When the Desire for Lifestyle Medicine Counseling Remains Unfulfilled: A Case Report

Abstract

More and more patients are suffering from multiple concomitant chronic conditions, which are often associated with an unhealthy lifestyle, including inadequate physical activity and poor nutrition. Patients increasingly seek thorough advice on lifestyle counseling, however, many physicians encounter this development with a pharmacotherapy-centered strategy—thereby paying insufficient attention to lifestyle modifications. This case report attempts to capture the concerning experience of a particular patient, who was hospitalized for uncontrolled type-2-diabetes in an American hospital. Despite curiosity and a great interest in lifestyle modifications, his desire for lifestyle medicine counseling was not addressed during a long inpatient stay. This case illustrates that patients wish to make sustainable lifestyle changes but apparently receive insufficient support from their physicians. This applies for both, dietary and exercise counseling. To address the patients’ needs and the increasing burden from chronic diseases, physicians must practice lifestyle medicine now. Appropriate educational resources for physicians are provided.

Introduction

It is now widely recognized that the burden from chronic illnesses is rising globally (1). More and more patients are suffering from multiple concomitant conditions that are frequently related to an unhealthy lifestyle, including poor nutrition and inadequate physical activity (1,2). Tackling this development by implementing lifestyle recommendations in daily clinical care can saves lives (3).

Approximately 80% of the population wishes to live in a better state of health, however, they do not know how to pursue it (3). More than 30 years ago, Levine already emphasized inadequacies in medical practice related to health promotion and disease prevention (4). A more recent special report by Bodai et al. found that apparently not much has changed (3). Minimal information is given to patients by health-care providers on how to implement an effective, long-term strategy to achieve better health (3).

Although there is now convincing evidence supporting the essential role of lifestyle medicine, its practical integration in daily clinical practice remains a challenge (5). This article attempts to capture the concerning experience of a particular patient in an American hospital, experiencing pharmacotherapy-centered medicine, while lifestyle modifications and sustainable interventions were not addressed.

This case report also emphasizes the pertinent role of lifestyle counseling and the importance of sustainable lifestyle medicine strategies to combat the increasing burden from chronic lifestyle-related conditions. If the medical community does not respond quickly to this challenge, patients will lose faith in the medical profession.

Description

Patient and clinician’s details are anonymized in this case report. The patient was not hospitalized in the author’s institutions. The semi-structured patient interview is included in the supplementary material appendix. Important details are narratively presented below. Written informed consent was obtained.

For technical and privacy reasons, the focus is put on lifestyle medicine-related questions rather than on medical details. The authors acknowledge that pharmacotherapy is often necessary, life-saving and a key component of hospital care. Nevertheless, this case report illustrates the urgent need for evidence-based and interdisciplinary lifestyle medicine approaches in clinical care.

This case report illustrates the case of a 56-year-old patient who was hospitalized twice for uncontrolled type-2-diabetes and hypertension. The patient was also diagnosed with overweight, congestive heart failure, atrial fibrillation, and suffered from diabetic ulcers. Moreover, he was diagnosed with endocarditis during his first inpatient stay, which was treated with intravenous antibiotics. After more than 2 weeks of intensive pharmacotherapy (including both insulin administration and oral hypoglycemic agents) and countless efforts to improve glycemic control, the patient was discharged.

Shortly after, he experienced a severe episode of hypoglycemia at home, most likely due to improper administering of his prescribed insulin. He was readmitted and hospitalized for another 2 weeks. During both hospitalizations, the patient signalized strong interest and curiosity in lifestyle modifications (see supplementary material). Despite thoughtful and attentive care by his health-care providers, his desire for proper lifestyle medicine counseling remained largely unfulfilled.

Although he was hospitalized for almost 1 month, nobody explained him the paramount importance of exercise and healthy nutrition. Given that he was administered for uncontrolled type-2-diabetes, the latter seems of particular importance. During the interview, the patient emphasized that he did “not feel well-supported” and did not get “adequate disease state management” in regard to lifestyle choices. Important topics such as diet, physical therapy, emotional resilience, and stress management were not addressed during ward rounds. He was left with the impression that physicians are inadequately trained in nutrition education and rather “focus on insulin and medication management” instead.

As a consequence, the patient urges other individuals with type-2-diabetes to do their own research and to embrace lifestyle medicine approaches that he perceives are safer and more effective than medication only. He invested considerable efforts and, given his great perseverance, managed to improve glycemic control and hypertension with regular exercise, stress management, and comprehensive dietary modifications. The latter included more plant-based meals, avoidance of processed foods and intermittent fasting. The patient temporarily consumed a mostly vegan diet. With this strategy, he managed to lose approximately 60 pounds. The interview ended with the patient’s recommendation for other individuals with type-2-diabetes to not always “depend on […] medical professionals” and to “become [one’s] self-advocate.”

Results

This case is illustrative of a most concerning trend taking place. While physicians and health-care providers invested maximum efforts to optimize pharmacotherapy, the patient’s wish for lifestyle counseling remained largely unfulfilled. Although he was hospitalized for more than 1 month, he received little to no information on diet and exercise. Only due to his own research and the caring help of his family and relatives, he managed to implement sustainable lifestyle modifications.

Although well-established chronic disease practice guidelines uniformly call for behavior change as the first line therapy in disease prevention and management (6), it has been suggested before that physicians experience difficulties in following these recommendations (6,7). This appears to be especially true for exercise recommendations (8) and dietary counseling (9,10). Limited training in lifestyle medicine, a lack of resources and time, and finally reimbursement methods that reward treatment over prevention are often cited barriers to the implementation of lifestyle medicine approaches in Western medicine (6,11). The lack of adequate nutrition education in current medical curricula appears to be of particular importance (12). This is most concerning, given the fact that almost one half of cardio-metabolic deaths in the United States could be prevented by proper nutrition alone (13).

This case report also emphasizes another key aspect: patients may lose faith in the medical profession if physicians do not change their attitude toward lifestyle medicine. Medicine that focuses on symptom management via expensive interventions and prescriptions, instead of “treating the cause” of disease (eg, poor nutritional habits and a lack of exercise), could lead to an erosion of public trust in health care and, to a lesser extent, in its providers. A recent analysis by Huang and colleagues revealed that the commodification of health care may play an important role in the increasing deterioration of public trust in physicians (14).

Patients seek thorough advice on lifestyle counseling, including exercise and dietary recommendations. They are increasingly empowered by technology to connect with others and to learn new information (15). Physicians must address this need for answers to lifestyle-related questions. Most importantly, there is no time to lose. To address the patient’s needs and to tackle the increasing burden from chronic diseases, physicians must practice lifestyle medicine now.

The American College of Lifestyle Medicine provides valuable resources for interested clinicians (16). Another interesting source for interested patients and physicians is the homepage “LifestyleFacts” by the Lifestyle Medicine Foundation (17). For questions about plant-based nutrition, the American nonprofit organization “Physicians Committee for Responsible Medicine” provides a wide range of freely accessible resources on their homepage (18).

Very recent evidence suggests that patients feel betrayed by the health-care system when they are not informed about the power of lifestyle medicine approaches, such as plant-based eating plans (19). Withholding such crucial information appears to be unethical (20). It is noteworthy that the patient in this case report tried a vegan diet in the first place—a diet shown to be particularly effective in the treatment of type-2-diabetes (21). However, he often felt hungry and experienced episodes of hypoglycemia. Both problems are frequently encountered pitfalls when individuals with type-2-diabetes and high insulin doses adopt a low-fat vegan diet. With proper support from an experienced lifestyle medicine physician and a strategy addressing these issues, it is not inconceivable that the patient would have pursued this diet. Yet, the infrastructure to support patients in sustainable lifestyle modifications seems not to be there.

Finally, it is crucial to note that pharmacotherapy will always have a key position in acute care and in emergency situations, however, to combat the skyrocketing burden from chronic diseases, lifestyle medicine approaches are desperately required now. Patients may quickly lose faith in their physicians if they do not change their attitude toward lifestyle medicine.

Lessons Learned

• Patients seek thorough advice on lifestyle counseling including exercise and dietary recommendations. They are increasingly empowered by technology to connect with others and learn new information.

• The medical community seems to be unprepared for this challenge. Physicians must urgently develop new strategies, enhance their lifestyle medicine knowledge, and enable themselves to provide answers to patient’s lifestyle-related questions.

• Patients will lose faith in the medical profession if physicians do not change their attitude toward lifestyle medicine.

• In the battle against chronic lifestyle-related conditions, physicians should focus more on comprehensive lifestyle-programs instead of relying only on pharmacotherapy.

Conclusion

An increasing number of patients is suffering from chronic lifestyle-related conditions. Many of them are associated with an unhealthy lifestyle including inadequate physical activity and poor nutrition.

Physicians often encounter this development with a pharmacotherapy-centered strategy, thereby neglecting the pertinent role of lifestyle-modifications. While pharmacotherapy can be life-saving in emergency situations, sustainable lifestyle modifications are required to tackle the increasing burden from lifestyle-related illnesses.

This case captured the concerning experience of a particular patient in an American hospital, whose desire for lifestyle medicine counseling was not addressed during a long inpatient stay. Patients wish to make sustainable lifestyle changes but receive insufficient support from their physicians. Physicians therefore have to rethink their attitude toward lifestyle medicine. Appropriate educational resources are provided to support them.

Author Biography

Maximilian Andreas Storz is a medical doctor from Germany. His main interests include plant-based whole-food diets and lifestyle medicine. He is also interested in climate change, animal welfare and environmental sustainability.