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Journal of Family Medicine and Disease Prevention





DOI: 10.23937/2469-5793/1510007



Expanding the Art-Science of Chronic Disease Management in Primary Care: A Lifestyle Medicine Perspective

Garry Egger*


Centre for Health Promotion and Research, Lifestyle Medicine and Applied Health Promotion, Southern Cross University, Australia


*Corresponding author: Garry Egger, AM, MPH, PhD, Director, Centre for Health Promotion and Research, Sydney, Adjunct Professor, Lifestyle Medicine and Applied Health Promotion, Southern Cross University, 14 Arthur St., FAIRLIGHT, NSW 2094, Australia, Tel: 61-2-99777753, E-mail: eggergj@ozemail.com.au
J Fam Med Dis Prev, JFMDP-1-007, (Volume 1, Issue 2), Perspective; ISSN: 2469-5793
Received: 6 April, 2015 | Accepted: July 28, 2015 | Published: August 01, 2015
Citation: Egger G (2015) Expanding the Art-Science of Chronic Disease Management in Primary Care: A Lifestyle Medicine Perspective. J Fam Med Dis Prev 1:007. 10.23937/2469-5793/1510007
Copyright: © 2015 Egger G. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.



Abstract

• An adjunct discipline of Lifestyle Medicine has arisen in the last decade to deal with environmentally driven lifestyle-related chronic disease

• To date however, there has been little structure or pedagogy around this form of practice

• The current paper considers such a structure under the headings of 'knowledge' 'skills/procedures' and 'tools'.

Changes in living patterns typically result in changes in disease structures within a society. The 'epidemiological transition', which describes the shift from infectious to chronic diseases for example, is common as countries shift from agrarian to industrial lifestyles [1]. Population levels of obesity for example change as societies become more developed, with equivalent BMIs pre development apparently less dangerous than during or after development, as shown recently in China [2]. Health practices then need to be modified to deal with such changes: Hence, the rise of a discipline of Lifestyle Medicine (LM) [3].

Professional associations in LM have arisen in the US, Europe and Australasia. Post-graduate specialties are currently offered in a number of Universities and texts and specialist journals are increasing [4,5]. Yet apart from recognizing the contribution of lifestyle and environmental factors to disease, the field has yet to develop its own structure or pedagogy. If it is to have a function, its contributions to existing care need to be elaborated.


Defining the Field

Lifestyle Medicine has been defined as: "...the application of environmental, behavioural, medical and motivational principles, including self care and self-management, to the management of lifestyle-related health problems in a clinical setting" [5]. The current state of the discipline can be summarised under three headings: 1. knowledge, 2. skills and procedures, and 3. tools.


Developing the Knowledge Base

With infectious diseases, causality can usually be ascribed to biological causes, using classical principles such as Koch's postulates [6]. With chronic disease, establishing causality is more problematic [7]. The closest we can often get is in defining determinants, or drivers, of disease.

The discovery of a new form of low grade, systemic, inflammation ('metaflammation') [8], linked with most, if not all, major classes of chronic disease, helps to delineate such determinants.

Metaflammation contrasts with the more classical type of inflammation first described by Aurelius Celsus some 2,500 years ago. As biological pathogens are usually not causally linked to this category of disease [9], ascription is limited to the level of lifestyle and environmental determinants associated with the major classes of modern chronic disease, in most, if not all, cases accompanied by metaflammation [10]. Considered as a whole, the determinants of chronic disease have been labeled 'anthropogens', or 'man-made environments, their bi-products, and/or lifestyles encouraged by those environments, some of which have biological effects which may be detrimental to human health' [11].

A limited number of anthropogens (poor nutrition, inactivity, stress, smoking) have been identified as explaining a significant proportion of chronic disease [12-14]. However there are other less apparent but still significant determinants that have been identified in the literature, all of which are directly, or indirectly associated with chronic disease, and most, if not all all of which have evidence of a metaflammatory association [10]. Table 1 provides a broad list of these, covering chronic disease determinants from proximal to distal.



Table 1: Lifestyle and environmentally related determinants of chronic disease View Table 1


Expanding Procedural Skills

While the science (epidemiology) of chronic disease is relatively well understood, a distinctive 'art', including the skills and procedures required to change unhealthy lifestyles and the environments driving these, is less clear. Environmental change for example is generally seen as a public health issue, primarily because this has involved largely structural (eg. sewerage, water, food quality etc) interventions. Modern environments on the other hand (eg. the obesogenic, profit-based, growth driven. environment) drive behaviour, making environmental health a significant part of LM. The link with traditional public health thus needs further elaboration.

At the behaviour change level, while all the usual counseling skills (motivational interviewing, health coaching, cognitive behaviour therapy, self management training etc) are necessary, they may not be sufficient for dealing with behaviours and the environments driving chronic diseases. Management may thus require a lateral shift.

At a conventional level, it has been assumed that the clinical process of one-on-one (1:1) counseling (despite the lack of data supporting this over other forms of clinical engagement), is set in stone and would play the part in chronic disease management that it has successfully done in the past for acute diseases and injury.

Yet chronic diseases (cardio-vascular, respiratory, metabolic, carcinogenic diseases, and even clinically severe obesity) have distinct requirements over acute care. By definition, they are long-term and need ongoing, often lifetime, attention. Secondly they have their determinants in complex behaviours that are difficult to change, rather than microbial causes. Consequently short consultations, as afforded by Medicare recompense determined in an acute disease era, are unlikely to be totally appropriate.

Health education in groups, with an experienced leader (diabetes educator, dietitian, exercise physiologist etc) arose to help overcome these problems, and education programs were developed in different countries in the late 20th Century to deal with this. But group education lacks medical input and has had limited uptake in medical payments systems. Individual 1:1 consulting on the other hand, has medical input, but lacks the educational component and time and peer support associated with group education.

Shared Medical Appointments (SMAs), are"...consecutive individual medical visits in a supportive group setting where all can listen, interact, and learn," [15]. SMAs involve 10-12 patients at a time over 1 to 1.5 hours, with a doctor and facilitator, who is usually a health professional experienced in group dynamics, and whose goal is to keep the consultations on track and utilize the peer support of the group [15]. SMAs have been used as an adjunct clinical approach in the US, Canada, and other countries and have now been successfully trialed in Australia [16]. They provide more time with the doctor, increased peer support, and greater opportunity for self-management. SMAs sit between clinical 1:1 care and group education as shown in figure 1. In the future they are likely to become part of the procedures defining Lifestyle Medicine.


.
Figure 1: Where SMAs FIT View Figure 1



.




Utilizing Tools

LM tools are centred mainly around the concept of the 'quantified self' [17], which is evolving the role of patient from a minimally informed recipient to an active collaborator in the patient-provider relationship. Improvements in technology however, have given rise to new devices and developments called 'mHealth', or health care and public health practices supported by mobile devices and other advances in telemetry (Table 2).



Table 2: LM 'Tools' View Table 2


Limited evaluations of single mHealth devices have appeared in the literature since 2003, shadowing the recognition of chronic ailments as a rising category of disease. Now two systematic reviews of such devices, have highlighted the potential of these as a new set of tools for chronic disease management [18,19].

A recent review notes that "Increasing adherence may have a greater effect on health than improvements in specific medical therapy [20]." Well controlled studies comparing adherence with mHealth devices compared to prescriptive advice controls typically show a 50% improvement in adherence from the former, more than justifying a serious look at these for chronic disease management.

SMS messages are the most popular current mHealth devices, used for medication reminders, education, or information about disease management. Simple SMS reminders or information about new programs or treatments are not only effective, but cost effective. As an example, one of us (GE) involved in the 1990s development of the successful men's waist loss program (GutBuster's) [21] found weekly advertising costs of $10,000 for recruiting men through mainstream media crippling, leading to the early retirement of the program.

Operating out of medical centres we have now found a personal SMS invitation to 10 times the desired number of men to fill a Shared Medical Appointment group of 10-12, identified through medical records systems as falling within the required audience (eg. BMI>35; Metabolic Syndrome etc), is not only successful, but virtually cost free. SMS is also used for follow-up weekly tips. Fine targeting, combined with a personalized invitation from the patient's GP could hold the key to better long-term chronic disease management in a number of disease areas [22].

Other mHealth devices include mobile phones plus software or applications, specific medical telemetry devices or phone plus wireless or Bluetooth compatible devices. Between them, these devices not only deliver education and reminders, but monitor functions such as blood pressure, heart rate and blood sugars to patients and providers.

Multiple outcome measures were used in the most recent review, including usability, feasibility and acceptability of the mHealth tools studied as well as adherence and disease specific outcomes. Examples of improved management included reduced HbA1C, hyperglycemic events and blood pressure, and improved lung function, use of nebulizers, fitness levels etc.

mHealth tools were also found to increase self-care awareness and knowledge, improve patient confidence to monitor chronic diseases, and decrease anxiety about disease. Improvements were noted across all age and SE categories. As might be expected, take up and use by adolescents, was shown to be particularly effective. Significantly, a mHealth system between the patient and provider was less burdensome and judgmental compared to face-to-face contact, making such tools likely to be even more effective in a Shared Medical Appointments context, or with individuals who are adverse to the 'scary' doctor-patient environment in a closed setting, such as Indigenous individuals.

When added to other modern telemetry tools such as movement sensors, portable sleep monitors, Bio-Impedence Analysis scales (BIA), grip strength dynanometers, pulse measures and other 'tools', for self-monitoring, motivation, brief assessments, self-care (primary prevention) and self-management (secondary/tertiary prevention), the future for chronic disease management, and the potential for lifestyle-related disease management through mHealth is encouraging-at least in comparison to the prescriptive environment developed for acute disease. Instantly accessible Internet assistance, self-help-groups and virtual games provide further assistance.


Summary

Although not a departure from conventional medicine, Lifestyle Medicine knowledge, skills and tools provide an adjunct approach to managing lifestyle and environmental determinants of much modern chronic disease. LM fits a role between clinical medicine and public health, enticing clinicians to consider more distal environmental determinants of chronic disease than merely risk factors and behaviours within their bailiwick. Shared Medical Appointments (SMAs) provide an adjunct process for conducting LM consultations, and new 'tools', such as mHealth for doing this by capitalizing on modern technological developments increase treatment options. No doubt the field will expand further with research further assessing these ideas.


References
  1. Harris B (2004) Public health, nutrition, and the decline of mortality: The McKeown thesis revisited, Soc Hist Med 17: 379-407.

  2. He Y, Lam TH, Jiang B, Li LS, Sun DL, et al. (2014) Changes in BMI before and during economic development and subsequent risk of cardiovascular disease and total mortality: a 35-year follow-up study in China. Diabetes Care 37: 2540-2547.

  3. Egger GJ, Binns AF, Rossner SR (2009) The emergence of "lifestyle medicine" as a structured approach for management of chronic disease. Med J Aust 190: 143-145.

  4. Rippe JM (2013) Lifestyle Medicine. (2nd edn). CJC Press, London, UK.

  5. Egger G, Binns A, Rossner S (2011) Lifestyle Medicine: Managing Diseases of the 21st Century. (2nd edn). McGraw-Hill, Sydney, Australia.

  6. Koch Robert (1882) "2 Die Aetiologie der Tuberkulose". Mitt Kaiser Gesundh 1-88.

  7. Austin Bradford Hill (1965) The environment and disease: Association or causation? Proc Roy Soc Med 58: 295-300.

  8. Hotamisligil GS (2006) Inflammation and metabolic disorders. Nature 444: 860-867.

  9. Medzhitov R (2008) Origin and physiological roles of inflammation. Nature 454: 428-435.

  10. Egger G, Dixon J (2014) Beyond obesity and lifestyle: a review of 21st century chronic disease determinants. Biomed Res Int 2014: 731685.

  11. Egger G (2012) In search of a germ theory equivalent for chronic disease. Prev Chronic Dis 9: 95.

  12. Arena R, Guazzi M, Lianov L, Whitsel L, Berra K, et al. (2015) Healthy Lifestyle Interventions to Combat Noncommunicable Disease-A Novel Nonhierarchical Connectivity Model for Key Stakeholders: A Policy Statement From the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine. Mayo Clinic Proceedings.

  13. Ezzati M, Riboli E (2013) Behavioral and dietary risk factors for noncommunicable diseases. N Engl J Med 369: 954-964.

  14. Carlsson AC, Wandell PE, Gigante B, Leander H, Hellenius ML,et al. (2013). Seven modifiable lifestyle factors predict reduced risk for ischemic cardiovascular disease and all-cause mortality regardless of body mass index: A cohort study. Int J Cardiol 168: 946-952.

  15. Noffsinger E (2013) The ABC of Group Visits. Springer, London, UK.

  16. Egger G, Binns A, Cole MA, Ewald D, Davies L, et al. (2014) Shared medical appointments - an adjunct for chronic disease management in Australia? Aust Fam Physician 43: 151-154.

  17. Swan M (2009) Emerging patient-driven health care models: an examination of health social networks, consumer personalized medicine and quantified self-tracking. Int J Environ Res Public Health 6: 492-525.

  18. Hamine S, Gerth-Guyette E, Faulx D, Green BB, Ginsburg AS (2015) Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review. J Med Internet Res 17: e52.

  19. Turner T, Spruijt-Metz D, Wen CK, Hingle MD (2015) Prevention and treatment of pediatric obesity using mobile and wireless technologies: a systematic review. Pediatr Obes.

  20. Brown MT, Bussell JK (2011) Medication adherence: WHO cares? Mayo Clin Proc 86: 304-314.

  21. Egger G, Dobson A (2000) Clinical measures of obesity and weight loss in men. Int J Obes Relat Metab Disord 24: 354-357.

  22. de Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R (2012) Mobile phone messaging for facilitating self-management of long-term illnesses. Cochrane Database Syst Rev.

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