Lifestyle Medicine Around the World: Lifestyle Medicine in Israel

Abstract

In 2015, the Centers for Disease Control in the United States declared that 7 of 10 deaths per year are caused by chronic diseases; in Israel, the situation is consistent with this assessment. Healthy Israel 2020, an Israeli Ministry of Health initiative, places physicians at the forefront of health promotion and preventive medicine. In 2012, the Israeli Society of Lifestyle Medicine (ISLM) was established under the auspices of the Israel Association for Family Physicians. This decision was taken because we, the authors, wanted to promote change in the primary care services through the recruitment of key leaders for implementation of lifestyle medicine (LM), including improved attitudes, knowledge, motivation, and skills of primary care physicians and health providers. Today, the ISLM is an active member of the Israeli Medical Association, promoting educational activities, physician’s health, and well-being initiatives; developing tools for health-promoting clinics; and more. Our future plans are to incorporate LM as an integral part of daily practice in all sectors of the medical profession in Israel. This is challenging, but we see this as the only way to effectively combat the noncommunicable disease epidemic.

‘Unhealthy lifestyle habits lead to metabolic and physiological changes such as increased blood pressure, overweight, obesity, and increased blood glucose and dyslipidemia, all of which increase the risk of chronic diseases.’

Background

The World Health Organization estimates that by the year 2020, two-thirds of the diseases around the world will stem from unhealthy lifestyle habits.¹ In 2015, the Centers for Disease Control in the United States declared that 7 of 10 deaths per year were caused by chronic diseases.² In Israel (Table 1),^3-5 the situation is consistent with this assessment: in 2011, 7 of the top 10 causes of death were chronic diseases, of which heart disease and cancer accounted for 42% of the total deaths in that year.⁵ Unhealthy lifestyle habits lead to metabolic and physiological changes such as increased blood pressure, overweight, obesity, and increased blood glucose and dyslipidemia, all of which increase the risk of chronic diseases.⁶

Table 1.

Statistics Relevant to Lifestyle Medicine in Israel.^3-5

Country: Israel

Population: 9 million

Growth rate: 3.3%

Jews: 74%

Arabs: 21%

Others: 5%

Life expectancy at birth: men 80.7 years; women 84.6 years

Percentage with chronic conditions: 69.9%

Leading causes of death: cancer, cardiovascular disease, diabetes mellitus

Percentage of leading causes of preventable death: 61.6%

Main lifestyle preventable health risks: • Overweight and obesity: 52.6% of men and 44.5% of women • Physical inactivity: 63.9% of men and 69.4% of women • Cigarette smoking: 24.7% of men and 15.1% of women

Maintaining a healthy lifestyle has been proven to be the most effective way to prevent the development of chronic diseases.^2,7‬‬‬‬‬‬‬‬‬‬‬‬‬‬ There is significant evidence to show that lifestyle improvement, under the guidance of medical professionals, is effective in promoting health among patients.^8,9

Healthy Israel 2020, an Israeli Ministry of Health initiative setting health behavior goals to be achieved by 2020, places physicians at the forefront of health promotion and preventive medicine. The initiative recommends integration of lifestyle interventions into the academic curricula for health professionals, including medical students; residency programs; and continuing medical education.¹⁰

The Distinctive Features of the Israeli Health Care System

Under the National Health Insurance Law (1995), the national health system provides universal, high-quality, government-subsidized coverage of approved medical services, medicines, and equipment (the health “basket”) for all citizens and residents in the country. The contents of the basket are reviewed yearly by a dedicated committee of health care professionals and public figures. Addition of novel treatments and technologies are determined based on expected patient benefits, patient load, and projected costs.

Medical services for individuals are provided by 4 national nonprofit Health Maintenance Organizations (HMOs). Membership in one of the HMOs is mandatory. Members pay a basic health tax and select their HMO to receive the basic basket of services; they may also purchase supplementary health plans through their HMO and/or the private sector. Preventive medicine is included in the basket, but promotion of healthy lifestyle practices, with the exception of smoking cessation programs, is not subsidized in the framework of the Health Law.¹¹

The health care system is based on a comprehensive array of primary care and community services. Approximately 32% of primary care physicians are family practice specialists. General hospitals serve mainly as referral and consultation centers for both acute care and ambulatory procedures.

Israel has 5 university medical schools, which typically follow the European 6-year training model, although the medical schools at Tel Aviv and Bar Ilan universities follow a 4-year program, similar to the American system. Four of the medical faculties also run specialization programs, including a Family Practice specialty, in addition to the postgraduate education of physicians and specialists in Israel.

In 2015, there were 3.1 professionally active physicians per 1000 residents in Israel—a ratio like the OECD average of 3.3. Nurses in Israel averaged 5 per 1000 of the population, much lower than the OECD average of 9.1 per 1000.

Life expectancy at birth is 82.5 years in Israel compared with the OECD average of 80.8 years. The infant mortality rate is 3.1 per 1000 compared with 3.8 in OECD countries.¹²

The Lifestyle Medicine Movement in Israel

In 2011, the Israeli Association of Family Physicians called for leaders to coordinate a course on nutrition and lifestyle (Table 2). Three family physicians responded to the challenge (including the corresponding author), and the first lifestyle medicine (LM) course was conducted. Results from this training program suggested that it can have a positive impact on physicians’ attitudes and perceptions of their role in implementing LM in their routine clinical work.¹³ Not long after the end of the course, in 2012, the Israeli Society of Lifestyle Medicine (ISLM) was established within the Israel Association for Family Medicine. This decision to merge with the larger organization was taken because we sought to promote change, first and foremost, in the primary care health services by identifying the key health care leaders in the field and to improve attitudes, knowledge, motivation, and skills of primary care physicians and health care leaders in implementing LM.

Table 2.

A Chronology of Events in Lifestyle Medicine (LM) in Israel.

First course in LM for primary physicians	2011
First steering committee meeting in Tel Aviv	2012
First National LM Conference in Israel	2013
Joined the European Society of LM	2014
Development of the syllabus for LM education	2014
Initiating and leading of the forum for physician’s health	2015
Joined the global LM movement	2015
Free online syllabus-based LM course in NGU	2016
Article (Postgrad Med J); feasibility of a national training program13	2016
The first physician’s IMA health conference	2018
Motivational interview for the nationwide instructors’ network	2018
Cognitive behavioral therapy tools for health care providers	2019

Abbreviations: IMA, Israeli Medical Association; NGU, Next Generation University.

The ISLM vision is the nationwide promotion of a healthy lifestyle in order to increase control and oversight of health, and management and treatment of diseases by means of multidisciplinary cooperation. We seek to raise the awareness of the importance of LM (thereby improving attitudes), to provide knowledge and tools (thus improving abilities), and to generate a cooperative and supportive work environment.

Membership and Organizational Structure

A member of the ISLM may be any member of the Israeli Medical Association (IMA), including members of the Family Physicians Association and of other professions associated with the activities of ISLM, such as nurses, dietitians, public health advocates, and others who have an interest in LM but are not members of the IMA (385 members as of June 2019). Membership is free of charge.

Each member of ISLM has the right to vote and be elected to the Executive Committee. The chairperson of ISLM may only be appointed providing he/she is a full member of the Family Physicians Association.

Members of the Executive Committee (15 as of June 2019) are elected every 2 years from among the members of ISLM, at the General Assembly. The Executive Committee, which convenes every 3 months, has formed working groups to promote various issues related to core ISLM activities.

Education and Training

Since 2011, we have been delivering courses to family medicine specialists, residents, and medical students. While conducting these courses, we realized that there was a need to refine the learning goals and objectives. The need for developing a syllabus for LM teaching arose from the input of many leaders in the field as well as from the Israeli Ministry of Health. We decided to take up the challenge.

The Syllabus for LM Education¹⁴ (2014)

This was developed by the ISLM committee members together with experts in the field. It consists of 9 chapters concentrating on the core essence of LM and is divided into 2 levels of study: practicing physicians and medical students. The material combines evidence-based medicine lectures with experiential learning. It has been recognized by the IMA and is recommended as a basic tool for teaching LM to all Israeli physicians. This year, we revised the syllabus and added 2 new modules: LM for the family and LM in old age.

LM Education Nationwide

Starting in 2014, we have coordinated and provided syllabus-based LM courses nationwide to family medicine specialists, residents, and medical students and have conducted 6 courses for family medicine specialists with the support of the Israeli Family Medicine Association and the HMOs.

We have been very successful with the family medicine residency program; we now teach in almost all the diploma-awarding bodies in the country (15 courses have been conducted to date). There are 5 medical schools in Israel, and we lead the LM teaching in 2 of them; the remaining 3 have a variable LM curriculum led by local teachers.

Since our founding, we have also delivered continuing medical education practical workshops on obesity, smoking cessation, and cognitive behavioral therapy to promote health behavior modification.

Motivational Interview Project

Another important tool we decided to develop is motivational interviewing (MI). Our vision is that all primary care physicians in the country will attain the necessary knowledge and use of these skills.

During 2015-2018, we held MI training sessions in all primary care departments throughout the country as well as an instructors’ course for 140 primary care physicians, delivered by Prof Steven Rollnick, a cofounder of MI. We created a support system for the instructors that includes an internet website¹⁵ (Hebrew) with free access to materials. We hope that this network of MI instructors will ultimately spread the tool to all health care providers in the country.

Free Online LM Course in Next Generation University

This important tool was developed to address the need for a free, high-quality, globally available LM educational aid developed by the corresponding author of the present article. The tool, which is based on competencies adapted from the American College of Preventive Medicine, the American College of LM, and the ISLM curriculum, contains 10 modules concentrating on the core essence of LM. The course is available online,¹⁶ free of charge, for every type of educational initiative, whether personal or public.

Initiating and Leading the Forum for Physician’s Health Within the IMA

One much-neglected issue in the area of health care is that of physicians’ own health and lifestyle choices. As we all know, physicians who are involved in keeping themselves healthy are better promoters of a healthy lifestyle for their patients and their families; thus, our society joined with the IMA to promote better health for practicing physicians. We initiated a forum with other IMA leaders in 2015.

To better understand the extent of the problem, we conducted a survey of IMA members¹⁷ on the topic of health practice behavior and barriers to health (receiving 4800 responses). The results were disturbing. We found wide discrepancies in levels of stress, eating habits, smoking, and exercise, which consequently led us to establish workgroups designed to formulate practical ideas to promote physicians’ health, some of which have already been implemented. Here are several examples: (1) The first physician’s IMA health conference, attended by 160 participants, took place in February 2018; (2) a survey, relating to how physicians take care of their own health, was delivered to IMA members; we are currently in the process of analyzing the data and drawing practical conclusions from the questionnaire; (3) workshops on mindfulness and smoking cessations for physicians were held at the IMA Center, and (4) A position paper on healthy food served at conferences and medical meetings was incorporated into IMA practice. There is much more in the pipeline and many challenges lie ahead, but we are happy to start the journey to address the health and wellness needs of IMA physicians.

Health-Promoting Clinics Project

This year we are adding an important tool to our website, intended for primary care physicians who wish to enhance their clinics by fostering health-promoting LM. The supplement contains an instruction manual and various online materials focusing on how to educate the health care professional staff in the clinic on LM, how to improve their personal health, and how to improve the clinical environment by using visual ways of delivering the notion of conducting a healthy lifestyle, such as patient information sheets, posters, and so on. This project is currently undergoing further strategic development and refinement.

Future Plans in Progress

Our plan for 2019-2020 is to initiate a designated training course for active family practitioners nationwide as instructors in LM. The graduating trainees will serve as consultants and mentors for their peers locally and in the academic institutions as well as in the HMOs in Israel.

Summary

Our experience has taught us to be resolute, even tenacious and brash—in Hebrew we call this chuzpah. In other words, if you have an opportunity to put your foot in the door for a good reason—such as introducing LM—then do it, and the door will open for you, because people truly want to learn about this wonderful way to maintain and improve their health. It seems that this brashness is sometimes the only way to introduce a new, pioneering vision into a somewhat outmoded, conservative system.