May 27, 2024

AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

What is lifestyle medicine? Is lifestyle medicine a medical specialty? What are the 6 pillars of lifestyle medicine? What do doctors do when they retire?

Our guest is Elizabeth Pegg Frates, MD, president of the American College of Lifestyle Medicine. AMA Chief Experience Officer Todd Unger hosts.

Speaker

  • Elizabeth Pegg Frates, MD, president, American College of Lifestyle Medicine

Unger: Hello and welcome to the AMA Update video and podcast. In honor of the AMA Senior Physician Recognition Month. Today, we’re talking with an expert in lifestyle medicine and learning how this new specialty can help reduce burnout in physicians, and particularly senior physicians.

Our guest today is Dr. Elizabeth Frates, president of the American College of Lifestyle Medicine in Boston. Dr. Frates is also a clinical associate professor at Harvard Medical School. I’m Todd Unger, AMA’s chief experience officer in Chicago. Dr. Frates, thanks so much for joining us today.

Dr. Frates: Thank you for having me, Todd. It’s a real honor.

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Unger: Well, before we discuss the issue of burnout, I want to talk a little bit about lifestyle medicine. That’s probably something that there are people that are unfamiliar with that as a newer specialty. And I’d love to understand a little bit of background about it. What’s driving the growth of this particular specialty? And tell us about your personal reason that you got into it in the first place.

Dr. Frates: Terrific. I love this opportunity because this is a passion of mine, both personally and professionally. Lifestyle medicine is the medical specialty—and you can get board certified in lifestyle medicine through the American Board of Lifestyle Medicine as of 2017. What are you getting boarded in? You’re getting boarded in the use of the six pillars of lifestyle medicine.

So we prescribe pills, yes, as traditional physicians. We also prescribe pillars. What are these six pillars? Routine physical activity; nutritious, delicious food; sound, restorative sleep; stress resiliency; positive social connection and avoidance of risky substances. These are our pillars in lifestyle medicine.

Why have we been growing and continue to grow? The American College of Lifestyle Medicine now has 11,000 members. We have about 3,000 board certified physicians. Because of the chronic disease epidemic we have in this nation and worldwide. Diabetes, obesity, coronary artery disease, metabolic syndrome, mental health conditions—these are lifestyle-related. Those pillars I just mentioned have an impact—a significant impact on those chronic conditions. And that’s why we are growing and growing as a specialty.

Unger: So interesting, a lot of the pillars that you outlined there, I feel like they’re right from my social media feed because so many of those topics are just top of mind today, especially people want very active lifestyles as they age. And so I’m really curious to learn more about the curriculum itself that you’ve been developing for medical schools. It’s something that might have been traditionally lacking in medical education. And so tell us more about why it’s so important to include it now.

Dr. Frates: Yes and this is about the time where you need to bring a patient into the room, don’t you, to really understand what’s happening. Let me tell you about the patient that continues to inspire me. And this is basically inspiration of 35-plus years or more.

So imagine a New York City businessman, overworked, overstressed, overweight, who dined almost exclusively on fast foods, ultraprocessed foods, like Oreos, hot dogs on the corner of New York City. Ate fast, walked fast, talked fast. Stress reduction was eating candy in his middle drawer at work. Sleep was nonexistent. Social connection—he’s married, has kids at this time, but when he’s home, he’s not really present because he’s thinking about his clients in his financial advising firm on Park Avenue. Think about that stress.

Now, I’m missing one of the major pillars—physical activity. This man was an outstanding athlete. But at this time of 52, he was basically sedentary. Sat most of the day, even though he was an outstanding basketball player, soccer player, baseball player. But midlife, like many people, he became sedentary because he was dedicated to his work.

Sleep—pretty non-existent. And sometimes he would have to sleep at work because he got so involved with work. He would sleep—there was a cot at work for him actually. If he did get home, he was sleeping three, four hours.

I want to go back to physical activity because I wasn’t fully truthful. There was one activity he did do, the exact same time every day, but you never know what day he would do it. But it was at 11:07 PM precisely that he would do this activity. I wonder if anyone’s thinking mad dashes sprinting, because that’s what it was, from 101 Park Avenue to Grand Central Station to catch the last train home.

This gentleman—overweight, overworked, overstressed, New York City businessman, had a little pain and pressure one night when running for the train. He didn’t want to sleep on that cot. So he sprinted hard and he made it. No pain, no gain. Foraged forward, made the train.

By the end of the train ride, yes, numbness and tingling down the left hand, diaphoretic, short of breath. Wife picks him up, takes him to local ER. Yes, he has a massive myocardial infarction and subsequent middle cerebral artery stroke leaving him paralyzed on the left side.

That is a story I saw a lot. Similar stories a lot in the ER and in physical medicine and rehab when I was training. But this is a story in a patient that sticks with me because that was my father, and that happened to him at 52 when I was 18.

Unger: Wow.

Dr. Frates: Now, when I was 18, things were different. Back then things even seemed simpler. But they seemed stressful back then. Things have only gotten more complicated. And the rates of diabetes, obesity and heart disease are not getting better. We do have more medications, so we’re managing some things better. But we have to tackle the lifestyle if we really want to get a hold of these non-communicable diseases.

Unger: Absolutely. And from what you just described there, a very personal story. You could just see the need and the benefit of an intervention based on evidence-based lifestyle medicine and the kind of prescription, so to speak, that you’ve been developing. Dr. Frates, can you talk to us about the lifestyle interventions a little bit more?

Dr. Frates: Yes, absolutely. And it does go to the curriculum that you had inquired about. So when we are studying lifestyle medicine, and yes, nutrition is meant to be in our core curriculum in medical school. In fact, we’re supposed to get 25 hours of it.

But medical schools are not—most medical schools are not contributing that amount into their core curriculum for medical students. And physical activity is maybe five, six hours. And some don’t even have it in their core curriculum. And then if you think of the other pillars, sometimes they’re put into case studies.

But a core curriculum in lifestyle medicine would go over the guidelines—the evidence-based guidelines for each of these pillars—so 150 minutes to 300 minutes of moderate intensity physical activity in the week, plus strength training twice a week.

Then a whole food plant predominant type of eating pattern. Several different types of Mediterranean-style diet, a DASH diet—Dietary Approaches to Stop Hypertension—which you’re well aware of, multiple diets that are whole food plant predominant.

Then sleep recommendations are seven to nine hours. Stress resiliency—about 15 minutes a day of stress reduction activity. Social connection—connecting with someone that you feel supported by each and every day for a total of at least seven interactions.

And then avoiding risky substances. What does this mean? Well, quitting tobacco absolutely. When we get to alcohol, we look at the American Heart Association, which says if you don’t drink, don’t start. If you do drink, limit yourself zero to one for a woman, zero to two for a man. And if you look at the cancer data, there is no safe limit of alcohol and it is considered a carcinogen.

These are all things you would learn in the curriculum for lifestyle medicine that I’ve created for college premeds and medical school. There’s a LM 101 curriculum—Lifestyle Medicine 101 curriculum—you can download right now from the American College of Lifestyle Medicine with 120 power points per pillar plus coaching, which is the secret sauce. You know the guidelines, but you need to know how to counsel on it. And positive psychology as well as self-care, which comes to our well-being.

So lifestyle medicine curriculum is really in depth as to the dose. And what is a dose? That is a frequency and intensity of the pillar, so of the exercise that we’re going to prescribe or the sleep. How could you have an intensity for sleep? Well, if you’re considering a nap, that’s going to be a very different prescription than an overnight prescription for solid sleep. The nap has to be before 3:00 and only 20 minutes. 20 to 30 if you really want to stretch it.

And then we have to consider caffeine. You learn things in this curriculum that you didn’t learn in medical school or your training. Like what receptor does caffeine bind to? I never learned this until I started studying lifestyle medicine in 2006. It binds to the same receptor as adenosine.

Adenosine builds up throughout the day. ATP is used and adenosine is building up to a maximum of—at 11:00 PM, it’s maximum. If you have caffeine, then you’re not going to get the signal for sleep. You’re not going to feel the fatigue that the adenosine, if it bound to the receptor, would give you.

These are the types of information, pieces of evidence-based information lifestyle medicine physicians know and then put into practice when someone comes to them, say with diabetes. Yes, you’re thinking about what are they eating. Absolutely. And you’re thinking about how are they moving their bodies. Absolutely. You’re thinking about are they sitting too much, because if they sit too much, that also disrupts their glucose.

But you’re also thinking about how are they sleeping. Why? Because evidence shows if someone is sleep deprived for five nights—they only get four hours of sleep—they reduce their insulin sensitivity by 24%.

So with lifestyle medicine, you learn the comprehensive approach to treating the whole patient, thinking about all the pillars. And then you can ratchet up the dosing—how much exercise you’re prescribing, how much you can increase the hours of sleep, how many more fruits and vegetables you can fit into the day with the patient, and also how much stress reduction they can do daily.

Unger: Dr. Frates, this is a basic question. So many of the things that you talk about, personally very appealing to me. How would I go about finding a lifestyle medicine specialist?

Dr. Frates: That’s a great question. So at the American College of Lifestyle Medicine, we get that question. So there is a website—lmpros.org. LM For Lifestyle Medicine. Pros like LM professionals.org. You can pop in a zip code and any LM professional that’s board certified and is open to new patients will be on that list. And you, too, could enjoy the care of a lifestyle medicine clinician.

Now, we also certify nurses and other health care providers. And that would be through the American College of Lifestyle Medicine. So I recommend you go to the American Board of Lifestyle Medicine, MD/DO. And if there’s an international audience, we have an International Board of Lifestyle Medicine for MD/DO as well.

And if other health care providers want to get certified, because it’s a team approach, then they can go through the American College of Lifestyle Medicine. You do have to take an exam. You have to have several CME hours in lifestyle medicine accrued and give a case study.

Unger: Interesting. Well, I want to ask you a slightly different question and thinking about senior physicians. What advice do you have for them specifically and particularly around practicing, let’s say after the age of 65? Is that helping for a healthy lifestyle, not? What advice would you have for them?

Dr. Frates: Yes. That’s a great question. And retirement in physicians is complex. And it is certainly not one-size-fits-all. So for some, continuing to work so they have that sense of purpose, and maybe their practice brings them great joy. And it’s also a place of socialization for them and low stress because they have a workflow that works for them and they have a system that is not mired in the technology and EMR so they’re actually spending more time with their patients than in front of the computer. So they want to continue this.

And for some, it’s a paycheck. It’s important to get that income, to stay enjoying the lifestyle that they currently enjoy. So for some continuing to work makes sense.

Now, for others, if they are planning to retire, my suggestion is to think about the whole person. So we know that physicians will suffer upon retirement when they don’t continue to live their purpose. So if you’re going to retire from your practice and you’re a physician, there’s a plethora of opportunities for you so that you can still fulfill your purpose and use your strengths. You could mentor. You could teach. You could consult. You could do so many things in your community with all the experience and knowledge that you have.

If you continue to stay social—some of us are really social with our colleagues, I know that. This could be in medicine or outside. But if you can continue to connect with them, but also create a new community of people that you are working with, socializing with outside of medicine, that’s really going to help. If you are retired, you’re going to have more time to manage these six pillars of lifestyle medicine and really think about your health holistically.

First, I want to encourage every single person listening to this to go see their own physician. Surely, we’re physicians, but we need to have our own physician. We need our own annual checkups, labs and routine procedures so that we can be sure that we are healthy.

I want you to think about for your body, exercise. You heard the recommendations. Don’t know where you fit in that 150 to 300 minutes of moderate intensity each week. Think about that. I want you to think about your diet, your sleep habits. And then for your mind, we want a peaceful mind at work and in retirement. So we want to think about stress resiliency, time-outs and our attitude. When we have an attitude of gratitude, when we have a growth mindset, we tend to be happier and healthier.

Then I want to think about this joyful heart that we can have in medicine and when we retire. We need to think about our energy—what drains our energy and what gives us energy. We need to think about our social connections. We want to cultivate high quality connections. And that sense of purpose is key for the joyful heart. So if you’re going to stay in practice or you’re going to leave, I’d love for you to think about the six pillars and your sense of purpose.

Unger: Dr. Frates, what great advice. It’s been so much fun talking to you and learning more about the pillars of lifestyle medicine. I really want to thank you for sharing this important information for senior physicians and really for all physicians out there.

The AMA is a leader in physician well-being. And we offer a wealth of resources to reduce physician burnout and bring back the joy in medicine, like Dr. Frates was talking about. We also have resources specifically for senior physicians. And you’ll find all of those links in the description of this episode.

To support the AMA’s work, you can become a member of the AMA at ama-assn.org/join. We have special discounts and benefits for senior physicians. That wraps up today’s episode. We’ll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today and please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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