Lifestyle Medicine - The Future of Chronic Disease Management (2) - Annotated

REVIEW
CURRENT
OPINION Lifestyle medicine: the future of chronic disease
management
Robert F. Kushner a,b and Kirsten Webb Sorensen b
1-3
3 notes:
Purpose of review
Lifestyle medicine is a new discipline that has recently emerged as a systematized approach for management
4-6 of chronic disease. The practice of lifestyle medicine requires skills and competency in addressing multiple
3 notes: health risk behaviours and improving self-management. Targets include diet, physical activity, behaviour
change, body weight control, treatment plan adherence, stress and coping, spirituality, mind body
techniques, tobacco and substance abuse. This review focuses on the impact of a healthy lifestyle on chronic
7-8 disease, the rarity of good health and the challenges of implementing a lifestyle medicine programme.
2 notes:
Recent findings
Unhealthy lifestyle behaviours are at the root of the global burden of noncommunicable diseases and
account for about 63% of all deaths. Over the past several years, there has been an increased interest in
evaluating the benefit of adhering to ‘low-risk lifestyle’ behaviours and ideal ‘cardiovascular health metrics’.
Although a healthy lifestyle has repeatedly been shown to improve mortality, the population prevalence of
healthy living remains low.
Summary
Lifestyle medicine presents a new and challenging approach to address the prevention and treatment of
noncommunicable diseases, the most important and prevalent causes for increased morbidity and mortality
worldwide.
Keywords
lifestyle medicine, prevention, risk factor reduction
9-12
4 notes:
INTRODUCTION alcohol, and their determinants, while at the same
13 Optimal health and wellness is achieved when time strengthening the capacity of individuals and
patients adopt positive lifestyle behaviours, includ- populations to make healthier choices and follow
Maccarena Riquelme
ing choosing a healthy diet, remaining physically lifestyle patterns that foster good health’. [4]. Thus,
active, maintaining a healthy weight, being a it is imperative that healthcare providers develop
14-15
the skills and systems necessary to improve their
2 notes:nonsmoker and limiting excessive use of alcohol.
These individual lifestyle behaviours are among patients’ personal health behaviours.
16-17
the multiple determinants of health as defined by
2 notes:Healthy People 2020, the science-based, 10-year
WHAT IS LIFESTYLE MEDICINE?
national objectives for improving the health of all
Americans [1]. Unhealthy lifestyle behaviours are Lifestyle medicine is a new discipline that has
18-19
2 notes:also at the root of the global burden of noncommu-
recently emerged as a systematized approach for
nicable diseases (NCDs), which are now the leading
cause of disability-adjusted life years (DALYs) [2] and
a
account for about 63% of all deaths. By 2030, it is Northwestern University Feinberg School of Medicine and bCenter for
Lifestyle Medicine, Northwestern Medical Faculty Foundation, Chicago,
estimated that NCDs may account for 52 million
& Illinois, USA
20-21
deaths worldwide [3 ]. One of the primary aims of
Correspondence to Robert F. Kushner, MD, Northwestern University
2 notes:the 2011 United Nations High-level meeting of the Feinberg School of Medicine, Northwestern Comprehensive Center on
General Assembly on Noncommunicable Diseases Obesity, 750 North Lake Shore Drive, Rubloff 9-976, Chicago, IL 60611,
is, ‘Reducing the level of exposure of individuals USA. Tel: +1 312 503 6817; fax: +1 312 503 6743; e-mail: rkushner@
and populations to the common modifiable risk northwestern.edu
factors for NCD, namely, tobacco use, unhealthy Curr Opin Endocrinol Diabetes Obes 2013, 20:389–395
diet, physical inactivity, and the harmful use of DOI:10.1097/01.med.0000433056.76699.5d
1752-296X ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-endocrinology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
22-23 Obesity and nutrition
2 notes:
disease. According to the Centers for Disease Con-

24-26 KEY POINTS
3 notes:
trol and Prevention (CDC), cardiovascular disease
Lifestyle medicine presents a new and challenging (CVD), cancer and diabetes are the leading causes
approach to address the prevention and treatment of of mortality, conditions that, in large part, are
27-29 noncommunicable diseases. preventable ([9], CDC). The estimated risk factor
3 notes:
exposure and attributable deaths from lifestyle
Adoption of ‘low-risk lifestyle’ behaviours and ideal
and metabolic risk factors are summarized in
‘cardiovascular health metrics’ is associated with
30-34 reduced mortality. Table 1 [10].
5 notes: Recently, multiple systematic reviews and meta-
To effectively implement lifestyle medicine programmes, analyses have been published that demonstrate
the healthcare system will need to support the provision the beneficial impact of lifestyle interventions
35-36 of preventive care services and clinicians will need to
2 notes: in reducing diabetes incidence in patients with
acquire a new skill set that includes behaviour change & &
counselling. impaired glucose tolerance [11 ,12 ], management

&
37-41
of diabetes [13 ,14], hypercholesterolemia [15] and
5 notes: the metabolic syndrome [16,17]. In the recently
published NIH-AARP population-based cohort study
42-45
management of chronic disease. The model has among 207 449 men and women, the 11-year risk for
4 notes: recently been defined by several authors. Lianov incident diabetes for men and women whose diet
and Johnson [5] defined lifestyle medicine as score, physical activity, smoking status and alcohol
46-47
‘evidence-based practice of assisting individuals use were all in the low-risk group had odds ratios
2 notes: and families to adopt and sustain behaviors that (ORs) for diabetes of 0.61 and 0.43, respectively,
can improve health and quality of life’. Egger compared with the high-risk group [18]. Diabetes
et al. [6] defined it as ‘the application of environ- and obesity are among the two most signifi-
48-51
mental, behavioral, medical and motivational cant NCDs that currently affect 366 million and
4 notes: principles to the management of lifestyle-related 500 million people worldwide, respectively [19,20].
health problems in a clinical setting’. In the second Often called ‘diabesity’ because of their close
52-55
edition of his textbook aptly titled Lifestyle Medicine, association, one of the most effective targets for
&&
4 notes: Rippe [7 ] provides the most comprehensive diabetes treatment is management of excess body
definition as, ‘the integration of lifestyle practices weight by diet and physical activity. The beneficial
into the modern practice of medicine both to lower impact of weight loss on diabetes control and
the risk factors for chronic disease and/or, if disease reduction of cardiovascular risk factors has
56-59
already present, serve as an adjunct in its therapy. been recently demonstrated in the Look AHEAD
4 notes: Lifestyle medicine brings together sound, scientific (Action for Health in Diabetes) trial. In this pros-
evidence in diverse health related fields to assist the pectively controlled, randomized study conducted
clinician in the process of not only treating disease, at 16 US research centres, 5145 overweight adults
but also promoting good health’. In a broader aged 45–76 years with type 2 diabetes were random-
sense, the practice of lifestyle medicine requires ized to either an intensive lifestyle-based weight
acquiring the skills and competency in addressing loss intervention (ILI) or a diabetes support and
multiple individual lifestyle practices, including education intervention (DSE) [21]. Although 4-year
diet, physical activity, behaviour change, body results showed statistically significant improve-
60
weight control, treatment plan adherence, stress ments in fitness, glycemic control and cardiovascu-
and coping, spirituality, mind body techniques lar risk factors, [22,23], the trial was discontinued in
Maccarena Riquelme and tobacco and substance abuse. September 2012 after a median follow-up of 9.6 years
on the basis of a futility analysis [24]. The probability
61-62
of observing a significant positive result at the
2 notes:
IMPACT OF A HEALTHY LIFESTYLE ON planned end of follow-up was estimated to be 1%.
CHRONIC DISEASE Proposed explanations for the lack of significant
There is a strong body of evidence that practicing difference in rates of cardiovascular events between
healthy lifestyle behaviours reduces the risk of the ILI and DSE groups include a 2.5% difference in
chronic disease. In 2009, multiple medical societies weight loss between groups at year 10, intensifica-
joined in publishing a comprehensive review tion of medical management of cardiovascular risk
&&
of scientific evidence for lifestyle medicine both factors and low event rate [25 ].
63
for the prevention and treatment of chronic disease Over the past several years, there has been
[8]. Twenty-four chronic diseases were reviewed an increased interest in evaluating the benefit of
Maccarena Riquelme in this publication, highlighting the impact of a adhering to ‘low-risk lifestyle’ behaviours on the
healthy lifestyle on improving the root causes of development of morbidity and mortality. Although
390 www.co-endocrinology.com Volume 20 Number 5 October 2013
64 Lifestyle medicine Kushner and Sorensen
Maccarena Riquelme
Table 1. Distribution of risk factor exposure and percentage of attributable deaths from US population
Percentage of
Risk factor Exposure categories attributable deaths
High blood glucose Fasting plasma glucose 126 mg/dl 60

Fasting plasma glucose 100–125 mg/dl 34
Fasting plasma glucose <100 mg/dl 6
High LDL cholesterol LDL 160 mg/dl 5
LDL 130–159 mg/dl 30
LDL <130 mg/dl 65
High blood pressure SBP 140 mmHg 66
SBP <140 mmHg 34
Overweight obesity (High BMI) BMI 30 kg/m2 65
BMI 25–29.9 kg/m2 29
BMI <25 kg/m2 8
High dietary salt Dietary sodium 2300 mg 88
Dietary sodium <2300 mg 12
Physical inactivity Inactive 74
Low active 19
Moderately active 7
Highly active 0
Tobacco smoking Current smokers 43
Former smokers 57
Never smokers 0
65-66 LDL, low-density lipoprotein. Adapted with permission from [10].

2 notes:
67-68
the criteria for defining ‘low-risk lifestyle’ factors 0.08, respectively. The proportion of SCD attribu-
2 notes:vary, these studies have shown that adherence table to smoking, inactivity, overweight and poor
to a healthy lifestyle is associated with improved diet was 81% [27].
69-70
health outcomes. In the European Prospective The Atherosclerosis Risk in Communities
2 notes:Investigation Into Cancer and Nutrition (EPIC) Study (ARIC), a prospective epidemiological study
study, 23 153 German participants aged 35–65 years of 15 792 men and women of ages 44–64 years at
71-74
were followed up for a mean of 7.8 years. Adherence enrolment, demonstrated that adopting a healthy
4 notes:to four health behaviours [not smoking, exercising lifestyle after age 45 results in substantial benefits
3.5 h per week, eating a healthy diet (high intake after only 4 years compared with people with less
of fruits, vegetables and whole-grain bread and low healthy lifestyles, reducing mortality and CVD
meat consumption) and having a BMI of <30 kg/m2] risk by 40 and 35%, respectively [28]. To further
at baseline was associated with 78% lower risk explore the relationship between change in
75-77
of developing chronic disease (diabetes 93%, myo- health behaviours, socioeconomic status and mort-
3 notes:cardial infarction 81%, stoke 50% and cancer 36%) ality, Stringhini et al. [29] followed a cohort of
than participants without a healthy factor [5,26]. 10 308 civil servants from baseline examination
In the Nurses’ Health Study, a prospective cohort (1985–1988) to phase 7 (2002–2004) in the British
study of 81 722 US women from 1984 to 2010, a low- Whitehall II study. After adjusting for sex and year
78-79
risk lifestyle was defined at not smoking, BMI of less of birth, those with the lowest socioeconomic
2
2 notes:than 25 kg/m , exercise duration of 30 min/day or position had 1.60 times higher risk of death from
longer and top 40% of the alternate Mediterranean all causes than those with the highest socio-
80-81
diet score, which emphasizes high intake of economic position. However, this association was
2 notes:vegetables, fruits, nuts, legumes, whole grains and attenuated by 72% when four health behaviours
fish and a moderate intake of alcohol. Compared (smoking, alcohol consumption, diet and physical
with women with zero low-risk factors, the multi- activity) were entered in the statistical model.
variate relative risk of sudden cardiac death (SCD) Another approach used to assess the burden
decreased progressively for women with one, two, of disease is to combine lifestyle and physiological
three and four low-risk factors to 0.54, 0.41, 0.33 and risk factors. This has been extensively applied to
1752-296X ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-endocrinology.com 391
82-84 Obesity and nutrition
3 notes:
85-86
CVD. In the INTERHEART study, case–control study Examination Survey (NHANES). Compared with
2 notes: of acute myocardial infarction across 52 countries, individuals with zero or one metric at ideal levels,
15 152 cases and 14 820 controls were enrolled those with six or more metrics at ideal level had 51,
between 1999 and 2003 to assess the effect of risk 76 and 70% lower adjusted hazards for all-cause, CVD
87-88
factors on development of coronary heart disease and ischemic heart disease mortality, respectively.
2 notes: [30]. The study showed that over 90% of the
proportion of risk for an initial myocardial infarc-
tion is collectively attributable to nine measured THE RARITY OF GOOD HEALTH
89
and potentially modifiable risk factors: cigarette Despite the importance of following a healthy
Maccarena Riquelme smoking, raised ApoB/Apo A1 ratio, hypertension, life, multiple population studies have shown that
90-93
abdominal obesity, psychosocial factors, daily con- only a minority of individuals adhere to healthy
4 notes: sumption of fruits and vegetables, regular alcohol lifestyle behaviours. In a comparative analysis of
consumption and regular physical activity. middle-aged adults aged 40–74 years participating
94
The concept of ‘cardiovascular health metrics’ in the NHANES III 1988–1994 and 2001–2006
has also emerged as a method to assess cardio- surveys, the proportion of adults who adhered to
Maccarena Riquelme vascular risk and coined as ‘Life’s Simple 7’ by all five healthy habits (at least five fruits and
95-99
the American Heart Disease (AHA) in their 2020 vegetables/day, regular exercise >12 times/month,
5 notes: strategic impact goals to target a 20% relative maintaining a BMI between 18.5 and 29.9 kg/m2,
improvement in overall cardiovascular health moderate alcohol consumption and not smoking)
in all Americans [31]. The AHA combines four decreased from 15 to 8% [35]. The prevalence of
100-103
health behaviours (smoking, diet, physical activity meeting six or more cardiovascular health metrics
4 notes: and body weight) with three health factors (plasma also decreased from 10.3% in NHANES 1988–1994
glucose, cholesterol and blood pressure) as their to 8.8% in NHANES 2005–2010 [33]. Adherence to
metrics and assesses adherence as poor, inter- the ideal health metrics was also analysed by Ford
&
104
mediate or ideal by distinct definitions (Table 2) et al. [36 ] using data from NHANES 1999–2002.
[32]. The AHA also recently published 11 compre- Overall, about 1.5% of participants met none of
Maccarena Riquelme hensive articles in a themed series titled ‘Recent the seven ideal cardiovascular health metrics, and
105-106
Advances in Preventive Cardiology and Lifestyle 1.1% of participants met all seven metrics; most
2 notes: Medicine’ that emphasize the multiple deter- adults met two, three or four ideal health metrics.
minants of cardiovascular health [33]. Finally, On the basis of analysis of the NHANES data,
&& &&
107
Yang et al. [34 ] analysed the associations between Huffman et al. [37 ] projects that the AHA goal of
the number of ideal cardiovascular health metrics reducing CVD by 20% by 2020 will not be reached.
Maccarena Riquelme and mortality over a median follow-up of 14.5 years Poor health behaviours are not confined to the
108 using data from the National Health and Nutrition USA. In the recently published Prospective Urban
Maccarena Riquelme
Table 2. Definitions of poor, intermediate and ideal cardiovascular health for each American Heart Association
(AHA) metric for adults >20 years of age
Goal/metric Poor health Intermediate health Ideal health
Current smoking Yes Former 12 months Never or quit >12 months
BMI (kg/m2) 30 25–29.9 <25
Physical activity None 1–149 min/week moderate intensity 150 min/week moderate
or 1–74 min/week vigorous intensity or 75 min/week
intensity or 1–149 min/week vigorous intensity or
moderate þ vigorous 150 min/week
moderate þ vigorous
Healthy diet scorea 0–1 components 2–3 components 4–5 components
Total cholesterol (mg/dl) >240 200–239, or treated to goal <200
Blood pressure (mm Hg) SBP 140 or DBP 90 SBP 120–139 or DBP 80–89 <120/<80
or treated to goal
Fasting plasma glucose (mg/dl) 126 100–125 or treated to goal <100
a
Healthy Diet Score is based on an overall dietary pattern that is consistent with a DASH (Dietary Approaches to Stop Hypertension)-type eating plan. Individual
components are fruits and vegetables: 4.5 cups per day; Fish: two 3.5 oz servings per week; Fibre-rich whole grains; three 1 oz equivalent servings per
day; Sodium: <1500 mg/day; Sugar-sweetened beverages: 450 kcal (36 oz) per week; nuts, legumes and seeds: 4 servings per week; processed meats: none
or 2 servings per week; saturated fat: <7% of total energy intake.
Adapted with permission from [32].
109-110 Lifestyle medicine Kushner and Sorensen
2 notes:
Rural Epidemiology (PURE) Study, 153 996 adults, disease management: healthcare organization,
aged 35–70 years, from 17 low, middle and high- community resources, self-management support,
111-112
income countries of the world were surveyed for delivery system design, decision support and clinical
2 notes:their health behaviours after a median of 5 years and information systems. Multiple studies suggest that
4 years after sustaining a coronary heart disease patients of practices implementing the CCM receive
event or stroke, respectively [38]. Despite having improved care [50]. A recent systematic review
known CVD, less than one in 20 individuals adhered found evidence that CCM approaches have been
113
to the three healthy lifestyle behaviours of avoiding effective in improving diabetes management in
cigarette smoking, undertaking regular physical US primary care settings [51]. Incorporation of the
Maccarena Riquelmeactivity and eating a healthy diet. The investigators patient-centred medical home [52] and enactment
114-116
also noted that, overall, individuals from upper of the Affordable Care Act (ACA) represent major
3 notes:middle-income and low-income countries had a steps that will further increase access to preventive
lower prevalence of three of the healthy lifestyle services.
117-121
behaviours than those from high-income and lower However, existing evidence for implementing
5 notes:middle-income countries. lifestyle medicine counselling in primary care is
There are multiple determinants of adherence mixed and limited. The US Preventive Services Task
122-126
to healthy lifestyle behaviours, including socio- Force (USPSTF) found that the health benefit for
5 notes:economic forces, healthcare delivery and access diet, physical activity and behavioural counselling
and affordability issues among many others. to prevent CVD in the primary care setting is small
&
127-129
A population change in lifestyle habits will require (Grade C) [53,54 ]. In contrast, the USPSTF found
3 notes:participation from multiple sectors of our society. stronger albeit modest evidence for behavioural
&
Structural interventions to facilitate increased counselling for obesity (Grade B) [55 ,56]. Nonethe-
130-134
physical activity, improved diet and decreased less, providers will need to acquire the skills and
5 notes:cigarette smoking are needed [39–42]. Although competency necessary to address multiple health
controversial, changes in food taxation [43,44], risk behaviours and enhance self-management to
135-136
labelling [45] and regulation [46] have also been practice Lifestyle Medicine [57]. The AHA recom-
2 notes:proposed. One programme that engages a broad mends that clinicians use counselling interventions
set of stakeholders involved with health and to promote healthy diet and physical activity that
healthcare, including clinicians, pharmacists, combine two or more of the following strategies:
insurers, healthcare systems, retailers, consumer set specific, proximal goals; provide feedback on
137-140
groups and others, is the Million Hearts Initiative progress; provide strategies for self-monitoring;
4 notes:[47]. Launched in 2011 by the US Department of establish a plan for frequency and follow-up; use
Health and Human Services (HHS), Million Hearts is motivational interviewing; and build self-efficacy
141-145
a national initiative that aims to prevent one million [58]. Two recent studies that evaluated the health
5 notes:heart attacks and strokes by 2017. Targets for outcomes from providing multiple behaviour change
the initiative are to improve patient adherence, counselling in primary care demonstrated limited
empower persons to make healthy choices, improve success [59,60]. Increased utilization of mobile
delivery of healthcare and focus on the ‘ABCS’ technology and other self-monitoring devices
(appropriate aspirin use for those at risk, blood may facilitate improved self-management, which
pressure control, cholesterol management and smok- is an important component for Lifestyle Medicine
ing cessation) [48]. [61].
146-147
IMPLEMENTING LIFESTYLE MEDICINE
2 notes:
CONCLUSION
PROGRAMMES
148-150 Lifestyle Medicine presents a new and challenging
3 notes: Despite the rationale and importance for providing
approach to address the prevention and treatment
lifestyle medicine, multiple challenges exist.
of NCDs, the most important and prevalent causes
Successful implementation will require changes in
for increased morbidity and mortality worldwide.
151-152
both systems and provider skills. The Chronic Care However, to be successful, the healthcare system
2 notes:Model (CCM) is a reasonable system of delivery to
will need to support the provision of preventive care
consider for lifestyle medicine [49]. Developed in
services and clinicians will need to acquire a new
153
the early 1990s, it was created to deliver patient-
skill set that includes behaviour change counselling.
centred, evidence-based, proactive care of chroni-
Maccarena Riquelmecally ill populations. CCM is composed of six
components that are designed to affect functional Acknowledgements

and clinical outcomes associated with chronic None.
Obesity and nutrition
22. The Look AHEAD Research Group. Long-term effects of a lifestyle inter-
Conflicts of interest vention on weight and cardiovascular risk factors in individuals with type 2
There are no conflicts of interest. diabetes mellitus. Four-year results of the Look AHEAD Trial. Arch Intern Med
2010; 170:1566–1575.
23. Gregg EW, Chen H, Wagenknecht LE, et al. Association of an intensive
lifestyle intervention with remission of type 2 diabetes. JAMA 2012;
308:2489–2496.
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Annotations
Lifestyle medicine: The future of chronic disease management

Kushner, Robert F.; Sorensen, Kirsten Webb
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disease. According to the Centers for Disease Con-

counselling. impaired glucose tolerance [11 ,12 ], management

390 www.co-endocrinology.com Volume 20 Number 5 October 2013

High blood glucose Fasting plasma glucose 126 mg/dl 60

65-66 LDL, low-density lipoprotein. Adapted with permission from [10].

392 www.co-endocrinology.com Volume 20 Number 5 October 2013

components that are designed to affect functional Acknowledgements

394 www.co-endocrinology.com Volume 20 Number 5 October 2013

Lifestyle medicine: The future of chronic disease management

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