Lifestyle Medicine

Standards

Lifestyle Medicine Standards Taskforce

Editor: Jennifer Rooke, MD, MPH, FACOEM, FACPM
John Gobble, DrPH, RD, LD, MCHES
Tasha Ballard, PhD, RN
Willy Oglesby, PhD, MSPH, FACHE
George Guthrie, MD, FACPM
Corey Howard, MD, FACP
R. Jason Newsom, MD

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Health is a state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity. - Preamble to the Constitution of the World Health Organization, 1946

Lifestyle is the set of behaviors that reflect an individual’s beliefs and values.

DEFINITION OF LIFESTYLE MEDICINE

Lifestyle Medicine is the therapeutic use of evidence-based lifestyle interventions to treat and
prevent lifestyle related diseases in a clinical setting. It empowers individuals with the
knowledge and life skills to make effective behavior changes that address the underlying causes
of disease.

Table 1: Lifestyle Medicine Compared to Other Approaches to Patient Care

Type of Practice Features
-Emphasis on promoting behavior changes that allow the body to heal itself.
-Focus on evidence-based optimal nutrition, stress management and fitness prescriptions
-Patients are active partners in their care
Lifestyle Medicine -Treats the underlying lifestyle causes of disease
1

-Physician/Provider educates, guides and supports patients to make behavior changes

-Medications used as an adjunct to therapeutic lifestyle changes
-Patient’s home and community environment are assessed as contributing factors..
Conventional - Emphasis on making a diagnosis and treatment with pharmaceuticals or surgery
Medicine1 -Patient is passive recipient of care
-Focuses on symptoms or signs of disease not the underlying lifestyle causes.
-Patient is not expected to make significant behavior changes
- Physician/Provider directs care - medical model.
- Medications are the primary therapeutic intervention.
-Patient’s home and community environment are typically not considered
Integrative -Emphasis on integrating conventional treatment with alternative treatments.
Medicine2 Focus on treatments such as acupuncture, biofeedback and nutraceuticals along with some
evidence-based lifestyle interventions.
-Patient may be an active or passive recipient of care
Treats symptoms or signs of disease not the underlying lifestyle causes.
-Patient may not be required to make significant behavior changes
-Physician/Provider directs care - medical model
-Patient’s home and community environment typically not considered
Functional -Emphasis on evidence-based, systems biology approach that addresses underlying
Medicine3,4 dysfunction rather than treating symptoms.
-Focus on evidence-based lifestyle interventions with the use of pharmaceuticals,
nutraceuticals, and biologicals when appropriate.
-Patients are active participants in their care.
-Patients must typically make lifestyle changes in order to improve their health.
-Physician guides and supports patients to take control of their own health.
-Environmental exposures and social dynamics are assessed as contributing factors.
Naturopathy/ -Emphasis on homeopathic and naturopathic treatments such as herbs and colonics.
Homeopathy5 -Treatments may be based on traditional practices rather than scientific evidence.
-Focuses on treating presenting symptoms but may address underlying lifestyle causes
-Patients may be active or passive recipients of care depending on the practitioner.
- Patient may be required to make significant behavior changes
-Provider directs care based on medical model
-Patient’s home and community environment may be considered.

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LEVELS OF LIFESTYLE MEDICINE PRACTICE
The ideal of medical care is to treat the cause of disease and restore patients to health. LM brings
medical practice closer to its ideals by treating the underlying lifestyle causes of disease. LM
may be practiced on two levels. The first basic level involves the recognition by all health care
providers that lifestyle is a significant determinant of health and an important modifier of
individual patient responses to pharmaceutical or surgical treatments. At this level all physicians
should use lifestyle interventions as an adjunct to their standard treatment protocols. The second
level is specialty care practiced by LM experts as a separate, eventually board certified, medical
specialty where lifestyle interventions are the main focus of treatment and pharmaceutical or
surgical treatments are an adjunct to treatment when necessary.

Recommendations for Basic Lifestyle Medicine Practice for All physicians

The basics of LM should be taught at all medical schools and residency training programs in the
same way that the basics of cardiology are taught to all physicians in training. The basic
competencies of LM are clearly outlined in the Physician Competencies for Prescribing Lifestyle
Medicine by Liana Lianov and Mark Johnson.6 All physicians should have knowledge with both
clinical and personal experience of evidence-based lifestyle interventions such as plant-based
nutrition, stress management techniques and exercise prescriptions that they can easily share
with their patients during the traditionally brief doctor-patient encounter. All physicians should
be encouraged to adopt a patient-centered communication style that fosters motivation and health
literacy in their patients. Appropriate encouragement of evidenced-based lifestyle changes and/or
referral to a LM Specialist should be considered standard of care.

Lifestyle Medicine Certification

Requirements for certification to practice LM as medical specialty would be similar to all current
medical specialties:

 MD or DO from an accredited Medical or Osteopathic school

 Completion of Residency Training or an equivalent alternate pathway that includes
completion of academic coursework and practice experience in Lifestyle Medicine as
determined by an ACLM Credentialing/Certification Committee.
 Certification by a primary Board accepted by the American Board of Medical Specialties
or the American Board of Physician Specialists.

Current medical training does not routinely include a focus on the use of evidence-based lifestyle
interventions such as nutrition, exercise and stress management techniques in the treatment of
lifestyle-related diseases.7, 8 Physicians interested in practicing LM as a specialty must have the
specialized academic knowledge and practical experience to ensure a consistently high standard
of practice. LM curricula for medical schools and LM residency programs are needed. A
credentialing process that measures acquisition of the knowledge and skills determined to be
necessary to practice LM is also needed. The content of the curricula and standards for
certification should be determined by an ACLM Credentialing/Certification committee based on
the principles of LM established in these and future disease-specific guidelines.

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LIFESTYLE MEDICINE PRACTICE TEAM
Lifestyle Medicine practice offers a unique opportunity to develop an interdisciplinary team of
professionals who can work together to provide effective patient-centered care. Similar to any
medical practice the team will work under the supervision and guidance of a Licensed Physician
who is trained or has demonstrated expertise in Lifestyle Medicine. The range and level of
staffing needed to operate a Lifestyle Medicine practice will depend on the services offered,
financial considerations and the needs of the community and the patients served, however it is
highly recommended that Lifestyle Medicine practices include the following professionals as
appropriate.

Licensed Dietitians/Nutritionists
Nutrition is an essential therapeutic intervention in Lifestyle Medicine. The knowledge and skills
of the nutrition professional will determine the success of nutrition treatments offered by the
practice. The basic requirement for this position should be a degree in Nutrition, preferably an
advanced degree, such as MS; a state license to practice as a Dietitian or Nutritionist; and
completion of either formal course or informal training with practical experience in the use of
plant-based nutrition in the treatment of chronic degenerative diseases. Personal experience of
plant-based nutrition is highly recommended.

Exercise Physiologists/Exercise Coaches/Personal Trainers

Fitness assessments and exercise prescriptions are essential components of a Lifestyle Medicine
treatment plan and exercise professionals are essential members of a Lifestyle Medicine
treatment team. They should have American College of Sports Medicine/Exercise Is Medicine TM
certification or equivalent certification that would allow them to write exercise prescriptions for
patients.9 As members of a Lifestyle Medicine treatment team they must be knowledgeable about
plant-based nutrition in disease management. They may or may not also be nutrition
professionals but they are role models for patients and may be asked by patients for nutrition
advice. All patients of a Lifestyle Medicine practice should receive the same clear consistent
message from all members of their treatment team.

Psychologist/Licensed Therapists/Health Coaches

Behavior modification is the key element of Lifestyle Medicine treatment. Professionals who can
assist patients to understand and transform unhealthy behaviors into health promoting ones are
essential members of the Lifestyle Medicine treatment team. These professionals should have a
degree in psychology or a related field or certification as a health coach; a valid state license to
practice if needed; and training in the principles of Lifestyle Medicine to ensure that all patients
get the same clear consistent message from all members of their treatment team.

Nurse Practitioners/Physician’s Assistants/Nurses/Medical Assistants

Medical office staff with direct patient contact can reinforce or detract from the Lifestyle
Medicine message of the practice. These professionals need standard certifications and state
licenses plus formal or in-service training on the basic principles of Lifestyle Medicine. An
ACLM sponsored Lifestyle Medicine training curriculum and certification process is needed.
Training would include the benefits of a plant based diet, regular exercise, and stress
management techniques that these professionals can incorporate into their personal lives and
share with patients. All patients should receive the same clear consistent treatment message.

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LIFESTYLE MEDICINE INTERVENTIONS AND PRACTICES
In the conventional medical model patients interact with healthcare providers in a one-on-one
fashion that is primarily focused on disease management. Preventive care as currently practiced
focuses on screening to detect diseases that can be treated with pharmaceuticals drugs or surgery.
Lifestyle issues are not always effectively addressed in the setting because of provider training
and time constraints. There is a need for development of effective complementary methods to
provide lifestyle health information to patients such as:
 Workplace environmental and human resource interventions
 School presentations or incorporation of Lifestyle principles into school curricula.
 Retail sales interventions such as NuVal and Walmart’s “Great for You” labels. 10, 11
 Media exposure; internet or computer based education, radio and TV programing
 Group programs in community locations such as CHIP,12 and Wellspring Diabetes.13
 Internet motivation tools for lifestyle change such as CREATION Health,14 Win Wellness,
15
The Way to Eat,16 and Weigh Forward.17

These and other examples of current programs and others yet to be developed, will expand the
effectiveness of lifestyle interventions. The ideal practice model for lifestyle medicine is
evolving, and different practitioners will have their preferences but one model that has been
successfully implemented by a number of lifestyle medicine practitioners is the Shared Medical
Appointment or “SMA.”

Shared Medical Visits/Shared Medical Appointments 18

Shared medical visits are an innovative, interactive approach to providing healthcare that brings
patients together with one or more healthcare providers. It is an excellent way to assist patients to
form community around solving their health care problems. Currently, the typical patient spends
15- 30 minutes with a doctor/health provider during an individual medical appointment. Patients
often report that before they were finished relating their problem the provider was writing a
prescription and indicating that the session is over with no explanation of the medical problem or
the medications prescribed. A shared appointment can last from 90 minutes to 3 hours depending
on the structure of the Lifestyle Medicine intervention. This allows patients to spend more time
with their healthcare team and with other patients who have similar health issues. Patients can
learn from the health care team and from each other, sharing stories and ideas and creating social
bonds. The support of SMAs is particularly valuable to patients with lifestyle-related conditions
such as hypertension and diabetes who are struggling to make healthy lifestyle changes in
unsupportive home or social environments.

BASIC LIFESTYLE MEDICINE INTERVENTION GUIDELINES

Lifestyle medicine is based on scientific evidence that the body will heal itself when the factors
which cause disease are removed. Diseases such as cardiovascular disease, diabetes and Crohn’s
disease that were once thought to be irreversible have all been completely reversed by
comprehensive lifestyle changes.19, 20, 21, 22 The goal of a Lifestyle Medicine intervention is to
replace unhealthy behaviors with behaviors that promote health. There is a wide variety of
health promoting behaviors that have been successfully used in the treatment of lifestyle diseases
but generally most lifestyle related diseases benefit from the same simple lifestyle behavior
changes. These include, but are not limited to optimum nutrition, physical activity, stress
management, tobacco cessation, and improved interpersonal relationships.

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BASIC NUTRITION GUIDELINES FOR LIFESTYLE MEDICINE PRACTICE
Nutrition is an essential element of LM practice; it the underlying cause of many lifestyle
diseases, and changing eating habits alone can reverse many lifestyle diseases 22, 23, 24 Nutrition is
also the most confusing and controversial area of LM for both healthcare professionals and
patients. Eating behaviors are formed in childhood and determined not by conscious thought but
by unconscious sociocultural norms, beliefs, and taste preferences.25 When new scientific
evidence regarding health and diet conflicts with accepted beliefs, the result is often cognitive
dissonance, and the science is likely to be rejected in favor of established behaviors. 26 Awareness
of the unconscious influences that sustain unhealthy eating habits is crucial for successful eating
behavior changes among both healthcare professionals and their patients. 27

All patients should be given accurate nutrition information that is based on the most current
scientific evidence regardless of their gender, ethnic group, income status, education level or
perceived readiness to change. The most current scientific evidence available supports the use of
whole unprocessed or minimally processed plant foods as treatment for most of the lifestyle
related illnesses in our population 28, 29, 30, 31 Regardless of medical specialty, all physicians should
be educated about this scientific literature, and advising patients to make these dietary changes
should be considered the standard of care.

All patients in a LM practice should be given an initial nutrition assessment that includes a
questionnaire about their current eating habits and laboratory tests for serum lipids, blood
glucose, and vitamin D levels. Routine screening for non-specific nutritional deficiencies is not
recommended. Nutrient testing should be targeted based on a patient’s symptoms and signs. A
brief nutrition survey should be repeated periodically at follow-up visits to assess progress or
deterioration. Nutrition/dietary treatment prescriptions should be based on the results of nutrition
assessments and evidence-based nutrition research.

When nutrition deficits are identified the role of the LM Treatment Team is to educate patients
about healthy eating options and then motivate, guide and support them as they make and sustain
the necessary behavior changes. This can include a wide variety of activities such as providing
nutrition clinics, seminars and other resources, introducing patients to new foods at food
sampling events, holding cooking classes, providing personalized meal plans with shopping lists,
leading supermarket and farmers market tours, visiting urban farms, starting community gardens,
organizing personal chef services and/or providing packaged foods services to make healthy food
choices more convenient for busy patients.

Every five years the Federal government issues dietary guidelines that are intended to promote
health and also satisfy food industry interests. Reliance on these dietary standards may not
always produce the desired health outcomes expected by patients who chose a LM practice. LM
Practitioners should be able to modify and translate these dietary guidelines into simple practical
advice that patients can understand and follow. Current Federal dietary guidelines recommend
decreasing cholesterol and saturated fat intake, and increasing intake of fruits, vegetables,
legumes and whole grains.32 Advising patients to adopt an ad libitum diet of whole, unprocessed
or minimally processed plant foods may be the easiest and most effective approach to achieve
sustainable adherence to these dietary recommendations.32 Table 2 below compares current
Federal Dietary guidelines with current scientific evidence.

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Table 2: Federal Dietary Guidelines vs Current Scientific Evidence
Macronutrients Federal Dietary Evidence-Based Recommendations
Guidelines32
Protein 10 -35% from animal 10–12% preferably from plant sources
% of calories and plant sources Animal protein/higher protein % promote cancer cell
adults 19+ years old growth.28
Carbohydrates 45–65% 45 - 75% of calories 33
% of calories From whole unprocessed or minimally processed sources
All ages and
genders
Total Fiber Females: 22 - 28 g/dayFemales: > 25 g [> 14 g/1000 kcal 33, 34
Adults 19+ Males: 28 -34 g/day Males > 38g with no upper limit]
Total fat 25–35% <15% Whenever possible obtain from whole unprocessed
% of calories plant sources 35
adults 19+ years old
Saturated Fat <10% from plant and Not essential 35
% of calories animal sources Limit intake and only obtain from plant sources
All ages and
genders
Linoleic Acid 5-10% from plant and 5-10% - From whole unprocessed plant sources whenever
(⍵-6 Fatty Acids) animal sources possible.35
% of calories
All ages and
genders
⍺-Linoleic Acid 0.6–1.2% - from plant 0.6–1.2% - From whole unprocessed plant sources
(⍵-3 Fatty Acids) and highly processed whenever possible.35
% of calories animal sources such as
All ages and gender fish oils
Cholesterol <300 mg/day Not essential/harmful. Dietary cholesterol crystals injure
All ages and endothelial cells and start the inflammatory process that
genders leads to heart disease and strokes.36 It increases the risk of
gallbladder disease.37

PHYSICAL ACTIVITY/EXERCISE GUIDELINES

Regular physical activity results in short and long-term health benefits and reduces the risk of
adverse health outcomes. The health benefits of exercise apply to children and adults of all ages
and social groups and to patients with chronic diseases and disabilities.38 The importance of
exercise is generally accepted by most healthcare professionals and advice to exercise is often
the only lifestyle advice that patients receive. Any lifestyle improvement advice given by health
care professionals is valuable, but exercise advice alone without dietary changes will be
ineffective for many patients. Exercise without dietary changes may maintain current weight but
will not lead to significant weight loss or reversal of lifestyle diseases such as atherosclerosis.22, 39
Cardiac rehabilitation programs that focus only on exercise may improve patient quality of life,
but they do not prevent restenosis of stented coronary arteries or subsequent cardiac events.40
Exercise is most effective when it is prescribed as part of a comprehensive LM Treatment
program that includes plant based nutrition and other modalities such as stress management.

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All patients in a LM treatment program should have an initial fitness assessment and exercise
prescriptions based on the results of their assessment. A basic assessment measures flexibility,
strength, and cardiovascular endurance, other parameters may be added as needed. Exercise
prescriptions are individualized according to the results of their fitness assessment and
standardized by use of the 2011 ACSM Guidelines for Prescribing Exercise which are consistent
with the 2008 Federal Physical Activity Guidelines. 38, 41 Periodic assessments to measure progress
towards fitness goals and to update exercise prescriptions should be completed at regular
intervals depending on the treatment needs of the patient and the program structure.

Table 3: ACSM Physical Activity Recommendations38

Age No Diagnosed Diseases Diagnosed Health Conditions
Children and -At least 60 minutes or more of physical activity/ day. Most of ¨When possible try to meet the
Adolescents the time should be either moderate- or vigorous-intensity guidelines. Get as much activity as
aerobic physical activity. the health condition allows. ¨Avoid
(6-17 years inactivity.
old) -They also should do muscle-strengthening and bone-
strengthening activity at least 3 days/ week. ¨Refer to the ACSM Prescription for
Health guidelines.
www.exerciseismedicine.org
Adults (18- -At least 150 minutes a week of moderate intensity, or 75 Follow the adult guidelines. If this is
64) minutes a week of vigorous-intensity aerobic physical activity not possible, patients should be as
or an equivalent combination of moderate- and vigorous- physically active as their abilities
intensity aerobic physical allow.
activity.
¨Always avoid inactivity
¨Activity should be performed in episodes of at least 10
minutes, preferably spread throughout the week. Refer to the ACSM Prescription for
Health guidelines.
¨Activity may be increased to 5 hours (300 minutes) a week of www.exerciseismedicine.org
moderate-intensity aerobic physical activity, or 2 hours and 30
minutes a week of vigorous-intensity physical activity, or an
equivalent combination of both for additional health benefits

¨Muscle-strengthening activities that involve all major muscle

groups performed on 2 or more days per week.
Older Adults Follow the adult guidelines, or be as physically active as Develop an activity plan with
(65+) possible. a health care professional.

Avoid inactivity; some activity is better than none. Avoid inactivity; some activity is
better than none.
Exercises that maintain or improve balance if at risk of falling.
Refer to the ACPM Prescription for
People without diagnosed chronic conditions (such as diabetes, Health guidelines
heart disease, or osteoarthritis) and who do not have symptoms www.exerciseismedicine.org
(e.g., chest pain or pressure, dizziness, or joint pain) do not
need to consult with a healthcare provider about physical
activity

**Pedometers, step-counting devices used to measure physical activity, are not an accurate measure of exercise quality and
should not be used as the sole measure of physical activity.
38

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STRESS MANAGEMENT/ GUIDELINES
Stress can defined as “any demand for change.”42 The stress response is a cascade of
physiological events that can lead to improved health and productivity or to anxiety, depression,
obesity, immune dysfunction and poor health outcomes. 42,43,44 Assisting patients to recognize
maladaptive stress responses and transform them into responses that improve health and well-
being is an essential part of Lifestyle Medicine practice at all levels.

All patients should be screened initially and periodically for signs of unhealthy stress responses
and stress-related conditions such as depression. The U.S. Preventive Services Task Force
(USPSTF) recommends screening adults for depression in clinical practices that have systems in
place to assure accurate diagnosis, effective treatment, and follow-up.45 There are several
screening instruments available such as the Patient Health Questionnaire for Depression and
Anxiety (PHQ-4).46 These screening tools are not diagnostic, patients with positive screens should
be evaluated and treated by a mental health professional either in the Lifestyle Medicine practice
or on referral. Lifestyle Medicine providers should be knowledgeable about basic evidence-based
stress management techniques that they can share with patients. Common evidence-based stress-
management techniques include:

Autogenic training/Guided Imagery,47 are relaxation techniques that involves visualizations to

induce a state of relaxation. Patients can use an instructor, tapes, or scripts to guide them through
the process. Practiced daily for 15 minutes 3 times a day the technique has been shown to
alleviate many stress- related life conditions such as chronic pain, tension headache, anxiety, and
depression.

Cognitive Behavioral Therapy (CBT)47 is based on the notion that thoughts lead to emotions
that lead to behavior, therefore changing thoughts can change behavior. Distorted
thoughts/cognitive distortions underlie many forms of unhealthy behaviors and mental illnesses.
There are several approaches to CBT but most approaches assist patients to understand the
beliefs that underlie their thoughts; increase awareness of cognitive distortions; and reframe
distorted self-talk to support healthy behavior changes. Although CBT is used to treat a wide
range of mental illnesses, it can also be used with success to promote healthy behaviors among
Lifestyle Medicine patients.

Diaphragmatic Breathing 47 is a breathing technique that focuses on movement of the abdomen

when breathing. As air enters the lungs the diaphragm relaxes and expands the abdomen. This
type of breathing has been shown to lower blood pressure, reduce pain, and reduce anxiety
especially in children with asthma.

Meditation 47 is a catch-all term for a wide variety of practices where individuals attempt to
focus awareness. Countless studies have shown the benefits of meditation as treatment for stress
related health conditions.48 The most researched method is Transcendental Meditation but other
methods that achieve the same physiological effects are equally effective at producing positive
health outcomes. Measurable physiological changes such as decreased heart rate, respiration,
blood pressure and positively altered brain wave activity have been documented during
meditation. Meditation has been shown to promote relaxation, improve cognitive function and
relieve depression, anxiety and chronic pain.

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Progressive Muscle Relaxation 47 is based on the physiological finding that anxiety causes
unconscious muscle tension; consciously relaxing tense muscles should be able to reduce
anxiety. This technique involves alternately tensing and relaxing muscle groups over the legs,
abdomen, chest, arms and face in a sequential pattern while focusing on the difference between
the feelings of the tension and the feelings of relaxation. Evidence shows benefits significant
reduction in generalized anxiety.

Other evidence-based stress reduction techniques that Lifestyle Medicine Practitioners should
be aware of include relaxation response, biofeedback, emotional freedom technique,
mindfulness-based stress reduction exercises and emotional freedom techniques. 47 Patients with
specific stressors can be taught trigger-specific management. The services offered in a LM
practice depends on the available facilities and staff but where possible inclusion of services such
as therapeutic massage, yoga and Tai-chi instructions,49 and workshops to improve problem-
solving skills, time management, humor and assertiveness may be useful ways to assist patients
to transform unhealthy stress responses. 50 In addition LM practitioners should encourage patients
to engage in creative, expressive activities such as dancing, playing musical instruments, singing,
and art to increase the likelihood of flow experiences that improve quality of life. 51

TOBACCO USE CESSATION GUIDELINES

The dangers of tobacco use are well documented, it increases the risk of mouth throat and lung
cancer, heart disease and chronic obstructive pulmonary diseases. 52, 53, 54 Tobacco use disorder is
itself considered a chronic disease that requires repeated interventions and multiple attempts to
resolve. The US Public Health Service Guidelines for Treating Tobacco Use and Dependence
recommends that all clinicians identify and document the tobacco use status of every patient in
their practice.55 Tobacco use cessation, including treatment options should be discussed with all
current tobacco users regardless of their perceived readiness to quit tobacco use. Clinicians
should be aware of motivational techniques to encourage patients who are not ready to make quit
attempts.

Tobacco use cessation counseling and medications can be effective when either one is used
alone but they are most effective when used together. In a Lifestyle Medicine practice the
method used should be individualized to suit patient needs and preferences. Tobacco use
cessation medications are contraindicated in certain groups such as pregnant women, smokeless
tobacco users, light smokers, and adolescents. Tobacco use cessation counseling may be
conducted in individual one-on-one sessions, groups, or on telephone quit lines. Important
components of tobacco use cessation counseling are practical problem solving/skills training
and social support. 55

Lifestyle Medicine providers should know how to safely prescribe tobacco cessation
medications alone or in combination. 55 Currently 2 basic types of quitting aids are available
nicotine-replacement products and non-nicotine medications. The nicotine replacement
products are available over-the-counter in 5 forms, as gum, inhaler, lozenge, nasal spray and
patch. The non-nicotine medications Varenicline (Chantix) and Bupropion SR (Zyban) are only
available on prescription. Tobacco use cessation treatment is an important part of Lifestyle
Medicine treatment and may be offered alone or as part of a comprehensive lifestyle
intervention program.

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INTERPERSONAL/GROUP/COMMUNITY RELATIONSHIPS
Humans are social beings; the need for social connection is a basic survival urge that is
hardwired into our nervous systems. The areas in our brain involved in processing social stimuli
and decision making are noticeably larger in those with large social networks.56 Social
relationships are as important to our health as diet, exercise and smoking habits, in fact the
quality of our relationships may determine whether or not we chose to engage in healthy lifestyle
behaviors.57 Repeated studies show that unhealthy social relationships, isolation and loneliness
are associated with increased mortality and morbidity especially among individuals with
established lifestyle-related diseases.57, 58, 59 Identifying patients at risk for social isolation and
assisting them develop or improve the social skills necessary to form and maintain healthy
relationships should be an important part of a Lifestyle Medicine practice.

Individuals who live alone are not always the most socially isolated or lonely. People with
seemingly caring families and demanding jobs may be most in need of genuine social
connection.60 All patients in a Lifestyle Medicine practice, regardless of marital status, living
arrangements or mental health status, should be screened for social isolation/loneliness. There
are several screening tools such as the UCLA Loneliness Scale that measure perceived feelings
of isolation and are easy to administer in a clinical setting. 61 Review of screening results in the
context of a patient-provider relationship that includes active listening and expressive empathy
may be a comforting for patients experiencing social isolation and resulting mood disorders.
Patient with mental health problems should be referred appropriately.

Lifestyle Medicine prescriptions for developing or improving social relationships should be

personalized to meet the needs of individual patients. Advice to prevent social isolation may
include volunteering for a meaningful cause, involvement in spiritual/religious activities or
participation in communication skills workshops such as Compassionate (nonviolent)
Communication.62 When an individual makes lifestyle changes to improve personal health, they
may meet with resistance from their friends, family, social groups members, coworkers and even
health care providers. This is especially true when the changes involve new ideas and behaviors
that are different from accepted sociocultural norms. The ability to understand criticism and
handle rejection and possible social isolation will determine whether the new healthy behaviors
are sustained. Helping patients to develop these skills should be a consideration in a Lifestyle
Medicine practice. The practice may offer or facilitate access to workshops that assist patients to
improve health literacy,63, 64 develop active listening skills, resolve internal and external conflicts
to produce win-win solutions,65 improve intimacy,57 and improve workplace relationship with a
view to negotiating successful personal lifestyle changes in possibly resistant family and other
social settings.

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