Lifestyle Medicine: Intensity of Intervention Versus Intensity of Patient Response

“Our power as LM clinicians is that we have many tools to use to help people treat, prevent, and in some cases reverse chronic conditions.”

There are various intensity levels of lifestyle medicine (LM) intervention that may be employed by the LM clinician, and there are various corresponding intensity levels of engagement in lifestyle change by the patient. Both factors should be considered in the approach to a specific patient, and both factors will be pertinent to the expected outcome of any LM intervention.

Lifestyle medicine is defined by the American College of Lifestyle Medicine (ACLM) as “A medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions including, but not limited to, cardiovascular diseases, type 2 diabetes, and obesity. Lifestyle medicine certified clinicians are trained to apply evidence-based, whole-person, prescriptive lifestyle change to treat and, when used intensively, often reverse such conditions. Applying the six pillars of lifestyle medicine—a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, avoidance of risky substances and positive social connections—also provides effective prevention for these conditions.” ¹ These six pillars are medicine in many ways, and as with any medicine, dosing is critical to the clinical effects of treatment and largely determines clinical outcomes. ² In general, effective LM treatment depends upon the strong positive association between dosing and disease severity—the more severe the disease, the higher the dosing and lifestyle change required to effectively treat and reverse the condition, while for less severe disease, lower dosing and less lifestyle change may be needed for treatment or prevention.

With pharmacological interventions, higher dosing generally means increased milligrams of medication. With lifestyle interventions, higher dosing generally translates to closely following evidenced-based guidelines for each pillar and reaching the maximum effort to achieve these to yield maximal lifestyle changes. The amount or degree of lifestyle change made by patients is generally positively associated with the intensity or extent of lifestyle interventions employed, but there are exceptions.

Low-dose LM may involve watching a powerful movie like “Forks Over Knives” or “Game Changers,” attending a lecture about the power of healthy lifestyles by a dynamic speaker, reading a book like the China Study, or speaking to a friend who has had success with weight loss by following a particular eating plan like a whole-food, plant-predominant pattern. A patient who is newly diagnosed with high blood pressure may go home and search for diets to lower blood pressure. After looking through the internet, a patient may decide to follow the DASH diet and fill their refrigerator with fresh produce and toss out all their processed foods because they read a research study that concluded following the DASH diet can reduce systolic blood pressure by 5.5 mmHg. ³

Moderate-dose interventions may include working with a LM clinician who guides the patient over the course of several visits to make slow and steady change in one or more of the six pillars or dimensions of lifestyle medicine. Another moderate-dose intervention could be a six-week group lifestyle medicine intervention during which the lifestyle medicine clinician coaches the group and co-creates SMART goals with each participant following each session.

An LM group intervention that meets twice a week for multiple weeks could be delivered at a high intensity dose, depending upon the goals and recommendations of the program. If the program is encouraging participants to exercise for 150 minutes at moderate intensity each week, to adopt a whole-food, plant-predominant pattern of eating while eliminating all sources of animal foods, work on sleep hygiene to meet the goals of 7–9 hours of sleep per night, enjoy positive social connections at least 7 times a week, start a mindfulness stress-reduction program (MBSR) with daily 20-minute sessions, and to quit smoking and eliminate or moderate alcohol consumption, this could be a high-dose intervention. Residential or outpatient full day lifestyle medicine programs that offer whole-food plant-predominant meals for 10–14 days with daily supervised exercise as well as opportunities for walking outdoors, engaging in positive social connection and participating in daily stress resiliency classes such as meditation, relaxation response, or yoga (like the “Undo It with Ornish” program by Dean Ornish, MD) are high-dose interventions. These are just some examples to consider. Many clinicians do not have the time, skills, or set up to provide these high intensity treatments.

Low-intensity interventions can result in high intensity lifestyle changes, and high intensity interventions may produce minimal changes. There are two connected but distinct dimensions of intensity—intensity of lifestyle interventions delivered by the clinician, and intensity of lifestyle changes made by the patient. And the key here is the patient. Factoring in the stage of change the patient is in, their internal motivators, their external environment, social determinants of health, the social ecological model of change, and their self-efficacy will be essential for any dose intervention to be impactful.

It is also important to understand the power of utilizing all six pillars and to identify which pillars are being used in specific LM interventions. Our power as LM clinicians is that we have many tools to use to help people treat, prevent, and in some cases reverse chronic conditions. Some interventions target one pillar, such as nutrition. Others target two or three, such as nutrition, physical activity and stress reduction, for example. Still others work with all six pillars of LM.

As lifestyle medicine research progresses, it will be important to include the specifics of the interventions used—how many pillars are addressed, what are the exact recommendations for each pillar, how are the patients kept accountable, and what are the goals for the patient during the research program. This will help differentiate low-, moderate-, and high-dose interventions. Pre- and post-evaluations of the patients’ biometrics, tracking devices, and or self-report questionnaires will indicate the level of response to the intervention. Noting the training of the individuals who are leading the interventions will also be important. Are the LM clinicians diplomates of the American Board of Lifestyle Medicine or ACLM or neither? The more detailed LM clinicians are in describing their interventions, the better. This applies to reporting results to colleagues, giving Grand Rounds or other presentations, and writing up research.

Research and clinical experience reveal that maximum dosing is achieved with intensive therapeutic lifestyle change treatment (ITLC) that involves greater frequency and duration of patient contact—more and longer encounters per week. ⁴ This can be accomplished in a variety of ways, including residential programs, outpatient group programs, and one-on-one sessions, for example. In some patients with high confidence and self-efficacy, extensive lifestyle changes adequate to reverse advanced disease can be made with minimal patient contact, depending on the receptiveness and motivation of the patient.

For some patients who struggle to make even small lifestyle changes, high-dose interventions may be necessary to achieve maximal therapeutic lifestyle change. Success breeds success, so the greater the change and disease reversal experienced, the greater the motivation for ongoing lifestyle change. Patients with a history of repeated attempts to make and sustain beneficial lifestyle change tend to lose hope and develop a form of learned hopelessness. These patients may benefit from a residential program to maximize dosing and help them to get on a successful path.

LM treatment includes six pillars which should be assessed and addressed using evidence-based methods for every patient in a comprehensive, systematic LM program or practice. LM assessment addresses each pillar of lifestyle to identify transtheoretical readiness for change in order to use appropriate pillar-specific interventions. ⁵ Patients are often at different stages of readiness for the different pillars. Thus, the interventions need to be specific for the patient’s level of readiness. The types of interventions with suggestions for each stage of readiness are described in the official ACLM Board Review Course text ⁶ and in the Lifestyle Medicine Handbook. ⁷

Unlike pharmaceuticals, some of which have dangerous risks from overdosing, therapeutic lifestyle change (TLC) and even ITLC carry no significant risks of “overdosing.” ⁸ Even high-dose LM will not “overtreat” chronic disease. Patients taking medications such as those for high blood pressure or diabetes must be closely monitored by an LM clinician trained and qualified to safely deprescribe these medications. ⁹ In some research studies using ITLC, medications to reduce blood pressure or reduce blood glucose were stopped when ITLC treatments began because the strong effects of ITLC can be manifest within a few days. ¹⁰

Residential high-dose lifestyle medicine interventions are often the safest and most effective way to maximize dosing and lifestyle change in patients with severe or acute disease who need lifestyle change the most; it needs to be utilized appropriately. LM intensivists are specifically trained and qualified to treat such patients safely and effectively. ¹¹ These LM intensivists are able to work with complex patients who are taking different medications for arrythmias, diabetes, high blood pressure, chronic kidney disease and other conditions whose medical management can be complex.

Summary:

Lifestyle medicine practitioners including physicians and all other healthcare professionals must be aware of the impact of intensity and dosing of prescriptions in the six pillars. There can be a high or low intensity intervention offered by the LM practitioner. Then, there is the intensity of change dictated by the patient and the patient’s response to the intervention. The patient’s responsiveness to change and the coordination of the intervention to match this level of readiness to change will help patients move forward in their lifestyle journeys to adopt and sustain routine exercise, nutritious and delicious eating patterns, sound sleep, positive social connections, stress resiliency practices, and avoiding risky substances. When high dose interventions are implemented or high intensity change is experienced by the patient, it is important to factor in the fact that patients taking medications like antihypertensives, and diabetes medications may need prescription adjustments to accommodate their bodies’ responses to the healthy lifestyle changes. Sharing detailed descriptions of lifestyle medicine interventions in the research, in CME presentations, and in conversations will help LM practitioners to gain a better understanding of the specialty’s impact as well as help it to realize its full potential.