Making lifestyle medicine part of your practice

Hosted by Alex McDonald, MD, and featuring guest Regina Ragasa, DO, DipABLM, our PermanenteDocs Chat delved into the world of lifestyle medicine and its challenge to traditional notions of treatment and prevention. The discussion emphasized the powerful impact of diet, sleep, exercise, and stress relief on health and well-being.

If you missed the event, the recording of this conversation is now available for you to watch and catch up on.

Guest:

Regina Ragasa, DO, DipABLM, family medicine physician, Southern California Permanente Medicine Group

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Hey, everybody! Welcome to this week’s PermanenteDocs Chat. My name’s Alex McDonald. Thank you from wherever you may be listening or watching or tuning in today. I’m very excited for this topic, a topic near and dear to my heart, which is lifestyle medicine. Today we are joined by physician co-chair, co-lead for lifestyle medicine, Dr. Regina Ragasa. Thank you, Dr. Ragasa, for joining us today.

Regina Ragasa, DO, DipABLM: Thank you for having me on here. I’m super excited.

AM: Great! Well, we’re going to keep this short and high yield. Those of you who are watching or listening live, if you have questions, please drop them into the Q&A. We’ll get to as many as we can, although it’s only 20 minutes, so get those questions in early. We are going to jump right in here. Dr. Ragasa, tell us a little more about who you are and what you do.

RR: I’ve been practicing with Southern California Permanente Medical Group for about 7 years now and been doing family medicine since I graduated from residency. About 4 years ago, I got really interested in lifestyle medicine. I was introduced to it through a colleague, through another talk, and I was like, wait, you can use food to reverse disease? I can’t believe that! And then it was just a really crazy rabbit hole, I just went chasing after it. So, I got certified 4 years ago, and I’ve been practicing ever since. It’s really revived my interest in medicine again, and I absolutely love it.

AM: Wonderful! I love that comment about reviving your interest. It’s almost like a burnout prevention, but we’ll get into that later. Let’s first take a step back. We’ve been all hearing this term lifestyle medicine. So, what is lifestyle medicine, and how exactly does it differ, or complement, traditional Western medical approaches?

Overview of lifestyle medicine

RR: That’s a great question. Lifestyle medicine uses evidence-based literature to offer guidance on lifestyle habits that can be used to prevent, treat, and even reverse chronic diseases. I actually see lifestyle medicine as the core of conventional medicine, because oftentimes we tell our patients you should diet and exercise. But oftentimes we don’t give more guidance beyond those 3 words. So, lifestyle medicine helps to define what that optimal diet is, and that optimal exercise, that optimal sleep. There are actually 6 pillars that lifestyle medicine relies on; those are the first 3. The other ones are social connection, stress management, and avoidance of risky substance use.

AM: I always love telling my patients that diet, sleep, exercise, and stress relief — although I know it’s only 4 of the 6 pillars — those 4 things will do more for you than any medication I will ever prescribe in my lifetime. And anytime I meet a new patient I start with that that level-setting, just to have them understand who I am and the way that I practice medicine. I’m a family physician as well, I’m biased, I feel like lifestyle medicine is family medicine. But now there’s more structure, there’s more data, and there’s more research behind it, in terms of prevention. Again, as family doctors, that’s what we do every single day. Can you tell us more about some of the data and some of the research emerging behind lifestyle medicine? I know we could probably talk for 20 minutes about that alone, but just give us a sneak peek about those big pieces and how we’re trying to systematize lifestyle medicine to help empower physicians and patients.

Data and research supports the clinical benefits of lifestyle medicine

RR: Yeah, also a very great question. And yes, you are totally right. We could talk about this not only for just 20 minutes, for like, days. There’s just so much literature out there, and we’re finally putting it together and putting in some way for us physicians to be able to digest it. Because, unfortunately or fortunately, there’s so much for us to learn in medical school, and I think we took lifestyle practices for granted, and we just assumed well, obviously just healthy eating, whatever that means, right? But lifestyle medicine goes beyond that. And they actually define all those different things. You know, up to 85% of chronic conditions are actually influenced by poor lifestyle choice choices. By educating not only ourselves, because it starts with us, we can educate our patients on how to actually do preventive medicine, not just early detection of chronic disease.

So, there’s tons of research out there. The 3 that I really love to focus on are studies that focus on hyperlipidemia, hypertension, and diabetes. Those are the 3 big things that we see in clinic all the time. Some really landmark studies that help support the hyperlipidemia is the portfolio diet. I don’t know if you’re familiar with that, but basically they pitted a low-fat diet versus low-fat plus a statin versus a whole food, plant-based diet, which at the time they called a portfolio diet. When they did this diet, I think it was only for 4 to 8 weeks, they actually found that the people doing low-fat plus a statin had the same outcome as those who were on a whole food, plant-based diet alone, without statin. So, it’s really powerful to be able to choose the right foods for our body.

And again, this was something completely new to me, 4 years ago I had no idea that there was a right way to eat. And then there’s great, big people in the lifestyle world. You’ve probably heard of Dean Ornish, and maybe Caldwell Esselstyn. They have fantastic studies on reversal of coronary artery disease. Again, something that we don’t learn about more in medical school. We’re like, you have it and we’re just hoping you don’t get another one by taking all these medications. But you can actually reverse it and see the diameter of the blood vessel open up again when you actually consume a diet that’s really anti-inflammatory, high in fiber, and low in the saturated fats.

And then diabetes, my favorite. Mostly because my patient zero for diabetes — a personal case study, I guess — who was on metformin, maxed out on metformin, maxed out on sulphonylurea, and then was on 60 units of insulin daily, and her A1C was 8.5. And I asked, are you even taking your medicine? She said yes, and I said, well, you must be eating wrong. And she tells me she has oatmeal for breakfast, salad for lunch and dinner with a little piece of chicken or fish, and then, if she was hungry, she’ll have a piece of cheese or yogurt. To any normal person that sounds like an incredibly healthy meal, and I said, you’re not telling me about the cookies and all that stuff. She said, no, I take my health very seriously and I do not indulge in those things. I said, okay, fine, you probably don’t exercise. And then she says, I do cardio 45 minutes a day. So I put on the traditional medicine hat, and said well, if you’re doing all those things, I guess we add more insulin. And she said, no, you’re not going to do that to me.

Right around the same time I started learning about lifestyle. And I said, listen, I don’t know if this is going to work. But why don’t you replace your animal proteins with plant proteins and see what happens? Have beans or lentils, instead of your chicken or fish, and instead of your yogurt or piece of cheese for your snack, have a handful of nuts and a piece of fruit. She said, sure, I already have a strict diet, no problem. A week later she’s completely off her insulin and a month later she’s off all her oral diabetic medications and her A1C is controlled within 2 months. It was incredible.

AM: That’s amazing. I think a lot of it, too, is foods like yogurt, for example. A lot of people think yogurt is a healthy food, but a lot of these yogurts are in the refrigerator section and have tons of sugar added to them, or other artificial sweeteners. That’s just such a phenomenal case study about the power [of lifestyle medicine]. When I was learning about lifestyle medicine, we talked about the dose of lifestyle medicine. We tell people, you should go exercise. But we don’t ever say, here’s some metformin, you should take some metformin. We don’t prescribe medications like that. I think we need to think about how we can prescribe lifestyle in very specific doses to get a specific response. I think in your situation, she was applying lifestyle medicine but she wasn’t applying it in the right doses, so to speak. And then she did that with the right applications, and lo and behold! So, I think that’s a concept, a bit of a frame shift, that as physicians we should think about and not just say, oh, exercise. We should say, oh, what do you do for exercise? How many exercises? How frequently?

RR: I think you’re right about setting the expectations. We all learn about SMART goals, right? It’s really big within our health education series as well. When we teach our patients, at the end of each class we say, okay, what’s your next SMART goal? It has to be something that you can define and not just, I’m going to eat healthier, because that’s so broad. If your definition of I want to eat healthier is I’m going to have a cup of broccoli every day, that’s something you can measure out and track.

Ways to incorporate lifestyle medicine in clinical practice

AM: For me, one of the biggest barriers to lifestyle medicine is time, especially time with patients and time in clinic. Can you talk a little bit about that and some of those physician barriers to practicing and implementing lifestyle medicine?

RR: I 100% agree with you. Time is a huge barrier because often, even when we’re prescribing medications, you need to get that patient on your side. There’s a lot of motivational interviewing, understanding where they’re coming from, and getting their trust. For a while I kept running behind in my clinic, and I said, I’m going to cut out the lifestyle and just put it in their after-visit summary and then maybe they’ll read it. But I find that if I don’t at least mention it to them, even just a 2-second blurb: by the way, I recommend all my patients to adopt a whole food, plant-based diet, regardless of their chronic conditions, to prolong health span, that little blurb can make a big difference to someone.

And when they see it on their after-visit summary, they’re able to say, oh, yeah, she mentioned that whole food, plant-based thing, what is that about? And then I list a bunch of resources underneath it so they can read it on their own time. But, as you know, everyone’s got their own timeline. So not everyone’s going to be on board with that. I’ve definitely had some people say stop talking, I’m not going to listen to you right now. I’m okay on my keto, leave me alone. And I said, okay, and I just have to back off and say if your keto is not working for me, I’m happy to talk to you again about this later. It’s about feeling your patients out.

AM: That’s a good point. There’s actually a question here in the chat which is related: do you find that you have patient barriers to lifestyle medicine when they look at you like [you want them to] eat more like a hippie? Do you [hear] that stigma that this healthy plant-based diet is not mainstream or not something a lot of people would want to eat or be interested in?

Overcoming patient resistance to adopting healthy eating habits

RR: That is such a great question. I’ve been practicing this for 4 years, and one patient in particular, she’s Latina, she said, every time you mention plant-based to me, I just thought you wanted me to eat white-people food. And I said no, no! I think all of our cultures have some type of roots within a plant-based diet. You know, if you think about Latino culture, they tend to eat a lot of rice, beans, tortillas. Those are all plant-based. And it’s not until they got more Westernized, and meat became more prevalent, and it’s something that was expected.

But this goes back a little bit further, because we’re talking about social economics. Hundreds of years ago [meat] was expensive, only the rich could have those things. But now we indulge in those things like 3 times a day, which leads to a lot of our chronic conditions. But going back to that question, eating like a hippie, yeah, some people definitely send me those comments. But I try to remind them that I’m not trying to take away their culture at all. I want them to dig back to their roots, keep cooking the foods that they enjoy, but try to find replacements for those proteins. Switch out the animal proteins for plant proteins, and they’ll see a huge difference in their weight, if that’s their goal, it makes a difference in their A1C. It makes them a little curious, and I love sharing success stories with them because I think it motivates them.

AM: Stories are definitely very powerful motivators. And I use them myself in clinic. One thing that I tell people is this doesn’t have to be an all-or-nothing thing. You don’t have to completely eliminate all animal proteins from your diet, just cut down to a few times a week, or even just start with meatless Monday. And then you realize you can have a meal which is satisfying without animal protein. So, it doesn’t have to be an all-or-nothing type of thing, there are variations. And again, going back to that dose-response curve, if you have a more serious medical condition you’re trying to treat, you need a higher dose to treat it, whether it’s sleep or diet or exercise or stress relief. All of those are parts of lifestyle medicine. I want to stress it’s not just about the diet, although that’s obviously a big piece.

RR: I think it’s great that you talked about a dose dependence, because I think that’s huge. A lot of us who can get away with eating whatever we’re eating now, have gorgeous cholesterol levels, no problem with their A1C. And I’m like, you’re not the population I’m trying to fix. I’m trying to help those who have abnormal metabolic profiles and are trying to live their life with the least amount of medications possible. And you’re right, there’s that dose-response [relationship]. But there is a magic number I aim for [with] people who already have some issues with their metabolic profile. I’ll tell them to aim for about 90% plant-based and that allows them some wiggle room; they can eat out with their friends and family members once or twice a week without any guilt. And the rest of the time they’re just eating really well. This is how we ate hundreds of years ago anyway. Meat was seen as a celebratory-type food.

AM: I love that 90/10 rule. I told my patients that as well, people who are trying to get better sleep, lose weight, improve their A1C, a lot of times they feel like it’s all or nothing. And if they can’t do it 100% of the time and be perfect, they just throw their hands up in the air, feel defeated, and they give up. I really encourage them to try a little bit, and we’re all going to slip up, we’re not going to be perfect all of the time. But if we aim for 90% of the time, we know we’re going to set ourselves up for success. And [we should] have a little leniency with ourselves. People tend to be very hard on themselves when they’re trying to make these lifestyle changes, which are really challenging to flip a switch and make.

RR: Absolutely. I’m going to add one more thing to that. You said take baby steps, try that meatless Monday, try one meal that’s plant-based, and that one meal can actually make a huge difference. There’s a study that showed that for every 3% of a person’s calorie intake coming from plant protein versus an animal protein, they reduce their risk of premature death by 5%. So even those small little changes can make a huge difference in your life.

AM: Wow! That’s amazing. I’m going to use that one for my patients. As I mentioned, this takes time. We’ve already mentioned a couple of tips, a single comment about it, and then putting more information in the after-visit summary or through email. What other tools or tips do you recommend for physicians to integrate into their practice and encourage their patients that doesn’t take a lot of time?

RR: The other things I also do is, obviously we all draw labs on our patients. So anytime there’s that abnormal A1C, maybe they’re pre-diabetic. I’ll put it into their email, no discussion. And it’s really encouraging that even those patients who I haven’t talked to personally yet and trying to convince them to go plant-based, they read those emails, they read those letters and they trust you. I’ve seen people sign up for the class without even talking to me. For Permanente physicians, we have our Center for Healthy Living, and they offer plant-based classes virtually. A quick referral to them is really easy to get it started. And, again, slipping it into the after-visit summary or into their follow up with their labs.

AM: I know there are a lot of community-based resources which are trying to really engage patients in their diet, their exercise, their lifestyle pieces as well. So, for people who don’t have KP insurance, who don’t have access to Center for Healthy Living, there’s lots of community-based resources which are doing this work as well. Where can physicians find these resources, or where can they learn more about how to educate themselves regarding lifestyle medicine, and then also how to educate their patients regarding lifestyle medicine?

Lifestyle medicine resources for physicians and patients

RR: That’s a great question. There’s the American College of Lifestyle Medicine, a great place to start. This year they offered free CME — I meant to look this up before the interview to see if they were still offering it — but they want so many more physicians to be educated on this that I think that’s not something that they’re going to stop doing. They really want people to spread this information, because, as you know, unfortunately, our chronic disease burden is just getting worse and worse. And the answer isn’t medications, the answer is lifestyle. The more education we get as physicians, the more we can educate our patients and hopefully they start making those small little steps towards health.

And there’s tons of books out there. There’s this book written by Dr. Greger, Michael Greger. His book was the first book I read, and it was How Not to Die. It’s a little bit of a morbid title, I don’t totally love it. Sorry, Dr. Greger, I love you! But you know, it’s really great because he has individual chapters dedicated to lots of different conditions. And then he has a whole research team that summarizes everything that supports what type of diet would be most optimal for that and why. They’re really short snippets. I became obsessed with this book, I started photocopying and I’m like, here, read this chapter on diabetes and handing it out to my patients. But now we have our own resources, so I don’t have to do that.

What I also like to do is refer my patients based on what they’re focusing on, what their concerns are. For example, if I have a young, healthy patient with a high lipid profile, and they like to work out, I will refer them to the movie The Game Changers. And then there’s also really good book called The Plant-Based Athlete, which summarizes a bunch of athletes and talks about their gains while they were plant-based, and also offers recipes towards the end of the book. If people are having gut issues, another really great doctor and author Dr. Will Bulsiewicz, he wrote Fiber Fueled. Oh, and Mastering Diabetes, that’s another good one.

AM: There’s just so many resources out there, right? Just start somewhere. We’ve talked a lot about diet, cause that’s obviously one of your areas of expertise. One question in the chat here, is meditation or mindfulness part of lifestyle medicine? I would give it a resounding yes, but I’d love to hear your thoughts.

RR: As you know, there’s tons of research behind this. With mindfulness, it helps to reduce the cortisol levels in your body, and that falls into the stress management portion of lifestyle medicine. So yes, 100%. I’d like to dive more into that eventually, and maybe give a talk on that. but for now I just love, love, love, love nutrition, that’s why I focus on it so much. But all the pillars are individually important to your life, and I wouldn’t say one is more important than the other.

AM: Maybe we’ll have to do a whole episode just on stress relief and mindfulness and meditation, not only for our patients, but for our physicians as well. I do want to keep this high yield, I’m dying to ask you a million more questions. Real quickly, tell us how Kaiser Permanente is uniquely situated to embrace and build on lifestyle medicine? I feel in our DNA is prevention, based on the way we’re designed and the way we’re set up, and I think this is just such a perfect piece to capitalize on who we are as Permanente Medicine and as Kaiser Permanente. Can you share some of your thoughts about that?

RR: Yeah, for one, this podcast, right, this is a great way for us to connect as physicians to learn more, and really learn how to become our best selves, so that we can support our patient population even better. I think we offer lots of CME and lots of medical centers that are widely available. Thanks to the pandemic, we’ve seen all the amazing things we can do virtually with each other and we’re just a wealth of information. We have thousands of doctors working together, so I think that makes us incredibly special compared to other medical centers.

AM: Last question, I promise. Tell us what makes you most proud to be a Permanente physician.

RR: Again, that supportive educational environment. I think it’s always encouraged here, and I love that about Permanente [Medicine]. I love our coordinated care and that we share our patients together. Whoever comes in with their own expertise, we all work together to make sure that that patient gets what they need. A I love the population that we serve, I actually grew up in the San Fernando Valley, and I’m back here again. These are my people.

AM: That’s awesome, wonderful. Well, Dr. Ragasa, I think we only scratched the surface here. We’ll definitely have to have you back. Thank you so much for joining us, as well as for your expertise today.

RR: Thank you for having me.