In autumn of 1985, in my 2nd year of medical school, time and again my professors listed the causes of a disease as: tobacco, poor diet, obesity, excessive alcohol and street (recreational) drug use. Lots of diseases, but very often it was the same list. A few years later, lack of regular exercise and being out-of-shape were added to the list.
My classmates and I were learning to use polypharmacy and procedures to treat disease. To me, this seemed like trying to extinguish a fire while doing nothing to cut off the fuel supply! I asked why we weren’t trying to do something help people stop harming themselves, and was told “It’s not your job to tell patients how to live their lives”. In hindsight, my professors probably confused persistent paternalistic thoughts about making someone change with helping them decide to change.
In those days, medicine was shifting from “doctor knows best” to one of respecting the patient’s autonomy and right to self-determination. This perspective was reinforced in my 3rd year clerkships at Parkland Hospital in Dallas, TX, where I saw the effects of the “Friday Night Knife and Gun Club”, the ravages of alcohol and drug addiction, and the challenge of caring for the homeless. It was evident that it wasn’t my job to judge those people, and it was so much easier to sweep the social problems under the rug and just use technology to solve the immediate crisis.
That’s how I found medicine giving lip service to lifestyle intervention as a first line of treatment, but then skipping over that and just relying on ever-fancier and more expensive “medical fire extinguishers”.
Thirty-five years later, diseases stemming from obesity – diabetes, cardiovascular disease and musculoskeletal disability – are making America’s disease-care costs soar. Mainstream and alternative system health care spending now tops $2.8 trillion a year [Nahin]. Nearly half of all Americans have either diabetes or pre-diabetes: 30 million (9%) Americans are diabetic and 84 million more – a third of Americans – are at high risk for diabetes [CDC].
Diabetes and poorly controlled hypertension are the top 2 causes of end-stage renal disease, which costs $79,000 per patient per year in 2016 [USRDS]. By 2030, up to 1.25M Americans are expected to need dialysis [McCullough, et al.], which may cost as much as $100 billion annually. Given the difficulty of sustaining weight loss and today’s prevalence of obesity, it’s not difficult to imagine that someday 1-2% of Americans will end up on dialysis and costing over $500 billion a year in today’s dollars.
This is what happens when we ignore the root causes of disease and rely on medical technology for 3 or 4 decades.
Meanwhile, modern agribusiness practices have reinforced those root causes by selling what author Michael Pollen calls “edible food-like substances”. Food production is also the leading producer of greenhouse gases, unintentionally linking obesity and malnutrition with the health impacts of climate change [Swinburn, et al.].
Fortunately, over the last 3 decades we’ve learned a lot about how to help people change their behavior and lose weight. In a recent study of weight loss and exercise for type 2 diabetes, 31 out of of 36 participants who lost at least 15 kg (33 lbs) and exercised for 15,000 steps a day were able to completely quit all diabetes medications [Lean, et al.]. And while those who lost less than 15 kg weren’t as successful, 46% of 149 subjects achieved a complete remission of diabetes (defined as having normal blood glucose while taking no diabetes medications).
So, when you hear a doctor say that a patient needs bariatric surgery (one of our more costly “medical fire extinguishers”) because lifestyle interventions don’t work, you can reply “Not true”! Health coaching can help reverse diabetes, heart disease and other problems caused by lifestyle [Sforzo, et al.]. Plant-based whole food diets, especially vegan, vegetarian and pesco-vegetarian, can also reverse diabetes and improve outcomes [Toumpanakis, et al.].
Our challenge is to develop the knowledge, skill and ability to help everyone, not just half of the people.
As a lifestyle medicine practitioner, I’ve found that much of what patients need is often not about health behaviors. We’ve also begun to understand the influence of social determinants of health, including adverse childhood experiences, as factors that determine health outcomes as adults [Burgess, et al.; Felitti, et al.]. More and more health systems are finally looking at these ecological causes of disease – so-called “Upstreamism” – and working to help people whose life circumstances put them at risk [Gottlieb, et al.].
Health coaches help patients discover their own motivations and then use their strongest resources to adopt and maintain better health habits. We need health coaches in medicine because we can’t afford the technological solutions and there’s just no substitute for healthy eating, being physically active, maintaining a positive emotional well-being (including avoidance of tobacco and intoxication) and sleeping well. But sometimes the key to behavior change lies in resolving the social and environmental circumstances that fosters the formation of bad habits that are really hard to change. When we combine health coaching with helping patients overcome social determinants, I believe we’ll use a lot less medical technology.
Good health and well-being to you.
Geoffrey E. Moore, MD FACSM
Citations
Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet 393, 10173: 791-846, 2019. DOI: https://doi.org/10.1016/S0140-6736(18)32822-8
Nahin RL, Barnes PM, Stussman BJ. Expenditures on complementary health approaches: United States, 2012. (433KB PDF) National Health Statistics Reports. Hyattsville, MD: National Center for Health Statistics. 2016.
US Renal Data System. 2018 Annual Data Report. USRDS Coordinating Center, Ann Arbor, MI. accessed August 2, 2019 https://www.usrds.org/2018/view/Default.aspx
McCullough KP, Morgenstern H, Saran R, Herman WH, Robinson BM. Projecting ESRD Incidence and Prevalence in the United States through 2030. J Amer Soc Nephrol, 30 (1) 127-135; 2019. DOI: https://doi.org/10.1681/ASN.2018050531
Lean MEJ, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, Peters C, Zhyzhneuskaya S, Al-Mrabeh A, Hollingsworth KG, Rodrigues AM, Rehackova L, Adamson AJ, Sniehotta FF, Mathers JC, Ross HM, McIlvenna Y, Stefanetti R, Trenell M, Welsh P, Kean S, Ford I, McConnachie A, Sattar N, Taylor R. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 391: 541–51, 2018. http://dx.doi.org/10.1016/ S0140-6736(17)33102-1
Toumpanakis A, Turnbull T, Alba-Barba I. Effectiveness of plant-based diets in promoting well-being in the management of type 2 diabetes: a systematic review. BMJ Open Diabetes Res Care 2018;6:e000534. doi: 10.1136/bmjdrc-2018-000534
Sforzo GA, Kaye MP, Todorova I, Harenberg S, Costello K, Cobus-Kuo L, Faber A, Frates E, Moore M. Compendium of the Health and Wellness Coaching Literature. Am J Prev Med 12(6):436-447, 2017. doi: 10.1177/1559827617708562
Burgess E, Hassmén P, Pumpa KL. Determinants of adherence to lifestyle intervention in adults with obesity: a systematic review. Clin Obes 7(3):123-135, 2017. doi: 10.1111/cob.12183.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al. The relationship of adult health status to childhood abuse and household dysfunction. Am J Preventive Med 14:245- 258, 1998.
Gottlieb LM, Tirozzi KJ, Manchanda R, Burns AR, Sandel MT. Moving electronic medical records upstream: incorporating social determinants of health. Am J Prev Med 48(2):215-218, 2015. doi: 10.1016/j.amepre.2014.07.009.