January 28, 2015 by Nicholas Spence
The epidemiological transition describes the shift in causes of illness and death through time from infectious diseases to chronic diseases. With about half of all adults suffering from a chronic health condition in the United States, the Centers for Disease Control notes the following: 86% of health care resources are allocated towards the treatment of chronic conditions. Despite these daunting numbers, there is much hope as we know that chronic conditions are directly related to modifiable lifestyle factors that can be effectively addressed for individuals and populations. A recent article in The Lancet provided a short list of the main culprits: tobacco use, poor diet and physical inactivity, excessive alcohol consumption, uncontrolled high blood pressure, and hyperlipidaemia. The World Health Organization has indicated that elimination of risk factors would result in prevention of at least 80% of all heart disease, stroke, and type 2 diabetes and 40% of cancer.
Medicine, at the forefront of client care, has begun to question its traditional roles and efforts given the pervasiveness of chronic disease and its determinants. Of particular note, the rise of “lifestyle medicine,” with its main advocate, the American College of Lifestyle Medicine (ACLM), has a primary interest in lifestyle interventions to prevent, treat and manage chronic disease. The logic is simple: lifestyle practices are among the top determinants of health and intervention efforts should be commensurate with this importance; changing unhealthy behaviors is foundational to medical care, disease prevention, and health promotion; the physician’s trusted relationship with clients, accompanied by support from family, peers, community, and an interdisciplinary client care team is the path to promoting healthy behaviors and outcomes.
These ideas are far from pie in the sky! Initiatives such as the Institute for Lifestyle Medicine at Harvard School of Medicine have made strides in collaborative efforts to make lifestyle medicine a formal part of standard practice, given the evidence supporting the role of modifiable behaviors in affecting mortality, disease and health care costs. Echoing these goals, in a recent post by Walter M. Bortz II, MD, Clinical Professor of Medicine at Stanford University, he notes the development of a related curriculum and its incorporation into certifying examinations of the major societies, from surgeons to urologists to orthopedists, as they all should include lifestyle approaches in client care.
The capacity of clinicians to improve client outcomes in a manner consistent with lifestyle medicine is premised on the skills in their toolbox related to modifying lifestyle behaviors. One of the tools garnering much attention is motivational interviewing (MI), which is a client-centered path to communication, engaging clients and families in a supportive manner that facilitates internal motivation to change behavior by having them identify goals and obstacles, promoting autonomy, and empowering them to develop solutions. It is strength-based, focused on existing assets in clients and families that promote health and foster shared decision making and self-efficacy. Is it evidence based? Yes. In a systematic review and meta-analysis of randomized controlled trials, the efficacy of MI was illustrated across a variety of health related outcomes, including intention to change, client confidence, self-monitoring, dental caries, cholesterol levels, bodyweight, physical strength, sedentary behavior, HIV viral load, blood pressure, substance use (licit and illicit), quality of life, and death rate. Indeed, it has become an indispensable tool in lifestyle medicine and other clinical settings.
Given the merit of MI in facilitating behavior change, it has been integrated into lifestyle medicine education programming (Institute for Lifestyle Medicine, ACLM), and uptake has also been observed in clinical settings; for example, recently, a news release revealed the Massachusetts Hospital Association (MHA) has engaged in a multi-year partnership with Geneia to facilitate efficiency in health care institutions—raise the quality of care, enhance customer satisfaction, and reduce costs (who can’t relate to these goals?). This will be accomplished through the provision of MI courses for client care teams, providing clinicians with the capacity to affect behavior change in a more effective manner.
In an age of chronic disease, there is no doubt that changing unhealthy lifestyle behaviors will pay dividends across health, economic and social outcomes. It is encouraging to see momentum increase using the lifestyle medicine approach, and it will be crucial to ensure that the prerequisite skills are mastered to optimize care.