Lifestyle medicine

@#There is now an epidemiologic shift in the burden of illness from infectious diseases in the last century to lifestyle diseases in the current. Mortality due to lifestyle diseases like diabetes, hypertension and heart disease is now ranked higher than infections. The medical community is now realizing the importance of lifestyle intervention to address the problem. We hope that this issue of our journal focused on lifestyle medicine will help inform our colleagues in family and community practice the necessity and available strategy of lifestyle intervention. Lifestyle Medicine is the use of evidence-based lifestyle therapeutic approaches, including a whole food, plant-based eating pattern, regular physical activity, restorative sleep, stress management, the avoidance of risky substances, and positive social connection as a primary modality delivered by trained and certified clinicians, to prevent, treat, and often reverse chronic disease.1 It is distinct from other disciplines, such as functional, integrative, complementary, and alternative medicine. Lifestyle medicine focuses on conditions that consume 80% of healthcare visits, hospitalizations, and costs. Hence, it is recommended as the first line and the foundational intervention for non-communicable diseases that address the modifiable lifestyle and behavioral risk factors impacting the disease trajectory, quality of life, and overall health outcomes.2 Despite the advances and increasing availability of medical care, these chronic lifestyle-borne diseases continued to increase exponentially, causing 74% of all deaths globally.2 However, healthcare providers do not receive adequate education, foundational skills, and personal experiential references to efficiently prescribe the recommended lifestyle therapy in primary and specialty care. Thus, lifestyle medicine initiatives align with the quadruple healthcare aims to deliver better patient experience, better outcomes, lower costs, and better clinician satisfaction.3 Through the lifestyle medicine lens and the empowerment of patients, healthcare providers often bring whole health management and disease remission into the scope of care at a lower cost. Lifestyle is an individual’s choice. The study by Longakit reveals an individual choice of lifestyle practice for wellness elements like physical, social and emotional state. While the study of Alimorong is a an individual’s choice when he or she has health risk like hypertension. Physicians should be able to influence this patient’s choice and there are several strategies available. The case studies of Solijon, Acero and Tan are different strategic methods to promote lifestyle change. The interventions given are usually structured and conducted face-to-face. On the other hand, the studies of Cristobal and Ngo uses digital health interventions to promote lifestyle change. While the studies on lifestyle interventions presented in this issue are not robust evidence like randomized trials, these are experiences by local physicians with their patients. These experience may be a good enough basis to increase awareness and provide training for family and community physicians on lifestyle medicine, as advocated by the study of Palma.

Occupational health: COVID-19 pandemic and post-pandemic era

@#The COVID-19 pandemic has resulted into issues on occupational health, especially in health care services sector. Due to the nature of their work, this sector is at an increased risk of exposure to the virus. In this issue, we further discuss the importance of occupational health as our special theme. Occupational Health is an area of work in public health to promote the highest degree of physical, mental, and social well-being of workers in all occupations. Occupational health deals with all aspects of health and safety in the workplace and has a strong focus on primary prevention of hazards. The Philippine College of Occupational Medicine (PCOM), which is an affiliate specialty society of the PAFP, is responsible for promoting occupational health in the country. PCOM, formerly known as the Philippine Occupational and Industrial Medical Association (POIMA), was established in 1977 through the merger of three occupational health associations, namely the Industrial Medical Association of the Philippines (IMAP), the Philippine Association of Occupational Health (PAOH), and the Philippine Association of Compensation Medicine (PACOM). As a medical specialty society and a DOLE-accredited safety and health training organization, PCOM is a prime mover in the preservation, promotion, protection, and enhancement of health, safety and wellness of workers in all occupations through its active members nationwide and collaboration with various stakeholders both locally and internationally.

Introduction to evidence-based family practice

@#While the definition of EBM can be straightforward in other medical field, family and community medicine practitioners take on very different roles in different health systems. Despite the challenges presented, EBM is still necessary in family and community practice. Family and community medicine practitioners must be able to obtain, assess, apply and integrate new knowledge based on available evidence throughout their professional life. From the definition of EBM and the nature of family practice described previously, we propose to define “Evidence-based Family Practice as the conscientious and judicious use of the current, relevant, applicable and best available evidence in making shared clinical decisions for patient care. Such decisions must account for the capacity and setting of the family practitioner and patient preference”. The proposed steps are: 1) Framing the Clinical Problem, 2) Searching for the Evidence, 3) Critical Appraisal, 4) Informing the Patient About the Evidence, 5) Shared Decision Making, and 6) Evaluation of the Decision.

Diagnosis and management of Dyslipidemia in family practice

Background@#Atherosclerotic cardiovascular disease (ASCVD) is a top cause of mortality in the Philippines. A known modifiable risk factor for ASCVD is dyslipidemia. Thus, proper diagnosis and management of dyslipidemia in family practice clinic could significantly decrease the burden of cardiovascular disease in the country@*Objectives@#This clinical pathway was developed to guide family and community physicians on the diagnosis and management of dyslipidemia.@*Methods@#To develop evidence -based recommendations, the authors searched for the latest guidelines of reputable international and local societies. They also searched PubMed using the terms “dyslipidemia”, “diagnosis”, “therapeutics”, “family” and “community medicine”. The more rigorous meta-analysis of clinical trials and observational studies were prioritized over lowquality trials in the formulation of the recommendations.@*Recommendations@#Thorough ASCVD risk assessment for all adults should be done during initial visit in family practice. The physician should review patient’s present medication; probe regarding lifestyle habits; conduct complete physical examination; use family assessment tools; and assess risk for ASCVD using calculators or risk factor counting method. For patients ≥ 45 years old and all adult patients regardless of age at increase ASCVD risk the following should be requested: lipid profile, urinary albumin- creatinine ratio/ urinary dipstick test, alanine transaminase (ALT), 12-lead electrocardiography (12-L ECG) and fasting blood sugar (FBS). During subsequent visits, re-assessment of ASCVD risk; checking compliance to non-pharmacologic intervention; and review of medication adherence and adverse effects should be performed. Repeat measurement of lipid profile should be done 6-8 weeks after initiation of statin therapy; 8-12 weeks after dose adjustment; and biannually for patients with controlled lipid levels. For individuals on statin therapy who have already achieved their low-density lipoprotein cholesterol (LDL-C) goal, compute for non- high density lipoprotein cholesterol (non-HDL C). Repeat ALT 6-8 weeks after initiation of statin therapy for those at high risk of statin-induced liver injury. Request creatine kinase (CK) if with development of muscle symptoms while on statin therapy. For primary prevention, start low-moderate intensity statins for following: individuals with diabetes mellitus (DM) Type 2 without ASCVD; individuals with mild-moderate chronic kidney disease (CKD); and individuals without ASCVD aged ≥ 45 years old with LDL -C ≥ 130 mg/dl AND with ≥ 2 risk factors. Start high intensity statins for individuals diagnosed with Familial Hypercholesterolemia. Give high intensity statins as secondary prevention for individuals with established ASCVD. For individuals with ASCVD on maximally tolerated statin therapy not meeting target LDL-C, ezetimibe could be added to their regimen. Low saturated fat diet rich in fruits and vegetable; regular exercise; and smoking cessation should be advised for all adult patients. The physician should also engage other family members to adopt healthy lifestyle. Formation of a community-based lifestyle intervention program to reduce cardiovascular risk should also be supported by the family physician.@*Implementation@#Adherence to pathway recommendations that are graded as either A-I, A-II or B-I is strongly advised. However, the authors also recommend using sound clinical judgment and patient involvement in the decision making before applying the recommendations.