Six Pillars of Lifestyle Medicine

There are many converging contemporary definitions of lifestyle medicine. The American College of Lifestyle Medicine (ACLM) defines it as: “A medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions including, but not limited to, cardiovascular diseases, type 2 diabetes, and obesity.” 

The discipline of lifestyle medicine calls for the prevention, management, and reversal of lifestyle-related diseases through its six (6) pillars – whole-food, plant-based eating pattern (WFPB diet), physical activity, restorative sleep, stress management, positive social connections, and avoiding harmful substance use – with a patient-centered approach.

This approach enables an individual to develop and sustain a healthy lifestyle in the long run. Incorporating these ideals into an economically viable clinical practice could arguably present the best approach to face the ongoing chronic disease epidemic as health professionals engaged in direct patient care.

A Whole-food, Plant-based Diet

According to the Global Burden of Disease report of 2017, poor dietary practices are now recognized as a major cause of NCDs worldwide. They are responsible for more deaths globally than tobacco or high blood pressure and are accountable for one in every five deaths. Lifestyle Medicine advocates a WFPB diet, which comprises plant-based foods that are minimally processed, such as whole-grains or minimally processed grains and grain products, beans, legumes, whole soy or minimally processed soy and soy products, vegetables, fruits, nuts, and seeds. Low-fat WFPB diets are associated with favorable health outcomes such as weight loss or maintenance, reduced total cholesterol, lower risk of cardiovascular events, fewer medications, and good quality of life outcomes. 

In lifestyle medicine practice, one of the critical objectives is to help patients achieve dietary changes, i.e., health behavior change. In this regard, often in lifestyle medicine clinics, physicians, with the assistance of a dietitian, nurse clinician, or health coach, perform a nutrition assessment, including but not limited to 

  • Anthropometric data, e.g., BMI, waist circumference, and bioelectrical impedance analysis, 
  • Biochemical data, e.g., hemoglobin, albumin, urea and electrolytes, glucose, HbA1c, and lipid panel, 
  • Clinical assessment, including a comprehensive nutritional history and relevant clinical examination, and 
  • A thorough dietary assessment using validated tools such as 24-hour dietary recall, three-day food record, mini nutritional assessment for the elderly, or online tools. 

To make this process easier for the patients, clinicians often utilize food models and measuring utensils.  

Some specific evidence-based diets, besides nutrition counseling, health behavior change, and nutrition prescriptions, are used in certain medical conditions, such as the DASH diet for hypertension, the Ornish diet, and the Esselstyn plant-based diet for coronary artery disease, and the CHIP program diet for diabetes. Understanding the scientific basis of writing nutrition prescriptions, prescribing macronutrients, micronutrients and food preparation, and using SMART goals in prescription writing are some of the core competencies expected of a lifestyle medicine practitioner.   

Physical Activity 

Physical inactivity is the fourth leading risk factor for global mortality and is responsible for approximately 1 in 10 premature deaths. Interestingly, people who get the most exercise have the least years of life lost, despite being average weight, overweight or obese. The overall benefits of physical activity include increased muscular and cardiovascular fitness, improved bone health and less risk of falls and vertebral fractures, reduced risk of NCDs, and maintenance of a healthy weight. 

Physical activity is a vital sign in lifestyle medicine. Physicians are expected to interpret this vital sign and create an exercise prescription where necessary. Beyond the recommendation of Physical Activity Guidelines – adults need 150 minutes of moderate-intensity physical activity and two days of muscle-strengthening activity every week – exercise prescriptions are widely used in clinical practice. These prescriptions include frequency, intensity, type of exercise, and time duration of each exercise – commonly abbreviated as FITT. Furthermore, exercise preparticipation health screening algorithms are used before incorporating patients in physical activity programs/routines.

Sleep Health and Sleep Hygiene 

Sleep is an often overlooked and sacrificed pillar of health, particularly in shift workers, with detrimental effects. It has been evidenced that poor sleep quality and duration correlate with cardiovascular risk, NCDs, and mortality. In addition, poor quality sleep has also been linked to mood, cognition, learning, memory impairments, and cancer risk. Some core competencies expected of lifestyle medicine physicians in sleep health include a thorough understanding of circadian and sleep physiology, techniques used in sleep assessments, sleep hygiene assessments, and treatment strategies. Interventions for poor quality sleep include

  • Lifestyle prescriptions, including changes to sleep environment, managing light exposure, dietary changes, and techniques for minimizing stress, 
  • Intensive therapies such as cognitive behavioral therapy (first-line therapy for chronic insomnia), behavioral methods, cognitive methods, and  
  • Prescription of Melatonin (hypnotics/sedatives are typically avoided). 

Emotional and Mental Well-being  

It is estimated that 70% of primary care provider visits are stress and lifestyle related, while stressed individuals are less likely to engage in healthy lifestyle habits. Stress activates a complex series of hormones and neurotransmitters that alter the cardiovascular and metabolic functions of the body, which, if overwhelming and chronic, can lead to the suppression of the immune system, subclinical inflammation, and long-term organ and tissue damage. Depression is a comorbid illness for many chronic diseases, such as diabetes mellitus, and it is a recognized independent risk factor for cardiac events in patients with coronary artery disease. Lifestyle medicine focuses on building an effective and empathetic patient-physician relationship, incorporating positive psychology, cognitive behavioral therapy, mindfulness, and stress resilience in its practice to address these clinical scenarios. 

Tobacco Cessation and Managing Risky Alcohol Use  

Tobacco use is the single most significant preventable cause of mortality and morbidity, with well-known consequences of cancers and respiratory and coronary artery diseases. Smoking leads to many other conditions, such as diabetes, impaired immune function, impaired wound healing, problems with reproduction, and maternal and fetal complications. Similarly, heavy alcohol use has been linked to high blood pressure, stroke, unintentional injuries, and cancers. Lifestyle medicine physicians routinely screen for tobacco use and problematic alcohol use and employ effective evidence-based treatments such as counseling techniques in combination with appropriate pharmacotherapy. 

Upon identifying a risk factor such as smoking, enabling behavior change is critical. Among various models used in facilitating behavior change, the 5A’s in tobacco cessation and 5A’s of behavior change models are well-adopted by clinicians. Furthermore, with motivational interviewing techniques, the frequently used Transtheoretical Model helps guide patients through the change cycle during clinic visits. In addition, pharmacotherapy is routinely used to help patients to quit smoking. 

Connectedness and Positive Psychology 

Experts in positive psychology and psychophysiology tell us that positive social interactions and ‘micro-moments of connection’ lead to longevity and beneficial physiological responses, such as the activation of the parasympathetic nervous system, in contrast to unmanaged stress, which activates the sympathetic nervous system. Lifestyle Medicine allows individuals and communities to thrive through the use of models such as PERMA, which incorporates positive emotion, engagement, relationship, meaning, and accomplishments, which in turn can help facilitate long-term adherence to positive health behaviors. The longest-running study in the world from Harvard has concluded that the single most predictor of happiness and longevity is healthy social connections. 

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