Lifestyle Medicine’s Six Pillars
By Kayli Anderson, MS, RDN, DipACLM, ACSM-EP
Today’s Dietitian
Vol. 25 No. 8 P. 42

Expert Strategies for Applying a Revolutionary Evidence-Based Approach

From well-respected medical organizations to health and wellness influencers, many seem to tout the benefits of lifestyle medicine. However, the concept of using lifestyle as medicine is nothing new. In fact, it may just be the future of health care.

The use of lifestyle interventions to maintain or regain health dates back as far as Hippocrates 2,500 years ago.1 Cultures around the world have long relied on lifestyle to stay healthy and ward off disease. Pockets of the world with the highest concentrations of centenarians, called Blue Zones, credit longevity to lifestyle pillars such as strong social connections and daily physical activity.2 And, of course, dietitians have long been championing the therapeutic benefits of food, another lifestyle pillar.

Although lifestyle medicine may seem like the newest fad, its long history and the strong science supporting it ensure it’s much more a rising tide than a fleeting trend. Lifestyle medicine is here to stay, and dietitians have a crucial role to play in practicing this modality to address the nation’s top chronic diseases.

What Is Lifestyle Medicine?
According to the American College of Lifestyle Medicine (ACLM), lifestyle medicine is “a medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions, including but not limited to CVDs, type 2 diabetes, and obesity.”3

Health care providers trained in lifestyle medicine use evidence-based, prescriptive lifestyle interventions such as nutrition, physical activity, restorative sleep, stress management, social connection, and avoidance of risky substances to address disease. The use of these modalities, known as the six pillars of lifestyle medicine, prevent and treat many of the nation’s most devastating chronic diseases and is backed by a wealth of scientific evidence.

Although some overlap exists between lifestyle medicine and other fields like integrative medicine or preventative medicine, lifestyle medicine is unique. In lifestyle medicine, evidence-based lifestyle changes are prescribed as first line treatment for disease. Other evidence-based interventions, such as medications or procedures, also can be used, but only as supplementary to lifestyle change. Lifestyle medicine certainly can be used for disease prevention, but the focus is primarily on treatment, reducing disease severity, and sometimes the reversal of existing disease. Lifestyle medicine goes beyond just helping the healthy get healthier. It aims to significantly improve disease markers and quality of life for patients who need it most.

Is Lifestyle Medicine Worth Its Weight in Gold?
For starters, lifestyle factors such as tobacco and alcohol use, poor diet, and physical inactivity are considered the leading causes of mortality in the United States.4 Lifestyle medicine is designed to address these destructive lifestyle factors. Studies of intensive therapeutic lifestyle change programs, such as the Pritikin program and the Ornish program, in which participants make significant changes to their lifestyles, have shown impressive improvements in markers of diabetes and coronary heart disease.5-7 Many large epidemiologic studies also shine light on how lifestyle behaviors impact health. The Nurses’ Health Study concluded that by adopting a set of healthful lifestyle behaviors, more than 80% of heart disease and more than 91% of diabetes could be eliminated in women.8 The ability of dietary changes to improve cardiovascular and type 2 diabetes outcomes as well as cancer risk reduction also are well documented.9

Along with convincing evidence, lifestyle medicine is well positioned to help achieve what’s known as the Quadruple Aim in health care: “To enhance patient experience, improve population health, reduce costs, and improve the work life of health care providers.”1 It also restores career passion for many providers. In the age of health care burnout, this is an important bonus of lifestyle medicine.

Who’s Leading the Charge?
At the forefront of the lifestyle medicine wave is the ACLM, a medical society that provides quality education and resources to health care professionals committed to the practice of lifestyle medicine. With lifestyle medicine education sorely lacking in pre- and post-professional training for most health care providers, the ACLM offers these crucial learning opportunities for providers through continuing education courses, conferences, and lifestyle medicine board certification.

While it started as a physician-only organization, the ACLM now serves a global community of professionals across the spectrum of health care, including dietitians, researchers, and health care executives. The ACLM recognizes dietitians as a key part of successful lifestyle medicine outcomes. The medical society also sees community and public health entities as critical pieces of the lifestyle medicine puzzle. Because of this, it engages in advocacy initiatives to help move toward lifestyle medicine as the foundation of all health care. In the world of lifestyle medicine, the ACLM is at its core providing innovative resources, connecting like-minded stakeholders, and transforming health care.

The Six Pillars
The ACLM identifies six areas of lifestyle that can be used therapeutically to improve health outcomes: nutrition, physical activity, restorative sleep, stress management, social connection, and avoidance of risky substances. By incorporating five of the pillars alongside nutrition, dietitians can employ the whole-person approach of lifestyle medicine with their clients.

1. Nutrition
Every dietitian knows that food influences health, and the field of lifestyle medicine agrees that it’s one of the most important pillars. Based on scientific evidence, the ACLM has defined a recommended diet in their dietary position statement: “For the treatment, reversal, and prevention of lifestyle-related chronic disease, the ACLM recommends an eating plan based predominantly on a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds.”3 This dietary approach centered on whole plant foods has been shown to support disease prevention, treatment, and risk reduction, which is the aim of lifestyle medicine.9

If using this dietary approach within the context of lifestyle medicine is new to you, in collaboration with the recent White House Conference on Hunger, Nutrition and Health, the ACLM now offers the Lifestyle Medicine & Food as Medicine Essentials course bundle.10 Paulina Shetty, MS, RDN, CPT, DipACLM, senior director of education at ACLM, describes the bundle as “an introduction to the field of lifestyle medicine and nutrition for prevention, longevity, treatment, and risk reduction that’s 5.5 hours of CE.” The ACLM also offers an array of nutrition education resources for use with patients, including a Whole Food Plant-Based Plate, a Food as Medicine Jumpstart Guide, and a Culinary Medicine Curriculum.

2. Physical Activity
Physical activity earns its place as one of the six pillars of lifestyle medicine, as it positively impacts seven of the 10 most common chronic diseases.11 Plus, discussing this important pillar with clients and patients pays off. One study found that promoting physical activity in a primary care setting significantly increased the activity level of patients for up to one year.12

Even if dietitians aren’t trained in exercise physiology or a related field, sharing the Department of Health and Human Services’ Physical Activity Guidelines with clients can go a long way. The guidelines recommend at least 150 minutes per week of moderate-intensity activity and two or more strength training sessions that incorporate all major muscle groups.13 Helping clients discover simple ways to move more throughout the week and supporting them in working through their barriers to exercise also is critical.

3. Stress Management
According to a 2020 report issued by the American Psychological Association, the United States is experiencing a stress-related mental health epidemic that seeps into all areas of health.14 Stress has been linked to coronary artery disease, heart failure, rheumatoid arthritis, and various mental illnesses like anxiety.15 For any dietitian who’s helped clients navigate stressors to improve their relationship with food or nutrition status, this is no surprise.

It’s important to note that not all stress is bad. Moderate stress tends to improve performance. It’s when stress reaches high levels and becomes chronic that a person’s health is negatively impacted. Along with screening and referrals for more advanced mental health conditions, lifestyle medicine employs many different stress management techniques to target chronic stress and improve health outcomes. The list of techniques includes spending time in nature, meditation, and mindfulness as well as other lifestyle medicine pillars like improved sleep, exercise, and nutrition.15 Since all of the pillars of lifestyle medicine are interconnected, improving one can help improve others.

4. Restorative Sleep
Poor sleep is connected to higher rates of chronic disease, morbidity, and mortality.16 Lifestyle medicine also emphasizes that without adequate sleep, it’s much more difficult for people to build momentum with other lifestyle medicine pillars such as good nutrition or consistent exercise. Although the amount of sleep needed varies slightly from person to person, eight hours still stands as the best average recommendation for most adults.16

Upgrading clients’ sleep quality usually requires a deep dive into the other lifestyle medicine pillars, taking a critical look at eating habits, caffeine intake, physical activity, substance use, and stress levels. Improving these pillars greatly supports better sleep. Sleep hygiene strategies such as reducing screen time and setting up a bedroom environment that promotes sleep also are emphasized in lifestyle medicine. In addition, working with a physician to address sleep issues like sleep apnea is key.

5. Social Connection
Perhaps the most unexpected pillar of lifestyle medicine is positive social connection, keeping in mind that the COVID-19 pandemic brought isolation and loneliness to the forefront of health. A 2020 report from the National Academies of Sciences, Engineering, and Medicine states that loneliness and isolation are associated with higher incidence of premature mortality.17 Conversely, positive social connection has been associated with better health outcomes.18

When it comes to social connection, screening and referrals are key. Once at-risk patients are identified, lifestyle medicine providers can help connect them to social support resources in their communities. True to the interdependent nature of lifestyle medicine, tending to social connection has the power to help bolster all other areas of lifestyle for clients and patients.

6. Avoidance of Risky Substances
The final pillar of lifestyle medicine addresses the use of tobacco, alcohol, and recreational drugs. Along with the direct health effects of these substances, there are indirect effects on food choices, sleep, and stress management. The lifestyle medicine approach calls for identifying patients who use these substances and referring them to evidence-based resources for cessation or supporting them in balanced use.19

How to Apply Lifestyle Medicine
Dietitians who are interested in lifestyle medicine and want to know how to apply it to daily practice can take the following four steps.

Broaden Your Education
As experts in nutrition, dietitians have a head start when it comes to lifestyle medicine. Becoming educated in the other five pillars gives dietitians the ability to take a whole-person approach with patients. The ACLM offers a plethora of CE courses. Shetty describes how lifestyle medicine education enhances a dietitian’s existing training and gives them an edge. “While RDNs receive expert training in nutrition science, prevention, and medical nutrition therapy for chronic and acute diseases and conditions, lifestyle medicine focuses on not only prevention and treatment but also evidence-based nutrition for remission of chronic diseases and conditions. Not only does lifestyle medicine focus on therapeutically dosed nutrition for remission but it also includes well-rounded education on the other pillars.”

Educational offerings include the previously mentioned Lifestyle Medicine & Food as Medicine Essentials course bundle and the Foundations of Lifestyle Medicine Board Review, a self-paced 30-hour CE course to prepare those seeking lifestyle medicine certification. Dietitians also can attend the ACLM’s annual conference in the fall.

Get Certified
If RDs want to take their lifestyle medicine expertise to the next level, they can get board certified in lifestyle medicine. Alexandra Regalado, RDN, DipACLM, certified health and well-being coach, clinical outpatient dietitian at Stanford Health Care, and secretary of the ACLM Registered Dietitian Member Interest Group, has experienced the benefit of certification firsthand. “Certification has enhanced my ability to provide patient-centered care and given me the opportunity to connect with like-minded professionals committed to preventing, treating, and reversing chronic conditions.”

Alison Ozgur, MAT, MHS, RDN, DipACLM, the director of wellness programs for the Center of Nutrition Studies, agrees. “I have worked as a registered dietitian for 22 years, and while I believe that nutrition is the foundation of wellness and disease prevention, we cannot overlook the other lifestyle pieces that must be practiced in order to achieve optimal health.” For that reason, Ozgur chose to obtain lifestyle medicine board certification. “It was essential for me to strengthen my knowledge and expertise in the other pillars of lifestyle medicine. As a result, my clients and workshop participants achieve better results with their health goals.”

Partner With Other Lifestyle Medicine Providers
The practice of lifestyle medicine is meant to be interdisciplinary, and dietitians are considered an invaluable part of the lifestyle medicine health care team. Dietitians can join forces with physicians, health systems, or private practices interested in implementing the lifestyle medicine model of care.

Sherry Valente, MA, RD, LDN, CDCES, DipACLM, is product manager of nutrition and lifestyle medicine at Premise Health in Brentwood, Tennessee, a leading direct health care provider that employs more than 50 dietitians. With dietitians as a key part of their health care teams, Valente says, “Many health care employers are moving toward a lifestyle medicine approach to care, aiming to treat the root cause of disease and improve overall health outcomes. Lifestyle medicine–certified registered dietitians understand that chronic diseases can be prevented, managed, and perhaps even reversed by utilizing a lifestyle medicine approach. This type of approach, enhanced by the use of health behavior change coaching skills, can decrease health care spending for both employers and patients, improve overall health outcomes, and help activate patient autonomy and motivation for sustainable, lifelong behavior change.”

Lilian Correa, MA, MPH, RDN, DipACLM, a dietitian at Bellevue Hospital lifestyle medicine program in New York City, also knows the power of the lifestyle medicine team approach. NYC Health + Hospitals recently expanded Bellevue’s innovative program across New York City, and Correa serves as director of education and training for the expansion. “In our team approach, for example, what’s great is that the physician helps to identify nutrition-related issues to address by taking a detailed food history during the initial visit. This history, which is part of the physician’s initial assessment in all six pillars of lifestyle medicine, gives the RDN a great blueprint from which to work. I can begin to see the connections between the sleep or stress pillars, for example, and how these areas may be affecting a patient in the nutrition pillar. My questions can then be more pointed, more guided, when I do my initial assessment.”

Being part of a lifestyle medicine team also means that all providers reinforce lifestyle medicine messaging. “What’s great is that when patients come into my consult room, they have a better understanding and are more receptive to the recommendations we’re making around a plant-based eating pattern because the lifestyle medicine approach has been validated by the physician,” Correa says.

For RDs interested in being part of a lifestyle medicine team, the ACLM offers resources on how to structure lifestyle medicine programs, reimbursement education, and many networking opportunities. If dietitians don’t have a team, they still can incorporate lifestyle medicine into their work. Correa says dietitians can “help patients make the connections between how the other pillars can deeply affect eating patterns, relationship with food, and management of chronic conditions,” adding that the relationship between exercise and blood glucose control and the relationship between eating patterns and sleep are two examples.

Get Involved With the ACLM
The ACLM is the hub of lifestyle medicine, so becoming a member is an important first step in becoming a lifestyle medicine expert. The organization has much to offer dietitians, including a Registered Dietitian Member Interest Group; working groups organized by specialties, including culinary medicine and women’s health; patient-facing resources; an annual conference; and countless networking opportunities. Joining the ACLM plugs you into the epicenter of lifestyle medicine.

— Kayli Anderson, MS, RDN, DipACLM, ACSM-EP, is founder of the women’s health website Plant-based Mavens (plantbasedmavens.com) and lead faculty of the American College of Lifestyle Medicine’s Food as Medicine course.

References
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