Practice Spotlight: Kerry Kuehl, MD, DrPH, MS

  

Healthcare has the potential to transform lives.  The work of Dr. Kerry Kuehl and his colleagues may very well transform healthcare.  In their leading-edge research, Dr. Kuehl and his team at Oregon Health & Science University are not only demonstrating the powerful impact of lifestyle on health, but are now revealing answers to some of the most challenging questions in healthcare: how to best motivate and bring about positive lifestyle change.  And their research demonstrates the substantial cost savings in doing so.

Associate Professor of Medicine and Co-Director of the Human Performance Laboratory at Oregon Health & Science University, Dr. Kuehl also maintains a clinical practice in primary care. Specializing in cardiovascular disease prevention and sports medicine, his scope of practice includes annual physicals, preventive services, women’s health, care of the elderly and care for conditions including hypertension, diabetes, osteoporosis, depression, obesity, and tobacco use. His emphasis within the Human Performance Lab involves exercise, nutrition, weight loss, and athletic performance.

Dr. Kuehl’s earliest research – conducted while working as an exercise physiologist at OHSU – reveals a passion for Lifestyle Medicine: comparing exercise to medication in the treatment of hypertension, and comparing nutrition to medication in the treatment of high cholesterol.  He went on to attend Loma Linda University School of Medicine, where he received an MD and a DrPH degree in nutritional epidemiology under the direction of Mervyn Hardinge, MD, DrPH, PhD investigating the effects of diet on bone density.

After returning to Oregon for residency training in Internal Medicine, he re-joined his mentors Linn Goldberg, MD and Diane Elliot, MD, in the Division of Health Promotion & Sports Medicine at OHSU.  Recipient of a prestigious career development award from the National Institutes of Health, Dr. Kuehl adapted the Division’s team-centered health promotion programs, developing the CHOICE Trial (Changing Health Outcomes in Clinical Environments) which examines behavior change strategies among overweight, sedentary primary care patients.

“We know what works…not smoking, exercising most days of the week, eating ten servings of fruits and vegetables each day, eating whole grains, maintaining optimal body weight, maintaining mental and emotional well-being.  The question is how to get people to develop these healthy behaviors.  My research now focuses on motivation.”  The CHOICE Trial assigned 120 patients to one of three lifestyle interventions: 1) physician advice, 2) health coaching, or 3) group-based approach; each meeting twelve times over the course of one year. 

Dr. Kuehl and his team found that among patients receiving on-going physician advice, 7% made significant lifestyle changes at a cost of $2400 per patient.  Among the patients assigned to health coaching, 14% made significant lifestyle changes at a cost of $1200 per patient – twice the effectiveness at half the cost.  But the most impressive changes were seen among patients assigned to the group approach: 37% made significant changes at a cost of just $100 per patient.

“We saw the most improvement for the lowest cost in the group intervention.  We call it a team-based approach to healthy living.”  Dr. Kuehl relates the success of the group to social theories which suggest that we are strongly influenced by what other people do.  The CHOICE group was self-facilitated; provided with guide books and resources such as pedometers.  “We gave them the tools, but the group was self-directed.  They motivated one another.  They became competitive, challenging one another.  They exchanged e-mails and became socially connected. The group exerted peer pressure and developed a new set of social norms, norming toward healthier behaviors.”

“We’re developing a cost-effective model, but based on what we’re learning, I realize that my intervention will likely not be as cost-effective as a group-based approach.”   Physicians in the CHOICE study were trained using the well-designed, scripted, and validated Patient-Centered Assessment and Counseling (PACE) intervention, developed by a team of health behaviorists at the San Diego Center for Health Interventions.  Even so, the study found only modest behavior change in the physician advice group.  “Looking at our data, physician counseling wasn’t especially effective - only 7% of patients made lifestyle changes.”

Despite the results, Dr. Kuehl acknowledges the critical role of the provider, pointing out that every patient in the CHOICE study initially met with and received an assessment and lifestyle recommendations from his or her physician.  “As providers, we need to track nutritional status, weight, cholesterol, blood pressure, smoking, and other parameters, and we must be willing to take a few minutes at each visit to acknowledge health behaviors.  This is the first step.  But because there’s very little reimbursement for counseling, we also need to have resources available for referral.”  His clinic now has a support group in place for lifestyle change.  “If I see a patient who is ready for change, I’ll invite them to join a group and make the referral.  If not, I let them know that when they are ready, I’m here for them.”

Dr. Kuehl asserts that the principles of Lifestyle Medicine are paramount with every patient.  

“I will always use Lifestyle Medicine first.  Sometimes medications are necessary, but I give patients the option of lifestyle-based treatment.  If I have a patient with arthritis, I’ll prescribe medications for pain control, to allow them to exercise so that they can build muscle and lose weight.  I’ll recommend foods that are anti-inflammatory.  If I have a person with diabetes, I’ll use medication to control blood sugars, allowing them to be more active, so that they can lose weight.  If I’m seeing a patient with hypertension, it’s the same philosophy.”  He compares it with golf, in that he uses almost the same stroke with each patient. “This is the way I practice medicine.  I may change the club depending on the condition, but the principles are the same.”

He goes on to say, “the beautiful thing about Lifestyle Medicine is that it both prevents and treats disease.  Lifestyle Medicine is going to be the most cost-effective approach to treatment.  In the OHSU school of medicine, we now teach nutrition as medical therapy, and exercise as medical therapy.  Lifestyle Medicine is the most cost-effective model and it will be the most effective treatment option long-term. 

Dr. Kuehl offers insight into practicing Lifestyle Medicine and motivating patients for change:

First, he emphasizes the importance of tracking important variables, using health parameters such as waist-to-hip ratio, weight, blood pressure, cholesterol, bone density, glucose and other measures.  “One way to motivate is to show results, to allow patients to see progress. The best motivator for weight loss is when someone loses even just two or three pounds.  We can also point out negative trends, for example if they’ve been under a lot of stress, we can show them the impact: their HDL has gone down, their weight is up, their bad cholesterol is up...we can make the point that the small things we do every day do make a difference.”

Second, Dr. Kuehl emphasizes the importance of the provider’s approach to behavior change, urging providers to ask about lifestyle at every visit in a non-threatening and caring manner.  “We must show that we care, we must be sensitive to readiness, and we must never give up on a patient.”  He describes the need for intrinsic motivation, based upon why a person wants to change, stating that “attempts at extrinsic motivation, such as fear and guilt, are ineffective, especially over the long-term.”  His team uses Motivational Interviewing - a directive, patient-centered counseling style for eliciting behavior change (the team received training from the founder of the approach, William Miller, PhD.)  “The key to identifying internal motivation is to listen more...doctors generally interrupt or redirect patients before they’ve finished speaking.  It’s important that we learn non-advice giving” offering the following example: “In discussing high cholesterol, I might ask the patient to tell me why they think it’s bad,” using careful listening, feedback, insight, and reflection to lead and allow the patient to identify his or her own solutions.

Third, he highlights the need for resources, such as team-based lifestyle change groups, and the value of enlisting social support, encouraging patients to bring in their spouse or significant other into visits and groups.

After carrying out a similar and highly successful study with fire fighters(the NIH-funded PHLAME program; see link for more information), Dr. Kuehl’s team is now applying their findings with those in law enforcement with the goal of helping them adopt healthier behaviors.  “We just received funding to continue our study with fire fighters and now with law enforcement, populations with high risk of injury and illness.  These are taxed-based, government employees and we’ve shown that we can facilitate lifestyle change and that these changes reduce the economic burden for tax payers. This is of major significance: for every $1 spent, tax payers save $10 every year.  We’re showing immediate results, and this isn’t even considering the long-term benefits.”  He points to the need for training in Lifestyle Medicine, training new doctors to practice in this way and offering continuing education for practicing physicians, affirming the importance of the ACLM as “a great resource for doctors and clinicians who aren’t trained in prevention and wellness.” 

Dr. Kuehl describes his vision for the future, “I’m encouraged.  I see that money is being put into health promotion and into wellness.  We’ll see great changes in healthcare in the next decades.  This research speaks volumes.  Government agencies and insurance companies are looking at this and paying attention to evidence-based practice models.  Blue Cross is now looking at a team-based approach and exploring how to make it more accessible and more convenient.  We’re now being funded to put this research into practice.  This is a BIG step.” 

Click here to learn more about the PHLAME project

Click here to learn more about Dr. Kuehl and OHSU’s Division of Health Promotion & Sports Medicine