LM RECERTIFICATION - MODULE 1
OBJECTIVES
- Discuss the update on the Lifestyle Medicine Core Competencies
- Identify the new competencies added in the 2022 LMCC update
the evolution and updating of the lifestyle medicine core competencies
Liana Lianov, 2020
Initial Development of the Lifestyle Medicine Core Competencies
Although a small group of health practitioners have been using the term “lifestyle medicine” since 1988, a standard definition of the new field was not developed until more than two decades later. The American College of Lifestyle Medicine (ACLM) was founded in 2004 and defines LM as “… the use of evidence-based lifestyle therapeutic approaches, such as predominantly whole food, plant-based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substance use and other non-drug modalities, to prevent, treat, and, oftentimes, reverse lifestyle-related chronic disease” (www.lifestylemedicine.org).
Leaders in the field from both ACLM and the American College of Preventive Medicine (ACPM) recognized that a more widely vetted and standardized definition and clinical practice competencies (Table 1) were needed to guide high quality and consistent education, training, health care services, and research. With special funding from the Ardmore Institute of Health, the ACLM and ACPM convened a panel of representatives from an array of medical specialty and health professional societies (Table 2) to develop this standard definition and identify the knowledge and skill competencies physicians need in order to offer high quality lifestyle medicine services. These competencies were referred to as the lifestyle medicine core competencies for physicians, and were subsequently informally adopted by other clinicians.
The definition that the panel developed is “the evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life” (Lianov 2010). They noted that this approach includes, but is not limited to, healthy eating, physical activity, sleep and avoiding risky substance use. The panel also recommended core competencies in several key areas: 1) perform comprehensive lifestyle assessments, including risk factors and patient readiness to change modifiable risk factors; 2) use national guidelines in lifestyle prescriptions, when appropriate; 3) use a team approach and establish effective patient and caregiver relationships; 4) make referrals when appropriate; 5) use information technology to maximize continuity of care; 6) personally practice a healthy lifestyle and; 7) promote healthy behaviors as the foundation for clinical care and lifestyle medicine. Table 1 lists all 15 core competencies in five competency domains.
Table 1: Lifestyle Medicine Core Competencies Identified by 2009 National Consensus Panel
Initial Development of the Lifestyle Medicine Core Competencies
Although a small group of health practitioners have been using the term “lifestyle medicine” since 1988, a standard definition of the new field was not developed until more than two decades later. The American College of Lifestyle Medicine (ACLM) was founded in 2004 and defines LM as “… the use of evidence-based lifestyle therapeutic approaches, such as predominantly whole food, plant-based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substance use and other non-drug modalities, to prevent, treat, and, oftentimes, reverse lifestyle-related chronic disease” (www.lifestylemedicine.org).
Leaders in the field from both ACLM and the American College of Preventive Medicine (ACPM) recognized that a more widely vetted and standardized definition and clinical practice competencies (Table 1) were needed to guide high quality and consistent education, training, health care services, and research. With special funding from the Ardmore Institute of Health, the ACLM and ACPM convened a panel of representatives from an array of medical specialty and health professional societies (Table 2) to develop this standard definition and identify the knowledge and skill competencies physicians need in order to offer high quality lifestyle medicine services. These competencies were referred to as the lifestyle medicine core competencies for physicians, and were subsequently informally adopted by other clinicians.
The definition that the panel developed is “the evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life” (Lianov 2010). They noted that this approach includes, but is not limited to, healthy eating, physical activity, sleep and avoiding risky substance use. The panel also recommended core competencies in several key areas: 1) perform comprehensive lifestyle assessments, including risk factors and patient readiness to change modifiable risk factors; 2) use national guidelines in lifestyle prescriptions, when appropriate; 3) use a team approach and establish effective patient and caregiver relationships; 4) make referrals when appropriate; 5) use information technology to maximize continuity of care; 6) personally practice a healthy lifestyle and; 7) promote healthy behaviors as the foundation for clinical care and lifestyle medicine. Table 1 lists all 15 core competencies in five competency domains.
Table 1: Lifestyle Medicine Core Competencies Identified by 2009 National Consensus Panel
The consensus panel recommendations were published in the Journal of the American Medical Association in 2010. This successful collaboration across a spectrum of medical and health professional societies to define LM and its core competencies was seen as a breakthrough for the field. The core competencies are increasingly recognized as essential to primary care and other specialties in order to achieve improved health outcomes and support the shift to value-based care.
Programs and Educational Materials Evolved from the Core Competencies and Expansion of the Field
In 2015, the ACLM and ACPM released the joint Lifestyle Medicine Core Competencies Curriculum, which provided online training modules on each of the 15 core competencies, as well as lifestyle medicine modalities (nutrition, physical activity, sleep, substance use, emotional well-being) and expanded topics of relevance, such as weight management. To complete the curriculum, the core competencies and modality areas were expanded into detailed subtopics and learning objectives--referred to here as the expanded lifestyle medicine competencies (Appendix A). When the American Board of Lifestyle Medicine (ABLM) was established the following year, it based its first lifestyle medicine board certification examination on these expanded competencies, as well as additional educational resources for in depth coverage of key topic areas, such as nutrition, that were recommended by lifestyle medicine experts.
Interest in the board examination quickly grew nationally and internationally (conducted in over 20 countries) with the need to provide training and content review. The ACLM with leadership from expert faculty developed a board review course and manual largely based on the same source materials as those used for the examination. Using these resources, faculty at Loma Linda University developed a lifestyle medicine residency curriculum and implemented the inaugural program at Loma Linda University. A question bank of lifestyle medicine-related questions is also under development for contribution to the National Board of Medical Examiners.
While the field of lifestyle medicine gained momentum, poor health outcomes and high health care costs in the US health care system spurred the need for change in clinical practice, as well as public health. Lifestyle interventions are gaining greater recognition by fields outside of lifestyle medicine. For example, not only is a healthy lifestyle emphasized in prevention (e.g. the 2019 American College of Cardiology/American Heart Association Guidelines for Primary Prevention of Cardiovascular Disease), but also in disease management/treatment (e.g. the 2018 American College of Cardiology/American Heart Association Cholesterol Clinical Practice Guidelines). The number one recommendation among the ten key messages in the latter set of guidelines is “in all individuals, emphasize a heart-healthy lifestyle across the life course.” Similar clinical guideline and standards changes and recommendations are developing internationally. One controversial area continues to revolve around the recommendation to prescribe a solely whole-food plant based diet versus a predominant one has been debated by experts in lifestyle medicine and across other medical fields. Although education and implementation of lifestyle medicine has not expanded as widely as necessary to address health outcomes and costs, the health care emphasis of a healthy lifestyle in treatment has grown.
The core competencies were initially designed for primary care physicians. However, due to their relevance across medical specialties and the entire health care team, they have been applied by a broad array of health practitioners. Hence, they have evolved as the competencies for the generalist in lifestyle medicine. Subsequently, lifestyle medicine leaders interested in differentiating these generalist competencies from competencies for those specializing in lifestyle medicine convened a panel of lifestyle medicine experts to identify and release specialty competencies, listed in Appendix B (Kelly, Karlsen & Lianov 2019).
Rationale for Updating the Core and Expanded Competencies
On the heels of such developments, a decade after the release of the core competencies, it’s high time to review and update them. Several reasons support this need: 1) continued mounting evidence in support of a healthy lifestyle to treat and potentially reverse, as well as prevent, lifestyle-related diseases, 2) release of new studies that suggest some novel and/or nuanced healthy lifestyle recommendations, 3) revised national clinical practice guidelines by medical specialties that recognize lifestyle interventions as essential to treatment, 4) increasing involvement in the field of lifestyle medicine by a variety of primary and specialty care practitioners, 5) expanded trainings in lifestyle medicine for professionals-in-training and continuing education purposes, 6) development of lifestyle medicine residency and specialist fellowship training curricula, 7) release of competencies for those specializing in lifestyle medicine (Kelly, Karlsen & Lianov 2019, 8) release of hierarchies of evidence applied to lifestyle medicine—HEALM (Katz, et al 2019), and 9) recommendations to add new topic areas, such as positive psychology (Lianov 2019).
The Core Competency Development and Updating Process
The initial core competencies were developed by a panel of representatives from several health professional organizations.
Organizations on the 2009 Core Competencies National Blue Ribbon Panel
Although these representatives were not formally speaking on behalf of their organizations, they were selected by their organizations to contribute to the panel and they provided insights and perspectives from a range of medical fields. The goal of bringing a variety of organizations to the table was to garner interest and support for lifestyle medicine. The panel met in person for one day to develop the framework of the competencies and communicated over the subsequent year to finalize and agree on the specific wording of the definition and each competency. Involvement of a broad group of organizations in defining the field and its competencies helped it gain recognition and likely boosted the positive response for publication by the JAMA editorial team.
The new panel used a similar process for updating the competencies by involving the initial organizations and additional ones representing a broad group of health care and medical specialty representatives and international representatives from the Lifestyle Medicine Global Alliance. This approach helped further increase wide acceptance of the key elements of lifestyle medicine as essential to health care in general, promote the field and garner champions for expanding it across health care settings. A review of the literature and significant prep work by the new identified panelists was conducted which prepared a productive meeting during the revision process. The meeting was followed by more rounds of editing to complete a final revised set of competencies, and process took more than 12 months.
An international panel was assembled from among the lifestyle medicine community leaders in the conduct of review process. The review identified any new significant evidence and subtopic areas that need to be added, as well as subtopic areas that are significantly out of date. The overall structure, content and approach of the core and expanded competencies remain the same. Detailed review to address the latter along with a complete literature review was conducted by an expanded panel which included the panelists, members of the organizations that participated in the original 2009 blue ribbon panel and representatives from a variety of other medical specialties who are emphasizing lifestyle medicine. Acknowledging that the initial competency development had a U.S focus, the detailed review panel was also tasked with considering whether and how the competencies should be customized to account for cultural and other differences in countries outside of the US.
Future Vision: Lifestyle Medicine Core Competencies
As the first round of revisions to the core competencies, the question arises about how the competencies should be updated in the future. There is a need to consider the impact of frequent changes on existing training programs and curricula. Involving faculty, educators and clinician leaders who are constructing lifestyle medicine education and programs is essential to determining the way forward. Both the content and process of updating needs careful consideration.
In support of the vision that the core competencies are, indeed, “core” to the general practice of medicine, and with the optimistic view that ultimately, these core tenets of lifestyle medicine will be included in medical education, residency and fellowship training, and general clinical practice, it is possible to envision a future when lifestyle medicine core competencies for the generalist are no longer necessary as a separate guidepost for education and practice. Only competencies for those specializing in lifestyle medicine would be maintained. The core competencies would be fully integrated into the health care education and practice systems. That outcome could be viewed as the ultimate success of the core competencies development process.
Conclusion
The lifestyle medicine core competencies released in 2010, along with the expanded competencies that were subsequently developed to guide curricula, training and board examination need to be reviewed and updated. The international review panel performed an expedient process to update significant gaps or outdated areas. A detailed review followed to look at the structure and content of the core and expanded competencies and address questions that have arisen as a result of developments in the field over the past decade. The detailed updating process was carefully considered by the steering committee, as this first round is setting precedent for conducting future reviews and revisions.
Programs and Educational Materials Evolved from the Core Competencies and Expansion of the Field
In 2015, the ACLM and ACPM released the joint Lifestyle Medicine Core Competencies Curriculum, which provided online training modules on each of the 15 core competencies, as well as lifestyle medicine modalities (nutrition, physical activity, sleep, substance use, emotional well-being) and expanded topics of relevance, such as weight management. To complete the curriculum, the core competencies and modality areas were expanded into detailed subtopics and learning objectives--referred to here as the expanded lifestyle medicine competencies (Appendix A). When the American Board of Lifestyle Medicine (ABLM) was established the following year, it based its first lifestyle medicine board certification examination on these expanded competencies, as well as additional educational resources for in depth coverage of key topic areas, such as nutrition, that were recommended by lifestyle medicine experts.
Interest in the board examination quickly grew nationally and internationally (conducted in over 20 countries) with the need to provide training and content review. The ACLM with leadership from expert faculty developed a board review course and manual largely based on the same source materials as those used for the examination. Using these resources, faculty at Loma Linda University developed a lifestyle medicine residency curriculum and implemented the inaugural program at Loma Linda University. A question bank of lifestyle medicine-related questions is also under development for contribution to the National Board of Medical Examiners.
While the field of lifestyle medicine gained momentum, poor health outcomes and high health care costs in the US health care system spurred the need for change in clinical practice, as well as public health. Lifestyle interventions are gaining greater recognition by fields outside of lifestyle medicine. For example, not only is a healthy lifestyle emphasized in prevention (e.g. the 2019 American College of Cardiology/American Heart Association Guidelines for Primary Prevention of Cardiovascular Disease), but also in disease management/treatment (e.g. the 2018 American College of Cardiology/American Heart Association Cholesterol Clinical Practice Guidelines). The number one recommendation among the ten key messages in the latter set of guidelines is “in all individuals, emphasize a heart-healthy lifestyle across the life course.” Similar clinical guideline and standards changes and recommendations are developing internationally. One controversial area continues to revolve around the recommendation to prescribe a solely whole-food plant based diet versus a predominant one has been debated by experts in lifestyle medicine and across other medical fields. Although education and implementation of lifestyle medicine has not expanded as widely as necessary to address health outcomes and costs, the health care emphasis of a healthy lifestyle in treatment has grown.
The core competencies were initially designed for primary care physicians. However, due to their relevance across medical specialties and the entire health care team, they have been applied by a broad array of health practitioners. Hence, they have evolved as the competencies for the generalist in lifestyle medicine. Subsequently, lifestyle medicine leaders interested in differentiating these generalist competencies from competencies for those specializing in lifestyle medicine convened a panel of lifestyle medicine experts to identify and release specialty competencies, listed in Appendix B (Kelly, Karlsen & Lianov 2019).
Rationale for Updating the Core and Expanded Competencies
On the heels of such developments, a decade after the release of the core competencies, it’s high time to review and update them. Several reasons support this need: 1) continued mounting evidence in support of a healthy lifestyle to treat and potentially reverse, as well as prevent, lifestyle-related diseases, 2) release of new studies that suggest some novel and/or nuanced healthy lifestyle recommendations, 3) revised national clinical practice guidelines by medical specialties that recognize lifestyle interventions as essential to treatment, 4) increasing involvement in the field of lifestyle medicine by a variety of primary and specialty care practitioners, 5) expanded trainings in lifestyle medicine for professionals-in-training and continuing education purposes, 6) development of lifestyle medicine residency and specialist fellowship training curricula, 7) release of competencies for those specializing in lifestyle medicine (Kelly, Karlsen & Lianov 2019, 8) release of hierarchies of evidence applied to lifestyle medicine—HEALM (Katz, et al 2019), and 9) recommendations to add new topic areas, such as positive psychology (Lianov 2019).
The Core Competency Development and Updating Process
The initial core competencies were developed by a panel of representatives from several health professional organizations.
Organizations on the 2009 Core Competencies National Blue Ribbon Panel
- American Academy of Family Physicians,
- American Medical Association,
- American College of Physicians,
- American College of Preventive Medicine,
- American College of Lifestyle Medicine,
- American Osteopathic Association,
- American Academy of Pediatrics,
- American College of Sports Medicine
Although these representatives were not formally speaking on behalf of their organizations, they were selected by their organizations to contribute to the panel and they provided insights and perspectives from a range of medical fields. The goal of bringing a variety of organizations to the table was to garner interest and support for lifestyle medicine. The panel met in person for one day to develop the framework of the competencies and communicated over the subsequent year to finalize and agree on the specific wording of the definition and each competency. Involvement of a broad group of organizations in defining the field and its competencies helped it gain recognition and likely boosted the positive response for publication by the JAMA editorial team.
The new panel used a similar process for updating the competencies by involving the initial organizations and additional ones representing a broad group of health care and medical specialty representatives and international representatives from the Lifestyle Medicine Global Alliance. This approach helped further increase wide acceptance of the key elements of lifestyle medicine as essential to health care in general, promote the field and garner champions for expanding it across health care settings. A review of the literature and significant prep work by the new identified panelists was conducted which prepared a productive meeting during the revision process. The meeting was followed by more rounds of editing to complete a final revised set of competencies, and process took more than 12 months.
An international panel was assembled from among the lifestyle medicine community leaders in the conduct of review process. The review identified any new significant evidence and subtopic areas that need to be added, as well as subtopic areas that are significantly out of date. The overall structure, content and approach of the core and expanded competencies remain the same. Detailed review to address the latter along with a complete literature review was conducted by an expanded panel which included the panelists, members of the organizations that participated in the original 2009 blue ribbon panel and representatives from a variety of other medical specialties who are emphasizing lifestyle medicine. Acknowledging that the initial competency development had a U.S focus, the detailed review panel was also tasked with considering whether and how the competencies should be customized to account for cultural and other differences in countries outside of the US.
Future Vision: Lifestyle Medicine Core Competencies
As the first round of revisions to the core competencies, the question arises about how the competencies should be updated in the future. There is a need to consider the impact of frequent changes on existing training programs and curricula. Involving faculty, educators and clinician leaders who are constructing lifestyle medicine education and programs is essential to determining the way forward. Both the content and process of updating needs careful consideration.
In support of the vision that the core competencies are, indeed, “core” to the general practice of medicine, and with the optimistic view that ultimately, these core tenets of lifestyle medicine will be included in medical education, residency and fellowship training, and general clinical practice, it is possible to envision a future when lifestyle medicine core competencies for the generalist are no longer necessary as a separate guidepost for education and practice. Only competencies for those specializing in lifestyle medicine would be maintained. The core competencies would be fully integrated into the health care education and practice systems. That outcome could be viewed as the ultimate success of the core competencies development process.
Conclusion
The lifestyle medicine core competencies released in 2010, along with the expanded competencies that were subsequently developed to guide curricula, training and board examination need to be reviewed and updated. The international review panel performed an expedient process to update significant gaps or outdated areas. A detailed review followed to look at the structure and content of the core and expanded competencies and address questions that have arisen as a result of developments in the field over the past decade. The detailed updating process was carefully considered by the steering committee, as this first round is setting precedent for conducting future reviews and revisions.
ARTICLE REVIEW
MODULE TASK
TASK 1
There are ten sections on the updated Lifestyle Medicine Core Competencies (LMCC) expanded with various objectives that comprise 88 updated core competencies. Review the articles in this module, evaluate your current lifestyle medicine practice based on the ten key sections of the updated LMCC, and write a reflective essay with the following inclusions:
There are ten sections on the updated Lifestyle Medicine Core Competencies (LMCC) expanded with various objectives that comprise 88 updated core competencies. Review the articles in this module, evaluate your current lifestyle medicine practice based on the ten key sections of the updated LMCC, and write a reflective essay with the following inclusions:
- Introduction to Lifestyle Medicine. Carefully review your medical practice by comparing and contrasting lifestyle medicine to other fields of health and medicine. Are you practicing other modalities other than conventional medicine and lifestyle medicine? How do you delineate and integrate lifestyle medicine from other practices?
- The Role of the Practitioner’s Personal Health and Community Advocacy. Discuss your personal practice of healthy lifestyles and identify your personal readiness and action plan to effectively represent and conduct LM practice and advocate on behalf of Lifestyle Medicine.
- Nutrition Science, Assessment, and Prescription. Discuss how you implement culinary medicine (include a sample of your program) and refer patients to a lifestyle medicine trained registered dietician to translate and further personalize nutrition prescriptions.
- Physical Activity Science, Assessment, and Prescription. Discuss how you integrate physical activity into your treatment protocols (include a sample of your PA program).
- Sleep Health Science and Interventions. List the tools you use to perform sleep assessment and describe how you refer patients to a program or sleep specialist.
- Treating Tobacco Use Disorder and Managing Other Toxic Exposures. Discuss how you apply patient screening tools for substance use and implement patient-centered substance use treatment plans using practice guidelines and behavioral interventions (include a sample of your program).
- Key Clinical Processes in Lifestyle Medicine. Describe how you leverage your interdisciplinary team, including referral and collaboration with medical specialists and other health professionals, such as dieticians, health educators, fitness trainers, and psychologists. Cite the strategies you are using for effective office systems and tools to track the screening frequency, test results, and follow-up.
- Fundamentals of Health Behavior Change. Summarize how you use behavior change techniques in your clinical practice, including the application of motivational interviewing, cognitive behavioral, health coaching, and positive psychology techniques.
- Emotional and Mental Health Assessment and Interventions. List the screening tools you use for stress, depression, and anxiety in clinical practice. Describe how you utilize evidence-based and patient-centered mental and emotional health interventions, including MBSR.
- The Role of Connectedness and Positive Psychology. List the positive psychology activities you conduct and describe how you apply them when you work on health behavior change counseling.
TASK 2
Lifestyle medicine is an evidence-based practice. All certified specialists in this field should have a good practice of evidence-based medicine which is a lifelong, self-directed, problem-based learning process.
Lifestyle medicine is an evidence-based practice. All certified specialists in this field should have a good practice of evidence-based medicine which is a lifelong, self-directed, problem-based learning process.
- Review the useful EBM references and tools using the links provided.
- Search for an article related to the updated LMCC. Select an appropriate tool for the article you extracted and conduct your appraisal. Submit your recorded video report.
- https://guides.mclibrary.duke.edu/ebptutorial
- https://docs.google.com/presentation/d/14NBZXoOMinQGslwwaW__xQ_enIbvrzHL/edit#slide=id.p71
- https://drive.google.com/file/d/1khM0pHPy0KwtGRn64DtzAkxUotZ-Sa23/view
