Practice Spotlight: Mladen Golubic, MD, PhD
Cleveland Clinic's "Lifestyle 180" Lifestyle Medicine Program


Mladen Golubic, MD, PhD has had a very interesting journey in arriving at his present position as one of the physicians at the Cleveland Clinic's Lifestyle 180 program.

Dr Golubic obtained his MD degree from University of Zagreb in Croatia, and went on to get his PhD in Immunogenetics from the Max Planck Institute in Germany. In 1990 he traveled to the U.S. to get some exposure to the medical scientific community in America, but when war broke out in his home country he remained in the United States.

He continued his work in research with fatty acids and signal transduction at the Cleveland Clinic. He was especially interested in nutritional influences on cancer development, and focused on inflammatory pathways and RAS oncogenes.

When he first came to the United States in 1990 he met Caldwell Esselstyn, MD, one of ACLM's Advisory Board and a pioneer in the reversal of heart disease with a nutritional approach. He was very inspired by Dr. Esselstyn, but as time went on he realized that Dr. Esselstyn was essentially a lone voice advocating for a more rational approach to disease reversal.

After sixteen years of research, he decided that he wanted to become more involved in clinical medicine, and thus did a three year residency in Internal Medicine from 2006-2009. Upon completing this residency program he became the second full time MD in the Lifestyle 180 program.

The Program

The Lifestyle 180 program was initially set up as part of a new Center for Disease Reversal within the Wellness Institute chaired by Michael Roizen, MD, the first Chief Wellness Officer in the country. This Center has two branches, one of which is Dr. Esselstyn's program, the other is the Lifestyle 180 program.

Cleveland Clinic's Lifestyle 180 consists of a year-long program of 18 classes, each approximately 4 hours in length. Classes are held twice weekly for six weeks, and then they become progressively more spaced apart with a final interval of two months. Groups going through the program have been composed of 4-16 persons, although they have more recently been limiting this to 12 people to maximize the benefit the participants receive.

The classes are composed of the three primary elements of Lifestyle Medicine: exercise or physical activity, nutrition and cooking, and stress management. Each lasts approximately an hour per session. 

In the fitness class, exercise physiologists customize workouts to provide aerobic, as well as strength and functional training. Participants learn exercises that can easily be done at home with inexpensive equipment.

The nutrition portion involves a cooking demonstration and hands-on experience followed by a Registered Dietitian led presentation and discussion while participants eat together. In the second week of the program, they will make grocery store visits with the dietitian to learn label reading and grocery store navigation, learn mindful eating, portion control, and other valuable nutrition tools. The nutrition program is based on a Mediterranean diet.  It is plant based, but includes limited portions of chicken, turkey, fish, oil and nuts. They advocate five servings of vegetables and five servings of fruit per day.

In the stress management portion participants learn from behavioral health providers, practice stress management techniques, and a certified yoga instructor teaches simple postures and breathing exercises for relaxation.

Four separate questionnaires are used for tracking changes; these include standardized questionnaires on psycho-social support, stress, quality of life, and a depression scale.

The program does not assume medical care of the patient. The primary care provider (PCP) must sign a form authorizing patient participation and program staff coordinate care with the PCP. The patient's PCP then manages medications, though the program physician may make recommendations.

Starting in 2008 as a pilot program, it was composed of patients who had failed a standard chronic disease management program. Since then, the program has expanded the list of diseases treated to include obesity, hypertension, diabetes, metabolic syndrome, prostate cancer, breast cancer, fatty liver disease, IBS, and multiple sclerosis.

Participants are composed of two basic groups, including self-paid, and those sent by local companies who want their employees to benefit. They represent a wide cross-section of the population, including hospital CEOs, mechanics, police officers, finance executives and construction workers.

At this point in time they've gone through 14 cycles of the program, and have had approximately 500 participants.

Staffing has included two full time MDs and two full time nurse case-mangers, as well as behavioral health specialists, RDs, and yoga therapists. Many of these individuals are considered top quality providers in their respective areas of expertise.

Dr. Golubic functions as a full time staff physician and interim Medical Director for the program, and his duties include meeting with the various teams, giving lectures, looking at retention issues, keeping up to date on the literature, looking at class structure issues and maximizing benefit from the program, visiting company sites, and determining additional conditions for which they will admit participants into the program.  He notes that his own lifestyle is pretty nice for a physician - no beeper constantly going off, regular hours with no night work, and consistent evenings and weekends with his family.

Lifestyle 180 staff have currently submitted a paper for potential publication involving about 200 participants with over six month's worth of data. While they are not at liberty to discuss specifics prior to publication, in general they are seeing improvements in things such as weight, HDL, LDL, triglycerides, and inflammatory markers.

They wish to follow their initial paper with another paper addressing healthcare costs and demonstrating financial savings from participation in the program.

Administrative Issues

The Lifestyle 180 program has had the benefit of a strong advocate in Michael Roizen, MD who established the Center for Disease Reversal and facilitated the initiation of this program. Dr. Golubic states that it is very difficult to make a meaningful difference for patients in the typical short-patient-visit, medical model. There are also challenges with reimbursement for the program, as no insurers are providing coverage at this time. They are hopeful that once they are able to demonstrate the financial advantage that this will change. The program currently costs $3,000 for the one year.  This cost includes basic labs approximately four times per year - lipids, TSH, vitamin D and some inflammatory markers.

The program is integrated into the Electronic Health Record (EHR) system that the entire Cleveland Clinic system uses.  Providers throughout the system can make a referral directly through the EHR

Program cost is of course a challenge. A few progressive, self-insured, local companies saw the potential advantage and began covering the cost for their employees to participate.  These companies found that they recovered their financial investment within the first year with reductions in medication and other expenses.  Media coverage and "the word getting out" has led to other companies participating.

Dr. Golubic states that the single most important factor in the establishment and continued progress of the program has simply been that participants have achieved consistently good results.

When asked about acceptance within the Cleveland Clinic system, Dr. Golubic says that initially many physicians simply did not know the program existed while others were plainly skeptical.  But as time went on and physicians started seeing the benefits in their patients who had participated in the program, they increasingly became believers in this approach.  He also feels that they are recognizing that they are simply unable to provide these types of services to their patients in the short office visits that constitute typical medical care.

Marketing and promotion has included the production of a video on the program.  He has done lunch presentations to local providers to make them aware of the program and its potential benefits. Local and national media has helped as well, especially stories following individual patients going through the program and experiencing the benefits. Lifestyle 180 and its participants have been featured on the Dr. Oz Show, in Time Magazine, and in a CNBC documentary called "One Nation Overweight".

From Dr. Golubic's perspective the future looks very bright. He sees the Cleveland Clinic's Lifestyle 180 program on a good path to financially "break even." He recognizes the importance of demonstrating the financial benefit as key to Lifestyle Medicine's establishment in general, and is doing his part to contribute to that.

Dr. Golubic concluded our interview by expressing his own passion and appreciation for Lifestyle Medicine, for its development as a field, and for the progress that ACLM has made as a professional association.  Dr. Golubic has been an "early adopter," being an ACLM member since shortly after its creation.  He is excited to be part of this movement of getting more effective, higher quality care to the patients that we serve, and plans to continue to participate in the development of Lifestyle Medicine and ACLM going forward.  Thank-you Dr. Golubic for your passion and dedication to a better kind of healthcare!