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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 and their connection to modifiable lifestyle choices to adequately equip healthcare team members to assess and intervene in the primary care setting. Objectives: Identify screening tools for stress, depression, and anxiety; review indicators for referral to a mental health professional. Evaluate the relationship between emotional distress and poor health. Assess depression as a comorbidity for diabetes and coronary artery disease. Communicate the management of depression and anxiety in patients with comorbidities. Access free multiple choice questions on this topic.

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 medical 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 are critical 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.

Given that most people with mental health concerns first seek help from their primary care provider, streamlined screening is essential to implement lifestyle medicine in a fast-paced clinical environment realistically. 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 screen patients' status in the 6 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), is titled Lifestyle Medicine Assessment Screening Tool. It consists of 21 questions assessing all pillars except stress management. The other measure, the lifestyle assessment form, was developed in a collaboration between Loma Linda University and ACLM and 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. Of course, data from screening measures for mood typically already used in primary care can be utilized (eg, 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)).

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. Of course, data from screening measures for mood typically already used in primary care can be utilized (eg, 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. Given time constraints, interventions within the primary care context are best when 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 most effective offer specific behavior prescriptions, personalized advice according to patient factors and goals, and 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]

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 them, are 2 techniques that 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 that 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, 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 (eg, diabetes and depression) or the patient presents with severe mental illness (SMI) or suicidality.

Lifestyle medicine is used in primary, secondary, and tertiary prevention models to prevent 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 how to improve. 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 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, to help the patient set goals and make changes.[31] It can be facilitated by various 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 (eg, 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.