Counseling Patients About Lifestyle Modification

US Pharm. 2008;33(1):38-45.

Obtaining the knowledge and skills required to perform disease-prevention patient interventions is becoming increasingly more important for pharmacists and other health care professionals. The overall health of almost all populations appears to be better if diseases are prevented rather than treated once they occur. Chronic diseases create a significant burden upon the U.S. health care system at a societal and personal level as well as from a financial standpoint. The Centers for Disease Control and Prevention (CDC) reports that 70% of the deaths of all Americans and 75% of the annual health care costs in the U.S. are related to chronic diseases.¹ These data indicate that a focus on the prevention of these chronic diseases may produce better overall outcomes for patients and be cost effective for the U.S. health care system.

Pharmacists have long been known to be highly accessible and trusted health care providers. They have frequent contact with patients who could potentially benefit from lifestyle-modification education. Pharmacists are, therefore, in an ideal position to offer patients information, guidance, and counseling regarding lifestyle changes that can help manage their medical conditions. Training student pharmacists to become proficient with the knowledge and skills to educate patients about lifestyle-modification strategies may decrease the burdens that chronic diseases impose on the U.S. health care system and is justifiable for several other reasons as well. The purpose of this article is to provide justification for why student and practicing pharmacists should be trained to educate and treat patients using lifestyle-modification strategies.

Educating Health Care Practitioners
Preventing and treating chronic diseases through lifestyle modifications is becoming an important aspect of patient-care regimens. As a result, educating and training health care practitioners with the proper skills needed to care for patients through the use of lifestyle modifications is now becoming an important issue in health professions education. In 2003, the Institute of Medicine (IOM) published a report outlining its recommendations for educating students in the health professions.² The recommendations describe the need for all programs that educate health care professionals to integrate five core competencies. One of the five core competencies includes delivering patient-centered care, described as a type of care that continuously advocates for disease prevention, wellness, and the promotion of healthy lifestyles. ²

Pharmacy-specific educational recommendations have also been proposed. In 2004, the American Association of Colleges of Pharmacy's (AACP) Center for the Advancement of Pharmaceutical Education (CAPE) released its Educational Outcomes.³ The major recommendations of the 2004 Educational Outcomes include an emphasis on pharmaceutical care, systems management, and public health.³ The public health component is intended to promote health improvement, wellness, and disease prevention.³

Also in 2004, the National Association of Boards of Pharmacy (NABP) released new blueprint standards for the North American Pharmacist Licensure Examination (NAPLEX).⁴ Competency 3.2.2 states: "Provide health care information regarding nutrition, lifestyle, and other non-drug measures that are effective in promoting health or preventing or minimizing the progression of a disease or medical condition." ⁴ Both the CAPE Educational Outcomes and the NAPLEX blueprint standards are important documents for pharmacy programs to consider when educating students.

Organizations outside of higher education have also stressed the importance of lifestyle modifications for improving overall health. Healthy People 2010 (sponsored by the U.S. Department of Health and Human Services) is a set of health objectives for the U.S. to achieve over the first decade of the century.⁵ The objectives focus on 28 major areas that were developed by leading federal agencies with the most relevant scientific expertise. Ten Leading Health Indicators (LHI) are identified in Healthy People 2010 that reflect the major health concerns in the U.S. at the beginning of the 21st century.⁵ The top three LHI include physical activity, overweight and obesity, and tobacco use, all of which are lifestyle behaviors.

In 2002, the Healthy People Curriculum Task Force was established by the Association of Prevention Teaching and Research (APTR) and the Association for Academic Health Centers (AHC) as a multidisciplinary group of seven health professions disciplines, including pharmacy.⁶ Its mission is to fulfill the Healthy People 2010 Objective 1.7, which states: "Increase the proportion of schools of medicine, schools of nursing and health professional training schools whose basic curriculum for health care providers includes the core competencies in health promotion and disease prevention."⁶ The curricular framework outlined by the task force includes the areas of evidence-based practice, clinical preventive services, health promotion, health systems and health policy, and community aspects of practice. It is recommended that each health profession (i.e., pharmacy) adapt the curricular framework to meet the needs of its discipline.⁶

Leading Versus Actual Causes of Death
Many times, health care professionals and the public tend to focus on the leading causes of death as a benchmark for the diseases that should receive more attention when treating patients and considering population health matters. Certainly, the U.S. health care system adequately directs resources and attention to these leading causes of death. However, consideration should also be given to addressing the actual reasons why individuals die from a certain disease or circumstance. For example, heart disease has been the leading cause of death for several decades. Among the most common reasons that Americans develop heart disease are related to conditions such as hypertension, dyslipidemia, and diabetes mellitus.^7,8 Taking this one step further, among the most common reasons that individuals develop these conditions are tobacco use, poor nutrition, physical inactivity, and obesity.^7,8 Therefore, greater resources and attention should be placed on controlling the risk factors that can ultimately prevent the final death outcomes, such as lifestyle-related behaviors.

In 2004, Mokdad et al from the CDC published a study listing not only the leading causes of death from 2000 but the actual causes as well.^7,8 The top three leading causes of death in 2000 were heart disease, cancer, and stroke. The top three reasons why individuals died from these diseases, however, were tobacco use, poor diet and physical inactivity, and alcohol consumption. Therefore, even though heart disease, cancer, and stroke are the most prevalent reasons for death in America, they result from lifestyle behaviors that can be modified in many individuals.^7,8 The leading causes of death and actual causes of death from the year 2000 are listed in TABLE 1.^7,9

Treatment Guidelines
Because lifestyle behaviors have been shown to be effective in preventing and treating several types of diseases that can ultimately lead to a high prevalence of morbidity and mortality, several widely accepted treatment guidelines for specific diseases include lifestyle-modification strategies. The lifestyle-modification strategies that are most commonly recommended within treatment guidelines include proper nutrition, physical activity, weight control, tobacco cessation, alcohol moderation, and health behaviorñchange strategies. Several diseases are listed in TABLE 2 in which the treatment guideline for that disease recommends lifestyle-modification strategies as part of its treatment and prevention regimen.

Pharmacy Practice Application
When looking at the drugs that are most commonly dispensed in a pharmacy setting, it is easy to see that many of these medications treat conditions in which lifestyle modifications are recommended for treatment and prevention. An analysis of the top 200 drugs by prescription count in 2005 shows that 31% (62/200) of these drugs are prescribed for the medical conditions of hyperlipidemia, hypertension, glycemic control, osteoporosis, or osteoarthritis.²⁹ As shown in TABLE 2, the treatment guidelines for each of these conditions recommend one or more lifestyle-modification strategies. Therefore, if pharmacists are truly practicing pharmaceutical care and medication therapy management (MTM), lifestyle-change behaviors should be incorporated in the patients care plan along with appropriate drug therapy and drug therapy counseling. The 10 most commonly dispensed drugs of 2005, with their primary indication, are listed in TABLE 3.²⁹

When looking at the U.S. adult population health-behavior data, it is also easy to see that a great need exists for pharmacists and other health care professionals to educate the general public about lifestyle behaviors. From 2003 to 2004, an estimated 66% of the U.S. adult population was considered overweight or obese and nearly 21% of adults were active cigarette smokers.^30,31 Additionally, in 2005, 52% of U.S. adults were physically inactive or engaged in insufficient amounts of physical activity.³² That same year, more than 76% of U.S. adults did not consume the recommended amounts of daily fruits and vegetables.³³ These data show that a large percentage of the general population could benefit from lifestyle-modification interventions that could be offered by pharmacists and other health care professionals.

Discussion
Incorporating lifestyle-modification patient care into the practice of pharmacy requires an increased educational focus in this area on the part of both practicing pharmacists and student pharmacists. Practicing pharmacists can obtain education and training through continuing education credits, and students can gain the knowledge and skills as part of their pharmacy curriculum. One of the current limitations for students to obtain this type of training may be the lack of opportunities that pharmacy schools currently offer their students or the fact that students may not be aware that pharmacists can be well suited to offer their patients this type of information.

In order to assess student pharmacists' beliefs, interests and perceptions about pharmacists offering lifestyle-modification services to patients, the Creighton University School of Pharmacy and Health Professions recently conducted a survey. As part of a special project, a third-year pharmacy student delivered a presentation to the student pharmacists at Creighton on the topic of lifestyle-modification education in pharmacy schools. Following the presentation, the students who attended were asked to complete a survey with the purpose of obtaining 1) student beliefs about counseling patients on lifestyle-modification topics in pharmacy practice; 2) student perceptions of pharmacists' qualifications to counsel patients on lifestyle-modification topics; and 3) student interest in learning more about lifestyle-modification topics. For the purposes of the survey, lifestyle-modification topics were defined as physical activity, nutrition, weight control, and smoking cessation.

A total of 38 students attended the presentation and all 38 completed the survey. Fifty-five percent of the students were in their third year of pharmacy school, while 16% and 29% were in their second and first years, respectively. Seventy-six percent of the survey participants were female.

The results of the survey showed that all students who attended (38/38) believe that lifestyle-modification counseling should be part of the overall care plan for patients and 89% (34/38) felt that it was part of the duties of a pharmacist to offer lifestyle-modification counseling to patients. Most of the students (54%, 20/37) felt that pharmacists are qualified or very qualified to counsel patients on lifestyle modifications. Additionally, 97% (37/38) would like to receive more training on smoking cessation and weight control, and 95% (36/38) would like to receive more training on implementing physical activity and nutrition strategies into a patient's care plan. Lastly, 100% (38/38) of the attendants would like a greater overall focus on lifestyle-modification training in the pharmacy curriculum at Creighton.

The major limitation to this survey was that participation was not mandatory for the entire student body. Therefore, it is likely that those students who attended the presentation were interested in the topic, making it difficult to generalize the results to all students. Nonetheless, all students who attended the presentation participated in the survey and overwhelming expressed a very high interest in incorporating lifestyle modification strategies into patient care. Such information is encouraging and should prompt pharmacy schools to considering offering courses that include this type of patient care, not only because many national organizations state that they should, but because there may also be high student interest as well.

Recently, the Creighton University School of Pharmacy and Health Professions began teaching an elective course designed to train student pharmacists about lifestyle-modification strategies in conjunction with medication therapy. The course objectives are to educate students about proper nutrition, physical activity, weight control, tobacco cessation, and health-behavior change strategies. Students spend approximately half of the course time applying these strategies to sample case patients with diseases such as hypertension, dyslipidemia, diabetes mellitus, obesity, and metabolic syndrome. The course topics and allotted number of student contact hours for the 15-week semester are listed in TABLE 4. Other diseases could also be incorporated into the course, such as coronary heart disease, stroke, peripheral arterial disease, heart failure, cancer, osteoporosis, and osteoarthritis. The course places a major emphasis on developing wellness prescriptions that are designed to work in conjunction with a patient's existing drug therapy regimen to either prevent disease or more effectively manage existing disease. Courses such as this could be incorporated at other schools and colleges of pharmacy to help meet recommendations for training students to promote health and prevent disease. Likewise, continuing education programs with this same design could be offered to practicing pharmacists to improve their skills in counseling patients about lifestyle modifications.

The American Pharmacists Association (APhA) Foundation has sponsored several projects to show that lifestyle-modification strategies can be incorporated into pharmacy practice settings.^34-40 These projects have focused on treating diseases such as hyperlipidemia, osteoporosis, diabetes mellitus, and asthma.^34-40 Results from these studies show that incorporating lifestyle-modification strategies into pharmacy practice settings can logistically be accomplished, improve patient outcomes, and are reimbursable and cost effective.^34-40 Training student and practicing pharmacists to acquire the skills necessary to perform this type of care should begin in the pharmacy schools and be given through continuing education sessions for practicing pharmacists. This would give pharmacists greater opportunities to practice clinical patient care and receive reimbursement for doing so.

Conclusions
Pharmacists are in an ideal position within the community to offer lifestyle-modification counseling to patients with the purpose of preventing and/or controlling disease, but they must receive adequate training in order to do so. The sections described in this article outline several reasons why pharmacy schools should incorporate lifestyle-modification strategies as a component of their curriculum and offer practicing pharmacists more opportunities to obtain knowledge and skills related to lifestyle-modification counseling. Many higher education organizations, both in and outside of pharmacy, recommend that student pharmacists receive training on these topics. Additionally, if pharmacy schools are training their students to practice high-quality pharmaceutical care and MTM, lifestyle-modification strategies should be part of the overall treatment plan according to many disease-treatment guidelines. Pharmacists are in regular contact with patients who could benefit from lifestyle-modification interventions simply by the prescriptions they dispense and by the proportion of the general public with whom they are in contact and who could benefit from these strategies. The aggregate of this information indicates that pharmacy schools should consider ways in which to incorporate lifestyle-modification strategies into their current curricula to decrease the burdens that chronic diseases impose on the U.S. health care system.

References
1. Department of Health and Human Services. Centers for Disease Control and Prevention. Chronic Disease Prevention. At a Glance 2007. Available at: www.cdc.gov/nccdphp/publications/AAG/steps.htm. Accessed May 9, 2007.
2. Greiner AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Executive Summary . Institute of Medicine of the National Academies. Washington, DC: The National Academies Press; 2003:3-4.
3. Educational Outcomes 2004. American Association of Colleges of Pharmacy. Center for the Advancement of Pharmaceutical Education. Available at: www.aacp.org/Docs/MainNavigation/Resources/ 6075_CAPE2004.pdf. Accessed May 9, 2007.
4. NAPLEX Blueprint. The NAPLEX Competency Statements. Available at: www.nabp.net/ftpfiles/NABP01/updatednaplexblueprint.pdf. Accessed

May 9, 2007.
5. Healthy People 2010, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. Available at: www.healthypeople.gov. Accessed May 9, 2007.
6. Healthy People Curriculum Task Force, Association of Prevention Teaching and Research. Available at: www.aptrweb.org/taskforce/ HPC_Taskforce.html. AccessedÜ May 9, 2007.
7. Mokdad AH, Marks JS, et al. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.
8. Mokdad AH. Correction: actual causes of death in the United States, 2000. JAMA. 2005;293:293-294.
9. Minino AM, Heron MP, Smith BL. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System. Nat Vit Stat Rep. 2006;54:30.
10. Chobanian AV, Bakris GL, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.
11. National Institutes of Health, National Heart, Lung, and Blood Institute. Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). NIH Publication No. 02-5215. September 2002.
12. HHS Publication number: HHS-ODPHP-2005-01-DGA-A, Dietary Guidelines for Americans 2005, United States Department of Health and Human Services, United States Department of Agriculture. Available at: http://healthierus.gov/dietaryguidelines. Accessed May 9, 2007.
13. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 5th ed. Home and Garden Bulletin No. 232. Washington, DC: U.S. Department of Agriculture, 2000.
14. Goldstein LB, Adams R, et al. AHA Scientific Statement. Primary prevention of ischemic stroke: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Circulation. 2001;103:163-182.
15. Gordon NF, Gulanick M, et al. AHA Scientific Statement. Physical activity and exercise recommendations for stroke survivors. Circulation. 2004;109:2031-2041.
16. Hirsch AT, Haskal ZJ, et al. ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease [Lower Extremity, Renal, Mesenteric, and Abdominal Aortic]). J Am Coll Cardiol. 2006;47:1239-1312.
17. Hunt SA, Abraham WT, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). American College of Cardiology Web site. Available at: www.acc.org/clinical/guidelines/failure//index.pdf. Accessed May 9, 2007.
18. American Diabetes Association. Position Statement. Standards of medical care in diabetes--2006. Diabetes Care. 2006;29(suppl 1):S4-S42.
19. American Diabetes Association. Position Statement. Nutrition principles and recommendations in diabetes. Diabetes Care. 2004;27(suppl 1):S36-S46.
20. Feld S. The American Association of Clinical Endocrinologists medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management--2002 update. Endocrine Practice. 2002;8(suppl 1):40-82.
21. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 1998. NIH Publication No. 98-4083.
22. The Practical Guide. Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2000. NIH Publication No. 00-4084.
23. ACSM position stand on the appropriate intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2001;33:2145-2156.
24. Grundy SM, Cleeman JI, et al. Diagnosis and management of the metabolic syndrome. An American Heart Association/National Heart, Lung, and Blood Institute scientific statement: executive summary. Circulation. 2005;112:1-6.
25. Khan R, Buse J, et al. The metabolic syndrome: time for a critical appraisal. Joint statement from the American Diabetes Association and the European Association for the Studies of Diabetes. Diabetes Care. 2005;28:2289-2304.
26. U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General; 2004.
27. Kohrt WM, Bloomfield SA, et al. American College of Sports Medicine: position stand: physical activity and bone health. Medicine and Science in Sports and Exercise. 2004;36:1985-1996.
28. Messier SP. Arthritic disease and conditions. Kaminsky LA, et al, eds. In: ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore, MD: Lippincott, Williams and Wilkins; 2006:500-513.
29. Pharmacy Times Top 200 Prescription Drugs of 2005. Available at: www.nationaltechexam.org/pdf/top_200_drug_list05.pdf. Accessed May 9, 2007.
30. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. Prevalence of overweight and obesity among adults: United States, 2003-2004. Available at: www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/ overwght_adult_03.htm. Accessed May 9, 2007.
31. Department of Health and Human Services. Centers for Disease Control and Prevention. Smoking and tobacco use. Available at: www.cdc.gov/tobacco/data_statistics/tables/adult/table_2.htm. Accessed

May 9, 2007.
32. Department of Health and Human Services. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System (BRFSS), 2005. U.S. physical activity statistics. Available at: http://www.cdc.gov/nccdphp/dnpa/physical/stats/index.htm. Accessed

May 9, 2007.
33. Department of Health and Human Services. Centers for Disease Control and Prevention. Fruit and vegetable consumption data statistics. Available at: http://apps.nccd.cdc.gov/5ADaySurveillance. Accessed May 9, 2007.
34. American Pharmacists Association Foundation. Available at: www.aphafoundation.org. Accessed May 9, 2007.
35. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in Project ImPACT: hyperlipidemia. J Am Pharm Assoc. 2000;40:157-165.
36. Goode JV, Swiger K, Bluml BM. Regional osteoporosis screening, referral, and monitoring program in community pharmacies: findings from Project ImPACT: osteoporosis. J Am Pharm Assoc. 2004;44:152-160.
37. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc . 2003;43:173-184.
38. Garrett DG, Martin LA. The Asheville Project: Participants' perceptions of factors contributing to the success of a patient self-management diabetes program. J Am Pharm Assoc. 2003;43:185-190.
39. Garrett DG, Bluml BM. Patient self-management program for diabetes: first-year clinical, humanistic, and economic outcomes. J Am Pharm Assoc. 2005;45:130-137.
40. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma . J Am Pharm Assoc. 2006;46:133-147.

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