Lifestyle Prevention Measures for the Clinic Visit

Function

The Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks initiative was funded by the Robert Wood Johnson Foundation (RWJF) in association with the Agency for Healthcare Research and Quality (AHRQ).[4] 

The $9 million six-year initiative was launched in 2002 with the aim of counseling patients to change their unhealthy behaviors by experimenting with evidence-based models in primary care settings. The initiative's primary focus concentrated on the four top unhealthy lifestyle behaviors related to premature death: smoking/tobacco use, unhealthy diet, unhealthy alcohol use, and the lack of physical activity.

Four unhealthy behaviors were designed, experimented with, and assessed by 27 applicable evidence-based methods in 22 primary care practice-based research networks (PBRNs) to enhance the change of unhealthy behaviors in primary care settings. The initiative was conducted between 2003 and 2007, following two rounds of funding by The Prescription for Health, which rewarded 27 grants, 17 in round one and 10 in round 2. The first round focused mainly on the feasibility of implementation strategies for improving the spread and usefulness of behavior change counseling in primary care settings. In contrast, the second round aimed to gauge the effectiveness and expenditures related to more comprehensive health behavior change approaches.[4]

As discussed by the American Board of lifestyle medicine (ABLM), other successful primary care and office-based models for lifestyle modification can include the Primary Care First (PCF) model, which is intended for physician practices, or the Direct Contracting (DC) model, intended for Accountable Care Organizations (ACOs) and health plans. The PCF model comprises a voluntary five-year alternative payment model (APM) that can be further classified into the general and high-needs population models.

The PCF model aims to provide shared savings, value, and quality to physician practices by proposing a prescient payment system to provide progressive primary care services. The PCF model aims to improve patient care, primarily for those with complex chronic conditions, seriously ill patients, and the high-needs population.[5]

Issues of Concern

The discipline of lifestyle medicine has advanced vastly over the years as patients with NCDs pursue tangible outcomes of their lifestyle diseases. Issues of concern throughout the field include implementing lifestyle medicine into practice following certification by healthcare professionals. Barriers include time restrictions, reimbursement issues, and inexperience in clinically counseling patients.[6]

Fifteen core lifestyle medicine competencies were established in 2009 by the American College of Preventive Medicine (ACPM), aiding PCPs in their approach to incorporating lifestyle medicine into their practice. The core competencies are further subclassified from their main four components: Leadership, Assessment Skills, Management Skills, and the Use of Office and Community Support. (Table 1)[7]

Strategies for incorporating wellness into the clinic, medical office, or other healthcare settings include essential leadership, assessment, and management skills, alongside support from the interdisciplinary team of healthcare professionals in each patient's care.[6] Another vital factor to patient success is participation and support from the local community. Initial health behavioral changes begin with readiness and willingness from the patient alongside solid family and community support. During the office visit, evaluating each patient's social, behavioral, and biological preconceptions of the intended health outcomes is essential. 

Table 1: The 15 core competencies of lifestyle medicine for the clinic visit.

Clinical Significance

Each office visit should entail a history and physical examination focusing on lifestyle-related health status and well-being. Lifestyle "vital signs" that should be explored thoroughly in each individual include diet, body mass index (BMI), physical activity, tobacco and alcohol use, stress levels, sleep hygiene, and emotional well-being. Pertinent laboratory tests should be obtained to further investigate each individual's assessment to screen, diagnose, monitor, and better understand each patient's health and lifestyle-associated ailments.

There are measures available that incorporate tools that are validated in the medical literature. Physical activity can be assessed by asking about the duration and intensity of exercise the patients conduct each week.[8][9] The Alcohol Use Disorders Identification Test (AUDIT-C).[10][11] It is a brief screening instrument that identifies alcohol use at hazardous levels. Body mass index is another measure that can be routinely incorporated into routine clinic visits and can be used to predict the risk of diabetes and other comorbidities.[12]

Diet is also an important factor to evaluate during the lifestyle wellness assessment. While a variety of tools exist to evaluate diet, currently, there is a need for a tool to assess diet that is not focused on a particular diet subset. General requirements are available from the US Department of Agriculture.[13] May contemporary practices incorporating lifestyle preventive strategies emphasize the use of whole food, a plant-based diet based on recent studies showing improved outcomes with vegetarian diets, such as the large Adventist Health Study.[14] 

Sleep is another important "vital sign" to address during a clinic visit focusing on lifestyle prevention. Assessment tools exist, including the National Sleep Foundation's Sleep Health Index, and the Pittsburgh Sleep Quality Index [15][16]

Established guidelines for managing chronic diseases such as hypertension, diabetes mellitus, heart disease, obesity, and tobacco and alcohol dependence should be utilized to support patients in the self-management of their lifestyle and health routines and behaviors. Patient rapport is vital in gaining trust between the care provider and the patient and their families to adapt and maintain behavioral changes. Evidence-based treatment plans and counseling methods on behavioral changes, disease prevention, and management through routine patient follow-ups and lifestyle prescriptions demonstrate effective relationships and improved patient outcomes.

Lifestyle prescriptions entail a precise written evidence-based action plan that is feasible and attainable by the patient. Healthy lifestyle routines and practices should be regularly encouraged, and patients should be further referred to health care specialists promptly for their lifestyle-related conditions if needed. Concise and efficient encounters focusing on coaching straightforward, easy-to-follow concepts during the office visit are fundamental. Patients can then readily build on the concepts acquired during the encounters with educational practices at home. Suitable community referrals to health coaches and external programs can also be beneficial additions to supporting behavior change and lifestyle.[6]

Other Issues

The reported deaths from NCDs account for 63% of all causes of mortality worldwide.[1] The most significant factor to date contributing to NCD-associated morbidity and mortality remains unhealthy lifestyle choices and practices.[1] Patient education on dietary consumption, its role in overall health, and its significance in disease onset and prevention is crucial during the clinic visit. A thorough patient understanding leads to readiness and willingness to change dietary behaviors and lifestyle.

As our understanding of the functions that various foods, essential nutrients, and other food components play in health and disease changes, so does the notion of what makes up a healthy diet. Studies indicate that consuming specific nutrients and food groups improves overall health and prevent prevalent non-communicable diseases (NCDs). Among its initiatives aimed at lowering NCDs risk factors, the World Health Organization (WHO) also includes strategies for tackling unhealthy eating habits in its Global Action Plan for the Prevention and Control of Noncommunicable Diseases.[17]

A healthy diet comprises a suitable balance of macronutrients such as carbohydrates, proteins, and fats and micronutrients such as vitamins and minerals consumed in reasonable proportions supporting the body's metabolic and physiologic requirements.[18] Carbohydrates can be further categorized into multiple types, which include starches, sugars, and fibers. Glucose, the primary energy source for the brain, CNS, and RBCs, is provided by starches and sugars. Fiber helps regulate water content in stool and promotes healthy digestive habits. A diet rich in fiber can further aid in preventing and reducing lifestyle diseases such as DM, CAD, obesity, and other NCDs.[19]

The Institute of Medicine (IOM) set a recommended daily allowance (RDA) for carbohydrates for adults and children older than 1-year-old at 130 g/d. Foods high in carbohydrates, such as grains, fruits and vegetables, legumes, nuts, seeds, and dairy products, are recommended for appropriate carbohydrate intake. Proteins are large molecules comprised of a combination of 20 amino acids in various sequences. They are vital for building and repairing cells and tissues throughout the human body. The RDA for protein is 0.8 g per kg of body weight, irrespective of age. Dietary sources of proteins can be found in animals (meat, dairy, fish, and egg) and plants (soy, nuts, grains, seeds, and legumes).[18][19][20][21]

The main structural elements of cellular membranes, fats, also serve as a source of cell energy. The four types of dietary fats are monounsaturated, polyunsaturated, saturated, and trans. Among these, trans and saturated fats are linked to adverse health effects, including an increased mortality risk. The US Department of Agriculture (USDA) recommends that healthy adults (over the age of 19) should have 20 to 35% of their daily calorie intake come from fats, and young children (between the ages of 1 and 3) need up to 40% of their daily calories to come from fat, with trans fats being restricted as much as possible and saturated fats limited to less than 10%.[19][22][23]

The human body needs vitamins and minerals for optimum cell growth and development, maintaining metabolic integrity and water regulation. Vitamins can be grouped into two categories; fat-soluble (A, D, E, and K) and water-soluble (B-complex and C). Deficiencies result from insufficient vitamin consumption, as the vitamins required cannot be found in one food source. Because of this, various diets are necessary to satisfy the body's vitamin needs. Asides from inadequate dietary vitamin consumption, other factors such as hereditary conditions, diseases of the intestinal tract, adverse effects of medication, and chronic alcohol use also result in vitamin deficiency.[24]

Enhancing Healthcare Team Outcomes

Collaborative efforts by the interdisciplinary team comprised of primary care physicians, nurses, health coaches, and nutritionists can prevent the onset and progression of chronic diseases, limit secondary and tertiary care visits, and further improve and enhance the quality of life. Individuals who are at risk for lifestyle choices associated with ailments such as hypertension, type 2 diabetes mellitus, hyperlipidemia, obesity, sexually transmitted infections (STI), stroke, cancer, liver disease, and chronic obstructive pulmonary disease (COPD) should be continually encouraged and counseled during routine visits on preventative self-care practices. Counseling should focus on dietary improvements catered to each individual and their predispositions to disease and underlying comorbidities.[25]

Screening for lifestyle-related diseases is highly recommended during the clinic visit. Routine blood pressure checks and screening for hypertension should be done in all patients aged 18 years and above. A lipid screening for cholesterol should be conducted in men aged 35 and older and females 45 and above. Earlier checks can be conducted in patients at greater risk or with a significant family history. Patients taking medications routinely for conditions such as hypertension and diabetes should be instructed on routine home monitoring of blood pressure and blood glucose.

Smoking cessation and screening for lung cancer via low-dose CT scan (LDCT) in smokers with a history of 20 or more pack years, ages 50 and 80 years old, and are currently smoking or have stopped within the past 15 years is recommended. Smokers should also be educated on the development of COPD and cancer and provided information and support for cessation. An increased focus should also be given to individuals of low socioeconomic status in low-income neighborhoods who suffer from health disparities as they are affected by preventable diseases disproportionately.

The healthcare team should also counsel patients thoroughly on dietary habits and exercise as it strongly influences CVS disease, obesity, and DM. Information and guidance on a health coach and nutritionist should also be provided to patients as it will increase patient readiness and willingness to incorporate healthy lifestyle behaviors. The healthcare provider should provide lifestyle prescriptions as an evidence-based action plan with clear instructions for the patients to follow. Prescriptions should be implemented on a case-by-case basis tailored to each individual's healthcare needs and achievements. Each person's feasibility of following the plan should also be assessed.