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Lifestyle Medicine
Lifestyle Medicine
Third Edition

Edited by
James M. Rippe, MD
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2019 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-138-70884-6 (Hardback)

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Library of Congress Cataloging‑ in‑ Publication Data

Names: Rippe, James M., editor.

Title: Lifestyle medicine / [edited by] James M. Rippe.
Other titles: Lifestyle medicine (Rippe)
Description: Third edition. | Boca Raton : Taylor & Francis, 2019. | Includes
bibliographical references.
Identifiers: LCCN 2018043101| ISBN 9781138708846 (hardback : alk. paper) |
ISBN 9781315201108 (General eISBN) | ISBN 9781351781008 (pdf) | ISBN
9781351780995 (epub) | ISBN 9781351780988 (mobi/kindle)
Subjects: | MESH: Primary Prevention | Health Promotion | Health Behavior |
Healthy Lifestyle
Classification: LCC RA427 | NLM WA 108 | DDC 610--dc23
LC record available at https://lccn.loc.gov/2018043101

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com

and the CRC Press Web site at

http://www.crcpress.com
 Dedication

To my beautiful wife, Stephanie Hart Rippe, and our wonderful children

Hart, Jaelin, Devon, and Jamie who make my life worth living.
 Contents
Preface.............................................................................. xiii
Acknowledgments........................................................... xvii
About the Editor................................................................ xix
Contributors...................................................................... xxi
Part I Lifestyle Management and
Prevention of Cardiovascular Disease
James M. Rippe, MD
Chapter 1: The Rationale for Intervention to Reduce
the Risk of Cardiovascular Disease..................................... 3
James M. Rippe, MD and Theodore J. Angelopoulos
PhD, MPH
Chapter 2: Lifestyle Strategies for Risk Factor
Reduction, Prevention and Treatment of
Cardiovascular Disease..................................................... 19
James M. Rippe, MD and Theodore J. Angelopoulos,
PhD, MPH
Chapter 3: Physical Activity and Fitness in the
Prevention of Cardiovascular Disease............................... 37
Robert F. Zoeller Jr., PhD
Chapter 4: Clinical Strategies for Managing
Dyslipidemias..................................................................... 53
Ulf G. Bronas, PhD, ATC, FSVM, FAHA,
Mary Hannan, MSN, APN, AGACNP-BC, and
Arthur S. Leon, MS, MD, FACSM
Chapter 5: Lifestyle Management and Prevention of
Hypertension...................................................................... 65
Ulf G. Bronas, PhD, ATC, FSVM, FAHA,
Mary Hannan, MSN, APN, AGACNP-BC, and
Arthur S. Leon, MS, MD, FACSM
Part II Nutritional Aspects of Lifestyle Medicine
  James M. Rippe, MD
Chapter 6: The Concept of Nutritional Status and Its
Measurement..................................................................... 77
Johanna T. Dwyer, DSc, RD and Regan L. Bailey, PhD,
RD, MPH, CPH
Chapter 7: Dietary Guidelines for Americans,
2015–2020: National Nutrition Guidelines....................... 101
Elizabeth B. Rahavi, RDN, Jean M. Altman, MS, and
Eve E. Stoody, PhD
Chapter 8: Nutrition and Cardiovascular Disease............111
James M. Rippe, MD
Chapter 9: Optimal Nutrition Guidance for Older Adults...... 125
Alice H. Lichtenstein, DSc
Chapter 10: Effects of an Active Lifestyle on Water
Balance and Water Requirements................................... 135
Gethin H. Evans, BSc, PhD, Ronald J. Maughan, BSc,
PhD, and Susan M. Shirreffs, BSc, PhD
Part III Physical Activity
  Edward M. Phillips, MD
Chapter 11: Implementation of the Exercise
Prescription...................................................................... 147
Rachele M. Pojednic, PhD, EdM, Caroline R. Loveland,
MS, and Sarah Tierney Jones, BS
Chapter 12: What Physicians Need to Know, Do, and
Say to Promote Physical Activity..................................... 153
Mary A. Kennedy, MS
Chapter 13: Physical Fitness Evaluation.......................... 163
Peter Kokkinos, PhD and Jonathan Myers, PhD
Chapter 14: Exercise Prescription for Apparently
Healthy Individuals and for Special Populations............. 177
Paul G. Davis, PhD, ACSM-CEP
Part IV Behavioral Medicine
  Elizabeth Pegg Frates, MD
Chapter 15: Behavior Change.......................................... 193
Elizabeth Pegg Frates, MD and
James E. Eubanks Jr., DC, MS
Chapter 16: Applying Psychological Theories to
Promote Healthy Lifestyles.............................................. 197
Maryam Gholami, PhD, Cassandra Herman, MS,
Matthew Cole Ainsworth, MPH, Dori Pekmezi, PhD,
and Sarah Linke, PhD, MPH
Chapter 17: Motivational Interviewing and Lifestyle
Change............................................................................. 207
Peter Fifield, EdD, LCMHC, MLADC, Joji Suzuki, MD,
Samantha Minski, PhD, and Jennifer Carty, PhD
Chapter 18: Transtheoretical Model................................ 219
James O. Prochaska, PhD and Janice M. Prochaska, PhD
Chapter 19: The Impact of Positive Psychology on
Behavioral Change and Healthy Lifestyle Choices......... 229
Shelley H. Carson, PhD, Andrea Cook, PhD, Stephanie
Peabody, PsyD, Sandra Scheinbaum, PhD, and
Leslie Williamson, BA
Chapter 20: The Intention–Behavior Gap........................ 241
Mark D. Faries, PhD and Wesley C. Kephart, PhD
vii
viii Contents
Chapter 21: Cognitive and Behavioral Approaches
to Enhancing Physical Activity Participation and
Decreasing Sedentary Behavior...................................... 253
Barbara A. Stetson, PhD and Patricia M. Dubbert, PhD
Chapter 22: Enhancing the Nutrition Prescription
Using Behavioral Approaches......................................... 269
Jonas Sokolof, DO, Margaret Loeper Vasquez, MS,
RD, LDN, Jenny Sunghyun Lee, PhD, MPH, CHES,
CWP, CHWC, BCLM, Daniel B. Clarke, MBA, and
P. Michael Stone, MD, MS, IFMCP
Chapter 23: Behavioral Approaches to Manage
Stress............................................................................... 281
Elise Loiselle, RN, MSN, FNP-C, Darshan Mehta, MD,
and Jacqueline Proszynski, BS
Chapter 24: Health Coaching and Behavior Change...... 299
Karen L. Lawson, MD, ABIHM, NBC-HWC,
Margaret Moore, MBA, ACC, Matthew M. Clark, PhD,
Sara Link, MS, NBC-HWC, and Ruth Wolever, PhD
Chapter 25: Digital Health Technology for Behavior
Change............................................................................. 311
Jeffrey Krauss, MD, DipABLM, Patricia Zheng, MD,
Courtenay Stewart, DO, and Mark Berman, MD, FACLM
Part V Women’ s Health
Paulette Chandler, MD, MPH
Chapter 26: Breast Health: Lifestyle Modification for
Risk Reduction................................................................. 331
Beth Baughman DuPree, MD, FACS, ABOIM and
Jodi Hutchinson, PA-C
Chapter 27: Sports and Physical Activity for Women
and Girls........................................................................... 341
Elizabeth A. Joy, MD, MPH, FACSM
Part VI Endocrinology and Metabolism
  Jeffrey I. Mechanick, MD, FACP, FACE,
FACN, ECNU
Chapter 28: Impact of Lifestyle Medicine on
Dysglycemia-Based Chronic Disease............................. 355
Michael A. Via, MD and Jeffrey I. Mechanick, MD,
FACP, FACE, FACN, ECNU
Chapter 29: Lifestyle Medicine and the Management
of Prediabetes.................................................................. 367
Karla I. Galaviz, PhD, MSc, Lisa Staimez, PhD, MPH,
Lawrence S. Phillips, MD, and Mary Beth Weber, PhD,
MPH
Chapter 30: Lifestyle Therapies for the Management
of Diabetes....................................................................... 383
Marion J. Franz, MS, RD, CDE
Chapter 31: Implementing Nutritional Lifestyle
Treatment Programs in Type 2 Diabetes......................... 393
George Guthrie, MD, MPH, CDE, CNS, FAAFP, FACLM
Part VII Lifestyle Issues in the Prevention
and Treatment of Cancer
  Cindy D. Davis, PhD and
Sharon Ross, PhD, MPH
Chapter 32: Diet and Cancer Prevention......................... 409
Cindy D. Davis, PhD and Sharon Ross, PhD, MPH
Chapter 33: Lifestyle Approaches Targeting Obesity to
Reduce Cancer Risk, Progression, and Recurrence..........419
Debora S. Bruno, MD, MS and Nathan A. Berger, MD
Chapter 34: Physical Activity and the Prevention and
Treatment of Cancer........................................................ 431
Case H. Keltner, MPH and Heather R. Bowles, PhD
Chapter 35: Nutrition Therapy for the Cancer Patient.......441
Sandeep (Anu) Kaur, MS, RDN, RYT-500 and Elaine
Trujillo, MS, RDN
Part VIII Obesity and Weight Management
  John P. Foreyt, PhD
Chapter 36: Epidemiology of Adult Obesity.................... 455
R. Sue Day, MS, PhD, Nattinee Jitnarin, PhD,
Michelle L. Vidoni, MPH, PhD, Christopher M.
Kaipust, MPH, and Austin L. Brown, MPH, PhD
Chapter 37: Exercise Management for the Obese
Patient.............................................................................. 473
John M. Jakicic, PhD, Renee J. Rogers, PhD, and
Katherine A. Collins, MS, CBDT
Chapter 38: Dietary Management of Overweight and
Obesity............................................................................. 483
Nina Crowley, PhD, RDN, LD, Katherine R.
Arlinghaus, MS, RD, LD, and Eileen Stellefson Myers,
MPH, RDN, LDN, CEDRD, FADA, FAND
Chapter 39: Pharmacological Management of the
Patient with Obesity......................................................... 491
Magdalena Pasarica, MD, PhD and Nikhil V.
Dhurandhar, PhD
Chapter 40: Surgery for Severe Obesity......................... 505
Robert F. Kushner, MD and Lisa A. Neff, PhD
Chapter 41: Adiposity-based Chronic Disease a New
Diagnostic Term............................................................... 517
Michael A. Via, MD and Jeffrey I. Mechanick, MD,
FACP, FACE, FACN, ECNU
Chapter 42: Future Directions in Obesity and Weight
Management.................................................................... 529
Theodore K. Kyle, RPh, MBA

Part IX Immunology and Infectious Disease
  Gregory A. Hand, PhD, MPH, FACSM, FESPM
Chapter 43: Exercise, Inflammation, and Respiratory
Infection........................................................................... 539
Wesley D. Dudgeon, PhD, David C. Nieman, DrPH,
FACSM, and Elizabeth Kelley, MS, ACSM-RCEP
Chapter 44: Chronic Exercise and Immunity................... 547
Melissa M. Markofski, PhD, Paul M. Coen, PhD, and
Michael G. Flynn, PhD
Chapter 45: HIV and Exercise.......................................... 555
Jason R. Jaggers, PhD and Gregory A. Hand, PhD,
MPH, FACSM, FESPM
Chapter 46: Exercise, Aging, and Immunity.................... 563
Jeffrey A. Woods, PhD, Yi Sun, PhD, and Brandt D.
Pence, PhD
Part X Pulmonary Medicine
  Nicholas A. Smyrnios, MD, FACP, FCCP
Chapter 47: Respiratory Symptoms................................ 573
Jeremy B. Richards, MD and Richard M. Schwartzstein,
MD
Chapter 48: Asthma......................................................... 589
David E. Ciccolella, MD and Gilbert E. D’Alonzo, DO
Chapter 49: Occupational and Environmental Lung
Diseases........................................................................... 611
Sunkaru Touray, MBChB, MSc, Emil Tigas, MD, and
Nicholas A. Smyrnios, MD, FACP, FCCP
Chapter 50: Venous Thromboembolic Disease............... 621
Joseph Gallant, MD and Ryan Shipe, MD
Chapter 51: Influenza....................................................... 631
Gail Scully, MD, MPH
Chapter 52: Indoor Air Quality......................................... 639
Anthony C. Campagna, MD, FCCP and Dhruv Desai, MD
Part XI Obstetrics and Gynecology
  Amanda McKinney, MD, FACLM, FACOG, CPE
Chapter 53: Antenatal Care—Nutrition and Lifestyle
to Improve Conception and Pregnancy Outcomes......... 653
Amanda McKinney, MD, FACLM, FACOG, CPE
Chapter 54: Exercise in Pregnancy................................. 663
Kristin Bixel, MD and Christie Mitchell Cobb, MD
Chapter 55: Breast-Feeding............................................ 673
Julia Head, MD, Stephanie-Marie L. Jones, MD, Marcie
K. Richardson, MD, and Angela Grone, MD, FACOG
Contents  ix
Chapter 56: Contraception.............................................. 687

Karen Carlson, MD and Sadia Haider, MD, MPH
Chapter 57: Prevention, Screening, and Treatment of
Sexually Transmitted Infections....................................... 697
Karen Carlson, MD
Chapter 58: Menstrual Disorders and Menopause......... 707
Amanda McKinney, MD, FACLM, FACOG, CPE
Chapter 59: Risk Reduction and Screening for
Women’s Cancers............................................................ 715
Amanda McKinney, MD, FACLM, FACOG, CPE and
Jo Marie Tran Janco, MD
Part XII Cardiovascular Rehabilitation and
Secondary Prevention
 Kathy Berra, MSN, NP-BC, FAANP,
FPCNA, FAHA, FAAN and
Barry A. Franklin, PhD
Chapter 60: Medication Dosing and Adherence in
Secondary Prevention..................................................... 735
Ozlem Bilen, MD and Nanette K. Wenger, MD, MACC,
MACP, FAHA
Chapter 61: Using Digital Health Technology to
Promote Cardiovascular Disease Risk Reduction in
Secondary Prevention......................................................741
Neil F. Gordon, MD, PhD, MPH, FACC, Richard D.
Salmon, DDS, MBA, Mandy K. Salmon, ChBE, and
Prabakar Ponnusamy, MS
Chapter 62: Psychosocial Risk Factors as
Modulators of Cardiovascular Outcomes in
Secondary Prevention..................................................... 751
Joel W. Hughes, PhD, FAACVPR and David Ede, Jr., BS
Chapter 63: A Patient’s Perspective on the Keys
to Longevity 40 Years after Undergoing Coronary
Artery Bypass Surgery..................................................... 761
Joseph C. Piscatella, BA
Chapter 64: Lipid Management in Secondary
Prevention........................................................................ 767
Paul D. Thompson, MD and Antonio B. Fernandez, MD
Chapter 65: Complementary Effects of Lifestyle
Modification on Cardioprotective Medications in
Primary/Secondary Prevention........................................ 771
Xisui Shirley Chen, MD and Philip Greenland, MD
Chapter 66: Counseling Cardiac Patients to Facilitate
Behavior Change............................................................. 781
Lola A. Coke, PhD, ACNS-BC, CVRN-BC, FAHA,
FPCNA, FAAN, Nancy Houston Miller, RN, BSN,
FAHA, FPCNA, FAACVPR, and Kathy Berra, MSN,
NP-BC, FAANP, FPCNA, FAHA, FAAN
x Contents
Chapter 67: Extreme Exercise and High Intensity
Interval Training in Cardiac Rehabilitation....................... 787
Kathy Berra, MSN, NP-BC, FAANP, FPCNA, FAHA,
FAAN and Barry A. Franklin, PhD
Chapter 68: Counseling Coronary Patients About
Their Body Weight: Implications Regarding the
Obesity Paradox.............................................................. 801
Sergey Kachur, MD, Carl J. Lavie, MD, FACC, FACP,
FCCP, FESPM, and Richard V. Milani, MD
Chapter 69: Vitamins and Supplements: Evidence
in the Prevention and Treatment of Cardiovascular
Disease............................................................................. 811
Jenna M. Holzhausen, PharmD, BCPS and Aaron D.
Berman, MD, FACC
Chapter 70: Intensive Cardiac Rehabilitation:
Evolution, Preliminary Outcomes, Considerations,
and Future Directions...................................................... 825
Jenna Brinks, MS, FAACVPR and Amy Fowler, BS
Chapter 71: Alternative Models to Improve the
Delivery and Impact of Cardiac Rehabilitation................ 833
Randal J. Thomas, MD, MS, Robert Scales, PhD, and
Regis Fernandes, MD, FACC, FASE
Chapter 72: Primordial/Primary Prevention:
Implications and Challenges for Families and Children..... 841
Laura L. Hayman, PhD, MSN, FAAN, FAHA, FPCNA
and James M. Muchira, MSN, PhD candidate
Part XIII Lifestyle Components of Pediatric Medicine
  Stephen R. Daniels, MD, PhD
Chapter 73: Pediatric Lifestyle Medicine......................... 851
Jonathan R. Miller, PhD, Richard Boles, PhD, and
Stephen R. Daniels, MD, PhD
Chapter 74: Life Course Approach to Prevention of
Chronic Disease............................................................... 861
Katherine A. Sauder, PhD and Dana Dabelea, MD, PhD
Chapter 75: Cardiovascular Risk and Physical
Activity in Children........................................................... 873
Lars Bo Andersen, Dr Sc and Robert G. Murray, PhD
Chapter 76: Cardiovascular Risk and Diet in Children....... 887
Jessica L. Hildebrandt, MS, RD and Sarah C. Couch,
PhD, RD
Chapter 77: Sleep and Obesity Prevention in
Children and Adolescents............................................... 901
Jill Landsbaugh Kaar, PhD and Stacey L. Simon, PhD
Chapter 78: Childhood Obesity....................................... 909
Jaime M. Moore, MD and Matthew Allen Haemer, MD,
MPH
Chapter 79: Identification and Management of
Children with Dyslipidemia.............................................. 921
Julie A. Brothers, MD and Stephen R. Daniels, MD, PhD
Chapter 80: Diagnosis, Management, and Treatment
of Systemic Hypertension in Youth, Updates from
the 2017 American Academy of Pediatrics Clinical
Practice Guideline............................................................ 937
Carissa M. Baker-Smith, MD, MS, MPH, FAAP, FAHA
and Samuel Gidding, MD
Chapter 81: Prevention of Osteoporosis in Children
and Adolescents.............................................................. 951
Heidi J. Kalkwarf, PhD
Part XIV The Practice of Lifestyle Medicine
   George Guthrie, MD, MPH, CDE, CNS,
FAAFP, FACLM
Chapter 82: Definition of Lifestyle Medicine.................... 961
George Guthrie, MD, MPH, CDE, CNS, FAAFP, FACLM
Chapter 83: Health Provider Core Competencies in
Lifestyle Medicine............................................................ 969
Liana Lianov, MD, MPH, FACPM, FACLM
Chapter 84: Lifestyle Medicine Clinical Processes......... 977
Ingrid Edshteyn, DO, MPH
Chapter 85: Sleep as Medicine and Lifestyle
Medicine for Optimal Sleep............................................. 995
Virginia F. Gurley, MD, MPH
Chapter 86: Emotional Health and Stress
Management.................................................................. 1003
Neil Nedley, MD and Francisco E. Ramirez, MD, BS, SC
Chapter 87: High-intensity Therapeutic Lifestyle
Change........................................................................... 1019
John Kelly, MD, MPH
Chapter 88: Physician Health Practices and Lifestyle
Medicine......................................................................... 1033
Erica Frank, MD, MPH, FACPM and Debora Holmes,
MES
Part XV Substance Abuse and Addiction
   Elizabeth Pegg Frates,
MD and Joji Suzuki, MD
Chapter 89: Introduction to Addiction Section.............. 1047
Joji Suzuki, MD, Elizabeth Pegg Frates, MD, and Irena
Matanovic
Chapter 90: History of Alcohol and Opioid Use and
Treatment in the United States...................................... 1051
Sanchit Maruti, MD, MS and Steven A. Adelman, MD
 Contents  xi

Chapter 91: Behavioral Approaches to Enhancing Chapter 104: The Employer’s Role in Lifestyle


Smoking Cessation........................................................ 1057 Medicine..........................................................................1175
Joseph T. Ciccolo, PhD, CSCS, Nicholas J. Dexter Shurney, MD, MBA, MPH
SantaBarbara, MS, and Andrew M. Busch, PhD
Chapter 105: Why, How, and What in Leveraging the
Chapter 92: Alcohol Use Disorders: Diagnosis and Value of Health................................................................1181
Treatment....................................................................... 1069 Ron Loeppke, MD, MPH, FACOEM, FACPM
Chwen-Yuen Angie Chen, MD, FACP, FASAM and Sara
C. Slatkin, MD
Chapter 106: International Health & Lifestyle.................1191
Wayne N. Burton, MD, FACP, FACOEM
Chapter 93: Diagnosis and Treatment of Opioid Use
Disorders........................................................................ 1083
Joseph R. Volpicelli, MD Chapter 107: The Community as a Catalyst for
Healthier Behaviors........................................................ 1199
Chapter 94: Cannabis Use Disorder and Treatment....... 1093 Jane Ellery, PhD and Peter Ellery, PhD, MLA
Christina Aivadyan, MS and Deborah Hasin, PhD
Chapter 108: Motivation as Medicine............................ 1209
Chapter 95: Smartphone-Based Technologies in Jennifer S. Pitts, PhD
Addiction Treatment....................................................... 1105
Emily Wu, MD and John Torous, MD Chapter 109: Future Directions of Health Promotion:
Role of the Physician......................................................1217
Chapter 96: Psychosocial Interventions for Alyssa B. Schultz, PhD
Treatment of Substance Use Disorders.........................1113
Saria El Haddad, MD
Part XVIII Exercise Psychology
Part XVI Lifestyle Medicine in Geriatrics    Steven J. Petruzzello, PhD
  Arthur S. Leon, MS, MD, FACSM
Chapter 110: My, How Those Seedlings Have Grown:
Chapter 97: Lifestyle Medicine and the Older An Update on Mind/Body Interactions
Population: Introductory Framework..............................1123 in the Exercise Domain.................................................. 1225
Arthur S. Leon, MS, MD, FACSM and Charlotte A. Steven J. Petruzzello, PhD, Allyson G. Box, BS, and
Tate, PhD Dakota G. Morales, MS

Chapter 98: Reducing Aging-associated Risk of
Sarcopenia......................................................................1127
Arthur S. Leon, MS, MD, FACSM
Chapter 99: Aging-Associated Cognitive Decline and
its Attenuation by Lifestyle..............................................1141
Arthur S. Leon, MS, MD, FACSM
Chapter 100: Aging Successfully: Predictors and
Pathways.........................................................................1147
Debra J. Rose, PhD
Chapter 101: Role of Physical Activity in the Health
and Wellbeing of Older Adults........................................1157
Andiara Schwingel, PhD and Wojtek J. Chodzko-Zajko,
PhD
Chapter 111: Genetic Influences on Regular Exercise
Behavior......................................................................... 1235
Matthijs D. van der Zee, MSc, Nienke Schutte, PhD,
and Marleen H.M. de Moor, PhD
Chapter 112: The Influence of Physical Activity
on Brain Aging and Cognition: The Role of
Cognitive Reserve, Thresholds for Decline,
Genetic Influence, and the Investment
Hypothesis..................................................................... 1251
Maureen K. Kayes, MS and Bradley D. Hatfield, PhD,
FACSM, FNAK
Chapter 113: Physical Activity and Anxiety................... 1271
Katharina Gaudlitz, MSc, Brigitt-Leila von
Lindenberger, MSc, and Andreas Ströhle, MD

Part XVII Health Promotion Chapter 114: Physical Activity and Depression............. 1281
Kayla N. Fair, DrPH and Chad D. Rethorst, PhD
  Dee W. Edington, PhD

Chapter 102: Health Promotion Introduction................ 1169

Dee W. Edington, PhD Part XIX Injury Prevention
  David A. Sleet, PhD, FAAHB
Chapter 103: Health Promotion: History and
Emerging Trends.............................................................1171 Chapter 115: Injuries and Lifestyle Medicine................. 1293
Michael Parkinson, MD, MPH, FACPM David A. Sleet, PhD, FAAHB
xii Contents
Chapter 116: Traffic Injury Prevention: Strategies
That Work....................................................................... 1303
Ann M. Dellinger, PhD, MPH, David A. Sleet, PhD,
FAAHB, and Merissa A. Yellman, MPH
Chapter 117: Review and Implementation of the CDC
Guideline for Prescribing Opioids for Chronic Pain.......1315
LeShaundra Cordier, MPH, CHES and Helen Kingery,
MPH
Chapter 118: Improving the Care of Young Patients
with Mild Traumatic Brain Injury: CDC’s Evidence-
Based Pediatric Mild TBI Guideline............................... 1319
Kelly Sarmiento, MPH, Angela Lumba-Brown, MD,
Matthew J. Breiding, PhD, CDR, US,
Wayne Gordon, PhD, ABPP/Cn, David Paulk, PA-C,
EdD, DFAAPA, Kenneth Vitale, MD FAAPMR, and
David A. Sleet, PhD, FAAHB
Chapter 119: Older Adult Falls: Epidemiology and
Effective Injury Prevention Strategies............................ 1327
Ann M. Dellinger, PhD, MPH, David A. Sleet, PhD,
FAAHB, and Jeanne Nichols, PhD, FACSM
Chapter 120: Prevention of Suicidal Behavior............... 1337
Alex E. Crosby, MD, MPH, Deborah M. Stone, ScD,
MSW, MPH, and Kristin Holland, PhD, MPH
Chapter 121: Unintentional Injuries to Disabled
Persons: An Unrecognized Yet Preventable Problem...... 1349
Louis Hugo Francescutti, MD, PhD, MPH, David A.
Sleet, PhD, FAAHB, Linda Hill, MD, and Henry Xiang,
MD, MPH, PhD
Part XX Public Policy and Environmental
Supports for Lifestyle Medicine
  Gregory W. Heath, DHSc, MPH FAHA, FACSM
Chapter 122: Lifestyle Medicine in an Era of
Healthcare Reform— Seven Years of Healthcare
Disruption: 2010– 2017................................................... 1357
Aaron F. Hajart, MS, ATC, FACNA, Sandra Weisser,
MSEd, ATC, Gary B. Wilkerson, EdD, ATC, and
Gregory W. Heath, DHSc, MPH, FAHA, FACSM
Chapter 123: Policy and Environmental Supports for
Physical Activity and Active Living................................ 1365
Elizabeth A. Dodson, PhD, MPH and Gregory W.
Heath, DHSc, MPH, FAHA, FACSM
Chapter 124: Policy and Environmental Supports for
Healthy Eating................................................................ 1375
Charlene Schmidt, PhD, MS, RDN, Emily Maddux, MS,
MPH, RD, LDN, and Elizabeth Hathaway, PhD, MPH
Chapter 125: Building Strategic Alliances to Promote
Healthy Eating and Active Living................................... 1383
Risa Wilkerson, MA, Elizabeth A. Baker, PhD, MPH, Matt
M. Longjohn, MD MPH, Shewanee D. Howard-Baptiste,
PhD, Kara C. Hamilton, PhD, and Kori Hahn, BS, MS
Chapter 126: Obesity and Health.................................. 1391
James M. Rippe, MD and Theodore J. Angelopoulos,
PhD, MPH
Index������������������������������������������������������������������������������ 1405
 Preface
There is no longer any serious doubt that daily habits
and actions profoundly impact both short- and long-term
health and quality of life. The scientific and medical lit-
erature that supports this concept is now overwhelming.
Thousands of studies provide evidence that regular physi-
cal activity, maintenance of a healthy body weight, not
smoking cigarettes, as well as following sound nutrition,
stress reduction, and other health promoting practices all
profoundly impact health. Conversely, an inactive life-
style, obesity, high levels of stress, and cigarette smoking
or exposure to cigarette smoke and other pollutants all
significantly and negatively impact health.
Since the publication of the second edition of Lifestyle
Medicine (CRC Press, 2013), this literature has continued
to grow stronger and even more robust. The field of life-
style medicine has continued to expand around the globe,
and multiple new initiatives in the area of lifestyle medi-
cine have sprung up in the last few years.
Because the field of lifestyle medicine has grown and
expanded, it is necessary for our Lifestyle Medicine text
to continue to grow and expand in order to serve the needs
of an increasing number of individuals who are incorpo-
rating lifestyle medicine practices in various components
of health care. The text also serves other physicians and
other health care professionals in their practices. Serving
all these providers is the goal of the third edition of
Lifestyle Medicine.
This edition has been thoroughly rewritten and
updated, and incorporates a number of new sections
which address the needs and concerns of lifestyle medicine
practitioners and other physicians throughout the world.
The evidence-base for lifestyle medicine procedures
and practices is based on the enormous strength of the
literature and underscored by its incorporation into vir-
tually every evidence-based clinical guideline addressing
the prevention and treatment of metabolic diseases. For
example, the following guidelines and consensus state-
ments from various prestigious medical organizations all
provide significant emphasis on lifestyle medicine prin-
ciples and practices as key components of the prevention
and treatment of disease:
• JNC VIII Guidelines for Hypertension, Prevention
and Treatment
• ACC/AHA Guidelines for the Prevention, Detection,
Evaluation and Treatment of High Blood Pressure
• NCEP (ATP IV) Guidelines for Blood Cholesterol
• Institute of Medicine Guidelines for Obesity
Treatment
• ACC/AHA Scientific Consensus Statement on the
Treatment for Blood Cholesterol
• Guidelines from the American Diabetes Association
for the Management of Diabetes
• Dietary Guidelines for Americans 2015–2020
• American Heart Association Nutrition
Implementation Guidelines
• Guidelines from the American Academy of Pediatrics
for the Prevention and Treatment of Childhood
Obesity
• Guidelines from the American Academy of Pediatrics
for the Treatment of Pediatric Blood Pressure
• Guidelines from the American Academy of Pediatrics
for the Treatment of Lipids
• Guidelines from the American Heart Association
and the American Academy of Pediatrics for
the Prevention and Treatment of the Metabolic
Syndrome
• American Heart Association Strategic Plan for 2020
• Joint Statement from the American Heart
Association and American Cancer Society for the
Prevention of Heart Disease and Cancer
• Presidential Advisory from the AHA and American
Stroke Association
• AHA/ACC/TOS Guideline for the Management of
Overweight and Obesity in Adults
• ACC/ADA/AHA Scientific Statement on Preventing
Cancer, Cardiovascular Disease and Diabetes
• Physical Activity Guidelines Advisory Committee
Report of 2018
Unfortunately, despite the widespread recognition in these
evidence-based guidelines and consensus statements about
the important role of lifestyle measures and practices in
the prevention and treatment of metabolic diseases, lit-
tle progress has been made in improving the habits and
practices of the American population. In fact, in some
instances, risk factors for chronic diseases have actually
continued to increase in the past decade. For example,
consider the following:
• Cardiovascular disease, which remains the leading
killer of both men and women in the United States,
resulting in over 37% of all mortality each year, has
multiple lifestyle factors as underlying risk factors.
• Over 80% of the adult population in the United
States does not get enough physical activity to result
in health benefits.
• Over two-thirds of the adult population in the
United States is either overweight or obese
• The prevalence of pediatric obesity has tripled in the
past 20 years.
• Less than one-third of the adult population con-
sumes adequate levels of fruits and vegetables and
follows other simple evidenced-based nutritional
practices related to good health.
• Over 15% of individuals still smoke cigarettes.
• Over 40% of the adult population in the United
States has high blood pressure.
xiii
xiv Preface
• The choice of an inactive lifestyle increases the risk
of an individual developing heart disease by as much
as smoking a pack of cigarettes a day does.
• Obesity is the leading cause of osteoarthritis in
women and the second leading cause in men.
• Cigarette smoking is the leading cause of cancer in
the United States and obesity is the second leading
cause.
There is now a wide body of scientific evidence that posi-
tive lifestyle factors dramatically lower risk factors for
chronic disease and promote good health. For example,
in the Nurses’ Health Study, 80% of all heart disease and
over 91% of all diabetes in women could be eliminated if
they would adopt a cluster of positive lifestyle practices,
including maintenance of a healthy body weight (BMI of
19–25 kg/m 2), regular physical activity (30 minutes or
more on most days), not smoking cigarettes, and follow-
ing a few simple nutritional practices such as increasing
whole grains and consuming more fruits and vegetables.
The U.S. Health Professionals Study showed similar dra-
matic reductions of risk in men from these same positive
lifestyle factors. Importantly, if individuals adopted only
one of these positive factors, their risk of developing coro-
nary artery disease would be cut in half. Unfortunately,
numerous studies have shown that less than 5% of adults
in the United States follow most or all of these health-
promoting practices.
The power of daily lifestyle practices and habits has
also been shown in multiple large, randomized controlled
trials. For example, in the Diabetes Prevention Program,
individuals with baseline glucose intolerance who
increased physical activity and lost 5–7% of their body
weight also reduced their risk of developing diabetes by
58%.
In the LOOK AHEAD Trial, individuals who lost 7%
of their body weight significantly reduced risk factors for
heart disease and diabetes. Importantly, in both of these
studies, over 90% of initial weight loss was maintained
over four years for individuals who continued to follow
the program and received periodic follow-up from health
professionals. Levels of physical activity remained high in
both of these studies in follow-up periods of up to four
years.
Because the literature to relating lifestyle practices and
habits has continued to grow deeper and more complex,
the challenge for physicians and other health care profes-
sionals to keep abreast of this ever-expanding field and
incorporate these findings into modern medical practice
has become even more daunting. To further complicate
the challenge, the literature relating lifestyle and health
is spread over a wide variety of disciplines, journals, and
textbooks. The need to provide comprehensive evidence-
based summaries concerning lifestyle and health in a text-
book that spans the field of lifestyle medicine has clearly
become even more evident in the five years since the pub-
lication of the second edition of our textbook. Another
goal for the third edition of Lifestyle Medicine has been to
address this need.
With the first edition of Lifestyle Medicine in 1999
we coined the term “lifestyle medicine” and summarized
key findings across multiple disciplines that existed in the
late 1990s. Following the publication of the first edition
of Lifestyle Medicine, a number of initiatives took place,
including the launch of a peer-reviewed academic journal
in lifestyle medicine (the American Journal of Lifestyle
Medicine; SAGE Publications). A consensus statement
on the core principles of lifestyle medicine was published
in the Journal of the American Medicine Association
based on recommendations from representatives from
major medical groups, including the American Medical
Association, the American College of Physicians, the
American Academy of Pediatrics, the American College
of Sports Medicine, the American College of Preventive
Medicine, and others.
In addition, an academic medical society in lifestyle
medicine, the American College of Lifestyle Medicine,
has been established for physicians and other health
care workers. This organization has more than doubled
its membership each year for the past five years and has
launched a number of important initiatives in the educa-
tion and practice of lifestyle medicine. Other professional
groups have increasingly embraced the concept of lifestyle
medicine. These include the American Heart Association,
which now has a council entitled the “Council on Lifestyle
and Cardiometabolic Health.” The American Academy of
Family Practice and the American College of Preventive
Medicine now offer education tracks for individuals inter-
ested in adding lifestyle medicine as a key component of
their medical practices.
All of these advances are welcome and will enhance
the likelihood of formal adoption of lifestyle medicine
practices within the medical community. Unfortunately,
however, at the current time, less than 30% of physicians
routinely counsel their patients on weight management,
physical activity, and proper nutrition. This is a squan-
dered opportunity, since more than 75% of the adult
population sees a primary care physician at least once
per year. This gap between evidence and application rep-
resents an enormous mandate and opportunity to under-
score the links between lifestyle habits and practices and
health outcome.
So what is “lifestyle medicine?” In the first edition of
our textbook we defined it as “the integration of lifestyle
practices into the modern practice of medicine both to
lower the risk factors for chronic disease and/or, if dis-
ease is already present, serve as an adjunct in its therapy.
Lifestyle medicine brings together sound, scientific evi-
dence in diverse health-related fields to assist the clinician
in the process of not only treating disease but also promot-
ing good health.” While this definition was put forth over
almost two decades ago, it has largely stood the test of
time. Other organizations have offered very similar defi-
nitions of lifestyle medicine, and these definitions serve as
the defining principle behind the third edition of Lifestyle
Medicine.
The third edition of Lifestyle Medicine is divided into
20 parts related to lifestyle medicine; each part’s chapters
have been edited by a leader of that particular discipline.
All chapters have been fundamentally rewritten or sub-
stantially revised and brought up-to-date with current
understandings and practices. There are also many new
chapters and several new parts added to reflect modern
understandings and particular areas which have emerged

as critically important in lifestyle medicine over the past
five years.
The third edition of Lifestyle Medicine opens
with Part I, Lifestyle Management and Prevention of
Cardiovascular Disease. I chose to have this as the initial
part for a number of reasons. First, I am a cardiologist,
and my initial interest in lifestyle medicine came through
issues related to lowering the risk of cardiovascular dis-
ease. Secondly, the area of cardiovascular medicine has
been one of the leaders in adopting lifestyle habits and
practices to reduce the risk of disease. These concepts are
further articulated in the AHA Strategic Goals for the Year
2020. In addition, the council that I sit on within the AHA
has changed its name from the “Council on Nutrition,
Physical Activity and Metabolism” to the “Council on
Lifestyle and Cardiometabolic Health,” a welcome recog-
nition of the key role that lifestyle plays in the prevention
and treatment of heart disease. Within this opening part
are state-of-the-art chapters on various aspects of risk
reduction incorporating the most recent guidelines pro-
mulgated by the American College of Cardiology (ACC)
and the American Heart Association (AHA).
Part II, is Nutritional Aspects of Lifestyle Medicine.
Of course, nutrition plays a very prominent role in healthy
lifestyle habits and actions. This section has been entirely
updated and includes such new chapters as the one on the
Dietary Guidelines for Americans 2015 and one on hydra-
tion, which is an important area that is often overlooked
in nutrition.
Part III is a greatly expanded section on Physical
Activity. This Part contains state-of-the- art chapters on
exercise prescription in various populations and what phy-
sicians should know about prescribing exercise and physi-
cal activity. Levels of physical activity remain extremely
low in the American population, and I hope that this sec-
tion will encourage physicians to play a more active role
in this area. Physical activity is one of the most powerful
tools we have to lower the risk of chronic disease. These
chapters further elucidate the findings of the Physical
Activity Guidelines for 2018 Advisory Committee report,
which documents the expanding list of health benefits of
physical activity for both adults and children.
Part IV is also a greatly expanded section on
Behavioral Medicine. Understandings of how to change
behaviors are fundamental to virtually every other aspect
of lifestyle medicine. This Part includes not only chap-
ters on theoretical frameworks for how to apply psycho-
logical theories to promote healthy lifestyles but also
important new chapters on Motivational Interviewing,
the Transtheoretical Model of Change, and Positive
Psychology. An important new chapter delves into how
to address the gap between what people intend to do and
what they actually do. This “Intention-Behavior Gap”
has not received enough attention in the past, but the
state-of-the-art chapter on this topic provides practical
advice in this important area. Three chapters focus on
how to use behavioral approaches in the areas of physical
activity, nutrition, and stress management. The section
concludes with a state-of-the-art chapter on the emerg-
ing field of health coaching and a chapter on the latest
technologies and devices which hold great promise for
facilitating behavioral change.
Preface  xv
Part V focuses on specific issues related to Women’s

Health and includes chapters on breast health and physi-
cal activity. Part VI, Endocrinology and Metabolism, is a
thoroughly updated and expanded section which focuses
on lifestyle factors particularly in the area of the preven-
tion and management of diabetes and the metabolic syn-
drome. Part VII, Lifestyle Issues in the Prevention and
Treatment of Cancer, represents an important area which
has been underestimated in many clinicians’ practices.
The chapters are written by leading world experts not only
from the Centers from Disease Control but from various
universities. These chapters are particularly important
since many physicians are unaware of the multiple links
between lifestyle practices and a wide variety of cancers.
Part VIII, Obesity and Weight Management, has been
thoroughly rewritten with state-of-the-art chapters on epi-
demiology, exercise management, dietary management,
pharmacologic management, and surgery for obesity. Also
included is a new chapter entitled “Impact of Lifestyle
Medicine on Dysglycemia-Based Chronic Disease,” which
focuses on recently released statements from the American
College of Endocrinology and provides an intriguing new
framework for considering obesity-related conditions.
The Immunology and Infectious Disease and
Pulmonary Medicine sections have both been entirely
rewritten and updated. The section on Obstetrics and
Gynecology contains a number of new chapters and revi-
sions of other chapters related to how lifestyle impacts on
pregnancy and other key issues in obstetrics and gynecol-
ogy, such as breastfeeding, contraception, sexually trans-
mitted diseases, menstrual disorders, and risk reduction
of cancers. Part XII is an entirely rewritten and expanded
section on Cardiovascular Rehabilitation and Secondary
Prevention, which provides contemporary information on
the intersection between traditional cardiac rehabilitation
and emerging areas of secondary prevention in cardiovas-
cular medicine.
Part XIII, Lifestyle Components of Pediatric Medicine,
contains state-of-the-art chapters by world leaders in the
application of lifestyle practices to the treatment of the
pediatric population. We have increasingly come to under-
stand that many diseases which are manifested in adults
have their roots in childhood. Key issues related to cardio-
vascular risk, obesity, diabetes, lipids, blood pressure, and
osteoporosis in children are all highlights of this impor-
tant section.
Increasingly individuals are opting to make lifestyle
medicine the cornerstone of their medical practice. For
this reason we have included an entirely new section, The
Practice of Lifestyle Medicine, which contains chapters
by leading practitioners within the American College of
Lifestyle Medicine (ACLM). Many of these chapters relate
specifically to educational efforts by the ACLM to engage
physicians in this area and provide the core competencies
needed to practice lifestyle medicine.
Part XV is an entirely new section in the area of
Substance Abuse and Addiction. It will come as no sur-
prise to members of the medical community that the
United States is in the midst of an opioid epidemic, but
there are also a variety of other addictions such as alcohol,
tobacco, marijuana, and so on which should be part of
the knowledge base for every physician. There is also an
xvi Preface
important chapter in this section on emerging technolo-
gies and apps for treating addiction.
Individuals over the age of 65 represent the fastest
growing portion of the United States population. The
expanded section on Lifestyle Medicine in Geriatrics
deals with a number of issues that are highly relevant to
this segment of the population. In particular, age-related
declines in skeletal muscle and cognitive function which
are increasingly prevalent in this population have both
been demonstrated to be significantly ameliorated by life-
style practices and habits. There are two new chapters on
these topics. In addition, a separate chapter on physical
activity in individuals over the age of 65 is presented as
well as a general overview on the concept of “success-
ful aging.” This latter concept has changed the way we
approach lifestyle measures in people over the age of 65.
Rather than focusing on declining physiological and emo-
tional characteristics in this population, there are now
data and programs that show how individuals in this
phase of life can maintain a healthy lifestyle and benefit
from their wealth of experience while slowing down the
normal physical and mental declines often experienced
with aging.
Part XVII, Health Promotion, is an important concept
in lifestyle medicine, and this section contains a substan-
tial increase in the number of chapters devoted to this
very important topic. This Part focuses largely on differ-
ent venues where health promotion can be delivered and
offers practical, evidence-based advice about successful
health promotion programs. The psychological benefits of
exercise represent an area of increasing research, interest,
and application. The expanded and updated section on
Exercise Psychology (Part XVIII) deals with the science
that is known about how exercise impacts psychological
well-being. New chapters on the role of physical activity
to ameliorate anxiety and depression as well as improve
or maintain cognitive function are important chapters in
this area.
Often injuries are not considered in the area of life-
style medicine. However, injuries have a direct impact on
lifestyle for many individuals. These topics are handled
in detail in the expanded Part XIX, Injury Prevention.
These chapters are largely written by experts from the
National Center for Injury Prevention and Control at the
Centers for Disease Control.
Of course, lifestyle changes do not occur in isola-
tion. Public policy issues play a very important role in
how the environment either supports or undercuts indi-
viduals’ ability to improve their health through lifestyle
measures. The final section of the book, Public Policy and
Environmental Supports for Lifestyle Medicine, deals
with this important aspect of lifestyle medicine in consid-
erable detail.
The work of generating this comprehensive and up-to-
date volume in lifestyle medicine involved the hard work
and talent of 21 section editors who have devoted enor-
mous energy and talent to the difficult task of organizing
and editing parts and ensuring that they are both scien-
tifically accurate and clinically useful. What has resulted
from their efforts and those of over 250 distinguished
contributors is a textbook which I hope and believe will
be clinically useful in guiding health care professionals
and providing state-of-the-art summaries and practical
applications of modern science and medical understand-
ings related to the interaction between lifestyle practice,
medicine, and good health.
We have further emphasized clinical utility in the
third edition of Lifestyle Medicine by asking each author
to list “Key Points” at the beginning of each chapter and
“Clinical Applications” at the end of each chapter. These
additions, we hope, will respectively be a helpful introduc-
tion to each chapter and guidance for applying the infor-
mation in the chapter to the daily practice of medicine.
As in previous editions, we hope this work will help our
patients lead happier, healthier, and more productive lives
while lowering their risk of chronic diseases and enhanc-
ing their quality of life.
Over the two decades since the publication of the first
edition of Lifestyle Medicine, important and extensive
new information has emerged to provide scientific links
between daily habits and actions and their ever-expanding
impact on short- and long-term health and quality of life.
A key consideration remains for those of us in the health
care community with respect to applying these under-
standings to the modern practice of medicine. Lifestyle
medicine is, in my view, the single greatest opportunity
that we have to improve health outcomes and lower cost.
This is crucial to underscoring and advancing the value
proposition in the practice of medicine. This is both the
challenge and the enormous opportunity in front of all
of us who are blessed as gatekeepers to the health of our
patients in our country. I hope that this edition of Lifestyle
Medicine will continue to support the magnificent efforts
of all of those who strive to enhance the health of all their
patients.
James M. Rippe, MD
Boston, Massachusetts
 Acknowledgments
Textbook writing and editing are collaborative efforts
that involve the hard work and passion of numer-
ous contributors. Individuals who have stimulated
my thinking about the interaction between lifestyle
and health over many years are too numerous to
acknowledge all by name. However, I would like to
particularly thank a few individuals who have made
substantial contributions to the third edition of
Lifestyle Medicine.
First, my longtime Editorial Director, Beth Grady,
who plays a critically important role in all of the major
writing and editing projects that emerge from my research
organization, deserves special thanks. The third edition of
Lifestyle Medicine is one of over 50 books that Beth has
managed which have been generated through our organi-
zation. In addition to the current textbook, she provides
editorial direction to two academic journals which I edit
as well as a major intensive-care textbook (Irwin and
Rippe’s Intensive Care Medicine, 8th Edition, Wolters
Kluwer, 2018). She also helps to coordinate other academic
endeavors. Beth possesses superb editorial skills and puts
in enormous efforts with unfailing good humor to make
all of these complex and difficult projects possible.
I would also like to thank 21 section editors who con-
tributed hard work and exceptional editorial skills to
ensure scientific accuracy and clinical relevance for each
of the sections of this book. I am deeply grateful to all of
these individuals. A special thanks goes out to the more
than 250 scientists and clinicians who have contributed
chapters to this textbook. These individuals, who are
internationally renowned experts in the key fields related
to lifestyle medicine, have made invaluable contributions
to assemble and explain enormous amounts of data in this
rapidly emerging discipline.
I would also like to express my appreciation to my
office support staff, including my Executive Assistant,
Carol Moreau, who seamlessly coordinates my schedule
and travel plans to free up the time necessary for such large
writing and publishing projects. Our Office Assistant,
Deb Adamonis, assists all of us in the multiple daily tasks
required to expedite diverse projects in our office, while
our Chief Financial Officer, Connie Martell, makes sure
that the financial processes are in place for all or our
projects to move forward smoothly. The research team at
Rippe Lifestyle Institute has always contributed enormous
insights to clarify my thinking about a number of aspects
of lifestyle medicine, while our Director of Marketing and
Client Services, Amy Continelli, coordinates the day-to-
day interactions with multiple research sponsors.
I would also like to thank the outstanding editorial
team at Taylor & Francis Group/CRC Press. Included in
this group are Randy Brehm, Senior Editor, who has been
an early key supporter of our textbooks, Jay Margolis, the
Project Editor who managed every step of the production
process with expertise, patience, and knowledge, Laura
Piedrahita, Editorial Assistant, who prepared and orga-
nized our files for production while managing communi-
cation with hundreds of authors, as well as Rachel Cook,
Senior Project Manager at Deanta, who managed the edit-
ing, design, and typesetting of the book with great skill.
Finally, I am grateful to my family, including my lov-
ing wife, Stephanie Hart Rippe, and our four beautiful
daughters, Hart, Jaelin, Devon, and Jamie, who continue
to love and support me through the arduous process of
many major textbooks and journals and the other diverse
professional responsibilities that I juggle along with my
family life.
If there are errors or omissions in Lifestyle Medicine,
the responsibility is mine. If there is credit due for this
project, it belongs to the numerous people who have made
substantial contributions along the way.
James M. Rippe, MD
Boston, Massachusetts
xvii
 About the Editor
James M. Rippe, MD , is a graduate of Harvard College
and Harvard Medical School. His postgraduate training
was at Massachusetts General Hospital. He is currently
the founder and director of the Rippe Lifestyle Institute.
Over the past 25 years, Dr. Rippe has established and
run the largest research organization in the world that
explores how daily habits and actions impact short- and
long-term health and quality of life. This organization,
the Rippe Lifestyle Institute (RLI), has published hun-
dreds of papers that form the scientific basis for the fields
of lifestyle medicine and high-performance health. RLI
also conducts numerous studies every year on physical
activity, nutrition, and healthy weight management.
A lifelong and avid athlete, Dr. Rippe maintains his
personal fitness with a regular walk, jog, swimming, and
weight training program. He holds a black belt in karate
and is an avid wind surfer, skier, and tennis player. He
lives outside of Boston with his wife, television news
anchor Stephanie Hart and their four children, Hart,
Jaelin, Devon, and Jamie.
xix
 Contributors

Steven A. Adelman, MD Carissa M. Baker-Smith, MD, MS, MPH, FAAP,

Director of Massachusetts Physician Health Services FAHA
Clinical Associate Professor of Psychiatry Assistant Professor of Pediatrics
University of Massachusetts Medical School Division of Cardiology
Worcester, Massachusetts University of Maryland School of Medicine
Baltimore, Maryland
Matthew Cole Ainsworth, MPH
Doctoral Trainee Christie Mitchell Cobb, MD
Department of Health Behavior Partner
University of Alabama at Birmingham Little Rock Gynecology & Obstetrics
Birmingham, Alabama Little Rock, Arkansas

Nathan A. Berger, MD
Christina Aivadyan, MS
Distinguished University Professor
School of Social Work
Hanna-Payne Professor of Experimental Medicine
Columbia University
Professor of Medicine, Biochemistry, Oncology, Genetics
New York, New York
and Genome Sciences
Director, Center for Science, Health and Society
Jean M. Altman, MS Case Comprehensive Cancer Center
Nutritionist Case Western Reserve University School of Medicine
Office of Nutrition Guidance and Analysis Cleveland, Ohio
Center for Nutrition Policy and Promotion
U.S. Department of Agriculture Aaron D. Berman, MD, FACC
Alexandria, Virginia Clinical Chief, Department of Cardiovascular Medicine
Beaumont Hospital
Lars Bo Andersen, Dr Sc Royal Oak, Michigan
Professor and
Faculty of Teacher Education and Sport Associate Professor, Oakland University William
Western Norwegian University of Applied Sciences Beaumont School of Medicine
Oslo, Norway Rochester, Michigan

Theodore J. Angelopoulos, PhD, MPH Mark Berman, MD, FACLM

Professor & Chair Head of Health
Department of Rehabilitation and Movement Sciences Better Therapeutics, LLC
University of Vermont San Francisco, California
Burlington, Vermont
Kathy Berra, MSN, NP-BC, FAANP, FPCNA, FAHA,
Katherine R. Arlinghaus, MS, RD, LD FAAN
Department of Health and Human Performance Co-Director
University of Houston The LifeCare Company
Houston, Texas Nurse Practitioner
Cardiovascular Medicine and Coronary Interventions
Redwood City, CA
Regan L. Bailey, PhD, RD, MPH, CPH Stanford Prevention Research Center
Associate Professor of Nutrition Science Stanford University School of Medicine (Ret)
Purdue University Menlo Park, California
West Lafayette, Indiana
Ozlem Bilen, MD
Elizabeth A. Baker, PhD, MPH Cardiology Fellow
Professor and Chair, Behavioral Science and Health Department of Medicine
Education Division of Cardiology
Saint Louis University School of Public Health Emory University School of Medicine
St. Louis, Missouri Atlanta, Georgia

xxi
xxii Contributors

Kristin Bixel, MD Debora S. Bruno, MD, MS

Division of Gynecologic Oncology Assistant Professor of Medicine and Oncology
Department of Obstetrics and Gynecology Hematology/Oncology Division
Ohio State University Department of Medicine
Columbus, Ohio Case Western Reserve University
School of Medicine
Richard Boles, PhD MetroHealth Medical Center
Associate Professor, Pediatrics-Nutrition Cleveland, Ohio
University of Colorado School of Medicine
Aurora, Colorado Wayne N. Burton, MD, FACP, FACOEM
Former Global Corporate Medical Director
Heather R. Bowles, PhD American Express Company
Epidemiologist Chicago, Illinois
Biometry Research Group
Division of Cancer Prevention Andrew M. Busch, PhD
National Cancer Institute Hennepin Healthcare
Bethesda, Maryland University of Minnesota Medical School
St Paul, Minnesota
Allyson G. Box, BS
Graduate Student Anthony C. Campagna, MD, FCCP
Department of Kinesiology and Community Health PCCM Fellowship, Program Director
University of Illinois Urbana-Champaign Department of Pulmonary and Critical Care Medicine
Urbana, Illinois Lahey Hospital and Medical Center
Burlington, Massachusetts
Matthew J. Breiding, PhD, CDR, US
Public Health Service Karen Carlson, MD
Traumatic Brain Injury Team Lead Assistant Professor
Division of Unintentional Injury Prevention Obstetrics & Gynecology
National Center for Injury Prevention & Control University of Nebraska Medical College
Centers for Disease Control & Prevention Nebraska Medicine Obstetrics & Gynecology
Atlanta, Georgia Omaha, Nebraska

Shelley H. Carson, PhD

Jenna Brinks, MS, FAACVPR
Associate
Business Manager
Department of Psychology
Heart & Vascular Services
Lecturer in Extension
Beaumont Hospital
Harvard University
Royal Oak, Michigan
Cambridge, Massachusetts
Ulf G. Bronas, PhD, ATC, FSVM, FAHA Jennifer Carty, PhD
Associate Professor Behavioral Health Fellow
The University of Illinois at Chicago University of Massachusetts Medical School
College of Nursing Worcester, Massachusetts
Department of Biobehavioral Health Science
Chicago, Illinois
Paulette Chandler, MD, MPH
Assistant Professor of Medicine
Julie A. Brothers, MD Harvard Medical School
Assistant Professor of Pediatrics and Medical Director Division of Preventive Medicine
Lipid Heart Clinic Associate Epidemiologist and Associate Physician
The Perelman School of Medicine at the University of Phyllis Jen Center of Primary Care
Pennsylvania Brigham and Women’s Hospital
The Children’s Hospital of Philadelphia Boston, Massachusetts
Philadelphia, Pennsylvania
Chwen-Yuen Angie Chen, MD, FACP, FASAM
Austin L. Brown, MPH, PhD Primary Care and Population Health in the Department
Instructor of Medicine
Department of Pediatrics Hematology & Oncology Medical Director of Primary Care Chemical Dependency
Baylor College of Medicine Program
Houston, Texas Stanford University School of Medicine
 Contributors  xxiii

Xisui Shirley Chen, MD Andrea Cook, PhD


Division of General Internal Medicine Department of Psychology
Department of Medicine University of California Santa Cruz
University of Pennsylvania Perelman School of Medicine Santa Cruz, California
Philadelphia
LeShaundra Cordier, MPH, CHES
Wojtek J. Chodzko-Zajko, PhD
Communications Team Lead
Dean
Division of Unintentional Injury Prevention (DUIP)
Graduate College
National Center for Injury Prevention and Control
Shahid and Ann Carlson Khan Professor in Applied
(NCIPC)
Health Sciences
Centers for Disease Control and Prevention (CDC)
University of Illinois at Urbana-Champaign
Atlanta, Georgia
Urbana, Illinois

David E. Ciccolella, MD Sarah C. Couch, PhD, RD

Department of Thoracic Medicine and Surgery Professor and Vice Chair
Temple Lung Center Graduate Program Director
Louis Katz School of Medicine Department of Rehabilitation, Exercise and Nutrition
Temple University Sciences
Philadelphia, Pensylvannia University of Cincinnati
Cincinnati, Ohio
Joseph T. Ciccolo, PhD, CSCS
Assistant Professor of Movement Science and Kinesiology
Department of Biobehavioral Sciences Alex E. Crosby, MD, MPH
Teachers College Medical Epidemiologist
Columbia University Centers for Disease Control and Prevention (CDC)
New York, New York National Center for Injury Prevention and Control
(NCIPC)
Daniel B. Clarke, MBA Division of Violence Prevention (DVP)
Executive Chef Atlanta, Georgia
Spaulding Rehabilitation Hospital
Boston, MA Nina Crowley, PhD, RDN, LD
University of Massachusetts, Boston, MA (MBA) Surgery Program Coordinator Metabolic and Bariatric
The Culinary Institute of America Surgery
Hyde Park, New York Medical University of South Carolina
Charleston, South Carolina
Matthew M. Clark, PhD
Professor of Psychology
Chair for Research Gilbert E. D’Alonzo, DO
Department of Psychiatry and Psychology Department of Thoracic Medicine and Surgery
Mayo Clinic Temple Lung Center
Rochester, Minnesota Louis Katz School of Medicine
Temple University
Paul M. Coen, PhD Philadelphia, Pennsylvania
Translational Research Institute for Metabolism &
Diabetes Dana Dabelea, MD, PhD
AdventHealth Conrad M. Riley Professor of Epidemiology and
Orlando, Florida Pediatrics
Director
Lola A. Coke, PhD, ACNS-BC, CVRN-BC, FAHA,
Lifecourse Epidemiology of Adiposity and Diabetes
FPCNA, FAAN
(LEAD) Center
Associate Professor
Colorado School of Public Health
Johns Hopkins School of Nursing
University of Colorado Anschutz Medical Campus
Baltimore, Maryland
Aurora, Colorado
Katherine A. Collins, MS, CBDT
Graduate Student Researcher Stephen R. Daniels, MD, PhD
University of Pittsburgh Chair
Department of Health and Physical Activity Department of Pediatrics
Healthy Lifestyle Institute University of Colorado School of Medicine
Physical Activity and Weight Management Research Pediatrician-in-Chief
Center Children’s Hospital Colorado
Pittsburgh, Pennsylvania Aurora, Colorado
xxiv Contributors

Cindy D. Davis, PhD Patricia M. Dubbert, PhD

Director of Grants and Extramural Activities Associate Director for Research Training
Office of Dietary Supplements Professor (Retired)
National Institutes of Health South Central Veterans Affairs Mental Illness, Research,
Bethesda, Maryland Education, and Clinical Center
Department of Psychiatry
Paul G. Davis, PhD, ACSM-CEP University of Arkansas for Medical Science
Associate Professor Little Rock, Arkansas
Department of Kinesiology
The University of North Carolina at Greensboro Wesley D. Dudgeon, PhD
Greensboro, North Carolina Associate Professor and Chair
Department of Health and Human Performance
R. Sue Day, MS, PhD College of Charleston
Professor of Epidemiology Charleston, South Carolina
The University of Texas Health Science Center at
Houston (UTHealth) Beth Baughman DuPree, MD, FACS, ABOIM
School of Public Health Adjunct Assistant Professor
Department of Epidemiology, Human Genetics & University of Pennsylvania
Environmental Sciences Medical Director
Southwest Center for Occupational and Environmental Oncology Service Line Northern Arizona Healthcare
Health VP Holy Redeemer Health System
Michael & Susan Dell Center for Healthy Living Sedona, Arizona
Houston, Texas
Johanna T. Dwyer, DSc, RD
Eco J.C. De Geus, PhD
Senior Nutrition Scientist (contractor)
Professor
Office of Dietary Supplements NIH
Department of Biological Psychology
Bethesda, Maryland
Vrije Universiteit
Amsterdam, The Netherlands
David Ede, Jr., BS
Ann M. Dellinger, PhD, MPH Graduate Student
Division of Unintentional Injury Prevention Department of Psychological Sciences
National Center for Injury Prevention and Control Kent State University
Centers for Disease Control and Prevention Kent, Ohio
Atlanta, Georgia
Dee W. Edington, PhD
Marleen H.M. de Moor, PhD Professor Emeritus
Assistant Professor University of Michigan
Section of Clinical Child and Family Studies, Methods Principal, Edington Associates
Faculty of Behavioural and Movement Sciences Ann Arbor, Michigan
Vrije Universiteit Amsterdam
Amsterdam, The Netherlands Ingrid Edshteyn, DO, MPH
Associate Physician
Dhruv Desai, MD Department of Medicine
Fellow Center for Human Nutrition
Department of Pulmonary and Critical Care Medicine David Geffen School of Medicine at UCLA
Lahey Hospital and Medical Center Los Angeles, California
Burlington, Massachusetts
Saria El Haddad, MD
Nikhil V. Dhurandhar, PhD Instructor
Professor and Chair Harvard Medical School
Department of Nutritional Sciences Department of Psychiatry
Texas Tech University Brigham and Women’s Faulkner Hospital
Lubbock, Texas Boston, Massachusetts

Elizabeth A. Dodson, PhD, MPH Jane Ellery, PhD

Research Assistant Professor Project For Public Spaces
Brown School and Prevention Research Center in St. and
Louis School of Kinesiology
Washington University in St. Louis Ball State University
St. Louis, Missouri Muncie, Indiana
 Contributors  xxv

Peter J. Ellery, PhD, MLA John P. Foreyt, PhD


School of Architecture & Built Environment Professor
Deakin University—Geelong Waterfront Campus Department of Medicine
Geelong, Victoria, Australia and
Director
James E. Eubanks, Jr., DC, MS Behavioral Medicine Research Center
Research Scholar Baylor College of Medicine
MD Candidate, Class of 2018 Houston, Texas
Brody School of Medicine at East Carolina University
Amy Fowler, BS
Department of Physical Medicine and Rehabilitation
Senior Exercise Physiologist
Greenville, North Carolina
Preventive Cardiology & Rehabilitation
Beaumont Health
Gethin H. Evans, BSc, PhD Royal Oak, Michigan
Principle Lecturer in Healthcare Science
School of Healthcare Science Louis Hugo Francescutti, MD, PhD, MPH
Manchester Metropolitan University Professor
Manchester, UK School of Public Health
Department of Emergency Medicine Faculty of Medicine
Kayla N. Fair, DrPH University of Alberta
Postdoctoral Researcher Edmonton, AB, Canada
Center for Depression Research and Clinical Care
Department of Psychiatry Erica Frank, MD, MPH, FACPM
University of Texas Southwestern Medical Center Professor and Canada Research Chair
Dallas, Texas University of British Columbia
Founder and President, www.NextGenU.org
and
Mark D. Faries, PhD Principal Investigator
Texas A&M AgriLife Extension Service Healthy Doc = Healthy Patient
Texas A&M School of Public Health Vancouver, BC, Canada
Texas A&M University College of Medicine
College Station, Texas Barry A. Franklin, PhD
Director, Preventive Cardiology and
Regis Fernandes, MD, FACC, FASE Cardiac Rehabilitation
Medical Director, Cardiac Rehabilitation Program Beaumont Health
Mayo Clinic Beaumont Health & Wellness Center
Scottsdale, Arizona Royal Oak, Michigan
Assistant Professor of Medicine
Mayo Clinic School of Medicine Marion J. Franz, MS, RD, CDE
Scottsdale, Arizona Nutrition/Health Consultant
Nutrition Concepts by Franz, Inc.
Minneapolis, Minnesota
Antonio B. Fernandez, MD
Director
Cardiac Intensive Care Unit Elizabeth Pegg Frates, MD
The Heart and Vascular Institute Lifestyle Medicine Specialist
Hartford Hospital Health and Wellness Coach
Hartford, Connecticut Wellness Synergy, LLC
and
Assistant Professor, Part Time
Peter Fifield, EdD, LCMHC, MLADC Harvard Medical School
Adjunct Faculty Harvard Extension School
Department of Education Boston, Massachusetts
University of New England
Biddeford, Maine Karla I. Galaviz, PhD, MSc
Assistant Professor
Michael G. Flynn, PhD Hubert Department of Global Health
Division Director of Research Rollins School of Public Health
HCA South Atlantic Emory University
Charleston, South Carolina Atlanta, Georgia
xxvi Contributors

Joseph Gallant, MD George Guthrie, MD, MPH, CDE, CNS, FAAFP,

University of Massachusetts Medical School
Division of Pulmonary, Allergy, and Critical Care
Medicine
Worcester, Massachusetts
Katharina Gaudlitz, M.Sc
Dr. rer. medic
Zentrum fuer Angst- und Depressionsbehandlung
Zuerich (ZADZ)
Switzerland
Maryam Gholami, PhD
Department of Family Medicine and Public Health
University of California, San Diego
La Jolla, California
Samuel Gidding, MD
Chief
Division of Pediatric Cardiology
Department Nemours Cardiac Center
Alfred I. duPont Hospital for Children
Wilmington, Delaware
Neil F. Gordon, MD, PhD, MPH, FACC
INTERVENT International
Savannah, Georgia
and
Centre for Exercise Science and Sports Medicine
School of Therapeutic Sciences
University of the Witwatersrand
Johannesburg, South Africa
Wayne Gordon, PhD, ABPP/Cn
Jack Nash Professor and Vice Chair
Department of Rehabilitation Medicine
Icahn School of Medicine at Mount Sinai
New York, New York
Philip Greenland, MD
Harry W. Dingman Professor
Department of Preventive Medicine
Northwestern University
Feinberg School of Medicine
Chicago, Illinois
FACLM
President
American College of Lifestyle Medicine
Centre for Family Medicine
Florida Hospital Medical Group
Florida Hospital Graduate Medical Education
University of Central Florida
Winter Park, Florida
Matthew Allen Haemer, MD, MPH
Associate Professor
University of Colorado School of Medicine
Department of Pediatrics
Section of Nutrition
Medical Director
Lifestyle Medicine Level One Weight Management
Program
Children’s Hospital Colorado
Aurora, Colorado
Kori Hahn, BS, MS
Master of Science Candidate
Department of Health and Human Performance
University of Tennessee at Chattanooga
Chattanooga, Tennessee
Aaron F. Hajart, MS, ATC, FACNA
Assistant Dean, Clinical Strategy and Development
Office of Clinical Affairs
Rutgers New Jersey Medical School
Newark, New Jersey
Sadia Haider, MD, MPH
Associate Professor
Chief, Family Planning and Contraceptive Research
Department of Obstetrics and
Gynecology
University of Chicago Medicine
The University of Chicago
Chicago, Illinois
Kara C. Hamilton, PhD
Assistant Professor, Department of Health and Human
Performance
University of Tennessee at Chattanooga
Chattanooga, Tennessee

Gregory A. Hand, PhD, MPH, FACSM, FESPM

Angela Grone, MD, FACOG
Professor
Obstetrician/Gynecologist
Department of Epidemiology
Beatrice Women’s & Children’s Clinic
Robert C. Byrd Health Sciences Center
Beatrice Community Hospital and Health Center
West Virginia University
Beatrice, Nebraska
Morgantown, West Virginia

Virginia F. Gurley, MD, MPH Mary Hannan, MSN, APN, AGACNP-BC

AxisPoint Health and HGS Healthcare PhD student
Lisle, Illinois Department of Biobehavioral Health Science
College of Nursing
University of Illinois at Chicago
Chicago, Illinois
 Contributors  xxvii

Deborah Hasin, PhD Jessica L. Hildebrandt, MS, RD


Professor Clinical Dietitian
Department of Psychiatry Lifestyle Medicine Program
College of Physicians and Surgeons, Children’s Hospital Colorado
Department of Epidemiology, Mailman School of Public Aurora, Colorado
Health
Columbia University Linda Hill, MD
New York, New York Director
Center for Human and Urban Mobility
and
Bradley D. Hatfield, PhD, FACSM, FNAK
Director
President National Academy of Kinesiology
Preventive Medicine Residency
Professor and Chair
and
Department of Kinesiology
Professor
and
Department of Family Medicine and Public Health
Associate Dean for Faculty Affairs
School of Medicine
School of Public Health
University of California, San Diego
Affiliate – Neuroscience and Cognitive Science Program
San Diego, California
University of Maryland
College Park, Maryland
Kristin Holland, PhD, MPH
Lead Behavioral Scientist
Elizabeth Hathaway, PhD, MPH Division of Violence Prevention (DVP)
Assistant Professor Centers for Disease Control and Prevention (CDC)
Exercise Science National Center for Injury Prevention and Control
Department of Health and Human Performance (NCIPC)
University of Tennessee at Chattanooga Atlanta, Georgia
Chattanooga, Tennessee
Debora Holmes, MES
Laura L. Hayman, PhD, MSN, FAAN, FAHA, FPCNA Chief Editor
Professor NextGenU.org
Department of Nursing Clear Lake, Washington
College of Nursing and Health Sciences
Jenna M. Holzhausen, PharmD, BCPS
University of Massachusetts Boston
Clinical Pharmacy Specialist, Critical Care
Adjunct Professor of Medicine
Cardiac Intensive Care Unit
Department of Medicine
Beaumont Hospital
Division of Preventive and Behavioral Medicine
Royal Oak, Michigan
University of Massachusetts Medical School
Boston, Massachusetts
Shewanee D. Howard-Baptiste, PhD
Associate Professor
Julia Head, MD Department of Health and Human Performance
Clinical Fellow University of Tennessee at Chattanooga
Department of Obstetrics and Chattanooga, Tennessee
Gynecology, and Reproductive Biology
Beth Israel Deaconess Medical Center Joel W. Hughes, PhD, FAACVPR
Harvard Medical School Professor
Boston, Massachusetts Department of Psychological Sciences
Kent State University
Gregory W. Heath, DHSc, MPH FAHA, FACSM Kent, Ohio
Guerry Professor, Public Health Program
Jodi Hutchinson, PA-C
Department of Health and Human Performance
Director of Integrative Medicine
University of Tennessee at Chattanooga
Holy Redeemer Health System
Chattanooga, Tennessee
Meadowbrook, Pennsylvania

Cassandra Herman, MS Jason R. Jaggers, PhD

Doctoral Trainee Assistant Professor
Department of Health Behavior Department of Health & Sport Sciences
University of Alabama at Birmingham University of Louisville
Birmingham, Alabama Louisville, Kentucky
xxviii Contributors

John M. Jakicic, PhD Christopher M. Kaipust, MPH

Distinguished Professor and Chair Predoctoral Fellow
Department of Health and Physical Activity The University of Texas Health Science Center at
Director Houston (UTHealth) School of Public Health Division
Healthy Lifestyle Institute of Epidemiology, Human Genetics, & Environmental
and Sciences
Director Southwest Center for Occupational and Environmental
Physical Activity and Weight Management Research Health
Center Michael & Susan Dell Center for Healthy Living
University of Pittsburgh Houston, Texas
Pittsburgh, Pennsylvania
Heidi J. Kalkwarf, PhD
Jo Marie Tran Janco, MD Professor
Clinical Fellow Department of Pediatrics
Department of Obstetrics, Gynecology, University of Cincinnati College of Medicine
and Reproductive Biology Division of Gastroenterology, Hepatology
Beth Israel Deaconess and Nutrition
Medical Center Cincinnati Children’s Hospital Medical Center
Harvard Medical School Cincinnati, Ohio
Boston, Massachusetts

Nattinee Jitnarin, PhD Sandeep (Anu) Kaur, MS, RDN, RYT-500

Principal Investigator Nutritionist
National Development and Research Institutes, Inc. Nutritional Science Research Group
Institute for Biobehavioral Health Research Division of Cancer Prevention
Leawood, Kansas National Cancer Institute
National Institutes of Health
Sarah Tierney Jones, BS Rockville, Maryland
Exercise Physiologist
Simmons University Maureen K. Kayes, MS
Boston, Massachusetts Department of Kinesiology
University of Maryland
Stephanie-Marie L. Jones, MD College Park, Maryland
Clinical Fellow
Department of Obstetrics, Gynecology
Case H. Keltner, MPH
and Reproductive Biology
MD Candidate
Beth Israel Deaconess
Oregon Health & Science University School
Medical Center
of Medicine
Harvard Medical School
Portland, Oregon
Boston, Massachusetts

Elizabeth A. Joy, MD, MPH, FACSM Elizabeth Kelley, MS, ACSM-RCEP

Medical Director Lab Manager
Community Health, Health Promotion & Wellness, Food Health and Human Performance
& Nutrition College of Charleston
Intermountain Healthcare Charleston, South Carolina
Salt Lake City, Utah
John Kelly, MD, MPH
Jill Landsbaugh Kaar, PhD Oak Haven Lifestyle Medicine Center
Assistant Professor American College of Lifestyle Medicine
Department of Pediatrics Preventive Medicine
University of Colorado Anschutz Medical Campus Loma Linda University, California
Aurora, Colorado
Mary A. Kennedy, MS
Sergey Kachur, MD Institute of Lifestyle Medicine
Assistant Professor of Medicine at the University of Harvard Medical School
Central Florida Boston, MA
Associate Program Director of the Internal Medicine and
Residency Program Exercise Medicine Research Institute
Department of Graduate Medical Education Edith Cowan University
Ocala Regional Medical Center Joondalup, Western Australia
Ocala, Florida Australia
Another random document with
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but when relieved or cured of this, suddenly a new manifestation
occurs. A new figure appears upon the scene, or perhaps I might
better say a new actor treads the boards. Even in these cases,
however, it would be difficult to say that the phenomena are really
simulated. They are rather induced, and get partly beyond the
patient's will.

A remarkable case of this kind is well known at the Philadelphia

Polyclinic and College for Graduates in Medicine. She is sometimes
facetiously spoken of as the “Polyclinic Case,” because she has
done duty at almost every clinical service connected with the
institution. The case has been reported several times: the fullest
report is that given by Harlan.100 The patient was taken sick in
September with sore throat, and was confined to the house for about
two weeks. She was attended by S. Solis Cohen. There was
difficulty in swallowing, and some regurgitation of food. At the same
time she had weakness of sight in the right eye. Later, huskiness of
voice came on, and soon complete aphonia. Her voice recovered,
and she then had what appeared to be pleuro-pneumonia. During
the attack her arms became partially paralyzed. She complained of
numbness down her legs and in her feet.
100 Transactions of the Amer. Ophthalmological Soc., 20th annual meeting, 1884,
649.

Before these symptoms had disappeared twitchings of the muscles

of the face set in, most marked on the right side. The face improved,
but in two days she had complete spasmodic torticollis of the left
side. One pole of a magnet was placed in front of the ear, and the
other along the face; and under this treatment in a week the spasm
ceased entirely.

In a short time she complained of various troubles of vision and a

fixed dilatation of the pupil. Homonymous diplopia appeared.
Reading power of the right eye was soon lost. The pupil was slightly
dilated, and reacted imperfectly to light. She had distressing
blepharospasm on the right side and slight twitchings on the left. Two
months later a central scotoma appeared, and eventually her right
eye became entirely blind except to light. The pupil was widely
dilated and fixed, and the spasm became more violent and extended
to the face and neck. The sight was tested by Harlan by placing a
weak convex lens in front of the blind eye, and one too strong to
read through in front of the sound eye, when it was found that she
read without any difficulty. The use of the magnet was continued by
Cohen. Blepharospasm and dilatation of the pupil improved. She,
however, had an attack of conjunctivitis in the left eye, and again got
worse in all her eye symptoms. A perfect imitation of the magnet was
made of wood with iron tips. Under this imitation magnet the pupil
recovered its size and twitching of the face and eyelids ceased.

The next campaign was precipitated by a fall. She claimed that she
had dislocated her elbow-joint; she was treated for dislocation by a
physician, and discharged with an arm stiff at the elbow. A wooden
magnet was applied to the arm, the spasm relaxed, and the
dislocation disappeared.

This ends Harlan's report of the case, and I had thought that this
patient's Iliad of woes was also ended; but I have just been informed
by J. Solis Cohen and his brother that she has again come under
their care. The latter was sent for, and found the patient seemingly
choking to death. The right chest was fixed; there was marked
dyspnœa; respiration 76 per minute; her expectoration was profuse;
she had hyperresonance of the apex, and loud mucous râles were
heard. At last accounts she was again recovering.

This patient's train of symptoms began with what appeared to be

diphtheria. The fact that she had some real regurgitation would seem
to be strong evidence that she had some form of throat paralysis
following diphtheria. She was of neurotic temperament. From the
age of seven until ten years she had had fits of some kind about
every four weeks. Because of her sore throat and subsequent real or
seeming paralytic condition she came to the Polyclinic, where she
was an object of interest and considerable attention, having been
talked about and lectured upon to the classes in attendance.
Whether her first symptoms were or were not hysterical, those which
succeeded were demonstrably of this character. Frequently some
real disease is the starting-point of a train of hysterical disorders.

DURATION AND COURSE.—Hysteria is pre-eminently a chronic disease;

in the majority of cases it lasts at least for years. Its symptoms may
be prolonged in various ways. Sometimes one grave hysterical
disorder, as hysterical paralysis, persists for years. In other cases
one set of symptoms will be supplanted by others, and these by still
others, and so on until the whole round of hysterical phenomena
appears in succession.

Deceptive remissions in hysterical symptoms often mislead the

unwary practitioner. Cures are sometimes claimed where simply a
change in the character of the phenomena has taken place. Without
doubt, some cases of hysteria are curable; equally, without doubt,
many cases are not permanently cured. It is a disease in which it is
unsafe to claim a conquest too soon. In uncomplicated cases of
hysteria the disorder often abates slowly but surely as age
advances. As a rule, the longevity of hysterical patients is not much
affected by the disorder.

COMPLICATIONS.—We should not treat a nervous case occurring in a

woman or a man as hysterical simply because it is obscure and
mysterious. Unless, after the most careful examination, we are able
by exclusion or by the presence of certain positive symptoms to
arrive at the diagnosis of hysteria, it is far better to withhold an
opinion or to continue probing for organic disease. I can recall five
cases in which the diagnosis of hysteria was made, and in which
death resulted in a short time. One of these was a case of uræmia
with convulsions, two were cases of acute mania, another proved to
be a brain abscess, and the fifth a brain tumor. Hughes Bennett101
has reported a case of cerebral tumor with symptoms simulating
hysteria in which the diagnosis of the true nature of the disease was
not made out during life. The patient was a young lady of sixteen at
the time of her death. Her family history was decidedly neurotic. She
was precocious both mentally and physically, was mischievous and
destructive, sentimental and romantic; she had abnormal sexual
passions. She had a sudden attack of total blindness, with equally
sudden recovery of sight some ten days afterward. Sudden loss of
sight occurred a second time, and deafness with restoration of
hearing, loss of power in her lower limbs, and total blindness,
deafness, and paraplegia. Severe constant headaches were absent,
as were also ptosis, diplopia, facial or lingual paralysis, convulsions
with unconsciousness, vomiting, wasting, and abnormal
ophthalmoscopic appearances. She had attacks of laughing, crying,
and throwing herself about. Her appearance and character were
eminently suggestive of hysteria. The patient died, and on post-
mortem examination a tumor about the size and shape of a hen's
egg was found in the medullary substance of the middle lobe of the
right hemisphere.
101 Brain, April, 1878.

The association of hysteria with real and very severe spinal

traumatism partially misled me in the case of a middle-aged man
who had been injured in a runaway accident, and who sustained a
fracture of one of the upper dorsal vertebræ, probably of the spines
or posterior arch. This was followed by paralysis, atrophy of the
muscles, contractures, changed reactions, bladder symptoms, bed-
sores, and anæsthesia. The upper extremities were also affected.
Marked mental changes were present, the man being almost
insanely hysterical. The diagnosis was fracture, followed by
compression myelitis, with descending motor and ascending sensory
degeneration. An unfavorable prognosis was given. He left the
hospital and went to another, and finally went home, where he was
treated with a faradic battery. He gradually improved, and is now on
his feet, although not well. In this case there was organic disease
and also much hysteria.

Seguin102 holds that (1) many hysterical symptoms may occur in

diseases of the spinal cord and brain; (2) in diseases of the spinal
cord these diseases appear merely as a matter of coincidence; (3) in
cases of cerebral disease the hysterical symptoms have a deeper
significance, being in relation to the hemisphere injured. He collects,
as illustrative of the propositions that hysterical symptoms will
present themselves in persons suffering from organic disease of the
nervous system, the following cases of organic spinal disease: One
case of left hemiplegia with paresis of the right limbs, which proved
after death to be extensive central myelitis, with formation of cavities
in the cord; two cases of posterior spinal sclerosis, two of
disseminated sclerosis, and one of sclerosis of the lateral column. In
some of these cases the organic disease was wholly overlooked.
Sixteen cases of organic disease of the brain accompanied by
marked hysterical manifestations are also given: 9 of left hemiplegia;
2 of right hemiplegia with aphasia; 1 of left alternating with right
hemiplegia; 1 of hemichorea with paresis; 1 of double hemiplegia;
and 2 of general paresis. It is remarkable and of interest, in
connection with other unilateral phenomena of hysteria, that
emotional symptoms were present in 14 cases of left hemiplegia and
in only 2 of right.
102 Op. cit.

Among the important conclusions of this paper are the following: “1.
In typical hysteria the emotional symptoms are the most prominent,
and according to many authors the most characteristic. In all the
cases of cerebral disease related there were undue emotional
manifestations or emotional movements not duly controlled. 2. In
typical hysteria many of the objective phenomena are almost always
shown on the left side of the body, and we may consequently feel
sure that in these cases the right hemisphere is disordered. In nearly
all of the above sixteen cases the right hemisphere was the seat of
organic disease, and the symptoms were on the left side of the
body.”

The possibility of the occurrence of hysteria in the course of acute

diseases, particularly fevers, is often overlooked. Its occurrence
sometimes misleads the doctor with reference to prognosis. Such
manifestations are particularly apt to occur in emotional children. A
young girl suffering from a moderately severe attack of follicular
tonsillitis, with high fever, suddenly awoke during the night and
passed into an hysterical convulsion which greatly alarmed her
parents. Her fingers, hands, and arms twitched and worked
convulsively. She had fits of laughing and shouting, and was for a
short time in a state of ecstasy or trance. Once before this she had
had a similar but slighter seizure, during the course of an ephemeral
fever.

Among other complications of hysteria which have been noted by

different observers are apoplexy, disease of the spleen, mania-a-
potu, heart disease, and spinal caries, and among affections alluded
to by competent observers as simulated by hysteria are secondary
syphilis, phthisis, tetanus, strychnia-poisoning, peritonitis, angina
pectoris, and cardiac dyspnœa.

DIAGNOSIS.—Buzzard103 significantly remarks that you cannot cure a

case of hysteria as long as you have any serious doubt about its
nature; and, on the other hand, if you are able to be quite sure on
this point, and are prepared to act with sufficient energy, there are
few cases that will not yield to treatment. The importance of a correct
diagnosis is a trite topic, but in no affection is it of more consequence
than in hysteria, that disorder which, although itself curable, may, as
has been abundantly shown, imitate the most incurable and fatal of
diseases.
103 Clinical Lectures on Diseases of the Nervous System, by Thomas Buzzard, M.D.,
Philada., 1882.

A few remarks with reference to the methods of examining hysterical

patients will be here in place. Success on the part of the physician
will often depend upon his quickness of perception and ability to
seize passing symptoms. It is often extremely difficult to determine
whether hysterical patients are or are not shamming or how far they
are shamming. The shrewdness and watchfulness which such
patients sometimes exercise in resisting the physician's attempts to
arrive at a diagnosis should be borne in mind. A consistent method
of procedure, one which never betrays any lack of confidence,
should be adopted. “Trifles light as air” will sometimes decide, a
single expression or a trivial sign clinching the diagnosis. On the
other hand, the most elaborate and painstaking investigation will be
frequently required.

The physician should carefully guard against making a diagnosis

according to preconceived views. On the whole, the general
practitioner is more likely to err on the side of diagnosticating organic
disease where it does not exist; the specialist in too quickly
assigning hysteria where organic disease is present, or in failing to
determine the association of hysteria and organic disease in the
same case.

Special expedients may sometimes be resorted to in the course of

an examination. Not a few hysterical symptoms require for their
continuance that the patient's mind shall be centred on the
manifestations. If, therefore, the attention can, without arousing
suspicions, be directed to something else during the examination,
the disappearance of the particular hysterical symptom may clear
away all obscurity. In a case reported by Seguin,104 in which
staggering was a prominent symptom, the patient was placed in the
middle of the room and directed to look at the ceiling to see if he
could make out certain fine marks; he stood perfectly well without
any unsteadiness. In the case of a boy eleven years old whose chief
symptoms were hysterical paralysis with contracture of the lower
extremities, great hyperæsthesia of the feet, and a tremor involving
both the upper and lower extremities, and sometimes the head, I
directed him, as if to bring out some point, to hold one arm above his
head and at the same time fix his attention on the foot of the
opposite side. The tremor in the upper extremities, which had been
most marked, entirely disappeared. This experiment was varied, the
result being the same.
104 Op. cit.

The method adopted in the cases supposed to be phthisis, but which

proved to be hysterical, which has already been alluded to under the
head of hysterical or nervous breathing, is worthy of note. The
patients, it will be recalled, could not be induced to draw a long
breath until the plan was adopted of having them count twenty
without stopping, when the lungs expanded and the diagnosis was
clear.

It is important to know whether or not children are of this hysterical

tendency or are likely, sooner or later in life, to develop some forms
of this disorder. In children as well as in adults the hysterical
diathesis will be indicated by that peculiar mobility of the nervous
system, which has been referred to under Etiology. It is chiefly by
psychical manifestations that the determination will be made. These
are often of mild degree and of irregular appearance. Undue
emotionality under slight exciting cause, a tendency to simulation
and to exaggeration of real conditions, inconsistency in likes and
dislikes, and great sensibility to passing impressions, are among
these indications. Children of hysterical diathesis are sometimes,
although by no means always, precocious mentally, but not a few
cases of apparent precocity are rather examples of an effort to
attract attention, which is always present in individuals of this
temperament.

It is also important, as urged by Allbutt,105 to make a distinction

between hysterical patients and neurotic subjects, often incorrectly
classed as hysterical. Many cases of genuine malady and suffering
are contemptuously thrown aside as hysteric. Allbutt regards some
of these neurotic patients as almost the best people in this wicked
world. Although, however, this author's righteous wrath against the
too frequent diagnosis of hysteria, hysterical pain, hysterical spine,
etc. is entirely justifiable, he errs a little on the other side.
105 On Visceral Neuroses, being the Gulstonian Lectures on Neuralgia of the
Stomach and Allied Disorders, delivered at Royal College of Physicians, March, 1884,
by T. Clifford Allbutt, M.A., M.D. Cantab., F. R. S., Philada., 1884.

Hysteria and neurasthenia are often confounded, and, while both

conditions may exist in the same case, just as certainly one may be
present without the other. The points of differential diagnosis as
given by Beard106 are sufficient for practical purposes. They are the
following: In neurasthenia convulsions or paroxysms are absent; in
hysteria they are among the most common features. In neurasthenia
globus hystericus and anæsthesia of the epiglottis are absent,
ovarian tenderness is not common, and attacks of anæsthesia are
not frequent and have little permanency; in hysteria globus
hystericus, anæsthesia of the epiglottis, ovarian tenderness, and
attacks of general or local anæsthesia are all marked phenomena.
The symptoms of neurasthenia are moderate, quiet, subdued,
passive; those of hysteria are acute, intense, violent, positive.
Neurasthenia may occur in well-balanced intellectual organizations;
hysteria is usually associated with great emotional activity and
unbalanced mental organization. Neurasthenia is common in males,
although more common in females; hysteria is rare in males.
Neurasthenia is always associated with physical debility; hysteria in
the mental or psychical form occurs in those who are in perfect
physical health. Neurasthenia never recovers suddenly, but always
gradually and under the combined influences of hygiene and
objective treatment; hysteria may recover suddenly and under purely
emotional treatment.
106 Op. cit.

An affection termed general nervousness has been described by

Mitchell. It does not seem to be strictly a neurasthenia, nor does it
always occur in hysterical individuals. These cases are sometimes
“more or less neurasthenic people, easily tired in brain or body; but
others are merely tremulous, nervous folks, easily agitated, over-
sensitive, emotional, and timid.” It is sometimes an inheritance;
sometimes it results from the misuse of alcohol, tobacco, tea or
coffee. Usually, it is developed slowly; occasionally, however, it
arises in a moment. Thus, Mitchell mentions the case of a healthy
girl who fell suddenly into a state of general nervousness owing to
the fall of a house-wall. General nervousness is to be distinguished
from hysteria, into which it sometimes merges, only by the absence
of the mental perversions and the special motor, sensory, vaso-
motor, and visceral disorders peculiar to the latter.

The differential diagnosis of hysteria and hypochondria, or what is

better termed hypochondriacal melancholia, is often, apparently at
least, somewhat difficult. Formerly, it was somewhat the fashion to
regard hysteria in the male as hypochondria; but this view has
nothing to support it. Hypochondria and hysteria, as neurasthenia
and hysteria, are sometimes united in the same subject; one
sometimes begets the other, but they have certain points of
distinction. Hypochondria more frequently passes into real organic
disease than does hysteria; it is more frequently associated with
organic disease than is hysteria. Hypochondria is in the majority of
cases a true insanity, while hysteria can only be regarded as such in
the special instances which have been discussed. In hypochondria
the individual's thoughts are centred upon some supposed disease
until a true delusional condition is developed; this does not often
occur in hysteria. Hypochondria is seen with as great a frequency in
the male as in the female, while hysteria prevails much more largely
in the female sex. In typical hypochondria more readily than in
hysteria the patient may be led from one set of symptoms to another,
the particulars of which he will detail in obedience to questions that
are put to him, these symptoms not unusually partaking of the
absurd and impossible. In hypochondria are absent those distinctive
symptoms which in nearly all cases of hysteria appear in greater or
less number, such as convulsions, paralysis, contracture, aphonia,
hysterical joints, and the like. In hypochondria is present the
groundless fear of disease without these outward manifestations of
disease. The symptoms of hypochondria, as a rule, but not
invariably, are less likely to change or abate than those of hysteria.

It is often of moment to be able to distinguish between two such well-

marked affections as common acute mania and hysterical mania. In
acute mania the disorder usually comes on gradually; in hysterical
mania the outbreak of excitement is generally sudden, although
prodromic manifestations are sometimes present. This point of
difference is not one to be absolutely depended upon. In acute
mania incoherence and delusions or delusional states are genuine
phenomena; in hysterical mania delusional conditions, often of an
hallucinatory character, may be present, but they are likely to be of a
peculiar character. Frequently, for instance, such patients see, or say
that they see, rats, toads, spiders, and strange beasts. These
delusions have the appearance of being affected in many cases;
very often they are fantastical, and sometimes at least they are
spurious or simulated. In hysterical mania such phenomena as
obstinate mutism, aphonia, pseudo-coma, ecstasy, catalepsy, and
trance often occur, but they are usually absent in the history of cases
of acute mania. In acute mania under the influence of excitement or
delusion the patients may take their own lives: they may starve or kill
themselves violently; in hysterical mania suicide will be threatened or
apparently attempted, but the attempts are not genuine as a rule;
they are rather acts of deception. In acute mania the patients often
become much reduced and emaciated; in hysterical mania in
general, considering the amount of mental and motor excitement
through which the individuals pass, their nutrition remains good. In
acute mania sleeplessness is common, persistent, and depressing;
in hysterical mania usually a fair amount of sleep will be obtained in
twenty-four hours. In many cases of hysterical mania the patients
have their worst attacks early in the morning after a good night's
rest. Acute mania under judicious treatment and management may
gradually recover; sometimes, however, it ends fatally: this is
especially likely to occur if the physician supposes the case to be
simply hysterical and acts accordingly. Hysterical mania seldom has
a serious termination unless through accident or complication.

In order to make the diagnosis of purposive hysterical attacks

watchfulness on the part of the physician will often suffice. Such
patients can frequently be detected slyly watching the physician or
others. Threats or the actual use of harsh measures will sometimes
serve for diagnostic ends, although the greatest care should be
exercised in using such methods in order that injustice be not done.

In uræmia, as in true epilepsy, the convulsion is marked and the

condition of unconsciousness is usually profound. An examination of
the urine for albumen, and the presence of symptoms, such as
dropsical effusion, which point to disorder of the kidneys, will also
assist.
Hysterical paralysis in the form of monoplegia or hemiplegia must
sometimes be distinguished from such organic conditions as
cerebral hemorrhage, embolism or thrombosis, tumor, abscess, or
meningitis (cerebral syphilis).
When the question is between hysteria and paralysis from coarse
brain disease, as hemorrhage, embolism, etc., the history is of great
importance. The hysterical case usually has had previous special
hysterical manifestations. The palsy may be the last of several
attacks, the patient having entirely recovered from other attacks. In
an organic case, if previously attacked, the patient has usually made
an incomplete recovery; the history is of a succession of attacks,
each of which leaves the patient worse. In cerebral syphilis it
happens sometimes that coming and going paralyses occur; but the
improvement in these cases is generally directly traceable to specific
treatment. Partial recoveries take place in embolism, thrombosis,
hemorrhage, etc. when the lesion has been of a limited character,
but the improvement is scarcely ever sufficient to enable the patient
to be classed as recovered. The exciting cause of hysterical and
organic cases of paralysis is different. While in hysterical paralysis
sudden fright, anxiety, anger, or great emotion is frequently the
exciting cause, such psychical cause is most commonly not to be
traced as the factor immediately concerned in the production of the
organic paralysis. In the organic paralysis an apoplectic or
apoplectiform attack of a peculiar kind has usually occurred. In
cerebral hemorrhage or embolism the patient suddenly loses
consciousness, and certain peculiar pulse, temperature, and
respiration phenomena occur. The patient usually remains in a state
of complete unconsciousness for a greater or less period. In hysteria
the conditions are different. A state of pseudo-coma may sometimes
be present, but the temperature, pulse, and respiration will not be
affected as in the organic case.

Hysterical monoplegia or hemiplegia, as a rule, is not as complete as

that of organic origin, and is nearly always accompanied by some
loss of sensation. The face usually escapes entirely. In organic palsy
the face is generally less severely and less permanently affected
than the limbs, but paresis is commonly present in some degree.
Hysterical palsies are more likely to occur upon the left than upon
the right side. Embolism is well known to occur most frequently in the
left middle cerebral artery, thus giving the palsies upon the right. In
hemorrhage and thrombosis the tendency is perhaps almost equal
for the two sides. Some of these and other points of distinction
between organic and hysterical palsies have been given incidentally
under Symptomatology.

In organic hemiplegia aphasia is more likely to occur than in

hysterical cases; and acute bed-sores and wasting of the limbs, with
contractures, are conditions frequently present as distressing
sequelæ. Such is not the rule in hysterical cases, for while there may
be wasting of the limbs from disuse and hysterical contractures, bed-
sores are seldom present, and the wasting and contractures do not
appear so insidiously, nor progressively advance to painful
permanent conditions, as in the organic cases. Mitchell mentions the
fact that in palsies from nerve wounds feeling is apt to come back
first, motion last; while in the hysterical the gain in the power of
motion may go on to full recovery, while the sense of feeling remains
as it was at the beginning of treatment. This point of course would
help only in cases where both sensory and motor loss are present.

The examination of an hysterically palsied limb, if conducted with

care, may often bring out the suppressed power of the patient.
Practising the duplicated, active Swedish movements on such a limb
will sometimes coax resistance from the patient. As already stated,
electro-contractility is retained in hysterical cases.

The disorders from which it may be necessary to diagnosticate

hysterical paraplegia are spinal congestion, subacute generalized
myelitis of the anterior horns (chronic atrophic spinal paralysis of
Duchenne), diffused myelitis, acute ascending paralysis, spinal
hemorrhage, spinal tumor, posterior spinal sclerosis or locomotor
ataxy, lateral sclerosis or spasmodic tabes, multiple cerebro-spinal
sclerosis, and spinal caries.

In spinal congestion the patients come with a history that after

exposure they have lost the use of their lower limbs, and sometimes
of the upper. Heaviness and pain in the back are complained of, and
also more or less pain from lying on the back. Numbness in the legs
and other disturbances of sensation are also present. The paralysis
may be almost altogether complete. Such patients exhibit evidences
of the involvement of the whole cord, but not a complete destructive
involvement. A colored woman, age unknown, had been in her
ordinary health until Nov. 24, 1884. At this time, while washing, she
noticed swelling of the feet, which soon became painful, and finally
associated with loss of power. She had also a girdling sensation
about the abdomen and pain in the back. She was admitted to the
hospital one week later, at which time there was retention of the
urine and feces. She had some soreness and tenderness of the
epigastrium. She complained of dyspnœa, which was apparently
independent of any pulmonary trouble. It was necessary to use the
catheter for one week, by which time control of the bladder had been
regained. The bowels were regulated by purgatives. She was given
large doses of ergot and bromide and iodide of potassium, and
slowly improved, and after a time was able to get out of bed and
walk with the aid of a chair. An examination at the time showed that
the girdling pain had disappeared. There was distinct loss of
sensation. Testing the farado-contractility, it was found that in the
right leg the flexors only responded to the slowly-interrupted current,
while in the left both flexors and extensors responded to the
interrupted current. In both limbs with the galvanic current the flexors
responded to twenty cells, while the extensors responded to fifty
cells. She gradually improved, and was able to leave after having
been in the hospital three months.

The diagnosis of subacute myelitis of the anterior horns from

hysterical paraplegia is often of vital importance. “A young woman,”
says Bennett,107 “suddenly or gradually becomes paralyzed in the
lower extremities. This may in a few days, weeks, or months become
complete or may remain partial. There is no loss of sensation, no
muscular rigidity, no cerebral disturbances, nor any general affection
of the bladder or rectum. The patient's general health may be robust
or it may be delicate. She may be of emotional and hysterical
temperament, or, on the contrary, of a calm and well-balanced
disposition. At first there is no muscular wasting, but as the disease
becomes chronic the limbs may or may not diminish in size. The
entire extremity may be affected or only certain groups of muscles.
Finally, the disease may partially or entirely recover, or remain
almost unchanged for years.” This is a fair general picture of either
disease.
107 Lancet, vol. ii. p. 842, November, 1882.

Two facts are often overlooked in this connection: first, that

poliomyelitis is just as liable to occur in the hysterical as in the other
class; and, secondly, that the symptoms of hysterical paraplegia and
poliomyelitis may go hand in hand.

The history is different in the two affections. Frequent attacks of

paralysis in connection with hysterical symptoms are very
suggestive, although not always positive. In poliomyelitis the disease
may come on with diarrhœa and fever; often it comes on with
vomiting and pain. The patellar reflex is retained, often exaggerated,
and rarely lost, in hysteria, while it is usually lost in poliomyelitis.
Electro-muscular contractility is often normal in hysterical paralysis,
although it is sometimes slightly diminished quantitatively to both
faradism and galvanism: the various muscles of one limb respond
about equally to electricity: there are no reactions of degeneration in
hysterical paralysis as in poliomyelitis. In poliomyelitis reactions of
degeneration are one of the most striking features. The cutaneous
plantar reflex is impaired in hysterical paraplegia; bed-sores are
usually absent, as are also acute trophic eschars and the nail-
markings present both in generalized subacute myelitis and diffused
myelitis. True muscular atrophy is also wanting in hysterical
paraplegia, although the limbs may be lean and wasted from the
original thinness of the patient or from disuse. The temperature of
the limbs is usually good. There is no blueness nor redness of the
limbs, nor are the bowels or bladder uncomfortably affected.

Buzzard108 gives two diagrams (Figs. 16 and 17), which I have

reproduced. They are drawn from photographs. They show two pairs
of feet, which have a certain superficial resemblance. In each the
inner border is drawn up into the position of a not severe varus. They
are the feet of two young women who were in the hospital at the
same time. A (Fig. 16), really a case of acute myelitis, had been
treated as a case of hysteria; and B (Fig. 17), really a case of
hysteria, came in as a paralytic. In these cases the results of
examination into the state of the electrical response and of the
patellar-tendon reflex was sufficient to make a diagnosis clear. In the
organic case the electrical reactions were abnormal and the patellar-
tendon reflex was abolished. These conditions were not present in
the hysterical case.

FIG. 16. FIG. 17.

108 Clin. Lectures on Diseases of the Nervous System, London, 1882.

The diagnosis of hysterical paraplegia from diffused myelitis is

governed practically by the same rules which serve in subacute
myelitis of the anterior horns, with some additional points. In diffused
myelitis, in addition to the motor, trophic, vaso-motor, electrical, and
reflex disorders of myelitis of the anterior horns, affections of
sensibility from involvement of the sensory regions of the cord will
also be present. Anæsthesia and paræsthesia will be present.

Acute ascending paralysis, the so-called Landry's paralysis,

particularly when it runs a variable course, might be mistaken
sometimes for hysterical paralysis. In one instance I saw a fatal case
of Landry's paralysis which had been supposed to be hysterical until
a few hours before death. In Landry's paralysis, however, the swiftly
ascending character of the disorder is usually so well marked as to
lead easily to the diagnosis. In Landry's paralysis the loss of power
begins first in the legs, but soon becomes more pronounced, and
passes to the arms, and in the worst cases swallowing and
respiration become affected.

Spinal hemorrhage and spinal tumors, giving rise to paralysis, may

be mistaken for hysterical paralysis, partly because of the
contractures. Reactions of degenerations are usually features of this
form of organic paralysis. The contractures of hysterical paralysis
can be promptly relieved by deep, strong pressure along supplying
nerve-trunks; this cannot be accomplished in the organic cases.
Severe localized pains in the limbs, sometimes radiating from the
spinal column, are present in the organic cases. Pain may be
complained of by the hysterical patient, but close examination will
show that it is not of the same character, either as regards severity
or duration.

Hysterical locomotor ataxy is usually readily distinguished from

posterior spinal sclerosis, although the phenomena are apparently
more marked and more peculiar than those exhibited as the result of
organic changes. Hysterical ataxic patients often show an
extraordinary inability to balance their movements, this want of co-
ordinating power being observed even in the neck and trunk, as well
as the limbs. In hysterical cases a certain amount of palsy, often of
an irregular type, is more likely to be associated with the ataxia than
in the structural cases. The knee-jerk, so commonly absent in true
posterior spinal sclerosis that its absence has come to be regarded
as almost a pathognomonic symptom of this affection, in hysterical
motor ataxy is present and exaggerated. In hysterical locomotor
ataxy other well-marked symptoms of general hysteria, such as
hysterical convulsions, aphonia, etc., are present.

In the diagnosis of spastic spinal paralysis from hysterical paraplegia

great difficulties will sometimes arise. A complete history of the case
is of the utmost importance in coming to a conclusion. If the case be
hysterical, usually some account of decided hysterical manifestation,
such as aphonia, sudden loss and return of sight, hysterical
seizures, etc., can be had. Althaus holds that a dynamometer which
he has had constructed for measuring the force of the lower
extremities will, at least in a certain number of cases, enable us to
distinguish between the functional and spinal form of spastic
paralysis. In the former, although the patient may be unable to walk,
the dynamometer often exhibits a considerable degree of muscular
power; while in the latter, more especially where the disease is
somewhat advanced, the index of the instrument will only indicate
20° or 30° in place of 140° or 160°, and occasionally will make no
excursion at all.

The diagnosis of multiple cerebro-spinal sclerosis from hysteria

occasionally offers some difficulties. Jolly goes so far as to say that it
can only with certainty be diagnosticated in some cases in its later
stages and by the final issue—cases in which the paralytic
phenomena frequently alter their position, in which paroxysmal
exacerbations and as sudden ameliorations take place, and
convulsive attacks and disturbances of consciousness of a like
complicated nature as in hysteria are met with. Disorders of
deglutition and articulation, also characteristic of multiple cerebro-
spinal sclerosis, are now and again observed in the hysterical.
Recently, through the kindness of J. Solis Cohen, I saw at the
German Hospital in Philadelphia a patient about whom there was for
a time some doubt as to whether the peculiar tremor from which he
suffered was hysterical or sclerotic. At rest and unobserved, he was
usually quiet, but as soon as attention was directed to him the tremor
would begin, at first in the limbs, but soon also in the head and trunk.
If while under observation he attempted any movement with his
hands or feet, the tremor would become violent, and if the effort was
persisted in it would become convulsive in character. The effort to
take a glass of water threw him into such violent spasms as to cause
the water to be splashed in all directions. The fact that this patient
was a quiet, phlegmatic man of middle age, that his troubles had
come on slowly and had progressively increased, that tremor of the
head and trunk was present, that cramps or tonic spasms of the
limbs came and went, indicated the existence of disseminated
sclerosis. The knee-jerk was much exaggerated, taps upon the
patellar tendon causing decided movement; when continued, the leg
would be thrown into violent spasm.

Spondylitis, or caries of the vertebræ, is sometimes difficult to

distinguish from hysterical paraplegia or hysterical paraplegia from it,
or both may be present in the same case. Likewise, painful
paraplegia from cancer or sarcoma of the vertebræ may offer some
difficulties. A woman aged forty-four when two years old had a fall,
which was followed by disease of the spine, and has resulted in the
characteristic deformity of Pott's disease. She was apparently well,
able to do ordinary work, until about five years before she came
under observation, when her legs began to feel heavy and numb,
and with this were some pain and slight loss of power. These
symptoms increased, and in three months were followed by a total
loss of power in the lower extremity. She was admitted to the
hospital, and for about three years was unable to move the legs. She
went round the wards in a wheeled chair. The diagnosis was made
of spondylitis, curvature, and paralysis and sensory disorders
depending on compression myelitis, and it was supposed she was
beyond the reach of remedies. One day one of the resident
physicians gave her a simple digestant or carminative, soon after
which she got up and walked, and has been walking ever since. She
attributes her cure entirely to this medicine.

What is the lesson to be learned from this case? It is, in the first
place, not to consider a patient doomed until you have made a
careful examination. There can be much incurvation of the spine
without sufficient compression to cause complete paralysis. In this
patient organic disease was associated with an hysterical or
neuromimetic condition. This woman had disease of the vertebræ,
the active symptoms of which had subsided. The vertebral column
had assumed a certain shape, and the cord had adjusted itself to this
new position, yet for a long time she was considered incurable from
the fact that the conjunction of a real and a mimetic disorder was
overlooked.