Abstract
The Institute of Lifestyle Medicine (ILM) plays a critical role in today's complex medical landscape. Providing clinicians with the educational tools they need to truly address the root cause of patients' problems, the Institute offers a variety of innovative venues for the advancement of clinicians' knowledge. Edward M. Phillips, MD, Founder and Director, ILM, Assistant Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School, and Chief of Physical Medicine and Rehabilitation at the VA Boston Healthcare System, Boston, Massachusetts, commented, “In today's complex and evolving medical system, it has become increasingly apparent that getting to the root cause of diseases, which lead to exorbitant health care costs and premature death is essential.” He added, “We know that 80% of chronic disease, at least two-thirds of health care dollars, and more than half of premature deaths are related to simple behaviors that we—including practitioners and patients—almost universally fail or are not fully successful in one area or another.” Phillips called on clinicians to first be the patient and practice appropriate self-care because this has a significant effect on helping patients succeed at making behavioral changes.
The root causes of chronic disease stem from an unhealthy diet, lack of physical activity, poor stress resiliency, and tobacco and excessive alcohol use, according to Phillips, who stated, “If a person improves their habits in these areas, his or her chance of reducing the risk of dying prematurely, reducing costs and preventing disease increases tremendously. The need for lifestyle medicine has probably never been greater than it is today.”
Establishing Lifestyle Medicine as Standard Practice
Founded 10 years ago, the ILM, a nonprofit organization within the Department of Physical Medicine and Rehabilitation at Harvard Medical School, was initiated with the idea of filling the lifestyle medicine educational void for clinicians. The ILM started with continuing medical education (CME) programming, and since its opening, clinicians from >115 countries and >10,000 people have taken their online courses, which are available through Harvard Medical School (
Practicing lifestyle medicine is more than just a sound health practice—in fact, it is becoming the way of the future. With the shifting payment systems, lifestyle medicine is going to be a key ingredient in the way that physicians are remunerated for their services, according to Phillips, who stated, “As billing and payment structures change, these courses attract people who need to understand more about changing patient's behavior. We use to see the early adopters attend our CME courses—people who are naturally passionate about lifestyle medicine. However, now, people approach me and say, ‘It turns out that I am going to be paid based on my patients’ behaviors. I would like to continue to make a living, and I do not know how to change anyone's behavior.' That is the content we focus on and teach, and people need to know how to help their patients adopt and sustain new and healthy behaviors.”
Phillips stated that the VA has a system-wide effort called Whole Health, which uses integrative medicine and principles of behavior change to improve the heart health behaviors of veterans in an effort to improve their lives, reduce chronic disease, and save money. He said, “This is probably one of the strongest systems that I have seen where what I call lifestyle medicine is being integrated. So that is one level of systematic transformation.”
The ILM has also initiated efforts to transform medical education and change the way that physicians train. In 2013, the ILM, along with colleagues from around the country, started an effort now called the Lifestyle Medicine Education Collaborative, (LMEd). The LMEd Collaborative seeks to institute lifestyle medicine as a foundational part of the curriculum and training of U.S. medical students. That effort (
Elizabeth Pegg Frates, MD, Lifestyle Medicine Specialist, Health and Wellness Coach, Wellness Synergy, LLC, Director of Wellness Programming, Stroke Institute for Research and Recovery at Spaulding Rehabilitation Hospital, and Assistant Professor, Harvard Medical School, started one of the first lifestyle medicine interest groups at Harvard Medical School. Since 2009, she has run a group where interested medical students can supplement their curriculum with content not taught in the core curriculum such as motivational interviewing, health coaching, and stress resiliency.
Frates commented on how she first became interested in teaching students about lifestyle medicine: “My father had a heart attack and stroke when he was 52 years old. At that time, I was 18 years of age, and his health setback inspired my medical career. I watched him change his habits, and change his life. He lived 27 wonderful years filled with love, laughter, and a sense of well being. For the past 30 years, I have been on a mission to learn as much as possible about how lifestyle affects health and to spread the word about the power of lifestyle medicine.” She added, “I started a lifestyle medicine interest group (LMIG) to inject lifestyle medicine into Harvard Medical School in a way that would not disrupt the current medical school system. Instead, the parallel curriculum adds to the students' education without taking time away from an already packed schedule of lectures and required courses. For the LMIG, I present lectures on introduction to lifestyle medicine, collaboration and negotiation for behavior change, exercise basics, nutritional counseling, and motivational interviewing, etc.”
Frates also shares her approach with other professors and students through the American College of Lifestyle Medicine (ACLM) so they can begin their own LMIG at their schools. Frates said, “The ACLM has a Professionals- in-Training (PiT) committee dedicated to helping health professionals in training learn about lifestyle medicine. I have been the Board Liaison for that committee for two years, and was recently elected to the Board of Directors of ACLM and will be helping with the Education Committee as well.”
Frates, along with her family, created an award in honor of her father who passed away in 2012. She said, “My passion for helping students learn about lifestyle medicine early in their career runs deep. The Donald A. Pegg Award encourages healthcare professional students to create LMIGs in their schools. There is an application process, an application review committee, and a monetary award for the winners so that they have funds for lunch meetings or other resources they need to start a LMIG. The ACLM has been a wonderful partner for this national award.”
The lifestyle medicine curriculum has extended to other parts of the university that may benefit from such information as well. Frates said, “In 2014, I was invited to teach a college and graduate school course on lifestyle medicine at Harvard Extension School. I put together 14 weeks of material with two one-hour lectures and a one-hour discussion session each week. The students who participate are pre-medical, psychology masters, biology majors, engineers, pre-law, lawyers, business people, and practicing physicians. By opening up this course to everyone from college to beyond, I am spreading lifestyle medicine principles to practitioners and patients alike. The sooner people learn about the power of healthy living, the sooner they can adopt healthy habits and enjoy a life filled with love, laughter, and a sense of well being. I am striving for the same.” Frates hopes that eventually lifestyle medicine becomes an integral part of medical school, included in the pathology, neurology, cardiology, rheumatology, dermatology, and other classes offered. “Lifestyle is medicine,” she said. “Prescribing exercise, nutrition, sleep, and stress management will be mainstream so that patients will expect these prescriptions and practitioners will routinely dispense this medicine.”
Additional important developments related to lifestyle medicine include the formalization of the world of health coaching. This year marks the first national examination for health coaches, and it is the first year that the American Board of Lifestyle Medicine (
Culinary Health Education Fundamentals Coaching
Culinary Health Education Fundamentals (CHEF) Coaching is a unique program offered through the ILM and is the brainchild of Rani Polak, MD, Chef, MBA, and Program Director, CHEF Coaching, Institute of Lifestyle Medicine, Spaulding Rehabilitation Hospital Research Associate, Physical Medicine and Rehabilitation Department, Harvard Medical School, Boston, Massachusetts. Polak realized that a lack of culinary literacy among patients hinders them as they try to change their diets. In other words, literally, how we prepare food, how we store food, and how we plan our meals. Phillips said, “This is a fascinating initiative, and we have been running courses on this topic. Now is the first time that Harvard is actually going to give CME credits for these courses.”
In an interview, Polak commented on his interest in the topic: “The first time that I understood the traditional medical system needed to change was during medical school. I remember this teaching moment as clearly as if it were today. My colleagues and I were in clinical rounds with one of our attending physicians, and he introduced us to one of his patients, offering a long, detailed ‘to do’ and ‘not to do’ list. This list was relevant to the patient's new health condition, but it was very clear to me that the patient had no idea what his physician was talking about or how he would implement these instructions into his daily life. One of my take home messages from that experience was that an effort needs to be made to develop solutions and methods that will help patients to implement that which is medically advised.”
Polak took a break in his medical education to attend culinary school. He said, “During that time, I didn't have a clear vision of how everything was going to come together, but I had a strong gut feeling that this should be my next step, and while pursuing my culinary education I began to understand why. How can you consume whole grains if you do not know how to prepare them? How can you incorporate more vegetables in your diet if basic culinary skills are missing? With the completion of my culinary training, I realized that the culinary world could address the gap that I had identified—providing tools to accomplish nutritional efforts and medical recommendations. From that point on, the direction of my career became clearer to me, and I went back to medical school. Since then I have been working in a field that is now defined as Culinary Medicine.”
Polak stated that his most important ILM initiative is CHEF Coaching, which has two programs: Clinicians CHEF Coaching for providers/clinicians, and Patients CHEF Coaching for clients and patients. He said, “Both programs share one key focus area—improving participant's home cooking. In other words, patients/clients and providers/clinicians share a common barrier/focus area, which is improving self-care. In my opinion, this is one of the most beautiful parts of Lifestyle Medicine, which is different from other fields in medicine where the providers may not face the same challenges as their patients. The providers program, of course, has an additional focus area too—educating others to improve their nutrition.”
Last year, the ILM led an important project, which was summarizing the worldwide culinary medicine programs (primarily in the United States), according to Polak. He said, “This summary helped us to identify several gaps. First, all of the programs are delivered in teaching kitchens that might be ideal, but include high costs and low accessibility. Second, all curricula were focused on culinary skills, which is an important barrier to home cooking; however, other barriers such as low confidence and lack of time were not addressed. Third, although adopting home cooking is a major lifestyle change, none of the programs were focused on the specific behavioral change aspects of this area.”
The key goal of CHEF Coaching is to address these gaps, as an innovative approach that combines culinary skills with coaching principles as a two-pronged approach to improve nutrition through home cooking efficiently and cost-effectively. It is a low-cost remote program, melding health-coaching principles and culinary skills and other facilitators of home cooking such as management skills. Polak commented, “To date, preliminary data evaluating the Patient CHEF Coaching shows that the program improves participants' confidence to cook, their nutritional consumption and health status. Further, preliminary data evaluating our professional training shows that providers who use the CHEF Coaching tools are effective in helping individuals consume healthier nutrition.”
In the future, Polak hopes that formal studies will prove the effectiveness of Patients CHEF Coaching on patients' nutrition consumption and overall health and that CHEF Coaching principles used by providers will be proven effective. He said, “I hope to expend the program to address individuals with disabilities. Current data shows that the rate of obesity among adults with disabilities is alarming—currently 57% greater than the non-disabled adults. It is time to develop an approach that will be specifically focused on that population.”
Take-Home Messages for Clinicians
So what are the key take-home messages for clinicians regarding lifestyle medicine today? Phillips commented on three important messages: • “I am closely affiliated with integrative physicians and people who are willing to look beyond the bounds of what we were taught in medical school. Probably the part that all clinicians need to emphasize takes a lot more than just telling the patient what is wrong and making some recommendations. Hyperfractionating a patient's lipids is great, but unless the results lead to behavior change that the person is ready, willing and able to make, we really have not succeeded.” He added, “So the magic here is knowing about the behaviors as the root causes, and then having the skills, tools and the experience to help patients to adopt and sustain new behaviors. A clinician can recommend an important and effective herb, but the person has to take it in order for there to be change.” • “The number two take home message is that the clinicians' health and behaviors directly impact their patients. One does not have to be perfect, just the process of trying to increase exercise, get enough sleep and manage stress is a process that clinicians can share with their patients. Even if they do not share their own process, there is still an impact on the patients. With all of the stressors facing clinicians today, we must be committed to taking better care of ourselves.” • “Number three—the practice of lifestyle medicine can be fun and less of a struggle than a more paternalistic, disease based system of care. In this world, a skilled clinician learns to dance with their patients rather than wrestle with them. A clinician may initially lead the dance, but in due course, the patients take over. They lead the dance, and it is a much kinder, gentler way with more sustainable benefits to the patient.”
Phillips continued, “In lifestyle medicine, we move beyond the disease-based model of care and look at the behaviors and at the root causes. Of course, it is really a genetic conundrum to determine, for the same poor behaviors, whether one patient develops diabetes, a stroke or a heart attack or all of the above, versus another. But the behaviors are the commonality.”
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The Future
Fortunately, the world is interested in becoming healthier, according to Phillips, yet he believes that the field of medicine has lagged behind. He said, “For years, people would go to their doctor, who would say nothing about their lifestyle habits, which is often perceived as condoning the bad behavior. Now, we are trying to remedy that so people hear a consistent message—you have got to be physically active, eat right, and manage your stress.” Phillips said that the interest in lifestyle medicine is becoming global, and other countries are adopting lifestyle medicine initiatives and associations. He stated, “My hope is that the field of lifestyle medicine becomes foundational to the training of all health professionals. The early signs are that if we stay the course we are going to be successful at changing the way health professionals think and how they work with their patients and that is the chance we have to decrease the risk of premature death, two-thirds of healthcare costs, and 80% of chronic disease. So I am hopeful that we can make an impact in these areas.” ■