Building Health Equity: Action Steps From the American College of Lifestyle Medicine's Health Disparities Solutions Summit (HDSS) 2020

Lifestyle approaches to hypertension for prevention of stroke and vascular cognitive impairment: a realist review protocol

INTRODUCTION

Stroke and vascular cognitive impairment (VCI) are major global public health pandemics. The increased incidence of stroke and VCI is in part due to modifiable risk factors (MRFs), with hypertension (HTN) being the strongest single MRF. Even though the underlying causes of HTN are multifactorial, lifestyle choices (eg, poor diet, physical inactivity, alcohol consumption) are chief contributors. Lifestyle medicine (LSM) is a medical and evidence-based discipline that is a promising approach for preventing stroke and cognitive impairment, including VCI. The empirical evidence from systematic reviews, meta-analyses and large population-based studies has reported on the effectiveness of LSM interventions. However, the evaluation of such complex, social and behavioural interventions warrants more information to allow its successful implementation into innovative clinical care models. More importantly, we need to understand how such interventions work, who it works for and under what circumstances to successfully manage HTN and other MRFs (eg, hyperlipidaemia, smoking, alcohol use and diet).

METHODS AND ANALYSIS

This realist review will follow the Realist and Meta-narrative Evidence Synthesis: Evolving Standards. The review will comprise four stages: (1) clarify the scope, (2) search for the evidence, (3) critically appraise primary studies and extract data focusing on the context, mechanism and outcome configuration and (4) synthesise evidence and draw conclusions.

ETHICS AND DISSEMINATION

Research ethics board approval is not required for this review. The primary output of this review will be an evidence-based programme theory for LSM interventions for the management of HTN and other MRFs to reduce the risk of stroke and VCI. Findings from this review will be disseminated at three levels: micro (eg, patients, caregivers, clinicians, non-research partners), meso (eg, public, national not-for-profit organisations, professional associations and centres) and macro (eg, policymakers and government partners).

PROSPERO REGISTRATION NUMBER

CRD42024511566.

A review of health equity considerations in cochrane reviews of lifestyle interventions for cardiovascular health in adults

OBJECTIVES

Cardiovascular disease (CVD) is the leading cause of global disease burden and rising health-care costs. Systematic reviews (SRs) rigorously evaluate evidence on health interventions' effects and guide personal, clinical, and policy decision-making. Health equity is the absence of avoidable and unfair differences in health between groups within a population. Assessing equity in lifestyle interventions for cardiovascular health is important due to persisting health inequities in CVD burden and access to interventions. We aim to explore how health equity considerations are addressed in Cochrane SRs of lifestyle interventions for cardiovascular health.

STUDY DESIGN AND SETTING

This is a methodological review of Cochrane SRs of lifestyle interventions for cardiovascular health using the PROGRESS-Plus framework. PROGRESS-Plus stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital, while "Plus" stands for additional factors associated with discrimination and exclusion such as age, disability, and comorbidity. Using predefined selection criteria, two authors independently screened all Cochrane reviews published in the Cochrane Database of Systematic Reviews (CDSR) between August 2017 and December 2022. PROGRESS-Plus factors in the SRs were sought in the Summary of Findings (SoF) table, Methods/Inclusion criteria, Methods/Subgroup analyses, Results/Included studies, Results/Subgroup analyses, and Discussion/Overall completeness and applicability of evidence.

RESULTS

We included 36 SRs published by 10 Cochrane groups, addressing 11 health conditions with mostly dietary and exercise interventions. The most common PROGRESS-Plus factors assessed were gender/sex, age, and comorbidity. PROGRESS-Plus factors were most addressed in the inclusion criteria (64%), the discussion (75%), and the included studies (92%) sections of the SRs. Only 33% of SoF tables referenced PROGRESS-Plus. Sixty-nine percent of the included SRs planned for subgroup analyses across one or more PROGRESS-Plus factors, but only 43% of SRs conducted subgroup analyses, suggesting limited reporting of PROGRESS-Plus factors in primary studies.

CONCLUSION

Equity factors are not sufficiently addressed in Cochrane reviews of lifestyle interventions for cardiovascular health. Low reporting of PROGRESS-Plus factors in implications for practice and research sections of Cochrane SRs limit equity-focused guidance for current clinical practice, public health interventions, and future research.

Promise of Lifestyle Medicine for Heart Disease, Diabetes Mellitus, and Cerebrovascular Diseases

The burden of noncommunicable chronic diseases has relevant and negative consequences to persons, health care systems, and economies worldwide. Chronic diseases are the leading cause of disability and mortality and are responsible for 90% of health care expenditure. The most common chronic diseases are diabetes mellitus (DM), cardiovascular disease, and cerebrovascular disease (stroke and vascular cognitive impairment). Modifiable risk factors (MRFs) for these conditions include hypertension, hyperlipidemia, smoking, poor diet, and low-physical activity; with hypertension being the most prevalent MRF. Most MRFs can be successfully targeted through lifestyle medicine (LSM), which is a medical specialty that addresses the root causes of chronic diseases through its primary, secondary, and tertiary preventative approaches. Lifestyle medicine comprises 6 pillars (nutrition, physical activity, sleep health, stress reduction, social connections, and substance use) which through various behavioral approaches, focus on regular physical activity, healthy eating, good quality and quantity sleep, and meaningful social connections coupled with the reduction of stress and substance use. This paper will briefly review the evidence and promise of individual LSM pillars in addressing the underlying MRFs of DM, cardiovascular and cerebrovascular disease (specifically stroke and vascular cognitive impairment). Lifestyle medicine holds a great promise for comprehensive and much improved population health. However, the adoption of LSM at the societal scale requires a multifaceted approach and widespread integration would galvanize a paradigm shift to prevent, treat or reverse chronic diseases from the root causes and achieve health equity.

American College of Lifestyle Medicine Expert Consensus Statement: Lifestyle Medicine for Optimal Outcomes in Primary Care

OBJECTIVE

Identify areas of consensus on integrating lifestyle medicine (LM) into primary care to achieve optimal outcomes.

METHODS

Experts in both LM and primary care followed an a priori protocol for developing consensus statements. Using an iterative, online process, panel members expressed levels of agreement with statements, resulting in classification as consensus, near consensus, or no consensus.

RESULTS

The panel identified 124 candidate statements addressing: (1) Integration into Primary Care, (2) Delivery Models, (3) Provider Education, (4) Evidence-base for LM, (5) Vital Signs, (6) Treatment, (7) Resource Referral and Reimbursement, (8) Patient, Family, and Community Involvement; Shared Decision-Making, (9) Social Determinants of Health and Health Equity, and (10) Barriers to LM. After three iterations of an online Delphi survey, statement revisions, and removal of duplicative statements, 65 statements met criteria for consensus, 24 for near consensus, and 35 for no consensus. Consensus was reached on key topics that included LM being recognized as an essential component of primary care in patients of all ages, including LM as a foundational element of health professional education.

CONCLUSION

The practice of LM in primary care can be strengthened by applying these statements to improve quality of care, inform policy, and identify areas for future research.

Predictors of Patient Engagement With an Interprofessional Lifestyle Medicine Program

Background

Changes in lifestyle habits can reduce morbidity and mortality, but not everyone who can benefit from lifestyle intervention is ready to do so.

Purpose

To describe characteristics of patients who did and did not engage with a lifestyle medicine program, and to identify predictors of engagement.

Methods

This was a single-center, retrospective cohort study of 276 adult patients who presented for consultation to a goal-directed, individualized, interprofessional lifestyle medicine program. The primary outcome was patients' extent of engagement. Candidate predictors considered in multivariable multinomial logistic regression models included baseline sociodemographic, psychological, and health-related variables.

Results

A predictor of full engagement over no engagement was having private or Medicare insurance (rather than Medicaid, other, or no insurance) (OR 4.2 [95% CI 1.3-14.2], P = .021). A predictor of partial engagement over no engagement was having a primary goal to lose weight (OR 3.1 [1.1-8.4], P = .026).

Conclusions

System-level efforts to support coverage of lifestyle medicine services by all insurers may improve equitable engagement with lifestyle medicine programs. Furthermore, when assessing patients' readiness to engage with a lifestyle medicine program, clinicians should consider and address their goals of participation.

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

Lifestyle Medicine: Prevention, Treatment, and Reversal of Disease

Lifestyle medicine (LM) expands the scope of preventive medicine by focusing on the promotion of healthy lifestyles while preventing, treating, and reversing the vast majority of chronic diseases caused by behaviors and environmental factors. LM focuses on six pillars-a plant-predominant eating pattern; physical movement; restorative sleep; management of stress; avoidance of risky substances; and positive social connections. Advances in LM competencies, education, certification, resources, and practice models are accelerating with a particular need and focus on underserved and most seriously impacted patients and communities. A comprehensive and integrated strategy addressing "whole person health" is emerging as a compelling framework for providers and health systems which combines a foundational commitment to prevention with a systematic approach to the actual and root causes of premature disease, disability, and death.

HEALing Our Nation - Health Equity Achieved Through Lifestyle Medicine Capturing Highlights From the "HEALing Our Nation" Session at LM2023 and Outlining the Important Work of the HEAL Initiative

Since the COVID-19 pandemic, health equity has been placed front and center in the conversations surrounding healthcare as well other fields. This conversation has also been occurring in the field of lifestyle medicine with an intentional focus on developing solutions at the intersection of lifestyle medicine and health equity. Initiated by a call to action by ACLM Past President Dexter Shurney at the 2019 Lifestyle Medicine conference, the HEAL Initiative was created with that intention, to address health disparities and advance health equity through lifestyle medicine. Since 2019, the HEAL initiative has grown considerably in its work and impact, creating solutions aligned with the AMA strategic planning recommendations as well developing projects that are examples of community engaged-lifestyle medicine. The work of the HEAL initiative culminated in a full circle moment at the 2023 Lifestyle Medicine Conference which featured an interview (facilitated by Dr. Dexter Shurney) with former US Surgeon General Dr. Jerome Adams and review of HEAL's work over the past 3 years. This article will capture the key highlights of the HEALing our Nation opening session and the cumulative work of HEAL Initiative.

Sport: A Holistic Approach to Lifestyle Medicine

Sport represents a holistic health tool that unifies multiple pillars of lifestyle medicine. Sport can mitigate both the ongoing health disparities in communities that were present before COVID-19 and those exacerbated after COVID-19. The significance of this recommendation is highlighted by the impact sport participation has on creating healthy relationships, managing stress, and delivering physical activity among diverse populations. Importantly, sport can offer meaning and value to its participants, particularly when COVID-19 has limited people's ability for purposeful activity and social interaction. Clinicians are urged to consider the broad utility of sport for the prevention and treatment of unhealthy behaviors.

Future Directions for Health Equity and Lifestyle Medicine: Insights from Former US Surgeons General

Lifestyle medicine practices address root causes in the realm of patient care, healthcare systems, community health, and public health policy. It often takes consistent messaging and robust scientific evidence to buy in support of patients, health administrators, community leaders, and government officials. Four former U.S. surgeons general—the Honorable Admiral David Satcher, MD; Vice Admiral M. Joycelyn Elders, MS; Vice Admiral Antonia Novella, MD; and Vice Admiral Richard Carmona, MD, MPH, FACS—participated in a town hall during the American College of Lifestyle Medicine’s 2021 annual conference to discuss health equity and its relationship to LM. Moderated by Dexter Shurney, MD, MBA, MPH, immediate-past president of the American College of Lifestyle Medicine and president of the Blue Zones Well-Being Institute, the discussion also explored the challenging role and responsibilities of the nation’s top medical officer, the emergence of LM as an undervalued but high-potential tool for addressing complex issues such as health disparities, and specific actions—especially related to leadership—that would accelerate wider adoption of LM. In this article, Drs. Shurney and Carmona share their insights and highlights from the conversation and consider future directions of LM.