Will We Always Wait Until It's Too Late?

By ignoring the root causes of disease and neglecting to prioritize lifestyle measures for prevention, the medical community is placing people at harm. Advanced nations, influenced by a Western lifestyle, are in the midst of a health crisis, resulting largely from poor lifestyle choices.

Though I feel them powerfully, the preceding words are not even mine. They comprise the opening for Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival which appeared in the 09/20/2017 epublication of The Permanente Journal (unless noted otherwise all quotes are from that article). Perhaps more astonishingly, the article was co-authored by nearly two dozen physicians who plead:

For future generations, for our own health, and for the Hippocratic Oath we swore to uphold (“First do no harm”), the medical community must take action. It is our hope that the information presented will inspire our colleagues to pursue lifestyle medicine research and incorporate such practices into their daily care of patients. The time to make this change is now.

The time for such change is indeed now. However, our current sick care system insists on waiting.

Instead of awareness and prevention we wait until so many chronic diseases have taken root. Well-known non-clinical health determinants (e.g., diet) have been proven for years to benefit health, especially for chronic diseases. Non-clinical (but effective) therapies like Tai Chi, Yoga, massage, herbal supplements, etc. pose negligible or no risk and offer great benefits to those with chronic illnesses. Yet we wait to include Lifestyle and non-clinical approaches in "health care".

As a Society, do we wait until it's too late because patients are not informed? Do we wait until it's too late because the medical community does not want to change from prescriptions and procedures? Do we wait until it's too late because payers do not want to add real prevention and remediation for many chronic illnesses to their payment schedules? Let's see.

The Money

Throughout my graduate studies and my professional career, the one truth I have learned about how a Government or a Company sets its priorities is to "follow the money." When I created the following chart from data provided by the Centers for Disease Control and Prevention, I was not struck by the increases; I knew healthcare costs had gone up over the decades. However, I was shocked to see that the categories used to measure healthcare expenditures were EXACTLY the same in 2014 as 1960!

Source: CDC's Table 94. National health expenditures, average annual percent change, and percent distribution, by type of expenditure: United States, selected years 1960-2014

Lifestyle was not a threat in 1960. Chronic diseases and their co-morbidities were not rampant in 1970. Even the 1980's were still quite slow and had only just witnessed the first Personal Computers and the Internet was still only for military and academic purposes. When did we become aware of threats from a modern Lifestyle, of growing chronic diseases, of a 24x7 fast-paced and stress-ridden Society? Was it in the 1990s? Perhaps at the new millennium in 2000? Surely we had some idea of the impact of Lifestyle in 2010? Probably, but the cries for help fell on a sick care industry intent on curing the disease instead of serving the person by changing "health care" expenditures to address the new epidemic.

Chronic diseases are presently the leading cause of morbidity and mortality and are responsible for most of our health care expenditure. Most of these chronic conditions are preventable and are the result of an unhealthy lifestyle. More than 80% of chronic conditions could be avoided through the adoption of healthy lifestyle recommendations. Eighty percent of the population wants to live in a better state of health but do not know how to pursue it. Minimal information is given by health care practitioners on how to implement an effective, long-term plan to achieve health. The ongoing acceptance and adoption of a healthy lifestyle remains our greatest challenge. Implementation of lifestyle recommendations can save lives because lifestyle-related diseases are now the leading cause of mortality in the “modernized” world.

Sad. In a time where Lifestyle is a leading threat to health that is literally killing us there is nothing like a Lifestyle Coaching category when we measure "health care" spending. The projected spend for "health care" in the US for 2016 is $3.4 trillion. Those $3.4 trillion just cover the traditional National Health Expenditures Accounts (NHEA) categories as in 1960: hospitals, physician & clinical services, pharmaceuticals, and so on.

However, in a study of 2012 US expenditure on healthcare, Deloitte found: "Consumers are paying more of their health plan premiums and experiencing higher out-of-pocket (OOP) cost-sharing for all types of health care services. Moreover, government estimates of health care spending do not take into account discretionary consumer spending on a number of products and services". [Emphasis added]

Any spending for nutrition coaching, exercise therapy, emotional coaching, lifestyle devices or applications come from the consumers' pocket and are not part of "health care" (Note: I understand that a few items can be coded for insurance payment... but those are the exception). The Deloitte study put that number at $672 Billion, or nearly 20% of the total 2012 healthcare expenditure (not just the NHEA categories). And the consumer out-of-pocket amount was growing!

With thousands of years of clinical results, such approaches as Traditional Chinese Medicine, Ayurveda, Qi Gong, or Yoga don't merit even a thin little slice of a healthcare expenditure category in this new era of chronic disease? Eighty percent of our chronic disease epidemic (and human suffering) could be avoided by better Lifestyle decisions? Even the most ardent defenders of status quo medicine will concede that non-clinical determinants such as diet, exercise and stress play a major role in health. Yet still we wait for sick care to catch up.

For far too long, patients have experienced chronic illnesses because our health care system has not taken a proactive role in promoting healthy eating, active living, and the promotion of emotional resilience.... The medical community has been proud to announce major achievements in health care and their impact, yet a recent analysis on cardiovascular mortality brings into question such advances; the decreasing rate of CVD [Cardiovascular Disease] that has been noted since the 1970s appears to be declining at a slower pace. Advances in CVD survival no longer approach the prior rate of decline despite improvements in treatment. Perhaps the management of CVD should focus more on lifestyle recommendations and prevention than on treatment once the disease has become symptomatic. In addition, it has been suggested that the recently noted decline in cancer incidence may be related to the recession of 2008, which may have decreased screening accessibility for many. It is increasingly recognized that the real issue in health care—lifestyle—should become the primary prescription for the leading causes of disease that result in the highest rates of mortality. The slow progress in decreasing mortality rates from CVD incriminates an unhealthy diet and a sedentary lifestyle as major contributing factors.

How Skewed Is Sick Care?

Currently, multiple forces maintaining the status quo exist at the systemic level. Special interest groups, including certain lobbyists, maintain barriers by spending monies to influence governmental and professional targets. For example, national dietary guidelines are watered down out of a concern over the economic interests of certain industries instead of reflecting on the evidence-based recommendations regarding the consumption of meat and dairy products. On the societal level, the hedonistic aspects of food are promoted over their health and nutritional aspects.

It is no secret that the American Lifestyle threatens the American Dream. We spend more than any developed nation for "health care" and have the worst outcomes among those nations (and even some lesser developed countries). That equation begs for special interest influence to maintain the status quo. To get a sense of how inattentive sick care is to our suffering, we only need to look at the recent debate on "health care" in Washington, DC.

The Republican party has been fighting against the Democrat's Affordable Care Act ("Obamacare") since it became law in 2010. For nearly a decade, we have heard arguments about how many people will be insured or not insured. There is a never-ending cadre of pundits and experts who will explain why pharmaceutical costs are / are not the reason for escalating healthcare costs. The positions have covered the spectrum from a Bernie Sanders' "single payer" system to the GOP's recent Graham-Cassidy bill.

We spend so much energy arguing about who is or is not covered by health insurance and who is to blame for rising costs. Sadly, the answer is obvious but we wait. We wait while chronic illnesses like diabetes claim ever-younger victims. We wait while obesity runs rampant throughout our entire population. We wait while stress burns us out physically, mentally, and spiritually. To paraphrase Shakespeare, "what doth it profit a man to have insurance if the illness could have been prevented"?

In the Western world, we subject ourselves to a poorly recognized, self-inflicted death sentence. We have become victims of three major conditions endemic to the Western World: inflammation, obesity, and type 2 diabetes, which are intricately interrelated and largely result from poor lifestyle choices. Combined, these diseases are lethal. That’s the bad news. The good news is that we can now affect these “invaders” of our health through lifestyle changes. Recent reports have addressed the importance of lifestyle interventions (maintaining a healthy body mass index [BMI], a healthy diet, increasing physical activity, and managing stress) on chronic disease management.

The Answer?

So why are we sick and dying prematurely? Cardiovascular disease (CVD) and cancer have come to be known as the two “killer diseases” and account for more than half of all deaths in the US. We are experiencing these diseases in the wealthiest nation in the world, which spends more on health care per capita than any other advanced economy and yet has some of the poorest health outcomes. The most important problem is our poor lifestyle choices based on misinformation.

"The most important problem is our poor lifestyle choices based on misinformation"? Wow. I'm glad someone else said that! But that is the answer... and consumers know it.

Source: 2017 Patient Survey Report For The Physicians Foundation

Over 90% of people surveyed (aged 27-75 who had seen the same physician twice in that year) understand that a healthy lifestyle leads to better quality of health. Only 38% agreed that physicians should not go beyond health issues when caring for patients. The vast majority understand the role of Lifestyle in health and a sound majority believe it is part of the physician's job. The Permanente article authors agree and see this as part of Lifestyle Medicine:

Given the benefits of lifestyle medicine interventions, it would seem that our health care system would rush to embrace this movement; however, nothing could be further from the truth. Through the decades, leading proponents of lifestyle interventions have faced resistance or marginalization. Such resistance to change has to do with barriers on multiple levels affecting patients, clinicians, administrators, government, and society in general. Most patients typically gather their food and nutrition information from popular media rather than from clinicians, many of whom may have limited knowledge of lifestyle interventions. In addition, much of this may reflect the limited time available in a typical office visit. Perhaps a more important issue stems from the formal education in medical school, residency, or fellowship programs, which lack a focus on scientific evidence supporting the importance of nutrition related to a healthy lifestyle. Health care practitioners as well as administrators are often focused on the bottom line and find it challenging to direct resources toward new and innovative practices given low reimbursement rates for counseling on lifestyle changes. Adding to this, they may fear that patients will find such changes difficult and not sustainable. We are long overdue for a “rethink” about health care to achieve a more directive role in the lifestyle intervention of patients.

Is There Hope?

Yes. We know the answer to battling much of chronic disease is overcoming "our poor lifestyle choices based on misinformation." We also know that the current sick care system, whether for simple inability or purposeful obstruction, has been wildly unsuccessful in changing to meet the new challenges of chronic diseases. Overall, the "health care" system today is the same as 1960 and many in the system like it just like that. But change is already underway and consumers are leading it with their own dollars.

Despite the status quo, there is a groundswell of interest in lifestyle medicine and a hunger for change. There exists reason for optimism. The growing interest in wellness programs and the mainstreaming of yoga, tai chi, and mindfulness practices are examples of such changing attitudes. Integrating lifestyle medicine into clinical practice in the areas of food, nutrition, exercise, and stress reduction is becoming more commonplace. Multiple organizations, including health care systems and large successful corporations, have come to realize the enormous benefits of a healthy lifestyle not only to wellness but also positively influencing enhanced productivity.

This is not simply about bolting on a tai chi class in a vacant hospital office. Some health systems have implemented real change. Geisinger Health System's Fresh Food Pharmacy did so... and improved health for those enrolled: "The Fresh Food Pharmacy gives free groceries and meal plans to low-income patients with type 2 diabetes in Shamokin, Pa.... So far, the results have been mind-blowing. All patients in the program are seeing similar results to Tom. They have significant declines in their hemoglobin A1C levels, the blood test that shows how well blood sugar levels are controlled. That drop in A1C gives them a much better chance to avoid the complications of type 2 diabetes. They won’t go blind; they won’t have kidney disease; they won’t lose a toe or a foot." That is healthcare.

As Deloitte demonstrated in its study, consumers have begun to look into the whole of Lifestyle on their own: non-clinical practices, complementary medicine, nutrition, wellness, well-being, and more. When consumers look, vendors respond. We see more health food stores (e.g., Whole Foods, Trader Joe's, Fresh Thyme). There are more restaurants, like national chain Panera Bread, that only serve "clean food". Groupon inundates my email with deals on massage therapy (which I occasionally do get to enjoy!).

Sick care will continue to focus on treating trauma (for which I am sincerely grateful) and conventional disease management (for which I am far less grateful). However, new healthcare opportunities continue to arise. More physicians want to engage in Lifestyle Medicine (or Integrative Medicine, Functional Medicine, etc.). There are more clinicians who offer complementary medicine (i.e., Traditional Chinese Medicine, Ayurveda). More devices that measure sleep, help you sleep, monitor your heart and more come to market daily.

Holistic Health opportunities continue to grow and so do the number of people who will no longer wait until it's too late to take control of Lifestyle.

Be Well!

-Tim

Tim Perry, MPA, MS, CPHIMS, PCMH CCE, CISSP is the Chief Information Officer of Consumer Health platform HealthCareToo.com and Chief Technology Officer for consultant / adviser group NEW Ventures LLC. Tim has a deep passion for transforming and improving healthcare that spans two decades. He is blessed with a wonderful wife and two inspiring children. Tim has practiced Tai Chi (Taiji Chuan) for over 15 years and enjoys cooking wholesome (and easy) meals.

Other Articles by Tim

What If We Treated The Whole Person?

Why Patient Engagement Is So Hard: and why it won't change anything

Healthcare Is A Team Sport-- an IT Perspective

A Quick History of the US Healthcare System: How Not To Repeat It (written w/ Microsoft Sway)

Clinical Care ≠ Healthcare

Can You Handle the Truth about Healthcare?

Bending the Healthcare Cost Curve

When Will The Healthcare Dam Burst?