Abstract
Chronic diseases place a growing burden on older adults who may suffer from diminished quality of life. Although the risks of disease and disability clearly increase with advancing age, poor health is not an inevitable consequence of aging. 1 Much that is associated with chronic disease is avoidable through known prevention measures, such as practicing a healthy lifestyle and early screening for reproductive cancers.
Health promotion, wellness, and disease prevention are becoming increasingly important for the public as well as for healthcare professionals.
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As far back as 1979, the Surgeon General's Report, Healthy People, laid the foundation for a national prevention agenda, which has been followed by an annually updated evidence-based Guide to Clinical Preventive Services based on recommendations from the U.S. Preventive Services Task Force
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Although there is evidence of improved outcomes for chronic care, a growing number of women suffering from chronic diseases will face many obstacles in coping with their conditions, often because their medical care does not provide for effective clinical management, psychological support, or adequate communication. 2,3,8 One reason for this is the mismatch between patient needs and the treatment options presented to them.
Historically, advances in conventional medical care have resulted from evidenced-based findings, but the opposite is occurring with integrative care, where high patient demand for alternative forms and styles of medicine is driving their use. Scientific evidence exists for some complementary and alternative therapies (CAM), but for most, rigorous clinical trials have not been done and are unlikely, given the high cost and lack of incentives to do so. 9,10 In effect, there is a built-in limitation to achieving an evidence basis in an integrative medicine model similar to that of conventional medicine. Therefore, moving into the realm of CAM, it is important to remain open to the possible benefits and potential efficacy of strategies for an individual patient. Integrative care requires a thoughtful balance between evidenced-based data and judgment given the needs and history of the patient if the best outcomes are be achieved. A final element is the patient's own desires, motivation, and compliance, which are critical for a successful outcome regardless of the therapies used. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes, particularly among women; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and outcome. 11
Whereas a disease care system is necessary to manage the population at large, individual lifestyle factors dictate the health of the population. In fact, the ability to prevent chronic diseases can be reduced by 80% by attending to basic lifestyle behaviors—smoking, diet, and physical activity—a relationship that has been recognized for at least 15 years. 12,13 The dilemma remains: How to promote adoption of good lifestyle behaviors or induce needed changes to these modifiable lifestyle behaviors to successfully reduce individual disease risk?
Clinicians must approach the challenge of prevention with a dose of humility. The truth is that the medical community is overreaching by placing ourselves at the center of prevention as an end point because there is little to be done clinically with respect to lifestyle behaviors. The construct of prevention must start at home and extend to the educational system and exist at the supermarket, in restaurants, and on the job, essentially anywhere and everywhere that food and people come together. Yet, all patients deserve to hear from knowledgeable providers that what they do on a daily basis affects their chronic disease risk. 3,10,14 Women, therefore, should be educated about the fundamentals of healthful eating and reminded about the negative impact of smoking, and they deserve good guidance about the right level of physical activity needed to promote health. 6,12,13,15 –17 Beyond that, there is an important role for clinicians as agents of health-promoting changes to stand behind a cultural shift—advocating for positive community offering, such as daily physical activity in schools and nutrient-dense school meals. Any physician can submit an Op-Ed piece or letter to the community paper, join a PTA health and wellness committee, or give a talk to a PTA to pave the way for others to carry these ideas forward.
The implications of lifestyle behavior ought to be addressed adequately in medical education across the spectrum of physician specialties; that it is not is an unacceptable deficiency. 14,18
Physicians as a whole have not been taught to approach patient care outside the conventional box. Although the current medical model has served the population sufficiently well for established chronic conditions, such as hypertension or hyperlipidemia, there are many women who would gain greater benefit from alternative regimens. The paradigm is shifting to incorporate complementary strategies; it is just happening very slowly. There is acknowledgment that a strictly traditional approach to care may be inadequate when patient complaints fall outside the data—as when a woman has unexplained symptoms, such as chronic pain, persistent nausea, recurrent migraines, or chronic fatigue, that do not respond to conventional treatments.
The integrative model of care approaches patient care in an interactive manner that reflects a responsible and responsive use of science. Integrative care involves reconciling responsible use of evidence-based data with an understanding of the patient—her history and complaints and the therapeutic strategies attempted. Intuitively, the integrative approach offers more options, which probably will lead to greater patient satisfaction and likely save money because fewer patients come back for more tests and different medications when the clinician has addressed the needs of the whole person. 19
It would be great to see an allocation of federal funds to assess the comparative efficacy of conventional and nontraditional approaches—drugs, lifestyle behaviors, nutraceuticals—as it would provide a specific mechanism to gather supportive data. This is critical if we are ever going to achieve reimbursement from third party payers. The intention is not to suggest that evidence-based care is overvalued or that anecdotal care be embraced; rather, evidence must be interpreted for each individual patient, not in a present/absent manner, and achieving a successful outcome in the eyes of the individual patient should be paramount. 9
Clinicians may consider the value of broadening clinical skills to become acquainted with integrative strategies. A curriculum model for lifestyle counseling developed at Yale is now being adapted for online training to expand access to the curriculum for physicians who have limited time. 18
There is a need for effective teamwork even at the primary care setting. 2 Such teamwork can be as simple as suggesting that a patient seek assistance from a registered dietitian to optimize food choices or providing a referral to a physical therapist to get the patient mobile enough to initiate some form of physical activity. Those strategies may not be enough, however, because the best intentions can be foiled by the bombardment of products and messages offered in the real world. 20 Just trying to make educated food choices can be hopelessly confusing, and competing sources of information make the ability to choose wisely even more difficult.
Two thirds of consumers check the nutrition facts panel while shopping for food, but many do not understand what it means.
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Researchers from Vanderbilt University Medical Center evaluated consumers' understanding of the nutrition facts panel. Many consumers found the information difficult to understand and interpret, especially if they had lesser math and literacy skills.
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At points of purchase, consumers need a transparent method to help them make informed food choices. There is at least one scientifically rigorous food product system—the Overall Nutritional Quality Index (ONQI™) or NuVal, a food scoring algorithm—available in some grocery stores. The NuVal (
In contrast, a more widely marketed program—Smart Choices™—claims credibility from nutrition criteria derived from the Dietary Guidelines for Americans, reports from the IOM, and other sources of consensus dietary guidance. The tipoff is the inclusion of other sources, which are food industry representatives. With such products as sugar-free Jell-O, Diet Coke, and Popsicles being given the Smart Choices ✓, it is quickly evident that although these foods are lower in sugar and calories, they do not measure up as nutrient dense or healthy by any scientific assessment. Worse still, such cereals as Frosted Flakes and Cocoa Puffs have been approved to carry this symbol. (As of November 2, 2007, the Smart Choices program was suspended pending an investigation of the Connecticut Attorney General and the FDA.)
Thus, it is important for clinicians to be part of the solution, 1 which means knowing the policies and programs that may impact or influence the ability of your patients to pursue healthy lifestyles. It behooves every practitioner to visit the grocery store with the intention to buy only nutritional preferred foods. Only then can they initiate informed discussions with patients about making wise food choices and common obstacles to avoid. Similarly, clinicians will want to become familiar with community and worksite programs that reinforce the goals established for patients so potential pitfalls to desired health outcomes can be anticipated and addressed.
It is far better to have credible sources—physicians and public health experts—whose only interest is the well-being of patients advocating for clinically sound policies than those whose self-interest is for profit not health. Clinicians should be spearheading the information and approaches that will impact public health, for instance, offering guidance to implement federal and state food wellness policies within the local school district, which might lead to improved menus that reflect the healthy choices necessary to promote a healthy weight and reduce disease risk. That is prevention.
Food and beverage taxes are a blunt strategy that have the potential to make a modest contribution to improve diet similar to the success of the tobacco wars, especially if the revenue raised is wisely applied to nutrition programs. 22,23 If the goal is to discourage soda or junk food consumption, however, it would have to be a steep tax, as has become the case with cigarettes or to elicit behavior change. It would be preferable for revenue raised from a soda or junk food tax to be earmarked for nutrition education.
I am advocating to apply a credible food rating system to food stamp purchases so that in any given category food products that fall in the bottom quartile for nutritional quality are worth one dollar, whereas foods in the top quartile may be worth two dollars. By doubling the value of nutrient-dense foods, a positive incentive would be created to motivate food selection and influence decision making among low-income families. If this incentive program proves effective with food stamps, a similar approach could be useful for other federal programs, such as subsidized school lunch menus. Clinicians can join in advocating for these types of policy changes and innovations to improve lifestyle behaviors locally or nationally.
An array of cultural norms undermines much that clinicians might hope to do in an effort to reduce chronic, avoidable diseases. It is not enough to educate our patients; we must support health-promoting messages with concrete strategies that lead to positive changes in our practices and within our communities.
Footnotes
Disclosure Statement
No competing financial interests exist.