Preventing and Managing Chronic Conditions With Lifestyle Medicine

How you can use lifestyle changes, such as exercise and weight management, to keep yourself healthy

Our health is more within our control than we may realize. Through the power of lifestyle changes, it's possible to maintain a healthy weight, manage chronic conditions and even prevent new chronic illnesses. RUSH family nurse practitioner Elizabeth Simkus, DNP, and clinical health psychologist Rebecca Wilson, PhD, of the RUSH Prevention Center share how lifestyle medicine can enable almost anyone to improve their own health.

Please tell us a little bit about your roles at Rush and about the Prevention Center.

Elizabeth Simkus: I'll start by explaining who makes up the clinician team of the Prevention Center. We have Laura Zimmermann, MD, as our medical director. She's board-certified in internal medicine and a primary care provider and also certified in lifestyle medicine. We also have preventive cardiologist Philip Liebson, MD, and three behavioral health psychologists, Rebecca Wilson, PhD, who's with us today, Brad Appelhans, PhD, and Amanda Matthews, PhD, which Rebecca will touch on their roles in just a second.

I am a family nurse practitioner and Dr. Zimmermann and I practice lifestyle medicine. We do one-on-ones with the patients and our first visits with them are about an hour long. Our follow-up visits are about a half an hour long. And we do chronic disease management prevention treatment through lifestyle medicine techniques and we also have a Facebook group for our patients. So we will post recipes. We interview other specialists throughout the health system and put tips and other ideas out there to keep patients engaged in-between our visits.

Rebecca Wilson: I'm a clinical health psychologist. A lot of times when new patients come to see me they have the question of what is a clinical health psychologist? We have clinical training but we work with a lot of people on health concerns specifically. We learn a lot about what creates behaviors, how to create behavior change. Myself and Dr. Appelhans, we both work with a lot of people who want to manage their weight. And Dr. Matthews, she works with people who are trying to reduce or quit smoking. We try to understand what are the challenges for making those changes and help them come up with strategies to be successful.

What does lifestyle medicine consist of?

Simkus: The American College of Lifestyle Medicine is relatively new. It was formed in 2017. But health care providers, dating back forever almost, have always promoted healthy eating, physical activit, and some of the principles of lifestyle medicine. But what it really compromises of is looking at six different pillars of health and using evidence-based therapies or interventions to help people get at the root cause of a lot of the chronic illnesses that we're seeing today at high rates, like high blood pressure, heart disease, diabetes, pre-diabetes, sleep apnea, or obesity.

And so the six pillars encompass diet, physical activity, sleep, relationships, stress-management, avoidance of risky substances because all of that plays into how well our body is able to function and prevent or manage some of the chronic illnesses.

Who are your typical patients at the Prevention Center and what do they come there for specifically?

Wilson: We will get referrals from a lot of different places around the Rush System. We get a lot of referrals from the Sleep Center. There are a lot of patients who've just been diagnosed with having sleep apnea and they're very motivated to be able to address that sleep apnea and there's a relationship between that and weight. So if they can lose weight, they may be able to get off of the CPAP, that's the hope. We'll be referred by different specialty clinics.

We also get a lot of referrals from primary care. So perhaps their blood sugar levels have been starting to creep up or their seeing their hypertension creeping up. And so these will be people who are interested in addressing it through lifestyle changes like Elizabeth mentioned, changes to sleep patterns, to diet, to exercise, stress-management. So primarily most of our patients do have an interest in weight loss as a component of improving their health.

But there will also be a lot of other focuses as well, like preventing diabetes, preventing hypertension and, in general, improving their health.  I'll get some referrals as well for people who maybe there's emotional eating or binge eating as one of the components so that we can work on those patterns specifically as well.

Where do you typically start when you begin working with a patient?

Simkus: We start with a chief complaint or asking, 'What brings you into the Prevention Center today?' And I get a wide variety of answers from that question. I may be very specific like, 'I've gained weight during the pandemic and I want to lose 25 pounds.' Or, 'I had blood work recently from my doctor and my cholesterol is high, or I'm pre-diabetic.' Or I get some people who come in and say, 'I don't know why I'm here. My doctor told me to come.' So, it's a wide variety. We start with where they're coming in, what their reasonings are.

Then we do a pretty extensive health inventory kind of questionnaire. That's why our first visit is an hour. We will go through medical history, family history, we'll look at their blood work, and then get into weight history. What was your weight as a child, growing up, now? And then getting into those lifestyle pillars where we really look at the details in diet, physical activity, sleep, our stress-management, work, because all of it plays. And then we look for opportunities of where we want to focus on our plan of care.

Wilson: I would say my first visits are very similar. It's really trying to get a good, comprehensive overview of what's going on with this person, what their concerns are, and particularly trying to get a good sense of what their daily patterns are like, what their daily life is like, so I can understand where we might start to make some changes.

And then, if it's appropriate, I may also ask some questions about mood and anxiety and eating patterns and things like that as well. With a lot of people that's not really something we go into in-depth but a lot of times there is a relationship between the two. Maybe some anxiety's actually making it hard to stick with the lifestyle changes that this person really wants to make, so it's really important to understand those relationships.

What kind of support do you offer patients once they've shared their history and what's bothering them?

Simkus: That's a good question and honestly, it all depends on the patient and it all depends on what they need. After we go through everything of the health inventory and we talk about their health goals, what they want to achieve and why, the importance of why they want to achieve it.

Then we'll look at those opportunities, we'll talk about what's the recommendation or we'll talk about areas where, a lot of times people will come in and they'll say, 'I know. I know my issue might be sweets or it might be sugar-sweetened beverages.' We support them by starting with collaborating and coaching and determining what our first focus is going to be, what they want to try to address first. A lot of times we'll set a smart goal, which it's going to be specific, measurable, attainable, relevant to their overall goal, and then timely, or time-sensitive. Having something tangible and objective like that can help them to start to make those behavior changes.

I have a plethora of resources from the American College of Lifestyle Medicine on recipe books, websites, Instagram accounts, videos. We'll share that. It's basically whatever the patient needs. Two other things that I often like to share with patients, especially in the beginning, are if anyone in Illinois has a Link Card, then there are resources in the city and beyond that have, in farmer's markets they have a program where when you're buying fruits or vegetables they will match up to a certain amount, say $25, where they can spend $10 or $20 worth and then they match that for the fresh fruits, vegetables, produce. I like to share that if a barrier might be cost of eating healthy.

Or we'll share ideas from YouTube or we'll share free apps and also the Chicago Park District. If you live in the City of Chicago and you meet the criteria, a doctor or health care provider, including myself, can write you a prescription for a membership that you could utilize at facilities for free for three months. We have all of this information that we just love sharing and trying to support, and whatever we can do to help the patients meet their health goals. That's what we're here for.

What are some of the ways that you try to help patients with their weight management?

Wilson: We'll often focus in a few different areas. For example, focus on behavioral changes, changes in thought patterns and also managing stress. When it comes to behavioral changes, that's probably very similar to what Elizabeth will do as well, where we will really look at their daily patterns and think about where can there be some changes made, how can we make those changes? Often it will be about starting small, finding some small changes that can really make a difference.

For example, a lot of people drink pop on a regular basis and they may not realize that one pop a day actually is equivalent to about 15 or more pounds over the course of a year. So if we can find some small changes that often helps people, 'cause it can be overwhelming to think about making all of these different changes in your lifestyle at once. If you can find some small places to start we can build some momentum.

Another place that I will especially focus in on would be thought patterns. Often our thoughts play a big role in being successful, even just our definition of success. Because when you are trying to change your lifestyle or you're trying to lose weight there's going to be lots of ups and downs along the way. A lot of times people think, 'I'm just going to make this one change, follow this diet, and I'm going to stick to it forever,' which never happens, right?

We'll see things like all-or-nothing thinking patterns where either they're on the plan or they're super off the plan. We're trying to challenge those thought patterns and say, 'OK, maybe you overate this afternoon, but you don't have to wait until Monday. You could have a nice like meal for your dinner and just get right back on track.' We want to challenge those patterns.

Another thought pattern that's very common with our busy, stressful lives is, 'I deserve it. I deserve this treat. I need this treat.' Helping people think through, well, maybe that's true. You certainly can have that, but maybe there's other things that you really want for yourself that you deserve as well, that by changing those patterns you could be able to have them in your life. We really want to understand those thought patterns.

Something people overlook sometimes is the role of environment. Our environments have a big influence on us. For example, if you get a dog, suddenly you're going to be walking more. It's not because you suddenly decided to walk more, but because your environment changed. If you can put the snack foods up on a high cabinet or down in the basement, that's going to change your environment and it's going to have an effect on your behavior. We also want to look for as many changes that we can make to the environment as possible.

What are some everyday tips around diet and exercise that can help most people?

Simkus: In this country, the sugar-sweetened beverages are kind of a low-hanging fruit of things that are not providing any nutritional value but have a lot of added sugar and calories, that if we are able to cut them out it can make a really big impact. So, trying to cut out the sugar-sweetened beverages. I'll have patients come in that they switch from soda or pop to green tea, and they buy big bottles of tea not looking at the nutrition label that that green tea has almost just as much sugar as a soda.

Also, increasing our water intake. Our metabolism also is more efficient earlier in the day so if we can get our nutrition in morning, afternoon, early evening, and not eat late at night then that's going to help with both our waistline, prevention of diabetes and overall health.

The other thing is, as much as we can, cutting out the ultra-processed food that is taking over our food industry and our food supply right now. The more whole food, plant-based, fruits, veggies, nuts, seeds, beans that we can include that will help with our overall health and prevention of the chronic diseases. And look at the nutrition label. Start practicing. I'll go over that a lot with patients, how to look at the nutrition label, looking at the serving sizes, looking at the sodium content, the added sugar content. We want to pick the item that has the least amount of added salt or sodium and the least amount of added sugar. Those are dietary ideas.

For physical activity, I always say start where you're at. Start small. If you have chronic illnesses or other conditions, speak with your health care provider before starting any physical activity routine. But walking is a fantastic cardiovascular physical activity. It doesn't have to be anything fancy, but do something that you enjoy. Finding a workout buddy to help you stay engaged and motivated when you have those days that you don't feel like doing it. If somebody comes in and says, 'I am not a gym person. I don't like walking on a treadmill,' I'm not going to say that's what you have to do, 'cause you don't. You can dance. You can swim. You can do so many other things.

The recommendation is to do at minimum 150 minutes per week of moderate physical activity. That includes brisk walking, riding a bike, swimming. And then two days a week of strength training, using small weights, resistance bands, body-weight exercises. That's really key. A lot of times people will focus on the cardio, but strength training is important because as we age as adults we tend to lose muscle mass every year that we age. So counteracting that with strength training helps maintain the muscle mass, which is good for bone health and it's good for our metabolism because our body's able to metabolize blood glucose better and prevent diabetes.

It can be difficult to get going and stay motivated when it comes to someone's personal health and weight. What are some ways that people can continue to find motivation as they go through things?

Wilson: I think this is really a key issue. I might not even call it motivation but ambivalence. Most people who we see, they are motivated. They have a lot of reasons why they want to change and they very much value their health or else they wouldn't be in the room with us. But there's also reasons on a daily basis that keep them from doing the change and that creates that ambivalence. Maybe you're very motivated to prevent diabetes, but on a daily basis you have a long work day, you come home, you're really tired so you want to go for something really convenient. That actually makes sense in the short-term. It's just in the long-term that it doesn't really make sense.

So part is recognizing the difference between short-term rewards and long-term rewards. Those short-term tend to win out over long-term. One of the goals that we have is to try to really make the long-term as present as possible. Maybe we will really get in-depth of what your vision is, why this is important to you, try to make it as close to you as possible. Then you could write it down, what all your reasons are for making these changes and read it every day so that you can keep it more front of mind and bring the long-term into the present.

Acknowledging those short-term things, recognizing that it totally makes sense for me to get something convenient when I come home. What could I do to change that pattern? Maybe I have a healthy option that is super convenient. For the time being, maybe I do Healthy Choices — like a frozen meal — when I get home. Or maybe I will do some meal prep on the weekend. Recognizing short-term reasons and coming up with creative solutions allows you to work with them rather than trying to pretend as if they weren't having a big influence on you.

Sometime we wait to be motivated and actually a lot of motivation comes from taking action. It comes back to identifying those small actions that you can take and really trying to take them even when you're not feeling motivated, because that's going to build your motivation. I see too many people come in and say, 'I'm just not motivated. I can't do it.' But if they were to walk to the end of the block every day for a week, they so often will start to build that motivation from doing that small action on a regular basis. Definitely starting small is the best part.

It seems inevitable that people are going to indulge in an unhealthy snack or drink from time to time. How do you support people when they try to get back on track?

Simkus: I'll often give some anticipatory guidance in our first visit, just letting them know it's to be expected. We're human. We're not perfect and we're not going to be. We can allow some of that wiggle room for holidays, birthdays, vacations, stressors, where we may fall off track a little bit. But what the key is is recognizing when you have fallen off track.

I tell people a lot of times, just get back to the basics. What has worked for you in the past? Start tracking your food again, writing it down, seeing where there's opportunities. Focus on a couple small things to change. Since you've done it before in the past, that's more motivation and encouragement that you can do it again. And then come back and see us. Sometimes people think, 'I shouldn't follow-up because I haven't met my goals or I've fallen off track.' But that's exactly when you come back. Trust me, there is no judgment here. We are here to support you on the journey. Give yourself some grace when things happen, 'cause life is going to happen.

What kind of tools do you provide patients to help them manage their stress?

Wilson: We'll start by understanding what's happening in your body and with your thoughts and feelings when you're experiencing stress and anxiety. Then often we'll focus on some action-based tools, like for example, if you change your breathing pattern. Simply slowing down your breath can help your body go into a relaxation response. So we'll focus on some small things. Often I'll do some meditation practices with patients. These are actions that they can take to help themselves manage stress directly.

We'll also focus on, 'Are you having thought patterns that are increasing your stress?' Life is stressful, but then often our thought patterns are making it even more stressful. Trying to look for opportunities to change how we think about things can help us be less affected by those day-to-day stressors. Sometimes it'll be about boundary setting. Getting some practice saying "no" to things or asking for help when you need it. That can be really tough to do, so we'll be practicing it together and coming up with ways to be able to do so. Hopefully we can change some of the stressors that are changeable.

What's the most effective treatment for stress eating?

Wilson: I will always look first at eating patterns, because a lot of emotional eating happens in the context of what we call "chaotic eating," which is not really having a very regular eating pattern, things are not very well-defined, meals, and snacking. Usually I'll focus on trying to get onto a regular eating pattern. Often the stress eating will be so much more manageable when that's happening.

In addition to that, we can use cognitive-behavioral therapy. What are the thought, feeling, action patterns that are happening with stress eating? What are the triggers? What are the thoughts that are happening inside your head that are causing you to feel stressed? It could be a lot of different emotions that are causing the eating. What are different actions that you can take to manage those feelings that don't involve eating?

Simkus: I heard this on a health podcast recently but I liked it. It's a similar concept, really checking in, taking a moment to pause and see how you feel and then if you can recognize that you're stressed or whatever feeling your having and maybe your response is to typically eat. If we can take a pause with that and try to interject a different activity, that can give you that same stress relief response without offsetting our health goals. Maybe take a pause and go for a walk or call a friend. I have patients who are chewing more gum and drinking a lot more water to interrupt that pattern of walking to the pantry.

What you think of the apps like Noom that try and help people with weight management and stuff like this?

Wilson: Noom is interesting. It's actually based on a lot of the same principles like from the cognitive-behavioral therapy approach, so there's a lot of overlap in what people learn through Noom and what they would learn working with myself. I've had a few patients using Noom and they really seemed to benefit from it and like it. What I like too is that you can use it like as needed. It can really incorporate into your life and that's one of the important things when you're making lifestyle changes, that it actually incorporates into your life on a daily basis.

Any tool that works for you, that you find encouraging, will help. A big part of Noom is tracking, which is so helpful for making our unconscious patterns very conscious. We can become much more aware of what's really going on. There are also tools like MyFitnessPal, Lose It. These help you become much more aware of what's going on. I'm a big believer in what works for you is going to be,  just keep doing it if it's helping you.

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