So , welcome back to our audience for our fourth session today . The title is Integrating Lifestyle and Performance Medicine In Team Based Care presented by Air Force Captain Matthew B . Dion and Doctor Reagan , a Stigma Air Force . Captain Matthew B DAO is a physician assistant and lifestyle medicine , lifestyle performance medicine specialist at the United States Air Force Academy in Colorado Springs , Colorado . Doctor Reagan , a Stigma is a lifestyle and performance medicine physician and a former US Air Force Flight surgeon at the United States Air Force Academy in Colorado Springs , Colorado . Please welcome Captain Dia and Doctor Stegman . All right . Thank you , Colonel Keel . Uh Hello , everyone . Uh , in regards to today's disclosures for this presentation , uh please bear with me as I read through this uh Air Force Captain Matthew dot has no relevant financial or non-financial relationships to disclose relating to the content of this activity . Doctor Reagan Stig's relevant financial or non-financial relationships to disclose relating to the content of this activity include consultant , uh Department of Defense Department of Veteran Affairs and civilian entities . The views expressed in this pre presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense nor the US government mention of trade names , commercial products or organizations do not imply endorsement by the US government . This continuing education activity is managed and accredited by the Defense Health Agency J Seven Continuing Education Program office or CO DH AJ seven co and all accrediting organizations do not support or endorse any product or service mentioned in this activity . DH AJ seven CO staff , as well as activity planners and reviewers have no relevant financial or non-financial interest to disclose commercial support was not received for this activity . And case presentation is a composite with no personal identifiers and now I'll hand it off to doctor student . Thanks so much Kev Die . I just want to review the learning objectives really quickly and then we are going to dive right in for what's going to be a super exciting session here um uh this morning or this afternoon wherever you are . So we're going to describe and define lifestyle medicine and lifestyle performance medicine . We're going to identify the impact of suboptimal lifestyle on morbidity , mortality and readiness . We're gonna discuss and summarize these six pillars of lifestyle medicine and efforts done thus far to integrate lifestyle and performance medicine within the military health system . We're also going to explain how lifestyle performance medicine incorporates a team based approach and how it aligns with the H A's quadruple aim . We're then finally gonna examine each clinical team within primary specialty care for both patients , health care professionals , to foster mental health resiliency , chronic disease , mitigation , and enhance quality of life and longevity . So that brings us to the next question and basically the fundamental discussion of why we are even here today . Well , as many of you know , the US spends about $3.8 trillion annually and go to the next slide , please . Um And I'll give you a quick update . That number for 2021 has actually grown to $4.3 trillion annually on health care . And about 90% of those costs are attributed to treating patients with chronic conditions . According to the CDC , the department of dispense alone on obesity spends 1.5 billion on not only obesity but obesity related health care costs for current and former service members and their families . And I'm sure as you have all heard before , this sick care system is truly unsustainable and we need to improve the health and longevity of all of our military service members and other beneficiaries . We also need to drastically reduce the cost required to sustain it next slide . And so as we evaluate what those costs actually truly look like from a financial impact for um lifestyle related expenditures within the dod . Um the dollar amounts are truly staggering . We're looking at nearly uh and not even nearly over $8.1 billion annually spent on obesity , obesity related health care issues , tobacco and subsequent health care issues related to that musculoskeletal injury and alcohol misuse . And this creates a very clear picture of how important lifestyle interventions and strategic ones at that um are are critical for truly making a dent on this health care burden and on uh impacting economic feasibility for the Department of Defense . Next slide . So why does it cost so much ? Um when we're looking at those economic impacts ? Well , um it's because of statistics that you see here that are from the RAND Corporation that have just been ballooning since the mid nineties , when it comes to truly the foundational components of why we care so much about investing in lifestyle medicine centric interventions . Um You see um 51% overweight , obesity rates rising steadily year after year , 51% in 2008 61% in 2017 69% . And you can only imagine what has happened now post pandemic and why this is even more of a relevant discussion here . Next slide . Um When we just look at a snapshot of something like musculoskeletal injuries and the significant impact that um prede pre uh previously diagnosed conditions such as overweight , obesity have on something like muscular ske skeletal injury , which we know is costing 3.7 billion annually for the dod . Um We have to heed uh looking at a more upstream cause of how we can strategically intervene . Um And we know that 1/5 of service members in 2020 alone , once again , sort of like pre pandemic , uh , dates were obese next slide . Uh This is also why lifestyle medicine is so important because it's , it's increasingly important based on these disease trends that we just see growing and growing over time within our active duty populations and certainly our veteran populations as well who are no strangers to disease to actually have a significant impact . We're looking at nearly 6000 cases of type two diabetes in active duty . Um uh The US active duty uh subsector with nearly 500 new cases being added annually , not to mention nearly a $10,000 additional price tag per person per year . When AD AD M type two diabetes diagnosis is rendered next slide . Uh you know , and as mentioned , uh not only is this impacting uh service members and ranks but also veteran populations who have been shown to bear some of the most heavy disease burdens after serving either careers or for their duration and tenure in uh in uniform and type two diabetes mila prevalence is nearly two times that of the general population . Um And , and we're seeing these trends that show that in a population of over 12,000 veterans , less than 33% had an A one C less than 5.7 . Um So that is a significant burden of metabolic um de optimization or um disorders , prediabetes , diabetes . And even individual veterans who had hemoglobin , a one C is greater than 5.7 cholesterol , greater than 200 triglycerides , greater than 1 50 had a fivefold risk of developing diabetes uh alone . So , next slide , this is this is really um an in an issue that we have the opportunity to really , uh not only identify but really do something about . And we have to look at the literature and we know that uh this publication out of the lancet in 2019 is one of the most heavy hitting um research articles that has come to the forefront , showing that poor diet is now the leading cause of death and disability in the United States . Um And almost nearly worldwide when you're looking at um a significant proportion of the top killers of Americans being directly linked to lifestyle choices , heart disease , blood pressure , um high cholesterol , diabetes , cancer , strokes . Um We're really in a , in a place where we have the capacity and certainly as an enterprise to fully , fully um sort of impact and strategically interject opportunities to um shift those uh upstream lifestyle habits that we can actually impact for , for an enterprise as a whole and for the individual service member and families as well . Next slide . And ultimately , the effects that we see as a result of this significant chronic disease burden is what is , what truly lands us in the space of a threat to our national security . Um Our military readiness is at a place where it can be quantified as sub par . Uh We need to not only be ready to deploy , we need to be optimized to deploy . And we , we have to not only fight against our adversaries , but we have to fight against ourselves . And the chronic diseases that affect the service member affects the mission significantly and directly . So , you know , it , we don't want this to be a woe is me moment . Go ahead to the next slide . Um So when we show up with a problem , we also like to show up with a solution and that's what we're going to discuss here a bit further into the dialogue . Next slide , please , we're going to talk about the solution and that solution is lifestyle medicine or in the military , what we refer to as lifestyle and performance medicine . So lifestyle medicine itself is a medical subspecialty . It's one of the fastest growing medical subspecialties , agnostic of what kind of health care professional you are . You can practice uh medicine in the lifestyle medicine fashion and you can get certified and that we'll discuss at the end as well . Um But in the military , we've adapted uh the principles of lifestyle medicine to um essentially make it a little bit more relevant to not only um the evidence based uh foundations of LM or lifestyle medicine and preventing treating and at times even reversing chronic disease . But adding that extra component of optimizing human performance through biop physiological um cellular regulation . And that is truly just dialing in lifestyle choices on a daily basis to have um a higher return on investment for things that are unique to the military or subsector , like perform performance in the deployment space , optimization in the readiness space . Um Things of that nature . Next slide . So what is lifestyle medicine at its core ? There are six principles that of lifestyle medicine which are truly evidence based , which have been proven time and again , for nearly a century in the research . Um and it supports that it makes individuals healthier and that is choosing to eat a primarily whole , whole food plant , predominant um diet , focusing on quality and quantity of sleep , getting regular and consistent physical activity , minimizing and eliminating the use of risky substances , learning effective coping mechanisms for reducing stress and improving social connectedness . Next slide . And it is really the CDC and the who who have described how simply changing one's lifestyle can reduce up to 80% of the non infectious chronic disease burden that we're seeing today . And while we're talking about diabetes , um it's worth noting that lifestyle medicine strategies work significantly well , for many other chronic diseases like heart disease , hypertension hyperlipidemia , some forms of cancer . Um even neurocognitive diseases like Alzheimer's and dement and dementia . Next slide . So as mentioned , lifestyle medicine is truly an evidence based approach that is shown to prevent and treat and even in some cases reverse disease altogether , it treats the underlying root cause of disease as opposed to the symptoms that are all too often uh managed in this disease . This disease management um uh medical enterprise in which most of us are living with pills and procedures as opposed to root cause analysis . And because it treats the , the cause and not just the symptoms , um it is only through lifestyle medicine that we can alter the course of this spiraling health care um concerns that we have to face every single day um in , in western medicine at large . So next slide , um on this slide , we're gonna just discuss very briefly the differences between conventional medical care and lifestyle medicine . Um And a lot of that has to do with treating , as mentioned previously , uh the root cause , as opposed to just symptom management , we make patients active partners , not just passive consumers of health care . Um Patients have to become activated , you have to find that light switch moment that's really gonna flip on the activator for your patient and that's gonna be different for everyone . Um The , the end goal of lifestyle medicine treatment is the long game , not the short game or the , the short quick wins that um a lot of Americans are quite habituated to . Uh we also share responsibility in the , in the space of uh what the patient is capable of doing , how the providers are capable of nudging and holding the patient accountable as well . Um There is also always a space for figuring out where and when medication is used . Also , there's room for discussion for what medication deescalation should look like , uh which warrants its own separate lecture here . Um We find ways to truly dial in motivational interviewing component pieces of it . And once again , you find that niche and why of what's gonna launch your patient into ? Um AAA True lifestyle pivot for themselves . Um And we also look at how we involve a , a health care uh multifaceted team , uh which is exactly what cabin diet is going to discuss today . Um So next slide , we , we really just want to footstep here just the foundations before we launch into how to integrate um a team based approach to lifestyle medicine . And knowing that uh prevention of disease is truly the best intervention , but it's never too late to start a patient on a lifestyle medicine journey . And lifestyle medicine has been shown to treat prevent and even reverse chronic disease and age at any age . Um So , uh we're going to actually shift into our very first polling question just to sort of stoke the , the intellectual fires here . Uh And you can see the poll instructions , you can join by web or by text here . Uh You can text co ce po to 22333 and the questions here and we're going to see them coming in live are what methods do you use in your practice to educate and guide your patients in achieving their health goals and select all that apply . A is patient handouts , models , charts , B books , audio books , cookbooks , C podcasts , mobile apps , websites , D social media , youtube , videos , documentaries , e demonstrations , like cooking exercise , et cetera . F um Other , please write in the chat and we can see . Thank you for everybody tossing your responses in a lot of , a lot of votes coming in for a patient handouts , um which is great too because streamlining a consistent message across the team is vital for patient buy in as well . Um Appreciate the input here and we're seeing the pro uh highest proportion coming in at patient handouts . About 35% followed quickly by podcasts and social media , youtube , documentaries , demonstrations , et cetera . So um really appreciate everybody who has um added your input for the pole . And at this juncture , I am going to hand the mic over to Captain Dion for us to launch into team based care through the lens of lifestyle medicine . So Captain Die . Take it away . All right . So , uh thank you doctor for that wonderful presentation and summary of lifestyle medicine . So now we're gonna talk about uh team based care . So , uh this is essentially a common formality within our daily clinical practice lives that we have some understanding of . However , the focus today will be on team based care within the lifestyle medicine model uh slide , please . All right . So uh lifestyle medicine is a team sport , right ? So this is a key , key concept uh employ a strong team approach for improved outcomes . It can further be defined as health care practices that systematically identify and effectively utilize local national or global resources for healthy lifestyle support . Uh And keep in mind that methods of connecting to these resources may be modern or traditional and we'll we'll discuss more on that later slide , please . So this is kind of the quarterback wide receiver safety linemen , uh et cetera analogy , right ? So , so improved outcomes with a team approach . Yes , we do get better outcomes with a team approach . Uh in lifestyle , interdisciplinary team , each team member should be advocating for lifestyle modification for chronic disease and we should be supporting high levels of self efficacy and self management . Uh And , and each team should be associated with a high level of compliance and improved health outcomes . Slide , please . So who else is part of your team who is or is not part of your team , either in your current office or functionally in the total care of your patients ? I'm gonna suggest that anybody who comes into contact with a patient is part of the health care team . So for example , the receptionist does the patient feel cared about ? Um you know , always factor staff into the clinical context , regardless of direct or indirect patient care uh office staff , primary care providers , uh lifestyle medicine , specialist , family , friends , physical therapy , dietician nutritionist , behavioral medicine , lots of support . Uh under each specialty slide , please . So if we focus on a medical practice in terms of a specialty practice or in primary care , again , keeping the patient in the middle , figure out how it is best done to connect all these different resources to implement lifestyle care . Uh slide , please . So this is an example of uh the health wellness coaching uh through military . One source . So how can a coach help me ? So the health and wellness coaching through military . One source is available to the service members and their families , including teens , uh survivors are also eligible . Uh And what does a coach do ? Uh health and wellness coaches can also connect you with other helpful resources through military . One source , like interactive resilience tools , uh relationship support , uh education , career counseling and more next slide . So other measures of improved outcomes with the team approach , some models have used um lay health educators uh and these lay health educators would effectively recruit participants uh and help implement lifestyle interventions in rural senior centers , uh lifestyle modification in primary care , acceptance and referral to the program would be essentially dependent on the level of facilitation provided by program coordinators . Um and and nurse uh practice nurse . Uh involvement was important to sustain , sustain lifestyle uh implementation . Uh but lack of referral services threaten the maintenance of the lifestyle changes , particularly relative to vascular disease . So there's many different approaches to doing this next slide . OK . So a specific example of improved outcomes with the team approach , let's take a common thing of weight loss . Uh So Cochran database , 1.2 kg uh loss in weight if the general practitioner is doing this on their own , uh dietician on their own much better 5.6 kg . But the best was combined , right ? 6.0 kg . Again , the team approach provides better outcomes . Uh next slide and I'll turn it over to doctor Simon to uh present this polling question . All right . So the polling question number two that you're gonna see in front of you . What other health professionals do you collaborate with or refer patients to in your practice ? A health and wellness coach , B , life coach slash executive coach , C , fitness trainer , D behavioral health professional , E registered dietician slash nutritionist f community health programs , diabetes prevention program , young men's Christian Association , Y MC A or G military specific prevention programs . So , uh for those who have access uh online on the poll or the texts , please go ahead and toss those numbers in . We're getting some all of the above in the chat DD echo . So we've got behavioral health professionals . That's great . Registered dieticians , nutritionists . That's fantastic . Uh military specific prevention programs . Um And from the poll itself , we're looking at behavioral health professionals uh leading the charge here right next to registered dieticians and nutritionists as the top um responses . So , thanks so much . Back to you . All right , thanks so much . So , uh so , so let's start a big picture kind of top level and then we'll , we'll come down . So World Health Organization , innovative care for chronic conditions , they list eight essential elements for taking action . Uh So number one support a paradigm shift . So I'm glad they put this as number one , right ? It's , it's so so true . You know , we need fundamental major paradigm shift . Number two , manage the political environment . Uh You know , a lot of times we often don't think about that . Number three , build integrated health care . Number four , align sectoral policies for health uh five use health care personnel more effectively . Uh And so we have a lot of room to significantly improve that . And that's part of how we're likely going to have or need fewer providers if we leverage them effectively . Number six , center care on the patient and the family , seven support patients and their com uh in their communities , uh their , their context and uh their environment uh and boom emphasize prevention , right ? That's huge . Uh And it needs to start early next slide . So here's a model . Uh This is called the collaborative care model uh or collaborative care manager model . Excuse me . Uh This was actually one implemented in an academic setting as you can partly tell the bottom left uh placing a resident in the picture but patients are in the center . So they set goals develop skills assume self-care . Uh The rest of this is intended to facilitate the patient in their self care processes with a lot of structured uh intentional support . Next . So here's another model . So the chronic care model by Wagner uh and , and so , functionally at the heart of this model is productive interactions and , and basically , that's to create informed active patients working together in combination with a prepared and proactive health care team . Uh that is basically supported in the context of community and health system structures that would support this for improved outcomes . So , again , specifically , relative to diseases . Next slide , I want to pull one specific instance here . So the the collaborative care models have a lot of room for and typically integrate behavioral health . So as we move towards more value based care with accountable uh care organizations , primary care , medical homes and similar , there's a lot of opportunity for financially incentivizing better quality , better coordinated care , especially with primary care . Uh and , and integration with behavioral health is is especially key . Again , we're fundamentally in the lifestyle medicine talking about behavior change . So the more we can do was often called a warm handoff . So if I was an MD seeing a patient and I'm busy with primary care , but identified the patient is interested and willing to make changes , I can hand them off maybe a personal introduction if you will to someone and then you know who can spend more time with them . Uh and get into the details of that change process . Uh And so that provides the support systems necessary to achieve successful behavior change with things like lifestyle prescriptions . Um We do not necessarily formally have to use those , but you certainly could next slide . All right . So team roles . So this is an example of the program and who's involved in that . So keep in mind the staff that may be necessary and very important to make things work may not be clinical staff members . Sometimes we clinicians see the world from our own eyes , but we need to increasingly see the whole team in that process . Next slide . All right . So let's walk through this in a little bit more detail just to get a better sense of what these different staff members are doing in a lifestyle medicine program . So someone like a nurse , they do educational presentations with staff or other team members . They do biometric assessments . Uh They're involved in uh continuity of care and follow up of chronic conditions . Uh Exercise , physiologists are similar . Uh They do physical activity readiness questionnaires , individual and group exercise supervision . They may participate in biometric assessments . Uh They're engaged with fitness safety and principles of presentations , depending on their skill set and interest and so forth . So , uh a lot of this has overlap and , and that's important to keep in mind um health coach . So what's gonna happen with the patient ? Right ? Who's gonna hold their hand , who's gonna talk to them and so on . Um Health coaches offer that kind of consistent support through the change process and there's a level of uh built in accountability uh for that slide , please . All right . So stress management , uh specialists again , stress clinically is a huge issue . Uh They can do uh introductions to various mind body techniques . They can facilitate groups , provide support and participate with individual and group fitness instruction . Again , multi component shared activities , uh a dietician . So one on one , nutritional counseling guidelines , recipes , uh resources uh support , right ? Food should be enjoyable . Um A chef or food services which can provide kind of that great mouthwatering experience to facilitate proper food selection and presentation . Next slide , a group , group support specialist . So again , this may be a behaviorist or as another group type visit of context , they're uh they are actively facilitating the dynamics of community and social connectedness to group growth uh and a focus of uh on the lifestyle impact of intervention . That's , that's huge , hugely important . Uh administrative assistant , people who make the wheels turn . So the paperwork , scheduling rooms , uh phone calls , referrals , educational materials , uh et cetera , whatever it is , uh marketing directors . So these lifestyle medicine programs or programs are beasts . So they need to be managed as such . And that often means business issues such as marketing and communication with the health care team and community as a whole . Next slide . All right . So the program director So in the military setting , this could be like the medical director or the MS C or G PM . Uh This is essentially the master organizer , the people responsible for making everything work for coordinating everything , keeping staff synchronized . Uh They manage the plan , the team and monitor metrics and they make everything , make sure everything is working well , divide and conquer . So now most of us will not have the , have the luxury of having these roles be a separate full-time person . And that's ok . Uh You know , we just , you know , adjust this list to understand uh you know , the many different functions , figure out who on your team , these roles or functions should be assigned to and make sure you're not missing any important pieces . Next slide . All right . So uh team building checklist , so you're going uh to build your lifestyle medicine , health care team . What is your checklist and what do you need to make this work ? Uh Well , you're gonna need the right kind of providers for this situation and your program . So , is it a , you know , a dietician , a behaviorist , et cetera , uh provider , passion and orientation . So , are you on the same page ? Are the people passionate uh programs that are successful are often the ones that engage people that are generally passionate about these kinds of issues ? Uh You may have hi a issues . Uh So pay attention to this one . Cross your T and dot your I's coverage and affordability issues . So luckily in the military health system , this is typically not a problem but issues could arise . So is the patient willing to pay out of pocket if not covered by insurance ? Uh things to think about sustainability issues ? So , right . Yeah , I mean , if your program is not sustainable , then you have no program . Um Are we sharing enough common language and and systems ? So many of us are trained in different paradigms and kind of are in our own silo world . Sometimes we struggle to have a common shared language and systems . Next slide we need in the modern era to consider the internet our community . Um Right , so everything is global now . Um We all know this everything . Um And , and it's even kind of becoming more local . So even uh local is increasingly connected via the web . Um and we've shifted from newspapers and magazines that are local to even doing that uh on the web . Next slide . All right . So we're rapidly moving toward this kind of internet enabled smartphone , universal connectivity . So this changes a lot of things many companies offer lifestyle change support with their own systems , their own digital technology and for different conditions like brain issues , heart issues , et cetera , stress cognitive improvement . Um There's all these different apps and things that we can connect to . So digital technology offers us resources and different ways to support many different functions . So patients can be connected to specialists . Uh There are telemedicine resource , lifestyle centers of excellence to connect to . There are lifestyle aspects like nutrition or coaching or exercise support . Um So all these forces and factors through which digi digital connection is a is a really key , key dynamic . Next slide . So we want to systematically identify these resources on a national or global level . So here's an example table of how we can break things down . So in lifestyle medicine , things can be categorized either by condition , like what's the diagnosis or by modality ? What is the lifestyle medicine modality ? Uh There's organization type . So example , being government , which in this case uses the modality of exercise . So this includes , you know , health dot gov for , for example , physical activity guidelines , uh professional organizations such as the American College of Cardiology for Hypertension Guidelines or the American College of Sports Medicine for Exercise or other guidelines . Uh There's also nonprofits out there . So a good example of that is the VA S free Cognitive behavioral Therapy for Insomnia app . Uh And of course , there's commercial entities which can be a bit more problematic due to really the validity of the information just because there's so many apps and various websites available . Uh Then there are consumer driven types such as patient networks , like online , social media and blogs , et cetera . Next slide . So here are some community resource tools . So most of us are most uh mostly aware um of this . Uh And these are great . Uh for accessing guidelines , recipes , phone apps . Um and it has sections for patients to understand uh or areas more specific to uh the provider . Uh regarding guidelines slide , please . Um very similar again . Um You know , here are some additional community resources uh on the national level . Um So yeah , you can kind of read through those obviously CDC uh pretty common , some of these other ones . Uh we may not be so familiar with slide , please . So how are we gonna go about finding local resources ? So , don't forget uh about your patients , right ? So patients are amazingly connected and have different degrees of experience finding learning , uh figuring things out for themselves . Uh you know , things in gyms , farmers markets , uh et cetera and of course , you know , online tools I please . Uh so just some examples uh I'm familiar with or are already engaged with . So some specialists may run local independent practice associations , healthy living program for like tobacco , for diabetes , for prenatal care , uh and so forth . They're kind of a connector or hub . Uh There are connectors for healthy living scattered around your area . So how do you connect with them and leverage networking ? What is your local hospital interested in ? What about local grocers or natural foods department in a local or national grocery store ? Uh What about your local public health department ? What do they have going for this Department of Health Care ? Uh Consider schools , right ? Obesity is a hot topic ? School lunches are a hot topic . Uh city or uh sorry , city planners . Uh How do we plan for uh safe walking , uh biking paths , community gathering areas , et cetera . And can you engage with um ac OS to gauge interest in lifestyle medicine ? Uh You know , we don't want to forget our employers who are often the really true payers for um much of health care slide , please . So , translating this to our military community . So team based resources may be available at your local military installation . So for example , joint base , San Antonio and Fort Sam Houston have been partnering with the San Antonio Food Bank to deliver food on the installation once per month for food insecure active duty members and their families . Uh A recent poll was taken by uh market primary care Po CS who were involved with hosting screening campaigns for patients uh that had like breast cancer or colon cancer , for example . Uh But none said that they were using that time to also educate patients about what they could do personally to minimize their risk of cancer like through , you know , nutrition , tobacco cessation , et cetera . So I think there's um a missed opportunity and perhaps something that uh DH a uh primary care um can uh can help with and help develop uh a handout that could uh or would include these things and could be given out at community awareness fairs um or notifying patients when they're due for screening uh cooking classes . So ideally making cooking classes virtual to accommodate more participants , which is ideal . However , there are um in person cooking class opportunities uh currently under way . So for example , Wolford Hall Nutritional Medicine Department in San Antonio , they're trying to do this virtually uh to offer convenience of attending virtually , please . So these are just some examples kind of uh provided through the military or the Air Force medical service . Um These are free to check out here's a link , so feel free to jot that down slide , please . Uh So examples of specific local resources . So a map of the local area where people can walk or eat uh nutrition centers , uh healthy dining , there's walk with the dock programs , farmers markets , community five K runs . Uh Sometimes um uh sometimes the five K runs are non-specific to a medical condition like breast cancer . Just don't encourage them to have red meat barbecues when they're raising money for breast cancer . For example , it's really counterproductive . Uh Anyway , moving on uh cooking classes , stress management , mindfulness programs and of course fitness centers or community centers . Next slide . So what might this look like in your community ? There's a few hospitals in this country that set up dedicated full department , lifestyle medicine practices . Uh But this is pretty rare . So lifestyle medicine and primary care uh I is premium . Uh There , there's really no substitute for having your core fundamental um uh health care at home . There's , there's also places where you can function as a lifestyle medicine specialist and to function as a specialist in your community . Kind of being that connecting point if you will I utilize these specialists in the hub of expertise in your local area . Slide , please . So as a lifestyle medicine professional in your community , as a resource in your community , you know , look beyond health care community as a subsection of your overall community . So how can you engage with your community as a whole ? Is it the walk with the doc program ? Is it advocating for patients in some way ? Uh Is it helping to develop resources for people or groups of people ? Uh connecting technologies are functioning at the community level as well ? Slide please . All right . So a little bit of a transition here . So we're going to talk about group visits . So uh these group visits , they can be a great way to deliver team based care . It can meet all the criteria for a regular office visit , but it's delivered in a group context one at a time . Uh In that process , everyone in the group is learning . People can share their story or people can offer support . You've basically changed the dynamic from one person in a cubicle or office for 5 to 10 minutes . And basically you tell them all the things that they should or should not do and they go back and it's basically them against the world . Uh So this creates a different context . It , it starts to create community , you know , it's not one person against the world . Everybody is dealing with the same things , finding solutions and overcoming challenges . Um So you can bring a pharmacist , a dietician or a coach . Classically , a behaviorist would run the group , but it's not necessarily required uh group visits , restores more human relationships and connections because we human beings have always functioned in community or in tribes . And it's actually an aberration that we do this kind of five minutes in the office , right ? It's not normal in the context of uh human history or function . Next slide . So , group visits or shared medical appointments , uh it's proven effective method for enhancing a patient's self-care for chronic conditions , uh increasing patient satisfaction and access to care and improving outcomes and patients can leverage uh each other for support as well . And the benefits are associated with the team based health care delivered uh in a group setting . Next slide . So the published literature shows uh myriad benefits to patients associated with the group visit model . So including more time uh for the patient to spend with their provider , uh patients sharing uh self management tips uh among others , um or sorry among each other . Uh using kind of nonpharmacologic treatment , uh improved quality of care , decreased emergency room visits and improved self management of chronic disease . Next slide . Uh So for uh health , for , for the health care provider , uh some of the benefits are you get to spend more time with your patients . Uh The amount of time it takes to manage chronic disease . Using current guidelines is estimated to be much higher than the typical 17 to you know , 24 minute duration of the average primary care visit . Um Resource efficacy , uh decreased risk of physician burnout , uh and increased revenue are all demonstrated benefits to clinicians and group visits . Next slide . Uh So group visits are typically led by um like a physician , a physician assistant or a nurse practitioner . A second facilitator is needed when the provider is talking with or um examining patients . Uh The provider must spend private time with each patient in order to code for the type of provider for that group . So the provider completes like a focus uh focused physical exam reviews , labs , biometrics , uh goals and progress with the patient and they'll also order future labs and medications as needed . Uh A nurse can gather biometric data and draw labs if needed . Um An administrator uh helps arrange the session , takes notes checks patients in schedules future visits . Uh A group visit typically lasts between roughly about two hours . Uh So to foster patient participation and achieve financial viability or in the military's case , buy-in from the clinic or hospital leadership , at least 10 to 12 participants is recommended . Uh And so the American College of Lifestyle Medicine and the American Academy of Family Physicians have more information on group visits . So I would highly encourage you to explore these resources if this is something you would like to integrate into your practice . Next slide . Uh So the revisit should be documented um in each patient's health record , uh you should only diagnose in the chart , the condition for which the focus of the group is intended . So such as like , you know , diabetes or obesity , for example , uh standard em codes are used commonly and should be based on the complexity of the individual visit slightly . Uh So these are some of the codes that uh non primary care providers commonly use for group visits . Uh dieticians , nurses , diabetes , educators , and psychologists , they'll , they'll bill under their own uh NP I number , for example , uh next slide . So let's review a few well accepted practice pas to just kind of streamline the process for facilitating group visits . So , completing consent forms and chart review for each patient before the group visit will help facilitate each patient's care . It will also assist with documenting complexity levels . Uh Again , using standardized auto text for the group visit can expedite documentation . However , documentation uh of the content of the private discussion between the patient and the provider uh is important . So the documentation should really be detailed as such that anyone who reads , it should understand what the patient experienced during the group visit and details of their private session with the provider . Uh and finally structuring each group session around a theme such as aerobic and strengthening physical activity that can ensure a variety for patients and kind of build upon their goals that they set for themselves during individual sessions . Uh The provider would give like a 20 to kind of 30 minute lecture on a topic , then maybe show a video or have a second facilitator lead A Q and A session about the topic while the provider gets to kind of spend that one on one time with with each patient . Next slide . So what is the central goal of an effective health care team ? So it is to provide coordinated , effective and collaborative care centered on the patient . Uh So , in this case , specifically to treat the cause , so let's get to the root of the problem and treat their , help them have a truly satisfying long and quality life next life , right ? So this is kind of the uh lifestyle performance medicines take uh with the defense health agencies quadruple aim , which is centered on basically these four primary goals that you can see here . Um Lifestyle medicine foundations have been proven to really support three of the four of these outcomes including better health , better care at a lower cost . And as far as increased readiness , the cost benefit analysis within the military population um currently underway but shows significant promise for future lifestyle medicine efforts and cost effectiveness uh in military populations . All right , now , I will turn it back over to doctor Steven for the third polling question . Fantastic much diet . Just a really remarkable snapshot of um how to , how to streamline and really just efficiently make a shared medical appointment or group visits relevant for um wherever clinic you might be uh physically located . But as we shift into polling question , number three , that question is which of the following lifestyle pillars do you want to improve the most in your own life right now ? And I think this is a really relevant discussion piece . I'm gonna read the um questions . Uh Excuse me , the answer is really fast . Is it a nutrition um angle , physical activity , um C sleep D stress management , resiliency , e social connections or f avoiding risky substances such as tobacco or alcohol . Um And cam die obviously , why this is such an important uh polling question um for us to address is because we know that there's research out there that substantiates that the healthier a clinician is when they show up for patient intervention . Certainly . Um multiple patient interventions , simultaneously , shared medical appointments , um group visits . Exactly what we've just dialogued on for the last um three quarters of an hour . Um the more , the more value and the more um strength and impact and efficacy that we know that that clinician has on their patients . And this is truly us as , as physicians , us as medical professionals in any instance , putting our money where our mouth is . And I think that is such a vital capacity and understanding point that we , we need to collectively stand behind . Um because certainly we know that the the medical sector and the dod is not being spared at these chronic disease burdens as well . Medical providers are significantly impacted with the chronic degenerative diseases that we know we can collectively address . So , um thank you for everyone for putting your answers in the chat as well and it seems like physical activity is the the leading lifestyle pillar that we know that health care professionals or um people just in the health realm are most interested in addressing . Um now followed by sleep and then nutrition , then stress management and resiliency , and then social connections . So we also know how um significantly integrated all of these um health health pieces are to our general picture of health at large . Um So thank you all for voting and if you'll go to the next slide , um we're gonna dive a little bit more into um just before we're opening the floor to questions here in just a couple of minutes . Uh We want to make sure that everybody has the appropriate um means to access more or learn more . And as uh Captain Diet had mentioned a handful of times , um we've been collaborating significantly for well over the past half decade with the American College of Lifestyle Medicine that can be found at lifestyle medicine dot org . Um They have been incredibly uh valuable partners and assets . To us and helping to share and disseminate information for not only providers but for patients alike . Uh And we will certainly um help sort of set that foundation for you and share with you . Um , some of the stellar opportunities that we've been growing and um , if you'll scoot to the next slide , um it's really just how to , how to learn more and that's the most useful thing . So , next slide , please . Um I had the , the great opportunity to , to help launch the US Air Forces lifestyle and performance medicine working group . Um along with a handful of other um highly motivated individuals who are still keeping this effort strong and going and um what it , what it is , it's an , it's an officially endorsed working group that has a charter . Um It's found and it's housed within uh the champ website as one of our official collaborators . Um And , and we knew that in order to get buy in from a higher leadership level that we would need to um have goals and have objectives and have mission and have shared vision . Um And we have , we have um had remarkable return on investment and interest because lo and behold when you teach people how to reclaim that art of healing their patients , that is what um mitigates burnout . That's what reignites us as clinicians and health care professionals , regardless of what um profession you're in . Um And this is where we want to invite you all to join us as well . Um So , um here's a QR code on the screen and it's essentially um how to get involved or become part of our coalition of the interested , which has grown significantly and rapidly to over 350 joint service , health care professionals , um va professionals and professionals . And um we're really encouraging people just to , to help us show up and help us capture . Um essentially de silo is what this effort is actively doing and doing well . I might add . Um So we're , we're aware , we need to just capture what everyone is working on how they can contribute to substantiating and normalizing this effort . And , you know , in , in closing , what cap and die had mentioned was this idea of having a common language , having something that is scalable and having something that is standardized , which is why lifestyle medicine is such a critical piece for um for getting certified in having that education and training um foundation in so that , you know , that your quarterback is having the same discussion with your patient uh as the , as the defensive end , as the wide receiver and that we're all able to , you know , accomplish getting points on the board by throwing a well coordinated pass into our patient who is standing in the end zone . So um please do feel free to email us if you're interested in learning more about the um air forces , lifestyle and performance medicine , working group . Um You can email us , we have a dis list , it's lifestyle performance med at gmail dot com . Also on the screen is a um Google form um hyperlink and you'll have to do that on a personal device just due to some dod firewall uh limitations , but also the QR code to learn more and um check out our , check out our charter uh reach out to us . Um This is the beauty part of um building these unique uh grassroots efforts with colleagues who are just as motivated um to , to help see health reclaimed for our service members . So , um with that being said , um I'm going to turn the mic back over to Colonel Keel . Um who will um we're , we're gonna walk through the rest of our questions and resources . Uh And we can open the floor , I believe Colonel Keel . Are you there ? Thanks so much , Doctor Stegman and Captain DAO for that really relevant and quite valuable presentation . I wanna remind our audience that if you haven't um put any questions in the chat yet , we're happy to take those . Now , we have about eight minutes or so left until the end of this session . So please go ahead and we'll respond to as many questions as we can get to in the time . Um But let me just double check so very well done . Um And , and honestly , quite insightful information , there is a comment that I just wanna um or actually , I'll get back to that , but there's a question about how often do you have patients that reject this approach or are unable to catch the vision ? Sort of , more of a practical question ? I think . Um , I'll , I'll add my two cents first . Um , I , I think , um , that's part of the job of the team is to , like I mentioned , find that fire stoker and find that , um , you know , fodder for the fire , what's going to be that motivational piece that's going to ignite a switch ? Is it going to be , you know , living long enough to see your grandkids graduate from college or to , to see those big life events , you know , it's the quality of life that captain die was mentioning as well . A lot of people overlook that and we've sort of accepted this status quo plateau of just hitting X age and expecting life to decrease in quality from there . And that's just , that's , that's wrong , first of all . And we need to start engaging our patients in a narrative that shows to them and prove to them that they can actively change that slope of that status quo diet . Do you have any thoughts on that ? I , I mean , yeah , I just wanted to add that , I mean , essentially we're , you know , we're , we're certified salesmen , right ? So , you know , we have a way of discussing the condition with a patient in order to really make them value their own care and kind of take that path forward . So getting them self motivated is a big one . But I , you know , typically , uh you know , I do have a lot of patients that are , are motivated and willing to make that change . Uh And some are not , um you know , and we work on that as , as lifestyle specialists . So , um but yeah , that's , that's pretty much kind of a sum up . So thank you . Great um discussion . There , there is a question that asks , how often do you have patients or ? Sorry ? Um How , how do we um engage and make sure that our mental health providers are included in this lifestyle performance medicine model ? Uh Yeah , absolutely . I'll , I'll take that one . So , so really just knowing who's on your team , um you know , if you're new to a base , uh you know , I , I typically wanna show up in person at that specialty and , you know , get their contact information and , and really just kind of link and , and make that network connection with other specialists . Uh I , I mean , it's , it's tremendously important and uh you know , to some extent , we , we really need to do that because a lot of lifestyle medicine and the care that we provide is based with the team approach . Um And so , so , you know , a lot of times , uh I try to use that as a requirement for most of my patients because a lot of this is behavior change , you know , lifestyle change is , is really behavior change , right ? It starts , it starts up here with , you know , helping the patient be educated on what's going on and then further motivate , motivating them to get them to their goals . So that's kind of where I would . Yeah , leave that . I love that . Yeah . And I think um just from uh my professional experience de silo in our health care system can be so helpful in helping bring all of our health care staff members kind of together and moving towards this vision . Uh There is a just a comment , I'll say that maybe you can comment on . It's speaking to the slide that uh showed the traditional versus lifestyle medicine approaches comparison that says it appears to be stated in a frame of fact , which is all true . However , from a patient's perspective , um the slide appears to be slanted in the direction of viewing the traditional med as the ease of therapy direction , making that the easy optimal way . Clearly the impact of lifestyle medicine therapies far outweigh most all classic primary , secondary and tertiary medical therapies . So this comparing contrast list is truly a standalone slide at its core , just to comment . And I think that's , that's a good point to just always bring up is that there are , there are myriad different components that are limiting us as health care professionals in this largely disease management model . Uh the most essential of which in my opinion is time . Uh , the second most essential of which is standardized education , that point blank for the most part . Uh , I know I can speak for myself . Uh , going through medical school , I got next to no education on the impact of nutrition . Certainly not in the context of disease prevention treatment reversal . Um , cer certainly not discussing the idea of medication deescalating or de prescription either which I think is vital and we are having far too many uh discussions just about uh that , that's gonna be what's gonna be the rest of your life is a pharmaceutical prescription . And um that's , that's a detriment and a disservice to our patients that so I appreciate that . Um that comment there . Yeah , thanks for that . Uh One more question is asking about , are there certain medical conditions that would not improve when lifelong performance medicine approaches are implemented ? Yeah . So , so I mean , we do a great job in this country uh with like trauma acute care , things like that when it comes to disease management . Um you know , that's what we are , right ? But as lifestyle specialists , we're , we're more of that disease prevention and we also reverse , reverse and treat disease . Uh But I think the thing is is that , you know , a lot of times we , when we do our focused comprehensive lifestyle assessments with our patients , we also do need to , to include a little bit of Ala Paic Western medicine , right ? Because we can't just strip them off of all their medications and , you know , tell them to start exercising 300 minutes a week . Right . Like we need to take this step wise approach . So a lot of times we will do this in combination and that's really the safest way to go because we need to kind of tight them up accordingly and , and safely as well . Right . So , safety is a big part of this . Um , But yeah , absolutely . I mean , very good question . Perfect . Thank you . Uh There's a little bit of just discussion about some , well , people had put some comments in the chat about various um entities outside that can be used programs and things to help refer patients to like walk with the dog and um other various online sources as well . Um One person is asking uh is lifestyle performance medicine um in correlation with the va whole health program , which is another opportunity to engage patients about lifestyle . I could feel that one . we've been working on more of an inter-agency collaboration in this space because we know that obviously dod patients turn into va patients and the whole health model is um it's a step in the right direction when it comes to um leveraging a lot more of these lifestyle centric things , they integrate a lot more of um uh of uh C AM cam uh complementary alternative medicine modalities um and um things of that nature and we're trying to help make this make sense . We are getting some in some like plant forward , for example , menu , menu recipe items within the va nutrition um platform and um online portfolios . Uh But I think we do once again and we need to find that that common language and that standardization approach uh which is fully evidence based through the lens of lifestyle medicine that can complement more of an integrative medicine approach , which is where whole health um leans a little bit harder on . So I think we're , we're on the right path to working in a collaborative sense to make once again that interagency lift , make sense for the dud and the va great question . Thanks so much . All right . Well , we're at the end of our time , but I do want to say thank you to Captain Dia and Doctor Sigman for this wonderful presentation . In summary , just uh you know , we talked about how this medical specialty called lifestyle medicine can be uh utilized and executed in our health care system to help provide patients with more tools and resources and the support they need to move forward and uh making progress with their particular health goals to mitigate chronic disease . So I wanna thank you so much again .