Conquering chronic disease with lifestyle medicine

As physicians, how often do you instruct patients to clean up their diets, begin exercising or better manage their stress--and wonder if they'll ever follow through? For how many of them could you avoid writing prescriptions later--which studies show up to half to patients don't take correctly anyway--if you could get patients to improve their lifestyles now?

For many patients who need to change their ways most, such as those on the verge of or already battling chronic disease, the message to eat better is not only vague (Eat what? How much?) but gets interpreted as a mere offhand suggestion. Too often, it takes a surgery date to really get their attention.

But in many cases, that's the way conventional medicine works--except that it's not working, according to Huffington Post blogger and physician Mark Hyman, MD, whose step-father died of complications of diabetes and heart disease.

"He had the best medical, pharmaceutical, and surgical care available," Hyman writes. "Nonetheless, he suffered from very poor health and functioning." Despite the $400,000 in medical care his step-father received, including a cardiac bypass operation followed by a month in intensive care to combat a MRSA infection, Hyman equates the lack of a program for sustainable and comprehensive lifestyle change to a modern-day Tuskegee experiment--in which physicians know the cure for a disease (in Tuskegee, Ala., from 1932 to 1972, it was penicillin for syphilis) and withhold it just to see what happens.

However, medicine's acute-care mentality of matching a diagnosis to a treatment (a drug to a disease) doesn't translate directly when applied to chronic care, adding yet another layer to the problem, says Kenneth Welker, MD, a board-certified surgeon who today focuses on providing functional medicine, wellness coaching and nutritional optimization at Oregon Optimal Health, his aptly named practice in Eugene. "As conventional medicine practitioners, our training came out of acute-care medicine," he tells FiercePracticeManagement. "We became enamored that we can use a drug for a diagnosis and get an outcome."

As a result, conventional medicine has become reduced down to this paradigm and has not included ideas of how to get synergism with a person's lifestyle, Welker says. His practice, which does not provide primary care, is dedicated to filling this void. The office will courtesy bill patients' health plans (excluding Medicare and Medicaid), but many of its services are self-pay. It's the results that make the model work, he says. "When people realize they can feel a lot better in short period [typically a 12-week program], they're much more willing to participate--even if it means out-of-pocket [expense] on their part."

Even in the current reimbursement environment, physicians can be paid to supervise one-on-one interaction between a patient and a lifestyle educator, Welker says. Typically, the educator would spend about 30 minutes with the patient with the physician present to review what was discussed (e.g., what foods to buy and cook or stress management techniques) for perhaps the last five minutes. "This can be billed as a profit center," Welker says. In addition, many insurers currently reimburse for shared medical appointments, which often are targeted toward helping a group of like patients manage a specific chronic disease.

Nonetheless, physicians in traditional practice still are not widely paid to attack the root causes of disease, Hyman writes, but rather to prescribe pills and perform surgery. "We're targeting the wrong things--we need to treat the cause, not the effects," he points out. "High blood pressure, high cholesterol, and high blood sugar are NOT the cause of heart disease or diabetes. The real culprit is what we eat, how much we exercise, stress, and environmental toxins."

Help is available for physicians who want to integrate lifestyle medicine into their practices but don't know where to start, says Welker, a three-year satisfied customer of Metagenics, a company that educates physicians and their staff on the clinical and business aspects of providing these services.

There is also promise that the new healthcare bill--which not only provides for community-based wellness initiatives but also favors a medical home model in which patients will have access to a team of health providers to offer preventive care--will help shift this climate.

In addition, more attention is recently being paid to the "apple a day" adage at the medical school level and even earlier. At Lenox Hill Hospital in New York, for example, doctors in training participate in six seminars on everything from nutrition, to weight management to exercise and a cooking class at the Institute of Culinary Education in Manhattan, reports the Wall Street Journal.

And at three health centers in Massachusetts, physicians have begun issuing 'prescriptions for produce' in the form of vouchers to local farmers' markets in an effort to fight obesity in children of low-income families. Perhaps this will be an intervention that yields true preventive medicine for generations to come. "When I go to work in the morning, I see kids standing at the bus stop eating chips and drinking a soda," Boston Mayor Thomas Menino told the New York Times. "I hope this will help them change their eating habits and lead to a healthier lifestyle." - Deb