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Integr Med (Encinitas). 2016 April; 15(2): 20–25.
PMCID: PMC4898278

Elizabeth Frates, md, and Kristi Hughes, nd: Creating Strategies for Prescribing Effective Lifestyle Modifications

Elizabeth Frates, md, is trained as a physiatrist and a health and wellness coach. With expertise in lifestyle medicine, she empowers patients to reach their optimal level of wellness through adoption of healthy habits, such as regular physical activity, a healthy diet, a resilient mindset, and stress management. As the director of medical student education at the Institute of Lifestyle Medicine, Dr Frates is the faculty adviser for the Lifestyle Medicine Interest Group at Harvard Medical School. She is passionate about developing programs focused on lifestyle medicine and wellness.

Kristi Hughes, nd, founded the Center of Natural Healing Arts more than a decade ago with a vision of providing integrated health care solutions for the public, as well as health care providers both locally in Minnesota and internationally. Dr Hughes became an Applying Functional Medicine in Clinical Practice graduate in 2000 and eventually joined the faculty. She became director of medical education in 2014. She has lectured internationally on lifestyle and functional medicine for more than a decade and has been instrumental in providing functional medicine resources for clinicians and nutrition professionals in South Africa.

Dr Frates and Dr Hughes are members of the expert panel convened to prepare the curriculum for the Institute for Functional Medicine’s (IFM’s) 2016 Annual International Conference to be held May 12 through 14, 2016, in San Diego, California. IFM has chosen the theme “Modifiable Lifestyle Factors: Innovative Movement and Restorative Strategies to Optimize Patient Outcomes.” For more information, please visit http://www.functionalmedicine.org/aic/

Integrative Medicine: A Clinician’s Journal (IMCJ): After focusing on cutting-edge research in recent conferences, this year’s iteration tackles a topic that is fundamental to the integrative approach: modifiable lifestyle factors. What motivated this return to the basics?

Dr Frates: Hippocrates, the father of Western medicine said, “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”

This emphasis on lifestyle factors is at the core and foundation of medicine. It has been part of the Functional Medicine Matrix for years, at the bottom of the matrix—the root of the tree. With advances in pharmacology and supplement formulas, the focus on pills has been a major theme in health care practices, education, and training. Learning how these pills, either drugs or supplements, work biochemically is a big focus of the process of becoming a health care practitioner. It is an important aspect of our jobs. However, even with the development of combination pills and long-acting formulas, we still have a diabetes and obesity epidemic in the United States and worldwide. To change this, we need to put not only our cells under the microscope, but also our lifestyles.

Genomics and the Human Genome Project have allowed for major advances in medicine, and last year’s focus on this groundbreaking work highlighted the value and importance of understanding the structure and function of our cells, genes, and DNA. This year, we build on that powerful knowledge and go from a focus on the molecules to a focus on the whole person. The lifestyle requirements for the whole body to be healthy, to function at a high level of wellness, and to reach peak performance—physically and mentally—is the goal of this year’s conference. Describing the critical combination of movement and rest that the whole person needs for achieving high-level functioning, enjoying healthy living, treating disease, and preventing disease takes a macroscopic lens while still comprehending and acknowledging the intricate cellular systems and changes that result from lifestyle changes.

In this way, the focus on genomics last year and a deep dive into modifiable lifestyle factors this year make perfect sense, as we strive to understand human existence from both the cellular level and the whole-person level.

Dr Hughes: Chronic disease continues to overtake our health care system. According to the Centers for Disease Control, or CDC, treatment for people with chronic diseases makes up 86% of health care costs in the United States. As we know, much of this chronic disease epidemic is due to lifestyle factors. As clinicians, we need to focus on core health-promoting behaviors to help our patients get better. Research is beginning to demonstrate that by using technologies like text messaging and methods for lifestyle interventions, we can improve outcomes for our chronic disease patients.

Systematic approaches for lifestyle interventions are crucial. For lifestyle interventions, the sum is truly greater than the parts, so synthesizing intervention information across many modifiable lifestyle factors offers synergistic effects.

IMCJ: Although these factors are often acknowledged for the role they play in health and wellness, why are they so often glossed over in the course of medical education, diagnoses, and treatment?

Dr Frates: What makes doctors and health care providers different from counselors and therapists is that they can prescribe pills—drugs, herbs, or supplements—to heal patients and treat diseases. They can also perform interventions, injections, and surgeries, which can relieve pain, remove tumors, and save lives. The medical education systems were set up to teach students these skills and tools that can heal patients relying on the practitioner’s pills or interventions. The focus on the fact that the patient could heal themselves by performing certain behaviors that can prevent or treat disease by exercising regularly, meditating, and getting restful sleep has resurged as “good medicine.”

The growing research in lifestyle medicine is helping to prove that exercise, diet, and sleep are, in fact, medicinal. Dean Ornish, md, and his colleagues have been working on randomized, controlled studies where they compared angiograms before and after his interventions and followed biomarkers and biometrics. These studies have shown that diet and exercise can reverse heart disease. His group worked with Elizabeth Blackburn, phd, who received the Nobel Prize in Physiology and Medicine in 2009 for discovering telomerase. Together, Blackburn’s group and Ornish’s group demonstrated that a healthy lifestyle intervention with a focus on diet, stress management, activity, and social connection could increase relative telomere length in men with low-risk prostate cancer in a 5-year follow-up study published by the Lancet Oncology in 2013.1 This reveals the importance of looking at the big picture, whole-person approach along with cellular markers of longevity in research. This type of research could not have been accomplished without the recent advances in technology as well as biochemical discoveries.

Thus, the lifestyle risk factors for disease might have been glossed over in the past because wisdom from the ages—Hippocrates and others—indicated that these daily behaviors were important, but it is not until recent years that the understanding of genomics, molecular biology, and biochemistry have reached a level to allow researchers to study the effects of these behaviors on cells, molecules, and biomarkers in the body.

To make a difference, patients and clinicians need personalized tools that help connect behavior changes to outcomes and measure patient progress. The curriculum at this year’s conference is focused on collaborating with patients to help them see the value in these important lifestyle changes and implement them sustainably.

Dr Hughes: The list of challenges for implementing lifestyle intervention is long and includes: (1) lifestyle interventions primarily take place outside the clinical setting, (2) successful lifestyle interventions change behavior over the long term, and (3) most medical training focuses on acute care rather than chronic disease prevention or wellness.

A general lack of confidence in ability to conduct lifestyle counseling also hinders some clinicians. Many clinicians report barriers to lifestyle counseling even when they know its importance. Lifestyle interventions certainly aren’t new to medicine, but clinicians need the confidence, time, tools, and education materials to implement them successfully. Medicine needs a sea-change to embrace lifestyle counseling in order to counteract the epidemic of preventable chronic disease.

IMCJ: So you feel that there is a “comfort factor” at play in the use of modifiable lifestyle factors that has relegated these issues to “lip service” representation at patient consultations?

Dr Frates: It is more likely discomfort that drives the “lip service” that lifestyle factors receive in clinical consultations. The discomfort comes from a lack of education and experience with counseling patients on lifestyle factors. This comes from a lack of understanding about how these lifestyle factors affect the whole person, body, cells, and epigenetics. This lack of understanding comes from a lack of research in this area, which prohibited an emphasis on it during education and training. Most health care practitioners, especially physicians, are not trained in nutrition, exercise, or stress management for their patients or for themselves. This leads to a discomfort in counseling, which drives the “lip service” or superficial mention of lifestyle behaviors instead of the deep dive that they deserve during the clinic visit.

Many physicians and practitioners do not practice healthy lifestyle habits themselves. Research that I performed as a resident in 1999, which was published in the Clinical Journal of Sports Medicine in 2000,2 demonstrates that physicians who exercise also counsel on exercise. Specifically in our survey of physicians, we found that physicians who perform strength training counsel on strength training and physicians who perform aerobic exercise counsel on aerobic exercise. If physicians do not perform strength training, they do not counsel on it and the same is true with aerobic exercise. This study has been replicated over the years with similar correlations.

Other research shows that practitioners will counsel on exercise, nutrition, smoking cessation, and drinking in moderation if they practice these lifestyle behaviors themselves. A great research study would be to examine all of these habits and correlate them to counseling practices. No one has done that particular study yet.

By becoming a student of lifestyle medicine, a person who seeks to adopt and sustain healthy behaviors, a practitioner takes the first step in feeling comfortable about counseling on modifiable lifestyle factors. By learning more and more about how exercise, sleep, and restorative practices affect health, mood, and well-being, a practitioner becomes more and more comfortable with the topic inside and outside the clinic.

With the knowledge that many clinicians have indicated a need for more practical information and solutions in their approach to prescribing modifiable lifestyle factors, the expert panel charged with developing the structure and curriculum of the 2016 conference—Elizabeth Frates, md; Kristi Hughes, nd; Dan Lukaczer, nd; Dan G. Tripps, phd; and Phyllis C. Zee, md, phd—put particular emphasis on clinical innovations. From the technologies that make tracking and using patient data clinically relevant to developing appropriate sleep and exercise timelines and prescriptions, this year’s conference provides clinicians with successful techniques for improving clinical outcomes and taking care of their own health.

IMCJ: Are we at a point where people—doctors and patients alike—have been so conditioned to revere medical technology that they need to have the power of these basic modifiable lifestyle factors proven all over again? If so, how would one craft the message?

Dr Frates: The American Heart Association, or AHA, put forward a goal to decrease cardiovascular and stroke deaths by 20% and to increase cardiovascular health by 20% by the year 2020. An important bar graph revealing information from the NHANES study is included in an article published in the journal Circulation titled “Heart Disease and Stroke Statistics—2016 Update: A Report From the American Heart Association.”3 The article included a bar graph that speaks louder than words on this topic.

It denotes cardiovascular risk factors on the x-axis and the percentage of Americans affected on the y-axis. On the bar graph, different colors represent different levels of control over the risk factors on the x-axis. The red sections show areas where Americans are experiencing poor control of their risk factors. This graph clearly shows how America will be able to reach the AHA’s goal for 2020. By looking at the colors on the graph and noting the areas with the most red in the bar, it is clear that physical activity, weight management, and healthy diet are the areas that need the most work by US adults. Regarding physical activity, 48.2% are in poor control of that risk factor; for body weight, 35.8% are in poor control; and for diet, 72.5% are in poor control. Cholesterol levels, blood glucose levels, and blood pressures appear to be in much better control, as these bars reveal the least amount of red. Pills have helped tremendously in controlling these risk factors, with only 8% to 13% of Americans demonstrating poor control in these areas.

So the bottom line is that if we want to increase the cardiovascular health of Americans, we need to work on lifestyles, and there is no drug or supplement formula that can change people’s behaviors. It is clear where our focus needs to be.

Many studies have compared lifestyle interventions aimed at increasing people’s physical activity, improving diet, and controlling weight to drugs aimed at treating a specific disease such as diabetes. A landmark lifestyle medicine study performed by the Diabetes Prevention Program Research Group published by New England Journal of Medicine in 2002 brought lifestyle interventions to the level of medications.4

In this randomized, controlled trial, lifestyle medicine interventions were compared to metformin and placebo in a group of nondiabetic individuals with elevated fasting and postload plasma glucose concentrations. The lifestyle medicine intervention had the goals of at least 7% weight loss through a low-fat, low-calorie diet and 150 minutes or more of moderate intensity physical activity per week. The intervention was 24 weeks and patients were followed for about 2.8 years. The results revealed that the lifestyle intervention was more effective at protecting the subjects from converting to a diagnosis of diabetes. The lifestyle medicine intervention reduced the incidence of diabetes by 58% and metformin reduced it by 31%, compared to placebo.

In a more recent article published by the British Journal of Sports Medicine in 2015, the effectiveness of exercise was compared with drug interventions on mortality outcomes in a metaepidemiological study.5 Existing evidence from randomized, controlled trials suggested that exercise and drug interventions are often similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

This bolsters the parallel between exercise and medicine, which supports and promotes the Exercise is Medicine campaign managed by the American College of Sports Medicine.6 It also bolsters the idea of exercise prescriptions as similar to prescriptions for medications. Crafting the message to take lifestyle behaviors seriously and treat them like medications is a good tactic, as it speaks to patients and physicians, alike. As stated earlier, practitioners are trained to prescribe medications and supplements and patients are accustomed to these types of prescriptions. Thus, putting exercise and lifestyle interventions into the terminology patients understand and expect from their physicians is a powerful way to convey the message that lifestyle is medicine. That message is at the heart of this year’s conference.

IMCJ: Has there been an increase in the level of the research or findings of this type that has changed the landscape?

Dr Frates: Randomized, controlled studies comparing lifestyle interventions to medications have helped to change the landscape. Research results proving the effectiveness of lifestyle medicine interventions that include exercise, diet, and stress reduction have opened many doors for patients to benefit from these programs. Probably the most important factor that has changed the lifestyle landscape is the fact that Medicare now covers lifestyle programs for intensive cardiac rehabilitation such as Dr Ornish’s Program for Reversing Heart Disease, the Pritikin Program, and the Benson-Henry Institute Cardiac Wellness Program. These programs are covered for patients with a diagnosis of cardiac disease. With more time and research to prove the effectiveness of these programs for prevention, they will hopefully be covered for more than just cardiac patients.

Practitioners are trained to do what they get paid to do. Thus, if practitioners get paid to counsel patients on exercise, diet, and stress management in the same way that happens in the Ornish, Pritikin, and Benson-Henry programs, they may be more likely to use exercise, diet, and stress management as medicine.

If one reads the research landscape and tracks the increasing practice of prescribing lifestyle as medicine, it follows that these skills will eventually also be included in the curriculum of medical schools and of other health care educational institutions.

IMCJ: What has recent research uncovered in terms of the body’s need for restorative practices and how they relate to chronic disease?

Dr Frates: In terms of the obesity epidemic, there is a lot of interest in the role of sleep and the regulation of ghrelin and leptin—hormones that influence appetite. Short sleep duration—less than 6 hours—has been linked to greater energy intake, snacking between meals, and lower protein intake, according to a 2014 paper in the American Journal of Lifestyle Medicine by Shechter et al.7

In terms of our number-1 killer, cardiovascular disease, a recent systematic review and meta-analysis of prospective studies connected sleep duration with cardiovascular outcomes. They reported that both short- and long-duration sleep are predictors, or markers, of cardiovascular outcomes. Sleeping 9 hours or more increases risk of cardiovascular disease, and sleeping 5 hours or less increases risk as well.8

Over the years, sleep deprivation has been associated with depression, anxiety, obesity, heart disease, decreased cognition, impaired memory, lower performance, impaired decision making, impaired immunity, fatigue and work-related accidents, car accidents, suicide risk, substance abuse, obesity cardiovascular disease, metabolic dysfunction, poor behavior control, and impaired executive function.

The exact mechanism for these correlations is an area of active research with researchers investigating many potential pathways, including sleep deprivation’s effect on endothelial cells and the bioavailability of nitric oxide, its disturbance of the hypothalamic-pituitary axis, disruption of appetite hormones, and its effects on lipid and glucose metabolism.

IFM’s 2016 conference shines the spotlight on daytime restorative processes like guided imagery, mindfulness activities, and meditation. Attendees will learn how to conduct a stress-reducing and mindfulness-based patient education class and they’ll hear from expert panels on how to help patients change their daily responses away from the familiar patterns of chronic stress. IFM is committed to providing clinicians with tools in this conference that they can use right away to make a difference in patient outcomes.

IMCJ: In a similar way, what has research provided recently that explains or changes the perspective on the connection between movement and health?

Dr Frates: Research studies reveal that physical activity affects all areas of the Functional Medicine Matrix from the center to each of the 7 nodes. The matrix provides an apt framework through which to address the ways in which movement impacts overall health.

As for the center of the matrix, exercise has been shown to improve memory, increase the size of the hippocampus, and increase levels of brain derived neurotrophic factor. Exercise studies have demonstrated an increase in mood and decreases in depression symptoms, anxiety, and stress levels. In addition, research reveals that exercise can improve psychosocial well-being and self-efficacy.

With respect to the defense and repair node of the Functional Medicine Matrix, exercise has been shown to improve the function of the immune system, decrease inflammation, and increase natural killer cell activity.

As for the energy node, exercise can increase energy and decrease fatigue. Research demonstrates that exercise is involved with the browning of white adipose tissue, which occurs by increasing the number of mitochondrial in the white adipose tissue. Exercise also is linked with increases in mitochondria biogenesis and increases in adenosine triphosphate, or ATP production.

In the biotransformation and elimination node, research indicates that exercise increases skeletal muscle glucose disposal as well as improves bowel function and elimination of waste.

When people think about exercise, they most often think of the benefits to the transport node, including increasing heart rate variability, increasing maximal oxygen consumption, improving anaerobic threshold, decreasing resting heart rate, decreasing blood pressure, decreasing LDL cholesterol, increasing HDL cholesterol, decreasing triglycerides as well as total cholesterol, increasing flow mediated dilation, increasing angiogenesis, and improving endothelial function.

With respect to the communication node, research demonstrates that exercise increases insulin sensitivity, reduces HbA1c, increases AMPK, increases nitric oxide, increases vagal tone, and decreases adrenergic activity.

Research on exercise has also been focused on the structural integrity node. It reveals that exercise can change body composition, increase muscle mass, reduce body fat, help maintain a healthy body mass index, increase fibrinolysis, decrease platelet adhesiveness, decrease fibrinogen, decrease blood viscosity, and increase fibrinolysis.

In the assimilation node, recent research is focusing on the effects of exercise on the microbiome. An article in Immunology & Cell Biology in December 2015 reported on the possibility that early-life exercise may promote lasting brain and metabolic health through gut bacterial metabolites.9

How do you help patients increase and sustain movement and activity levels across a lifespan and how do you inspire movement in a clinical setting? At the IFM’s 2016 Annual International Conference, clinicians who are helping patients make meaningful changes in their daily activity levels will share what works for them.

IMCJ: What will attendees take away from the conference in terms of skills and tools that can be implemented immediately in clinical practice?

Dr Hughes: Expert functional medicine practitioners will showcase the clinical tools and technologies they use to affect and track lifestyle modifications. Attendees will leave the conference with a deeper understanding of the physiology of each of these 4 overlooked lifestyle factors—sleep, restoration, fitness, and movement—as well as tools for working with patients to optimize these factors and improve health outcomes.

We have developed a collection of new clinical tools and patient education handouts that help clinicians and patients address these lifestyle factors in the real world. Clinicians will go home with practical tools to gather, track, organize, and interpret patient data and information around sleep, restoration, exercise, and movement. Focused questionnaires and organizing documents will allow clinicians to get a history of a patient’s lifestyle in the areas or rest and movement and implement appropriate changes in the office.

Our goal is for clinicians to leave with confidence, empowered to successfully work with patients in the critical areas of sleep, restoration, fitness, and movement.

Table 1
Age-standardized prevalence estimates for poor, intermediate, and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the American Heart Association 2020 goals among US adults aged ≥20 years, National Health and Nutrition ...

Footnotes

Facilitated by the Institute for Functional Medicine’s 2016 Annual International Conference held in San Diego, California, May 12 through 14, 2016.

References

1. Ornish D, Lin J, Chan JM, et al. Effect of comprehensive lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study. Lancet Oncol. 2013;14(11):1112–1120. [PubMed]
2. Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and counseling practices of primary care physicians: A national survey. Clin J Sport Med. 2000;10(1):40–48. [PubMed]
3. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics-2016 update: A report from the American Heart Association. Circulation. 2016;133(4):e38–e360. [PubMed]
4. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403. [PMC free article] [PubMed]
5. Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: Metaepidemiological study. Br J Sports Med. 2015;49(21):1414–1422. [PMC free article] [PubMed]
6. Exercise is Medicine. [Accessed March 18, 2016]. http://www.exerciseismedicine.org/
7. Shechter A, Grandner MA, St-Onge MP. The role of sleep in the control of food intake. Am J Lifestyle Med. 2014;8(6):371–374. [PMC free article] [PubMed]
8. Cappuccio FP, Cooper D, D’Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: A systematic review and meta-analysis of prospective studies. Eur Heart J. 2011;32(12):1484–1492. [PubMed]
9. Mika A, Fleshner M. Early-life exercise may promote lasting brain and metabolic health through gut bacterial metabolites. Immunol Cell Biol. 2016;94(2):151–157. [PubMed]

Articles from Integrative Medicine: A Clinician's Journal are provided here courtesy of InnoVision Media