The United States population suffers from staggering numbers of lifestyle related diseases. We know the situation is not improving. Recent research found that over half of the country has prediabetes or diabetes. The facts don’t lie—the vast majority of the US burden of disease are due to lifestyle.
Photo Credit: Dr. DArriush Mozzafarian
People know they should eat less and exercise more, but they don’t. They don’t because without the right knowledge and direction, behavioral change is really hard. Doctors also know they should be advising their patients on lifestyle, but they don’t.
http://bipartisanpolicy.org/wp-content/uploads/2015/11/BPC-CAPP-Health-Survey.pdf
A recent study by the Council of Accountable Physician Practices entitled, Better Together: High Tech and High Touch, found that the majority of primary care doctors are not recommending prevention, nutrition, weight loss, or physical activity for their patients.
Doctors lack the right training and time to implement wellness into their practices. Most medical school curriculums don’t include lifestyle medicine coursework. By the time a doctor gets into practice he or she is equipped with the tools to advise patients about illness, not wellness. When I was a medical student, I recognized this was an issue and I created a course entitled, “Physician Heal Thyself: Evidence Based Lifestyle.” I decided to do this because behavioral medicine changed my life.
I was able to beat my anxiety and improve my exam scores by making lifestyle changes. Since medical school I have been on a mission to figure out how we can use our minds to reprogram our bodies to function optimally.
The question is, what can we possibly do about these seemingly insurmountable, population-wide, lifestyle-related diseases? Where do we even begin? Right now, the medical industry is searching for drug and surgical solutions to obesity because doctors are paid to deliver these interventions. Although these hammers may sometimes be effective, they can do a lot of damage in the process. Perhaps we need more delicate tools for the job?
“Effective weight loss interventions involve a package of behavioral and cognitive strategies designed to improve lifestyle behaviors and clinical outcomes.”[i]
Before I go into which tools doctors should be recommending and patients should be using, I want to first touch on an important point: people behave better when they’re being observed. This is known as the “Hawthorne Effect” or “the psychological observation of behavior adjustment with participant awareness that what is being measured is being examined.”[i] Basically, engagement with measuring and logging daily behaviors or intake can psychologically impact the patient, regardless of what is measured. This heightened awareness can potentially have significant results even without perfect adherence to tracking applications.
Over the last four years I have spent part of my time working with technology companies because I felt like this industry was poised to make a huge impact through the consumerization of healthcare. I learned a lot in the process of testing, evaluating, and researching all kinds of mobile apps, wearable tech, and connected devices. Recently, I started giving CME (continued medical education) talks to doctors on these new technologies because I believe they can support adherence by adding insight into the patient’s lifestyle. Health happens between doctor’s visits, but we are largely blind to this reality.
So what are the best tools for monitoring nutrition, body mass index, blood pressure, and physical activity and how should these be prescribed and to whom? With the dizzying array of new technologies hitting the marketplace, it can be really hard to discern between what’s useful and what’s useless.
Fortunately, I’ve taken the time to figure this out for you.
Use MyFitnessPal as a nutritional diagnostic test: This app is great for a variety of reasons. It has a vast database of foods (the site claims to have world’s largest nutrition and calorie database), and it connects with wearable activity trackers and connected scales. But, tracking food every day is tedious and cumbersome. My recommendation is to prescribe a three-day food diary using the app so you can get an idea of what the patient is eating and the macronutrient breakdown. But, most importantly, this activity can help an individual become mindful of everything they are eating.
Use a fitness tracker as an activity diagnostic test: Most people have no idea how much activity they are getting. What I like about fitness trackers is that they can give me a baseline understanding of my patient’s activity levels. How many commercials on TV tell you to ask your doctor before you start a fitness program? How many orthopedic surgeons see exercise related injuries in their office from patients who are over-zealous in beginning their fitness program? If a patient is completely sedentary, getting them to 3,000 steps a day can improve insulin sensitivity. And, it can give them a sense of accomplishment. Most trackers can be connected to MyFitnessPal so the rough data on calories burned will be automatically uploaded into the account.
Use a connected scale for weight and BMI monitoring between office visits. The two biggest names in this category are iHealth and Withings. Both of these are great because once they are synced with your phone, they can enable effortless tracking just by stepping on the scale. These scales can also be connected to MyFitnessPal so that the weight, body fat %, and BMI will be automatically uploaded into the account.
For patients with high blood pressure, connected BP cuffs are awesome. It’s a bit silly to diagnose blood pressure based on two visits to a doctor’s office. White coat syndrome is real. What I like about these cuffs is that they are portable, easy to use, and they help track blood pressure over time. It can also be helpful for managing medications. If a patient’s blood pressure is not improving, they will know it, and you can tell them to schedule an earlier appointment than six months to come in to try different options. I like the model by Withings because its FDA approved.
For patients with high cholesterol, Cardiocheck makes a home cholesterol monitoring kit. This can be useful for patients who refuse to take medication to control their cholesterol. Each kit allows for three different testing sessions (cholesterol, HDL and triglycerides), and you can buy it on Amazon.
For patients with prediabetes or diabetes, iHealth’s connected glucometer is a really good option. This FDA approved device works wirelessly with your smartphone making it easy to track fasting and pre- or post-meal glucose levels.
An important point to know is that these tools work really well synergistically. For example, showing a patient how reaching 3,000 steps a day improves their blood glucose levels can help them find the motivation to make it to 10,000 steps, which can lead to a three times greater improvement in insulin sensitivity.[i] Seeing the calories you consume with more activity can help you regulate your intake better. These simple insights can add up over time into better habits and better health.
It’s no surprise to me that primary care doctors are recommending these technologies even less often than they are giving out wellness advice. They are very new, and a lot of physicians doubt their efficacy and the evidence supporting them. Interoperability, legal, and privacy issues may prevent healthcare professionals from approaching this data or making use of it.
http://bipartisanpolicy.org/wp-content/uploads/2015/11/BPC-CAPP-Health-Survey.pdf
But, fundamentally, it makes logical sense that tracking can lead to better health outcomes. Patients want to feel like their doctor cares about them. Knowing your doctor will even look at your numbers recorded in between visits can encourage adherence. Information from quantified patient self-monitoring applications may be usedby cliniciansto:[i]
- promote positive and long-lasting behavioral and lifestyle changes
monitor chronic disease
better control chronic diseases
increase information for preventive care
promote overall wellbeing
improve quality of care
A simple recommendation to start tracking different biometrics can be an empowering experience for a patient. I believe for the doctor-patient relationship of the past to be restored, we need to move forward with a high-touch, high tech system that embraces the best technologies and encourages patient responsibility and participation.
Pagoto, Sherry, and Gary G. Bennett. “How Behavioral Science Can Advance Digital Health.” Translational Behavioral Medicine 3, no. 3. (September 2013): 271–76. doi:10.1007/s13142-013-0234-z.
[1]Appelboom, Geoff, Melissa LoPresti, Jean-Yves Reginster, E. Sander Connolly, and Emmanuel P.L. Dumont. “The Quantified Patient: A Patient Participatory Culture.” Current Medical Research and Opinion 30, no. 12 (December 2014): 2585–87. doi:10.1185/03007995.2014.954032.
[1]“Association of change in daily step count over five years with insulin sensitivity and adiposity: population based cohort study” T Dwyer, A-L Ponsonby, O C Ukoumunne, A Pezic, A Venn, D Dunstan, E Barr, S Blair, J Cochrane, P Zimmet, J Shaw BMJ 2011; 342:c7249 doi: 10.1136/bmj.c7249.
[1]Hansen, M. M., T. Miron-Shatz, A. Y. S. Lau, and C. Paton. “Big Data in Science and Healthcare: A Review of Recent Literature and Perspectives: Contribution of the IMIA Social Media Working Group.” IMIA Yearbook 9, no. 1 (2014): 21–26. doi:10.15265/IY-2014-0004.
[1]Appelboom, Geoff, Melissa LoPresti, Jean-Yves Reginster, E. Sander Connolly, and Emmanuel P.L. Dumont. “The Quantified Patient: A Patient Participatory Culture.” Current Medical Research and Opinion 30, no. 12 (December 2014): 2585–87. doi:10.1185/03007995.2014.954032.
Molly Maloof is a physician in private practice in the Bay Area.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204402/
https://www.systemsbiology.org/research/100k-wellness-project/
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