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The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Allison Crawford talking about lifestyle medicine.
[00:00:10] Dr. Crawford: Why do I think lifestyle medicine is important? I think we can all appreciate this as physicians, but I'm just going to throw out an NIH statistic just to orient ourselves to the gravity that 80% of chronic conditions are driven by modifiable behaviors. It's amazing.
[00:00:30] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. Allison Crawford. Dr. Crawford is an assistant professor of medicine here at the University of Chicago.
She came to us after getting her MD at the University of Illinois Chicago College of Medicine and completing an internal medicine residency at Brown. Allie did a postdoctoral clinical research fellowship at Columbia University where she studied cardioprotective diets and completed a master's degree in clinical epidemiology also at Columbia.
She is a professionally trained chef and graduate of the Natural Gourmet Institute for Culinary and Healing Arts in New York City. Thanks so much for joining me today.
[00:01:20] Dr. Crawford: Thank you.
[00:01:22] Dr. Cifu: So with all your experience and expertise, I hate to focus on only one thing, but I'd like to discuss lifestyle medicine. For those who don't know, can you tell us what lifestyle medicine is?
[00:01:34] Dr. Crawford: Yes. So lifestyle medicine, how the American College of Lifestyle Medicine would define it is the use of evidence-based lifestyle therapeutic interventions. So that would include a whole foods plant predominant diet, regular physical activity, restorative sleep, stress management, avoidance of risky substances like tobacco and excessive alcohol, and fostering lots of positive social connections to prevent, treat, or reverse chronic disease.
[00:02:03] Dr. Cifu: So it's interesting, it sounds like it's a combination of both kind of therapeutics and behavioral counseling, is that right?
[00:02:11] Dr. Crawford: Yes, it would be a combination of sort of overall lifestyle habits and lots of principles from health psychology and coaching for behavior change to have sustainable, small daily habits over time that generate your optimal health.
[00:02:26] Dr. Cifu: Okay. So I guess as I said, a combination of, you know, behavioral change and interventions for your health, I mean, it's just medicine but your tools, your sort of non-pharmacologic tools, I guess, are better defined than what we would think about in regular primary care.
[00:02:45] Dr. Crawford: Exactly.
[00:02:46] Dr. Cifu: Yeah. What attracted you to the field, like how did you get into this? What led you here?
[00:02:51] Dr. Crawford: So initially, nutrition. I spent five years in between college and medical school working in public health nutrition in Chicago in low-income settings to help people receiving SNAP benefits eat healthier on a budget. Spent a lot of time with community dietitians out in the community teaching people about food, learning about nutrition, learning about barriers to healthy eating.
So then when I came to medical school, I had this orientation towards nutrition, and healthy lifestyle, and healthy eating. And I was sort of surprised as many folks are, that there's not a whole lot of practical nutrition taught in medical school. So I sort of had this abundance of knowledge and I wanted to put it into practice for patients.
So then I thought to myself, well, I have all this nutrition knowledge, what's the best way to translate this for patients, to put it into action? And I decided that the tool was cooking. And so that led me to go to culinary school because at the time I didn't know how to cook. So I thought, okay, first layer is knowledge, I have that, I can talk about it, but the doing is so important. So if I could support patients in this way with showing them how to put it into action, you know, literally, or you know, figuratively, so culinary school, and I thought that the road would end there but then I realized that after you have the knowledge and the tools, then you have the foundational layer, which is the behavior change and all of the principles of health psychology that go into that.
And it kind of led me back a little bit to connection with my undergraduate degree which was in psychology, I became very interested in that and I started to read about, well, how do I optimize people's ability to do these things now that they have the knowledge and the tools, how do they then work it into their lives?
And that ultimately led me to lifestyle medicine because our eating habits and the psychology involved, it can't really be addressed in isolation because there're so many synergistic effects between the other domains of lifestyle medicine. If you think, for example, about your relationship between diet and sleep and how those affect each other or diet and stress or alcohol and diet, you really have to take somebody's entire lifestyle in context to address some of the issues that patients are facing and how to get them towards their health goals.
[00:05:14] Dr. Cifu: It sounds like your career has had even less pre-planning than most of our careers, right? This is totally off the subject, so just briefly, it's interesting to me when you talk about nutrition in medical school, I feel like even during my career, nutrition has had less and less and less of a place in undergraduate medical education. And it's interesting because if anything, it seems to be, maybe because of social media, kind of more of a focus of just the lay discussions about health. I wonder why we've, I don't know, why we've sort of shirked our responsibility in a way in medicine to pay more attention to it. How do you think?
[00:05:58] Dr. Crawford: I just think that it's an overwhelming topic.
[00:06:01] Dr. Cifu: Yeah.
[00:06:02] Dr. Crawford: I think people feel sort of sometimes that there's no real anchor in how you have a discussion.
[00:06:08] Dr. Cifu: Yeah.
[00:06:10] Dr. Crawford: Somebody's nutrition in a clinic visit is large and overwhelming and then there's a disconnect with, you know, the things that we're taught really are rooted in... Our initial exposure in medical school usually is in biochemistry, right? We're learning about, you know, structures and vitamins and so forth and never really gets integrated to that more practical level.
[00:06:32] Dr. Cifu: Yeah.
[00:06:33] Dr. Crawford: But I think, on both sides, there is a desire to know more and to spend more time on it. The patients want more, then the doctors want more, certainly, the medical students will bring it up, you know, all over, but I think you're right that social media has really opened the floodgates for so much health trend information. And then really appropriately patients are coming to their physicians to help decipher this, you know, what's true, what's not true, what should I be doing? And that's, I think, where we're exposing sort of the clinical gaps now later in our careers where, you know, some folks will feel confident counseling to some degree, but then there are limits to that as well.
[00:07:16] Dr. Cifu: So maybe the take I should have is instead of getting annoyed with the sort of social media, you know, diet, nutrition trends, I should look at it like advertising for pharma is that, well, you know, we can appreciate this because it does open discussions with things that people come and talk about their depression that they may not have had they not seen a Zoloft ad on TV, and people may come in with a, you know, completely whack a doodle diet idea, but at least it sort of puts it on the table to discuss.
[00:07:48] Dr. Crawford: I think that's exactly right, and I think we should look at it as a good thing that our patients are coming to us for the advice rather than, you know, going to another website or blog.
[00:07:59] Dr. Cifu: They're doing that too.
[00:07:59] Dr. Crawford: They're doing that, too. Well, hopefully, we can be the guideposts.
[00:08:03] Dr. Cifu: So this is both maybe an obvious question and not so, why do you think lifestyle medicine is important sort of above and beyond what people get from a really good primary care doctor, whether it be, you know, a family practice doctor, a pediatrician, a general internist? You know, what do you feel like your field, your specialty has to offer, which we don't do a good job of in regular practice?
[00:08:32] Dr. Crawford: Yeah, let me answer that in a couple of different parts. So first, why do I think lifestyle medicine is important? I think we can all appreciate this as physicians, but I'm just going to throw out an NIH statistic just to orient ourselves to the gravity that 80% of chronic conditions are driven by modifiable behaviors. So 80%.
[00:08:53] Dr. Cifu: It's amazing.
[00:08:53] Dr. Crawford: It's amazing. And we know, especially as physicians that are more often in the outpatient world, that most of the chronic disease we're seeing, hypertension, hyperlipidemia, diabetes, all of it falls under this category.
[00:09:07] Dr. Cifu: Yeah.
[00:09:08] Dr. Crawford: And if we think that if 80% of chronic disease and premature death could just be prevented by not smoking, being physically active, and adhering to a healthy diet, I mean, that's amazing. That's extremely powerful and in some ways uplifting to know that we can sort of turn this around. But what are the limits of regular primary care?
So I think we all sort of recognize the statistic and we know the information, we know that these things can be good for our patients but the limitation often is, we don't have a great way to deliver this to patients in a comprehensive way. So I'm going to give you an example that I've given you before.
So imagine we have these lifestyle medicine trials for, you know, blood pressure or prediabetes or, you know, coronary artery disease, et cetera and we put people in these research trial settings where we are able to deliver a very comprehensive, intensive lifestyle intervention, looking at one or more of these domains, and we see great outcomes. And then we publish papers and we say, you know, lifestyle interventions are effective, they're evidence-based, but then we don't have a way to replicate that in actual medicine and clinical practice. It would be almost as if you know, you have some patients come to you with mild osteoarthritis in their knees and you want to refer them to physical therapy because you know it's an effective option. It's not invasive, it's safe, it's relatively low cost but now imagine, there are no physical therapists or no physical therapy clinics that you could refer to. And instead, you know very well that this information, this intervention is helpful and evidence-based but the best you can do is give them a handout on some knee exercises, and it's just not the same, right? But it doesn't mean it doesn't work. So I would say that in lifestyle medicine, we don't have a really good way to deliver a really intensive, comprehensive program. And even if we did, we would have other barriers on, you know, patients being able... How they'd be able to work that into their life, et cetera.
So those are the sort of state of affairs for lifestyle medicine. And so as primary care doctors, I think it's important for us to try to, at least in each visit, work in some amount. You might not be able to do the whole intensive intervention in an office visit because of competing clinical concerns and other things, but we should at least try to make, you know, small attempts at each visit.
You know, we face really the same, some of the same issues when we think about, like, smoking cessation or convincing someone to get a vaccine or a cancer screening. You know, not everyone will agree and it won't work all the time, but it's still remarkably important that we try repeatedly.
[00:12:01] Dr. Cifu: Your comparison to physical therapy is actually what drove us getting together for this podcast. And I love that example so much because, you know, for whatever, 25 years in clinic, I'm always like, you know, yeah, yeah, yeah, this person should lose weight but, you know, I'm telling them to lose weight, I'll give them a little advice but, you know, that almost never works. And in the people it works, it probably works because of them and not because of me, but your example is so good because if you compared, say, weight loss or just a healthy lifestyle in general versus, you know, a rotator cuff injury, right? If someone has a rotator cuff injury, you're able to put an order into Epic. They go to a different practice, you know, to see a physical therapist, they have ten sessions, it's all paid for. And to be honest with you, rotator cuff injuries, they stink, but you know, for the most part, they get better over time.
While these lifestyle medicine interventions, when you quote, you know, 80% of, you know, chronic diseases are affected by this and we put so much less kind of effort and money and resources into it. It's kind of shocking.
[00:13:10] Dr. Crawford: It is. The stakes are much higher. And if you think about it, lifestyle change is the first recommended intervention supported by virtually every evidence-based clinical guideline and consensus statement for chronic conditions.
[00:13:24] Dr. Cifu: Right. Right, right. Everything you read, whether it be smoking cessation, weight loss, diabetes, right, hypertension, it all begins with, you know, some sort of diet, exercise, you know, lifestyle modification. That's a great point. I think what's interesting about it, and it came to mind as you were describing you know, sort of what you do if you kind of had, you know, a lot of money or just a medical center that was behind you to say, "Okay, you know, sort of build us a clinic that would help our patients, but that would do it in, you know, an affordable way," because as I hear you talk about things, there are some things that really sound like these are physician jobs. There are other parts of it that sound like they could be, you know, all of our support staff sounds bad, but our, I don't know, our affiliated healthcare professionals, right? Who could help us out with, so kind of what's the divide as far as seeing the patients and where do patients get information? Like how do you break all that stuff down?
[00:14:33] Dr. Crawford: Yeah, it's very much an interdisciplinary effort at best. And the great thing is that we have an entire field of health psychologists that really are designed to use, you know, the best of evidence-based psychology to help people make these changes.
So you're right if I had... If I had a way to put this in a physical practice, an in-person physical practice and to design an institute, I'd very much model it over as something that you could refer your patient to. Maybe, you know, think of... Another example would be like, you know, some sort of intensive rehab or other intensive outpatient behavioral medicine type clinic.
I think the ideal combination would be to have an interdisciplinary specialist in all these domains, right? You have, you know, obviously, health psychologists to facilitate behavior change with techniques that are appropriate specifically to where your patient is. Stress management, we've got excellent evidence on mindfulness-based stress reduction therapies.
[00:15:42] Dr. Cifu: Sure, sure.
[00:15:43] Dr. Crawford: Yoga, personal trainer, exercise, physiology, teaching kitchens are a remarkable way to help people engage dietitians, culinary experts to do, you know, hands-on teaching and learning and, you know, cooking is a great way to sort of solidify that knowledge to practice. So I would think that in an ideal scenario, a patient would get referred to me, a board-certified lifestyle medicine specialist/internist, and I would take a comprehensive intake in all of these areas. I would use our evidence-based tools to assess where somebody's diet is. We've got evidence-based dietary screening tools, just like we use in depression and anxiety. We've got these tools in stress, sleep, diet, exercise, we have validated tools, get a comprehensive idea of where somebody is, and then create a buildable plan that targets these areas of deficiency, but also knowing that these deficient areas, if they're focused on first, they have massive synergy with each other.
[00:16:48] Dr. Cifu: Right. Right.
[00:16:49] Dr. Crawford: Right? For example, if someone is coming to you in your clinic and they... The most common complaint is I want to lose weight, but say, you take this comprehensive history and you find out that this person has massive unaddressed anxiety, is coping with it with alcohol and not sleeping very much, your dietary intervention isn't going to be very effective unless you address these other areas first.
[00:17:14] Dr. Cifu: Right, and you may not have to do the dietary intervention if you address those.
[00:17:17] Dr. Crawford: Exactly, yeah. There's so much synergy to almost figuring out where the most deficient areas are and shedding light on that and looking at this with a bird's eye view and sometimes you know, the patient isn't... Sometimes they will, but sometimes they're not always going to necessarily be the best person to have that perspective and you can zoom out and you can see where it is and then you can, as long as they agree, and this is what I do in my lifestyle clinic, you know, "Really, I know you're here because you want to lose weight but I noticed over here, your stress level is really high. And if we target this first, you know, we might have a downstream effect there."
But then so the physician could sort of be, you know, the arbiter of this, you know, grand plan. And then if you had sort of a physical, say, lifestyle medicine institution, interdisciplinary, you could then, you know, get them connected with each of these different services and continually meet back with them as the provider to reassess, redirect the care plan and move them forward in their health goals.
[00:18:17] Dr. Cifu: It would be so exciting for an institution to tackle this not only for patient care but from a research perspective, right? Because you could certainly say that just sitting here, you know, it sounds like a moneymaker, right, to be able to offer this, to say, "Hey, you know, come to Medical Center X because we have this," right? That's going to attract people but imagine, you know, having physicians identify patients who could benefit from this and, you know, randomize them to a year in this practice versus a year of usual care. And looking at everything from, you know, quality of life to weight to actual markers to the number of medications used, all that stuff, you know, probably be very expensive to follow them to actual clinical endpoints but wow, just thinking about quality of life and the sort of surrogate markers after a year, you know, that could carry you a long way to getting this taken up everywhere.
[00:19:18] Dr. Crawford: Absolutely.
[00:19:19] Dr. Cifu: What you were interested in creating, two examples came to mind, and they're on such completely different ends of the spectrum, I wonder what you think about this and why. You know, I think in, maybe in our practice, where I see this most is actually in our bariatric surgery group, where they really have a multidisciplinary team to assess people before surgery, you know, see who are good candidates for surgery, which involves not only the surgeons but psychologists, sleep medicine people, kind of everybody. And then a lot of follow-up post-surgery to make sure that people are getting the most out of the intervention they had. On the other side was an experience I had as a fourth-year medical student working in a very underserved place, actually in rural India, which was for children. And when a child was admitted, usually with a diarrheal illness and severe malnutrition, after the child got out of the sort of intensive care hospital part of it, the mother and child were admitted to a month-long inpatient stay, where the mother was taught, you know, how to cook with the local produce and locally available goods and how to feed the child and how to keep the child safe. And it was really sort of the clinic embracing this and saying like, how are you going to do well going forward given, you know, how the child came in. And it's interesting that it can go from such a sort of underfunded to an overfunded way to intervene on these things.
[00:20:56] Dr. Crawford: That's really interesting. It's, you know, it's making the decision to shift the brunt of the work to the front end from the back end of care. And it's a lot of upfront investment in somebody, but the downstream in the long term is so much better than treating the back end of when this gets really severe.
[00:21:16] Dr. Cifu: Right, right. I guess my examples are both kind of secondary prevention, right? It's either someone who's already developed severe obesity or a child who's already gotten sick and saying, you know, how can we make this better the next time? You are actually certainly doing some secondary prevention, but also doing primary prevention, say, boy, I know where this is going to go in a decade and what can I do now to sort of prevent those outcomes that we see too much of.
[00:21:42] Dr. Crawford: Right. I think as, you know, we've been talking about the burden of chronic disease for many decades, but eventually, it's going to grow and grow and grow, and we're going to be sort of forced to shift where we're spending some of our efforts. I think, you know, another example is cardiac rehab for secondary prevention often is interdisciplinary and has a good framework.
I think we've made a lot of strides, especially during the pandemic when we converted so much of our care to virtual in readdressing mental health and, you know, another comparison would be with, you know, taking a dietary history or touching on lifestyle medicine in a visit is imagine you were screening someone for depression or anxiety in primary care and you didn't have a validated screening tool to anchor you and you didn't have a referral system. So we do have validated screening tools for dietary screening, but you know, the emphasis on mental health and how much we can accomplish virtually, I think that's shifted during the pandemic, certainly as folks' stress went up and so forth. And so, you know, with the advent of so much virtual medicine and that being fairly successful, it offers maybe another opportunity for us to do some of this, and build it into primary care.
[00:23:01] Dr. Cifu: I've got one brief final question. I think a lot of us feel like our jobs are sort of, you know, like Sisyphean, like we realize when we sit in the office that so many of the things we care for are just like reflections of societal ills, right? And it's not just us as general internists dealing with, you know, obesity, hypertension, diabetes, you know, sleep disturbance, anxiety, you could go on and on and on but it's the trauma surgeons, right, whose everyday is, you know, dealing with what's going on in many of our neighborhoods. This seems to me like kind of an optimistic way to say, huh, short of political advocacy that some of us are good at, some of us aren't good at, this is sort of a way of feeling like, "Okay, I'm not just putting band-aids on, you know, things which society is injuring and making me patch up."
[00:24:04] Dr. Crawford: Right. I think that certainly so much of our built environment contributes to the ways we have to sort of cope with our lifestyle, right? When we're stressed and working a lot and healthy food is not readily available and we sort of have to navigate our own environment. So then the onus is put on the patient. And what I think though could be maybe an optimistic way of looking at that is I think sometimes when there's an interest from patients to move in a particular direction, then society, in some ways, will tend to move towards that, right? Sort of a supply-demand.
And when patients are starting to become more interested in diet and there's sort of a revival of interest in non-pharmaceutical options and wellness and mental health, when that sort of zeitgeist shifts a little bit, then I think collectively as a society in many different domains, we move a little bit towards that.
I think we do see some of that because one marker we can look at is there are lifestyle medicine clinics popping up throughout the country, whether those are academically affiliated or otherwise trying to find ways to support patients in that way, and I see that as a positive shift. Doesn't mean that pharmaceuticals can't be part of the toolkit if needed or other invasive procedures but certainly, like a paradigm shift that this needs more weight, this needs more structure.
[00:25:42] Dr. Cifu: I'm just happy as a podcast devotee with 99% Invisible being one of my favorites that the term built environment has finally ended up on The Clinical Excellence Podcast.
Allie, thank you so much for joining us today, that was really terrific.
[00:25:58] Dr. Crawford: Thank you.
[00:25:59] Dr. Cifu: So thanks for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.