Heidi Prather, DO, is a physiatrist at Hospital for Special Surgery (HSS) who heads the new lifestyle medicine program for people with musculoskeletal conditions and coexisting lifestyle-related diseases. Medscape spoke with Prather about the principles of lifestyle medicine, the details of the HSS program, and how lifestyle medicine differs from conventional clinical practice.
What is lifestyle medicine?
Lifestyle medicine is an evidence-based approach that has been shown to prevent, treat, and reverse chronic lifestyle-related diseases. It uses six pillars of health: nutrition through a whole-food, plant-predominant diet; physical activity; managing stress; social connections; sleep health; and avoiding risky substances. Chronic lifestyle-related diseases include obesity/overweight, prediabetes/type 2 diabetes, hypertension, hyperlipidemia, cardiovascular disease, and some cancers.
Have lifestyle medicine programs previously been used in treating musculoskeletal conditions?
Not with an intensive interprofessional team; this is novel. It uses these six pillars of health in addition to usual musculoskeletal care to address both lifestyle-related chronic diseases and chronic musculoskeletal conditions. The program works by giving people simultaneous services via an interprofessional team. We provide services to enable people to reach their personal goals. Some people are ready to make lifestyle changes, and we provide them with intensive services. For those not ready for change, we provide education regarding the links between lifestyle choices, chronic disease, and musculoskeletal health. The focus is on the whole person.
The pilot lifestyle medicine program at HSS started in March 2022. What type of patients participated in the pilot?
The intensive pilot program was for people in an active state of behavioral change. People who joined the program developed lifestyle-related goals to improve health, reduce pain, and improve function. Conventional medicine provides interventions, and the patient is a passive participant. With lifestyle medicine, the patient must be an active participant in the process. My role as a medical practitioner is to be a facilitator, giving them the education and tools; they need to go out and take action for themselves.
The patients that we've had in the HSS program have musculoskeletal conditions and lifestyle-related chronic diseases and are interested in changing their lifestyle to help improve their pain and function. Thirty-one percent of these patients have three or more lifestyle-related chronic diseases, and 28% have more than four. On average, patients fit the criteria for class 3 obesity. So, we are caring for patients with a complexity of problems combined with a painful musculoskeletal problem that limits physical activity and, at times, the ability to make healthy choices. We also have patients in the program who are interested in preventing progression and better management of their musculoskeletal condition through lifestyle changes.
How did you go about finding people who would be interested in doing the program?
Nonoperative musculoskeletal medicine practitioners know that this type of program is very necessary and needed in their own practice, so the nonoperative providers at HSS have been immediately supportive of the program. HSS is a worldwide leader in orthopedic surgery and has long recognized that patients need help to get healthy prior to surgery to reduce the risk of surgery and improve outcomes and has invested in searching for a mechanism to provide this care. The joint-replacement surgeons have a very specific need for this care and immediately supported the program. They have referred presurgical patients at high risk for complications at the time of surgery, during the recovery period, and poor surgical outcomes related to their chronic disease. In the past, there has been no guided path for these patients in the healthcare system. About 32% of those people who come to us unable to have surgery because of their poor health are now qualifying for surgery. About 82% of those who enter the program with a surgical date goal can meet their goals within a set time. We are proud of those numbers.
What does the process look like for evaluating patients in terms of what they want to work on and what they want to achieve?
The patient starts with a one-on-one session to discuss their health and their past successes and challenges. We screen metabolic factors: We take labs looking at vitamin D, inflammatory markers, hemoglobin A1c, and lipid panels. We take histories on their physical activity in cumulative minutes and sleep health. We take two scores on mental health, pain scores, social connection score, and then discuss any tobacco and alcohol use. What are all their different lifestyle comorbidities? Are there any nonmodifiable issues? For example, I recently saw a patient who has a nonmodifiable nervous system condition in addition to osteoarthritis. We need to tailor the program to his specific needs and goals. Every patient's program is individualized.
After the screening process, we discuss the members of the interprofessional team who are available to them and set specific goals. If a patient wants to qualify to have their knee replaced, we work together to operationalize that goal. If they need to lose weight, that may also mean the patient has goals to increase physical activity, improve nutrition, and improve sleep health. We also counsel them on how all these factors contribute to chronic systemic inflammation that promotes these chronic lifestyle-related diseases. We also discuss their personal goals once they have successfully made changes to improve their health. Many respond that they want to spend more active time with family and friends and travel. Two people in the program plan to ride a rollercoaster, something they couldn't do at the time that they entered the program.
After this discussion, we ask them two important questions: On a scale of zero to 10, what is your willingness to make a lifestyle change and how do you rank your confidence in your ability to change? If people score somewhere at 7 or above [for both questions], they're probably in an active state of behavioral change and can benefit from these resources.
How often are patients meeting with a member of their team during this intensive phase, and how long does the program last?
The meeting cadence is tailored to the patient, and usually we have them meeting with two to three different practitioners during the program. In addition to individual 1:1 care, patients can participate in group programing. A lifestyle medicine provider delivers education regarding a specific health pillar followed by a group question and answer session. It is a safe place to ask questions. Patients give us great positive feedback regarding this delivery method. The patient’s graduation date is usually between 90 and 120 days, but it is really set around the patient achieving their goals. For example, say somebody comes in and they want to lose 50 pounds and they've had a tough time with increasing physical activity because of joint pain. The appropriate rate of weight loss is roughly 1 to 2 pounds per week, so patients with a high weight loss goal will be with us for a while. We also have people in the program who are doing well and meet their goals even after 8 weeks.
What is the next step after this intensive phase ends?
Maintenance is an important part of behavior change. We need to have resources available when someone falls off track. The HSS lifestyle medicine program has educational tools specifically created for this population. We will have digitally run, self-paced exercise and lifestyle-related interventions that patients can come back to at any time. We're hoping to also provide group learning opportunities for these patients, because not everybody has that social connection that helps them with healthy choices. Right now, we are building out some of the infrastructure. We need to include guidance on nutrition and modifications for exercise. It has been a real lift for the entire institution because we work with multiple departments to pull this off.
In May, HSS began requiring high-risk patients to take part in this program. Can you tell me more about that?
Right now, every presurgical orthopedic patient with a BMI of 45 or over is referred to the HSS lifestyle medicine program. We have two program tracks. One is intensive, which includes simultaneous one-on-one plus group programming care. The second is the selective track, for folks who are not in an active state of behavioral change. These patients meet one-on-one with a lifestyle medicine provider to introduce them to the concepts and, if they're a surgical patient, to discuss their additional risks of having surgery with a lifestyle-related chronic disease. We've developed a guide that can be provided to patients in paper or in digital form, that provides education regarding the six pillars of health, lifestyle changes, and guidance, especially regarding diet. Patients also receive education regarding SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goals and how to make them. What we try to do is meet people where they are and using motivational interviewing techniques, link health conditions they may not have understood were linked to one another. This includes a discussion around how a painful and swollen osteoarthritic knee is rooted in the same cause of type 2 diabetes, hypertension, and obesity: chronic systemic inflammation. Eating a healthy diet, getting restorative sleep, being physically active, manage stress, seek social connections and avoid risky substances cannot only improve type 2 diabetes control, hypertension and weight loss, but may also result in less knee pain and even progression of osteoarthritis.
We are asking patients with a BMI of 45 or higher to be referred to the program at least 3 months ahead of surgery, if not more. Since the program began, we’ve had 161 individuals referred and have enrolled 80% of them in the intensive track. HSS values the program in that it provides a mechanism to meet patients where they are and help them to improve their mental and physical health prior to surgery. Ultimately, this reduces their risks at the time of surgery, recovery after surgery, and the need for revision surgery. We hope the changes patients have made will be lifelong.
How is this program different from surgical optimization programs around the country?
It's different because it is following the guidelines of evidence-based lifestyle medicine and focuses on all aspects of risk and measures specific metabolic, anthropometric, and mental health changes. The intensive track of our program is interprofessional and utilizes a coordinator educated in lifestyle medicine to facilitate the patients’ progression through the program. Instead of having a checklist of identical benchmarks for every patient to meet, the patients are engaged in setting their own individual goals. We want this program to enable patients to make long-term changes. Our program also isn't only for surgical patients. We provide services and support for patients who are trying to avoid surgery, manage their musculoskeletal condition better, or have a musculoskeletal condition that is either not appropriate or amenable to surgery. Sometimes, there isn't a surgery that can help a patient with their condition. We advocate to help any patient looking to be enabled to make healthy choices.
Do you anticipate that these lifestyle medicine programs will become more numerous across the country?
I hope so. The biggest obstacle is the economics of running a program like this.
For the HSS program, we are hoping we can get to a bundled payment model. We are collaborating with a payer to determine how much the program costs and determine the healthcare savings that occur because of lifestyle change. Once we know where that margin is, we can work with payers and corporations to suggest "our program can manage both back pain and diabetes and your healthcare savings will be X." Then, we can get into true value-based care, and it won't matter that the dietitian isn't covered as an individual benefit of the health insurance because all care could be bundled into this payment package. There are so many people that need access to this type of care, and the people that need it most have the least amount of access. So, getting a payment model that's sustainable is a part of our long-term plan.
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Cite this: Lifestyle Medicine Program Uses Novel Approach to Care for People With Musculoskeletal Conditions - Medscape - Aug 16, 2023.