Lifestyle Interventions: The Best Medicine You’re Not Using

April 22, 2015

If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health. ― Hippocrates

As part of its 2020 impact goals, the American Heart Association has set out seven ideal health metrics: not smoking, a normal body mass index (BMI), physical activity, a healthy diet, normal cholesterol, normal blood pressure, and a normal fasting plasma glucose.[1] An analysis from the National Health and Nutrition Examination Survey showed that individuals who met five of the seven ideal metrics had a 78% reduction in the hazard ratio for all-cause mortality.[2] In the Multi-Ethnic Study of Atherosclerosis, just four core lifestyle factors had profound effect: A combination of regular exercise, healthy diet, not smoking, and maintaining a healthy weight led to an 81% reduction in the hazard ratio of all-cause mortality over 7.5 years.[3] These lifestyle interventions prevent heart disease in both men[4] and women.[5] From the INTERHEART study that included 52 countries, it is estimated that modifiable risk factors account for 90% of the population-attributable risk for heart disease in men, and 94% of the risk in women.[6] A healthy diet can also decrease the risk of developing diabetes,[7] high blood pressure,[8] and heart failure.[9]

“A very short list of lifestyle practices has a more massive influence on our medical destinies than anything else in all of medicine,” says Dr David Katz, director of the Yale University Prevention Research Center and president of the American College of Lifestyle Medicine, in a telephone interview. “There’s almost nothing in all of medicine that has the vast, consistent, and diverse evidence base.”

He remarked that there is no pill, and there never will be any pill, that can reduce the burden of chronic disease in the way that healthy lifestyle factors can.

So why don’t we use lifestyle factors more?

Part 1: The Myth of Futility

One part of the problem is that some practitioners simply don’t think lifestyle interventions will be effective. For just as every silver lining has a cloud, some studies of lifestyle interventions have been negative and shown no benefit. Chief among them is the recently published Look AHEAD trial,[10] which failed to show any benefit of intensive lifestyle interventions in reducing the risk for cardiovascular outcomes in more than 5000 obese or overweight adults with type 2 diabetes. Indeed, the study was stopped early owing to futility.

Similarly, the HF-ACTION trial[11] investigated the role of a structured exercise program in patients with heart failure. The primary analysis showed no benefit in cardiovascular mortality or rehospitalization, whereas in a prespecified analysis that adjusted for prognostic predictors of the primary endpoint, exercise training was associated with modest significant reductions in all-cause mortality and all-cause hospitalization.

Look AHEAD is not the only clinical trial of lifestyle interventions in patients with type 2 diabetes. The STENO-2 trial studied a multifactorial intervention of lifestyle modification and medical therapy vs conventional therapy in 80 patients. The strategy was associated with a reduction in the hazard ratio of cardiovascular disease of 53% compared with conventional therapy.[12] The discrepancy between STENO-2 and the much larger Look AHEAD trial may be in part because of the lower-risk patient population in the latter study: Roughly 16% of the control group experienced an event in Look AHEAD, compared with 44% of the control group in STENO-2.

The Look AHEAD trial did show significant benefits in several areas.[13] Participants who were randomly assigned to the intensive lifestyle intervention lost more weight than controls, and they had decreases in waist circumference and improvements in physical fitness. They also had a significant improvement in A1c, blood pressure, high-density lipoprotein cholesterol, and albuminuria. Exploratory analyses suggested an increased rate of remission of diabetes in those receiving the lifestyle intervention.[14] The intervention group also had significant reductions in their medications for diabetes, hypertension, and cholesterol. Finally, there were measured improvements in quality of life, mobility, and depression.

“The message of hope that I have from the Look AHEAD trial is that there is a subset of folks in that trial who lost 10% of their body weight and kept it off,” says Dr William Polonsky, associate clinical professor, University of California, San Diego, in a telephone interview. “There is a subset of folks who are very successful.”

The bulk of the evidence suggests that lifestyle interventions are beneficial, and even the “negative” trials show improvements in various health outcomes. If the problem isn’t with the science, then maybe the problem is with implementing it.

The Desire to Change

“The major problem we have in promoting lifestyle interventions is that it’s really, really hard,” admits Polonsky. “We should be respectful and humbled by how difficult it is to make these changes, especially in the long term.”

A meta-analysis from 2014 showed that dietary interventions that resulted in weight loss at 6 months lost benefit over time, with 1-2 kg of the weight regained by 12 months.[15] “The problem is that most patients regain the weight in the long term,” noted Robert Eckel, professor of medicine at the University of Colorado and lead author of the 2013 American College of Cardiology/American Heart Association guidelines on lifestyle management to reduce cardiovascular risk, in a telephone interview.

Similarly, in the HF-ACTION trial, participants who were physically active slacked off after the study’s structured exercise program ended.[11] In the Women’s Health Initiative study, participants randomly assigned to a low-fat diet were supposed to cut fat intake to 20% of daily calories. However, by 6 months, that number was at 24%, and by 1 year it had crept back up to 29%.[16]

Many trials have shown that adherence to diet or lifestyle intervention is one of the most important predictors of successfully achieving the target goal.[17,18] Unfortunately, high dropout rates, especially in trials that require dietary interventions, are common.[19]

Financial incentives may prove to be one method of overcoming the barriers to lifestyle change. Researchers in the United Kingdom examined whether paying pregnant smokers to quit would improve abstinence rates. About 300 women were offered a total of £400 (about $600) in shopping vouchers for completing the program. The vouchers were parceled out as £50 for coming to the first meeting, another £50 for being verifiably smoke-free at 4 weeks, £100 at 12 weeks, and a final £200 at the end of the pregnancy if they remained smoke-free. The program showed a statistically significant difference in quit rates compared with the control group of pregnant smokers, who were offered smoking cessation counseling and free nicotine replacement therapy. The study demonstrated a number needed to treat of 7.2.[20]

Does the public support paying people to stop their bad habits? Some surveys have suggested that the public would support the notion of financial incentives for lifestyle change.[21] It may depend on who pays for the incentives. In a US study, participants were presented with a fictional antismoking public policy with options that included medication, an unspecified treatment, or an incentive paid to the smoker. Fewer than one half of the 1000-plus respondents supported any intervention if it resulted in a $25 increase in their annual healthcare premiums. The financial incentive scored lowest in support but did not differ statistically from the other two options.[22]

How much does it take to persuade someone to adopt a healthy behavior or quit an unhealthy one? An analysis of web survey data from the United Kingdom suggests that the level of compensation needed may not be uniform.[23] Men seem to require more compensation than women, and healthy individuals of normal weight require more incentives than individuals who already suffer from health problems and risk factors.

Dr Katz believes that focusing only on motivation and the desire to change is overly simplistic. Although most patients have the desire to change, they just can’t, he noted, using the analogy of climbing Mount Everest.

“Desire doesn’t get you to the top of Everest. Desire gets you to the base camp. Mountaineering skills get you to the summit,” he commented, adding that we need to teach patients the skills they need to succeed if we truly want them to make changes in their life.

Are Physicians the Best Teachers?

Who should be teaching patients these skills? As physicians, we routinely bemoan our failure to prescribe lifestyle interventions, and yet we consistently underutilize these options.[24,25] Surveys of primary care physicians found that counseling regarding diet and exercise dropped 22% between 1996 and 2001.[26]

Part of the problem may be that medical school curricula and residency programs do not provide trainees with the skills needed for proper health promotion.[27] It’s no surprise, then, that physicians report a lack of confidence in prescribing lifestyle interventions to their patients.[28]

Perhaps it shouldn’t be physicians who counsel patients about lifestyle. The evidence demonstrates that nurses[29] and pharmacists[30] provide benefit as both replacements for and adjuncts to physician care, and a report by the Institute of Medicine has called for an expanded role of nursing in multidisciplinary clinics.[31] Having nurses or dietitians do the lifestyle counseling is obviously appealing, considering that physicians consistently list time as a major barrier to providing care.[32] Therefore, the decision by the Centers for Medicare & Medicaid Services to remunerate physicians for behavioral therapy may be helpful, because 54% of primary care physicians in one survey said that they would spend more time on counseling if their time was compensated appropriately.[33]

Dr Eckel acknowledges that time is a limiting factor but cautions that if physicians are not willing to take at least some time, then patients will be less capable of following the advice of dietitians or therapists. There is in fact evidence to support this notion. Patients often state that physician advice motivates them to make lifestyle changes.[34,35] One study showed that the greater the strength of the physician’s recommendation, the more likely patients were to participate in a cardiac rehabilitation program.[36]

Dr Polonsky calls this recommendation the “warm hand-off,” a recommendation from a physician that is then elaborated upon by other members of the medical staff. “It doesn’t have to be time-consuming,” he says, “it’s just about the quality and strength of the recommendation.”

Dr Eckel also cautions about relying too much on allied health professionals for counseling. Not every clinic can afford to have a dietitian, and although some insurers cover a dietitian consult, some do not. “A physician must take the time to convince the patient that the strategy is going to prove successful, and hopefully there’s a dietitian to assist,” says Eckel.

Think Big: It Takes a Village

Perhaps working on an individual level is too limited. The most successful health interventions have always been broadly based public health interventions. Taxes and public smoking bans have had the greatest impact on smoking rates.[37] “We’ve seen this impressive drop-off from smoking, primarily because it’s more of a hassle to smoke and it’s not as cool. It’s certainly not from extra finger-wagging from healthcare providers,” says Polonsky.

Maybe we should focus our attention not on changing the minds of one person at a time, but in mobilizing government to implement some real public policy change.

One example is the proposed tax on sugary beverages. A systematic review of US studies found that higher fast-food prices were associated with decreased consumption of unhealthy foods.[38] Similarly, higher prices on fast food, coupled with lower prices on fruits and vegetables, were associated with lower weight and lower BMI in another review.[39] However, many of the data are based on modeling simulations, and concrete empirical evidence is lacking.[40]

One modeling study suggested that a 20% tax on sugar-sweetened beverages would prevent 95,000 coronary events, 8000 strokes, and 2600 premature deaths in the United States over 10 years. It would also save $17 billion in medical costs and generate $13 billion in annual tax revenue.[41]

However, a public opinion survey from 2011 shows Americans to be split on the matter, with the majority of those surveyed being against any such tax. The most common reasons against this policy are the belief that it would not be effective, that it would be a regressive tax on lower-income families, and that it represented an intrusion of government in personal decision-making.[42] A similar survey of Canadians found that 67% would support such a tax, provided that revenues were used to combat childhood obesity.[43]

There are other examples where government action has led to increases in healthy behavior. When sidewalks and crosswalks were improved in Florida, Mississippi, Washington, and Wisconsin, more students started walking and biking to school.[44] In Houston, the number of children walking and biking to school more than doubled after the city implemented a “walking school bus” program.[45] New bike lanes in New Orleans led to a tripling of the number of cyclists on those streets.[46] Twenty minutes of recess a day led to lower BMI in elementary students.[47] Finally, state-mandated physical education classes led to greater physical activity levels among school-age girls.[48]

Dr Polonsky suggests we should give extra money to urban planners and ask them, “Please redesign all American cities so that walking becomes part and parcel of what we do every day.” He would like to see “stairways as part of buildings so that they invite people to use them, as opposed to putting them in these scary little darkened areas behind huge metal fire doors.”

Conclusion: Close the Tap

Clearly, we need to do more as physicians to encourage lifestyle changes in our increasingly sedentary and aging population. The notion that lifestyle changes don’t work is flat-out wrong. The nonadherence of patients is an obstacle, but not an insurmountable one. Although nurses and other groups can provide lifestyle advice, physicians still have a role to play—and a beneficial role, at that. Finally, our contribution may be not just at the patient level, but also in influencing government and public policy.

Denis Burkitt (of Burkitt lymphoma fame) once said, “Doctors are like poor plumbers. They treat a splashing tub by cleaning up the water. These plumbers are extremely apt at drying up the water, constantly inventing new, expensive, and refined methods of drying up water. Somebody should teach them how to close the tap.”

Closing the tap of our unhealthy lifestyle habits will allows us to prevent disease rather than wait for it to manifest and treat the symptoms. If we can do this, we will have found, as Hippocrates said, the safest way to health.


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