Team-Based Strategy For Diabetes Reversal

Introduction to Lifestyle Medicine 0:00

Welcome to another episode of Reversing Your Type 2 Diabetes Summit 2.0. This is your co-host, Dr. Will Hsu today. We're going to be talking a little bit about lifestyle medicine. And I have the distinct pleasure of inviting one of my colleagues here, Dr. Artz, who works at Corewell Health. So, Dr. Artz, welcome. Hi. Will, great to see you. Thanks for inviting me and to discuss such an important topic. Our audience are interested to learn how do they put their diabetes into remission. We we use sort of more of a common term for reversing type 2 diabetes and and by definition, that means that we are we want to reduce the dependance on medications.

And how, you know, is there evidence out there And I know that that you're one of the pioneers in using lifestyle medicine approach to drive type 2 diabetes remission in this country. So, yeah, Tell us a little bit about your journey Dr. Artz. Yes. So my background is actually in emergency medicine, so I'm board certified in emergency medicine and practiced emergency medicine for nearly 20 years. It's just over the last couple of years that I've had the real pleasure and opportunity to move fully into the lifestyle, medicine, space.

And it's a journey that personally I've been on for about a decade, and Stan was truly from the growing prevalence and just the degree of illness, particularly related to chronic metabolic diseases, things like type 2 diabetes, obesity, fatty liver disease, just the growing prevalence of those conditions.

Dr. Artzu2019s Background and Shift to Lifestyle Medicine 2:06

You know, even as an emergency medicine physician, I would oftentimes be treating patients with chronic disease. But it just so happened it was their worst moment with that disease, whether it was stroke or heart attack or kidney failure. And it gave me a perspective of the way we deliver care in the United States. I mean, we're so fortunate that we have so many therapeutic tools that we can offer to our patients. Yes. So many people are suffering for years, if not decades. And it brought me to the evidence and the practice of lifestyle medicine, which really is root cause treatment for the vast majority of these diseases.

And we can deliver it in a highly effective way, just like we use other therapies like medications or procedures, for example. So this is really heartbreaking. So as an endocrinologist, I take care of people with diabetes and you see them at their most vulnerable moments when they ended up in the emergency room. And there is a statistics that that is absolutely astounding that about half of the people with type 2 diabetes actually initially presents already with a complication, meaning that they do not know that they have diabetes.

And by the time they find out, it's actually oftentimes when they have problems in their eyes, their problem, and, you know, with a heart attack, then all of a sudden they say, oh, okay, emergency room doctor, you know, ask them, do you have diabetes? Oh, I didn't know I have it before. So 50% of of newly diagnosed individuals with type 2 diabetes often present with a already a complication. And this is really, in a way, an accusation of our system that we still have very high rates of and diagnosis rate by a lot of people still walk around not knowing they have a diabetes.

So, you know, on this on this Summit, we've invited different folks speaking from different kind of expertise, some folks even from lifestyle medicine as well. But but I think this is still a very new concept. That's why I wanted to kind of revisit and especially from really a view from the trenches, if you will, the, you know, in your own words, like what is lifestyle medicine? Is it it's not sort of a common everyday language. Right. You know, people go to see their primary care doctor there, even although they're, you know, nurse, they're not oftentimes not specialists, but they are internists or they are family practitioners.

Right? You have endocrinologists, right? But what it's a lifestyle medicine practitioner. Yes. Lifestyle medicine for the audience is one of the fastest growing medical specialties. So while it may not be common knowledge or,

What Lifestyle Medicine Is and Why It Matters 5:24

you know, something that you've had access to previously, it's exciting to see the growth of this field of medicine. And so essentially what it is, is medical specialty where physicians, advanced practice providers like nurse practitioners, APPs, even clinical pharmacies, registered dietitians and others on the health care team can receive certification in what we describe as lifestyle practitioners, the therapeutic use of these lifestyle behavior change strategies, and it focuses on, again, what we call the six pillars of health, and that will focus on high quality dietary patterns that are typically very plant predominant regular physical activity, restorative sleep stress management, the importance of social connections.

And then, of course, avoidance of risky substances or reducing use of risky substances like alcohol, tobacco and nicotine products. And what's so powerful about using lifestyle as the therapy and as the medicine is that over 80% of chronic diseases are driven by lifestyle factors. And that's one of the initial conversations that I often have with patients, is many people feel they're, you know, kind of a victim of their genetics, so to speak. There's this common misperception that because maybe mom or dad or grandparents, aunts and uncles may have had a chronic condition, something like type 2 diabetes, for example, they often feel like it's just something that is written in the stars and it's going to happen to them as well.

And what we know from the evidence and there's a vast amount of evidence that's been published around, you know, the use of reducing and treating diseases with lifestyle therapy as well as, of course, prevention of these common diseases. And it's highly effective and can treat upwards of 80% or more of these chronic conditions. I think it's also a factor. One of the reasons why it's a growing medical specialty as well is just the extraordinary cost associated with treating chronic diseases. And that's a cost to the health care system as well as, you know, cost to the individual patients who are struggling with these conditions, whether it's high cost of medication therapies or developing complications as you mentioned, you know, these are costly conditions in terms of time spent at doctor's visits and obtaining treatments for these conditions.

And then on the health care system side, it's truly unsustainable at this point in terms of trying to manage effectively health care costs when we're up against just this high prevalence of disease. And if we you know, observe carefully, how then we how do we the and take care of patients is we then certainly give them medications to control and but with very little attention to treating the root causes. I mean this is everywhere right. As an endocrinologist I used to just prescribe medications because I really didn't have a lot of time to go over.

How do you change all the causes that led to this condition? Yes, there are genetic and genetics that we cannot modify, right? At least not yet. Right. But there's so many other modify able risk factors. And and this is where lifestyle medicine comes comes in. And and I think we both you and I, both are MDs and we don't pseudo kind of ride the benefits of medications. But there is a role for that. But yet there is and there is a role for really addressing these lifestyle factors. So that's maybe go paint a picture for our listeners, like what does your practice look like right when a patient goes through the lifestyle medicine clinic is do they just see you or is there other resources so they can get a picture of how that is actually a distinct a different than just a, you know, average seven minute visits or eight minute visits with your primary care doctor.

Yeah. So our practice is centered in a large integrated health system. And so I think that's also important. This this is medicine that's happening in our our health care systems right now. So you may actually have access to similar services, but as you mentioned, the way our practice is designed is that, you know, we're we're focused on enabling patients to make sustainable lifestyle changes so that that all those changes often happen not in the clinic visit itself, but of course, the changes that a person might be interested in making.

Team-Based Care in a Lifestyle Medicine Clinic 10:51

They do occur in their home or where they work or where they go to school. For example. But what our team and we work in a team based structure. So yes, we do have myself and two other lifestyle certified medical doctors. We have two registered dietitians on the team who have expertise and nutritional therapies. Of course, we have health coaches, so certified health and wellness coaches, some who have backgrounds in exercise science or social work or tobacco, nicotine, nicotine treatment. So we're we're really building the competencies within the team to address multiple different modifiable risk, as you mentioned.

So someone might as we as we see them as a new patient and we're often seeing new patients that are referred from our primary care doctors, our gastroenterologists, our vascular surgeons. Our cardiologists of course, are endocrinologists. So we see patients referred from across these different areas and specialties. And what I think is especially exciting is personally growing these services in a large health care system over the last seven or eight years is there has been the need to provide education to our practicing physicians and and providers as well, because a lot of this information about the application of lifestyle as medicine was not something that most physicians received in their typical medical school training or residency training.

So a lot of the education actually has, I hope, has benefited many of the the physicians that might refer patients to us. And then in the context of that new visit with a patient will assess their dietary quality, assess their exercise habits, their sleep habits, where do they receive social support, connection and purpose. And then we have multiple different programs and lifestyle pathways, if you will, that individual can select into depending on where they feel ready to make changes. And we really try to measure also that readiness to change based on behavior change science.

So all all of the practice of lifestyle medicine truly is rooted in behavior change science, as well as the evidence of using these therapeutic tools and as you mentioned, not in isolation from medication therapy or even surgery. If somebody needs that, but there oftentimes can be great synergy in those treatment strategies. And as patients make more and more changes, we oftentimes can see the escalating need for medication. So we might sequentially be able to reduce the dosage of an antihypertensive medication or work with that patient's clinical pharmacist, for example, and sequentially bring down the number of medications that they might need for type two diabetes, for example.

So that's really the goal that health improves. And by way of health improvement, we often times then will see the side effect, the great side effects of a reduced need for medication therapy. So this may seem very obvious, right to those of us who who are really want to drive disease, remission, reducing medications, why is it helpful? Why is it important? I mean, do people care? A lot of people care. I mean, that's the first question that I often will inquire. And, you know, when I meet a new patient is what are your health goals and what are your health concerns?

You know, a very kind of broad question that allows a person to reflect on where they are with our current health. And oftentimes a goal that I hear from patients is they'd really like to be on fewer medications and they have this understanding that there was a time in their life where they didn't need all of these medications. And is there a way in which they can be supported through evidence based lifestyle treatments to achieve disease reduction? And, you know, that's something that we absolutely will partner with a patient on and give them the tools and the skills.

And again, those lifestyle treatments to achieve that goal. So let's talk about the roles, right? You have so many different the team we call that kind of interdisciplinary approach to managing a chronic illness. Let's quickly go to your right. So you have registered dietitians already and a lot of our listeners might have met one before or they might have met a coach, a health and wellness coach. But why both? How do they help each other or complement each other? MM Yeah. Again, the registered dietitians, for example, I mean, they're truly the experts in using nutrition therapies and well, myself and for example, the two other physician colleagues that I work with, we have really spent time and extra training to learn nutrition and how to apply it in a therapeutic manner.

However, you know, maybe we have patients that have more complexity or unique needs

Nutrition, Fasting, and Metabolic Health 17:00

that our registered dietitians can truly address in more depth so their component to the lifestyle medicine team and and I believe truly to reimagined health care. I believe that our registered dietitians will serve a key role in transforming how we deliver care. So I'm a big proponent to elevating the role of the dietician, clinical pharmacists as well. They understand all the nuances of how these medications work. And as well as even the cost of the therapeutic cost of medications. So there are the team based structure allows everyone to contribute within their their area of expertise and provide the most optimal treatment strategy for that individual.

Now, health coaches, they're bringing need to the health care team. But truly, again, I feel like they always should have been here when we're trying to support an individual to achieving their stated health goal. It's really working with a coach who is trained in motivational interview doing and behavior change strategies and setting smart goals. And these this is how we actually apply lifestyle medication. We can talk about a lot of concepts, but it's really where the rubber hits the road and you apply these strategies.

That's where the health of personal occurs. Okay, So I'm going to push the envelope a little bit, right? So we talked about the clinical pharmacist, the are the coaches. So but what about the doctor? What what do we need doctors, Right. Especially when we're focusing on lifestyle. That actually I think it's that moment where, you know, trust can be built. And, you know, I feel really fortunate to be in a situation, you know, given the training and and being, you know, in the role as the physician on the team is that, you know, patients still have a lot of trust in their medical doctors and they want to understand, number one, are they doing something that's safe?

Number two, you know, can they can they be guided and supported by that medical doctor? And, you know, and number three is is just taking this more holistic look at their health and allowing that physician patient interaction to create that vision of where they're trying to go in terms of their care. So there's still a huge role for the physician on the team. However, that physician also needs to leverage the support of that interdisciplinary care team because they have different skills that can really allow that patient to be successful.

And, you know, in this journey to better health. And I think, you know, one, the one thing that that's for sure is when lifestyle medicine interventions, work, medication needs to come off right patient adjustment, let's say diabetes medicine, blood pressure medicine that needs to be done by a licensed physician. So I think also adds to the value of having this. Yeah, it's a great point. So fantastic. So let's talk a little bit about interventions in your interdisciplinary kind of approach to medicine, right?

What do you use it in your clinic to to do this? I know nutrition is a big part, so let's go there first. Yeah, I mean, nutrition is oftentimes the first place that patients want to go. And not surprisingly, I mean, we live in what's been described as an obesogenic environment. So we're seeing rapid rates of rates of weight gain, high, high amount of obese, overweight and obesity and our young people and our adult population. So I think most individuals know that that dietary change is often times a place that they might want to begin.

Now, that's where sort of the practice of lifestyle medicine is interesting because many of these patients I'll uncover are really struggling with restorative sleep. Sometimes we actually need to address the sleep challenges before someone is truly ready to make dietary changes, but we'll kind of put a pin in that. But for example, if someone truly is ready to make some of those dietary changes, we'll focus on what sort of our philosophy is improvement of diet, quality and minimizing misinformation that's out there.

So we really focus on diet quality improvement, which will be a plant predominant dietary pattern. There's a multiple that we can draw from from the evidence, whether it's dietary approaches to stop hypertension or Mediterranean dietary patterns or whole food plant based diets. I mean, these are all evidence based therapeutic dietary patterns that we draw upon. And then we talk about time restricted eating. We talk about intermittent fasting, and we also utilize periodic fasting with our patients as well.

Okay, That's fantastic. I know. So we also have been looking at various innovations in lifestyle medicine and one of the big trend right now is is intermittent fasting. How do you not only talk about what you eat, but also the timing of the meals,

Growing the Field and Finding Resources 23:00

how we incorporate into that? So do you have any insight into that? Yeah, I think where at least the science that I have been reading certainly is pointing us toward. And and again, I think we need to think more broadly about the metabolic condition. So cardiovascular disease and stroke, heart disease, diabetes, obesity, fatty, liver, all of these conditions really originate from common causes. And in particular, I think some of the most exciting science that we're seeing in terms of using, whether it's time restricted eating or intermittent fasting in particular around conditions where there is insulin resistance or pre-diabetes, type 2 diabetes and in association, a lot of times with that fatty liver disease or metabolic associated standard hepatitis, the new name I suppose, but we're seeing great improvement in those conditions when we apply intermittent fasting or even fasting, mimicking programs with our patients, plus diet quality improvement overall.

Yeah. And so yeah, this is really an exciting time. But I think I think across the country there are more and more lifestyle medicine practitioners, right? They're taking up sort of the challenge of driving food as medicine movement to us to, to all of you, how many lifestyle medicine physicians are there? are you in the U.S.? Oh, in the US. So I think there is at least now 10,000 or more that are members of the American College of Lifestyle Medicine. So and then globally, that number has probably been risen.

But it's an exciting time. Again, it's actually the 20th anniversary this year of the American College of Lifestyle Medicine. So this is not a new organization per say, although it is young, you know, in comparison to other medical specialties. But it's really coming at a critical time, as we talked earlier about just this high prevalence of these chronic cardiometabolic conditions and the role that lifestyle medicine certified providers can play in terms of reducing the impact of these diseases for individual and populations.

So for those listeners out there, if you're looking for an approach that is scientifically backed, that drives or addresses the root cause of type 2 diabetes with the goal of really helping you to reduce your dependance on everyday medications for for many of your chronic illnesses, including type 2 diabetes, you should probably really looking into lifestyle medicine as a solution. And Dr. Artz really appreciate the time today. If people want to find out more about your practice and about your philosophies of principles of lifestyle medicine, where can they find out more?

Yes, they can go to just search for Corewell Health and you can in the search bar and lifestyle medicine. We also have a culinary medicine program so the audience can even find lots of recipes that come from our culinary and registered dietitian team and some of the services that we offer. So thanks so much for having me. Dr. Artz, thank you so much for just painting a picture for us. And I think our listeners have have really gained additional piece of information that can empower their life. Thank you so much.