Bridging the Gap
Elizabeth Joy, MD, describes how lifestyle medicine training and tools for the full spectrum of healthcare providers can decrease the ever-increasing burden of chronic disease
Elizabeth (Liz) Joy, MD, MPH, FACSM, is the medical director for community health and clinical nutrition at Intermountain Healthcare in Salt Lake City. Dr. Joy practices family medicine and sports medicine at the LiVe Well Center at Salt Lake Clinic. She is an adjunct professor at the University of Utah in the department of family and preventive medicine. She completed a family medicine residency and primary care sports medicine fellowship at Hennepin County Medical Center in Minneapolis and earned her master's degree in public health at the University of Utah.
Dr. Joy is currently president of the Female Athlete Triad Coalition and also president of the American College of Sports Medicine (ACSM). In addition, she held two terms of office on the board of trustees for the American Medical Society for Sports Medicine. She is on the editorial board for the Clinical Journal of Sports Medicine and is associate editor for Current Sports Medicine Reports. She serves on the Exercise is Medicine® (EIM) Task Force for ACSM, and chairs the EIM Clinical Practice Committee. She developed and directed the Primary Care Sports Medicine Fellowship Program at the University of Utah from 1998 until 2010. Her research and advocacy interests lie in the areas of physical-activity assessment and promotion, the female athlete triad, sports-injury prevention and diabetes prevention.
ACE: You served as chair of the health-care sector of the National Physical Activity Plan (NPAP). Can you briefly summarize some of the key goals of NPAP and how they can have a positive impact on the obesity epidemic?
Elizabeth Joy: The National Physical Activity Plan has nine sectors: business and industry; community recreation, fitness and parks; education; faith-based settings; mass media;public health; transportation, land use and community design; sport;and health care. Each sector presents strategies aimed at promoting physical activity, and outlines specific tactics that communities, organizations, agencies and individuals can use to address the strategies. While the plan does not specifically target obesity, its focus on physical activity and energy expenditure through regular health-promoting physical activity directly influences the obesity epidemic we are facing here in the United States and elsewhere.
ACE: What do you feel is the greatest challenge that physicians and other healthcare professionals face when it comes to leading patients to sustainable, healthy lifestyle change?
Elizabeth Joy: When it comes to promoting healthy lifestyle, there are both challenges and opportunities for healthcare professionals. In terms of opportunities, healthcare payment reform is evolving in a way that will financially incentivize healthcare systems and physicians to keep their patients well. That means addressing lifestyle behaviors that contribute significantly to the ever-increasing burden of chronic disease. Another opportunity is the recent announcement from the Centers for Medicare & Medicaid Services regarding the outcomes of the National Diabetes Prevention Program (DPP) and pending reimbursement for the DPP program, which is one of the best examples of healthy-lifestyle promotion.
As for challenges, it's clear that physicians and other healthcare providers get insufficient training in lifestyle medicine and are therefore ill-equipped to effect meaningful lifestyle change in their patients. We simply must do a better job of educating the full spectrum of healthcare providers.
Another challenge has been a lack of tools and processes in lifestyle medicine. The inclusion of Physical Activity Vital Signs (PAVS) in electronic health records (EHR) is a step in the right direction, as is the integration of data from wearable physical activity tracking devices into EHRs and clinical practice. These processes provide information that can prompt discussions about physical activity for health promotion and disease management.
Finally, physicians and patients have too little face-to-face time to address lifestyle behaviors, and physicians are saddled with a reimbursement system that, while slowly changing, does not reimburse them for the time and effort it takes to connect with a patient working to improve his or her lifestyle.
ACE: Why do you think more healthcare professionals do not prescribe exercise or other lifestyle-related behaviors to their patients? What impact do you feel it would have if more physicians adopted that practice?
Elizabeth Joy: Healthcare providers want to do the right thing for their patients, but insufficient knowledge and a lack of clinical tools and processes for assessing and promoting physical activity have created barriers to regular physical-activity counseling. There is strong evidence that primary care physical-activity counseling does increase patients' physical-activity levels. Likewise, structured physical-activity counseling does not substantially increase the length of office visits and is positively perceived by primary care physicians. Systematic use of PAVS, followed by advice on physical activity and, ideally, referral into a physical-activity program will hopefully result in an increase in physical-activity levels.
ACE: What role do you feel health coaches and other well-qualified fitness professionals can have on the effectiveness of the healthcare team?
Elizabeth Joy: Medicine is most definitely a team sport, and the team is becoming increasingly diverse. The doctor and nurse are now joined by advanced practice clinicians, medical assistants, care managers, clinical pharmacists, mental health professionals and dietitians. Many sports medicine physicians work with certified athletic trainers. Some practices are adding health coaches and/or exercise physiologists. Many of these professionals have advanced training focused on behavior change and/or healthy-lifestyle promotion. The collective efforts of these specially trained professionals can add expertise to the healthcare team and provide care and counseling to patients in need.
ACE: What are some practices by members of the healthcare team that you feel need to happen in order to decrease the impact of obesity and chronic disease?
Elizabeth Joy: We have to move upstream from disease management to health promotion and disease prevention. We can no longer afford to focus our limited resources on treating chronic disease. In our healthcare system, for example, it is significantly more expensive to treat a patient with type 2 diabetes than an adult of the same age without diabetes. The greatest predictor of diabetes prevention is achieving a 5%–10% weight loss. If the healthcare team can become a highly functioning team focused on healthy- lifestyle promotion, we can make real headway in our fight against the progression of chronic disease. To achieve this, we will need to expand and improve professional education, continuing education, clinical tools and effective workflow. Finally, reimbursement/payment models need to be in place to support the efforts of these clinicians.