john stevens2

CEO of the AMSN Dr John Stevens has recently published his research on chronic disease and the role of shared medical appointments in addressing this growing problem in the Australian health system.

Please feel free to read these articles for your own personal use.

The art and science of chronic disease management

The potential for shared medical appointments in Australia

 

 
garry egger

 

 

 

 

Why Lifestyle Medicine Matters In Musculo-Skeletal CAre

Garry Egger:   Key note speaker at AMSN March Seminar in Byron Bay

(Garry Egger MPH PhD is Director of the Centre for Health Promotion and Research in Sydney and Professor of Lifestyle Medicine and Applied Health Promotion at Southern Cross University in Lismore, Founder of Australian Lifestyle Medicine Association.)

According to the Australian Institute of Health and Welfare, diseases with a lifestyle-based aetiology now account for 60-70% of all cases presenting to primary care.  General practitioners are being increasingly encouraged and rewarded for entering into team care arrangements with allied health professionals which suggests the time is right for a shift in thinking relating to the management of chronic disease.

Medical schools in the US are gearing up for greater training in lifestyle-related health issues.  Some (eg. Harvard, Florida, Loma Linda) are already offering ‘Lifestyle Medicine’ as a post-graduate specialty. This is less likely in Australia because of the move towards a greater involvement of allied health professionals supported by the Enhanced Primary Care (EPC) system.

But what constitutes a ‘lifestyle medicine’ approach? What does it target? And how would it supplement conventional medicine?

The main difference from the traditional approach it seems is the need to motivate a patient to become an active partner in his/her own care. While this seems obvious, and would also be useful in acute disease, it requires some knowledge of motivational principles, and a good dose of time to implement them.

Allied health involvement in chronic disease management is intended to relieve some of the time pressure experienced by general practitioners (although the current EPC system still needs to be modified to improve on this). Techniques to encourage patient involvement in their own care is something that is not well addressed in standard health care training, but is being looked at with programs such as motivational interviewing. However, there is a great need for more research in this area, and a simple and practical motivational ‘tool-kit’ (see box) for clinicians.

A second difference is that treatment in lifestyle related areas is usually always long term. Unlike the relatively quick response to anti-microbial treatments for example, the behaviour change necessary to moderate chronic disease goes through a cycle of recidivisms often taking up to two years to become permanent.

Lifestyle medicine differs from non-medical clinical practice in that it can include medication for lifestyle-related problems (eg. anti-depressants, drugs for smoking cessation or appetite suppressants etc.), and even surgery where appropriate (such as in the case of morbid obesity).

However it also requires a consideration that consequences of treatment may form part of the problem.

If prescription of an anti-depressant for example causes weight gain in a woman or erectile dysfunction in a man, is it reasonable to look at other options for management of (non-melancholic) depression?  Brief medication use, coupled with extensive lifestyle therapy, with an evidence base as strong as pharmacotherapy – exercise and cognitive therapy in particular – is likely to offer a more effective long-term outcome.

 

 

A related issue is that for many clinicians, chronic disease is defined by its risk factors: hyperlipidaemia, hyperglycaemia, hypertension etc, whereas a lifestyle medicine approach would target the cause of these risks (inactivity, poor nutrition etc) and the reason for those (stress, social pressure, poverty etc). This takes us outside the medical model.

Also there seems to be no relation to traditional disease aetiology. New findings in immunology however, have tended to make the link more apparent, and could help lifestyle medicine provide a bridge between the disciplines of clinical and public health. A rise in low-grade systemic inflammatory processes, called ‘metaflammation’, is providing a different insight into the cause and management of chronic diseases. It’s also showing how important lifestyle behaviours such as nutrition, exercise, sleep, anxiety, depression smoking, excess alcohol and drug use are to chronic disease aetiology.

 

While symptomatic treatment of chronic diseases will always be necessary, the time is ripe for a broader approach to management by changing lifestyles and examining the environment(s) which facilitate these, while using the advantages of modern medicine to achieve better outcomes. Now we just have to work out how to do it.

 

Some motivational tools in lifestyle medicine

• Check how ‘ready’ the patient is to change (patient’s ‘stage of change’), and aim to shift this to the next level (…contemplation, preparation, action);

• Test how ‘willing’ the patient is to change by asking how Important it is to them eg. on a scale of 1 to 10

• Test how ‘able’ the patient is by asking how confident s/he is in being able to change eg. on a scale of 1 to 10.

• Focus on raising the low scores – importance or confidence;

• List any barriers to change – and discuss ways of reducing their potency;

• List triggers for change – and discuss how to instigate these;

• Reduce ambivalence by getting the patient to weigh up the pros and cons of change

chronic disease states