Ironically, many healthcare providers–doctors, nurses, physician and medical assistants–are not trained in “health” at all but in “medicine” instead. Often, as providers, our instinct is to first reach for a pill bottle or a procedure and forget about lifestyle changes that could be safer and more financially feasible for our patients. As the burden of chronic disease continues to increase, it is crucial for providers to remember that first-line treatment might not be a prescription at all but simple, focused counseling.
I recently attended a keynote address by a public health physician who was passionate about innovating primary care. He compared two clinic models, showing how a patient with hypertension can go from not taking her medications to being compliant with her prescriptions. This speaker pointed to the second model and called it the “ideal health service delivery.” But something was still missing. Both models completely skipped over lifestyle measures. Many times, first-line therapy for elevated blood pressure is a diuretic–it should be losing weight and exercising, abstaining from tobacco and alcohol use, and decreasing sodium and fat intake. Treatment might come from the everyday behaviors of the patient rather than a prescription.
This issue is even more important since the latest guidelines from the American Heart Association and American College of Cardiology lower the definition of stage 1 hypertension from 140/90 mmHg to 130/80 mmHg. This change increases the estimated number of adults with high blood pressure by over 30 million. Previously, 130/80 mmHg was known as “prehypertension,” partly to encourage discussion of lifestyle changes to prevent or delay patients from tipping over into hypertension. Unfortunately, there is little evidence that these discussions happened.
Of course, not everyone can avoid medications or be successfully weaned off them. Some patients are too high-risk, others may not be able to change their lifestyles, and even among those who can change behaviors, the change and the time for it to be effective may be more than a few months. Others would point out that lifestyle changes depend on the patient, that a provider cannot control a patient’s diet or decision to smoke. While this is true–only that person can decide when they are ready to change–it is equally valid that patients do not always take their medications. In fact, on average 25% of prescriptions are taken incorrectly or not at all, a staggering number made even more troubling if the drug wasn’t indicated in the first place.
Despite the difficulty, health behaviors are still worth discussing with patients because of their potential. A multi-center clinical trial showed that a 4.4-pound weight loss nearly halved the progression of prediabetes to diabetes over a 10-year period when compared to metformin. We need to be teaching young trainees–and reminding older practitioners–to go back to the basics, to show that improving the health of individual patients and populations does not necessarily come from increased medicalization but changes in habits and attitudes of the public. Additionally, lifestyle changes can save money. A Swedish primary care-based trial showed cost-savings from enrollees in a diet counseling and physical exercise program.
As providers, we’ve navigated behavior chance conversations before. Many providers are quite good at talking about tobacco use. Clinics in primary care and several other specialties like cardiology, oncology, and nephrology routinely screen for cigarette use and utilize a wide range of options–from a simple conversation to a referral for a behavioral health specialist. There is a system in place and dedicated resources to help facilitate smoking cessation discussions and drive these decisions.
As healthcare shifts towards value-based care, it is time to start incorporating behavioral and lifestyle change counseling and programs into our everyday practice. It will be difficult, and incredibly taxing on an already overly-taxed workforce. To make it easier, let’s invest in research and new ways to promote these types of discussions in clinical settings. Lifestyle changes are good for our patients and good for the healthcare system. Our goal shouldn’t be ideal health service delivery but ideal health delivery.
Eunice Zhang