Lifestyle Medicine: Redefining “HEALTH” care

1

Lifestyle

Medicine:

Redefining

“HEALTH” care Brian Asbill, MD, FACC

October 6, 2017

Lifestyle Medicine Symposium

Outline

• State of the Union

• What is Lifestyle Medicine?

•The Evidence of Benefit

• Our Experience in Asheville

• Where Do We Go From Here?

Obesity, the common denominator of chronic

disease Overweight – 32%

Obese - 34%

Morbidly Obese - 6%

Obese men use 5.9 sick days

Obese women use 9.4 sick days

Obese men cost an extra $1152 in medical cost

Obese women cost an extra $3613 in medical costs

Source: Begley, Sharon. As America’s Waistline Expands, Costs Soar, Reuters, 2012

../Local Settings/Temporary Internet Files/OLK4/AbsenteeismPresenteeismCosts.pdf

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1945 1965 2005 1985

25%

20%

15%

10%

5%

900% age 60+

age 40-59

cdc.gov/diabetes/stats

Diabetes Trend (US 1945 to 2010)

“You can expect one heart attack per year in an average

hospital in an average sized town”. Prevalence of Coronary Heart Disease in North America, 1928

Medical Textbook by Sir William Osler, MD

Today, the number of heart attacks in the US is

1,460,000 a year!

Heart Disease… Less Than 100 Years Ago

• Bypass Surgery

• 400,000/year

• Averaging $60,000+ each

• 37-46% of vein grafts failed (75% narrowing) within 12

to 18 months

NEJM 2009, 361 (3) 235

• Angioplasties & Stents

• 1,000,000/year

• Averaging $35,000 each

Heart Disease Today…

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Let food by thy medicine

and medicine be thy food-

-Not Hippocrates?

180,000* serious or fatal adverse drug reactions

reported to the FDA,

making drugs a significant % of US deaths

*Properly or improperly prescribed

FDA, reported in 2011

Prescription Drugs

Are NOT the Answer

Which of the following statements is

true about adverse drug reactions?

a) Total cost for ADRs ranks 6th on annual national health

care expenditures

b) Total costs for hospital patients with an ADR are 5

times those of patients without an ADR

c) ADRs are responsible for 1 in 25 injuries or deaths per

year in the hospital

d) Hospitalized patients with an ADR have the same

mortality as those without an ADR

e) The annual costs for ADRs are greater than total costs

for cardiovascular or diabetic care

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Which of the following statements is

true?

a) ADRs are responsible for fewer deaths than pulmonary

disease, DM, and pneumonia

b) There are enough prescriptions filled yearly in the US

to average 10 prescriptions for every person in the US

c) On average, an increase in the number of concomitant

drugs does not increase the risk of an interaction until

6 are given at the same time

d) 47% of patient visits result in a prescription

e) In general, patients have little concern about potential

drug interactions

Someone has to stand up and say

that the answer isn’t another pill.

The answer is spinach

-Bill Maher

A Solution For Today’s Health Care

Dilemma

Lifestyle Medicine:

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Lifestyle Medicine Definition

• Lifestyle medicine is the evidence based practice of helping individuals and families adopt and sustain (natural) healthy behaviors that affect health and quality of life…

Lifestyle Medicine Pioneers

Dean Ornish, MD *Ornish Lifestyle Medicine

Prevent and Reverse Heart Disease

Lifestyle Interventions

1) Nutrition

2) Physical Activity

3) Stress Management

Rest/Sleep/Meditation

4) Social supports

* Environmental Exposures

Smoking cessation/Toxicology

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Lifestyle

Medicine

Growth

- Growth Numbers

- Growth Drivers

132

152

303

448

565

698

1116

0

200

400

600

800

1000

1200

2010 2011 2012 2013 2014 2015 2016

Annual Membership Growth

19%

38%

1531

Physician 56%

Doctoral 8%

Executive 1%

Professional 15%

Affiliate 4%

Retired 4%

Trainee 12%

ACLM Membership 2016

7

0

100

200

300

400

500

600

700

800

Physician/Doctoral Executive Professional/Affiliate Retired Trainee

Me

mb

ers

Membership Growth by Category (2015 – 2016)

Four Lifestyle Medicine

Growth Drivers

1) The Chronic Disease Epidemic

fueled by… food processing/preserving/shipping

modern transportation/communication tech


Growth Drivers




2) Increasing Health Care Costs

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Growth Drivers




2) Increasing Health Care Costs

3) Dissatisfaction with the Status Quo patients

physicians/providers

Discontent is the first necessity of

progress.

-Thomas Edison

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Growth Drivers

1) The Chronic Disease Epidemic fueled by… food processing/preserving/shipping modern transportation/communication tech

2) Increasing Health Care Costs 3) Dissatisfaction with the Status Quo patients physicians/providers

4) Science epidemiology, basic science, clinical trials

Data for Lifestyle Efficacy JACC 9/5/14 Akesson et al

• 20,721 men ages 45-79 followed for 11 years

• 5 lifestyle factors:

• Healthy diet

• Smoking

• Moderate etoh consumption

• Physical activity

• Abdominal adiposity

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Data for Lifestyle Efficacy JACC 9/5/14 Akesson et al

• 79% lower risk if met all lifestyle factors

• Only 1% of the study population

Data for Lifestyle Efficacy JACC 1/5/15 (Chomistek et al)

*88,940 women in NHS2 ages 27-44 with no h/o

cancer, CVD or DM

*6 lifestyle factors defined healthy living:

-no smoking

-diet in top 40% of healthy eating index

-physical activity at least 2.5 hrs/week

-TV watching <7 hrs/week

-BMI <25

-Alcohol not more than 1/day

Data for Lifestyle Efficacy JACC 1/5/15 (Chomistek et al)

*At 20 yrs f/u, those who adhered to all 6 lifestyle

factors had 92% lower CVD risk vs those with zero

*Only 4.6% of the study population were optimal

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Overview

Lifestyle intervention education program

100% evidence based

community based (not residential)

Regular group sessions over several weeks

Blood draws and Health Risk Assessments

Education, practical experience, reinforcement

“Whole of Health” approach

60,000+ participants over 25 years and counting…

25+ peer reviewed articles in medical journals

25 – 45 minutes of content delivery

25 - 45 minutes of facilitated group discussion,

based on these recurring questions:

• What was new to me?

• What did I like?

• What did I not like?

• What will I change from now on?

Food Sampling/cooking demos/

exercise (some lectures)

A typical CHIP session

CHIP Efficacy

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Asheville CHIP 1

30 day results (N=22)

DAY 1 DAY 30 Decrease

Average weight 228 lbs 218 lbs 4.4%

Ave. total chol 187 mg/dl 161 mg/dl 13.9%

Ave. LDL-C 110 mg/dl 93 mg/dl 16.1%

Ave TG 186 mg/dl 139 mg/dl 25.3%

Ave glucose 121 mg/dl 112 mg/dl 7.5%

Ave SBP 132 mmHg 122 mmHg 7.6%

Asheville CHIP 2

12 week results

• Weight Loss

– 27 participants lost a total of 363.5 lbs

– Average weight loss 13.5 lbs/person

– 61.5 inches on waist circumference lost (2.25 in/pt).

One man lost 8 inches

• Glucose

– 17 people had a fasting glucose >100. 8 of the 17 lowered

their glucose to <100 at 12 weeks

Asheville CHIP 2

results

• Lipids

– Only 6 had a total cholesterol >200 at the start with

an average TC of 242 mg/dl

• At 30 days it dropped 20% to 194 mg/dl

– 16 pts had an LDL >100 mg/dl with ave 134 mg/dl

• At 30 days it dropped 24% to 102 mg/dl

– 8 had TGs >150 mg/dl with ave 235 mg/dl

• At 90 days 17% decrease to 195 mg/dl

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Copyright © 2014 Healthways, Inc. All rights reserved. Copyright © 2014 Healthways, Inc. All rights reserved.

Dr. Ornish’s Program for Reversing Heart Disease™


Experimental group (Ornish participants) had more regression after 5 years than after 1 year.

Proven Regression

Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001-2007.

27.7% relative worsening in the control group.

7.9% relative improvement in the Ornish group.

91% decrease in angina

vs

165% increase

5y: 2.5 x increased

event rate

in control group

20% LDL reduction

in both groups

60% on statins vs 0%

99% stopped or reversed their CHD

with average 300% increase

in myocardial perfusion by PET scan


Long term regression

0%

10%

20%

30%

40%

50%

60%

70%

3 months 1 year 2 years 3 years

% Reporting No Angina

of intervention patients avoided revascularization,

with no increased frequency of cardiac events.

77% At three years

Ornish D, for the Multicenter Lifestyle Demonstration Project Research Group. Avoiding revascularization with lifestyle changes: The Multicenter lifestyle demonstration project. Am J Cardio 1998;82:72T-76T.

47% lower cost with $3.1 M savings

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Recent Results | Mission Health

The information below represents sample outcomes from the most recent Healthways clinical outcomes report.

Baseline 9 weeks Change

Weight Loss 199.7 192.1 -3.8%

BMI 29.8 28.6 -3.9%

Total Cholesterol 167.6 136.0 -18.9%

LDL Cholesterol 94.8 71.1 -25%

Triglycerides 164.7 141.1 -14.3%

Systolic Blood Pressure 121.3 119.5 -1.5%

Diastolic Blood Pressure 73.4 67.8 -7.7%

Exercise capacity (METS) 4.3 5.5 27.9%

HbA1c 6.7 6.4 -4.7%

Depression Score (CESD) 14.6 6.2 -57.7%


Quarterly Results – Q2 2017

Baseline 9 weeks Change

Weight Loss 200.0 188.4 -5.8%

BMI 31.5 29.7 -5.7%

Total Cholesterol 168.9 142.0 -16.0%

LDL Cholesterol 92.4 72.5 -21.5%

HDL Cholesterol 48.0 43.4 -9.5%

Triglycerides 152.6 133.6 -12.5%

Systolic Blood Pressure 129.6 121.5 -6.2%

Diastolic Blood Pressure 76.0 70.9 -6.7%

HbA1c 6.7 6.2 -7.4%

Depression Score (CESD) 11.4 5.6 -51.2%

Exercise Capacity (Mets) 3.7 5.5 47.5% Data is based off participants in Q2 2017 quarterly report. N-2786 participants.

Physical and Dietary Behavior Adherence Over 18

Months Physical and Dietary Behavior Mean change

at 18 mo

% of participants who

improved over 18 mo

Physical Activity

(steps/wk)

5,596

63

Kcal/day

-391

75

Vegetables servings/day

2.6

59

Dietary saturated fat g/day

-8

83

Dietary fiber g/day

4

67

Sweets kcal/day %

-3

69

Merrill RM, Aldana SG, Greenlaw RL, et al. Can Newly Acquired

Healthy Behaviors Persist? An Analysis of Health Behavior Decay.

Prev Chronic Disease. 2008 5:1;1-13.

Average

about 70%

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Medication continuation after myocardial infarction

in the community

Shah ND, Dunlay SM, Ting HH et al. Long-term Medication Adherence after

Myocardial Infarction: Experience of a Community. The Amer J of Med. 2009:122:10.

About 70%

at 18 mo

What are we to do?

• Barriers to success • Most providers are used to guideline driven

medicine.

• They don’t have time

• Lifestyle medicine data is not widely known

• Not trained in behavioral medicine techniques

• The whole world is against us?

What are we to do?

• Possible solutions • Educate providers about the power of lifestyle

medicine

• Development of wellness referral programs

employing team based care

• Hospital

• Business

• Local government

• Advocacy at local, state and national level

• Start to talk about this!

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The doctor of the future will give no

medicine, but will instruct his patient

in the care of the human frame, in

diet and in the cause and prevention

of disease.

-Thomas Edison

What is CHIP?

Overview

Lifestyle intervention education program

100% evidence based

community based (not residential)

Regular group sessions over several weeks

Blood draws and Health Risk Assessments

Education, practical experience, reinforcement

“Whole of Health” approach

60,000+ participants over 25 years and counting…

25+ peer reviewed articles in medical journals

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25 – 45 minutes of content delivery

25 - 45 minutes of facilitated group discussion,

based on these recurring questions:

• What was new to me?

• What did I like?

• What did I not like?

• What will I change from now on?

Food Sampling/cooking demos/

exercise (some lectures)

A typical CHIP session

Program Content

Phase 1 Lifestyle is the best medicine

Session 1 The rise and rise of chronic disease

Session 2 Lifestyle is the best medicine

Session 3 The common denominator of chronic disease

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Are Programs like CHIP Covered by

Insurance Plans? • Considered licensed “clinicians” that are capable of billing- M.D., D.O., NNPP,

PA, or RD are the most common clinicians who are able to bill using Medical

Nutritional Therapy (MNT) using CPT codes 97802-4

• Clinicians must be in their network or system

• Those providers use the proper CPT codes and have a referral for the

therapy, and a diagnosis, or reason for the referral, from the participant’s

primary care physician on file. At this point all insurance plans do require a

“diagnosis code” for reimbursement to be possible. Most common diagnoses:

obesity counseling, any diet related chronic disease state, and/or any

cardiovascular risk factor like hyperlipidemia, hypertension, or diabetes (all

great reasons for being in CHIP!)

ITLC Billing

Source Average Payment

Insurance $1483.68 / participant

Self Pay $699.00 / participant

(minus $350) = $349.00

16 classes were billed 99214

4 classes were billed 99213

2 Lab draws/assessments billed 99211

Labs billed through insurance Participants bought own textbooks

Self-Pay $699

Textbooks $250/ person

Labs $50/ person

$21.81 revenue/ session

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Phase 2 Optimal Lifestyle

Session 4 Optimal Lifestyle

Session 5 Eat more, weigh less

Session 6 Fiber, your new best friend

Session 7 Disarming Diabetes

Session 8 The heart of the matter – heart healthy

Session 9 Blood Pressure and & discovering protein

Session 10 Bone health essentials

Session 11 Cancer Prevention

Phase 3 Pause & Reflect

Session 12 Understand your results & take action

Asheville CHIP 1



Average weight 228 lbs 213 lbs 6.6%

Ave. total chol 187 mg/dl 167 mg/dl 10.7%

Ave. LDL-C 110 mg/dl 94 mg/dl 14.6%

Ave TG 186 mg/dl 158 mg/dl 15.1%

Ave glucose 121 mg/dl 109 mg/dl 10.0%

Ave SBP 132 mmHg 124 mmHg 6.1%

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Asheville CHIP 3



Ave total chol 188 mg/dl 167 mg/dl 11%

17 pts had TC >150

Avg = 199mg/dl

177 mg/dl 11%

9 pts had TC >200

Avg 225 mg/dl

198 mg/dl 12%

Waist circ 42.6 inches

40.1 in 2.5 in

11 pts had SBP >135

Avg 145 mmHg

128 mmHg 12%

7 pts had glc >100

Avg 176 mg/dl

132 mg/dl 25%

Asheville CHIP 3



4 pts had TG >150

Avg 241 mg/dl

184 mg/dl 24%

12 pts had LDL-C >100

Avg 131 mg.dl

110 mg/dl 16%

5 had LDL-C >130

Avg 152 mg/dl

127 mg/dl 17%

Asheville CHIP 3 and 4


• Weight loss 13.8 lbs/person. 509 lb total

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Asheville CHIP

(N=86)

• Total 1185 lbs weight loss = 13.8 lb/person

Phase 4 Get Set for Success

Session 13 Become what you believe

Your DNA is NOT your destiny

Session 14 Anger Management – practicing forgiveness

Session 15 Re-engineer your environment

Phase 5 From Health to Happiness

Session 16 Stress relieving strategies

Session 17 Fix how you feel

Session 18 From surviving to thriving

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Text Book

Work Book

Cook Book

Pedometer

Water Bottle

Live More

Learn More

Eat More

Walk More

Drink More

The Participant Tool Kit

CHIP Food Philosophy

CHIP is not a vegan program! It is about making good choices.

It seeks to help people move from the left side of the spectrum to the right side.

NOTE: The science indicates that for disease reversal, plant based eating gives the best outcomes.

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Live Healthy Asheville

…and please refer patients to

CHIP

Lifestyle

Medicine

Opportunities

- Educational

- Professional

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Asheville CHIP 1

12 week results

• Weight Loss – 22 participants lost a total of 312 lbs

– Average weight loss 14.2 lbs/person

– 5 participants lost at least 10% of their body weight

• Blood Pressure – 6 people had SBP >140 at day 1

– Only 1 person had SBP >140 at 12 weeks

– Of those with BP >140 on day 1, the average SBP was 161. After 12 weeks their average was 130 (20% decrease)

Asheville CHIP 1

12 week results

• Glucose

– Insulin requirements dropped by >50% in insulin

requiring diabetics

– 12 had glucose >100 at day 1 (diabetic or “pre-

diabetic”)

– Those 12 pts had an 18.5% decrease in fasting blood

sugar

– Only 7 had glucose >100 after 12 weeks

Asheville CHIP 1

12 week results

• LDL cholesterol

– 8 people had LDL >130 on day 1 (US 50th percentile)

– 3 people had LDL >130 after 12 weeks

– The 12 pts with an LDL >100 at baseline had an average

reduction in LDL of 22.9% over 12 weeks

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Asheville CHIP 1

12 week results

• Health age

– Average 3.5 years gained per participant

Lifestyle Medicine: Redefining “HEALTH” care

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