Wellness, Weight Loss, and Disease Prevention With the 5 Keys to Healthy Lifestyle Change
Tom Rifai, MD
Rifai T. Wellness, weight loss, and disease prevention with the 5 keys to healthy lifestyle change. Consultant. 2018;58(2):53-57.
Consistent with robust and emerging evidence from randomized controlled trials (RCTs) and observations of populations characterized by longevity,1-3 as well as through thousands of patients’ worth of clinical and personal experience as a physician and recovering overweight binge eater, I have learned how powerful therapeutic lifestyle is as a medicine. Lifestyle can drive, treat, or prevent many of the biggest contributors to premature death and reduced quality of life, particularly in the context of disease epidemics resulting from sedentariness and the standard American diet. For example, type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD) risks could be reduced by as much as 90%, especially in at-risk populations, by adopting a therapeutic lifestyle basis to medical care.4
Since as early as 1993, the top 3 causes of premature death have been related to what is done with forks (unhealthy food), fingers (smoking), and feet (low levels of physical activity), and these 3 factors alone accounted for 80% of premature death in the United States.5 The US Preventive Services Task Force (USPSTF) now recognizes 3 areas of metabolic health for which intensive lifestyle interventions may be effective: cardiometabolic risk (eg, dyslipidemia, hypertension, type 2 diabetes), prediabetes, and obesity.6-8
Therapeutic lifestyle change (TLC), especially in at-risk populations such as the estimated 30.3 million adults with diabetes and the 84.1 million with prediabetes9 and the additional millions with metabolic syndrome and overweight or obesity, has the potential to massively reduce lifestyle-driven metabolic disease-related costs and to markedly reduce lifetime risks for premature death and disability from cardiovascular events, cancers, dementia, chronic kidney disease, osteoporosis, and more, while at the same time improving quality of life with beneficial effects on mood, pain, and function. In short, lifestyle medicine is, or should be, the first line of defense against most modern chronic diseases.
With so many Americans at cardiometabolic risk, it is important that primary care providers identify lifestyle-driven risk factors and prescribe appropriate therapy, primarily lifestyle-based therapy. Addressing risk factors through lifestyle modification early in the continuum of disease risk could substantially improve patients’ quality and quantity of life.
Medical Intervention: Benefits and Risks
If the healing power of even modest lifestyle change could be encapsulated in a pill, it might easily be the biggest blockbuster drug in the history of humankind. However, treating metabolic conditions with medications is fraught with balancing benefit and risk. For example, statins can effectively reduce ASCVD risk in patients at elevated risk, but they are associated with an increased risk of myopathy and may increase the risk of type 2 diabetes. This occurs not only as a result of direct toxicity,10 but also simply because many people use statins as a rationalization to eat more, which blunts the drugs’ benefits.11 β-blockers may lower blood pressure in patients with hypertension, but some also may increase the risk of type 2 diabetes and pose a challenge to patients who are trying to lose weight, possibly by reducing tolerance to brisk physical activity.
In one of the largest RCTs of TLC, the Diabetes Prevention Program (DPP),2 intervention with metformin reduced the occurrence rate of type 2 diabetes by 31% in a high-risk population of patients with prediabetes. In contrast, a moderate 7% weight loss and 150 minutes per week of moderately intense physical activity resulted in a 58% risk reduction. It is also notable that metformin, despite its low-cost generic status and solid safety record, is prescribed to less than 10% of persons with prediabetes who qualify for it under American Diabetes Association guidelines. And if any drug could challenge lifestyle for effective disease prevention, it is metformin. Yet follow-up data more than 10 years after the DPP showed that participants assigned to lifestyle intervention still had a 34% reduction in the risk of type 2 diabetes vs participants in the placebo-usual care group2—still about double the benefit of metformin, our best disease-prevention drug in terms of cost, risk, and effectiveness combined. And the participants in the lifestyle arm who started the trial at age 60 years or older had a nearly 50% reduction in the risk of type 2 diabetes 10 years later, along with substantially improved quality of life.2 And metformin has associated risks, albeit mild ones, including gastrointestinal tract intolerance and vitamin B12 insufficiency.12
Therapeutic Lifestyle Change
Establishing long-lasting TLC after what might have been decades of a metabolically risky lifestyle is a long-term process, far more like a marathon than a sprint. This is not to say that coming out of the gate strong (ie, losing weight rapidly at first) is bad; it is not. Nevertheless, while dramatic initial behavior changes and their associated results increase the odds for longer-term success,13 the chances in the United States and most Westernized societies for further and sustained improvements in longevity are low, due in large part to potent environmental factors pushing toward metabolically risky behaviors. These factors include a dramatic shift from labor jobs to a more automated and chair-based work environment, with meaningful physical activity no longer required to sustain life; the ubiquity of highly calorie-rich and processed (CRAP) foods and beverages leading to increases in calorie and sodium intake. And to pour salt into the proverbial wound, there has been a concomitant marked increase in portion sizes. As such, TLC requires multiple face-to-face encounters for strategizing and planning. It also very much means accepting inevitable “slips” as opportunities to learn how to continue to hone skills in achieving and maintaining TLC for the long term rather than excessively worrying about any single event or moment in time.
Establishing effective TLC is analogous to learning a martial art. Individuals need to be motivated, because they will be bruised in “sparring sessions” on their way to better health. And in the process, they will go through a series of stages, similar to progressing from a white belt to a black belt, before achieving a self-sustainable level of skill and confidence.
Evidence suggests that at least 2 years of maintaining comprehensive lifestyle adjustment is necessary before the odds of long-term success greatly improve.14 In that time, individuals will need multiple episodes of healthy lifestyle training, ideally including regularly scheduled 1-on-1 or group education/counseling sessions, mental and physical exercises (such as lifestyle education sessions, grocery shopping tours, cooking demonstrations, dining experiences with professionals, and mindful eating exercises), cognitive behavioral therapy, and biochemical and physical testing that reflects achievements, signifying improving levels of proficiency.
Numerous experts and committees, including the USPSTF, the American Heart Association (AHA), and the American College of Cardiology (ACC), have recognized that TLC is best achieved through an intensive lifestyle intervention (ILI), where intensive refers to the time spent on developing new behaviors and skills rather than a myopic focus on diet plan of calorie restriction.6-8,15
In 2013, the AHA and ACC published ILI guidelines that describe comprehensive approaches that include nutrition, physical activity, and behavior therapy delivered over a minimum of 6 months by trained interventionists such as registered dietitians, psychologists, exercise specialists, and health counselors.15 Such time-intensive and comprehensive approaches are described as being more effective for achieving meaningful TLC than usual care alone.
USPSTF recommendations note that to be an effective ILI, at least 12 and up to 26 sessions must occur within 1 year, and that the most effective high-intensity interventions include “multiple behavioral management activities, such as group sessions, individual sessions, setting weight-loss goals, improving diet or nutrition, physical activity sessions, addressing barriers to change, active use of self-monitoring, and strategizing on how to maintain lifestyle changes.”8
Whether primary care providers attempt to provide ILI themselves (a challenging undertaking in our disease-care health care paradigm, to say the least) or refer patients to a high-quality, structured program, it is critical that they stay connected with their patients and understand the multiple aspects of lifestyle change that their patients will face while providing good health-coaching skills in the process. For TLC to be effective, both the patient and the health care provider must expect the process to take time and to require that multiple barriers to change be addressed. Patience, in this instance, is truly a virtue.
5 Keys to Healthy Lifestyle Change
To help patients and providers in the process of TLC, I have developed the 5 Keys to Healthy Lifestyle Change (Sidebar). The keys represent 5 different but interrelated and interdependent areas of focus: nutrition, physical activity, mind matters (psychological), environments (food, social, and physical), and accountability (largely reflecting monitoring and feedback). Ignoring any 1 of them places at risk the patient’s odds of long-term TLC success. Conversely, successfully addressing 1 key will subsequently improve at least some of the others. For instance, by addressing food choices available in the home (environment), or by addressing conflict-resolution skills (mind matters), nutrition typically improves. And engaging in regular brisk physical activity can help improve mood, outlook, and confidence (mind matters).
Organizing TLC into these 5 key domains can help patients and health care providers avoid getting lost in a sea of overwhelming interdependent but separate areas, each of which requires somewhat separate skill-building and attention. The 5 Keys can guide health care providers and patients toward finding where their energy is best focused and finding where their “reality meets science”—that is, translating science-based therapeutic lifestyle evidence into practical, achievable, step-by-step clinical applications.
By organizing history-taking and counseling into the 5 Keys, health care providers can be more effective, focused, and efficient in treating their patients. Each of the 5 Keys to Healthy Lifestyle Change should be addressed throughout the months of intervention and health coaching in order to increase the likelihood of establishing long-lasting healthy lifestyle change. Visits may focus on 1 very critical key or may focus on small achievable points within several keys. Ideally, action plans should be written so that patients can take the plans with them.
Successful long-term TLC is a complex and prolonged process, and having a guide to organize it is important. Time constraints typically make it impossible for most practitioners to focus on all of the necessary core aspects at once, and dividing process into multiple meetings and using the 5 Keys to Healthy Lifestyle Change to guide each meeting is a practical way of addressing this complex process. Addressing just 1 key will still likely have some downstream benefit to 1 or more of the other keys. Ultimately, understanding all 5 of these critical separate but interdependent keys of TLC can help you better manage your patients on their journey to a healthy, lower disease-risk lifestyle.
Tom Rifai, MD, is the Regional Medical Director of Metabolic Health and Weight Management for the Henry Ford Health System in Metro Detroit, Michigan; a clinical assistant professor of medicine at Wayne State University in Detroit, Michigan; and the founder of the health and wellness company Reality Meets Science. He is a fellow of the American College Physicians.
- Buettner D. The Blue Zones: 9 Lessons for Living Longer From the People Who’ve Lived the Longest. 2nd ed. Washington, DC: National Geographic Society; 2012.
- Knowler WC, Fowler SE, Hamman RF, et al; Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-1686.
- Pi-Sunyer X, Blackburn G, Brancati FL, et al; Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the Look AHEAD trial. Diabetes Care. 2007;30(6):1374-1383.
- Yang Q, Cogswell ME, Flanders WD, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307(12):1273-1283.
- McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270(18):2207-2212.
- LeFevre ML; US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(8):587-593.
- Siu AL; US Preventive Services Task Force. Screening for abnormal blood glucose and type 2 diabetes mellitus: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(11):861-868.
- Moyer VA; US Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373-378.
- Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017: Estimates of Diabetes and Its Burden in the United States. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed January 25, 2018.
- Ganda OP. Statin-induced diabetes: incidence, mechanisms, and implications. F1000Res. 2016;5:F1000 Faculty Rev-1499. doi:10.12688/f1000research.8629.1
- Huff C. The never-ending push-pull of statins. ACP Internist. April 2017. https://www.acpinternist.org/archives/2017/04/statins.htm. Accessed January 25, 2018.
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- Wadden TA, Neiberg RH, Wing RR, et al; Look AHEAD Research Group. Four-year weight losses in the Look AHEAD study: factors associated with long-term success. Obesity. 2011;19(10):1987-1998.
- Research findings. National Weight Control Registry. http://www.nwcr.ws/Research/published%20research.htm. Accessed January 25, 2018.
- Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S76-S99.