Brad Biskup, PA-C, a lipid specialist and ACSM Certified Exercise Physiologist®, runs the Lifestyle Medicine Clinic at UConn Health in Farmington, Connecticut. He worked in osteoporosis and exercise research as well as cardiac rehab before becoming a physician assistant in cardiology. Brad is active nationally as Physician Assistant Working Group co-chair through the American College of Lifestyle Medicine.
BB: Working in cardiology, I noticed a huge hole in medicine: For nutrition issues, we’d send patients to a registered dietitian; exercise wasn’t usually discussed. That’s why in 2010 I decided to focus on this area. I started with a lifestyle medicine lecture series on topics like non-prescription ways to improve cholesterol; the clinic evolved from there.
The key is taking an individualized approach — understanding what patients like to eat and finding foods that are also good for them instead of saying you can only have this, you can only have that as well as being supportive and educating people.
At a 55-year-old patient’s first visit, he weighed 240 pounds and his HbA1c was 7.1; he didn’t want to take medication. With lifestyle changes, his HbA1c was down to 5.2 within 6 months. He’d lost 50 pounds and was able to go off 3 blood pressure medications; he couldn’t believe it. In another 3 months, his reading was still down, at 5.3.
BB: Yes; it’s amazing when you sit down and talk to someone and find out what their lifestyle is like… you have to deal with first things first. When someone has a huge amount of stress at work or at home, until you deal with that you can’t address diet or exercise. That’s why we take a holistic approach.
BB: In cardiology, certain patients didn’t want to take statins; physicians didn’t know what to do with them and sent them to me. When patients talk about how great they feel, getting off medications, and enjoying a better quality of life… that’s what you want as a provider; you want them to live life to the fullest. The patients and outcomes are what promote the program.
We set specific guidelines, like if your blood pressure goes below — or above — this number, call your primary care provider. The physicians aren’t threatened by me; it’s an area of medicine that’s not taught. Most of them say, “Please go see Brad; he’ll take care of you.” It’s a win-win.
The biggest deficit in medicine right now is exercise; most providers just aren’t prepared. I take a start low, go slow approach. I tell patients you don’t have to be short of breath, you don’t have to feel exhausted. When you finish, I want you to feel like you can go another 10 minutes; I want you to have that positive feeling. You’ll see huge benefits just by walking. We have to rethink how we promote exercise. We need to meet patients where they are and help them figure out how to be active; we’re missing a huge population because the majority won’t go to a gym.
BB: So far it’s been everything. Some patients self-refer after visiting our website. I get a lot from the hypertension clinic, cardiology, primary care, and outside of our network at UConn; the clinic is open to everyone.
BB: The initial consultation is a 1-hour visit; we go over medical history, risk factors, family history, social history, stress, exercise history; any injuries or limitations; we also get into peak weight. We discuss how your body changes as you gain and lose weight. One patient was 500 pounds; he’s down to 270, and that’s probably going to be his healthiest weight. We focus on how are you eating, what’s your stress level, how are you exercising. But we never focus on the weight; that’s just the outcome. We focus on behavior.
At the next visit, we go over glycemic load, the importance of exercise intensity, what we’re trying to accomplish with exercise, and other ways to be active. They get a to-do list and a 7-day food log; they come back in 2 weeks, then 1 month, and 2 months, as needed. We check in by email between clinic visits. I surround them with as many positive things as possible: food, activities, people. Negativity doesn’t achieve long-term success.
For a lot of the visits, we do walk-and-talks; I can assess patients as we’re walking. When the patient is very deconditioned and trying to keep up with me, I explain “This is too fast for you; I want you working below this level to bring your triglyceride level down and also assist with fat loss.” Patients are more comfortable when they’re walking with me; what better way to promote movement than a walking visit?
BB: They focus too much on weight; and we set them up to fail when that’s all we emphasize. I don’t use scales except to keep patients on track. When I think of my 55-year-old patient, my goal is to help him live to 100 — being independent and active, doing what he wants to do. I try to keep them focused on the things that will get them there. I’ve had patients say, “I feel great; I didn’t know I could feel this good.”
You also have to help them cultivate social support. I try to get patients to join fitness classes, like Silver Sneakers, and find others to exercise with. We live in a tough world; the more we can support each other, the better. It’s easy to pick things apart, focus on what you’re doing wrong. But if you can foster something like eating an apple every day, they say, “I can do that.” They make it a habit, start feeling better, and share that with their families and friends.
BB: Physical activity is one of the biggest things. We have to look for ways to move more, even in the workplace. It’s been known for decades that if employees are more active, they perform better and have fewer sick days. Encourage them to take 15 minute walk breaks, conduct walking meetings, use a standing desk.
BB: Most providers I know deliver lifestyle medicine through primary care. The specialty is so new; there’s nobody practicing lifestyle medicine exclusively. I definitely see it growing through primary care practitioners, and with the reimbursement changes toward prevention, it’s a perfect adjunct.
Integrated into the clinical setting, a provider could assess a patient, see their triglycerides are up, they’re not exercising, they’ve got a high level of stress — and deal with those issues, right there, in the same office visit. There could also be stand-alone clinics like ours; UConn is developing a program for lifestyle medicine in breast cancer. There are many possibilities… lifestyle medicine for colon cancer prevention, neurosurgery, and more.
BB: I enjoy walking and doing anything active. My wife asked why I don’t hire someone to take care of the leaves, but I enjoy doing it; it’s continuous muscle movement. One of the other clinics where I work takes a 10-12 minute walk; we also have a Wednesday walking group, which is great because it gets me up and out, too. We spend time in Florida each winter, and we’re even more active there… biking, beach time, going to the Y. It’s really about variety and working it into everyday life.