December 2017 Issue
Using Food as Lifestyle Medicine
By Vicki Shanta Retelny, RDN, LDN
Vol. 19, No. 12, P. 36
This science-backed, holistic approach to disease prevention and management is making big strides in the dietetics world.
The focus on lifestyle choices to prevent and treat chronic diseases, such as obesity, type 2 diabetes, CVD, and multiple types of cancer, has gained momentum in the past decade. And rightly so, as the leading causes of death among adults in the United States are related to lifestyle, including tobacco use, poor diet, physical inactivity, and excessive alcohol consumption.1
The World Health Organization estimates that, by 2020, two-thirds of all diseases will be the result of lifestyle choices.2 Nutrition, physical activity, and obesity, as well as substance abuse and tobacco, are included among the Healthy People 2020 12 Leading Health Indicators, a set of high-priority public health issues in the United States.3
As a result, there's a strong push toward taking a lifestyle medicine approach to health care, and nutrition education plays a primary role in this movement. With physicians traditionally receiving little or no training in nutrition science and reluctant to counsel patients on lifestyle behaviors that many fail to practice,4 the time is ripe for a more formal educational framework around lifestyle medicine.
What is lifestyle medicine? According to one definition from the American College of Lifestyle Medicine (ACLM), the flagship medical organization in the lifestyle medicine movement founded in 2004, "Lifestyle Medicine is the therapeutic use of evidence-based lifestyle interventions to treat and prevent lifestyle-related diseases in a clinical setting. It empowers individuals with the knowledge and life skills to make effective behavior changes that address the underlying causes of disease."5
The following are the primary features of ACLM's Standards of Lifestyle Medicine5:
• It emphasizes promoting behavior changes that allow the body to heal itself.
• It focuses on evidence-based optimal nutrition, stress management, and fitness prescriptions.
• Patients are active partners in their care.
• The underlying lifestyle causes of disease are treated.
• The physician/provider educates, guides, and supports patients to make behavior changes.
• Medications are used as an adjunct to therapeutic lifestyle changes.
• The patient's home and community environment are assessed as contributing factors.
"ACLM is a galvanizing force for change," says Susan Benigas, executive director of ACLM and cofounder of The Plantrician Project, a nonprofit organization that hosts events and provides resources and tools for medical professionals who believe in the "food as medicine" pillar of lifestyle medicine. With health care costs skyrocketing to treat conditions caused by poor lifestyle choices, Benigas believes ACLM offers a beacon of hope. "As we teeter on the brink of health care cost-induced bankruptcy, we need to take swift action to educate, equip, and empower our medical professionals and those they serve with the 'good news' of lifestyle medicine," Benigas says.
ACLM, along with the American College of Preventive Medicine (ACPM), a national medical specialty society of physicians dedicated to disease prevention, health promotion, and systems-based health care improvement,6 are collaborating to fill the gap in medical education to include a foundational lifestyle medicine curriculum available online to all clinical specialties. With the belief that team-based care is an essential part of lifestyle medicine, ACPM's Associate Executive Director Danielle Pere, MPM, sits on the Academy of Nutrition and Dietetics Primary Care Provider Advisory Board to help develop and implement strategies at the national level that will promote successful collaboration between dietitians and primary care physicians at the local level.
The Primary Care Provider Advisory Board will be presenting at ACLM's annual meeting in May 2018 in Chicago on the importance of collaboration between dietitians and primary care providers to further individual and population health. ACPM believes lifestyle medicine is a core competency of preventive medicine and supports the continued exploration of the scientific basis, best practices, and the need for education in lifestyle medicine.7
Dietitians Are Major Players
As food and nutrition experts, dietitians play a key role in lifestyle medicine by educating other health care professionals about how food can and should be part of patient care and treatment plans and offering nutrition expertise to ensure success of treatment protocols in practice.
"In my mind, lifestyle has always been the platform for all nutrition intervention therapies I've recommended over my 30-year career," says Rosanne Rust, MS, RDN, LDN, an author and communications consultant based in Meadville, Pennsylvania. "Nutrition plays a huge role in lifestyle medicine. Every diagnosis has a nutrition therapy that should accompany it," she continues, adding that referrals to dietitians are one of the primary ways physicians can ensure results from diet therapy.
Dietitians can apply the most current scientific evidence available, which supports the consumption of whole, unprocessed or minimally processed plant foods as treatment for most of the lifestyle-related illnesses in the US population.5 RDs can make an initial nutrition assessment and provide patients questionnaires about their eating habits. They can recommend physicians order blood tests for patients to screen for serum lipids, blood glucose, and vitamin D levels. And dietitians can discuss healthful eating options with patients, develop personalized meal plans and shopping lists, and suggest they attend nutrition clinics, community garden tours, seminars, food sampling events, and cooking classes to taste and learn how to prepare healthful foods.5
Having worked within an interdisciplinary team with other health care professionals early in her career, Rust recalls the lifestyle as medicine model as "all about prevention and health education." However, with changes in health care coverage and the fact that insurance reimbursement policies don't always cover preventive services, including lifestyle change prescriptions, it has been challenging for providers to practice within this model. Even though the most widely accepted, well-established chronic disease practice guidelines uniformly call for lifestyle change as first-line therapy, physicians often don't include them in their practices.8 Nevertheless, the tide is turning.
Sarah Krieger, MPH, RDN, owner of SBK Nutrition, LLC, a private nutrition consulting practice in Tampa, Florida, works with Healthy Lifestyles Tampa Bay in St. Petersburg, Florida. "I work with a psychologist and a fitness expert. The three of us are the trinity for guiding clients on their weight loss journey," Krieger says. Healthy Lifestyles Tampa Bay offers a comprehensive treatment plan focused on nutrition, exercise, mental and emotional healing, and health. As a member of an interdisciplinary team, Krieger meets with the psychologist and fitness trainer to discuss each client's situation and mental health status, and to determine mutual goals.
"First, I provide a thorough lifestyle assessment, which includes labs, medications, diseases, and conditions, as well as work and family life, and, of course, typical meal patterns," Krieger explains. With motivational interviewing skills, she collaborates with her clients to establish big-picture goals and then realistic smaller goals to help guide them toward lifestyle changes. "My proudest moments as a registered dietitian nutritionist are when my clients tell me their insulin dose or oral hypoglycemic medications have been reduced or eliminated. It validates how I coach clients," Krieger says.
Audra Wilson, RD, LDN, a clinical dietitian at Northwestern Memorial Delnor Hospital in Geneva, Illinois, works alongside a nurse who conducts patient medical reviews and an endocrinologist bariatric physician who assesses underlying conditions for weight gain and obesity. They meet and discuss each patient's needs, level of learning ability regarding meal planning, and food tracking.
"By the time I meet with the patient, I have a lot of information and can tailor my nutrition education accordingly," Wilson says. The interdisciplinary team approach enables them to get a well-rounded picture of the patient. "In my initial visit with patients, I assess readiness to change and where the food and nutrition knowledge deficits are," Wilson says.
Lifestyle changes, such as tracking food intake, ridding the diet of liquid calories, and getting patients moving with regular exercise, are the first line of therapy for Wilson's patients. "My patients are pretty compliant, as they finally feel like they're getting knowledge from experts. It's important that they speak to a registered dietitian," Wilson says.
The team mindset carries over to Wilson's one-on-one counseling sessions with patients as she discusses the lifestyle changes, provides guidance on how to incorporate them into everyday life, and allows them to determine which ones to prioritize. "There's a mental and emotional piece to weight loss and patients have to feel like you're on their side as a partner in the process," Wilson says.
Nicole Eichinger, RD, LD, owner of the private practice Nutrition's My Life in Cibolo, Texas, also helps her clients incorporate lifestyle changes into their lives. Although she's a sole practitioner, she refers clients regularly to other experts. "When I'm working one on one with a client, I will refer to other experts based on the client's needs," Eichinger says. In her group work, she has experts call in to join her during counseling sessions, too. "My clients love the lifestyle approach, as they're given concrete tools, such as daily meditation practices for stress reduction, which can improve their gut health, which allows for better absorption of nutrients," Eichinger says.
Lifestyle homework is part of Eichinger's counseling protocol. "Although most clients are excited about lifestyle homework, they need weekly help and accountability to remind them of why these improvements are important," Eichinger says. She works with clients for at least six weeks to give them adequate support and encouragement to keep moving forward with lifestyle changes. "I know my expertise as a registered dietitian is food and nutrition; however, behavioral, mental, and environmental factors all play a role in achieving a healthful lifestyle. This is why having a team of experts you know and trust is important to help others achieve their healthful living goals," Eichinger says.
Rust adds, "While we don't have control over genetic factors, gender, age, and race, we have control over what we eat, if and how much we exercise, whether we smoke, our sleep habits, and how we handle stress. Helping patients with these controllable factors empowers them to take ownership of their health."
— Vicki Shanta Retelny, RDN, LDN, is a nationally recognized lifestyle nutrition expert, author, speaker, and culinary and media consultant in Chicago. She's the author of The Essential Guide to Healthy Healing Foods and Total Body Diet for Dummies. She blogs at SimpleCravingsRealFood.com.
1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-1245.
2. Chopra M, Galbraith S, Darnton-Hill I. A global response to a global problem: the epidemic of overnutrition. Bull World Health Organ. 2002;80(12):952-958.
3. 2020 LHI topics. HealthyPeople.gov website. https://www.healthypeople.gov/2020/leading-health-indicators/2020-LHI-Topics
4. Vickers KS, Kircher KJ, Smith MD, Petersen LR, Rasmussen NH. Health behavior counseling in primary care: provider-reported rate and confidence. Fam Med. 2007;39(10):730-735.
5. Rooke J, Gobble J, Ballard T, et al. Lifestyle medicine standards. https://www.lifestylemedicine.org/Resources/Documents/ABOUT/ACLM%20Standards_
6. Mission. American College of Preventive Medicine website. http://www.acpm.org/page/mission
7. Lifestyle medicine initiative. American College of Preventive Medicine website. http://www.acpm.org/page/lifestylemedicine
8. Lianov L, Johnson M. Physician competencies for prescribing lifestyle medicine. JAMA. 2010;304(2):202-203.
- American College of Preventive Medicine, www.acpm.org/lmprogram
- American College of Lifestyle Medicine, www.lifestylemedicine.org/lmcc
- Lifestyle Medicine Core Competencies Culinary Medicine Elective, www.acpm.org/culinarymedicine
- American Board of Lifestyle Medicine, https://ablm.co
- Institute of Lifestyle Medicine at Harvard University, www.instituteoflifestylemedicine.org
- Lifestyle Medicine Global Alliance, www.lifestylemedicineglobal.org
- The Plantrician Project, www.plantricianproject.org
BUILDING CONFIDENCE IN LIFESTYLE MEDICINE
The need for standards of care and core competencies to establish lifestyle medicine as a bona fide modality led to the collaboration of a panel of medical specialty societies. They included the American Medical Association, the American Osteopathic Association, the American Academy of Family Physicians, the American College of Physicians, and the American Academy of Pediatrics, jointly led by the American College of Preventive Medicine (ACPM) and American College of Lifestyle Medicine (ACLM). Together they developed the following Lifestyle Medicine Core Competencies:
- Leadership. Promote health behaviors as foundational to medical care, disease prevention, and health promotion; seek to practice healthful behaviors and create school, work, and home environments that support healthful behaviors.
- Knowledge. Demonstrate knowledge of the evidence that specific lifestyle changes can have a positive effect on patients' health outcomes; describe ways that physician engagement with patients and families can have a positive effect on patients' health behaviors.
- Assessment skills. Assess the social, psychological, and biological predispositions of patients' behaviors and the resulting health outcomes; assess patient and family readiness, willingness, and ability to make health behavior changes; and perform a history and physical examination specific to lifestyle-related health status, including lifestyle "vital signs," such as tobacco use, alcohol consumption, diet, physical activity, BMI, stress level, sleep, and emotional well-being. Based on this assessment, obtain and interpret appropriate tests to screen, diagnose, and monitor lifestyle-related diseases.
- Management skills. Use nationally recognized practice guidelines (such as those for hypertension and smoking cessation) to assist patients in self-managing their health behaviors and lifestyles; establish effective relationships with patients and their families to effect and sustain behavioral change using evidence-based counseling methods, tools, and follow-up; collaborate with patients and their families to develop evidence-based, achievable, specific, written action plans such as lifestyle prescriptions; help patients manage and sustain healthful lifestyle practices; and refer patients to other health care professionals as needed for lifestyle-related conditions.
- Office and community support. Have the ability to practice as an interdisciplinary team of health care professionals, and support a team approach; develop and apply office systems and practices to support lifestyle medical care, including decision support technology (computerized systems that help substantiate results); measure processes and outcomes to improve quality of lifestyle interventions in individuals and groups of patients; and use appropriate community referral resources that support the implementation of healthful lifestyles.
These core competencies in lifestyle medicine are the foundation for the Lifestyle Medicine Core Competencies Program (LMCC), a joint initiative of ACPM and ACLM, representing the first online evidence-based lifestyle medicine curriculum designed for physicians, nurses, nurse practitioners, dietitians, physician assistants, health coaches, and other allied health professionals. LMCC consists of nine program modules, one of which is devoted to nutrition and related electives, such as culinary medicine that encourages home cooking, plant-based nutrition practices, and culinary skills development for providers and patients.
Rosanne Rust, MS, RDN, LDN, an author and communications consultant based in Meadville, Pennsylvania, developed the Nutrition Assessment curriculum module for LMCC. "The goal of this session is to introduce primary care physicians to the idea of how to approach a patient's dietary needs first by understanding the nutrition assessment aspect of the nutrition care process," Rust says. This module provides the general principles for an evidence-based healthful diet, and how to approach patients about change and make referrals to dietitians for diet therapy.
— Resource: Lianov L, Johnson M. physician competencies for prescribing lifestyle medicine. JAMA. 2010;304(2):202-203.
CERTIFICATION IN LIFESTYLE MEDICINE
With numerous studies supporting the use of lifestyle medicine, practitioners clamored for a way to make it a legitimate medical specialty. Thus, in 2016, the American Board of Lifestyle Medicine (ABLM) was established. The ABLM is a not-for-profit organization dedicated to making lifestyle medicine more financially viable by implementing a framework for physicians and other health care professionals to receive continuing medical education (CME), as well as certification in lifestyle medicine. The inaugural certification examination was held on October 26, 2017, in Tucson, Arizona. With a concerted effort to get lifestyle medicine practitioners speaking the same language and using similar treatment protocols all over the world, ABLM, in conjunction with the International Board of Lifestyle Medicine (IBLM), has syndicated the ABLM certification examination globally. From the start, it has been the desire of the lifestyle medicine movement to be a global force,1 and as a result, the Lifestyle Medicine Global Alliance (www.lifestylemedicineglobal.org) was formed. With this alliance, members across the globe from Canada, Australia, the United States, Asia, Europe, Latin America, and more are partnering to recognize lifestyle medicine as the foundation for sustainable health care.
"It's an exciting time," says Stephan Herzog, executive director of ABLM. "For the first time in history, a medical discipline will have the same framework and examination all around the globe." With a platform based on prevention, Herzog and his colleagues at ABLM and IBLM are working to develop a framework for lifestyle medicine so it will become a medical subspecialty. "The idea of lifestyle medicine is ultimately because chronic diseases are 80% foodborne and lifestyle related," Herzog says. With science showing that chronic disease may be reversible with lifestyle medicine, "the goal is to get patients off medications or greatly reduce them," he says.
To sit for the certification exam in lifestyle medicine, the requirements include the following1:
- 30 hours of online CME through the ACLM/ACPM [American College of Lifestyle Medicine/American College of Preventive Medicine] Lifestyle Medicine Core Competencies Program, or the Institute of Lifestyle Medicine (ILM) courses at Harvard University, or the plant-based nutrition certificate at Cornell University;
- 10 hours of in-person CME that involves attending various workshops hosted by the ACLM, the ILM, the Food as Medicine summit, or the International Plant Based Nutrition Healthcare Conferences; and
- one case study involving outcomes associated with a lifestyle medicine prescription (for MDs and DOs only).
"Dietitians are getting certified in lifestyle medicine," says Wayne Dysinger, MD, chair of ABLM and IBLM. "I'd love RD programs to participate and apply for certification. Nutrition is the cornerstone of lifestyle medicine, as people are the most interested in food. Yet some practitioners don't even know that broccoli can decrease inflammation." With food at the forefront of the lifestyle medicine conversation, Dysinger wants every practitioner to have some lifestyle medicine skills to know how to prescribe nutrition as part of therapy. "I want patients to have the lifestyle medicine choice," Dysinger says.
Exposure is key to making health care providers comfortable with lifestyle medicine protocols. Research has found that when medical residents were immersed in lifestyle medicine education with rotations, as well as personal hands-on skills building with journal writing, online exercise monitoring, community walks, and experiential sharing in meetings, they were more likely to discuss lifestyle interventions with their patients.2
1. Herzog S, Dysinger W. The American Board of Lifestyle Medicine. Am J Lifestyle Med. 2017;11(3):230-231.
2. Nawaz H, Petraro PV, Via C, et al. Lifestyle medicine curriculum for a preventive medicine residency program: implementation and outcomes. Med Educ Online. 2016;21(1):29339.— VSR