Therapeutic Lifestyle Change (TLC) Programs

A New Opportunity for Health Care Practitioners

By Jeffrey S. Bland, PhD, FACN, CNS

You see them every day: patients with or at risk of developing, lifestyle-related chronic diseases. In the United States, type 2 diabetes, cardiovascular disease and other chronic conditions have reached epidemic proportions, affecting nearly half of the population and contributing to seven of every 10 deaths.¹

Perhaps even more disturbing is that these numbers could be drastically reduced with widespread adoption of simple lifestyle changes, including healthier eating and moderate exercise. Yet despite overwhelming clinical and scientific evidence, most health care practitioners fail to counsel their patients on these important issues.

A Global Epidemic

In the U.S., one in three adults is obese. One in five children is overweight and likely to carry their health-related problems into adulthood.² Twenty-one million people have diabetes, including 6 million who don’t know they have it. Another 54 million are insulin-resistant.³ One in five adults has doctor-diagnosed arthritis.⁴

Similar numbers have been reported from all seven continents. According to the World Health Organization, lifestyle-related chronic diseases contribute to 60 percent of all deaths and 80 percent of deaths in low- and middle-income countries.⁵

Why TLC Makes Economic Sense

In the U.S., more than $1.5 trillion is spent annually on the diagnosis and treatment of chronic illnesses,¹ including $60 billion for five of the top 10 classes of blockbuster drugs.⁶ How are we spending so much and getting so little in return? It’s worth noting that the American health-care delivery and financial-reimbursement systems traditionally have been structured on the use of high-cost diagnostics, procedures and pharmaceuticals developed to treat acute illness, while less emphasis has been placed on wellness and prevention. And ironically, despite its name, less than 3 percent of the Centers for Disease Control and Prevention’s 2008 budget is allocated toward chronic disease prevention,⁷ although its own Third Report of the National Cholesterol Education Program’s Adult Treatment Panel (ATP III) recommends the use of therapeutic lifestyle changes and medical nutrition therapy to reduce the risk for chronic heart disease.

Fortunately, the balance has begun to shift. A recent MetLife survey found more than a quarter of all employers offer some type of wellness benefit.⁸ And Medicare beneficiaries are now entitled to a one-time physical examination, key screenings, and nutritional and smoking cessation counseling and other wellness benefits. However, these are very limited. For example, cardiovascular screening will be covered only once every five years. Nutritional counseling will be covered only for patients already diagnosed with type 2 diabetes or kidney disease, and is limited to just three hours the first year and just two hours in subsequent years.⁹

Notwithstanding, wide-scale savings (billions of dollars and, more importantly, hundreds of thousands of lives) derived from therapeutic lifestyle changes (TLC) have been amply demonstrated. For example:

• Implementing Stanford University’s six-week Arthritis Self-Help Course among just 10,000 people with arthritis could save $2.6 million over four years, primarily through reduced physician visits.¹⁰
• A sustained 10 percent weight loss will reduce an overweight person’s lifetime medical costs by $2,200-$5,300 through lower costs associated with hypertension, type 2 diabetes, heart disease, stroke and high cholesterol.¹¹
• A reduction of 12-13 mm Hg in systolic blood pressure is associated with a 21 percent reduction in coronary heart disease, a 37 percent reduction in stroke, a 25 percent reduction in total cardiovascular disease deaths and a 13 percent reduction in overall death rates.¹²

Making a Difference, One Patient at a Time

A recent American Heart Association (AHA) survey of cardiologists and primary care physicians revealed the following:¹³

• Only one in 10 respondents were successful in helping their patients achieve healthy serum lipid levels.
• Only half of respondents said they were very knowledgeable about the use of lifestyle interventions to lower serum lipids.
• Few considered being overweight or having a sedentary lifestyle as important contributors to coronary heart disease.
• Dietary and lifestyle interventions were viewed as only somewhat or moderately effective.
• Respondents cited lack of patient compliance and office visit time as major obstacles in implementing the ATP III guidelines.

In his 2005 presidential address to the AHA, endocrinologist and researcher Dr. Robert Eckel challenged his colleagues to change these attitudes, saying, “We have an unprecedented arsenal of weapons [to prevent cardiovascular disease], including many potent medications. However, this power is not enough and, in fact, in some cases, it has led us to ignore some very simple, effective and human measures.”¹⁴ At the very heart of these measures are TLC.

Health care practitioners who appreciate the value of TLC and want to incorporate them into their practices must find ways to address the issues of communication, patient compliance, time management and financial reimbursement. These challenges could be overcome by taking several steps:

• Take time to ask patients about their lifestyles. A recent University of California San Francisco and Stanford University study concluded that most patients (especially those who are overweight or obese) want more support for weight management from their doctors, including dietary advice, help with setting realistic goals and exercise recommendations.¹⁵ Asking your patients about their lifestyles will not only open the door for a discussion of TLC; it also might instill in them a sense of urgency in following your recommendations.
• Closely monitor results. Regular follow-up visits are essential to the success of any TLC program. Follow-up visits allow progress to be monitored and adjustments to be made. Bioelectrical impedance analysis (BIA) offers a non-invasive option for measuring body composition, body mass index and other key indicators of health, with immediate results.
• Assemble a TLC team. Allied health professionals such as nurses, dieticians, fitness professionals or others experienced in health coaching or consulting can bring valuable skills and knowledge, including educating and inspiring patients regarding diet and lifestyle changes, conducting screenings and tracking progress.
• Integrate TLC into the office flow. Administrative staff members can schedule follow-up appointments, explain how the program works, advise patients regarding reimbursement issues (including insurance coverage, employer-sponsored reimbursement accounts or health savings accounts) and prepare educational handouts such as eating plans, exercise logs, etc.

A scientific statement from the Collaborative Writing Committee comprised of the American Cancer Society, the American Diabetes Association, and the AHA concluded that TLC represents a “new opportunity” for clinicians to target important risk factors and effect positive outcomes in the prevention and management of leading chronic conditions.¹⁶ Those who successfully implement a TLC program that addresses the issues of communication, patient compliance, time management and financial reimbursement will be well-positioned to create sustainable new revenues while improving their patients’ health.

References

1. Department of Health and Human Services. Centers for Disease Control and Prevention. Chronic Disease Overview. www.cdc.gov/nccdphp/overview.htm.
2. Center for Disease Control and Prevention. National Center for Health Statistics. Obesity Still a Major Problem. www.cdc.gov/nchs/pressroom/06facts/obesity03_04.htm.
3. National Institutes of Health. National Diabetes Statistics. http://diabetes.niddk.nih.gov/dm/pubs/statistics/#7.
4. Centers for Disease Control and Prevention. Arthritis Statistics. MMWR 2006;55(40):1089-92.
5. World Health Organization. Preventing Chronic Diseases: A Vital Investment. www.who.int/chp/chronic_disease_report/part2_ch1/en.
6. LaMerie Business Intelligence. R&D Pipeline News. www.lamerie.com.
7. Centers for Disease Control and Prevention. Budget Request Summary: Fiscal Year 2008. www.cdc.gov/fmo/PDFs/FY08_Budget_Summary_Final.pdf.
8. Press release: MetLife 5th Annual Employee Benefits Trend Study. www.metlife.com/Applications/Corporate/WPS/CDA/ PageGenerator/0,4773,P250 percent255ES1025,00.html.
9. U.S. Department of Health and Human Services. Medicare Preventive Services. www.medicare.gov/health.
10. Kruger JM, Helmick CG, Callahan LF, Haddix AC. Cost-effectiveness of the arthritis self-help course. Arch Intern Med, 1998;158(11):1245-9.
11. Oster G, Thompson D, Edelsberg J, et al. Lifetime health and economic benefits of weight loss among obese persons. Am J Public Health, 1999;89:1536-42.
12. He J, Whelton PK. Elevated systolic blood pressure and risk of cardiovascular and renal disease: overview of evidence from observational epidemiologic studies and randomized controlled trials. Am Heart J, 1999;138(3 Pt 2):211-9.
13. Goldberg RJ, Rosen J, Roselli A, Lewis B. Survey of physician's attitudes and practices toward lipid-lowering management strategies. Cardiology, 2007;107:302-6.
14. Eckel R. Preventive cardiology by lifestyle intervention: opportunity and/or challenge? Presidential address at the 2005 American Heart Association Scientific Sessions. Circulation, 2006;113:2657-61.
15. Potter MB, Vu JD, Croughan-Minihane M. Weight management: What patients want from their primary care physicians. J Fam Pract, 2001;50(6):513-8.
16. Eyre H, Kahn R, Robertson RM, et al. Preventing cancer, cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation, 2004;109(25):3244-55.