In lifestyle medicine, we talk a lot about food. This focus makes sense because improving what a patient puts on the end of their fork typically benefits their health more than improving any other area of their lifestyle. Not only is what we eat extremely powerful “medicine,” it is also where most Americans are furthest from what is optimal. The healthiest, longest-living populations on the planet are all eating 80% or more of their calories from whole plants: fruits, vegetables, whole grains, beans, potatoes, nuts and seeds. In contrast, the average American gets only about 10% of their calories from whole plants. (If you would like to see how your diet stacks up, go to 4Leafsurvey.com and take a free, 2-minute survey!)
According to both the US Centers for Disease Control and Prevention and the World Health Organization, about 80% of all the medical misery experienced here in the US is due to what we choose to do (or not do) in three key areas:
Fingers (toxic substance exposures like smoking, drug use and alcohol)
Forks (diet)
Feet (physical activity)
That is a whole lot of self-inflicted disease!! In addition to these three major areas of lifestyle habits, there are three additional lifestyle “pillars” that should also be evaluated in a patient who is contemplating making lifestyle change:
Sleep (how much, and of what quality)
Stress (how much, and how well is it handled)
Love (healthy relationships, sense of purpose, and positive motivators)
While typically Sleep, Stress and Love have only a minor direct effect on overall health, performing poorly on any of these pillars is highly likely to have the indirect effect of sabotaging a patient’s ability to make significant, lasting lifestyle changes with their Fingers, Forks, and Feet. Below are a couple of case examples to illustrate what can go wrong when the focus is primarily on food and these more “minor” lifestyle habits are not adequately addressed.
Case 1:
A 45-year-old obese male patient with hyperlipidemia and diet-controlled diabetes is seen in your office post discharge from the hospital after having a heart attack and stent placement to his LAD. Numerous subclinical blockages were also seen on his angiogram. You confirm that he has already been started on all the appropriate medications, which he is tolerating. He verbalizes that he is very motivated to improve both his diet and exercise habits because he is “terrified of having another heart attack and dying.” You talk to him about the very low-fat version of the whole food plant-based diet, which is the only diet that has been shown to reverse heart disease. He is excited to start on this immediately. He has cooking skills as well as time to prepare meals, and you suggest that he take the 15-Day Whole Food, Plant-based Jumpstart Program through the Rochester Lifestyle Medicine Institute. At his 3 month follow up appointment, he states that he completed the Jumpstart Program and followed the diet for 2 months but stopped eating this way about a month ago. He is back to eating all the meat, cheese, and processed foods that caused the heart attack in the first place. He also reports that while he started cardiac rehab once he was cleared by his cardiologist (6 weeks after his heart attack), he hasn’t been attending regularly since the first week. He says that he was motivated to eat a healthy diet and exercise for the first two months because he thought about dying every day, but that made him so anxious and depressed that he really didn’t feel like living anyway, so he felt he might as well enjoy all those tasty but “bad-for-him” foods he used to eat! He mentions that when he gave them up, he felt like he lost his best friend. When you ask about his support system, he tells you that he is single with no children, has no close friends, and isn’t in regular contact with the remaining members of his family of origin, although he used to be close to his brother and his niece and nephew before they moved to Washington state a few years ago. He previously belonged to a bowling league, which he really enjoyed. He did not keep in touch with his buddies from the league after his work hours changed and he was unable to participate, nor did he bother to rejoin the league when his work schedule changed again and no longer conflicted.
Lesson #1: Always start with Love! Fear is a terrible motivator for more than 2 months. Make sure patients both have and focus on the positive motivators in their lives as they make lifestyle improvements.
What should have been included in the initial recommendations for this patient? In addition to being referred to the Jumpstart Program, he should have been told that fear-based motivators don’t typically last more than a few months and been strongly encouraged to reconnect with his brother, niece, and nephew as soon as possible. A plane trip to visit them in person followed by weekly zoom visits after the trip would have been optimal. He should have also been encouraged to reach out to his previous bowling buddies and consider rejoining the bowling league. To be able to make healthy lifestyle changes that will last, he needs to remember and then focus on WHY he wants to be alive.
Case 2:
A 63-year-old male patient presents to the office for follow up on obesity, hypertension, diabetes, and hyperlipidemia. Other than a recent weight gain of 25 pounds, his medical conditions are currently well managed with medication, but he hates taking all of them. He states that he just switched to a much less demanding job and now that he isn’t working such long hours, he wants to improve his admittedly terrible diet and would like your suggestions. He expresses how much he loves his wife (who is very supportive of him making dietary changes), as well as his kids and grandkids. He would like to do what he can to try to be around for all of them for as long as possible. Both he and his wife enjoy cooking and have skills in the kitchen. You do an initial dietary intake and determine that he is getting about 10% of his calories from whole plants, with 40% of his calories from fat. You recommend that he use the Forks Over Knives Plan book and the 4Leaf Survey tools (available at www.4leafglobal.com) to gradually improve his diet as he is willing and able. You also notice in his chart that he was referred to the sleep clinic for suspected sleep apnea, but you do not see any report. You ask if he ever completed the sleep study, and he sheepishly admits that he never called the sleep center back to get scheduled. While he is sure that he does have significant sleep apnea because his wife tells him he stops breathing frequently at night, he was hoping to lose weight so that he didn’t have to use a CPAP machine. He is frustrated that instead of losing weight, he has gained another 25 pounds. He reports getting about 6 hours of sleep a night due to staying up late after “catching a second wind” in the evenings. He doesn’t nap but feels completely exhausted in the afternoons and typically drinks a Monster energy drink after lunch to keep him going. He drinks another Monster while crunching down an entire family-sized bag of potato chips to keep himself awake on his 45-minutes commute home from his new job five days a week. He then eats dinner as well because he doesn’t want his wife to know that he ate a whole bag of chips already! You discuss with him that all the calories in the potato chips are making him gain weight, which will only make his sleep apnea and all the rest of his medical issues worse. You also highly encourage him to stop the Monster drinks in the afternoon, which are likely interfering with him falling asleep at a reasonable time at night despite his overall level of fatigue, and to stop eating potato chips on the drive home! You ask your staff to set up his sleep study consult before he leaves the office, reinforcing to the patient how important it is to address his sleep apnea. He is set up for the soonest available appointment, which is in 3 months. Three weeks later you receive an ED report that he was in a bad car accident on his way home from work after falling asleep at the wheel.
Lesson #2: While sleep apnea typically improves with weight loss, it is often hard to lose weight (due to increased cortisol released during airway obstruction) until sleep apnea is adequately treated!
Lesson #3: Caffeine, sugary foods and drinks, and crunchy snacks are often used by sleep-deprived patients to help them stay awake, especially while driving. If these coping strategies are removed before the underlying sleep deprivation is addressed, you risk a catastrophic outcome!
What went wrong here? While the above recommendations regarding transitioning his diet were appropriate, there should have been a frank discussion with this patient about how caffeine and crunching were enabling him to stay awake on his drive home. He should have been allowed to continue to use the caffeine (only as much as was absolutely needed) until the sleep apnea was treated and he was no longer profoundly sleep deprived. (He could have been encouraged to switch the Monster drinks to unsweetened coffee to avoid the sugar load) While the afternoon caffeine eventually should be discontinued, staying awake while driving is obviously the more critical need at this time! And rather than eating nothing on the drive home, crunchy carrot and celery sticks could have been recommended to replace the potato chips.
Case 3:
A 35-year-old female patient with obesity, anxiety, depression, and previous alcohol abuse (last use 6 years ago) presents in your office to discuss starting Wegovy for weight loss. She does not have diabetes. Her anxiety and depression have been controlled for the past four years on duloxetine. She expresses that her work and family life are good, and she is generally happy about life except for her weight, which has been slowly increasing each year since she started taking duloxetine. Despite feeling that duloxetine has been the reason for her weight gain, she doesn’t want to discontinue it and try something else because it has worked so well to control her anxiety and depressive symptoms. She sleeps well and is moderately physically active. She has not tried any sort of diet for weight loss recently but noted that she had a lot of cravings in the past when she attempted to lose weight with calorie counting. She doesn’t think she would be able to lose weight without taking medication. On dietary review, she is vegetarian but eating mostly processed foods and cheese, getting only about 10% of her calories from whole plants. More than half of her calories are eaten in the afternoons and evenings as “snacks”. You discuss that her health insurance requires her to actively participate in a behavioral modification program to be eligible for medication coverage. Unfortunately, her insurance does not consider working intensively with a lifestyle medicine specialist an acceptable program, so the initial plan to schedule a comprehensive lifestyle medicine consult was scrapped. A week later, she sends you a confirmation letter that she has enrolled in Weight Watchers, which is one of her insurance’s approved behavioral programs. You submit the prior authorization paperwork for her Wegovy, which is approved a few days later. You send a prescription for the initial dose of Wegovy to her pharmacy and schedule a follow up for 4 weeks. A week before her scheduled follow-up appointment, she comes in for an urgent visit to discuss anxiety. She confesses that she started drinking again three weeks ago to help her deal with worsening anxiety and she had gotten another DWI. Both her marriage and her job are now at risk due to her relapse. She states that her previously well controlled anxiety had worsened significantly as soon as she started attending Weight Watchers, but seemed to increase further after the Wegovy was started. She hasn’t been able to eat much due to nausea from the medication but is very happy about the 8 pounds she has already lost. She doesn’t want to come off the Wegovy since she doesn’t believe it was what started the worsening anxiety, and just wants you to treat her with additional medication. When you ask what healthy coping skills she uses to manage her anxiety, she replies “Isn’t that what meds are for?”
Lesson #4: Many patients use calorie-dense food as a “drug” to cope with anxiety and/or depression, especially if they have a previous history of other substance abuse. If these patients have few healthy coping techniques available, taking away the food sets them up for returning to old addictions or to developing new ones.
What should have been done for this patient? Before referring this patient to a diet program or prescribing medication, a comprehensive look at her stress management skills with an assessment of how much she was using food to self-soothe should have been completed. The initial focus with this patient should have been strengthening her stress management skills, not diet or medication. Even though seeing a lifestyle medicine specialist wouldn’t have qualified her to receive the medication per her insurance, an initial consult appointment should have been recommended and completed prior to prescribing Wegovy. At this follow up appointment, both Wegovy and Weight Watchers should be stopped, and she should be referred to a program that treats both mental health and alcohol abuse.
Conclusion
Think these cases are a bit far-fetched? Well, I can attest that they are not, as they are all based on real cases from my former primary care practice before I pivoted to exclusively practicing lifestyle medicine. These epic “fails” resulted when I did not take the time to fully address these patients’ lifestyle habits. Due to other work demands, most physicians today are severely constrained in their ability to do the counseling that they know their patients both need and deserve. If you are one of those physicians, please continue to inform your patients how much their habits (especially their diet!) matter to their overall health. But, in addition, please consider referring them to a lifestyle medicine specialist for a comprehensive evaluation.
About the Author:
Kerry Graff, MD is board certified in both Family Practice and Lifestyle Medicine. She has recently transitioned to working solely as a lifestyle medicine consultant and practices telemedicine at Love.Life Telehealth. After spending the first half of her career putting patients on medications, she has dedicated the second half to helping patients get so healthy that they no longer need them! She is the co-author of the book 4Leaf Guide to Vibrant Health-Using the Power of Food to Heal Ourselves and Our Planet and serves on a volunteer basis as Chief Medical Officer of 4Leaf Global. All proceeds from the book are donated to further lifestyle medicine initiatives.
