lifestyle medicine and primary care - resource...

Lifestyle Medicine and Primary Care: Implementing Effective Lifestyle Changes

Brad Biskup, PA-C, MHS, MALifestyle Medicine Clinic

Pat and Jim Calhoun Cardiology Center

University of Connecticut Health

Learning Objectives

• Describe the benefits of lifestyle as

medicine.

• Understand guidelines for diet and

exercise.

• Identify the cost-effectiveness of

implementing lifestyle medicine within

primary care.

• 43 year old male:

– Hypertension - dyslipidemia

– insulin resistant diabetes - morbid obesity

– obstructive sleep apnea (OSA) - family history of CAD

• Meds: metformin, glyburide, Lisinopril, furosemide,

Nexium, wellbutrin, Androgel, vitamin D3, lovastatin,

trazadone, Celexa, and temazepam.

• After 3 years: stopped glyburide and Lisinopril; ½

dose of lovastatin and furosemide

Results?

“Bill”

8/2011 3/2012 2/2013 4/2014

Weight (lbs) 413 390 347 322 (-89)

Blood Pressure

(mm/hg)

106/70 110/70 72/58 94/60

Total Cholesterol

(mg/dl)

121 138 125 122

LDL (mg/dl) 59 69 56 28

HDL (mg/dl) 33 36 33 32

Non-HDL (mg/dl) 88 103 92 90

Triglycerides (mg/dl) 145 167 182 309 (NF)

Hemoglobin A1C (%) 9.1 6.1 5.9 5.5 (-3.6%)

“Bill”

After 3 years: - stopped glyburide and Lisinopril

- ½ dose of lovastatin & furosemide

Cause of Disease:Is it due to genetics?

The World Health Organization has

estimated that if the major risk factors for

chronic disease were eliminated, at least:

– 80% of all heart disease, stroke, and

type 2 diabetes would be prevented,

and

– more than 40% of cancer cases would

be prevented.

World Health Organization. Preventing chronic diseases: a vital

investment. Geneva: World Health Organization; 2005.

What is Lifestyle Medicine?

• Lifestyle Medicine (LM) is the use of

lifestyle interventions in the treatment

and management of disease.

– Interventions:

• nutrition

• exercise

• stress management

• smoking cessation

• a variety of other non-drug modalities

American College of Lifestyle Medicine

http://www.lifestylemedicine.org/define

Why Lifestyle Medicine?

• Today:

– 7 in 10 deaths in the U.S. are related to preventable

diseases such as obesity, diabetes, high blood pressure,

heart disease and cancer.

– 75% of our health care dollars are spent treating such

diseases.

– However, only 3% of our health care dollars go toward

prevention.”

- American Public Health Association

Current “Health Care System” in the U.S. =

“Disease Management System”

• A growing body of scientific evidence has

demonstrated that lifestyle intervention is

an essential component in the treatment of

chronic disease that can be as effective

as medication, but without the risks and

unwanted side-effects.

American College of Lifestyle Medicine

http://www.lifestylemedicine.org/define

Lifestyle Medicine Research

Cardiovascular Risk Factors

Mozaffarian, D et al. Circulation. 117(23):3031-3038, June 10, 2008.

• Treats individual risk factors

• Patient is often passive

recipient of care

• Patient is not required to

make big changes

• Treatment is often short

term

• Responsibility falls mostly

on the clinician

• Medication is often the

“end” treatment

Conventional Lifestyle

• Treats lifestyle causes

• Patient is active partner in

care

• Patient is required to make

big changes

• Treatment is always long

term

• Responsibility falls mostly on

the patient

• Medication, but as an adjunct

to lifestyle change

http://c.ymcdn.com/sites/www.acpm.org/resource/resmgr/lmi-files/lifestylemedicine-literature.pdf

• Emphasis is on diagnosis and

prescription

• Goal is disease management

• Little consideration of the

environment

• Side effects are balanced by

the benefits

• Referral to other medical

specialties

• Doctor generally operates

independently on a one-to-one

basis

• Emphasis is on motivation and

compliance

• Goal is primary, secondary and

tertiary disease prevention

• Consideration of the

environment

• Side effects are seen as part of

the outcome

• Referral to allied health

professionals as well

• Doctor is coordinator of a team

of health

http://c.ymcdn.com/sites/www.acpm.org/resource/resmgr/lmi-files/lifestylemedicine-literature.pdf

Conventional Lifestyle

40,842 men & 12,943 women from the Aerobic Cooper Longitudinal Study

Effect of CRF on MortalityAttributable Fractions (%) for All-Cause Deaths

Blair SN. Br J Sports Med 2009; 43:1-2.

Lifestyle Medicine

Modification Recommendation Approximate SBP Reduction Range

Weight reduction Maintain normal body weight (BMI=18.5-24.9)

5-20 mmHg/10 kg weight lost

Adopt DASH eating plan

Diet rich in fruits, vegetables, low fat dairy and reduced in fat

8-14 mmHg

Restrict sodium intake

<2.4 grams of sodium per day 2-8 mmHg

Physical activity Regular aerobic exercise for at least 30 minutes on most days of the week

4-9 mmHg

Moderate alcohol consumption

<2 drinks/day for men and <1 drink/day for women

2-4 mmHg

Lifestyle Modificationsfor Hypertension

Chobanian AV et al. JAMA. 2003;289:2560-2572

BMI=Body mass index, SBP=Systolic blood pressure.

Medication vs. Lifestyle Medicine:

Diabetes Risk

Diabetes Prevention Program

• 3,234 IGT (51 y, BMI 34, 68% female,

45% minority) randomized for 2.8 y

(study stopped early) to

– placebo, or

– metformin (850mg bid), or

– lifestyle-modification (7% weight loss

and 150 minutes physical activity per

week)

Diabetes Prevention Program Research Group, . N Engl J Med 2002;346:393-403

Cumulative Incidence of DiabetesAccording to Study Group

Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403

After 2.8 yrs-Placebo to Metformin = -31%

-Placebo to Lifestyle = -58%

Adverse Events in DPP TrialRR Lifestyle

vs Placebo

0.42

1.14

0.97

1.01

1.00

0.63

• Significantly lower risk of adverse events with

lifestyle than placebo (RR 0.42 - 1.14)

Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403

Exercise WithinLifestyle Medicine

Exercise and Disease

• Research shows that exercise

helps treat and prevent more

than 40 chronic diseases, such as

diabetes, heart disease, obesity

and hypertension.

Exercise and Cardiovascular Risk Reduction: Time to Update the Rationale for Exercise?

> 40% of the risk reduction associated with exercise cannot be

explained by changes in risk factors

Cardioprotection via a “Vascular Conditioning” Effect

Improvement in nitric oxide vasodilator function

Improved vascular function + altered vascular structure

Increased Parasympathetic, Decreased Sympathetic

Enhanced heart rate variability

?

Green DJ et al., J Appl Physiol 2008;105:766-768.


➢Can reduce mortality and the risk of recurrent

breast cancer by approximately 50%.1

➢Can lower the risk of colon cancer by over 60%.2

➢Can reduce the risk of developing of Alzheimer’s

disease by approximately 40%.3

➢Reduces the incidence of high blood pressure

and heart disease by approximately 40%.4-5

1- Physical activity and survival after breast cancer diagnosis. Holmes MD et al. JAMA 2005; 293:2479

2- Physical activity and colon cancer: confounding or interaction? Medicine & Science in Sports & Exercise: June 2002 - Volume

34 - Issue 6 - pp 913-919

3- Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Larsen EB et al.

Annals of Internal Medicine 2006; 144:73-81.

4- Cardiorespiratory fitness is an independent predictor of hypertension incidence among initially normotensive healthy women.

Barlow CE et al. Am J Epidemiol 2006; 163:142-50

5- Exercise in the prevention of coronary heart disease: today's best buy in public health. Med Sci Sports Exerc. 1994

Jul;26(7):807-14.


➢Lowers the risk of stroke by 27%.1

➢Reduces the incidence of diabetes by

approximately 50%.2-3

➢Can decrease depression as effectively as Prozac

or behavioral therapy. 4

➢Muscle strength decreases mortality risk. 5

1- Physical activity and risk of stroke in women. JAMA. 2000 Jun 14;283(22):2961-

2- The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in men.

Wei M et al. Annals of Internal Medicine. 1999

3- Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.

DPP Research Group. New England Journal of Medicine 2002; 346:393-403

The Diabetes Prevention Program Research Group: Within-trial cost-effectiveness of lifestyle intervention or

metformin for the primary prevention of type 2 diabetes. DPP Res Group. Diab Care 2003; 26:2518.

4- Exercise treatment for depression: efficacy and dose response. Dunn A et al. American Journal of Preventive Medicine 2005

Jan;28(1):1-8.

5- Association between muscular strength and mortality in men. Ruiz JR, Sui X, Lobelo F, Morrow JR, Jackson AW, Blair SN.

BMJ 2008; 337:a439.

Key Guidelines for Adults

➢ All adults should avoid inactivity. Some

physical activity is better than none, and

adults who participate in any amount of

physical activity gain some health benefits.

➢ For substantial health benefits, adults should

do at least 150 minutes (2 hours and 30

minutes) a week of moderate intensity, or 75 minutes (1

hour and 15 minutes) a week of vigorous-intensity aerobic

physical activity, or an equivalent combination of moderate-

and vigorous-intensity aerobic activity. Aerobic activity

should be performed in episodes of at least 10 minutes, and

preferably, it should be spread throughout the week.http://www.health.gov/paguidelines/

Key Guidelines for Adults (more)

➢ For additional and more extensive health benefits, adults

should increase their aerobic physical activity to 300 minutes

(5 hours) a week of moderate-intensity, or 150 minutes a

week of vigorous-intensity aerobic physical activity, or an

equivalent combination of moderate- and vigorous-intensity

activity. Additional health benefits are gained by engaging in

physical activity beyond this amount.

➢ Adults should also do muscle-strengthening activities that are

moderate or high intensity and involve all major muscle

groups on 2 or more days a week, as these activities provide

additional health benefits.

http://www.health.gov/paguidelines/

Key Guidelines for Older Adults

The Key Guidelines for Adults also apply to older adults. In addition, the

following Guidelines are just for older adults:

➢ When older adults cannot do 150 minutes of moderate-intensity aerobic

activity a week because of chronic conditions, they should be physically

activity as their abilities and conditions allow.

➢ Older adults should do exercises that maintain or improve balance if

they are at risk of falling.

➢ Older adults should determine their level of effort for physical activity

related to their level of fitness.

➢ Older adults with chronic conditions should under-

stand whether and how their conditions affect

their ability to do regular physical activity safely.


The Beneficial Effects of Increasing Physical Activity: It's About Overload, Progression, and Specificity

• Overload is the physical stress placed on the body when

physical activity is greater in amount or intensity than usual.

• Aerobic

• Muscle Strength

• Balance

• Progression is closely tied to overload. Once a person reaches

a certain fitness level, he or she progresses to higher levels of

physical activity by continued overload and adaptation.

– Small, progressive changes in overload help the body adapt

to the additional stresses while minimizing the risk of injury.–

• Specificity means that the benefits of physical activity are

specific to the body systems that are doing the work.


2Murtash E. et l. Walking: the first steps in cardiovascular disease prevention. Current Opinion in Cardiology. 25(5):490-496, September 2010.

Risk of Coronary Heart Disease in Women Walkers

Sitting, Fitness, and Exercise

Bouchard et al. Mayo Clin Proc, Nov 2015

All-

Cause

Mortality

Williams, M et al. Circulation. 116(5):572-584, July 31, 2007.

Aerobic vs. Resistance Exercise

Risk of cardiovascular disease mortality by cardiorespiratory fitness and body mass index.

Blair SN. Physical Inactivity: The Biggest Public Health Problem of the 21st Century. Br J Sports Med 2009;43:1-2.

2,316 men

with type 2

diabetes at

baseline, 179

deaths

Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

Normal BMI

2,316 men

with type 2

diabetes at

baseline, 179

deaths

Overweight




2,316 men

with type 2

diabetes at

baseline, 179

deaths

Obese




NHANES: Self-Report versus Accelerometry

None Insufficient Sufficient

NHANES –

Self-report

12.5% 25.6% 62%

Tucker JM, Welk GJ, Beyler NK. Physical activity in U.S. adults: Compliance with the physical activity

guidelines for Americans. Am J Prev Med. 2011;40(4):454–61.

NHANES: Self-Report versus Accelerometry

None Insufficient Sufficient

NHANES –

Self-report

12.5% 25.6% 62%

NHANES -

Accelerometry

53.0% 37.3% 9.6%

Tucker JM, Welk GJ, Beyler NK. Physical activity in U.S. adults: Compliance with the physical activity

guidelines for Americans. Am J Prev Med. 2011;40(4):454–61.

Recommendation for Exercise or Other Physical Activity From a Physician or Health Professional

SOURCE: CDC/NCHS, National Health Interview Survey.

If Exercise Is Medicine, Where Is Exercise in Medicine?

Review of U.S. Medical Education Curricula for Physical Activity-Related Content

Cardinal BJ, et al. If Exercise Is Medicine, Where Is Exercise in Medicine? Review of U.S. Medical Education Curricula for

Physical Activity-Related Content. J Physical Activity and Health. 2015; 12(9):1336-43.

This study provides an update on the amount and type of physical activity education occurring in medical education in the United States in 2013. It is the first study to do so since 2002.

MethodsReviewed U.S. medical schools’ websites, looking for all physical activity-related coursework. They reviewed both public and private schools, and schools of medicine and osteopathic medicine. In all, 118 of the 170 accredited schools had curriculum information available online.



Results• 51 percent offered NO physical activity related

coursework

• 21 percent offered only one course

• 82 percent of the schools reviewed did not require

students to take any physical activity-related courses

More than one-half of the physicians trained in the United States in 2013 received no formal education in physical activity and may, therefore, be ill-prepared to assist their patients in a manner consistent with Healthy People 2020, the National Physical Activity Plan, or the Exercise is Medicine initiative.



Conclusion

An In-Depth Look at the 2015-2020

Dietary Guidelines

Information adapted from the 2015-2020 Dietary Guidelines for Americans. Available at

DietaryGuidelines.gov.

Adherence to the 2010 Dietary GuidelinesMeasured by Average Total Healthy Eating Index-2010 (HEI-2010) Scores

of the U.S. Population Ages 2 Years and Older (Figure I-1)

Data Source:

Analyses of What We

Eat in America,

National Health and

Nutrition Examination

Survey (NHANES)

data from 1999-2000

through 2009-2010.

Note: HEI-2010 total

scores are out of 100

possible points. A

score of 100 indicates

that recommendations

on average were met

or exceeded. A higher

total score indicates a

higher quality diet.

1999-00

49.1%

2009-10

57.8%

Current Eating Patterns in the United StatesPercent of the U.S. Population Ages 1 Year and Older Who Are Below, At, or Above Each Dietary Goal or Limit (Figure 2-1)

Note: The center (0) line is the

goal or limit. For most, those

represented by the orange

sections of the bars, shifting

toward the center line will improve

their eating pattern.

Data Source: What We Eat in

America, NHANES 2007-2010 for

average intakes by age-sex

group. Healthy U.S.-Style Food

Patterns, which vary based on

age, sex, and activity level, for

recommended intakes and limits.

2015-2020 Dietary Guidelines for Americans:The Guidelines

1. Follow a healthy eating pattern across the lifespan. All food and

beverage choices matter. Choose a healthy eating pattern at an

appropriate calorie level to help achieve and maintain a healthy body

weight, support nutrient adequacy, and reduce the risk of chronic

disease.

2. Focus on variety, nutrient density, and amount. To meet nutrient

needs within calorie limits, choose a variety of nutrient-dense foods

across and within all food groups in recommended amounts.

3. Limit calories from added sugars and saturated fats and reduce

sodium intake. Consume an eating pattern low in added sugars,

saturated fats, and sodium. Cut back on foods and beverages higher in

these components to amounts that fit within healthy eating patterns.

Information adapted from the 2015-2020 Dietary Guidelines for Americans. Available at DietaryGuidelines.gov.

2015-2020 Dietary Guidelines for Americans:The Guidelines (cont.)

4. Shift to healthier food and beverage choices. Choose nutrient-dense foods and beverages across and within all food groups in place of less healthy choices. Consider cultural and personal preferences to make these shifts easier to accomplish and maintain.

5. Support healthy eating patterns for all. Everyone has a role in helping to create and support healthy eating patterns in multiple settings nationwide, from home to school to work to communities.

Key Elements of Healthy Eating Patterns:Key Recommendations

Consume a healthy eating pattern that accounts for all foods and

beverages within an appropriate calorie level.

A healthy eating pattern includes:

• A variety of vegetables from all of the subgroups—dark green, red and orange,

legumes (beans and peas), starchy, and other

• Fruits, especially whole fruits

• Grains, at least half of which are whole grains

• Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy

beverages

• A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes

(beans and peas), and nuts, seeds, and soy products

• Oils

A healthy eating pattern limits:

• Saturated fats and trans fats, added sugars, and sodium

Key Elements of Healthy Eating Patterns:Key Recommendations (cont.)

Key Recommendations that are quantitative are provided for several components of the diet that should be limited. These components are of particular public health concern in the United States, and the specified limits can help individuals achieve healthy eating patterns within calorie limits:

Consume less than 10 percent of calories per day from added sugars

Consume less than 10 percent of calories per day from saturated fats

Consume less than 2,300 milligrams (mg) per day of sodium

If alcohol is consumed, it should be consumed in moderation—up to

one drink per day for women and up to two drinks per day for men—

and only by adults of legal drinking age

Meet the Physical Activity Guidelines for Americans

Dietary Fiber Intake and Risk of Cardiovascular Disease

BMJ 2013;347:f6879

Nutritarian vs. Standard Diet

Nutritarian Diet

• Vegetable-based

• Lots of fruit, beans, seeds, nuts

• Oil used sparingly

• Animal products

0-3 times a week

• Focused on nutrient-dense calories

Standard Diet

• Grain based

• Lots of dairy and meat

• Oils supply a major caloric load

• Animal products

2-4 times a day

• Focused on nutrient-poor calories

Fuhrman J, Sarter B, Glaser D, Acocella S. Changing perceptions of hunger on a high

nutrient density diet. Nutrition Journal 2010;9:51.

Diabetes Study Summary

Baseline HND diet

Participants taking

Diabetes medication

10 1

BMI 34.4 26.8

HbA1C 8.15% 5.80%

Systolic blood

pressure(mmHg)

148 121

Triglycerides (mg/dl) 170.6 103.4

TC:HDLratio 4.67 3.62

Dunaief DM, Fuhrman J, Dunaief JL, et al: Glycemic and cardiovascular parameters improved in type 2 diabetes with the high nutrient density (HND) diet. Open Journal of Preventive Medicine 2012;2(3):364-371.

Ex. 5’10”: 240lbs to 187lbs (53lb weight loss)

Mean % Hgb A1C Response comparingnormal diet (○) to low glycemic diet (•).

Gannon M C , and Nuttall F Q Diabetes 2004;53:2375-2382

Copyright © 2011 American Diabetes Association, Inc.

(P ≤ 0.05)

“Dave”

11/2015 6/2016 9/2016 Change

Weight (lbs) 237 201.8 195.3 -41.7

Blood Pressure (mm/hg) 126/80 114/60 124/80 N/C

Total Cholesterol (mg/dl) 167 176 176 +9

LDL (mg/dl) 102 107 115 +13

HDL (mg/dl) 33 33 48 +15

Non-HDL (mg/dl) 134 143 128 -6

Triglycerides (mg/dl) 160 179 65 -95

Hemoglobin A1C (%) 7.1 5.2 5.3 -1.8%

Insulin (fasting) N/A 15 13 -2

Glucose (fasting) 152 102 88 -64

11/2015:

Toprol XL100mg qd,

Exforge 5/160mg qd

Crestor 5mg qd

9/2016: Zetia 10mg qd

Aune, D., et al: Nut Consumption and Risk of Cardiovascular Disease, Total Cancer, All-Cause and Cause-Specific

Mortality: A Systematic Review and Dose-Response Meta-Analysis of Prospective Studies. BMC Medicine 2016;14:207

Risk Reduction For 1 Serving Increase in Nuts/Day

Disease Relative Risk Reduction

Coronary Heart Disease 29%

Stroke 7%

Cardiovascular Disease 21%

Total Cancer 15%

All-cause Mortality 22%

Aune, D., et al: Nut Consumption and Risk of Cardiovascular Disease, Total Cancer, All-Cause and Cause-Specific

Mortality: A Systematic Review and Dose-Response Meta-Analysis of Prospective Studies. BMC Medicine 2016;14:207

Stress

Psychological Stress and

Cardiovascular Disease

Type of

Disease

Low stress High Stress

Stroke 1.0 2.24

CHD 1.0 2.28

Perceived Mental Stress and Mortality From Cardiovascular Disease Among Japanese Men and

Women: The Japan Collaborative Cohort Study for Evaluation of Cancer Risk Sponsored by

Monbusho (JACC Study). Hiroyasu Iso, et al. Circulation 2002;106;1229-1236

Risks of Stress

• Work-related stress can double one's risk of dying from heart disease1.

• Stress is linked to the six leading causes of death -heart disease, cancer, lung ailments, accidents, cirrhosis of the liver, and suicide2.

• People with high levels of anxiety can have between two to seven times the risk of heart disease3.

1(British Medical Journal, 2002); 2("The Stress Solution: An Active Plan to Manage the Stress in Your Life," Lyle H. Miller, Ph.D. and Alma Dell Smith, Ph.D.); 3("Emotional Longevity: What Really Determines How Long You Live," Norman B. Anderson and Elizabeth P. Anderson, 2003)

The Keys to Successful Lifestyle Medicine

History, History, History – Questionnaire

– Cardiovascular history and risk factors

• CAD, PAD, or stroke (when and previous

imaging studies)

• Hypertension

– Blood pressure monitor at home

– Routine monitoring and how they check it

• Diabetes

– Insulin dependent versus oral medication

– Nutrition consultation or how they have

monitored their diet

– History of gestational diabetes

Cardiovascular history and risk factors (cont.)

• Hyperlipidemia

– Prescription medication

– OTC supplements (ie., omega-3, fiber, or phytosterols)

• Family history

– CVD history and risk factors

– Premature CAD

• Sleep apnea

– Snoring and quality of sleep

– Previous sleep study

– Using CPAP and it is helping


– Cardiovascular history and risk factors (cont.)

• Smoking history

– Current or previous

– Smoking cessation methods used

– Triggers for smoking

• Social history

– alcohol, illegal drugs, and living situation

• Diet

– 7 day food log


– Cardiovascular history and risk factors (cont.)

• Exercise/activity history

– Limitations (physical, financial, geographic, and time)

– What have they done before and what they like to do

• Overweight

– lowest and heaviest adult weight

– Weight loss program previously used

• Stress

– Current and previous stressors

– Stress relief modalities (ie., therapy, journaling,

medication, and exercise)


Goals

• Blood pressure = less than 130/85

• Diabetes

– insulin dependent (Hgb A1C < 7.0)

– Oral medication (Hgb A1C < 6.5)

– No medication (Hgb A1C < 6.0)

• Cholesterol

– Set goal for HDL, LDL, triglycerides, and non-HDL

Diabetes

• Benefits of diet and exercise

– Increased insulin sensitivity with exercise

– Stabilizing blood sugar with diet (ie., low glycemic)

– Effects of stress on blood sugars

Hypertension

• Benefits of diet, exercise, and stress

management

– DASH/Mediterranean diet

– Effect of aerobic exercise on blood pressure

– Stress management

Cholesterol Levels

• Medications and/or over the counter

– Benefits of:

• Fiber

• Phytosterols/stanols

• Omega-3 supplements (high DHA/EPA)

• Exercise

• Low animal fat diet

• Medications

Smoking Cessation

• Start by not focusing on it

• Remember: 7 failures before success

• Start with exercises increases success 3

times

• Have them identify causes of smoking

• Give them resources to be successful

– Medications and 1-800-QUIT NOW

– Smoking programs available

– Diahann Wilcox, APRN program

– Dr. White’s smoking and hypertension study

Diet

• Review recent foods and look at label of the foods

• Substitutions within their diet

• Encourage high fiber/protein (ie., low glycemic

foods

– Explain how this helps decrease fat/sugar absorption

• 7 day food log

• Predominantly non-processed plant based foods!

• Treat = 100 calories/day

• Mayo Clinic Diet Book/Journal

• Dietary consult

Exercise/Activity

• Exercise prescription: What do you want it to do?

– Set them up for success!

– Dismiss the “No pain, no gain” theory

– Intensity: “Talk test”

• Don’t focus on heart rate

– Duration

• Gradually increase to goal of 30-45 minutes

– Days per week: 3-5 days or less

– Pedometer if not enough time

• Add 500 steps/day from baseline every 2 weeks until

~3,000 steps/day above baseline

Weight Loss

• Find what motivates them to lose weight

• It comes down to I’s and O’s (intake/output)

• Triggers to eating

• Change mind set to:

“Eating to live, instead of, living to eat” and

“Getting food to work for them”.

• Don’t focus on it

– Focus on the process of being healthy

Rate of Fat Metabolism at

Different Exercise Intensities

Stress

• Remember that you are always in control!

• Mental relaxation at least twice daily.

• Eat healthy and exercise.

• Positive self-talk.

• Find pleasure.

• Serenity Prayer.

http://www.123rf.com/photo_21407269_yoga-outdoors-silhouette-of-a-woman-sitting-in-a-lotus-position-on-the-beach-at-sunset.html

The Serenity Prayer

“God grant me the serenity to accept the things I cannot change, the courage to change the things that I can, and the wisdom to know the difference.”

Take Home Message

• You’re a consultant for your patient.

• Give them goals (“To Do List”) each visit and start

low and go slow.

• Reassess/Replan on a regular basis (ie., what

worked and what didn’t work).

• Keep it positive.

• The more focus you put on lifestyle change and

giving them the tools, the more successful they

will be.

Identify the cost-effectiveness of implementing lifestyle medicine

within primary care.

1. Individual visits

2. Group visits

Individual Visits

CPT Code Complexity Total Time Counseling

Time

99211

99212

99213

99214

99215

Physician vs. Advanced Practice Practitioner

One Day: Big Difference

• Individual visits only

• 20-25 patients

• Limited time foreducation

• Limited time forconnection

• 20-25 notes to complete

• 20-25 individual plans ofcare

• Staff ‘chasing’ you

• Inefficient use ofresources

• Group Visit day• 10-15 individual visits

• Group visit in last 1-2hours of my late day(typically 4:30-6:00 pm)

• 10-16 patients

• 30 min lecture & 60 minQ&A

• LEVERAGING TIME!

• Increased productivity

• Happier patients, clinicalstaff, providers

LEVERAGING TIME

• see 16 pa9ents

• in 90 minutes

• billed 99213 each

_______________________

Health

Efficiency

Produc9vity

The Math is EASY!

• A win-‐win opportunity – Patients pay less

• INSURANCE: 1 visit charge for 3 visits’ value

• CASH: Patient pays less (e.g. $75 for 90 minutes)

– Provider earns more • (e.g. $75 x 16 pts= $1200, or works out to ~$800/

hour)

• been shown to increase productivity 200-‐600%

• Must create supporting systems to leverage time

EXAMPLE OF MY HIPPA DISCLAIMER

Question to CMS/Medicare

"In other words, is Medicare payment for

CPT code 99213, or other similar evaluationand management codes, dependent upon

the service being provided in a privateexam room or can these codes be billed if

the identical service is provided in front of

other patients in the course of a sharedmedical appointment?"

Official Answer to AAFP

"...under existing CPT codes and Medicare

rules, a physician could furnish amedically necessary face-to-face E/M

visit (CPT code 99213 or similar codedepending on level of complexity) to a

patient that is observed by other patients.

From a payment perspective, there is noprohibition on group members observing

while a physician provides a service toanother beneficiary."

Getting Paid: Insurance

• Just like individual billing – Based on face-‐to-‐face time

– Group time is NOT billable

– Level of documentation complexity

– Regardless if done semi-‐privately, privately, or publicly

Billing & Coding Takeaways

• Medical necessity is first• Proper documentation (as usual)

• Bill typical E/M codes based oncomplexity of your visit note (as usual)

• Avoid ‘unique’ group or specialty codes

Group Visits

CPT Code Complexity Total Time Counseling

Time

99211

99212

99213

99214

99215

Physician vs. Advanced Practice Practitioner

Opportunities

Lifestyle can

be Medicine.

lifestyle medicine and primary care - resource...

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