Options for Fixing What Ails America

Sunday, July 28, 2024

In the first of this series of blogs, I diagnosed that what ails America stems from stress, primarily as pressure for time and money. To recap:

Americans have every day completely filled up with work and chores
Convenience foods have replaced home cooking in compensation
Home cooking has become a bit of a lost art as a result
Societal norms now prioritize expensive supervised youth activities over unstructured play and family time

Important but not mentioned in the first blog is that time pressures lead to inadequate sleep. The common thread is stress, primarily as pressure for time and money, with three or four generations (Gen X, Millennials, Gen Z and now Alphas) that have had this role modeling, each decade being a little more intense than the one before. While we’ll never fully know why Americans started gaining weight starting around 1980 [CDC], these factors are associated because they are all societal trends.

Very few patients have come to me thinking stress was their problem, it’s always heart disease or diabetes or a desire to lose weight or “I don’t know why I’m here, my doctor sent me to you”. But the vast majority of patients I’ve seen had a toxic brew of over-commitment in their daily calendars with resulting inadequate self- and/or family-time, reliance on convenience foods, lack of physical activity, limited stress coping skills and inadequate sleep.

With good health coaching, patients ultimately understand their lives and predicaments more objectively, and many come to recognize their diagnoses as symptoms and stress or at least time management as their root problem.

I had a beloved friend, now deceased, who had open heart surgery in his 40s (several years before we met). He had been a very successful, high-pressure tax attorney. After his surgery he went to cardiac rehabilitation, learned about “Type A personalities” and decided he needed to dial back his work life. Ever after, unless it was tax season, if the wind was blowing he would take the afternoon off to go sailing. He and his wife were fortunate that he could afford to be away from work, most Americans don’t have that kind of autonomy.

Anyone who finds themselves with a cardiometabolic diagnosis and in the clutches of doctors faces a similar work-life balance decision, of seeing one’s own self-truths and deciding on a preferred path of life. As my friend discovered, the options are limited.

Option A: Cling to one’s existing life path but spend more and more time going to doctor’s visits, having medical procedures and spending hundreds if not thousands of dollars a month on polypharmacy; or

Option B: Reallocate one's time and money (but not hundreds or thousands a month) on eating better (especially home cooking), engaging in recreational activities, i.e., play, to maintain physical fitness and robustness, getting enough sleep, avoiding toxic substances and finding peace of mind. Option B is the path to living longer with lower disease burden. [Blue Zones]

While there are many ways to go about doing Option B, the basic elements of a heart healthy diet, physical activity and tobacco cessation have been known for decades, delivered for most of that time through cardiac rehabilitation. One of the founders and namesake of the annual keynote address of the American College of Sports Medicine, Joseph B. Wolffe, was a cardiologist who spearheaded cardiac rehab at the Valley Forge National Heart Institute in Fairview Village, PA, in the early 1950s. [JTA]

Today, the elements of heart healthy living include whole food plant-forward diet, regular physical activity, stress coping skills, tobacco cessation, moderation in alcohol, social connections (sometimes through group exercise) and adequate sleep.[ACLM]

In essence, Americans need access to services akin to those in cardiac rehab, though most people don’t need a supervised exercise component. And, largely because overweight and obesity is much more prominent than decades ago when cardiac rehab services were codified by Medicare, Americans today need more emphasis on a diet for weight management and not just to be heart-healthy (they’re similar, but being heart-healthy doesn’t necessarily include weight reduction).

Most important, cardiac rehab programs have lots of regulations, whereas most Americans who need multifactorial risk reduction today will benefit from program flexibility. Still, cardiac rehabilitation programs and medical fitness facilities can provide a foundation in terms of both facilities infrastructure and human resources. [AACVPR]

Next time in this series of blogs, I’ll discuss options for how to structure multifactorial risk reduction (lifestyle medicine) programs, with an eye towards financial sustainability. Designing a lifestyle medicine program to be revenue positive is the most critically important element - even more than the clinical interventions. I’ve watched many cardiac rehab programs get closed down because they weren’t making money, and that trajectory didn’t help anyone.

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