Dr. Epstein's Evidence-Based Lifestyle Medicine Guide 

 

INTRODUCTION

 

The disease landscape has changed such that 70% of deaths are now caused by noncommunicable diseases. These are diseases of lifestyle such as heart disease, cancer, stroke, and type 2 diabetes. It is our duty as physicians to communicate and demonstrate the evidence-based lifestyle practices that we know can prevent and reverse such diseases. If we keep a repository of evidence-based advice in mind, this is an achievable goal even during a short patient interaction. Sharing one practice takes just minutes, and it makes a difference. Though we have wonderful nutritionist and dietician colleagues with whom we should partner, we are missing a huge opportunity as physicians if we do not start the ball rolling by engaging in a meaningful conversation with patients about healthy lifestyle practices. 

 

Why You Care: The Problem

  1. The decrease in mortality brought about by medical innovation has plateaued1. Further benefits likely depend largely on society and personal behavior.
  2. We can’t blame it on genes. Genes are not destiny!
    • A 2016 NEJM study of 55,685 adults examined the interplay of genetic risks for CVD and lifestyle risks for CVD. They found that, among those with high genetic risk, a favorable lifestyle was associated with 46% fewer coronary events2.
    • A 2016 JAMA Oncology study examined the impact of modifiable and nonmodifiable risk factors for breast cancer and found that healthy lifestyle factors such as maintaining a healthy weight and not drinking or smoking, as well as not using MHT decreased the risk of BRCA carriers (those with the highest risk owing to nomodifiable risk factors) down to the risk of an average woman in the general population.3
  3. Obesity, diabetes and other lifestyle-related chronic diseases are increasing worldwide at alarming rates. 
    • There is evidence that America’s children will be the first in the nation’s history to live shorter lives than their parents.4
    • Life expectancy in America has declined for two years in a row. (data from National Center for Health Statistics https://www.cdc.gov/nchs/)
    • 60% of today’s two-year-olds will become obese by age 35.5
    • Diabetes incidence has quadrupled since 1980 (Centers for Disease Control and Prevention: National Diabetes Surveillance System) 
    • The diabetes epidemic is likely to increase worldwide by 2030. These projections assume obesity remains constant; however, since obesity is increasing, they are likely an underestimate6. Note the 72% increase in incidence in the United States.

Why You Care: The Solution

  1. Learning from wisdom of the past
  2. “If we could give every individual the right amount of nourishment and exercise, not too little, not too much, we will have found the safest way to health.” Hippocrates (400 B.C.)
  3. “To administer medicines to diseases which have already developed and thereby suppress bodily chaos which has already occurred, is comparable to the behavior of those who would begin to dig a well after they have grown thirsty, or those who would begin to cast weapons after they have already engaged in battle. Would these actions not be too late?” From the Chinese Yellow Emperor’s Classic of Internal Medicine (400 BC) 
  4. The way we eat, move, and think influences our health and recuperative power. paraphrased from Chinese Yellow Emperor’s Classic of Internal Medicine (400 BC)
  5. Diet and lifestyle have a huge impact on morbidity and mortality… and there is room for great improvement.
  6. Mortality plummets the more cardiovascular health metrics are met (all of which are dependent on lifestyle), yet less than 2% of people meet all health metrics.24
  7. Mediterranean diet decreased MI, stroke, or CV death by 30%.7
  8. Mediterranean diet decreased diabetes incidence by 40%.8
  9. Mediterranean diet decreased breast cancer incidence by 62%.9
  10. Meeting exercise guidelines provides substantial health benefits20:
  11. Physicians need to model these healthy lifestyle practices because those who model the behavior are more likely to counsel patients about it.10  By encouraging physicians to be healthy, we can improve healthy habits among their patients—an innovative, beneficent, evidence-based approach to encouraging physicians to counsel patients about prevention.11

 

 

NutritionIINutrition

Emphasize plant-forward: plants are the majority of the meal, meats are a condiment.

Eat a dietary pattern that: 

 

  • emphasizes intake of 
    • vegetables
    • fruits
    • and whole grains
  • includes 
    • low-fat dairy products
    • poultry
    • fish
    • legumes
    • nontropical vegetable oils 
    • and nuts
  • and limits intake of 
    • sweets
    • sugar-sweetened beverages
    • and red meats19

 

Key evidence:

  • The Mediterranean diet has been highly studied via 2 RCT’s and 32 observational studies, ALL of which show decreased risk of CVD mortality, stroke, and MI. 
  • PREDIMED Trial: RCT of 7,447 participants without CVD but with high risk (type 2 diabetes or 3+ risk factors), randomized to Mediterranean diet + EVOO, Mediterranean diet + nuts, or a control low-fat diet. The key: they were able to demonstrate effective change in the overall dietary pattern. The results: Mediterranean diet is effective in decreasing MI, stroke, and CV death by 30%, diabetes by 40%, and breast cancer incidence by 62%7-9. The PREDIMED Plus trial is currently under way to evaluate the effect of the Mediterranean diet plus exercise on weight loss. 
  • Fat: it’s not about total fat consumption, it’s about replacing trans- and saturated fats (dairy fat) with monounsaturated and polyunsaturated fatty acids (vegetable oils, nuts, fish, avocado)12-13.
  • Protein: red meat should be replaced with other protein sources, especially nuts, soy, and legumes14-16.
  • Carbohydrates: it’s not about total carbohydrate consumption, it’s about consuming high-fiber whole grains rather than refined starch and sugar, especially sugar-sweetened beverages17-18.
  • Milk, calcium, & vitamin D: There is no benefit of increased milk consumption to fracture risk, and there is likely an increased risk of prostate cancer.25-26Maintaining adequate vitamin D doesdecrease risk of fractures and likely also colorectal and other cancers. Most will likely benefit from 1,000-2,000 IU supplementary vitamin D per day.

 

 

ExerciseExercise

Recommendations20

 

  • Preschool-aged children(3 through 5 years): physically active throughout the day to enhance growth and development. 
  • Children and adolescentsaged 6 through 17: 60 minutes or more of moderate-to-vigorous physical activity daily.
  • Adults: 150-300 minutes/week of moderate-intensity, or 75-150 minutes/week of vigorous-intensityaerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity. Should also do muscle-strengthening activitieson 2 or more days a week. 
  • Older adults: multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. 
  • Pregnant and postpartum women: 150 minutes/week of moderate-intensity aerobic activity. 
  • Adults with chronic conditions or disabilities(who are able): follow guidelines for adults and do both aerobic and muscle-strengthening activities. 
  • Moving more and sitting less will benefit everyone
  • Individuals performing the least physical activity benefit most by even modest increasesin moderate-to-vigorous physical activity. Additional benefits occur with more physical activity.

 

Definitions20

  • Aerobic activity: endurance/cardio, large muscles move rhythmically for sustained period.
  • Muscle-strengtheningactivity: resistance training and weight lifting, muscles work or hold against applied force/weight. Important to work all major muscle groups.
  • Absolute intensity: amount of energy expended during the activity, without considering a person’s cardiorespiratory fitness or aerobic capacity, expressed in metabolic equivalent of task (MET) units; 1 MET = resting metabolic rate (awake and sitting quietly) 
    • Moderate(3 to 5.9 METs):walking briskly (2.5-4 mph), playing volleyball, raking the yard. 
    • Vigorous (6+ METs):jogging/running, carrying heavy groceries, strenuous fitness class.
    • Some activities, such as swimming or riding a bicycle, can be either moderate or vigorous, depending on the effort. 
  • Relative intensity: level of effort required to do an activity compared with a person’s capacity. For an activity of a given absolute intensity, relative intensity will be higher for a person with lower aerobic capacity than for a person who is more fit. Canbe estimated using a scale of 0 to 10, where sitting is 0 and the highest level of effort possible is 10.
    • Moderate-intensity=5 or 6
    • Vigorous-intensity=7 or 8 
    • Talk test: moderate-intensity aerobic activity=can talk, but not sing, during the activity, while vigorous-intensity activity=cannot say more than a few wordswithout pausing for a breath. 
  • Can use either absolute or relative intensity measuresto assess guideline adherence, but relative intensity generally better for older adults.

 

 

Food Insecurity

3-Step Screening21

 

  1. MA provides 2-question screening questionnaire
  2. Over the past 12 months, were you worried whether your food would run out before you got money to buy more? Yesor no
  3. Over the past 12 months, did you find that the food you bought just didn’t last and you didn’t have money to get more? Yesor no
  4. Provider reviews questionnaire with patient
  5. MA gives resource list
  6. The EveryONE Project Toolkit (in particular, the Neighborhood Navigator https://www.aafp.org/patient-care/social-determinants-of-health/everyone-project/neighborhood-navigator.html) has incredible resources! You can search where your patient can get food, housing, transportation, employment aid, legal aid, and financial services in his/her neighborhood.

 

Food insecurity = chronic, unstable condition(upgrades visit from 99213 à99214):

“Screening for food insecurity done today, revealing that patient does not always have access to the proper nutrition required to manage [list chronic medical condition(s) impacted by diet]. Patient’s food insecurity is [new/chronic] and is [stable/worsening]. Patient was counseled about short- and long-term resources to assist with food insecurity.”

 

 

Stress Management

The Problem: Chronic Stress

 

2014 RWJF/HSPH/NPR survey of the US population on stress:

  • 49% reported having a major stress event in the past year
  • Among activities reported to reduce stress levels, 57% of respondents found meditation or prayer to be helpful
  • Impact on eating: 44% reported “eating less than usual,” 39% reported “eating more than usual”

 

The Solution: Mind-Body Medicine23

  • Practicing mindfulness can reduce effects of chronic stress, attenuate symptoms of burnout, and boost resilience
  • Mindfulness àcognitive reappraisal, positive psychology, reflection, appreciative inquiry, finding meaning in work àresilience
  • Mindfulness helps us return to baseline
    • Sustained cortisol impairs feedback regulation: implications for coping with new stressors
    • Chronic stress impairs memory, learning
    • Differentiating chronic stress from acute stress
  • Examples of mind-body medicine
    • Meditation
    • Imagery
    • Biofeedback
    • Autogenic training (self-hypnosis)
    • Breathing techniques
    • Exercise
    • Yoga, Tai Chi
    • Group support
  • Mindfulness meditation: Intentional self-regulation of attention conducted without judgment and focused on observation of the present moment. 
    • Philosophy: When we are able to focus on just what is happening in the present moment, our minds cannot be anxious, worried or distressed about other issues 
    • Physiological benefits: decrease HTN, decrease HR, decrease cortisol, reduced sympathetic arousal, strengthened immune system, reduced levels of pain
    • Psychological benefits: reduced stress level, decreased anxiety, decreased depression, improved confidence and concentration, undercuts processes such as worry and rumination, increased peace of mind, optimism, and self-worth
  • Mindful eatingàdecreased calorie consumption, weight loss, increased physical activity, decreased binge eating, improved glycemic control in diabetic patients
    • Recognize cues of hunger and satiety, engage all senses, eat slowly, savor small bites, chew thoroughly, eliminate other activities while eating, choose food wisely 

Tips for Clinicians: Where to Start

  • Assess diet, measure wt/ht/BMI, start the conversationàdecide whether to refer
  • Dietary assessment tools
    • 24-hr recall: “Starting yesterday morning, what did you have to eat?”
    • Food diary: “Write down everything you eat or drink for one/two days and send it to me” (EMR)
  • Obesity assessment: weight and BMI
    • Check weight at every visit
    • Check height annually àcalculate BMI (ideal <25)
    • Waist size <35” for women, <40” for men (especially useful if BMI 30-35)
    • Share data with patient regularly: recent trends, health risks
  • 5 simple tools 
    • Put obesity on the problem list23
    • Acknowledge overweight/obesity (patient might not realize!)
      • How are you feeling about your weight at this time?
      • Is your weight something you’d like to discuss today? If not, why?
      • I am concerned that your weight is causing/will cause problems for you. Are you concerned?
      • You’re on a concerning path towards heart disease and stroke.
      • Use people-first language: “your weight is in the obesity range” instead of “you are morbidly obese”
    • Write a prescription
      • 2 x ½-cup servings of fruit per day, 3 x ½-cup servings of vegetables per day
      • Cook at home—give some delicious, easy, healthy recipes!
    • Work with patients to set achievable goals
    • Focus on health, NOT weight loss: goal is to help patients live long, happy, and fulfilling lives! Weight loss will follow naturally.
      • Balance and persistence—it’s about the overall dietary pattern, not each individual meal (acknowledge poor choices, then nonjudgmentally get back on track)
      • Removes emotional barriers associated with weight
      • Strive for better, not perfection
      • Enjoy life: show patients that a healthy lifestyle need not be a punishment; rather, it can be happy, fun, achievable, inexpensive, and something to take pride in!

Burning Questions

  • Vitamins/supplements
    • Vitamin D: 1,000 IU/day for most
    • Vitamin B12: vegetarians, vegans, metformin, PPI, H2RA
    • Folate: fertile women
    • Vitamins A, C, E: no supplementation needed
    • Multivitamin: for high risk patients
    • Calcium: 1,000-1,2000mg/day through food, supplement unlikely benefit to fracture risk and potential harm (increased prostate cancer)25-26
    • Iron: supplement if deficient (determine cause)
  • Non-nutritive sweeteners(acesulfame, aspartame, luo han guo fruit extract, saccharin, stevia, sucralose)
    • Bottom line: NO, replace with seltzer water/water
    • Compensatory food intake27
    • Trains palate to crave sweet food
    • Glucose intolerance26
  • Coffee
    • Bottom line: if you like coffee and can tolerate it, drink it! Avoid cream and sugar.
    • Potential health benefits: T2DM, Parkinson’s gallstones, dementia, headaches, cancer
    • Observational studies: inverse association with total/cause-specific mortality28
    • Meta-analyses show decreased mortality29-30
    • 2017 multinational/multiethnic studies showed increased generizability31
    • Downsides: palpitations, GERD, caffeine withdrawal, calories if cream and sugar added, sleep disturbance
  • Sleep
    • Association of sleep deprivation with future weight gain and increased risk of T2DM
    • Potential target of weight gain prevention
  • Intermittent fasting?
    • RCT: Alternate day fasting32
      • 25% (lunch only) alternating with 125% (3 meals)
      • Results: not feasible, tended towards daily 75%, no difference in outcomes
    • Crossover study, T2DM, 2 vs. 6 meals33
      • Compared isocaloric: breakfast and lunch only vs. same calories over 6 meals
      • Results: when eating 2 meals, reduced body weight, hepatic fat content, fasting glucose
    • Controlled feeding trial (energy intake within specific time frames) in pre-diabetes34
      • Improved insulin sensitivity, beta cell responsiveness, BP, oxidative stress, and appetite
      • Effects not solely due to weight loss
  • Probiotics: data still emerging, evidence that eating fermented foods shifts microbiota composition, increases microbiota diversity, decreases inflammatory cytokines, decreases inflammatory signaling, and increases immune cell signaling capacity36
    • Bottom line: include fermented foods in diet (e.g. yogurt, kombucha), don’t bother with probiotic supplements yet (not enough data to prescribe, safety concerns, need trials)

 

Citations

  1. JAMA Cardio. 2016;1(5):594-599. doi:10.1001/jamacardio.2016.1326 
  2. Khera, AV, et al. N Engl J Med. 2016 Dec 15. 
  3. JAMA Oncol. 2016;2(10):1295-1302. doi:10.1001/jamaoncol.2016.1025
  4. Olshansky et al. 2005, NEJM; 352 (11):1138. 
  5. Ward ZJ. et al. N Engl J Med 2017;377:2145-2153 
  6. Hossain P et al. N Engl J Med 2007;356:213-215
  7. Estruch R, et al. N Engl J Med 2013 
  8. Salas-Salvadó J, et al. Ann Intern Med 2014;160:1-10. 
  9. Toledo E, et al. JAMA Intern Med 2015;175:1752-60. 
  10. Frank E. JAMA 2004;291(5)637 
  11. https://www.ncbi.nlm.nih.gov/pubmed/21214054
  12. Wang D et al. JAMA Intern Med, 2016
  13. Chen M et al. AJCN 2016
  14. Bernstein A, et al. Circulation. 2010;122(9):876-83
  15. Pan A et al, Arch Intern Med 2012
  16. Farvid MS et al., Int J Cancer 2014
  17. Salmeron et al,1997
  18. Schulze et al. 2004 JAMA
  19. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk
  20. US HHS, 2018 Physical Activity Guidelines for Americans
  21. Frank, B. (2019). Food Insecurity: Why It Matters and How Busy Clinicians Can Make a Difference.
  22. Haramati, A. (2019). Mindful Eating... Mindful Life.
  23. Ma J et al.  Obesity (2009) 17, 1077-85
  24. Yang, Q., Cogswell, M., Flanders, W., Hong, Y., Zhang, Z., Loustalot, F., Gillespie, C., Merritt, R. and Hu, F. (2012). Trends in Cardiovascular Health Metrics and Associations With All-Cause and CVD Mortality Among US Adults. JAMA, 307(12), p.1273.
  25. Bischoff-Ferrari et al.
  26. Snowdon et al, 1984
  27. Swithers. Trends Endocrinol Metab. 2013 Sep;24(9):431-41.
  28. Freedman ND et al. NEJM.2012;366:1891-904
  29. Ming Ding et al. Circulation. 2015;132:2305-2315
  30. Je and Giovannucci. Brit J Nut. 2013.
  31. Park S et al. Gunter JM et al. Ann Int Med 8/15/17
  32. Trepanowski et al. Alternate-Day Fasting. JAMA Intern Med. 2017:177(7):930-8.
  33. Kahleova et al. T2DM meals. Diabetologia. 2014:57(8):1552-60
  34. Sutton, E. Cell Metab. 2018 Jun 5;27(6):1212-1221.
  35. Sonnenburg, J. and Sonnenburg, E. (2019). Diet as Key Lever to Nurture a Healthy Gut Microbiome.

 

Additional recommended resources

Books:

  • Eat, Drink, & Be Healthyby Walter Willet
  • The Science of Breathby Swami Rama (for practical information about breathing exercises)
  • Savor: Mindful Eating, Mindful Lifeby Thich Nhat Hanh and Dr. Lilian Cheung
  • A Beautiful Heart Cookbookby Elizabeth Epstein (coming June 2019 with delicious, easy, simple, inexpensive recipes that follow the dietary principles discussed in this guide)

Articles:

  • The EAT-Lancet Commission Reportfor information about sustainable diets
  • 2018 Physical Activity Guidelines for Americans (referenced in this guide, worth reading the entire thing)

Websites:

 

Remember the power that we have as physicians. We can say something is important! Go make a difference. 

 

 

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