Blog | Wednesday, August 20, 2014

Lifestyle medicine and the parable of the tiny parachute

A commentary was published on the blog site of the prestigious British Medical Journal telling us, in essence, that lifestyle medicine is ineffective. Specifically, it said that screening for chronic disease risk factors in the general population, and addressing them with lifestyle counseling in the clinical setting, is of no value.

The commentary was in response to a paper published in the BMJ that reached essentially the same conclusion. An accompanying editorial was entitled: “General health checks don’t work“ and began with “it’s time to let them go.”

The trial that provoked these responses randomized a large sample of Danish adults either to screening for chronic disease risk factors with tailored lifestyle counseling, or usual care. After 10 years, the 2 groups did not differ for the rate of heart disease or all-cause mortality.

One additional tidbit is worth noting, and a tidbit it is. The “intervention” consisted of three individualized lifestyle counseling sessions of 15 to 45 minutes each, spread over the first 3 years of the 10-year study period. If you will, the intervention was itself a tidbit of lifestyle counseling. Additional 6-group sessions were available, but that means even for the rare participants who took advantage of all offerings, less than 1 counseling session per year of observation. The sessions were made available to those study participants with overt chronic disease risk factors, including smoking, high alcohol intake, poor diet, and/or lack of physical activity.

I can’t help but initiate my reaction to all this with a rhetorical question: would anyone actually expect that between 45 minutes and 2 hours of clinical counseling over 3 years would meaningfully change health outcomes over 10 years for people who potentially smoke, drink, eat badly and avoid exercise?

To say the least, I would not. In fact, I would sum all this up metaphorically with the parable of the tiny parachute.

Imagine that the utility of parachutes was as yet unproven, and the task of proving their worth falls to us. We design an experiment accordingly. Parachutes are attached to—well, we can go with wine bottles; or ceramic eggs; or real eggs for that matter; or people if we are feeling brave—and these objects are tossed out of airplanes. A remote control device deploys the parachutes and we land to ascertain what we’ve wrought.

We find a mass of broken glass and splintered eggshells. Let’s hope we didn’t involve any live volunteers, or we would also find a jumble of mangled bodies. And so it is proven that parachutes are useless.

But we know that isn’t true. What if our parachutes were ridiculously tiny, each the size of a postage stamp? Or what if they were opened too late, each deployed within mere inches of the ground? Or maybe they were both too little and too late.

In that case, our experiment actually tells us nothing about the value of parachutes. It simply tells us that too little is too little, and too late is too late.

And so it is with lifestyle medicine. Of course it works, when it’s good medicine, timely, and dosed appropriately. The parable of the tiny parachute reveals that what might in fact be a highly effective intervention done right can be an entirely useless intervention done wrong. We are mostly doing it wrong.

For one thing, we are working against a monumental force. In the case of the parachute, the monumental force is gravity. A parachute works, of course, but even at its best, it only slows our fall rather than stopping it. A pervasive, relentless force wins against even good interventions.

In the case of obesity and chronic disease, that force pervades our culture; or more bluntly, it is our culture. Schedules that preclude time and attention to health until there is virtually no good choice left; a food supply willfully adulterated to strip away nutritional value and maximize the calories it takes to feel full; an ever greater variety of labor saving technologies; and so on. Worst of all is the hypocrisy of a culture that frets about the health of its children, but nonetheless sanctions the aggressive peddling to them of multicolored marshmallows and the like, calling such junk “part of a complete breakfast,” adding to the blatant, epidemiologic injury an insult to our intelligence.

The power of lifestyle medicine is best revealed where lifestyle is working as medicine throughout the expanse of culture, rather than delivered in medicine as an antidote to cultural misdeeds. The world’s Blue Zones exemplify this. The longest-lived, healthiest, happiest people on the planet do not attribute these blessings to high quality clinical counseling; they attribute them to a culture that puts health on the path of lesser resistance, and to prevailing norms.

That said, high quality clinical counseling can make a difference, and is most needed where culture is least salutary. But it must be high quality counseling, and most of what is provided by non-experts falls well short of that bar.

Models exist that adapt the best behavior modification techniques into the primary care setting; my colleagues and I have developed one such, available for free. Intensive skill-building programs can do far more to help people lose weight and find health than a few sessions with a clinician spread over years. And when the problem is advanced, such as severe obesity in teens, the evidence favors truly immersive therapy to offer an adequate dose of the lifestyle remedy.

Clinicians can and should play an important role in delivering lifestyle as medicine. For that to happen, the standards of such counseling, and affiliated programming, need to rise. I am privileged to serve at present as President of the American College of Lifestyle Medicine, an organization devoted both to this proposition, and to the propagation of programs that empower clinicians to provide better help, and empower patients to put good guidance to better use. We have an exciting conference coming up in the fall, so please click here if interested in learning more. We have sister organizations around the world, helping us turn lifestyle medicine into the global movement it should be.

Good clinical counseling can function like a good parachute; it can make a meaningful difference. We simply don’t see such benefit when we do too little, too late.

We can, however, do even better than the best of parachutes. We can never eliminate the downward pull of gravity; we can only resist it. But we can reverse the downward drag of culture on our collective health. We can use clinics to provide customized guidance toward better health, but we could also use our culture to put health for all on a path of lesser resistance. I have elaborated the details of what I think that effort would entail on a number of prior occasions, and invite the action-oriented to see them here, and here, and here, and here and here.

For everyone else, the parable will suffice. Of course parachutes work, but only when they are good parachutes.

When we administer lifestyle medicine effectively not just in clinics, but throughout our culture, we can do even better than slow our fall. We can climb.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.