Adverse Childhood Experiences as "Upstream" Determinants of Lifestyle-Related Chronic Disease: A Scoping Perspective.

We have previously proposed a list of determinants (causes) of modern lifestyle-related chronic disorders, which provides a structure for the emerging discipline of lifestyle medicine. This consists of lifestyle factors with a common immune biomarker (metaflammation) that interact in a systems fashion linked with chronic disease outcomes. We considered this to be a work in progress and later added 3 psychosocial determinants into the causal mix: meaninglessness, alienation, and loss of culture and identity (MAL). Here, we propose adverse childhood experiences (ACEs) as deeper, or even more distal, disease drivers that may act directly or indirectly through MAL to influence later chronic disease. The links with metaflammation and the need for recognition of these embedded scars in the management of lifestyle-related health problems is discussed.

Re-imaging healthcare delivery in the era of COVID-19.

The COVID-19 pandemic has exposed the deficiencies of the current healthcare system in terms of a disconnect between primary and tertiary care and increasing subspecialisation, the focus on acute episodic care rather than on prevention in a time where chronic disease prevails and an inefficient use of healthcare resources. Herein, we present the case for an alternative model of healthcare delivery - shared medical appointments - which are efficient, effective and empowering and can be transitioned to the virtual environment successfully. We highlight the barriers to implementation and how these can be overcome.

Overweight and obesity management in musculo-skeletal primary care: a survey of Australian health practitioners exploring ‘the elephant in the room’.

BACKGROUND: Overweight and obesity has a bi-directional association with the growing burden of musculoskeletal (MSk) dysfunction and pain. It seems inevitable that MSk practitioners will see increasing numbers of patients who are overweight and or obese and require this to be addressed as part of their management. Little evidence exists to describe the engagement of patients and their MSk practitioner in weight management as an adjunct or direct component of their intervention or therapy. METHODS: A self-administered electronic survey was constructed with 13 items to collect self-reported data from Australian practitioners who have a focus on MSk management. The target group was from a multidisciplinary MSk network of 350 members. RESULTS: A total of 204 completed surveys were analysed from respondents working in one of seven MSk- related professions. It was found that 70% of patients/clients seen by respondents were overweight or obese and that <18% of these patients had weight management included as part of their treatment. CONCLUSIONS: Sixty percent of the respondents in this survey indicated that they do not include weight management as part of their practice despite 70% of their patients/clients being overweight and or obese. With the exception of Medical Practitioners and Exercise Physiologists, in this survey, the other therapists including Chiropractors, Osteopaths, Physiotherapists and Occupational Therapists, indicated that they lacked confidence, knowledge and methods to engage a systematic approach to weight management with their patients/clients.

Shared Medical Appointments and Mindfulness for Type 2 Diabetes-A Mixed-Methods Feasibility Study.

Introduction: Type 2 diabetes (T2DM) is a major health concern with significant personal and healthcare system costs. There is growing interest in using shared medical appointments (SMAs) for management of T2DM. We hypothesize that adding mindfulness to SMAs may be beneficial. This study aimed to assess the feasibility and acceptability of SMAs with mindfulness for T2DM within primary care in Australia. Materials and Methods: We conducted a single-blind randomized controlled feasibility study of SMAs within primary care for people with T2DM living in Western Sydney, Australia. People with T2DM, age 21 years and over, with HbA1c > 6.5% or fasting glucose >7.00 mmol/L within the past 3 months were eligible to enroll. The intervention group attended six 2-h programmed SMAs (pSMAs) which were held fortnightly. pSMAs included a structured education program and mindfulness component. The control group received usual care from their healthcare providers. We collected quantitative and qualitative data on acceptability as well as glycemic control (glycated hemoglobin and continuous glucose monitoring), lipids, anthropometric measures, blood pressure, self-reported psychological outcomes, quality of life, diet, and physical activity using an ActiGraph accelerometer. Results: Over a 2-month period, we enrolled 18 participants (10 females, 8 males) with a mean age of 58 years (standard deviation 9.8). We had 94.4% retention. All participants in the intervention group completed at least four pSMAs. Participants reported that attending pSMAs had been a positive experience that allowed them to accept their diagnosis and empowered them to make changes, which led to beneficial effects including weight loss and better glycemic control. Four pSMA participants found the mindfulness component helpful while two did not. All of the seven participants who contributed to qualitative evaluation reported improved psychosocial wellbeing and found the group setting beneficial. There was a significant difference in total cholesterol levels at 12 weeks between groups (3.86 mmol/L in intervention group vs. 4.15 mmol/L in the control group; p = 0.025) as well as pain intensity levels as measured by the PROMIS-29 (2.11 vs. 2.38; p = 0.034). Conclusion: pSMAs are feasible and acceptable to people with T2DM and may result in clinical improvement. A follow-up fully-powered randomized controlled trial is warranted. Clinical Trial Registration: Australia and New Zealand Clinical Trial Registry, identifier ACTRN12619000892112.

A Review of Small Screen and Internet Technology-Induced Pathology as a Lifestyle Determinant of Health and Illness.

Most advances in humanity have been related to the discovery or introduction of new innovations and/or technology. There should be no suggestion that all technology is pathological or that major advances in health, science, and well-being have not come from industrial and technological advances. However, just like the invention of the wheel would have no doubt caused people to be injured and modern lifesaving medicines can have side effects, modern technology can have a downside, which needs to be recognized. This article explores some of the pathologies linked to small screen and internet technologies (personal computers, communication devices, and the internet). The uptake and impact of this set of technologies is pivotal in redefining our lifestyle behaviors and environment: the way we work, shop, seek entertainment, communicate, socialize, reproduce, interact with the environment, and seek information.

Lifestyle Medicine in Australia: A Potted History-So Far.

Lifestyle medicine commenced in Australia in response to the rise in chronic diseases following the epidemiological transition that began in the 1980s. Today, it is flourishing with an annual conference, a variety of multidisciplinary members, and a developed pedagogy for the "art-science."

Programmed shared medical appointments for weight management in primary care: An exploratory study in translational research.

BACKGROUND AND OBJECTIVES: Programmed shared medical appointments (pSMAs) are an extension of shared medical appointments (SMAs) for managing chronic diseases. Acceptance and outcomes of a trial for weight management are reported here. METHOD: Six programmed sessions in weight management were carried out in seven NSW primary healthcare centres. RESULTS: Seventy-seven per cent of 216 participants (64 male, 102 female) completed at least four of six pSMAs over 16-18 weeks ('adherers'). Eighty-five per cent of adherers approved of pSMAs, and 73% said they would prefer these over a standard clinical consult. Providers also rated the process highly. Overall mean weight loss over 12 months was 3.2% (95% confidence interval [CI]: 2.2, 4.3; P <0.001). For adherers, mean weight loss was 4.3% for males (95% CI: 2.6, 6.1; P <0.001) and 4.2% for females (95% CI: 2.7, 5.7; P <0.001), with 46% of males and 35% of females maintaining clinically significant losses (>5%) after 12 months. pSMAs were calculated to be four times more cost effective and up to seven times more time effective than 1:1 consultations for weight loss. DISCUSSION: pSMAs are a popular, cost and time-effective adjunct to standard clinical management.

Lifestyle medicine: The 'why', 'what' and 'how' of a developing discipline.

BACKGROUND: Changes in living conditions throughout history typically result in changes in the pattern of diseases. The modern post-industrial era has resulted in a shift from predominantly infectious to predominantly chronic diseases, or those with a significant lifestyle/environmental aetiology. This has led to the development of an adjunct discipline of lifestyle medicine. OBJECTIVE: The aim of this article is to describe a basic structure for the discipline of lifestyle medicine as an introduction to other, more specific articles on the topic in this issue of Australian Journal of General Practice. DISCUSSION: There are currently four areas in which lifestyle medicine can add to the principles of conventional medicine. These are 1) the science (the epidemiology), 2) the art (the skills), 3) the materials (the tools) and 4) the procedures (the actions).

Psychosocial Determinants of Chronic Disease: Implications for Lifestyle Medicine.

We have previously identified a number of "determinants" of chronic disease, using the acronym NASTIE ODOURS. These have been given the collective term "anthropogens," in this journal and other publications, to help direct the management of modern chronic ailments to a monocausal focus, akin to that afforded infectious diseases by the "germ theory." We suggested the acronym NASTIE ODOURS as a starting point for a taxonomy of lifestyle medicine determinants. In the current article, we add 3, less quantifiable, but currently increasingly more important psychosocial experiences to these: Lack of Meaning, Alienation, and Loss of culture, changing the previous acronym to NASTIE MAL ODOURS. As with other determinants, all have accumulating evidence of an underlying low-grade, systemic, inflammatory physiological base ("metaflammation"), but with the need for further research to solidify these findings.

Establishing Proof of Concept for Clinical Processes in Lifestyle Medicine.

Lifestyle medicine is a relatively new discipline, designed to improve the management of lifestyle and environmentally induced chronic diseases. As such it is evolving new skills, tools, and procedures. But these are often not assessed for their potential before being adopted in practice. Proof of concept (PoC) is an initial stage of testing characteristic of new product or process development in the commercial world. It can be equally applied to new processes and practices in lifestyle medicine.

PROCESS AND SYSTEMS: A systems approach to embedding group consultations in the NHS.

Group consultations are an important care option that is -starting to gain traction in the USA and Australia. This review summarises the likely benefits accruing from a systems -approach to implementing group consultations widely in the NHS and other socialised healthcare systems. Existing evidence is mapped to five distinct systems approaches: (1) development; (2) different age groups; (3) patient-centred pathway of care; (4) NHS system changes; and (5) education. Implications are discussed for patients and staff, who both benefit from group consultations once embedded; ranging from improved access and efficiency to more enjoyable multidisciplinary team working, improved resource management, and maintained/better outcomes. Moreover, even patients who don't attend group consultations can benefit from system effects of long-term implementation. Changing behaviour and health systems is challenging, but change requires systematic experimentation and documentation of evidence. We conclude that group consultations have unique potential for delivering system-wide benefits across the NHS.

Defining a Structure and Methodology for the Practice of Lifestyle Medicine.

Lifestyle medicine (LM) is a relatively new branch of clinical practice (like travel medicine, sports medicine, etc), but to date with little accepted structure or methodology. The current review extends a previous attempt to define the determinants of chronic disease by expanding this to include (1) the knowledge base (the science) or epidemiology of chronic disease, (2) the skills (the art) or practice of LM, (3) the tools (the materials) that can add to LM diagnoses and prescription, and (4) the procedures (the actions) that help update conventional medicine to include practices required for a new era of lifestyle and environmentally related chronic disease.

Programmed shared medical appointments: A novel procedure for chronic disease management

BACKGROUND: In 2013, the Australasian Society of Lifestyle Medicine (ASLM) introduced shared medical appointments (SMAs) for managing chronic disease in clinical practice. The popularity of SMAs has increased with the shift towards a Health Care Homes model. Programmed shared medical appointments (PSMAs) are an extension of the standard SMA model, designed to help manage more complex and specific chronic disease issues. OBJECTIVE: The objective of this article is to describe the process of PSMAs and consider their use in primary care. DISCUSSION: PSMAs combine sequential medical consultations with peer support and interaction in a semi-structured group education arrangement. SMAs and PSMAs are ideally suited to the Health Care Homes model of clinical care currently proposed by the federal Department of Health. Proof of concept is currently being tested for PSMAs. Conditions suitable for future trials include overweight and obesity, diabetes (including pre-diabetes), cardiovascular diseases, chronic kidney disease, chronic obstructive pulmonary disease or emphysema, chronic pain or arthritis, mild anxiety or depression, perisurgical management and cancer survival.

Shared Medical Appointments May Be Effective for Improving Clinical and Behavioral Outcomes in Type 2 Diabetes: A Narrative Review.

Type 2 diabetes mellitus (T2DM) is a complex chronic disease affecting over 400 million people worldwide. Managing T2DM and its associated complications in individual patient consultations poses substantial challenges to physicians due to limited time and resources and lack of access to multidisciplinary teams. Shared medical appointments (SMAs) are consecutive medical consultations provided by a physician in a group setting, where integrated medical care and patient education are delivered in a single session. SMAs allow physicians to deliver the same level of care to multiple patients at the same time, thereby maximizing available resources. However, the effectiveness and practicality of SMAs in the management of T2DM remains unknown. This narrative review summarizes current and emerging evidence regarding the effectiveness of SMAs in improving clinical outcomes in patients with T2DM, as well as whether SMAs are associated with reduced costs and improved diabetes-related behavioral and lifestyle changes. An extensive literature search was conducted on major electronic databases including PubMed and Google Scholar using keywords, including SMAs, group visits, and T2DM to identify all studies of SMAs in patients with T2DM. Studies in type 1 diabetes or mixed or unspecified populations were excluded, as well as studies where SMAs did not involve a physician since these do not meet the classical definition of a SMA. Nineteen studies were identified and are included in this review. Overall, current evidence suggests that SMAs delivered regularly over time may be effective in improving glycemic outcomes, diabetes knowledge, and some diabetes-related behaviors. However, the main limitation of existing studies was the paucity of comparisons with standard care which limits the ability to draw conclusions regarding whether SMAs are superior to standard care in T2DM management. Moreover, the small number of studies and substantial heterogeneity in study designs, populations, and interventions creates difficulties in establishing the practicality and efficiency of SMAs in the clinical care setting. We conclude that there remains a need for larger studies to identify populations who may or may not benefit from the SMA model of care and to clarify the potential benefits and barriers to implementing SMAs into routine diabetes care.

Healthy living.

BACKGROUND: The nature of disease changes with the nature of societies. Modern chronic diseases that have superseded infections in the Anthropocene era, for example, have come largely from modern environments and lifestyles emanating from this. The concept of healthy living has subsequently changed accordingly. OBJECTIVE: The objective of this article is to examine the determinants of modern chronic disease and the changes that can be made at the individual level to reduce the impact of these. DISCUSSION: There is a hierarchy of determinants (sometimes incorrectly called 'causes') of the major modern chronic dieases. These are summarised under the acronym NASTIE MAL ODOURS and collectively under the term 'anthropogens', which are '… man-made environments and the lifestyles associated with these, many of which may lead to disease'. Attention to anthropogens in a systems fashion suggest guidelines for modern healthy living.

Shared medical appointments for Aboriginal and Torres Strait Islander men.

BACKGROUND: Aboriginal and Torres Strait Islander health is generally the worst of any population group in Australia. Inaccessibility to health services is one possible cause of this. Shared medical appointments (SMAs) appear to be a culturally competent and appropriate way of improving access to, and the quality of, primary healthcare services for Aboriginal and Torres Strait Islander peoples. OBJECTIVE: The objective of this article is to assess the acceptability and appropriateness of SMAs as an adjunct process in primary care for Aboriginal and Torres Strait Islander men. METHODS: As part of a broader study on SMAs, three SMA sessions were delivered at an Aboriginal men's health centre in northern New South Wales. One-day training sessions in SMA facilitation were also provided to two groups of 12-14 Aboriginal health workers (AHWs). Mixed methods were used to assess patient and provider satisfaction, subjective outcomes, and operational procedures in the SMA groups, as well as interest in the SMA process by AHWs. RESULTS: Satisfaction with SMAs among Aboriginal men was unanimously positive, with the numbers in the group increasing over time. Patients most enjoyed the 'yarn up' nature of SMAs with peer support, which reduced the 'scary' and culturally 'unnatural' nature of one-on-one consultations with a general practitioner (GP). AHWs who were trained to a level to conduct SMAs saw this as an effective way of improving cultural competence in, and accessibility of, their various Aboriginal health services. DISCUSSION: The results, though not generalisable, suggest that SMAs may offer a culturally safe and appropriate tool to enhance Aboriginal and Torres Strait Islander peoples' access to primary care.