lifestyle medicine for the PA student

1. Lifestyle Medicine for
the Physician Assistant
ASHWANI K. GARG, MD
NORTHSHORE UNIVERSITY HEALTHSYSTEM
BOARD CERTIFIED FAMILY MEDICINE AND LIFESTYLE MEDICINE
FELLOW, INTEGRATIVE MEDICINE

2. Learning Objectives
• Recognize the scope of the problem of chronic disease
• Define the specialty of lifestyle medicine
• List and explain the tools and treatment approaches of lifestyle medicine
• Rapidly develop a lifestyle treatment plan for a patient, including nutrition and
exercise prescription
• Describe the steps of certification for Physician Assistants in Lifestyle Medicine
• Apply additional billing codes to a lifestyle medicine visit

3. Chronic disease burden
• Chronic disease is known internationally as NCD (noncommunicable disease)
• Worldwide, chronic disease accounts for 60% of all death
• 35,000,000 worldwide (DOUBLE of all infectious disease, maternal/child death,
and nutrition deficiency COMBINED)
• According to World Health Organization, if risk factors were eliminated
• 80% of heart disease, stroke and type 2 diabetes can be prevented
• 40% of cancer can be prevented

4. Burden of Heart Disease
• Every 34 seconds, 1 American has a coronary event, and approximate every 1
minute 23 seconds, an American will die of one
• 1/6 deaths is related to heart disease (379,559 Americans)
• 620,200 will have a 1st heart attack
• 295,000 will have a recurrent heart attack
• 150,000 will have a SILENT heart attack
• CVD is the #1 cause of death globally (31% of ALL global death)

5. Even invasive therapy
is not significantly
effective
• COURAGE
• ORBITA
• ISCHEMIA
You can stent arteries but you can’t
stent an unhealthy lifestyle.

6. Epidemiology of
Diabetes
6Credit: Physicians Committee (with permission)

7. Cancer
• 1,700,000NEW cases of cancer will be diagnosed in the United States
•609,640people will die from the disease
• According to the AICR, estimated we can PREVENT 50% from happening
• Every day we have cancer cells developing; our body seeks/destroys
• Awareness? Or PREVENTION?

9. Lifestyle Medicine as a solution
• Lifestyle Medicine is the ONLY medical discipline
when applied, that has a net NEGATIVE cost for
the interventions, all of which are low cost and
high impact
• Lifestyle Medicine requires practitioners who are
ALSO devoted to the principles, reducing
“burnout”

10. Lifestyle Medicine as a specialty
• Lifestyle Medicine involves the use of evidence-based lifestyle therapeutic approaches,
such as a predominantly whole food, plant-based diet, exercise, sleep, stress management,
alcohol moderation and tobacco cessation, and other non-drug modalities, to prevent,
treat, and, oftentimes, reverse the lifestyle-related, chronic disease that's all too prevalent.
• 80% or more of all healthcare spending in the U.S. is tied to the treatment of
conditions rooted in poor lifestyle choices. Chronic diseases and conditions—
such as hypertension, heart disease, stroke, type 2 diabetes, obesity, osteoporosis,
multiple types of cancer—are among the most common, costly and preventable
of all health conditions.
• Lifestyle Medicine originated within the Am College of Preventive Medicine
• Lifestylemedicine.org (Lifestyle Medicine Core Curriculum)
• ABLM.CO (board cert available to PA and other professionals)

11. Dean Ornish, Early Pioneer
• Dean Ornish was the 1st to offer documented proof that
heart disease could be reversed by lifestyle
• Most patients, chest pain disappeared
• For 82%, artery clogging reversed
• This was REQUIRED READING during my medical
school years in the mid 1990s at Northwestern Feinberg
Medical School

12. What was the Ornish plan?
• Intensive lifestyle changes (10% low fat whole foods vegetarian diet, aerobic
exercise, stress management training, smoking cessation, group psychosocial
support) for 5 years.
• 1 year initial study extended to 5 years
• Decrease in stenosis in experimental group, increase in control group
• 2-1/2 times more events in the control group

13. Prevent & Reverse Heart Disease
• The Journal of Family
Practice. July 2014 Vol 63,
No 7 page 257
• DRESSELSTYN.COM

14. Tools of Lifestyle Medicine

15. Medical tools

16. VOLUME 28, ISSUE 5, P354-364, MAY 1, 2017

17. Tools of lifestyle medicine
• Motivational interviewing
• Art of interviewing patient, determining where they are at on the change spectrum,
and having them formulate a plan for themselves. In other words, getting them to do
what they want, and having them believe it was their idea.
• Group medical visit
• Groups of 10 to 20 clients, with facilitator, offering about 1-1/2 hour curriculum
• Can be billed as office visits with preparation
• Intensive lifestyle treatment (ILT)
Meet with client 1:1 every 1-2 weeks to follow them through the process
• Residential treatment
• Full immersion in lifestyle changes
• Intensive Cardiac Rehab (ICR) or “Ornish Program”

18. Other professionals in lifestyle medicine teams
• Physicians/Physician Assistants/Nurse Practitioners
• Registered Dietitians
• Personal Trainers
• Physical Therapists, Occupational Therapists
• Yoga/Tai Chi/Mindfulness Instructors
• Wellness coaches/nutritionists
• Culinary Medicine chef
• Health psychologists / Mindfulness Based Stress Reduction

19. Treatment Modalities of Lifestyle Medicine

20. Lifestyle Medicine:
Forks, Feet, Fingers, Stress, Sleep, Love
• Six Habits That Can Add Years to Your Life
• https://www.huffingtonpost.com/david-katz-md/healthy-lifestyle_b_884062.html

21. Forks: Plant-Based Nutrition

22. USA Food
Intake
22

24. Dietary Fiber intake
24
• Average intake in the USA is 15g/d for
women and 18g/d for men
• Most don’t meet adequate fiber intake
• Found in plant foods only, fiber improves
blood glucose control
• Fiber is linked to increased satiety and
reduced incidence of diabetes
Fiber Intake of the US population, What We Eat in America, NHANES 2009-2010
M. Katherine Hoy Ed. D, RD and Joseph D. Goldman, MA
Image: Ardmore Institute

25. Where do you get your protein?

26. Animal Proteins Tend to:
-Elevate Cholesterol
-Promote Heart Disease
-Increase osteoporosis
-Increase growth hormones / accelerate cancer cell growth
-Associated with Alzheimer’s, gout, kidney stones, gout, chronic
kidney disease, autoimmune diseases, and many others.

27. Plant Proteins Have
Opposite Effect:
nutritionstudies.org
A plant-based diet with adequate variety of foods and enough calories
will have enough protein
It’s not protein alone we need to worry about,
but many, many other nutrients
(vitamins/minerals/phytonutrients/antioxidants)

28. Nutrient Composition
Plant and Animal-Based Foods (Per 500 Calories of Energy)
1. USDA Nutrient Database for
Standard Reference.
http://ndb.nal.usda.gov/ndb/.
2. Holden JM, Eldridge AL, Beecher
GR, et al. “Carotenoid content of
U.S. foods: an update of the
database.” J. Food Comp. Anal.
12 (1999): 169–196.
3. The exact food listings in the
database were: Ground Beef,
80% lean meat/20% fat, raw;
Pork,fresh, ground, raw; Chicken,
broilers or fryers, meat and skin,
raw; Milk, dry, whole;
Spinach,raw; Tomatoes, red,
ripe, raw, year-round average;
Lima Beans, large, mature
seeds, raw; Peas,green, raw;
Potatoes, russet
*B12 is from soil bacteria and is variable; can be
obtained from supplements or supplemented
foods

29. Plant Foods are the best fuel for the body
• Nutrient-dense
• Anti-inflammatory, anti-oxidative stress
• Increased energy
• Optimized athletic performance
• Reduction and treatment of cancer
• Prevention AND reversal of heart disease

30. These foods do not have labels – more FARMacy
less PHARMacy

31. Power Plate guidelines:
(1)Eat a plant-based diet: fruits, vegetables, whole grains,
legumes
(2)Limit added fats (oil and animal products)
(3)Eat lower glycemic (beans, whole grains such as oats, sweet
potatoes, squash, berries and lentils)
(4)Aim for 40 gm of fiber/daily

32. Is eating “plants only”
healthy?
Statement by the Academy of Nutrition and Dietetics:
It is the position of the Academy of Nutrition and Dietetics that appropriately
planned vegetarian, including vegan, diets are healthful, nutritionally adequate,
and may provide health benefits for the prevention and treatment of certain
diseases. These diets are appropriate for all stages of the life cycle, including
pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for
athletes. Plant-based diets are more environmentally sustainable than diets rich in
animal products because they use fewer natural resources and are associated with
much less environmental damage. Vegetarians and vegans are at reduced risk of
certain health conditions, including ischemic heart disease, type 2 diabetes,
hypertension, certain types of cancer, and obesity… Vegans need reliable sources of
vitamin B-12
https://jandonline.org/article/S2212-2672(16)31192-3/abstract

33. Plant-Based
Intervention for
type 2 diabetes
33
Evidence of “low fat” and “high carb” approach:
• Walter Kempner MD (Rice Diet Program started 1939) Effect of rice diet on
diabetes mellitus associated with vascular disease (Postgrad Med. 1958 Oct;24(4):359-71)
• Anderson and Ward: High-carbohydrate, high-fiber diets for insulin-
treated men with diabetes mellitus insulin reduced more than ½. (Am J
Clin Nutr. 1979Nov;32(11):2312-21)
• Nathan Pritikin (1st book 1974) Long-term use of a high-complex-
carbohydrate, high-fiber, low-fat diet and exercise in the treatment of
NIDDM patients. (Diabetes Care. 1983 May-Jun;6(3):268-73.)
• Neil Barnard MD: A low-fat vegan diet improves glycemic control and
cardiovascular risk factors in a randomized clinical trial in individuals
with type 2 diabetes (Diabetes Care. 2006Aug;29(8):1777-83.)
• Rotterdam Study, Netherlands, prospective population based cohort
(Plant versus animal based diets and insulin resistance, prediabetes and
type 2 diabetes: the Rotterdam Study. Eur J Epidemiol. 2018Sep;33(9):883-893.
doi: 10.1007/s10654-018-0414-8. Epub 2018 Jun 8.)
• Dr. Hana Kahleova: A Plant-Based Meal Stimulates Incretin and Insulin
Secretion More Than an Energy- and Macronutrient-Matched Standard
Meal in Type 2 Diabetes: A Randomized Crossover Study.
(Nutrients. 2019Feb 26;11(3). pii: E486. doi: 10.3390/nu11030486.)

35. Nutrition Analysis
Go to 4leafsurvey.Com on your
browser, take a moment to enter your
data and see the results

36. Assessment of Nutrition Status
36
• Starting point for motivational interviewing
• Brings greater self-awareness and self-efficacy
• Establishes rapport
• Changes may be incremental small steps or a wholesale
change when discussing what is possible
• 4-leaf survey was created in 2012 and available in 8
languages, a rapid tool for identification of plant food
intake available free at 4leafsurvey.com; more
information at 4leafprogram.com
• Exercise: pause, go to 4leafsurvey.com on your device
and email yourself the results from the survey

37. • Code 99401 “Preventive Medicine, Individual
Counseling, 15 minutes”
• Payment can be only for non government
payors, in addition to E&M (not preventive)
code, wRVU 0.48
• Check with your compliance and billing
• Threshold for billing is 8 minutes (1/2 of the
visit time)
• Must document additional time spent,
assessment/counseling of nutrition
• Use ICD-10 code Z71.3 (diet counseling) and
Z71.82 if talking about exercise
Billing Codes for nutrition analysis
37

38. Feet: Exercise
• Goal
• 150 minutes / wk moderate intensity
or 75 min/wk of vigorous intensity
• Greater benefits with 300
minutes/week of moderate or 150
min/wk of vigorous activity
• Muscle strength 2d/week
(https://www.cdc.gov/physicalactivity/basics/adults/index.htm)

39. Exercise: Writing a prescription
• Frequency, Intensity, Time and Type (specific and measurable)
• Frequency: Exercise 3-5 days per week
• Intensity: Train at 60% of maximum heart rate
• Timing: 30-60 minutes daily
• Type: Aerobic (treadmill, cycle, power walking with weights)
Strength (light weights or yoga, resistance bands)
Stretching (yoga, tai chi, floor stretching)
Combination (7-minute workout by NY Times, other specific programs)

40. Fingers: smoking / drinking
• 480,000 die from smoking related illness yearly
• 80,000 die from alcohol yearly
• $300,000,000,000 annual costs (medical costs + lost productivity)
• 40+ cancers are related to tobacco use (1/3 of cancer death)
• Diseases: diabetes, rheumatoid arthritis, stroke/heart disease, COPD, impaired
immunity, reproductive problems in men and women, poor wound healing,
HPV related disease, AMRD, fracture, muscle pain, co-addiction
• QuitYes.Org, 1-866-Quit-Yes

41. 5 A’s for smoking cessation
• Ask (identify tobacco use/document EVERY TIME)
• Advise: strong, clear personalized advice to quit
• Assess: Is the user ready/willing to quit?
• Assist: counseling/pharmacotherapy
• Arrange: follow up, accountability, within 1 wk before quit date, 3d after
https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.html

42. Alcohol
• 17,000,000 adults have some form of alcohol disorder
• 26% of American adults are at risk drinkers or have mild alcohol disorder
• AUDIT-C (alcohol use disorder identification test)
• DrugAbuse.Gov AUDIT questionnaire

43. Sleep
• Culture: sleep is seen as inconvenient “wasted” time; extra work late night/early
• 20% of Americans sleep < 6h/night
• 37% of young adults sleep < 7h/night
• 10% of US adults seek medical attention for sleep disorders
• Sleep deficiency impairs function
• Circadian rhythm (light intensity, color; food, fluid, temperature)
• Sleep disorders (OSA, insomnia, PLMS)
• Treatment: Guided Imagery or CBT for Insomnia, herbal preparations, essential
oils, teas, exercise, mindful meditation

44. Sleep:
Short sleep is
associated with
(1) cognition impairment, mood disorders
(2) heart attack/stroke
(3) cancer
(4) accidents/injury

45. Stress
• 70% of primary care visits are related to stress and lifestyle
• Stress can make it less likely to engage in healthy habits
• Healthy habits can improve mood
• Perceived Stress Scale
• 10-question assessment to identify those who need closer follow-up
• 0-13: low
• 14-26: moderate
• 27-40: high

47. Mental health is related to outcomes
• Independent risk factor for coronary events (DOUBLE with depression)
• Endothelial dysfunction
• Lower heart rate variability
• Increased platelet adherence
• Worse lifestyle choices
• Diabetes is a risk factor for depression
• PHQ-2
• Over the last 2 weeks,
• Have you felt down, depressed or hopeless?
• Little interest or pleasure in doing things?

48. Nonpharmacologic stress management
Mindfulness, meditation, relaxation, contemplation
Abdominal breathing
Yoga/tai chi
Spirituality/fellowship
Nature therapy (Shinrin-Yoku)

49. Mindfulness
• Be like an observer of yourself
• Being present in the current moment
• Self-awareness, self-regulation
• Nonjudgement
• 10 minute mindfulness practice daily
• Mindfulness based stress reduction – group classes, usually 8 weeks, 9 sessions
• Course available through Coursera and Universitat Leyden:
De-Mystifying Mindfulness
https://academy.happiness.com/ - free MBSR course
Others – SoundsTrue.Com, Northwestern University Religious Studies dept

50. Zen: Mindfulness of the ordinary and every day
• Turning on the Water
Water flows from high in the mountains.
Water runs deep in the Earth.
Miraculously, water comes to us,
And sustains all life.
• Washing your Hands
Water flows over these hands.
May I use them skillfully
to heal those who are suffering and preserve our precious planet.

51. Love
• Compassion: maintain attitude of kindness, friendliness, gentleness towards self and
others
• Loving, caring relationships are essential in healing, both interpersonal and group
• Alone, we go faster
• Together, we go farther
• Showing compassion to others helps yourself and better outcomes for patients
• Healing presence
• Attitude of gratitude

52. Certifying in Lifestyle Medicine
Lifestyle Medicine certification as a professional or specialist is available to PhD
and master’s level candidates in a health or allied health discipline, NP’s, PA’s,
optometrists, podiatrists, chiropractors, naturopaths, psychotherapists, exercise
physiologists, OT’s, pharmacists, PT’s, SLP’s, psychologists, or dentists, as well as
medical doctors (MD and DO). Medical doctors can certify as lifestyle medicine
physicians or lifestyle medicine specialists, depending on experience and
education.

54. ABLM.CO: BOARD CERT REQUIRES 10h in-person / 30h online content
• Online content:
• ACLM/ACPM Lifestyle Medicine Core Competencies (LMCC) (view site)
• Institute of Lifestyle Medicine (Harvard) online courses (view site)
• e-Cornell certificate in plant-based nutrition (view site)
• EdX/Doane University Lifestyle Medicine Professional Certificate Program (view site)
• In-person learning:
• ACLM conferences & workshops (CME)(view site)
• Institute of Lifestyle Medicine (Harvard) conferences (CME)(view site)
• Food as Medicine conferences (CME)(view site)
• International Plant Based Nutrition Healthcare Conferences (CME) (view site)
• ACPM conference, lifestyle medicine stream (CME)
• Plant Based Prevention of Disease Conference 2018(view site)

55. Coaching mindset
• Coaching
• Partner
• Change facilitator
• Elicits client agenda
• Define possibilities together
• Focus on what’s right
• Discover answers together
• Dance with client
• Learn from client’s story
• Expert
• Authority
• Educator
• Defines agenda
• Solves problems
• Focus on what’s wrong
• Have all answers
• Wrestle with client
• Focus on own agenda, interrupt

56. Other training courses possible for PA’s
• Wellcoaches school of coaching
(https://www.wellcoachesschool.com/wellcoaches-certification)
• Certified Health and Wellness Coach
• Certified Personal Coach
• Wisdom of the Whole (https://www.wisdomofthewhole.com/)
• Food For Life by PCRM (https://www.pcrm.org/good-nutrition/plant-based-
diets/ffl)

57. • Code 99401 “Preventive Medicine, Individual Counseling, 15 minutes”
• Payment can be only for non government payors, in addition to E&M (not
preventive) code, wRVU 0.48
• Check with your compliance and billing
• Threshold for billing is 8 minutes (1/2 of the visit time)
• Must document additional time spent, assessment/counseling of nutrition
• Use ICD-10 code Z71.3 (diet counseling) and Z71.82 (exercise counseling) if
talking about exercise
Billing Codes for nutrition analysis
57

58. 58

61. VA’s Whole
Health Program
• VA.GOV/WholeHealth
• Includes movement,
mindfulness, work-life
balance, plant-based
eating, relationships, and
other modalities to deliver
cost-effective care within
the VA system

62. Summary
62
• The burden of chronic disease is staggering worldwide, with heart disease, cancer and
stroke taking 1,500,000 lives in the USA alone
• Lifestyle Medicine as a brand-new specialty seeks to treat the cause of chronic disease
• Just like traditional medicine has its tools and equipment, lifestyle medicine has special
modalities and disciplines
• Physician Assistants are uniquely qualified to participate in this brand-new specialty and
become leaders in the field. Lifestyle Medicine offers board certification on par with other
medical professionals for PA’s.
• Lifestyle Medicine also offers many tools for increasing reimbursement

63. • Team-based primary and specialty care
• Value based payments (payment for a diagnosis
and episodes of care instead of visits)
• Payment parity for physician assistants
• Removal of the physician supervision requirement
is possible in the future
• VA’s whole health program may offer unique
career opportunities
• Physician Assistants who certify in lifestyle
coaching and/or nutrition and cooking classes may
be able to have independent sources of income
Future Directions