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Upstream medicine: Case for prescriptive health-related behaviors

The current secretary general of the World Council on Cardiovascular and Pulmonary Rehabilitation likes to tell the story of a young cardiologist. He was standing on the edge of a riverbank enjoying the view when he spotted a man flailing in the water, being carried down the rapids toward a 1,000-foot waterfall. He immediately took his shoes off, jumped into the river, and pulled the man to safety.

As he was catching his breath back on the riverbank, he heard a scream coming from the river. Looking back, he saw another man being swept toward the edge of the great waterfall. He dove back into the frigid water and grabbed the second man, dragging him back to safety. Within minutes the same scenario repeated itself a third time.

An onlooker, seeing this incredible sequence of events, approached the heroic doctor. "My," he exclaimed in awe, "you've just risked your own life to save three strangers! That was an amazing display of selfless courage and skill! Do you mind if I give you some advice?"

"Why no, not at all" said the exhausted doctor. "Well," continued the bemused observer, "did you ever consider walking upstream to see who's throwing them in?"

Like the young doctor, traditional Western medicine is noted for practicing "downstream medicine." Our system, which has historically focused on disease care, is undeniably the most sophisticated and technologically advanced in the world. It is also the most expensive.

According to the 2004 report of the U.S. Department of Health and Human Services, we spent $1.9 trillion on health care, or 16 percent of our country's GDP. That's $6,280 per man, woman and child. 2008 data from the Organization for Economic Cooperation and Development reveals that we spend approximately twice as much on health care as every other industrialized nation in terms of both percentage of our country's GDP and dollars per capita. That would be fine if our health care and/or quality of life outcomes were equally notable. But that's simply not the case.

Unfortunately, our country's overall health care outcomes do not match our world dominance in either technology or spending. According to the latest statistics of the World Health Organization (WHO), the United States ranks 37th among the world's 191 member countries for overall quality of health care. Although critics cite this data as flawed, it is nonetheless an alarming statistic and should give us pause to consider what health care we're providing for our patients' medical buck.

One thing does seem clear. The majority of our health care dollars are spent taking care of medical concerns directly related to patients' lifestyles. Our choices of health-related behaviors are now the biggest etiologic factors in creating premature disease, chronic medical conditions and disability.

According to the U.S. Public Library of Science, in 2005 there were eight risk factors that accounted for approximately 80 percent of all deaths in the United States: smoking, physical inactivity, excess alcohol intake, diets high in salt and low in fruits and vegetables, elevated blood pressure, high cholesterol and being overweight. The key point here is that there are effective interventions for every one of these risk factors.

The question is, can our interventions really be effective?

Dr. Earl Ford from the Centers for Disease Control and Prevention and his colleagues completed a study of 23,153 middle-age people, focusing on four healthy-lifestyle factors: smoking, obesity, exercise and diet. Eight years later, as reported in the Aug. 10-24, 2009 issue of the Archives of Internal Medicine, those in the group who adhered to not smoking, having a BMI less than 30, eating a diet high in fruits, vegetables, whole grains and low in meat consumption had some astonishing statistical benefits. The hazard ratio for developing a chronic disease decreased progressively as the number of healthy factors increased. Participants with all four factors at baseline had an overall 78 percent lower risk of developing a chronic disease than participants without a healthy factor (diabetes was reduced 93 percent, myocardial infarction 81 percent, stroke 50 percent, cancer 36 percent).

The truth is that most patients know the majority of information regarding what constitutes healthy behaviors. The problem is getting them to adhere to more healthy practices on a regular basis.

A recent study at the University of Sheffield revealed that the least effective strategies in getting patients to successfully change behaviors involved instilling fear. The second least effective method was to instill guilt for past choices. Not surprisingly, the most effective strategies consisted of education, coaching, partnering, goal setting and establishing methods of accountability.

Many patients would like to change their behaviors if they can be convinced that they could actually be successful, and if they feel like they have someone who will respectfully guide them along the way. For others, they just need a plan. Some need motivation, and others just want someone to hold them accountable. Most already feel some sense of guilt, shame or failure around past efforts to change. The last thing they need or want is additional feelings of perceived negative judgment. It's a process, and the key is to not give up. With established and mutually agreed upon goals, objective feedback regarding key indicators of success and timely redirection, many patients achieve remarkable progress.

The most effective first step in a wellness program is increasing physical activity. Fewer than 25 percent of Americans get the exercise they need. On average, we watch 170 minutes of television and movies, but spend less than 19 minutes a day exercising. Yet studies are clear that exercise promotes self-esteem, increases energy, assists in normalizing the balance of brain neuropeptides, improves sleep, enhances immune response, assists in stabilizing mood, lessens sarcopenia and helps to control weight, blood pressure, serum glucose, lipids and the metabolic syndrome. It also lessens the overall risk of chronic diseases and is one of the most potent initiators of brain neurogenesis.

In the Nov. 21, 2007, issue of JAMA, a review of 26 studies showed that, overall, pedometer users increased their physical activity by 26.9 percent over baseline and decreased their BMI by 0.38. The simple act of giving patients a pedometer with a suggested goal of 10,000 steps per day may well be one of the most powerful interventions possible. It's a good example of "what gets measured gets addressed." The more specific exercise recommendations are, the more credible and influential they become to patients.

Motivating patients to alter ingrained lifestyles is difficult at best. It often takes a painful or frightening experience to convince someone that it's indeed time to pay attention to lifestyle. Significant change rarely occurs without clear intention and purpose.

Patients should be encouraged to develop a personal mission statement, clarifying what each one sees as his or her purpose in life. Then it's not a big leap to reason that only by maximizing both health and performance can their mission be truly accomplished. And all unhealthy behaviors can be seen as personal choices that undermine the mission.

The next step is development of true mindfulness regarding significant choices and encouraging patients to develop a passion for rigorous honesty concerning their own truth. A well lifestyle is then developed over time, much like a successful business plan evolves.

People who practice healthy lifestyles have developed a set of wellness skills that they learn to employ, self-monitor and correct as needed over time. As demands change, they develop new compensatory skills that allow them to stay on track. The really successful ones generally have nourished relationships with other successful people who act as mentors and coaches.

Patient surveys have repeatedly established that the most influential person in many patients' lives in determining whether or not they adopt healthy lifestyle choices is their physician. Yet in one survey, more than 80 percent of patients said they had never heard their doctor mention exercise to them.

Clearly, doctors have their work cut out for them. They owe it to patients to be guideposts regarding healthy lifestyles. They have an obligation to provide informed consent regarding the risks and rewards of health-related behaviors. But that's not enough. Doctors owe their patients an individualized, prescriptive plan for success. The future of our nation's health will largely depend on the developing willingness of physicians to be effective patient advocates, educators and mentors.


Dr. Rice, SDCMS and CMA member since 2009, is the founder and CEO of the Lifewellness Institute, specializing in preventative medicine, wellness and health promotion. He is the Dr. Jerry C. Lee Endowed Chair at National University, a clinical professor at Western University of Health Sciences and an associate clinical professor at UCSD School of Medicine. The preceding article was originally published in the January edition of San Diego Physician.

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