Characterization of Patients in a Lifestyle Medicine Practice

Abstract

Objective. Lifestyle medicine is a relatively new specialty within medicine. The aim of this report is to characterize patients who present to a lifestyle medicine clinical practice. Methods. LifeStyle Medical Centers is an independent, community-based practice; this report is based on over 3200 patients within this practice. Most of the data presented were obtained from an intake questionnaire developed by the practice to provide background and screening particularly relevant to lifestyle medicine, including areas such as stress, sleep, physical activity, health knowledge, motivation, weight loss history and goals, and smoking. Results. Patients who present for lifestyle care come with varied goals, past histories, and current lifestyle issues. Many express a very high level of motivation to lose an unrealistically large amount of weight. The prevalence of physical inactivity, inadequate sleep, high stress, and risk of depression are high, yet the importance of these to health and well-being are often not recognized by the patient. Over 90% of the cost of care was covered by insurance. Conclusions. Having a better understanding of the patients who come to a lifestyle medicine clinic will help practices better design their lifestyle programs and guide lifestyle medicine providers to better engagement and care of their patients.

‘A strong impetus for moving obesity and lifestyle care more to clinically trained providers came with the Affordable Care Act, which included requirements for insurance coverage of obesity evaluation and treatment . . .’

Until recently, the majority of weight loss services were typically provided outside of mainstream health care. Leading sources of information for the lay person included magazine articles at grocery checkout lanes and celebrities like Oprah Winfrey; the most widely available, best-known providers were commercial companies like Weight Watchers, Jenny Craig, and Nutrisystem. Obesity was not even recognized as a disease by the American Medical Association until June 2013.

A strong impetus for moving obesity and lifestyle care more to clinically trained providers came with the Affordable Care Act, which included requirements for insurance coverage of obesity evaluation and treatment that were fully phased in by January 2014. Prior to this, patients seeking clinical care for obesity and lifestyle issues had to pay for those services out of pocket. The “medically supervised weight loss clinics” at that time typically served highly motivated, self-referred patients willing and able to pay the high cost of medical care, and they expected in return a very rapid and significant weight loss. Little attention was paid to the lifestyle changes necessary to improve overall health and maintain weight loss.

LifeStyle Medical Centers (LMC) is an independent clinical practice started in June 2013 and focused on care of chronic diseases such as obesity, hypertension, diabetes, and hyperlipidemia that are strongly affected by lifestyle factors. The purpose of this report is to characterize the patients within this new type of clinical practice focused on “lifestyle medicine.”

Methods

LMC is an independent community-based private practice not affiliated with any other clinical practices, health care systems, or universities. Since starting with one clinic location in June 2013, LMC has expanded to 5 clinics in the Raleigh-Durham-Cary region of central North Carolina. LMC has had Patient-Centered Medical Home Level 3 certification since June 2015.

In the first 6 months of practice there were roughly 115 new patients and less than 450 billed encounters; in the 6 months of January to June 2018, there were over 1250 new patients and nearly 12 000 billed encounters. The majority of patients are adults with, or at risk for developing, lifestyle-related chronic diseases such as obesity, hypertension, diabetes, and/or hyperlipidemia.

LMC care providers are either registered dietitians (RDs) or clinicians who are nurse practitioners or physician’s assistants (advanced practice providers [APPs]) working under the supervision of the Medical Director. Billable encounters, roughly 65 000 total through June 2018, have been 85% with RDs and 15% with APPs. This distribution has shifted over time with changes and evolution in the care plans and programs; roughly 20% of the encounters are currently with a clinician. Most encounters are one-on-one provider-patient sessions, with less than 1% of the billed encounters done in a group setting. There were a small number of additional nonbilled group encounters that included persons who were and were not otherwise LMC patients, but there were no medical record entries that could be tabulated in the database.

Lifestyle modifications and medical nutrition therapies are the most widely used treatment modalities; medical management if utilized is most often provided by the patient’s outside primary care provider (PCP). LMC does not provide supplements, meal replacements, or other such products to patients.

Soon after starting practice, a general health history intake questionnaire and a LifeStyle Assessment Questionnaire (LAQ) were implemented. The LAQ was developed to provide background information particularly relevant to lifestyle medicine such as stress, sleep, physical activity, and health knowledge. Other information it was designed to obtain included things such as an assessment of motivation, weight loss history and goals, and screening for issues such as depression, sleep apnea, and smoking.

The LAQ underwent some early revisions, but the same version was utilized from August 2016 through April 2018 when it was again revised. This report focuses on the self-reported information obtained on the version of LAQ implemented in August 2016, with additional information obtained on these patients from their health history form and from administrative registration and billing data. A small percentage of the patients (<3%) came for lifestyle and nutrition issues related to pregnancy and the immediate postpartum period, or were less than 18 years old. These small subsets of somewhat atypical patients are excluded, leaving 3253 patients who constitute the basis of this report.

Data Management

Structured data are downloaded from the electronic medical record system on a quarterly basis using customized software; more than 1 000 000 pieces of discrete data were pulled at the most recent download. These data are then processed through an internally developed SAS (SAS Institute, Cary, NC) programming and analytical process resulting in >150 variables for a patient seen only once, and >300 variables in long-standing patients. If all the output was placed into a single large spreadsheet, it would contain over 10 million cells. This infrastructure is extensively utilized in careful assessment and continuous monitoring of multiple aspects of the practice.

Composite Scoring of Stress, Activation/Motivation, and Health Maintenance Assessments

Stress, activation/motivation, and health maintenance practices were felt to be areas of particular importance, and they were heavily weighted in the construct of the LAQ. Stress was assessed with the widely recognized 10-question Perceived Stress Scale¹; activation was assessed with 9 questions similar in content and construct to the 13 questions of the Patient Activation Measure.² Motivation was also assessed with a single, simple direct question asking the patient to rate their current level of motivation to make permanent lifestyle and weight changes. Health maintenance was assessed with 6 questions asking the patient about their most recent health maintenance evaluations: see their PCP, have a physical, get an EKG (electrocardiogram), and check blood pressure, hemoglobin A1c, and cholesterol.

Combined, these 3 assessments provided 25 responses per patient, and over 80 000 responses for summary presentation in this report. For more concise presentation, both in clinical practice and in this report, a simple composite average scoring system is utilized for each of these assessments. Examples of this with the activation assessment are provided in Table 1. Point values are assigned to the activation assessment responses, ranging from 0 points for a “strongly disagree” response up to 3 points for a “strongly agree” response. For an individual patient, the sum of each response multiplied by the point value of the response provides their total points. The total points divided by 9 responses gives the patient’s composite average score for activation.

Table 1.

Composite Scoring of Activation Assessment Questions.

Example: Patient A’s responses to 9 activation assessment questions
	Points		# Responses		Weighted Points
Strongly agree	3	×	5	=	15
Somewhat agree	2	×	3	=	6
Somewhat disagree	1	×	1	=	1
Strongly disagree	0	×	0	=	0
					22 total points
				÷ 9 =	2.4 patient’s composite average score
Example Question: I know how to prevent further problems with my health and maintain healthy lifestyle changes.
	Points		% Respondents		Weighted points
Strongly agree	3	×	39.0%	=	1.17
Somewhat agree	2	×	49.8%	=	1.00
Somewhat disagree	1	×	10.3%	=	0.10
Strongly disagree	0	×	1.0%	=	0.00
					2.27 question average score

A similar scoring system is applied to the 10 stress assessment questions, which have 5 categorical responses: 0 points for the least stressed response up to 4 points for the most stressed response. For the health maintenance assessment, points were assigned to the 6 categorical responses as follows: 3 points for “less than 6 months ago” and “6-12 months ago” responses; 2 points for “1 to 3 years ago”; 1 point for “more than 3 years ago” and “not sure”; 0 points for a “never” response.

In addition, when evaluating groups or subgroups of patients, a composite average score for each of the 9 activation assessment questions, 10 stress assessment questions, and 6 health maintenance questions were determined based on the distribution of patients across the response scale (Table 1).

Statistical Analyses

Statistical comparisons between various patient characteristics were dependent on the nature of the variables. Various χ² tests including correlation χ² tests were used to assess 2 ordinal variables, mean score χ² tests to assess 1 ordinal variable and 1 categorical variable, and general χ² tests of association for 2 categorical variables. T tests or nonparametric Wilcoxon rank sum tests were used to assess relationships between continuous variables and dichotomous variables, while ANOVA (analysis of variance) tests or nonparametric Kruskal-Wallis tests were used to assess associations between continuous variables and categorical variables. All statistical analyses were performed using SAS 9.4.

This was a retrospective review of patients’ medical records, with all material contained therein obtained as part of routine clinical care of the patient. These, and other clinic data, are routinely monitored as part of LMC’s quality improvement efforts. The data have been de-identified; confidentiality of individual patients has been maintained, and is not at risk. Patients are not subjected to more than minimal risk. This project was exempt from institutional review board review.

Results

Multiple different perspectives of this lifestyle medicine patient population are provided in the tables, with key findings provided in the summaries that follow.

Demographics (Table 2)

Table 2.

Demographics.

	n	%
Gender
Male	678	21%
Female	2575	79%
Age
18-30 years	375	12%
30-40	750	23%
40-50	924	28%
50-60	850	26%
>60	354	11%
Mean ± SD	44.6 ± 11.7 years
Median	45.0 years
Race
White	1635	53%	based on % of respondents
African American	1191	39%
Hispanic	104	3%
Asian	71	2%
Other	92	3%
Did not respond	160	(5% of study group)
Marital status
Married	1826	56%
Single	909	28%
Divorced	299	9%
Domestic partner	90	3%
Separated	62	2%
Widowed	43	1%
What is your highest level of education?
Some high school or less	35	1%	based on % of respondents
High school graduate	165	5%
Some college/technical schooling	724	23%
College graduate	1251	40%
Postgraduate/professional	930	30%
Did not respond	148	(5% of study group)
What is your annual household income?
Less than $30 000	207	7%	based on % of respondents
$30 000-$75 000	1183	41%
$75 000-$150 000	1059	37%
More than $150 000	443	15%
Did not respond	361	(11% of study group)

The mean age of the patients is 44.6 ± 11.7 years (± standard deviation). The age distribution is significantly influenced by the fact that LMC did not start accepting Medicare until the last few months of the study period.

Roughly 80% of the patients are female, which is particularly notable since the prevalence of lifestyle-related chronic diseases and the need for lifestyle interventions does not significantly differ between the genders. National data show that females in this age range do see PCPs more frequently than males, but the ratio of female to male visits is less than 2:1,³ as compared to 4:1 in this lifestyle medicine practice. Ease of access to care likely contributes to this gender difference. In the later portion of the study period, LMC began offering an “on-site” program in which services were provided at work places. Only 7% of this study group (218 patients) were involved in this program so reliability is limited, but the gender distribution in this subset was 35% male, suggesting that this mode of service delivery may increase engagement of male patients.

Overall racial distribution was 37% African American and 50% white. Racial distribution did significantly differ between clinics, ranging from 47% to 55% white patients at the 5 clinics. The 2 most disparate clinics are only 14 miles apart, suggesting that the racial makeup of the patients being served is at least partially dependent on the immediate proximity of the clinic location.

Socioeconomic Factors

Distribution across income and educational levels are also shown in Table 2, and it is important to note that 5% to 11%% of the patients declined to answer these questions. The magnitude of any differences between respondents and nonrespondents is unknown, creating a risk for selection bias and uncertainty in the findings. However, based on those who did respond, roughly 50% reported a household income of >$75 000, which compares to a median income of $63 000 in the metropolitan area served by the LMC clinics.^4,5 In addition, 70% of the patients in this lifestyle medicine practice had a college degree or beyond, and only 1% had not completed high school. In the local metropolitan area, roughly 10% of adults have not completed high school and less than 50% have a college degree or beyond.^5,6 As with race, there were socioeconomic differences between clinic locations: the percentage of patients with a household income >$75 000 ranged from 47% to 66% between the 5 locations, and the percentage with a college degree or beyond ranged from 66% to 74%.

Prevalence of Lifestyle-Related Chronic Diseases (Table 3)

Table 3.

Health and Health Maintenance.

					n	%
Body mass indexa (kg/m2)
<18.5				Under weight	18	1%
18.5-24.9				Healthy	228	7%
25-30				Overweight	664	20%
30-35				Obese	864	27%
35-40				Severely obese	709	22%
>40				Morbidly obese	762	23%
Mean ± SD					35.0 ± 8.0
Median					34.2
Have you ever had a high	Blood pressure measurement	Blood sugar or A1c	Cholesterol or triglycerides
Yes	48%	31%	40%
No	43%	57%	49%
Unsure	10%	12%	11%
Have you ever taken medication for	Hypertension or high blood pressure	Diabetes or high blood sugar	High cholesterol or low HDL
Never	62%	81%	73%
Yes, currently	32%	14%	19%
In the past	6%	4%	7%
Unsure	0%	1%	1%
When did you last	See a PCP	Physical exam	EKG	✓ Blood pressure	✓ A1c	✓ Lipids
Less than 6 months ago	71%	48%	16%	84%	51%	56%
6-12 months ago	14%	30%	11%	10%	14%	19%
1-3 years ago	7%	15%	17%	3%	7%	10%
More than 3 years ago	2%	3%	14%	0%	1%	2%
Never	2%	0%	24%	0%	5%	2%
Not sure	4%	4%	18%	2%	21%	11%
Composite average health maintenance scores (scale of 0-3, explained in Methods)
2.1-3.0	good health maintenance		80%
1.1-2.0			18%
≤1.0	limited health maintenance		2%
Mean ± SD			2.5 ± 0.5
Median			2.7

Abbreviations: HDL, high-density lipoprotein; PCP, primary care provider; EKG, electrocardiogram.

^aMeasured height and weight at first visit, not self-reported.

More than 70% of the patients in this lifestyle medicine practice were obese, with a third of those being morbidly obese (body mass index [BMI]≥ 40.0 kg/m²). Many patients reported being told that they had elevated blood pressure (48%), blood sugar or A1c (31%), and/or lipids (40%). Often medication is or has been taken for these conditions: hypertension 38%, diabetes 18%, and hyperlipidemia 26%.

Health Maintenance (Table 3)

Attention to lifestyle issues is an important component of health maintenance, and conversely, health maintenance is an important component of lifestyle medicine. Indicators of general health maintenance are shown in Table 3. More than 80% of the patients had seen their PCP and had their blood pressure checked in the previous year; 60% to 70% had serum lipid and/or diabetes screening; only 25% reported having an EKG in the previous year. The composite health maintenance score for all patients averaged 2.5, with a maximum score of 3.0 if the patient had all 6 of the health maintenance indicators within the previous year.

Weight and Weight Loss Goals and Prior History (Table 4)

Table 4.

Weight Goals and History.

	n	%
Usually there are multiple factors that can contribute to someone’s current weight. Mark all factors that play a role in your case:
Unhealthy eating habits (such as eating out frequently, considerable alcohol, or a “sweet tooth”)	2059	63%
Low activity level; not physically active enough to burn many calories	1719	53%
Time constraints: not enough time to eat healthy, plan meals, grocery shop	1577	48%
My home and work situations contribute to me gaining weight	1214	37%
Genetics/hereditary; my parents and siblings have all been heavy	1137	35%
Hormonal changes such as those related to pregnancy/child birth or aging	1029	32%
A low metabolism; even with a low-calorie intake I cannot lose weight	1019	31%
Limited nutrition/health knowledge; do not know enough about healthy foods and lifestyle	759	23%
Limited motivation; I have not made the commitment to change my weight	748	23%
Limited cooking skills; do not know how to prepare healthy foods	568	17%
Healthy foods are too expensive	525	16%
Other	436	13%
There are many good reasons to adopt a healthier lifestyle. Give your reasons for wanting to make changes to your current lifestyle (mark all that apply)
So that I am able to be more active in my daily life and have more energy	2341	72%
To look better	2130	65%
So my clothes fit better	1932	59%
To prevent developing health issues like pre-diabetes, diabetes, high cholesterol, high blood pressure, or other health issues	1846	57%
To treat existing health issues like pre-diabetes, diabetes, high cholesterol, high blood pressure, or other health issues	1616	50%
To improve joint pains and body aches	1518	47%
To improve my self-esteem	1334	41%
My doctor urged me to make some changes	735	23%
To improve my lab results	716	22%
My family, friends, and/or partner suggested I needed to get healthier	358	11%
For a special event (wedding, reunion, etc)	227	7%
Other reasons	414	13%
How much weight would you like to lose, what is your realistic target?
10 lbs or less	182	6%
10-30 lbs	1044	32%
30-60 lbs	1080	33%
>60 lbs	714	22%
I have no particular weight loss goals	113	3%
Not applicable, I am not interested in losing weight	116	4%
In the past 3 to 4 years, how often have you made significant effort to lose weight (eg, diet changes, weight loss programs, new exercise routine)?
None	360	11%
Once or twice	998	31%
Several times	1261	39%
Numerous times	631	19%
What methods have you previously tried to help lose weight? (mark all that apply)
Commercial weight loss program (Jenny Craig, Weight Watchers, Nutrisystem, etc)	1301	40%
Popular diets (Atkins, South Beach, Paleo, Zone, etc)	1066	33%
Over the counter weight loss supplements (hoodia, green tea extract, laxatives, garcinia cambogia, etc)	732	23%
Visits with nutritionist/registered dietitian	567	17%
Medical weight loss clinic (Physician Assisted Weight Loss, RICE Diet Clinic, etc)	340	10%
Not applicable, I have not previously tried to lose weight	355	11%
Other	1067	33%
What is the most weight that you lost with these efforts?
Less than 5 lbs	291	9%
5-10 lbs	666	20%
11-20 lbs	847	26%
21-40 lbs	691	21%
More than 40 lbs	463	14%
Not applicable, not previously tried to lose weight	281	9%
How would you describe the outcome of these previous efforts?
Mostly disappointing, usually did not lose as much weight as I wanted	810	25%
Was reasonably satisfied with the weight loss, but could not keep it off	1676	52%
Generally pleased, lost the weight and have been able to keep much of it off	424	13%
Not applicable, not previously tried to lose weight	313	10%

The LAQ provided some interesting insights into the patients’ weight-related goals and past experiences. Over half of the patients reported that their realistic target weight loss was >30 lbs; with an average starting weight of 215 lbs this amounts to a >14% body weight loss. The most common reasons for wanting to adopt a healthier lifestyle reported by 65% to 72% of patients were “to look better” and “to be more active in my daily life and have more energy”; prevention or treatment of chronic lifestyle-related diseases were goals for roughly just half of the patients.

Almost 90% of patients reported having made a prior effort to lose weight in the last 3 to 4 years. The most commonly used methods were a commercial weight loss program (40%), popular diets (33%), and over-the-counter weight loss supplements (23%). Fewer than 1 in 5 patients had ever met with a nutritionist or registered dietitian.

Reported maximum weight loss with previous efforts was 10 lbs or less for roughly 30% of the patients, and 10 to 20 lbs for 26%. Although half were “reasonably satisfied” with their previous weight loss efforts, there were still 25% who had been disappointed and only 13% who were pleased with both weight loss and subsequent maintenance of weight loss.

When asked to identify factors contributing to their current weight, the most common answers reported by 53% to 63% of patients were lack of physical activity and unhealthy eating habits. While recognition of the importance of lifestyle factors was prevalent, there was still strong sentiment (31% to 35%) that uncontrollable factors such as hormonal changes, low metabolism, and/or inherited genetics played a role.

Sleep (Table 5)

Table 5.

Sleep.

	n	%
On average, how many hours of sleep do you get per night?
Less than 5 hours	247	8%
5-7 hours	1776	55%
7-8 hours	1084	33%
More than 8 hours	141	4%
How many nights during the average week do you lie awake for 30 minutes or more trying to fall asleep or trying to return to sleep?
Never	973	30%
1-2 times/week	1246	38%
3-4 times/week	492	15%
Most nights	531	16%
Do you often feel tired, sleepy or fatigued during the day?
Yes	2218	68%
No	1026	32%
Do you snore loudly? (louder than talking or loud enough to be heard through closed doors)
Yes	978	30%
No	2263	70%
Has anyone observed you stop breathing during your sleep?
Yes	467	14%
No	2777	85%
Have you ever been diagnosed with sleep apnea?
No, never been diagnosed	2720	84%
Yes, in the past, but it has resolved	98	3%
Yes, currently	430	13%

The Centers for Disease Control and Prevention recommendation is for more than 7 hours of sleep per night,⁷ but as shown in Table 5, only 1 in 3 patients reported averaging at least 7 hours. Consistent with inadequate sleep time, two thirds of the patients often feel tired or sleepy. In addition to often feeling tired, 30% reported snoring loudly and 14% have been observed to stop breathing during sleep. Positive responses to any of these 3 questions increases the patient’s risk for having sleep apnea, according to the widely used STOP-BANG screening tool.⁸ One in 6 patients in this lifestyle medicine clinical practice report having a diagnosis of sleep apnea, and undoubtedly the true prevalence is much higher given the estimation that sleep apnea is undiagnosed in at least 80% of patients with the condition.⁹

Physical Activity (Table 6)

Table 6.

Physical Activity.

	n	%
How many times a week do you usually do at least 20 minutes of vigorous-intensity activity (makes you sweat, puff, or pant), such as hiking, fast biking, playing basketball, carrying heavy loads, jogging?
Never	1295	40%
1-2 times/week	1090	34%
3-4 times/week	606	19%
5 or more times/week	255	8%
How many times a week do you usually do at least 30 minutes of moderate intensity activity (makes you breathe harder than normal and increases your heart rate), such as water aerobics, heavy cleaning (washing windows, floors, vacuuming), biking at a regular pace, brisk walking, yard work?
Never	837	26%
1-2 times/week	1277	39%
3-4 times/week	820	25%
5 or more times/week	310	10%
How physically active is your typical work day?
Very sedentary, most always sitting at a desk, talking on the phone, or working at a computer	1093	34%
Mostly sedentary, some standing/walking but mostly sitting	1163	36%
Somewhat active, less than half the day sitting	596	18%
Very active, rarely just sitting	339	10%
Physically strenuous, manual labor, or heavy exertion much of the time	40	1%

A 2-question tool developed for primary care practices was used to screen physical activity level.¹⁰ The questions focus on minutes of moderate and vigorous intensity per week and, therefore, incorporate well when discussing with patients the recommended levels of physical activity. As shown in Table 6, 65% of patients reported at most 60 minutes per week of moderate-intensity physical activity, and 40% never do any vigorous intensity physical activity.

The positive impact of exercise on health has long been recognized, but only more recently has the negative impact of a sedentary daily routine been more fully appreciated. Exercise and sedentary behavior are independent determinates of health risk.¹¹ Seventy percent of the patients described their typical day as mostly or very sedentary.

Social Support (Table 7)

Table 7.

Emotional Well-Being.

	n	%
Social Support
Are you getting support or encouragement from anyone with your efforts to improve your health?
No	542	17%
Yes; if yes, mark all who are supportive	2704	83%
Spouse, partner, significant other	1790	55%
Friend (who is not a coworker)	972	30%
Coworker	783	24%
Parent	744	23%
Child	625	19%
Sibling	441	14%
Is there anyone around you who is discouraging, or might make it more difficult for you to improve your health?
No	2886	89%
Yes; if yes, mark all who are discouraging you	358	11%
Spouse, partner, significant other	186	6%
Parent	56	2%
Coworker	50	2%
Friend (who is not a coworker)	37	1%
Child	36	1%
Sibling	22	1%
Depression
In the last month, have you felt down, depressed, or hopeless?
Yes	1088	33%
No	2156	66%
In the last month, have you felt little interest or pleasure in doing things?
Yes	1020	31%
No	2219	68%
Motivation/Activation (2 of 9 questions shown)
When all is said and done, I am the person responsible for managing my health
Strongly agree	3046	94%
Somewhat agree	161	5%
Somewhat disagree	11	0%
Strongly disagree	28	1%
Question average score: 2.92
I am confident that I can maintain healthy lifestyle changes like diet and exercise during times of stress
Strongly agree	1201	37%
Somewhat agree	1591	49%
Somewhat disagree	398	12%
Strongly disagree	53	2%
Question average score: 2.21
Composite average activation scores (scale of 0-3, explained in Methods)
2.5-3.0 (very high activation)	2223	68%
2.0-2.4 (high activation)	897	28%
<2.0 (less activation)	125	4%
Mean ± SD	2.6 ± 0.3
Median	2.7
Stress (2 of 10 questions shown)
In the last month, how often have you felt nervous and stressed?
Never	242	7%
Almost never	580	18%
Sometimes	1413	43%
Fairly often	664	20%
Very often	350	11%
Question average score: 1.66
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
Never	895	28%
Almost never	1225	38%
Sometimes	849	26%
Fairly often	202	6%
Very often	72	2%
Question average score: 1.09
Composite average stress scores (scale of 0-4, explained in Methods)
3.0-4.0 (high stress)	60	2%
2.0-2.9	676	21%
1.0-1.9	1538	47%
≤1.0 (low stress)	973	30%
Mean ± SD	1.4 ± 0.7
Median	1.4

Over 80% of patients reported that they had at least one person who was supportive of their efforts to improve their health. Most commonly this person was their household partner, but friends, family, and coworkers were also identified as supporters. Conversely, it was uncommon (11%) for patients to identify someone who was an obstacle to their efforts, and here too the domestic partner was the person most likely to be influential.

Depression (Table 7)

Depression is a prevalent condition that can negatively affect health and health behaviors. The LAQ included a simple 2-question tool to screen for depression; 22% of patients screened positive for possible depression on both questions.

Motivation/Activation (Table 7)

Roughly 60% of patients reported they were “very strongly motivated” when directly asked about their motivation to make permanent lifestyle changes; only 2% acknowledged that they were “not particularly motivated.”

Representative and summary data for the more complex 9-question assessment of patient activation are also presented in Table 7. The responses indicated a high level of activation; 68% of the composite average scores were ≥2.5 on a 0 to 3 scale, indicating that the patient “strongly agreed” with at least 5 of the 9 questions. Included in Table 7 are the results for the 2 questions showing the highest and lowest levels of activation (highest and lowest question average scores, as described in Methods and Table 1). Ninety-four percent of patients strongly agreed with “I am the person responsible for managing my health” (question average score 2.92), but only 37% of patients strongly agreed with the statement that “I am confident that I can maintain healthy lifestyle changes like diet and exercise during times of stress” (question average score 2.21).

Responses to the 9 questions were significantly correlated with each other, with Spearman correlation coefficients ranging from 0.08 to 0.56. Similarly, patient response to the single direct question about their level of motivation was also significantly correlated with each of the 9 activation questions (correlation coefficients 0.08-0.29), and with the patient’s composite average activation score (correlation coefficient 0.27).

Stress (Table 7)

Composite average stress scores revealed that only a small percentage of patients had high stress scores, as compared to 30% with low stress scores; the majority of patients fell into the intermediate range. Representative questions provided in Table 7 demonstrate considerable variability in the level of stress reflected by the different questions. Sixty-six percent of patients never or almost never felt that difficulties were piling up so high that they could not overcome them; a question that reflected generally low stress levels (question average score 1.09 on 0-4 scale). At the other end of the spectrum, only 25% of patients never or almost never felt nervous or stressed (question average score 1.66). Correlation coefficients between the 10 questions ranged from 0.32 to 0.61; correlations with the composite average score ranged from 0.66 to 0.77.

Smoking and Alcohol (Table 8)

Table 8.

Smoking and Alcohol.

	n	%
Do you smoke cigarettes?
Never	2486	76%
In the past, but I have quit	641	20%
Yes, less than ½ pack per day	87	3%
Yes, more than ½ pack per day	32	1%
How often do you have a drink containing alcohol? (Consider a “drink” to be a 12-oz. beer, 5-oz. glass of wine, or a drink containing 1.5-oz. liquor/distilled spirits.)
Never	770	24%
Monthly or less	1039	32%
2 to 4 times a month	757	23%
2 to 3 times a week	456	14%
4 or more times a week	225	7%
How often do you have 6 or more drinks on one occasion?
Never	2579	79%
Less than monthly	493	15%
Monthly	113	3%
Weekly	54	2%
Daily or almost daily	5	0%

The LAQ was not designed to screen for alcohol use disorder, but some screening of alcohol intake was included. Roughly 80% of patients self-reported having alcohol at most a few times per month, and never having 6 or more drinks on one occasion. Only 4% of the patients are current smokers, as compared to 15% of all US adults as reported by the Centers for Disease Control and Prevention.¹²

Health Knowledge (Table 9)

Table 9.

Health Knowledge.

	n	%
Usually we can feel whether our blood pressure is high or not
True	682	21%
Falsea	1680	52%
I don’t know	885	27%
The hemoglobin A1c test measures the average blood glucose for the past
2 weeks to 1 month	305	9%
2-3 monthsa	908	28%
4-5 months	96	3%
I don’t know	1933	59%
Health knowledge correct responsesb
0 of 5	705	22%
1 of 5	845	26%
2 of 5	697	21%
3 of 5	527	16%
4 of 5	313	10%
5 of 5	166	5%

^aCorrect response

^bThere were 5 questions; 2 examples are shown.

The LAQ included 5 questions to screen the patient’s level of health knowledge. Two representative questions are shown in Table 9, as well as the distribution of correct number of responses across the study group. A broad distribution of correct responses was obtained, ranging from 22% of patients with no correct answers to 5% who answered all 5 correctly. Roughly 70% of the over 10 000 incorrect responses were “I don’t know,” indicating that lack of information was more the issue rather than misinformation.

Referrals and Payers (Table 10)

Table 10.

Referrals and Payers.

	n	%
How did you hear about us? (mark all that apply)
My doctor	1509	46%
Coworker	745	23%
Friend (not a coworker)	370	11%
Internet	211	6%
Walking by	41	1%
Social media	7	0%
Other	474	15%
Direct referral sent from outside health care provider?a
Yes	1200	37%
No	2053	63%
Insurance coverageb (% paid by insurance)
100% by insurance	892	27%
90% to 99.9%	1789	55%
60% to 90%	443	14%
40% to 60%	25	1%
10% to 40%	6	0%
0.1% to 10%	0	0%
0% (patient paid all)	64	2%
Mean ± SD	92.6 ± 15.6%
Median	96.8%

^aData obtained from registration records, not self-reported.

^bData obtained from billing records, not self-reported.

Patients were asked how they learned about LMC, and this could have been from more than one source. The most common source was “my doctor,” reported by nearly 50% of patients; one third of patients learned of LMC from other patients in the practice. Review of registration records showed that 37% of patients had a direct referral from an outside provider, with the provider’s office either directly contacting LMC or instructing the patient to contact LMC. Most of the services were extensively covered by insurance; over 80% of patients paid ≤10% of the costs, with roughly one fourth of patients paying nothing out of pocket. Only 2% of patients paid 90% or more of the costs. Overall, 93% of clinical receipts came from third-party payers.

Cross-Matching Items

It can be of interest to cross-match a patient’s response to one item or question, with their response to another item or question. However, Tables 2 to 10 include 46 variables, which means there are over 2000 possible pairings. It is statistically inappropriate to examine all pairings for a “statistically significant” relationship, and certainly not feasible to present them. What follows are brief summaries of selections felt to be of particular note.

Correlates of demographic and socioeconomic factors are important considerations given the disparities that exist not only in the prevalence of chronic diseases, such as obesity, hypertension, and diabetes, but also in the outcomes of treatment of these diseases.^13-15 As expected, the socioeconomic factors of household income and education level were correlated (Spearman correlation = 0.28, P < .0001). Taking this further, of note is that higher income and education level were associated with the following:

• Higher health knowledge score

• Lower BMI

• More hours of sleep per night

• Lower % of receipts paid by insurance

• More moderate physical activity sessions per week

• White race

These socioeconomic factors were not, however, associated with the following:

• Health maintenance scores

• Goals of preventing and/or treating lifestyle related chronic diseases

• Composite activation scores

Household income, but not education level, was associated with the following:

• Lower target weight loss

• Lower stress scores

• Positive depression screen, with the $30,000 to $75,000 category being the highest

These results reflect that the different demographic and socioeconomic factors have a varied amount of impact on factors of particular relevance to lifestyle medicine.

The target weight loss for many patients was unrealistically high. A higher target weight loss was associated with (all P values <.0001) the following:

• More previous attempts to lose weight

• “To look better” as a reason to adopt a healthier lifestyle

• Higher BMI

• Use of chronic disease medication

It is appropriate that weight loss goals are higher in patients with higher BMIs and on chronic disease medications. However, higher weight loss goals were also associated with more previous attempts and a greater focus on wanting to improve appearance. Help establishing realistic weight loss goals and adopting a sustainable weight loss process are particularly important in patients presenting with very high weight loss goals.

Only roughly half of the patients listed “prevention or treatment of chronic diseases” as reasons for adopting a healthier lifestyle. Patients with these goals, as compared to those without these goals (all P values <.0001):

• Had higher health maintenance scores

• Had higher health knowledge scores

• Were more likely to be on medication for blood pressure, diabetes, or lipids

• Had a higher BMI

• Were older

Unfortunately, these findings suggest that patients without close health maintenance and/or preexisting chronic diseases are less informed and have less interest in the impact of lifestyle on their health.

Over 70% of patients included “to be more active and have more energy” as a reason to adopt a healthier lifestyle. This subset of patients, as compared to the 30% that did not include this as a reason, were more likely to (all P values <.0001)

• Often feel tired or fatigued

• Have been diagnosed with sleep apnea

• Have fewer moderate intensity physical activity sessions per week

• Have higher composite average stress scores

• Screen positive for possible depression

Clearly, lifestyle interventions focused on more than weight loss are important to help patients reach their goals.

Stress and activation are 2 important components of lifestyle medicine, and received particular attention in the LAQ. There was a statistically significant relationship between these factors, with higher levels of activation correlating with lower levels of stress (Spearman correlation 0.26, P < .0001). An interesting comparison between these 2 factors is shown in Figure 1, the frequency distribution of patients’ composite average scores, ranging from 0 (lowest possible score) to 100 (maximum score). Stress scores ranged broadly with a near normal bell-curve distribution; in contrast, activation scores were very strongly skewed with patients generally reporting a high level of activation when starting care.

Figure 1.

Frequency Distribution of Activation and Stress Scores

Discussion

The Centers for Medicare and Medicaid Services provides a list of over 400 specialty taxonomy codes for Medicare providers; “Lifestyle Medicine” is not on the list.¹⁶ There is a “Preventive Medicine” category, with multiple subtypes specific enough to include “Aerospace Medicine” and “Undersea and Hyperbaric Medicine,” but the subtype of “Public Health & General Preventive Medicine” is perhaps the closest to lifestyle medicine. Clearly, lifestyle medicine is a new, and not widely recognized, field of medicine. The purpose of this report is to characterize the patients within this new type of clinical practice.

The strengths of this report include the large number of patients available for analyses, use of prospectively implemented assessment tools, and a sophisticated data management and analyses infrastructure within the practice. A key component of lifestyle medicine is the use of evidence-based approaches to patient care; this includes the willingness and ability to look within one’s own practice.

Limitations of this report include uncertainties over generalizability of the findings to other lifestyle medicine practices in other locations. As noted, some differences in patient characteristics were observed even within the relatively small regional distribution of the 5 LMC clinic locations. Of greater significance is that LMC is an insurance-based private practice that does not take Medicaid, and only very recently started taking Medicare. These factors significantly affect age and socioeconomic characteristics of the patients within LMC; a lifestyle medicine practice within a public health clinic would likely be considerably different in multiple ways. In addition, lifestyle medicine is an evolving field, becoming both more broadly based as an important component of general primary care practices, and also more specialized with its own board certification and an increasing number of residency programs. Over time, these factors may affect the characteristics of patients seen within a lifestyle medicine specialty practice.

It is important to note that the LAQ certainly did not provide a complete evaluation of factors important and relevant to lifestyle medicine. Mood disorders, body image issues, level of self-efficacy, and mindfulness behaviors are just a few examples of the breadth of factors involved when providing lifestyle medicine care with the overall goal of better health and well-being in our patients. The difficult challenge is to balance the volume of structured intake information that is asked for with the patients’ tolerance for providing it.

Encounters in the LMC lifestyle medicine practice are currently 20% with a clinician and 80% with an RD. This high utilization of RDs does not reflect our opinion as to the optimal mix of clinician and RD services for “lifestyle” care of patients, nor does it reflect that lifestyle issues are 80% diet related. Many PCPs are willing and able to provide some lifestyle medicine clinical care, but they and their practices have limited ability to provide nutritional counselling. In addition, some patients are referred by their PCPs for nutritional help with problems in addition to lifestyle-related chronic diseases. Examples include irritable bowel syndrome, gluten intolerance, dairy or other food allergies, and gout. These factors shift the distribution of encounters in the LMC practice more toward RDs. In addition, new LMC RDs are put through a 3- to 4-week training program before they provide any one-on-one patient care, regardless of their years of experience as an RD. This training focuses on other lifestyle issues besides nutrition, enabling LMC RDs to integrate broader lifestyle evaluation and care with their nutritional services.

It is interesting to note that, in general, patients were highly motivated to achieve unreasonably high weight loss goals. Activation scores were high, and 55% reported their “realistic” target weight loss was >30 lbs. This is despite over half of patients being previously unsuccessful at losing even 20 lbs. These findings indicate that for most new patients raising their level of activation is not the key issue; the question is how to maintain it. It is important to guide patients to SMART goals (Specific, Measurable, Attainable, Realistic, Time limited) very early in their care, before failure dampens their commitment.

Stress can significantly affect one’s physical and mental health,¹⁷ and dealing with stress is an important component of lifestyle medicine. Patients entering this lifestyle medicine practice showed wide-ranging levels of stress, emphasizing the importance of screening for stress to identify those patients most in need of help with this component of their lifestyle.

The patients’ basic understanding of the connection between lifestyle factors and health was frequently limited. The most commonly listed factors for excess weight were unhealthy eating habits (63% of patients) and low activity level (53% of patients), and but still 21% of patients did not include either one of these factors. The response to 44% of the health knowledge questions was “I don’t know.” There is increasing general awareness of the importance of lifestyle factors in one’s health, but clearly much more is needed. Significant responsibility for this rests with the patient’s PCP, who should use every patient encounter to at least briefly touch on the importance of lifestyle issues.

For lifestyle medicine care providers, the foremost goals include prevention and treatment of disorders caused by lifestyle factors, yet these were goals for just half of the patients. More commonly, patients wanted to look better and have their clothes to fit better. Certainly, these latter goals are not inappropriate goals, nor do they conflict with the goals of the providers. However, it is important to note that patient engagement is likely to benefit if providers bring more focus on the patient’s goals and perhaps less on their own goals.

Over 90% of patients came with the goal of weight loss, and over 70% also wanted “to be more active in my daily life and have more energy.” These goals are somewhat conflicting, since weight loss programs, particularly early on, do not increase patients’ energy level. The majority of patients seeking care in a lifestyle medicine practice sleep less than 7 hours, there is a high prevalence of stress, many screen positive for possible depression, and less than 1 in 10 get the recommended 150 minutes per week of moderate-intensity physical activity. Unfortunately, a common misconception of new patients presenting to the practice is that “lifestyle medicine” and “weight loss” are equivalent, rather than the latter merely one piece of the former. It is important to help patients first recognize and then address a broad spectrum of lifestyle issues in order to become healthier and attain their goals of being more active and having more energy.

Having a better understanding of the patients who come to a lifestyle medicine clinic will help practices better design their lifestyle programs, and guide lifestyle medicine providers to better engagement of their patients through realistic goal setting and education regarding the breadth of lifestyle medicine and the profound impact this has on health and well-being.