Chronic disease accounts for the majority of deaths in the United States and is often attributed to obesity. A sedentary lifestyle and poor nutrition are primary contributing factors to the development of obesity and thus chronic disease. Primary care providers are optimally positioned to prescribe exercise and nutrition (lifestyle medicine) as a treatment for chronic disease. Unfortunately, this opportunity seems to be regularly lost. Primary care providers often rely too heavily on weight loss pharmaceuticals and bariatric surgeries to treat obesity. This treatment approach however also does little to prevent and treat the accumulation of chronic diseases. The purpose of this review was to evaluate the efficacy of conventional medical weight loss treatments and determine why primary care providers may not prescribe exercise and nutrition more frequently. Our findings suggest that some primary care providers may be uncomfortable prescribing lifestyle medicine as they receive little formal education in this field. In conclusion, prescription of exercise and nutrition by primary care providers may elicit greater long-term weight loss than current medical weight management practices. Medical management is most likely effective when combined with lifestyle medicine. We propose that primary care providers be better trained in lifestyle medicine through their formal and clinical education. Rates of chronic disease accumulation may potentially decrease if providers prescribe lifestyle medical treatments more frequently.
Chronic disease currently accounts for the majority of deaths in the United States [
High infectious disease mortality rates have decreased over time due to the advent of modern medicine. As such, people have been living long enough to accumulate a myriad of chronic diseases. In turn, chronic disease has become the leading cause of death in developed nations [
One of the root causes behind the recent rise of chronic disease lies buried in the modern lifestyle. A sedentary lifestyle can be a major contributing factor to the onset of chronic disease. Accelerometer data indicated that adults are sedentary for almost 60% of their waking hours each day [
Since obesity is a large contributor to the accumulation and progression of chronic diseases, the treatment of obesity can decrease symptoms directly associated with excess weight gain, while simultaneously treating and preventing chronic disease. The CDC reported that about 40% of the adult U.S. population was obese in 2015 [
Clinical measurement of weight most often utilizes body mass index (BMI), the ratio of a person’s weight in kilograms to the square of their height in meters. BMI is then compared against national averages to determine weight status (BMI of 25 kg/m2 to 29.9 kg/m2 is overweight, 30 kg/m2 to 39.9 kg/m2 is obese, and 40 kg/m2 or greater is extreme obesity) [
A current review of clinical obesity management suggests that physicians should be first recommending lifestyle modifications, followed by pharmaceutical prescription, and lastly bariatric (weight loss) surgery to their obese patients [
Pharmaceuticals have been shown to induce statistically significant weight loss [
Clinically obese individuals meeting BMI standards (≥ 30kg/m2 or ≥ 27kg/m2 with obesity related comorbidities) are cleared for prescription pharmaceutical intervention [
Most drugs have between 10 and 100 possible side effects or adverse drug reactions [
Patients regain weight after pharmaceutical weight loss treatment ceases without parallel lifestyle changes [
In an effort to combat regaining weight, pharmaceuticals have been designed for both short-term (≤ 12 weeks) and long-term use (as long as desired) [
Bariatric surgery either limits the amount of food the stomach can hold (restrictive), reduces nutrient absorption efficiency (malabsorptive), or both (mixed) [
A patient must have a BMI of at least 40 kg/m2 or 35 kg/m2 with another obesity related illness to be considered for bariatric surgery [
Regardless of procedure complexity, all bariatric surgeries pose risks of complications up to and including death [
Bariatric surgeries certainly yield short-term weight loss, but most procedures eventually lead to some weight being regained. In order to prevent as much weight regain as possible, patients must sustain healthy lifestyle modifications post surgery [
Physical activity is presumed to help tilt the caloric balance toward a caloric deficit and thus elicit weight loss [
Until recently, the heart was believed to be incapable of generating new contractile cardiomyocyte cells [
The WHO states that 30% of all cancers, 80% of cardiovascular diseases, and 90% of type-2 diabetes cases could be prevented in part by consuming a nutritious and balanced diet [
Oils are a type of unsaturated fat typically viewed as a “healthy” fat, relative to other “unhealthy” or saturated fats, such as butter or lard. Saturated fats have traditionally been associated with increased morbidity and mortality by means of altering cholesterol concentrations, thus leading to cardiovascular disease [
A healthy diet alone is not entirely effective for the reduction of chronic disease as it cannot replace the beneficial effects physical activity has on the cardiovascular system [
Lifestyle modifications, or behavioral weight control, used to modify dietary habits, exercise habits, or both should be a clinician’s first choice for treating obesity [
Physical activity modifications are typically based on recognized guidelines for recommended weekly physical activity participation. The CDC recommends a minimum of 150 minutes per week of moderate intensity activity (3.0 - 5.9 METs), or 75 minutes per week of vigorous activity (6.0 METs or greater), or a combination of the two in bouts of 10 minutes or more [
There appears to be a difference between simply advising patients to increase physical activity and formally prescribing it. When patients were advised to increase physical activity, they tended to actually decrease physical activity by approximately 15 minutes per week [
Dietary prescription lifestyle modifications most commonly entail reducing the amount of total food and fat consumed daily in an effort to decrease caloric intake [
When comparing the Atkins diet to a more clinically prevalent low calorie/low fat diet, weight loss differences are statistically indistinguishable in the long-term [
Diet prescription efficacy appears dependent on the intensity with which the behavioral modification is promoted by the prescribing clinician. The frequency of visits to a clinician and the topics of discussion are directly related to the success of a particular diet plan. Foster et al. compared the Atkins and Ornish diets with intensive in-person behavioral treatment across two years, discovering similar, high diet efficacy so long as clinicians met regularly with their patients [
Primary care physicians are advised to screen adults for obesity and offer comprehensive weight management plans for obese adults, yet many fail to do so [
While physicians receive extensive training in the use of pharmacotherapy, the same cannot be said for prescribing lifestyle modifications [
Over 90% of medical schools offer some nutrition education, but it is often interspersed within other science courses, instead of as an exclusive nutrition course [
In formal physician training, content related to appropriate physical activity is taught even less frequently than nutrition content. An average of eight hours of physical activity education is provided at U.S. medical schools [
Clinicians should screen all patients for physical inactivity and poor dietary patterns. Physical activity and nutritional assessments should be treated as vital signs and patients should understand the health risks associated with a sedentary lifestyle and an unbalanced diet. Patient activity level and nutritional status are imperative to their longevity and more importantly, their quality of life. Standardizing physician assessment and prescription of physical activity and diet should be paramount. Most pharmaceutical treatments follow standardized, yet individualized practitioner prescribed schedules. Why then should the prescription of physical activity and diet protocols be any different? Standardized care provides several benefits, which include risk reduction, reduced payer costs, and consistent outcomes for different patients [
Several factors must be considered to program physical activity and exercise for a patient. Standardized exercise training programs could be developed for populations with common presentations (e.g. BMI ranges, specific chronic diseases, or overall morbidity and mortality risk). In many cases, evidence of effective programming for such populations and patients with specific diseases already exists. Individual dietary prescription outside of consultation with a certified dietary professional should be based on patient preference and should interfere the least with any pre-existing conditions the patient may have. Standardized treatment protocols could be established by leading experts in the field for unique patient populations. Primary care clinicians may then select the most appropriate lifestyle protocol for each patient. Clinicians could then make modifications depending on each patient’s individual needs, or refer them to an exercise physiologist or dietician for further refined care as needed. An alternative approach could include primary care clinics staffed with a dietician and exercise physiologist to facilitate this patient-centered care. Patients could the visit the dietician and exercise physiologist with greater frequency than the physician promoting lifestyle change maintenance.
Primary care clinicians should prescribe physical activity and diet as a curative and preventative measure for chronic disease. Recognizing that weight loss pharmaceuticals may not reduce cardiovascular metabolic risk factors alone, a concomitant treatment with physical activity and dietary prescription (combination therapy) would likely increase weight loss and improve metabolic disease risk factors [
Additional training in exercise and nutrition could be included during a medical student’s education. Dedicating a course in medical school towards the prescription of lifestyle medicine for the prevention of chronic disease may positively influence physician confidence regarding the prescription of exercise and nutrition. Physician residency programs could recommend or require a rotation in lifestyle medicine for medical students interested in primary care practice or specialties that focus on patients with chronic disease. If residency programs were to favor those individuals with training in lifestyle medicine, it may provoke more interest in these preventative treatments. At the very least this would expose medical students to lifestyle treatments they may use in later practice.
In order for current primary care physicians to provide lifestyle counseling and preventive prescriptions they should be better trained in lifestyle medicine. It has been shown that even a three-hour seminar on the benefits of exercise in medicine is sufficient to increase exercise prescription by physicians by 28% [
The major limitation to the prescription of exercise and nutrition is the heavy burden placed on the patient alone. Taking a medication is relatively easy, whereas consuming a healthy diet and exercising regularly is not. Further still, if lifestyle alterations are not sustained, excess weight regain is inevitable. These limitations make quick and simple solutions like pharmaceuticals and surgery more appealing options, despite arguably worse results and increased financial burden.
The authors acknowledge that educating physicians and changing how they prescribe exercise and nutrition is just the first step of reforming primary care to effectively combat chronic disease. Advances in the elimination of chronic disease lies mostly outside of the physician’s office. Patient behavior change is paramount to the success of lifestyle medicine. Patient non-compliance with an effective prescription of exercise and nutrition is as detrimental as a lack of this prescription in the first place. A shift away from curative treatment towards preventative treatment not only requires physician education and compliance, but necessitates a rearrangement of societal values. We must encourage deviation from a culture focused on instant gratification. Exercise and nutritional behavior change requires prolonged effort while current culture promotes care that minimizes the energy required on the patient’s end. Additionally, increased funds should be available for lifestyle medicine. Insurance providers would need to increase the accessibility to and reimbursement for lifestyle medical care.
Primary care clinicians are not appropriately utilizing lifestyle modifications as a preventive measure against or treatment for chronic disease. The increasing obesity prevalence in the United States is a strong indicator of a fundamentally flawed approach to health care. This obesity epidemic is directly related to elevated rates of mortality resulting from chronic disease. Current pharmaceutical and surgical treatments provide minimal relief to the obesity and chronic disease epidemic. Physical activity and balanced nutrition are paramount to the effective treatment of obesity and chronic disease. Primary care clinicians should increase their familiarity with exercise programming and dietary protocols to better provide comprehensive preventive and curative lifestyle modifications. In order to effectively combat chronic disease, clinicians should underscore the necessity of lifestyle treatment and prioritize its use in clinical settings. If primary care medical providers continue to neglect lifestyle medicine, lifespan and quality of life will be negatively impacted. Despite revolutionary medical advances in pharmacology and surgery over the past few centuries, there is no substitute for the benefits realized with appropriate physical activity and a balanced diet.
The authors would like to thank the participants and the undergraduate students who helped in data collection for this work.
The authors declare no conflict of interest.