The American College of Lifestyle Medicine (ACLM) has published a position paper in its flagship journal about the promises and potential of Lifestyle Medicine (LM). They argue that LM can address the chronic disease burden and can be the spark that transforms healthcare. However, digging into their evidence and claims reveals a less rosy colored picture.
LM is an unofficial medical specialty that uses lifestyle interventions to prevent and treat chronic conditions. It has six pillars: whole-food, plant-based diet, physical activity, stress management, avoidance of risky substances, restorative sleep, and social connection. It does this through a combination of patient education and coaching. I’ve covered LM in the past.
Critiques of Lifestyle Medicine
The American College of Lifestyle Medicine recently published a position paper that praises LM and claims it could be nearly revolutionary for our healthcare system. Two main critiques of LM provide important context for the position paper’s claims.
- Emphasis on individual responsibility: LM largely places emphasis on individual patient choices without acknowledging the structural and socioeconomic factors that also play a large role in people’s health, such as poverty, food deserts, and environmental factors. This can lead to blaming patients for their diseases.
- Trojan Horse: LM has a very broad umbrella with a limited evidence base. As such, it has flirted with non-evidence-based practice and alternative medicine. Similar to other areas of medicine that exist in a regulatory gray area, there are ample opportunities for profiteering through unproven commercial products and programs.
Does the new position paper address these foundational concerns? A review of the document’s five positions reveals that, unfortunately, the paper largely sidesteps them.
Lifestyle Medicine Position Paper
Lifestyle Medicine as a Framework for High-Value Care: A Position Statement from the American College of Lifestyle Medicine was published in the American Journal of Lifestyle Medicine. According to the abstract,
“It is the position of the American College of Lifestyle Medicine (ACLM) that: (1) The LM care delivery model addresses the escalating chronic disease healthcare burden; (2) LM is a powerful catalyst for healthcare transformation that delivers the Quintuple Aim; (3) LM is whole-person care implemented for all populations, across various settings, intensities and modalities; (4) LM providers are trained, interdisciplinary experts in chronic disease care across the continuum, from prevention to treatment and remission of disease; (5) nine core elements are essential to an effective and evidence-based LM care framework.”
Position 1: LM care delivery model addresses the escalating chronic disease healthcare burden.
They do not provide an argument or evidence for this statement. Rather, the claim is the argument. At its heart, LM relies on providing extensive patient education. They want LM to be reimbursable by insurance. Perhaps if providers were paid for their time, they would spend more of it on patient education. As a policy position, this seems like a defensible stance and one that I agree with.
However, patient education does not necessarily translate to better health outcomes. Even if patients know what a healthy lifestyle looks like, they may not always make the best health decisions. The critique of LM’s emphasis on patient choices is that it minimizes structural challenges. Patients can know what healthy choices look like and still make different choices for various reasons. We should engage in more patient education, and there is a real thirst from some people to engage in more meaningful and longer conversations about health. Health coaching as a profession is exploding for exactly this reason.
However, individual-level education and interventions will only go so far. Access to the pillars of healthy lifestyles, such as a mainly plant-based diet, is arguably as important as knowledge of those pillars. This narrow focus on the individual is particularly striking when viewed through the lens of public health frameworks, in which health is shaped by layers of influence, from personal behavior, peer pressure, economic circumstances, along with public policy. By focusing only on the former, LM’s proposed ‘solution’ is incomplete and inequitable.
Position 2: LM is a powerful catalyst for healthcare transformation. It enhances patient experience and outcomes.
This section relies heavily on patient experience and is extremely light on patient outcomes. Enhancing communication between provider and patient will undoubtedly lead to higher patient satisfaction. That much seems obvious. However, LM has stated that it can also provide for better patient outcomes. Outcomes are measurable clinical events and results, such as fewer emergency department visits and fewer diagnosed cases of type 2 diabetes.
If LM is based on solid evidence, why are outcomes so scarce in this section? Even when looking at the pillars individually, research on relevant patient outcomes is difficult to find. For example, diet and exercise as prevention and treatment for type 2 diabetes. In 2017, there was a Cochrane Review that concluded:
“There is moderate-quality evidence that diet plus physical activity reduces or delays the risk of type 2 diabetes. There is no clear evidence whether diet alone or physical activity alone influences the risk of type 2 diabetes. Data on patient-important outcomes such as mortality, macrovascular and microvascular diabetes complications and health-related quality of life are sparse.”
Without research into the relevant outcomes, the claims of LM’s effectiveness and potential to spark seemingly radical change in the healthcare system are difficult to swallow.
Position 3: LM is whole-person care implemented for all populations, across various settings, intensities, and modalities.
This section relies heavily on the perceived versatility of LM in its delivery in various settings, such as schools, workplaces, and telehealth modalities. Since the COVID-19 pandemic, telehealth has advanced in leaps and bounds, so this isn’t really all that different from what most of medicine is already doing. However, this particular position may be where the Trojan Horse critique is hiding.
The idea that LM is flexible in its practice and doesn’t require a clinical setting is both good and bad. It’s a slippery slope into influencer territory. Since LM isn’t an officially recognized specialty in medicine, it would be very easy to have a “practitioner” on a job site that “specializes” in LM but isn’t a licensed provider. A person claiming to specialize in LM may act as the in-house wellness trainer, while in reality, they are someone, perhaps with good intentions, with no relevant training, credentials, or experience.
Position 4: LM providers are trained interdisciplinary experts in chronic disease care across the continuum.
This section focuses on healthcare as a team effort. They discuss leveraging providers beyond physicians who have expertise in nutrition, physical activity, and sleep. Healthcare providers should function more as a team, and I think that physicians should be relying more on other healthcare professionals.
One of the main outcomes from changing the approach to healthcare to more closely align with this format is that providers may better understand the other roles in the healthcare team. For example, having physicians understand the difference between a nutritionist and a registered dietitian, and leveraging that expertise rather than attempting to act as nutrition experts if they aren’t.
Overall, advocating for our care providers to work more as a team is a good practice and something that we should strive for, but it is not a novel idea.
What Does LM Offer?
ACLM’s position paper repackages old ideas that fundamentally fail to address its overemphasis on individual responsibility and its vulnerability to non-evidence-based profiteering. It also, frankly, doesn’t add much to the conversation about healthcare. The good ideas are not new and have been advocated within healthcare for a long time. Many, if not most, providers want to spend more time with patients and would like to feel like healthcare is more of a team sport. But again, these are not new thoughts or desires.
Typically, when a new medical specialty is recognized, it is because of advances in understanding of the human body, technological advances, or both. However, there’s no real advancement here. Most of what they suggest is already a part of primary care. Additionally, they did not address the critiques of LM, which remain a concern, especially while it exists in a regulatory gray space.
While LM is not necessarily bad and I agree with large swaths of it, if LM is to be taken seriously, it needs to address the real possibilities of operating in spaces that lack, as Dr. Makary states, “gold-standard science” and opens the door to grifters and charlatans. By promoting individual action without addressing structural barriers and by operating in a gray regulatory space, the ACLM position paper ultimately reinforces, rather than refutes, the two most pressing critiques of Lifestyle Medicine.