A Journey To Lifestyle Medicine: Dr. Tom Rifai's path
By ACLM Member Tom Rifai, MD, FACP
President and CEO, Reality Meets Science LLC
As for many of you, lifestyle medicine is far more than just a profession to me as I not only treat people with major metabolic health issues, maladaptive eating patterns and behavioral health issues. I myself am also "one of them". Among other issues, I have been battling binge eating disorder for decades and still today. It is one of my major motivations to be the most compassionate lifestyle medicine physician possible. Before delving into the beginnings of my journey to lifestyle medicine, one “teaching moment” in establishing my “absolutely no judgment of patients…EVER” approach was a brutal early morning awakening of choking on my own vomit after a night of binge eating almost two large pizzas in rapid fashion. For a very critical moment, I truly thought I was going to die. In less than 5 seconds of awakening (but which felt much longer) I was “running” backwards into a wall in my apartment in an effort to dislodge my (not so comfortable) comfort food mix of refined flour, fatty cheese and salt. I don’t remember seeing my life flash before my eyes. Rather, I saw visions of a newspaper article: “Detroit Nutrition Doc Dies Choking on Pizza!”. This is the first I’ve ever mentioned this event in open public. Though I have been discussing it openly when appropriate with patients.
I have had the benefit (and yes, burden – but I try to look at the bright side) to have been educated by an emotionally traumatic and at times violent childhood blended with a family history of very bad eating habits, much driven by emotional eating. Then there was two years on anti-depressant therapy (one of those years on two medications combined) and a full continuous year of CBT and psychotherapy at 14-15 years of age – more on that to come.
But no, there really is no full "recovery" from bingeing nor end to “the journey of a lifestyle”, in my personal, and professional, opinion. At “the end of the day”, I view all of what I have gone through and “suffered” (quotations because suffering = opportunity to learn) as a glorious and worthy battle! And this is the same spirit in which I coach our lifestyle program patients.
And I didn’t exactly “get lucky” with a counterbalance of great family genes for metabolic health. Elevated lipoprotein (a), a genetic tendency towards low HDL and insulin resistance are all part of my genetic make-up. These have been further motivations to be the best lifestyle medicine physician, professionally and personally. Sadly, my beloved youngest brother passed away in January, much driven by frank binge eating tendencies.
My father was probably the first strong influence on my journey to lifestyle medicine. Formerly a world class urologist, he currently suffers from self driven type 2 diabetes, dementia, depression and a long history of over and binge eating. While he taught me great things in ethics, value of dedication in education and the importance of world history – his teaching in lifestyle was the most valuable. I'll never forget one “sentinel event” around 10 years of age. On a Saturday around 11:30 am, after rounding on his patients (skipping breakfast, of course), I watched him, almost literally, inhale his McDonald's bag of french fries before our hamburgers even hit the tray at the counter! And then, to shocked audience of me, dad ordered another bag of fries as soon as our burgers hit the tray. It was certainly an indelible, and influential, moment for me. Even as a youngster I knew what he did was not healthy and for whatever (or very good) reason, I can see the image and moment in my mind now as if it happened yesterday. And thanks to that experience, one of my “life missions” is “breaking the chain” of my family history of bad eating behaviors not only for me but, just as importantly, my two children. I’m proud to say that, almost assuredly due to lifestyle my recent carotid artery intima-media thickness (CIMT) ultrasound was consistent with a vascular age more than a decade younger than my biological age (mid 30's vs almost 50). Yes, a binge eater with a far less than stellar family history was literally saved by lifestyle (as) medicine. For me, the right attitude is “progress IS perfection”!
My path to lifestyle medicine wasn’t driven by a single "magic moment in time". Rather, there were a few sentinel events, the first being the McDonald’s scene with my father. Another began with my foray into martial arts, likely driven by bullying I experienced as a pre-teen. But also a semi-obsession with Arnold Schwarzenegger. I read everything I could regarding exercise and (his version of) nutrition in Arnold’s “Encyclopedia of Body Building”. There was a strong theme of minimally and unprocessed carbohydrates and very low fat. But, of course protein content was far more focused on muscle mass than necessary for true health. I was in approximately 5 significant local and state competitions. And believe it or not, in the process, I found Pritikin! I was preparing for a show and found a Lebanese food stand in a local food court that advertised “Pritikin Menu – Low Fat, No-Salt”. I asked the owner “where” Pritikin was (I thought it was a city in Europe or Russia!). She laughed, corrected me and clarified Nathan Pritikin was a man and that I should read one of his books if I wanted to learn more. Voila! A major step towards evidence based nutrition information began (Arnold + Nathan…seems odd, but that’s my story!). For body building I used a modified form of Pritikin, which differed only in the amount of protein (having more along the lines of 6-8 oz of lean and no salt fish and breast of poultry daily instead of the 4 oz limit).
But the rigidity with which I stuck to my modified Pritikin plan aggravated my binge eating. Like many athletes who, once “crossing the finish line”, “pig out” after the event, I did too. But I took it to an extreme. Example: as aforementioned I was 202 lbs at 19 years of age after bingeing up to it following my last “teen” bodybuilding competition. To “cut down” for my final competitive bodybuilding show (just days before I turned 21 and was in the midst of my undergrad degree at MSU) down to 162 lbs I was following my modified Pritikin plan 1000%. I mastered low fat and low salt with high fiber (plus extra protein). Then, like a pressure cooker without a pressure release valve, I “blew up” after the show back up to 195 lbs within only a few weeks after the end of a competition, beginning with about 3 days of non-stop pizza (and not the “thin crust with extra veggies and light cheese” type).
Thankfully, I swore to end the “madness” of competitive bodybuilding and with it ditching as much maladaptive behavior as I could. But as a “silver lining”, I kept much of what learned from Pritikin and, in wonderful fate (I don’t think irony), I became the Associate Medical Director of the Pritikin Longevity Center in South Florida in 2008. It was a truly self actualizing experience and one of the greatest professional honors of my professional life. I still serve on Pritikin’s Science Advisory Committee to this day.
19 years old at 202 lbs
Days before my 21st birthday at 162 lbs
After graduating high school, I was confident I wanted to become a psychologist thanks to both a great experience with counseling and therapy as well as what were natural powers of persuasion (I was a good debater since a teen). Cognitive behavioral therapy started for me at 14 years old. The final straw was my mother catching me skipping high school to come home to drink alcohol and “get wasted” with other delinquent friends. Thankfully, my mother had the insight to send me back home to Detroit (from Buffalo, where we were for less than a year before I decompensated into depression, alcohol and drugs) to live with some very close family friends back home in Metro Detroit, the Schwartz family. They treated me like one of their own children, one of which was and still is to this day one of my best friends, Stan. And they went over and above the call of duty by driving me to junior high school every day for a semester, until my mother found a way to find a position with General Motors back in the Motor City in order to move back to Detroit. Mrs Schwartz also drove me to my weekly meetings with my “shrink”, Dr. Frank. Dr. Frank, whom I still stay in touch with and reach out to when I feel the need to this day, was pivotal in not only saving my life, but also in teaching me the true dedication and intensive amount of time it takes to help coach someone back to mental health. A true and inspiring master of the art of behavior modification! That year of weekly (first 6 months) and biweekly (second 6 months) CBT was another major pillar of events leading me to lifestyle medicine. Even though I didn’t ultimately become a psychologist, the experience of about 40 transformative sit down sessions with “Dr Steve” helped lead me to pursue a future bachelors of science in psychology, which to this day I still feel is an excellent major to combine with a pre-med curriculum. But I wasn’t a pre-med student until I about the middle of my third undergrad year at Michigan State University. While in Boston, at a GRE (Graduate Records Examination) symposium to learn about different graduate psychology programs, I literally had a moderate panic attack realizing “something was wrong”. Not ironically, an anxiety attack was my “emotional brain’s” way of asking “are you SURE you want to be a psychologist??”. I called my father and had a serious discussion about needing to re-think my career choice. I knew I wanted to have psychology, counseling and behavior modification be a PART of what I did as a professional, but not the ONLY thing. He supported my going back to search for my “true calling”. I cannot thank my father enough for “having my back” at that critical time.
But before I knew pre-med, let alone lifestyle medicine, was my path, my journey “drove through” what seemed natural based on my serious, though informal, past self (but intensive!) education in nutrition and Pritikin principles, adding a nutrition focus to my undergrad curriculum. It was for just one term (Michigan State University still had 10 week terms, not semesters) and was great stuff! I LOVED it, but in a “limited love” way. I still had that “funny feeling” that I didn’t want nutrition to be the ONLY focus of my future career. But the next step was STILL not pre-med! Close, but not yet.
First came a switch of focus to exercise science in search for what I "really wanted to do". Exercise science students were the only students allowed in the cadaver lab of MSU other than med students and anatomical art students. Not even pre-med students were allowed in but it was where I needed to be to have my “epiphany”! In fact, a special moment in the MSU cadaver lab was the closest thing to an “epiphany” I have ever experienced in my journey to lifestyle medicine! One day while studying primary moving actions between muscles and bones (which is what we were limited to studying), I saw a group of medical students walk into the lab with a professor.
And then “the moment”…The professor subsequently began discussing coronary anatomy (specifically, atherosclerosis!) and how much "stress (psych topic), physical inactivity (exercise topic) and unhealthy eating (nutrition topic – rounding out all 3 of my undergrad “appetizers”!)" the person was suffering who lived with the heart he held in hand and lifted up for all the med students (and ME) to see. It was RIGHT THERE, RIGHT THEN that at literally THAT moment that the "epiphany bulb" went off! I realized that I truly “needed” to become a physician! Despite all my parents (especially mother) tried to do to dissuade me. It wasn’t a choice, it was a calling! Now, to clarify why it wasn’t so clear to me from much earlier was largely due to mom. She was also a physician (as was my father, who passively went along with mom and living in the “new country” – they were from Syria – so my dad was fine with me being a baseball player – after all, I was a GREAT little league player! LOL!).
Mom insisted I should avoid going to medical school because "all doctors are crazy". A true story: she would even whisper those exact words in my ear occasionally as a doctor whom she thought was "crazy" would walk by us in a hospital or clinic. To a degree, of course – at least regarding some (ok, ok, a lot) of us – she was somewhat right 😊. Nevertheless, mom was 1000% supportive (to my surprise!) when I nervously called her within minutes of my epiphany! She said something along the lines of: “if medicine is what you REALLY want to do, great! Just remember though, we didn’t force you – it’s YOUR choice and it will be hard”. Sage words from mom and I am, like when dad had my back earlier (he did here too), beyond thankful to her for her support and honesty to this day.
The final touches on my path from primary care medicine (a preventive spirit of which I always planned on practicing from the day I applied to medical school), I received an excellent medical education at Wayne State University School of Medicine, where there was a strong nutrition component. I squeezed my nutrition professor for what must have almost been a Masters degree worth of extra time after lectures and separate appointments I made with him (thank you Professor Sardesai!)! But as noted, I thought would be practicing lifestyle medicine via primary care. And I in fact chose the primary care (rather than standard) track for my internal medicine residency training emphasis at William Beaumont Hospital. My residency was another excellent experience. And – just as how I turned my medical school education into a “medicine + nutrition”, during my senior resident year, I became the directing resident coordinator for the Beaumont Hospital multidisciplinary Nutrition and Preventive Medicine Center, which focused on metabolic and lifestyle medicine (especially lipids and weight management). I realized truly then that lifestyle medicine could and needs to be a specialty in and of itself. The time required with patients for the highest odds for successful lifestyle change couldn’t, sadly (at least as our current “health” care “system” is set up), be effectuated in the “fast paced” primary care culture at that (nor this) time. Hopefully that will change. And while I couldn’t respect primary care docs more (some of my best teachers), I decided to go straight into multidisciplinary care lifestyle and metabolic medicine right from residency by joining my mentor, Dr Michael Doyle (who was originally primary care and then achieved an MPH with nutrition focus from University of Michigan) in an intensive lifestyle intervention program that he started and for which recruited me and which was appropriately partnered with a very large cardiology practice. The rest, along with my leadership role at the plant based pioneering Pritikin Longevity Center, my Lifestyle Medicine online CME course through Harvard Medical School (“Nutrition and the Metabolic Syndrome”) and my current role as Regional Medical Director of Metabolic Health and Weight Management for the world renown Henry Ford Health System, is lifestyle medicine history!