Much Ado About Diet and Lifestyle, for Good Reason

By Enoch Jiang

Peer Reviewed

“Counseled patient on diet and lifestyle.” Over the past few weeks on my Ambulatory Care rotation, this phrase has rapidly shot to the top of my internal gestalt of a prototypical primary care visit, second perhaps only to checking a patient’s hemoglobin A1c or offering them their annual flu shot. Most adults in the US have a health condition where counseling may be relevant: 73.6% of adults live with overweight or obesity,¹ 45% of adults have hypertension,² and almost 40% of adults have high total cholesterol,³ just to name a few common conditions.

Lifestyle counseling is a fundamental component of patient care, and all the adults in the room seem to think so. The United States Preventive Services Task Force (USPSTF) has endorsed it since publishing their first edition of 169 recommendations in 1989,⁴ the American Heart Association includes it in their core goals each decade,⁵ and the American Association of Family Physicians has created extensive guides and courses to help physicians “prescribe” lifestyle medicine to their patients.⁶ Anecdotally, I remember a lecture during my preclinical studies about statins in which the speaker, before continuing, paused to emphasize that the first-line therapy to reduce LDL-cholesterol is lifestyle change. Conceptually, there is no question that a healthier diet and lifestyle are key to improving one’s health–something I remind myself when I feel ambivalent about going to the gym on a Thursday evening.

There is a bevy of evidence for the value of lifestyle counseling. Multiple systematic reviews^7,8 have affirmed that counseling improves diet and physical activity, and leads to modest but significant reductions in cholesterol, blood pressure, weight, blood glucose, and diabetes incidence. And yet, I have occasionally heard pessimistic opinions from both healthcare providers and patients themselves about the effectiveness or feasibility of counseling. This is a loaded topic that takes some unpacking, but there is a well-documented disconnect^5,9 between the empiric utility of lifestyle counseling and how some physicians and patients feel about it. There are multiple reasons for that disconnect, starting from the roots of access to healthy lifestyles and ending in the clinic during a busy workday.

For lifestyle counseling to be effective, we must first do it, but often we don’t. Researchers have been highlighting for decades that lifestyle counseling only occurs in a minority of clinic visits,^10,11 whether a patient is disease-free or has five comorbid conditions. This is not necessarily an individual failing by doctors as much as a result of the time constraints placed on them. A 2022 study¹² found that a primary care provider with an average-sized patient panel would ideally spend over 10 hours a day purely on counseling (derived from USPSTF recommendations), and 27 hours per day to complete all of their work (yes, this is not a typo). Add in the pressure of staying on time—the average primary care visit lasts a whopping 18 minutes¹³—and it is easy to imagine why one might feel dissuaded from beginning a conversation on whole grains and plant protein at minute 17 of the visit.

Furthermore, most physicians don’t feel adequately equipped to counsel patients in the first place. Depending on which study^14,15 you look at, as few as 25% (and never a majority) of primary care physicians in the US believe that they have sufficient training in counseling patients on diet and lifestyle. This problem stems from the beginning of medical education. A 2010 national survey¹⁶ found that only 27% of US medical schools provided 25 hours of nutrition education (the minimum that the National Academy of Science has been recommending since 1985). Nutrition education during residency appears to be almost entirely absent,¹⁷ and it is notable that to this day you cannot find the words “nutrition” or “lifestyle” in the Accreditation Council for Graduate Medical Education common program requirements for residency programs.¹⁸ Education about exercise is even more sparse: as of 2015, only 12% of medical schools had a required course that was related to physical activity.¹⁹ There are still informal opportunities to learn from healthcare providers who are passionate about lifestyle medicine; I was fortunate to attend one such workshop led by one of the physician leaders of the Lifestyle Medicine Program at Bellevue Hospital. But these require investing extra time outside of school and work, when they would optimally be built into the core curriculum along with all the other knowledge that makes us into good physicians.

Even with enough time and knowledge on the physician’s end, larger barriers to success exist for many patients. A few years ago, when I was volunteering in a patient education program with patients undergoing bariatric surgery, I was struck by how many of the patients faced social and financial barriers to accessing healthier foods and lifestyles. Counseling a patient on eating more plant-based meals felt ineffectual when they lived in a food desert or didn’t have time to cook between long shifts. And it felt idealistic, if not out-of-touch, to suggest an expensive batch of easily perishable produce over cheaper and more reliable sources of calories. As of 2022, 12.8% of US households were food-insecure, and almost double that for Black or Latinx households.²⁰ Financial barriers, as well as access to healthy food and green spaces, are systemic issues that can stymy even the most motivated patient and provider.^21,22

Given all the factors stacked against lifestyle counseling, it is impressive that it has shown, time and time again, to have a significant and positive impact on public health. The movement and discipline are growing: lifestyle medicine first began as a formal medical specialty in 2004, and has since expanded to be included in over 300 residency programs, as part of the curriculum and as an interest group in over 60% of US medical schools.²³ Lifestyle medicine programs, which provide interdisciplinary individual and group programming, as well as fresh produce and credits for healthy foods, are gaining ground around the country.²⁴

One leader has been the NYC Health + Hospitals system, which now offers the program at five of its main hospitals.²⁵ The program was piloted at Bellevue in 2019, with more than 850 people requesting to enroll in the first few months.

There is still much room for progress on educating physicians at all stages of training, as well as reducing the societal inequities that contribute to these health problems in the first place. But if we can unlock the full capacity of a time-tested and simple intervention, we can radically improve the health of millions.

P.S. GLP-1 agonists, which exploded onto the weight-loss scene during the COVID-19 pandemic, suggest that we can treat weight loss effectively with medications.²⁶ While GLP-1 agonists are certainly potent instruments in the treatment of obesity and diabetes, they do not replace lifestyle interventions. They do not address the structural barriers that still hinder patients from reaching their health goals. In fact, they may perpetuate inequalities related to access, as they have already been shown to be disproportionately prescribed to White, higher-income patients.²⁷ Nevertheless, particularly for patients who have already implemented lifestyle interventions, these drugs can break past the ceiling of what one can accomplish with willpower.

One of the most significant side effects of the rise of GLP-1 agonists is that they are changing the way that we think about obesity.²⁸ Stigma towards overweight and obese people arises from a longstanding and pervasive bias that one’s weight is a moral choice (and that being overweight is thus a personal failure).²⁹ Decades of research have demonstrated that obesity is a complex, chronic disease, and the efficacy of GLP-1 agonists further drives home the fundamentally biochemical nature of this disease.²⁹

Enoch Jiang is a Class of 2026 medical student at NYU Grossman School of Medicine

Reviewed by Michael Tanner, MD, Executive Editor, Clinical Correlations

Image courtesy of Wikimedia Commons, source: https://commons.wikimedia.org/w/index.php?search=diet&title=Special:MediaSearch&go=Go&type=image  work by Stevepb from https://pixabay.com/zh/photos/diet-snack-health-food-eating-617756/ 

 

References

1. Fryar CD, Carroll MD, Afful J. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960–1962 through 2017–2018. Centers for Disease Control and Prevention. Updated February 8, 2021. Accessed April 11, 2024. https://www.cdc.gov/nchs/data/hestat/obesity-adult-17-18/obesity-adult.htm#Citation
2. Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension Prevalence Among Adults Aged 18 and Over: United States, 2017–2018. Centers for Disease Control and Prevention. Updated April 24, 2020. Accessed April 11, 2024. https://www.cdc.gov/nchs/products/databriefs/db364.htm
3. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation. 2022;145(8):e153-e639. doi:10.1161/CIR.0000000000001052
4. U. S. Preventive Services Task Force. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Williams & Wilkins; Baltimore, MD, 1989.
5. Hivert M-F, Arena R, Forman DE, et al. Medical Training to Achieve Competency in Lifestyle Counseling: An Essential Foundation for Prevention and Treatment of Cardiovascular Diseases and Other Chronic Medical Conditions: A Scientific Statement From the American Heart Association. Circulation. 2016;134(15):e308-e327. doi:10.1161/CIR.0000000000000442
6. American Academy of Family Physicians. Lifestyle Medicine. Accessed April 11, 2024. https://www.aafp.org/family-physician/patient-care/prevention-wellness/lifestyle-medicine.html
7. Lin JS, O’Connor E, Evans CV, Senger CA, Rowland MG, Groom HC. Behavioral counseling to promote a healthy lifestyle in persons with cardiovascular risk factors: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2014;161(8):568-578. doi:10.7326/M14-0130
8. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013;32(2):207-214. doi:10.1377/hlthaff.2012.1061
9. Kelly J, Karlsen MC, Lianov L. Establishing Competencies for Physicians Who Specialize in the Practice of Lifestyle Medicine. Am J Lifestyle Med. 2019;14(2):150-154. doi:10.1177/1559827619856542
10. Wee CC, McCarthy EP, Davis RB, Phillips RS. Physician counseling about exercise. JAMA. Oct 27 1999;282(16):1583-1588. doi:10.1001/jama.282.16.1583
11. Bleich SN, Pickett-Blakely O, Cooper LA. Physician practice patterns of obesity diagnosis and weight-related counseling. Patient Educ Couns. 2011;82(1):123-129. doi:10.1016/j.pec.2010.02.018
12. Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care. J Gen Intern Med. 2023;38(1):147-155. doi:10.1007/s11606-022-07707-x
13. Neprash HT, Mulcahy JF, Cross DA, Gaugler JE, Golberstein E, Ganguli I. Association of Primary Care Visit Length With Potentially Inappropriate Prescribing. JAMA Health Forum. 2023;4(3):e230052. doi:10.1001/jamahealthforum.2023.0052
14. Weinehall L, Johansson H, Sorensen J, Jerden L, May J, Jenkins P. Counseling on lifestyle habits in the United States and Sweden: a report comparing primary care health professionals’ perspectives on lifestyle counseling in terms of scope, importance and competence. BMC Fam Pract. 2014;15:83. doi:10.1186/1471-2296-15-83
15. Forman-Hoffman V, Little A, Wahls T. Barriers to obesity management: a pilot study of primary care clinicians. BMC Fam Pract. 2006;7:35. doi:10.1186/1471-2296-7-35
16. Chung M, van Buul VJ, Wilms E, Nellessen N, Brouns FJPH. Nutrition education in European medical schools: results of an international survey. Eur J Clin Nutr. 2014;68(7):844-846. doi:10.1038/ejcn.2014.75
17. Devries S, Willett W, Bonow RO. Nutrition Education in Medical School, Residency Training, and Practice. JAMA. 2019;321(14):1351-1352. doi:10.1001/jama.2019.1581
18. Accreditation Council for Graduate Medical Education. Accessed April 11, 2024. Common Program Requirements. https://www.acgme.org/programs-and-institutions/programs/common-program-requirements/
19. Cardinal BJ, Park EA, Kim M, Cardinal MK. If Exercise is Medicine, Where is Exercise in Medicine? Review of U.S. Medical Education Curricula for Physical Activity-Related Content. J Phys Act Health. 2015;12(9):1336-1343. doi:10.1123/jpah.2014-0316
20. Economic Research Service, U.S. Department of Agriculture. Key Statistics & Graphics. Updated October 25, 2023. Accessed April 11, 2024. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/key-statistics-graphics/#insecure
21. Deslippe AL, Soanes A, Bouchaud CC, et al. Barriers and facilitators to diet, physical activity and lifestyle behavior intervention adherence: a qualitative systematic review of the literature. Int J Behav Nutr Phys Act. 2023;20(1):14. doi:10.1186/s12966-023-01424-2
22. Helland MH, Nordbotten GL. Dietary Changes, Motivators, and Barriers Affecting Diet and Physical Activity among Overweight and Obese: A Mixed Methods Approach. Int J Environ Res Public Health. 2021;18(20):10582. doi:10.3390/ijerph182010582
23. Lippman D, Stump M, Veazey E, et al. Foundations of Lifestyle Medicine and its Evolution. Mayo Clin Proc Innov Qual Outcomes. 2024;8(1):97-111. doi:10.1016/j.mayocpiqo.2023.11.004
24. Twenter P. Health systems double down on weight loss programs. Becker’s Healthcare. Updated February 29, 2024. Accessed April 11, 2024. https://www.beckershospitalreview.com/pharmacy/health-systems-double-down-on-weight-loss-programs.html
25. Bean M. NYC Health + Hospitals expands lifestyle medicine program. Becker’s Clinical Leadership. Updated March 1, 2024. Accessed April 11, 2024. https://www.beckershospitalreview.com/patient-safety-outcomes/nyc-health-hospitals-expands-lifestyle-medicine-program.html
26. Powell A. Are new weight-loss drugs the answer to America’s obesity problem? The Harvard Gazette. Updated July 10, 2023. Accessed April 11, 2024. https://news.harvard.edu/gazette/story/2023/07/are-new-weight-loss-drugs-the-answer-to-americas-obesity-problem/
27. Elhussein A, Anderson A, Bancks MP, et al. Racial/ethnic and socioeconomic disparities in the use of newer diabetes medications in the Look AHEAD study. Lancet Reg Health Am. 2022;6:100111. doi:10.1016/j.lana.2021.100111
28. Szalavitz M. What Ozempic Reveals About Desire. The New York Times. Updated June 4, 2023. Accessed April 11, 2024. https://www.nytimes.com/2023/06/04/opinion/ozempic-weight-loss-addictions-desire.html
29. Westbury S, Oyebode O, van Rens T, Barber TM. Obesity Stigma: Causes, Consequences, and Potential Solutions. Curr Obes Rep. Mar 2023;12(1):10-23. doi:10.1007/s13679-023-00495-3

 

Share: Twitter | Facebook | Email