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By Paula Taylor, BSN, RN, CCM

Nutrition and physical activities are now recognized not just as incidental lifestyle habits but as important pillars of health. As case managers, we look for gaps in care and barriers preventing optimal health and healing. Nutrition and physical activity, though of paramount importance, are frequently overlooked or underserved in assessments and underdeveloped in care plans. Superficial attention to these lifestyles creates gaps in care and barriers to healing. The purpose of this article is to highlight the dire consequences if these lifestyle habits are overlooked, and the potential for significant health improvement if even a few improvements are adopted. I hope to convince my fellow case managers to research new evidence-based information related to these lifestyle habits and begin to implement this knowledge into everyday practice. This challenge is based on a new recognition that if these lifestyles are neglected or poorly addressed, patients cannot achieve their potential health, no matter what other interventions are provided. Not only will patients continue to decline and suffer, but the costs of healthcare will continue to increase astronomically.

As healthcare professionals, we all agree that lifestyle habits related to nutrition and physical activity are important for good health. Even most patients would agree in principle that better habits in these areas would translate into improved personal health. Despite everyone’s assent to this premise, there is often a disconnect when it comes to the actions of the healthcare team and of the patient. I submit to you that part of the reason is none of us quite realize the true significance of the impact small changes could make.

In past days, although we all inherently knew nutrition and physical activity contributed to health, little evidence existed to prove this belief. In recent years, multiple studies have been conducted in the fields of nutrition and physical activity as they relate to health and healing. This research validates scientifically just how valuable nutrition and activity are to the body with respect to health and healing. The information is becoming impressive and overwhelming, but for the sake of space and time, we will look at only a few broad conclusive results with the goal of impressing professional case managers and inspire further investigation.

A relatively new organization founded in 2004, American College of Lifestyle Medicine (ACLM), (https://www.lifestylemedicine.org) and corresponding American Journal of Lifestyle Medicine (AJLM) are dedicated to reporting evidence-based research validating therapeutic lifestyle interventions, not only as a component to other treatments, but in some cases, as a stand-alone treatment modality. Increasing numbers of studies support and emphasize nutrition and physical activity as able to make profound differences in health status, not only as preventive but as treatment of chronic conditions. Consider the implications of a quote from a well-respected source, the American Journal of Clinical Nutrition: "… diet and physical activity interventions that were once considered limited in their potential impact for the prevention and treatment of chronic diseases have increasingly shown improvement and benefits that equal if not surpass those of pharmacologic intervention, often with less risk, reduced side effects, and lower costs."

Case managers struggle daily, seeing diseases and sometimes the consequences of treatment plans sap strength and quality of life from patients. An article in 2018 in the Journal of Lifestyle Medicine reported on specific conditions found to be positively influenced by nutrition and activity. The list included cardiovascular diseases, diabetes, cancers, cognitive function and even included behavioral conditions of anxiety, depression and stress reduction. Major organizations, such as the American Institute for Cancer Research (AICR) and the International Agency for Research on Cancer (IARD) report that "there is sufficient evidence to link 13 human malignancies to excess body fatness. Excess body fatness is now the second leading preventable cause of cancer, behind only cigarette smoking."2 Although the diseases mentioned are usually adult conditions, the AICR also stated, "The same types of lifestyle measures that are applicable both for the prevention and treatment of chronic disease in adults are also very relevant to children."

Most of us know both from working with patients and from personal experience that lifestyle changes are difficult to make. Making small sequential improvements is easier and more practical than jumping into a totally different lifestyle. Fortunately, the research suggests that even adopting some positive behavior changes cuts an individual’s risk significantly. For example, according to one recent study on those with pre-diabetes in reference to physical activity, "…breaking up sedentary time (such as screen time) further decreases the risk of pre-diabetes being converted to diabetes." Obviously the more positive changes one can make in both nutrition and activity level the better, and the effect is compounded. According to an editorial abstract reporting The Nutrition Society Spring Conference 2017, "The overall conclusion from the meeting was that the interaction between diet and physical activity confers greater benefits to human health and performance than either component alone."

Given the serious personal suffering and incalculable financial burden of poor nutrition and insufficient physical activity to our patients and to our healthcare system, one would expect these lifestyle habits to be extremely high on the list of priorities to be addressed by everyone on the care team. However, there appears to be a disconnect in prioritizing and emphasizing these lifestyle changes. We must at this point examine why. Maybe the healthcare team feels chronically ill patients are too sick to be helped by lifestyle changes or that changes would be too difficult. This is poor reasoning and makes little sense in light of evidence that the body needs nutrition and activity to live. Perhaps there is a lack of confidence and competence to provide correct guidance, or perhaps for some, the importance of these habits was heretofore unknown. I believe a lack of confidence in the ability to identify and teach these topics is a main reason they are not tackled and emphasized. This an understandable consequence of not receiving proper education and of this topic being a relatively new one with a new scientific knowledge base. The American Journal of Clinical Nutrition published an article in 2014 stating, "Most healthcare professionals are not adequately trained to address diet and nutrition-related issues with their patients, thus missing important opportunities to ameliorate chronic diseases and improve outcomes in acute illness."1 The article, to some degree, justifies our knowledge deficit indicating that not only is nutrition not emphasized during training of healthcare professionals, but verifies that nutrition has been changing rapidly, and until recently, not much knowledge existed that was evidence-based. To compound the issue, the population has a severe knowledge deficit too. If healthcare professionals are not teaching about nutrition and physical activity, it is not surprising the population is uninformed. For example, the link between obesity and cancer already discussed above is unknown to half the population. AICR estimated "…unfortunately, only 50% of Americans are aware that obesity promotes cancer growth, so there is an important educational issue to combat…"

Case managers, we are part of the solution to the ignorance of the population regarding the importance of nutrition and physical activity. These habits can be health-changing, life-saving treatments about which patients should receive education. They deserve the most up-to-date validated research regarding nutrition and physical activity as they choose options. Poor nutrition and a sedentary activity level will limit health and healing progress even if patients follow their prescribed medication regimen, even if they keep timely appointments with providers, even if they have social determinants of health needs met and even if they possess other disease understanding and self-management skills. Though these are good and necessary topics on which to also spend time with the patients, none can overcome poor nutrition and a sedentary lifestyle. On the other hand, in the long term, given change + time, nutrition and activity may indeed be able to eliminate the need for some medications and treatments.

The intent of this article is certainly not to denigrate any care team member, much less to disparage the excellent care management sector, but rather to illustrate where there are gaps in care and opportunities for improvement. I submit to you that we owe it to our patients to begin to dig deeper, that we begin now to educate ourselves and our organizations as well as patients. It is imperative to begin to thoroughly assess nutritional intake and activity level, without which there is no identified place to begin. Only after understanding the baseline for each patient related to these two lifestyle habits and where they struggle, (the barriers), can strategies be developed to address knowledge gaps with education, motivation and action steps in corroboration with the patient. This work will be difficult, but it is our responsibility.

To summarize, if our healthcare system is going to meet the challenges of today and decrease future burdens of chronic diseases and rising prices and truly provide a higher quality of care, lifestyle changes must be viewed as valid modalities for health and healing and addressed accordingly. Lifestyle changes used in conjunction with the wonders of technology and drugs will give patients the best chance for better health and quality of life. (A review of specific recommendations is beyond the scope of this article but can be found in various clinical guidelines such as the 2019 American College of Cardiology/American Heart Association Clinical Practice Guidelines.)

By raising awareness, I hope many case managers will begin to educate themselves in this new field of research and become change agents within their organizations. By understanding what can be lost if we do nothing and what can be gained if we act, a new era of case management can be built. In this new era, lifestyle changes will be routinely approached with the same seriousness, detail and clinical thought as when assessing other aspects of health management. Begin now to treat lifestyle habits as the true pillars of health that the evidence proves they are by addressing them with the same vigor and serious intent as when addressing other issues and needs.

Better self-management is always the prized goal of case management. Lifestyle changes are the ultimate in self-management skills, so these are within our domain. Although it is extremely difficult to make lifestyle changes, imagine the empowerment of this concept to our patients. Lifestyle changes are the source of real power right in the hands of patients/families to change the trajectory of their health and future, based on their ability to shift to healthier daily habits.

Visit the CMSA Education Resource Library to learn more! (Link to the ERL - https://cmsa.org/education/educational-resource-library/

Is nutrition and wellness part of your patient engagement? How do you approach these topics?

Paula C. Taylor, BSN, RN, CCMhas been with Community Care of North Carolina in various roles for approximately 12 years, serving the Medicaid population. She has been a CAP/C case manager, inpatient referral coordinator and spent a short while as a supervisor of a team of case managers. For most of the past 5 years she has been a quality case auditor, evaluating content of documentation in real cases. This position has allowed her the opportunity to study assessments and care plans extensively. It is from this perspective that this article was written in hopes to inspire fellow case managers to learn about the powerful impact of lifestyle habits and to remember to evaluate and use them in their practice, as significant forces for health.