sometimes.”

Dr. Folch turned to the man’s wife and asked if they might go for half-hour walks together. “If you lose weight, you could not need medication,” he said.

But perhaps the star of the morning was the 83-year-old woman who had quit smoking three months ago after 50 years of more than a pack a day. Dr. Folch referred her for lung rehabilitation, and dealt with other medical issues, but perhaps this was his most potent medicine of all:

“Wow,” he told her, eyes alight with pride. “I’m so impressed!”


Further reading

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  • Dr David E Klein, DPM

    Improving outcomes and translating the new medical information into healthy lifestyle needs multiple disciplines working together for the common good of the patient as in the Diabetes (LEAP) Lower Extremity Amputation Prevention program.

  • Rdms87

    To make changes that last, it takes a lot more effort and follow up than what any doctor or in-office professional can do. It takes willingness to change, first, then effort on the patent’s part, along with coaching as an accountability piece, while changes are being made. Habits are not formed overnight, or in 21 days. Lifestyle medicine is only one piece is the bigger picture of individual choices. 

  • http://twitter.com/KENT_NORTON kent norton

    DO WE need an M.D. degree costing 1/2 million dollars to come full circle to where “health nuts” and personal trainers were about 30 years ago. i have never seen or heard a genral practitioner recommend this. sure its great but even so, will people listen…drugs still grease the gears of commerce in medicine;

  • Drweed

    I applaud Dr. Folch’s efforts to address the fundamental causes of 80% of today’s illnesses, but I sense that the individual approach is doomed to failure unless a whole range of community issues are also addressed, such as the availability of good food and education on how to prepare it, the availability of low or no-cost fitness resources such as safe walking routes close to home, and community-wide measures to discourage or prohibit smoking in all public places and to prevent its use by young people. In Fall River, MA, we have been working for seven years on these issues, including the creation of a low-cost annual Fitness Challenge that has enrolled over 800 people each year for the past five years (see http://www.HealthyCityFallRiver.org). Despite ample publicity and numerous attempts to work with the medical community, only one physician has even expressed an interest in learning how they might use these resources to assist their patients. When the medical community takes time away from their busy (and lucrative) practices to engage the larger community, then we can get begin to actually reduce the incidence of our increasingly expensive medical conditions.

  • Kristina

    Clearly this is the right direction.  But there are a couple of other elephants in the room.  First, do we really need MDs to deliver lifestyle medicine?  While the benefits of lifestyle modification are enormous and approproriately encouraged in a medical setting, far less training is required to move this along.  The other elephant in the room is the individual whose lifestyle needs managing.  It’s really only the individual who can do this.  One might think the pain of chronic illness and a debilitated future are incentive enough but they aren’t.  Can and should physicians really be financially accountable for the lifestyle choices of their patients? 

  • Kathryn

    This is exactly why the program ‘JustWalk/Walk with a Doc’ was born. To educate communities, engage our young med students and lead by example. Literally. I love this article! 

  • Sjfone

    What, no fast food or hours in front of electronics, sounds like an advanced sports clinic.

  • Mason

    Its curious how “complementary alternative medicine” has been saying this since the AMA (pro-prescription, corporation, and anti-lifestyle) made them look like quacks for doing so. Using natural healing methods such as nutrition, exercise, and avoiding pharmaceuticals is the way of the future. You don’t have to be a Harvard grad to figure that out, but you may have to realize the amount of money pharmaceutical companies make off of the obese. Sorry to throw the negative aspect out there. Be strong. 

  • Anonymous

    Time + Money = good health.

  • Kathleen

    Best medicine for aging well is behavior modification incorporating consistent exercise program. When this happens better nutrition habits follow.  So easy to write yet tough to do! Like many  my experience with positive lifestyle behavior mod is sketchy.  I find inspiration in articles such as this. The cheapest form of long term care insurance one can buy is regular exercise.  When ACOs contribute to higher out of pocket medical expense’ we will have even more incentive to be fit.  Time for a walk….

    • http://twitter.com/KENT_NORTON kent norton

       the only method to modify behavior is to begin with clearing our thoughts through mediation. it all works if you work it by lerning the Dao

  • Molly Sweezy

    What about nurses?  As a nurse in Primary Care, I have more time than the MD does to do lifestyle coaching…why no mention of nurses at all in this article??

    • Jchi2

      Because it’s an article about doctors. I agree with you, nurses are an integral part of the patient experience and offer an excellent source of counseling and education. I’ve read a number of articles specifically reporting on nurses’ roles in helping patients with lifestyle oriented healthy choices. This particular article just happens to be about docs.

    • http://twitter.com/KENT_NORTON kent norton

       there are several nurse practitioners on the faculty of Harvard Medical School, teaching LSM (life style management) as well as herbert bensons meditation for doctors.

    • Jeff G

      There exists a new degree specialty track for DNP (doctorate of nursing practice) in lifestyle medicine at Southern Adventist University in Tennessee

  • Anonymous

    Giving patients the tools to care for their own health will keep money in their pockets. When doctors suggest diet and exercise, patients need to ask for specific plans. If doctors can’t do that, then we need to ask for referrals for nutritionists or coaches. Beware: doctors are not coaches and most do not have expertise in the intricacies of effective and safe training. Find yourself a professional coach.
    http://whatstherealcost.org/video.php?post=five-questions

  • Lifestyle Medicine MD

    The reality is that the science shows the primary factors in developing, preventing, and treating most diseases of modern society are lifestyle.  We put physicians through crazy quantities of intense education only to leave them ignorant and dysfunctional on the most important and most powerful tools for dealing with health and disease.  This is just plain stupid. This must change!
      Yes, other practitioners are “cheaper” than MDs, can do much of the lifestyle work, and can often do it better in what they are specifically trained in.  But the physician is the ultimate authority in health care who is ultimately held responsible for the care delivered.  They must manage and coordinate all aspects and therapies in medical care – INCLUDING THE MOST POWERFUL ONES OF LIFESTYLE MEDICINE.  Lifestyle Medicine must be treated in all ways in our society and in health care as “medical care” – not that the second or third class approach it has been treated as thus far.  Pills and procedures should logically be “adjunct” to the more important therapies that “treat the cause”- lifestyle.
      Let’s not keep us in the dark ages of health care by keeping the physician team leaders as ignorant and far away as possible from the most powerful therapies there are.
      It is also true that most, health care professionals and patients alike, do not appreciate the challenge of effectively engaging and training people to make major and long lasting changes in their lifestyles.  The half-baked approach that is typically used simply doesn’t work.  It requires full blown “medical” intensity care (done very differently than the current/typical approach).  Giving “advice” for 5 minutes accomplishes just slightly more than nothing.  A different kind of science (change, human behavior) and completely different methods of operation are the foundations of lifestyle medicine.

  • Reasonable?

    I think the idea of doctors has lifestyle coach is nice.
    However does it really take 7 years of medical education to give diet, exercise and motivational advice.  I hope not!  Let’s see doctors work other professionals and staff to get this done.
    With the salary expectation of most physicians, this is simply not worth their time…..

  • Roger

    Am I the only one that finds it astonishing that people are not held accountable for their own health outcomes, doctors are?  I appreciate that doctors could do a better job on lifestyle coaching, but aren’t individuals ultimately responsible for our own health?  Who hasn’t been shut down by a loved one who eats too much or smokes and refuses to do anything about it?  Clearly the health benefits of healthier lifestyles are not enough to motivate most of those who need to change their lifestyles; so what financial incentives will individuals have?  Shouldn’t individuals have the same sticks and carrots their caregivers have?  

    This Safeway model (link below) must be looked at to complement any system that holds physicians accountable.  You need both.  

    http://online.wsj.com/article/SB124476804026308603.html