American Journal of Lifestyle Medicine 421 Lifestyle Medicine and Health Care Reform James M. Rippe, MD, Theodore J. Angelopoulos, PhD, MPH, and William F. Rippe, MD DOI: 10.1177/1559827609352287. From the Rippe Lifestyle Institute, Shrewsbury, Massachusetts (JMR); Tufts University School of Medicine, Boston, Massachusetts (JMR); University of Central Florida, Orlando (JMR); Center for Lifestyle Medicine, University of Central Florida, Orlando (TJA); the Department of Internal Medicine, Heartland Health, St Joseph, Missouri (WFR); and Rippe Health Evaluation, Orlando, Florida (WFR). JMR is the Editor-in-Chief and TJA is the associate editor of the American Journal of Lifestyle Medicine. Address correspondence to James M. Rippe, Rippe Lifestyle Institute, 21 North Quinsigamond Avenue, Shrewsbury, MA 01545; e-mail: bgrady@ rippelifestyle.com. For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Copyright © The Author(s) vol. 3 • no. 6 A s we write this editorial, an increasingly acrimonious debate is raging in our country con- cerning health care reform. Many ideas are being advanced, and competing plans seem to emerge on a daily basis. Unfortunately, whatever plan ultimately emerges appears likely to be more influ- enced by politics than sound public policy. Whatever plan (or combination of plans) survives the maelstrom, all would agree that the desired goal in the reform process must be a combination of improved health outcomes and control of costs. This is the holy grail of health care reform. While at this juncture it is impossible to predict which plan will prevail or which compromises will be required, we would argue that, in the United States, it is our daily lifestyle habits and practices that are harming our health and literally kill- ing us. Until we as physicians and health care providers do a better job of encour- aging our patients to become true part- ners in improving their health, through such proven lifestyle-related modali- ties as increased physical activity, proper nutrition, weight management, and ciga- rette smoking cessation, the goal of true health care reform will remain impossi- ble to achieve no matter what framework is erected. Consider the Facts There is no longer any serious doubt that what individuals do on a daily basis exerts a profound impact on both their short- and long-term health and qual- ity of life. This is the cornerstone of what we at the American Journal of Lifestyle Medicine have defined as our central mis- sion: the mission of “lifestyle medicine.”1 • Less than 25% of the adult popula- tion gets adequate servings of fruits and vegetables and follows other simple, evidence-based nutri- tional principles related to good health.3 • More than 70% of the adult popula- tion in the United States does not get enough physical activity to result in health benefits.4 Until prescription of positive lifestyle practices becomes a central component of modern American medicine, we are unlikely to improve outcomes or control costs of health care in the United States. Increasingly, the medical community and the public at large have come to under- stand that lifestyle habits, whether they be positive or negative, are profoundly impor- tant to health and quality of life. Consider the following facts: • More than two-thirds of the adult pop- ulation in the United States is either overweight or obese.2 • Twenty-five percent of the adult popu- lation in the United States still smokes cigarettes.5 • The incidence of childhood obesity has tripled in the past 20 years.6 • The metabolic syndrome is now thought to be present in between 23% and 40% of the adult population in the United States.7 F R O M T H E 422 American Journal of Lifestyle Medicine Nov • Dec 2009 • The incidence of diabetes has skyrock- eted in the past 20 years. Eight percent of the adult population in the United States currently has diabetes, which represents a 61% increase between 1991 and 2001.8 • Thirty-eight percent of the adult pop- ulation in the United States has high blood pressure.9 • More than 40% of the adult population has glucose intolerance (a precursor to diabetes).10 • Coronary artery disease, which remains the leading killer of men and women in the United States, resulting in 37% of all mortality each year, has multiple life- style factors as underlying risk factors.11 • Obesity, cigarette smoking, and unpro- tected sun exposure contribute to more than half of all cancers.12 • Obesity is the leading cause of osteoar- thritis in women and the second lead- ing cause of osteoarthritis in men.13 The reason that we list all of these conditions as a rationale for the critical importance of lifestyle medicine in health care reform is that all of these diseases, conditions, or practices have significant lifestyle components. Until prescription of positive lifestyle practices becomes a central component of modern American medicine, we are unlikely to improve outcomes or control costs of health care in the United States. We Have Met the Enemy . . . In addition to the poor health outcomes that are related to negative lifestyle mea- sures, there is a very significant economic burden of poor lifestyle choices, which further underscores the need for a firmer grasp of lifestyle medicine by the med- ical community. Each year, the United States spends more than $6700 for every man, woman, and child on what is essen- tially “sickness” care. In contrast, virtually every other industrial economy spends considerably less. For example, Greece, which ranks as the 16th largest economy in the world, spends less than $600 for every man, woman, and child on health care. Yet Greece achieves superior out- comes in virtually every recognized inter- national standard of health outcome than does the United States. Every other industrialized economy that expends less money than the United States also achieves better health outcomes. Clearly, until we embrace positive lifestyle mea- sures and practices in modern health care, we are not going to solve this enor- mous financial drain on the American economy and toll on human lives. As various culprits have emerged and been blamed for rising costs and poor outcome in American health care, the primacy of lifestyle medicine has failed to garner its proper place as a key con- sideration for why our health care is so expensive while our outcomes remain relatively poor. In this whole debate, per- haps the cartoon character Pogo said it best when he lamented, “We have met the enemy and he are us!” Consider the Opportunity There is ample reason to believe that positive lifestyle measures can have an impact on reducing the health care bur- den of poor habits and practices in our country. For example, from the Nurses Health Study, we know that more than 80% of all heart disease in women and more than 91% of all diabetes could be elimi- nated if all women would adopt a clus- ter of positive lifestyle practices including regular physical activity (30 minutes or more on most days), maintenance of a healthy body weight (body mass index of 19-25 kg/m2), not smoking cigarettes, and following a few simple nutritional practices.14 Moreover, evidence from the Diabetes Prevention Project shows that individu- als with baseline glucose intolerance can reduce their risk of developing diabe- tes by 58% just by increasing their phys- ical activity and losing 5% to 7% of their body weight.15 Smoking cessation has clearly been associated with decreased risk of can- cer and chronic obstructive pulmonary disease.16 Increased physical activity has been repeatedly shown to lower the risk of heart disease and many cancers.17 Proper nutrition has also been demon- strated in numerous studies to decrease the likelihood of developing many diseases.18 Consider the Evidence There are literally hundreds, if not thou- sands, of studies that support the concept that lifestyle habits and practices pro- foundly affect the likelihood of developing various metabolic diseases. In recogni- tion of this robust body of medical litera- ture, lifestyle practices form a cornerstone for many of the evidence-based guide- lines used to treat common illnesses in the United States. For example, all of the fol- lowing guidelines contain significant por- tions of lifestyle medicine practices: • Joint National Commission Guidelines for Hypertension Prevention and Treatment19 • National Cholesterol Education Program Guidelines for Cholesterol Management20 • Institute of Medicine Guidelines for Obesity Management21 • American Academy of Pediatric Guidelines for Cholesterol Management in Children22 • American Heart Association and American Cancer Society Joint Statement on the Prevention of Heart Disease and Cancer16 • American Diabetes Association Guidelines for the Management of Diabetes23 • American Academy of Pediatrics Guidelines for the Treatment of Metabolic Syndrome24 Those who might suggest that life- style practices such as increased physi- cal activity, proper nutrition, and weight management should not be part of main- stream medicine are simply ignoring the evidence-based guidelines that inform and guide our approach to the treatment of most of the chronic diseases seen in medical practice today. Squandering the Opportunity Despite the fact that most metabolic dis- eases could be either ameliorated or elim- inated by positive lifestyle practices, a distressingly low percentage of people in the United States follow the cluster of lifestyle practices known to decrease these risks. For example, in the Nurses American Journal of Lifestyle Medicinevol. 3 • no. 6 423 Health Study, only 4% of this popula- tion of health care workers followed all of the practices known to lower the risk of heart disease and diabetes.25 The Behavioral Risk Surveillance Study showed virtually the same appallingly low percentage of people following all of the practices known to lower the risk of chronic disease.26 Clearly, there is an enormous gap between what the evi- dence shows people should be doing and what they actually are doing. Physician Responsibility Numerous studies have shown that physician recommendation is a power- ful tool in changing patient behavior.27 Advice from physicians has been consis- tently shown to lead to patient attempts to improve overall lifestyle, increase physi- cal activity,28 and make a serious attempt to lose weight.29 Despite the potential for physician counseling to change behaviors, physicians often do not take advantage of this opportunity. It has been estimated that less than 1 of every 3 patients receive any form of lifestyle counseling during routine office visits. One aspect of physician involvement in lifestyle medicine that has not been prop- erly emphasized in the health care debate involves the values that we should fos- ter in our medical care system. This con- cept was eloquently discussed in a recent article authored by Michael Porter in the New England Journal of Medicine, in which he stated, The central focus must be on increasing value for patients—the health outcomes achieved per dol- lar spent. Good outcomes that are achieved efficiently are the goal. Not false “savings” from cost shift- ing and restricting services. Indeed, the only way to truly contain costs in healthcare is to improve out- comes: in a value based system, achieving and maintaining good health is inherently less costly than dealing with poor health.30(p109) Physicians are the key gatekeepers and should be the leaders in emphasizing this fundamental value in our health care system. Why Isn’t the Health Care Community More Involved? Numerous reasons have been given for why physicians do not place more emphasis on positive lifestyle counsel- ing and recommendations in their prac- tices. Some physicians blame lack of time in the typical office visit. Other stud- ies have suggested that physicians who are not personally committed to posi- tive lifestyle behaviors in their own lives are much less likely to provide counsel- ing and recommendations in this area for their patients.31-34 Lack of knowledge about how to prescribe physical activ- ity, proper nutrition, and weight manage- ment may also contribute to the paucity of activity in this area. A particularly disturbing excuse often given by physicians for not incorporat- ing lifestyle recommendations relates to a common viewpoint that patient behav- ior will not change no matter what the physician says. Perhaps equally perva- sive is the argument that physicians are not reimbursed for making these recom- mendations and therefore are unwilling to spend the time to make them. These insurance disincentives must be corrected to further stimulate and reward altered physician behavior. Whatever the excuse, it is clearly time that we in the medical community rec- ognize both our power and our respon- sibility to help our patients improve their health and start taking steps to incorporate this message in our daily practices. A Multifaceted Problem Lest it appear that we are laying this entire problem at the feet of the health care community, it is important to acknowledge the vital role of other stake- holders. Increased public education in these areas is mandatory. Public policy in health care must shift toward preven- tion. Insurance incentives must be shifted toward health preservation and enhance- ment rather than the current emphasis on expensive sickness treatments and sub- specialty treatments and procedures. Yet none of these are likely to happen with- out leadership from an active, engaged, and motivated health care community. True Reform Historically in the United States, there have been numerous reform movements. One of the periods of great foment in the area of reform occurred in the mid- 19th century around the time of the Transcendentalists, who were writing and discussing their views on human nature. A persuasive essay written during this period by the eminent American philos- opher Ralph Waldo Emerson argued that true reform could occur only when indi- viduals were first reformed. Only with individual reform could society then be reformed. As Emerson so eloquently stated more than 100 years ago, “The crit- icism and attack on institutions which we have witnessed, has made the thing plain, that society gains nothing whilst a man, not himself renovated, attempts to renovate things around him.”35 We contend that one of the key consid- erations that has been largely absent from the debate concerning various health care models is the key role that physicians can play by personally reconsidering and reforming issues of partnership with their patients and incorporating lifestyle med- icine recommendations into their daily practices. If this type of reform can occur, then the whole system can be reformed. Lifestyle Medicine Is Health Care Reform Let us restate and underscore our cen- tral premise of this editorial: no viable health care reform will occur in our coun- try to achieve better health care outcomes and control costs until we get control of the lifestyle issues that are driving both poor health outcomes and enormous expense. We in the health care community have both an enormous responsibility and opportunity in this area. The evidence is no longer debatable that positive lifestyle decisions profoundly affect both short- and long-term health and quality of life. In the name of health care reform, old and worn out excuses about lack of time, knowledge, and/or lack of reimbursement for failing to guide our patients toward 424 American Journal of Lifestyle Medicine Nov • Dec 2009 healthier lifestyles must come to an end. It is time for us in the medical community to embrace the abundant evidence that already exists that regular physical activ- ity, proper nutrition, weight management, smoking cessation, and other lifestyle- related habits and practices profoundly affect not only the health of our patients and their economic well being but also the very financial stability of our country. With true physician leadership, we can win the battle to educate our patients, reform insurance practices to incentivize health preservation and disease preven- tion, and turn health care in the positive direction it needs to go. It is time for us to remember why we entered health care in the first place: to make a difference in people’s lives. Forming true partnerships with our patients and offering evidence-based advice on how daily habits and actions profoundly affect long-term health is overdue. In this regard, there is no time to waste. 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