ACLM Expert Panel Discussion Treat the Cause: Evidence-based Practice
[Editor’s Note: The following Expert Panel discussion was recorded on October 19, 2014 as the opening session for the Annual Meeting of the American College of Lifestyle Medicine. The following individuals participated:
James M. Rippe, MD is Founder and Director, Rippe Lifestyle Institute and Professor of Biomedical Sciences at the University of Central Florida. He serves as Editor in Chief, American Journal of Lifestyle Medicine
David L. Katz, MD, MPH is a well-known commentator on nutrition, weight management, and chronic disease prevention and is the current President of the American College of Lifestyle Medicine.
Michael Greger, M.D., is a physician, author, and internationally known professional speaker and the Director of Public Health Director of Public Health and Animal Agriculture at the Humane Society of the United States.
John H Kelly, Jr., MD was a founder of the American College of Lifestyle Medicine and served as its founding President.
Margaret Moore, MBA is founder/CEO of Wellcoaches School of Coaching for health professionals which has trained more than 8,000 health and wellness coaches in 45 countries, and is co-founder and co-director of the Institute of Coaching at McLean Hospital.
Following are excerpts from the conversation, featuring Margaret Moore’s comments:
Ms. Moore: Developing the evidence base for lifestyle medicine that would support broad-based reimbursement is a huge challenge. My perspective is informed by what it takes to develop and launch new medicines. I grew up in the biotechnology industry, over 17 years in four countries, and led multiple R&D teams. I was focused on developing evidence for new medicines and vaccines. Bringing a new medicine to the market is a simpler undertaking than implementing lifestyle medicine. When testing the biological effects of a new medicine in humans, researchers focus on one bio/chemical compound used in narrowly defined populations with narrow inclusion/exclusion criteria, thus aiming to show the benefit of a single medicine at one dose in one homogeneous population. Clinical development through Phase 3 studies to market launch and reimbursement proceeds on this narrow basis. Only after a decade or more does a medicine get tested more widely.
Lifestyle medicine on the other hand is in fact many diverse medicines mixed together in a variety of ways with broad application across all demographics and health situations. The evidence needed to support financial reimbursement for a complex mix of lifestyle medicines on a broad basis is a heroic, long-lasting undertaking.
We face another challenge, which is to enable people to use these medicines day in day out, in sustainable ways. I left the biotech industry 15 years ago, because I saw that people weren’t taking good care of their health by engaging in healthy lifestyles. This gap seemed critical to the health of all. I thought that if we could help people take good care of their health and improve their behaviors for good we could make much more impact than many of the biotech medicines that I might help develop. So I asked “what can I do to support engagement in healthy lifestyles?”
My first step was to identify coaching skills and develop coaching protocols that could help people change their lifestyles, particularly when change is hard. Evidence was emerging on the aspects of human nature that are vital to the change process, that coaching could address. The scientific foundation of health and wellness coaching competencies and tools has strengthened considerably in recent years as evidence for the value of particular aspects of human nature has mounted. For example, empathy and self-compassion for negative emotions, and harvesting and amplifying of positive emotions, have gained recognition as interventions that improve health and support learning and positive change.
But like lifestyle medicine, coaches integrate numerous small interventions into a whole, with a wide range of skill mastery, which makes for a complex mix to implement and study. We then find ourselves with multi-faceted coaching interventions of widely varying quality that deliver multi-faceted lifestyle medicines to people who live diverse and multi-faceted lifestyles. The path to widely applicable evidence becomes even more challenging.
The way the biotech industry looks at medical research is to focus first on the most advanced and difficult cases. For example, researchers start with Stage IV cancer, not Stage I and certainly not cancer prevention. That strategy makes for a long, long road to wide dissemination across many lifestyle-related diseases where early intervention is ideal.
Following this strategy, I am fostering clinical evaluation of coaching for fibromyalgia, for which there is no good treatment other than exercise. However, it has taken 10 years to get to the place where we have enough coaches who are skilled enough to handle well the challenges of fibromyalgia on a large scale. So a focus on the toughest health challenges has not exactly offered low-hanging fruit from the perspective of evidence and reimbursement.
Thankfully developing an evidence basis for coaching and lifestyle medicine is not hopeless! I was inspired recently by Jeff Dusek who is an integrative medicine researcher at Allina, a hospital system in Minneapolis. He recommended that the health and wellness coaching field look to “practice effectiveness” studies, now more respected by the NIH, as a better way forward than the pursuit of many randomized controlled studies in many clinical populations. Rather than conducting lots of narrow, randomized studies on narrow homogenous populations, data is gathered and analyzed on tens of thousands of patients that all together create a picture of real world application and improved outcomes. This may be a better way to build an evidence base than pursuing a large number of narrow, randomized studies that could take decades to accumulate.
The health and wellness coaching field is serving tens of thousands of coaching clients now. Even if there is too much diversity today to develop a strong case for evidence and wide reimbursement now, there is an opportunity to orient many groups using similar coaching protocols to measure and collect similar data, so we can generate outcomes data on a large scale going forward. If we started today, a few years from now we could have a compelling evidence base.
My last point is on the state of evidence-based medicine today. Dan Friedland, a physician in San Diego, teaches physicians, medical schools, and other organizations, how to practice evidence-based medicine. He has developed a practical protocol starting with an online medical textbook and then drills down to find the randomized studies relevant to one’s circumstances. It turns out frequently that if you look for the evidence specific to your profile, you will drill down to find only one relevant study. One randomized study with maybe 150 people. That was a real eye opener for me.
In summary, given the challenges we face in developing an evidence-base for lifestyle medicine, I agree with Dr. Kelly. We must lead and get out in front, by defining and declaring sensible principles for evidence based lifestyle medicine that enable early and wide dissemination. The world is waiting. Many people are suffering.
Dr. Rippe: Here is the second question for all of the panelists. “How can lifestyle medicine specialists be best utilized in treating lifestyle disease?”
Ms. Moore: I agree that the most skilled people in any helping profession will deliver the best results. That is a great starting point.
Here’s another angle to consider. If you think about the fundamental principles of motivational interviewing, the two questions to ask are “how do we build confidence in the delivery of lifestyle medicine?” and “how do we build desire and motivation for improved health and well-being via lifestyle medicine?” On the first question, I think the world is now at a rock-bottom level of confidence about our collective ability to help people adopt healthy lifestyles. Motivation goes to sleep when confidence is low, so if we don’t build confidence levels, motivation will also not come alive.
Often I have conversations with physicians who say “I don’t see a lot of hope.” Even if we had a larger evidence base, we might still face the viewpoint that large scale change is difficult if not hopeless. So the question really becomes “how do we build collective confidence in the delivery of lifestyle medicine?”
Perhaps we need more storytelling, not just evidence. I think we need to find ways to tell the many, many good stories that already exist to help build hope. For example, what Kaiser Permanente has done to move the needle for healthy lifestyles and health improvements.
In my experience having talked about wellness over many years, I have found that people are not jumping out of bed in the morning to engage in personal wellness. I understand Medicare’s reimbursement for wellness visits hasn’t taken off like a rocket. So then we must ask “are we giving people what they really want? Is there a different way to present this opportunity?”
The lack of urgent interest in wellness has led me to think about two different directions. One relates to our country’s competitive advantage and economic potential. We are leaving a billions of dollars on the table because people don’t have the physical and mental energy to work hard and innovate. It would boost the economy significantly if everybody was really well and really healthy.
The second thing, relates to brain function. I find that people are significantly more interested and worried about their brain function than they are about their heart and lungs and limbs. I wonder, if we added to our agenda the concept of brain health and brain performance, whether people would come running to the offices of lifestyle medicine practitioners who could potentially offer an approach to reduce dementia risk. This is something all of us—especially the baby boomers–are really frightened about.
To summarize, let’s think about how to build confidence in the delivery of lifestyle medicine, and what would bring patients to lifestyle medicine practitioners because they want what we have.
Dr. Rippe: I have one final question that I would like to ask all of the panelists to briefly respond to: Given the preponderance of unhealthy food options, strong advertising and sales tactics by the food industry, the pharma-healthcare industrial complex, lack of health literacy, a broken healthcare system and more, how long do you think it will take for us as a nation to change our ways and make real strides in lifestyle medicine?
Ms. Moore: One of the benefits of all that we went through last year with the launch of the Affordable Care Act is that people got a wake-up call and started thinking more about their health. I agree with Dr. Katz, we have to make this cool. Just like it is not cool to smoke, whereas, 40 years ago it was. When I started my career 30 years ago it wasn’t all that cool to exercise. I worked with a lot of MDs and PhDs who thought “My brain works so well I don’t need to exercise.”
Let’s think about specific ways to make positive lifestyle decisions cool. How do we get celebrities on board? I think you’re starting to see that. Hip hop videos, etc. That’s the future. It is about selling and marketing and emphasizing the fun about making positive lifestyle decisions.
Dr. Rippe: Nobody likes being sick but survey after survey have shown that people don’t know they are sick because they associate health with the absence of disease rather than a platform for being happier and having a fuller life. In short, a platform for better performance in life and more enjoyment.
Dr. Rippe: I would like to thank the panelists for their thought-provoking comments. I would also like to thank this large audience for your passion and commitment to lifestyle medicine. It was Margaret Meade, the famous sociologist who said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” The people in this audience are the change agents. It is clear from what the panelists have articulated that the core concept of lifestyle medicine, that daily habits and actions profoundly impact on both short and long-term health and quality of life, must be placed front and center in our healthcare agenda. I would like to say one further thing. My wife and I put a quote on t-shirts for our children because we thought it was so impactful. The quote was “Without a dream there is no reason to work. Without work, there is no reason to dream.” So I challenge members of the lifestyle medicine movement that to make this happen, we already have the dream but now we are going to have to work harder than we ever have worked before to make it happen. The world is waiting for our message. Are we ready to answer the call?
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