"The Times They Are A-Changin":  Lifestyle Medicine Shows Up in Cardiology

By Cate Collings, MD; Cardiologist 
ACLM Board Member 

Chair, ACLM Education Committee

December 2016

Steven Poole’s recent book Rethink: The Surprising History of New Ideas enlightens us that “The story of human understanding is not a gradual, stately accumulation of facts” but rather “a wild roller-coaster ride full of loops and switchbacks.” Or stated another way, everything old becomes new again. Such has been my personal ride in cardiology and lifestyle medicine’s ride within the field of cardiology.

As an exercise physiology graduate student in the late 70’s, I supervised a cardiac rehabilitation program at the University of Wisconsin-Madison running with cardiac patients through snow and shine along the lovely Lake Mendota shoreline. Those were life-changing runs in my early 20’s—the wisdom of my older cardiac patients coupled with my exuberance to help people develop healthy lifestyles…well, you’ve all had similar experiences, and in the end, I became hooked on cardiology as a career path that would express my passion for the power of lifestyle.

I did not imagine where the field of cardiology would land after the years it took me to complete graduate school, medical school, and cardiology subspecialty training. About the time I was to launch into a real cardiology practice in the early 1990’s, interventional cardiology was truly seen as a game-changer--percutaneous coronary angioplasty and later stenting had become the norm of acute myocardial infarction (MI) care and the American College of Cardiology (ACC) and American Heart Association (AHA) published their first evidence based guidelines for management of acute MI. Interestingly, this was also about the time that Dean Ornish published his landmark book Arresting and Reversing Coronary Artery Disease and Caldwell Esselstyn hosted the National Conference on the Elimination of Coronary Artery Disease, each focused on coronary artery disease reversal through dietary and lifestyle interventions.

The cardiology community was swept away by procedural and drug interventions and we were off to the races while those that shared my interests in cardiac rehab and lifestyle interventions were trailing in last place. Indeed, the first ACC/AHA guidelines in 1990 detailed the in-hospital and discharge (secondary prevention) guidelines for acute MI based upon levels of evidence in none less than 38 pages and 223 references and allotted only a short, closing paragraph showing lifestyle measures very clearly in last place:


“The subcommittee decided to not include any detail regarding modification of coronary artery disease risk…because of space limitations. We urge clinicians to become involved in treatment of lipid abnormalities, stopping smoking, treating hypertension, weight control, exercise prescriptions, and seeing that this modification is a lifestyle change rather than just a temporary change induced by the fright of the acute episode.”

Fast-forward 30 years, and “the times, they are a-changin,” or is that, everything old is new again? In 2016, the annual conference of the ACC featured for the first time, an intensive focus on lifestyle medicine. OK, lifestyle was one wave in a sea of big pharma and tech, but it was there! The seats at the sessions were full and the walls lined with participants drawn to the headline: “A Little Less Drugs, a Little More Sex, and a Lot More Rock and Roll.” Among presenters or panelists were ACC President Dr. Kim Williams speaking on the heart benefits of a vegan diet, Dr. Dean Ornish on the topics of love, loneliness, and connection, and Dr. Caldwell Esselstyn as a panelist on nutrition and heart disease. It was clearly something better than last place!

Since that conference, I have taken a seat on the recently composed ACC Nutrition and Lifestyle Work Group as a liaison to ACLM. Doctors Ornish, Esselstyn, and Barnard are also contributors to that group. Key outcomes of the group’s work include letters to the FDA regarding manufacturer exploitation of food labels and a nutrition survey of cardiologist attitudes and knowledge of nutrition, revealing that over half of cardiovascular clinicians have not received any formal CME in nutrition. Additionally, the working group has submitted an article on “Nutrition facts and controversies” for the Journal of American College of Cardiology. An appetite for lifestyle education in the cardiology community has been recognized and a partnership with ACLM has been established.

Our ACLM membership has doubled this past year showcasing the enormous interest in our mission and a growing hunger for knowledge about lifestyle. Following our annual conference in October 2017, members will have the opportunity to take the inaugural American Board of Lifestyle Medicine certification. This is a milestone step for our field’s credibility within medicine. Our members, particularly those in the founding years, have been trailblazers of the lifestyle medicine movement, but a key next step is to ignite colleagues from a vast array of specialties. We increasingly understand the effect of lifestyle on the microbiome, endocrine system, and tumor growth, and our efforts could multiply several-fold with the support of, to name only a few, our gastroenterology, endocrinology, and oncology colleagues and their respective colleges. With ACLM as the beacon college in partnership with lifestyle working groups of other professional colleges, lifestyle medicine will have seeds into mainstream medicine. Engagement with other specialty colleges will accelerate education and our collective action with patients, insurers, and government.

And yes, cardiac rehab is back in style- a hat I still wear as medical director of my hospital’s program since 1994. The old in my cardiology career has become new again! National referral rates have been stuttering along for years at less than 30% of eligible patients. The Centers for Medicare and Medicaid Services (CMS) now recognize reduced medical costs and improved mortality in participating patients. Cardiac rehab will become mandatory in the proposed 2017 bundled payment programs after acute myocardial infarction and coronary bypass surgery. Additionally, CMS has proposed incentivized payments for cardiac rehab based upon number of sessions attended. The reimbursement is titrated upwards for increasing number of sessions according to established dose-effect response to lifestyle! A physician in any field who has the passion and expertise for lifestyle can provide medical directorship for cardiac rehab programs, so NOW is the time to approach your hospital, university, or clinic administration and set up a program.

ACLM and its members have the passion to bring lifestyle to mainstream medicine and to Anywhere Main Street, but only by engaging a larger audience of physicians and provider specialties can we accomplish this goal. Let’s think and rethink strategies and roll out a sustainable lifestyle movement in mainstream medicine with fewer loops and NO switchbacks!


Dr. Cate Collings is a cardiologist practicing with an independent subspecialty group in the Silicon Valley region of California. She provides medical directorship for a hospital Cardiac Rehabilitation Program. In addition to residency and cardiology fellowship training at Stanford, she has a graduate degree in Exercise Physiology, Wellcoaches Training, and Rouxbe Plant-based Professional Culinary Certification. She has been an ACLM board member since 2015 and, as chair of the recently established ACLM Education Committee, welcomes new members and ideas. Contact Dr. Collings at doccate@gmail.com to participate in the college’s education initiatives.