Cleveland Heartlab 5th Annual Symposium: Erin Martin, High Touch, Low Tech: Reversing Disease with Lifestyle Medicine

1. High Touch, Low Tech:
Reversing Disease with
Lifestyle Medicine
Erin Martin D.O., MPH
TrueMed Institute
Center for Integrative Medicine
Hood River, Oregon

2. Dr. Martin has no affiliations or conflicts to
declare.

7. ICD-10

8. Why We’re Failing:
• Lack of Time
• Lack of Knowledge
• Lack of Resources
• Lack of Caring
• Lack of Reimbursement
• Lack of Public Education

10. 20%

11. What Does This Mean?

12. Here’s the Big Problem...
• Physician involvement in promoting therapeutic lifestyle
change (TLC) therapy is too low:
• 2007 National Ambulatory Medical Care Survey showed pharmaceutical
medications were prescribed at 73% of visits in which high cholesterol was
initially diagnosed vs. 8-12% of visits in which counseling or education
services related to diet or nutrition and exercise were ordered or provided.1
• Why is this?
• “At present, dietary counseling by clinicians in primary care does not typically
contain consistent, clear suggestions for specific change, how these could be
achieved, and how progress would be monitored.”2
• “Most primary care providers believe physical activity (PA) counseling is
important and that they have a role in promoting PA among their patients.
However, providers are uncertain about the effectiveness of counseling, feel
uncomfortable providing detailed advice about PA, and cite lack of time,
training and reimbursement as barriers. Providers are more likely to counsel
their patients about PA if they are active themselves, or if they feel their
patients' medical condition would benefit from a lifestyle change.”3

13. So Why Do We
Think We Have to
Do it All Ourselves?
Because We Don’t!

14. Nurses Nutritionists/Dietitians Health Coaches
We Have Help!

15. WHY A TEAM-BASED
APPROACH?
Brief advice (involving five minutes or less of counseling),
including repeated advice to quit smoking during
healthcare visits, may be effective in some patients.
However, to achieve moderate changes in diet and
physical activity, medium (30-360 min) or high
intensity (>360 min.) counseling is usually required.4

16. Medium/High Intensity Diet and/or Physical
Activity Counseling: Does It Work?
• Primary outcomes
↓% energy saturated fat: 2.8–3.7%
↑fruit and vegetable:
• 0.4–2 serving/day
(Conventional Model)
↑PA: 38 min/week

17. Hallmarks of a Successful TLC Program
Initial Visit
TLC Panel:
•Advanced Lipid Panel
•hs-CRP
•HgA1c
•Fasting Insulin
•Homocysteine
•CMP, CBC
•25-OH Vitamin D
Follow-up Visit #1
•Review Labs (60 min.)
•Provide Resources
•Initiate TLC Program
•Exercise Rx (150 min./wk)
•Make Appt. w/Health Coach
Health Coach Program
•Custom Nutrition Program
•Bi-monthly visits (50 min.)
•Goal-setting
•Monthly BIA’s
•Stress Management **
•Lifestyle Change Support
•Accountability
6 wks
Follow-up Visit #2
•Evaluate & Intensify
•Diet
•Weight Loss
•Exercise
•Stress Management
•Complimentary Therapies
6 wks
REPEAT
LABS
Follow-up Visit #3
•Evaluate & Intensify
•Revise Custom Nutrition Plan
•Revise Exercise Rx
•Trouble Shoot Road Blocks
•? Repeat HgA1c, Glycomark
Provider Conference
with
Health Coach
6-12 wks
Maintenance vs.
Consider
Pharm.
Therapy

18. How Does it Look to Do Things Differently?

19. What it Looks Like
• Fewer Patient Visits
• Longer Visits (30-60 min.)
• A Plan & Commitment to Educate
• Get Educated Yourself!
• Health Coaches/Lifestyle Educators
• Goal Setting
• Group Classes (possibly)

20. How Does It WORK?
• Many Models
๏Hybrid Practices
๏Out-of Network
๏? Opt-out of Medicare
๏Fee for Service
๏Insurance with other
Services

21. But TLC can Benefit
so Many Patients,
How Do I Choose
What to Focus On?

22. Target Specific Disease Populations
• Many Diseases Affected by Lifestyle
• You Can’t Be the Jack-of-All-Trades
• Become the EXPERT in what your Patients need
MOST.
• Use Ancillary and/or Mid-Level Providers to cover other
areas as needed.
(Example: Physician provides cardiometabolic basic
training and health coach/lifestyle educator addresses
stress management, etc.)

24. How Does It Actually
Happen?
Getting the Train
to Leave the Station...

26. Making It Happen
✓You’re Committed You’re Staff is Committed
✓Make Small Changes Toward Goal to Start
➡Schedule longer visits to review labs with patients
➡More Frequent Follow-up Visits
➡Start Looking for Help - Ancillaries/Mid-Levels
✓Get Trained & Stay Focused (Don’t get distracted by “fancy
medicine,” most of it has no evidence that it makes long-term difference)
✓Don’t Take the Easy Way Out

27. It Takes: More Time,
More Focus,
More Energy
To Do Things Right
But...

28. You’ll get more high fives, more patient buy-in,
more job satisfaction, better patient outcomes,
less work in the long run...

29. ...and you’ll re-discover why you wanted to
become a doctor in the first place.

32. KEY POINTS TO GET
REALLY CLEAR ON...

33. What do you want to
offer?

34. Who is your audience?
(aka what specific conditions will
you target?)

35. How much time do you
need?

36. What is the financial
structure?

38. References
1. US Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: recommendations
and rationale. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=3494&nbr=2720.
2. Phillips K, Wood F, Spanou C, et al.; PRE-EMPT Team. Counselling patients about behaviour change:
the challenge of talking about diet. British Journal of General Practice 2012;62(594):e13−21.
3. Hébert ET, Caughy MO, Shuval K. Primary care providers' perceptions of physical activity counselling in a clinical setting:
a systematic review. British Journal of Sports Medicine 2012;46(9):625−31.
4. Lin JS, O’Connor E, Whitlock EP, et al. Behavioral Counseling to Promote Physical Activity and a Healthful Diet to
Prevent Cardiovascular Disease in Adults: Update of the Evidence for the US Preventive Services Task Force. Rockville,
MD: Agency for Healthcare Research and Quality; 2010. Available at www.ncbi.nlm.nih.gov/books/NBK51030.

39. Stay Connected
Please follow me
@DrErinMartin
DrErinMartin