Continuing Education Activity

Lifestyle medicine is the evidence-based practice of helping patients adopt and sustain behaviors that promote health and improve quality of life. Lifestyle medicine emphasizes six pillars of healthy habits: nutrition, exercise, relationships, stress, sleep, and substance use. Combined, these habits become a risk or protective factor for each person's physical and mental health and can also be modified to improve quality of life. This activity reviews the relationship between emotional distress and poor health, as well as their connection to modifiable lifestyle choices, to adequately equip healthcare team members to assess and intervene in the primary care setting.

Objectives:

• Discuss screening tools for stress, depression, and anxiety; review indicators for referral to a mental health professional.
• Describe the relationship between emotional distress and poor health.
• Identify depression as a comorbidity for diabetes and coronary artery disease.
• Explain the management of depression and anxiety in patients with comorbidities.

Introduction

Health results from the intricate interplay among genetic predisposition, socio-behavioral-environmental influences, and access to health care.[1] The World Health Organization defines mental wellness as “a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community.”[2] 

In the United States, people are increasingly sedentary, consume a less nutritious diet, are more socially isolated, and experience more sleep-wake cycle abnormalities than previous generations. The consequence is our mental health, evidenced by major depressive disorder becoming the leading cause of disability worldwide.[3][4] 

Mental illness, in turn, is associated with a high prevalence of comorbid substance use, physical inactivity, and poor diet, all of which are also known contributors to poor physical health. Primary care physicians are the first point of medical contact for most psychiatric patients and continue to be the leading med management providers for most of these patients.[5] Mental illness also complicates co-existing medical conditions, making them more challenging and expensive to manage.[5] These factors, in combination, make mental health an essential issue for primary care physicians.

In Australian populations, those with severe mental illness have a 10 to 20-year decrease in life expectancy compared to the general population.[4] These patients are 2 to 3 times more likely to have respiratory and cardiovascular disease, with up to 67% having metabolic syndrome.[4]

Mental health and affective symptoms play a critical role in choosing optimal health behaviors, which add to preventable chronic diseases over months and years.[6] While medication and therapy are used as first-line treatments to treat the symptoms of mental illness, as the name indicates, Lifestyle Medicine can address patients’ habits that are modifiable risk factors.[3]

Lifestyle Medicine seeks to address the root causes of disease by helping individuals find and incorporate healthy habits that affect health and quality of life, with the explicit purpose of preventing, treating, and reversing chronic disease.[1] Therefore, Lifestyle Medicine offers an approach to reducing the burden of physical and mental illness, which are intimately related.

Function

Given the current mental health crisis, the Lifestyle Medicine approach offers a safe and low-cost option for enhancing its management that may incorporate some clinical psychological techniques of motivational interviewing to motivate people to embrace lifestyle changes.[3] The pillars of Lifestyle Medicine are nutrition, exercise, relationships, stress, sleep, and substance use. These topics are all captured within the scope of a primary care visit.[6]

Nutrition – The most common dietary patterns in the United States typically include high-calorie saturated fats and refined sugar. Such nutrient-poor and energy-dense foods now constitute about 30% of the daily intake of American adults.[7] In recent years, growing evidence from both prospective and cross-sectional studies has come to suggest that poor diet may be a risk factor for the onset of depression.[3]

In the primary care visit, the first line of advice to patients at risk for hypertension or hyperlipidemia, both risk factors for cardiovascular disease, is to make lifestyle changes such as diet and exercise. However, many primary care physicians lack adequate training or time to delve into specific plans of transformation in detail. A pilot randomized controlled study by McMillan et al. demonstrated the significant effects of short-term dietary change on mood and cognition in healthy individuals, including improvements in self-rated vigor, alertness, and contentment in the group that ate the more nutritious diet for just ten days compared to the control group.[3]

Additionally, in 2017, a randomized trial showed that 32% of patients with moderate-to-severe depression disorder remit with nutritional interventions alone. Furthermore, in 2019, this trial was followed by a large meta-analysis of more than 45,000 participants showing that dietary interventions significantly reduce symptoms of both depression and anxiety, particularly in women.[8] 

Given increasing literature supporting connections to improved mood following improved dietary changes warrant consideration of incorporating specific dietary counseling into primary care encounters where behavioral health concerns are addressed.

There are four primary mechanisms by which diet notably affects psychological health: its impact on the gastrointestinal microbiome, inflammation, epigenetics, and macronutrients and micronutrients. The gastrointestinal microbiome contributes to the production of substances (e.g., GABA, dopamine, serotonin, and norepinephrine) that enter the brain through the bloodstream. Tryptophan, a precursor to serotonin, appears to have the most significant impact on mental health.[6]

Consuming healthy foods also positively impacts the diversity and composition of the microbiome via the production of the desirable effects of neuroendocrine pathways, with proven clinical improvement in patients with generalized anxiety disorder, schizophrenia, and bipolar disorder. In addition to eating adequate whole foods, diets should be low in processed foods, refined carbohydrates, sugars, and trans-saturated fats. It is hypothesized that highly processed foods are recognized as foreign invaders in the human body, consequently leading to inflammatory cascades (measured by Dietary Inflammatory Index) that ultimately are detrimental to physical and mental health.[9]

Unhealthy dietary behaviors may influence the onset and progression of many diseases through epigenetic mechanisms, while healthy dietary behaviors also result in health-promoting gene expression through epigenetic regulation.[6] Nutrients such as essential fatty acids, zinc, magnesium, and folate are critical for neurological function. Leafy green vegetables, legumes, and whole grains are good plant-based sources. Foods rich in polyphenols (e.g., berries, tea, dark chocolate, and certain herbs) are also valuable for cognitive and cardiovascular function.[3]

A dose-response relationship exists between the consumption of fruits and vegetables and happiness, even after controlling for numerous personal, social, and economic factors that influence emotional well-being.[9] Ultimately, seven to eight servings of fruits and vegetables each day were found to confer optimal happiness benefits, with study participants reporting feeling happier the day following higher consumption.[9]

The Mediterranean diet consistently demonstrates an association with a range of mental health benefits.[3] A study found that participants who moderately adhered to a Mediterranean diet had a 27% reduction in risk for depression, whereas those with high adherence experienced a 32% reduction.[6]

Exercise – The sedentary lifestyle is becoming increasingly commonplace, contributing to the worldwide obesity pandemic.[3] Obesity is directly related to the increased prevalence of diabetes and cardiovascular disease.

Regular physical activity is beneficial for attaining both healthy body habitus and increased mental well-being. While patients with sub-clinical depression rate lifestyle or psychosocial approaches as most helpful for improving mood, those diagnosed with clinical depression tend to rate exercise as the most effective intervention.[3] 

WHO and the Department of Health and Human Services (HHS) define adequate physical activity as at least 150 minutes of moderate-intensity aerobic activity per week, along with resistance, balance, and flexibility training.[10] Meeting this target is associated with fewer depressive symptoms, while insufficient physical activity increases depression risk. Exercise modulates a range of biological pathways, including oxidative stress, inflammatory cytokines, neurotrophins, and neurogenesis, in addition to helping to normalize cortisol levels and increase circulating beta-endorphins. As patients start to reap the psychological and physical benefits of exercise, it also helps to increase self-efficacy and self-esteem and may even have the additional benefit of increasing social engagement and improving body image.[3]

In 2018, the European Psychiatric Association issued new guidelines using physical activity as a fundamental method of managing depressive disorders and schizophrenia. Literature supports that physical activity can be equally effective in improving depressive symptoms and quality of life as antidepressants or psychotherapy, especially if under the guidance of an exercise specialist. Physical activity also reduces psychiatric symptoms and improves cognition in patients with schizophrenia spectrum disorders.[4]

Furthermore, exercise is associated with neuroprotective effects, thought to promote hippocampus neurogenesis, angiogenesis, and synaptogenesis. Functional magnetic resonance imaging studies show increased white matter volume throughout the brain following exercise, which may help reduce the risk for mental health symptoms. These findings correlate with evidence that a single ten-minute bout of exercise results in clinically significant improvement in mood, offering a stark contrast to the 6-week trial of antidepressant medication to detect effectiveness reliably.[9]

Relationships – A 75-year longitudinal study created to examine the predictors of healthy aging found that interpersonal relationships significantly impacted satisfaction with life. Positive and supportive relationships benefit general health, especially for maintaining psychological health. Lack of social engagement correlates to increased inflammation and impaired immune function, which are detrimental to brain health.[6] Therefore, purposefully scheduling and encouraging involvement in meaningful activities and ample social contact is essential for well-being.[3]

Volunteer activities can help attain the aforementioned mental benefits even without supportive friends and family. Volunteering weekly increases life satisfaction by the same amount as an income bracket increases from <$20,000 to >$75,000 annually.[9]

Stress – Chronic stress changes the regulation of the hypothalamic-pituitary axis, leading to immunosuppression and impairing serotonin transmission, thereby facilitating the development of depressive symptoms.[6] Two ways in which Lifestyle Medicine approaches mitigating stress include promoting mindfulness and practicing gratitude.

As quoted by Jon Kabat-Zinn, mindfulness is paying attention "on purpose, in the present moment, and non-judgmentally." Regular mindfulness practice may lead to increased cortical thickness in the prefrontal cortex, an area of the brain that demonstrates low activity in depression.[3] Mindfulness also leads to elevations in serotonin levels, a chemical that functions as a neurotransmitter in the brain.[3] Serotonin is associated with depression and anxiety when found in low concentrations, and first-line pharmacological treatments work to increase serotonin levels.

Practicing gratitude is another means of decreasing stress and improving mental health. Recording three positive takeaways at the end of each day for six months demonstrated improved emotional well-being for participants across the lifespan. Furthermore, a single gratitude visit that included composing and delivering a letter of gratitude to someone of significance to the participant also improved subjective personal well-being even one month later.[9]

Sleep – While the reasons behind the need for sleep are not fully elucidated, it is undisputed that sleep is essential to psychological and physical wellness. Numerous sleep problems, such as insomnia, obstructive sleep apnea, and restless leg syndrome, are all causes of inadequate sleep linked with impaired cognition, decreased immune function, and dysregulated mood.[6]

As demonstrated using functional magnetic resonance imaging, sleep-deprived individuals have more significant limbic region activity, translating to greater emotional reactivity when shown aversive images. Sleep-deprived individuals are also more than twice as likely to remember negative connotations for an arbitrary list of viewed words than those who are not. Indeed, sleep disorders are a risk factor for both new-onset and recurrent depression in all age groups, leading to increased severity and duration of depressive symptoms. Patients with schizophrenia with poor sleep quality are associated with increased symptom severity.[4]

The treatment strategy is based on educating patients on sleep hygiene, using cognitive behavioral techniques, and administering hypnotic and antidepressant medications. Lifestyle Medicine would additionally emphasize lifestyle modification, including addressing a sedentary lifestyle, poor diet, and caffeine and alcohol use.[3]

Substance use – Individuals with mental health conditions are also more likely to use substances. Many turn to substances to cope with mental illness symptoms such as depression, anxiety, and feelings of shame.[6]

In 2016, nearly 34% of adults diagnosed with a mental health condition reported using tobacco, which is 10% higher than the general population. Smoking tobacco is also associated with heavy alcohol use, prescription medication misuse, and the use of marijuana and other illicit substances.[6] 

A meta-analysis of more than 50,000 adults found that smoking significantly increased the prospective risk of depression over one to six years.[11] In 2014, in a systematic review of longitudinal studies of adults diagnosed with a mental disorder, smoking cessation for at least six weeks was associated with decreased symptoms of anxiety, depression, and self-reported stress, as well as improved mood and overall quality of life, with the reported effect sizes being greater than or equal to the effect sizes for treatment with antidepressant medications. Additionally, smoking not only worsens symptoms of depression and bipolar disorder, but it also diminishes the response to treatment by 30 to 50% due to its induction of the P450 liver enzyme, as well as its provocation of both inflammation and oxidative stress.[3] 

Since smoking is frequently a coping mechanism, barriers to smoking cessation include expectations that it would induce worsened anxiety and mental health. Therefore, discussing and addressing all aspects of patients' internal risk-benefit analysis concerning tobacco cessation is essential in identifying and driving self-motivation and intervention efficacy.[6]

While drinking alcohol is generally more socially acceptable than smoking tobacco, it is a powerful substance that affects dopaminergic, serotoninergic, γ-amino butyric acid (GABA), and glutamate pathways, leading to a 2 to 3-fold increased lifetime risk for depression and anxiety in those with substance use disorder. While acute alcohol use diminishes neuronal glutamate release, during alcohol withdrawal, a higher amount of rebound glutamate releases from the synapses. Combined with dysregulated neuroendocrine and monoamine pathways, it may provoke anxiety and dysphoria.[12]

Issues of Concern

Evidence-based medicine intersects with the best available scientific evidence, clinician expertise, and patient preference. While randomized control trials (RCTs) are generally considered the gold-standard method of gathering "evidence-based medicine," they have limitations in lifestyle medicine. Research in lifestyle medicine often needs to be based in real-world settings, involves multiple interventions, is highly customized for the patient, and cannot practically be confined to randomized studies with a control group. 

For example, over eight years, case evidence from 800 patients treated with plant-based nutrition and exercise programs for a myriad of illnesses led to hundreds of individuals decreasing the dose or stopping medications for many diseases, including but not limited to diabetes, hypertension, hyperlipidemia, arthritis, psoriasis, and gastroesophageal reflux. Simultaneously, many of these patients also had increased energy and functionality, improved cognition, and decreased anxiety and depressive symptoms.[13] While this type of research does not meet the definition of an RCT, the medical outcomes are tangible.

Adherence to lifestyle advice varies significantly, with most studies showing an average of about 50%. Many factors influence a patient's ability to implement lifestyle changes, including motivation, time, finances, treatment priorities, and perspective about the source of difficulties.[3]

Therefore, adherence and engagement to the plan for lifestyle adjustment increase with patient ownership of a treatment plan and a sense of partnership in its development and planning, considering personal barriers, and making concrete, stepwise actions to follow.[3] Improving long-term adherence requires a multidisciplinary team approach with increased behavioral health, health coaching, telehealth, and community engagement.[4]

The Royal Australian and New Zealand College of Psychiatrists 2015 clinical practice guidelines for mood disorders expanded the model of care to include evidence-based lifestyle interventions as important recommendations in conjunction with the standard psychological therapies, medication, and procedures.[4]

Further guidelines from other mental health societies and organizations will assist lifestyle medicine in becoming fully incorporated into the standard of care.

Clinical Significance

Out of all the factors that influence health, including genetic disposition, socio-behavioral-environmental factors, and access to health care, behavioral and social circumstances contribute most to premature death.[1] Lifestyle Medicine provides a link between the promotion of public health and clinical treatments, necessitating the application of environmental, behavioral, and psychological principles to enhance patient physical and mental health.[3] It does not aim to replace current mental health practices but to better account for the vast complexity of daily decisions that accumulate to make up human well-being.

The lifestyle medicine approach in the primary care setting benefits the whole patient, with evidence supporting both positive mental and physical health effects. Coronary artery disease may be significantly reversed in 1 year with sufficient adherence to a lifestyle medicine plan. A prospective, randomized, controlled trial showed that 82% of the experimental group who had a low-fat vegetarian diet, stopped smoking, received stress management training, and partook in moderate exercise experienced disease regression, as evaluated by 91% having less angina. Average total cholesterol decreased by 24%; average low-density lipoprotein decreased by 37%. Significantly, 195 of their coronary arterial lesions were also significantly reduced when analyzed by quantitative coronary angiography. There was also a strong dose-response in that the participants with the strictest adherence also significantly improved their coronary artery disease.[14]

A much larger European prospective study from 2009 investigated the relative risk of developing major chronic diseases in patients who adhered to healthy lifestyle factors of never having smoked, having a BMI <30, having a healthy diet (high intake of fruits, veggies, and whole grains; low intake of meat) and >3.5 hours of exercise per week over eight years.[1] Patients with all four protective factors had an overall 78% less risk of chronic disease, 93% less diabetes, 81% less MI, 50% less stroke, and 36% cancer risk reduction.[1]

This data is strong evidence for treating and preventing chronic diseases through adherence to the pillars of Lifestyle Medicine, which are essential to physical and psychological well-being.[3]

Enhancing Healthcare Team Outcomes

Given that most people with mental health concerns first seek help from their primary care provider, streamlined screening is essential to realistically implement lifestyle medicine in a fast-paced clinical environment. Screening tools are most valuable when they can be easily administered and provide quick feedback indicating symptom levels or areas of concern. Computerized screening allows for integration with electronic health records, which may optimize diagnosis, treatment, and follow-up and provide consistent data on outcome metrics.[15][16]

Two primary assessments are used for screening patients' status in the six lifestyle medicine pillars. Both measures are available through the American College of Lifestyle Medicine (ACLM) website. One measure, developed by Jonathan Bennett and recommended by the American Academy of Family Physicians (AAFP), titled Lifestyle Medicine Assessment Screening Tool, consists of 21 questions assessing all pillars except for stress management. The other measure, the lifestyle assessment form, developed in a collaboration between Loma Linda University and ACLM, is available in both long and short versions. 

The long form is comprehensive and assesses the status of motivation, sleep, nutrition, weight management, exercise, mental health, purpose and connection, smoking and substance history, medical symptoms, and preventive services. The short version assesses sleep, nutrition, weight management, exercise, purpose, connection/mental health, smoking/substance use, and motivation. These measures can help quickly identify areas for further assessment and targeting. Recommendations for additional measures specific to each pillar can be found on both the ACLM and AAFP websites.

Data from screening measures for mood typically already used in primary care can, of course, be utilized (e.g., Patient Health Questionnaire (PHQ-2/PHQ-9), Generalized Anxiety Disorder Scale (GAD-2/GAD-7), Perceived Stress Scale (PSS-10), Multidimensional Scale of Perceived Social Support (MSPSS)).

From a lifestyle medicine perspective, primary care that emphasizes the pillars of lifestyle medicine may address physical and mental health concerns, thereby being well-suited to prevent the onset, reduce the symptoms, and slow the progression of mental health symptoms and disorders.[6] Particular pillars may be emphasized, given the specific health concerns and the results from screening measures.

Interventions within the primary care context, given time constraints, are best when able to be quickly delivered; evidence supports the use of brief interventions for behavior change.[17][18][19][20] Targeting small changes has led to changes that compound over time.[21][22][23] 

In addition, self-efficacy may be enhanced as a function of achieving small lifestyle changes, fostering additional changes.[24] Lifestyle interventions delivered by PCPs that appear to be most effective offer specific behavior prescriptions, personalized advice according to patient factors and goals, use of behavioral supports like patient-facing informational handouts, referrals, and follow-up.[17]

Follow-up also resulted in increased effects compared to initial referral only.[25] Strategies like SMART goals (Specific, Measurable, Achievable, Relevant, and Time-Bound) can be enhanced with SMARTER (Evaluated, Readjust) and SMART-EST (Evidence-based, Strategic, Tailored to the patient), which specifically target the importance of follow-up.[26]

Action planning, helping patients move toward action, and coping planning, helping patients identify their barriers to change and proactively create plans to manage their barriers, are two techniques that also help the goal-setting and achievement process.[27][28]

Referral to a mental health provider with knowledge of lifestyle medicine can complement and strengthen any additional treatment which might be necessary. For patients who screen positive, further evaluation is necessary. Referral options vary by setting/organization: self-help, guided self-help, group treatment, integrated primary care (IPC), referrals within the organization, and outside referrals. Ideally, if integrated primary care is available, a "warm handoff" or referral for later follow-up can help connect the patient to behavioral health options.[29][30]

Factors that prompt referrals to mental health providers include patient preference, the need for mental health assessment and diagnosis, management of complicated medical regimens, and/or help with behavior change due to lack of initial response. In addition, referrals are common when mental health disorders are comorbid with specific physical illnesses (e.g., diabetes and depression) or the patient presents with severe mental illness (SMI) or suicidality.

Nursing, Allied Health, and Interprofessional Team Interventions

Lifestyle medicine is used in primary, secondary, and tertiary prevention models to prevent both mental and physical illness. Primary prevention may include informational handouts and self-assessment questionnaires to get patients thinking about how their lifestyle choices impact their health and encourage them to ask their provider about how to make improvements. 

Secondary intervention could include discussing questionnaire results with the patients and following up to develop concrete patient goals. At this level, risk factors and stressors in the patient's life are identified and addressed, along with potential subclinical depression and anxiety. The patient may be recommended for lifestyle modifications and given referrals to support organizations and contact persons. 

Tertiary prevention consists of a formal lifestyle management plan and any medication or psychotherapy a patient may already be utilizing. The patient's self-assessment results would then also be part of ongoing monitoring for the efficacy of the prescribed treatment.[2]

Lifestyle changes take time and personal commitment, but a community of like-minded individuals can increase adherence through accountability. A health coach can also be a touchpoint for ongoing motivation. 'Health coaching' refers to a diverse set of behavior change interventions, ranging from motivational interviewing and brief interventions, all to help the patient set goals and make changes.[31] 

It can be facilitated by any number of different people, including but not limited to clinicians (MDs, DOs, NPs, and PAs), peers, volunteers, nurses, case workers, and social workers, all operating as a cohesive, interprofessional healthcare team. For patients who struggle with adherence to lifestyle medicine recommendations, a referral to behavioral health (e.g., a health psychologist or psychiatrist) may address the barriers interfering with meeting health goals. Telehealth can also be an effective tool for those with mobility barriers or who need to travel a long distance to meet in person.