By Dr. Mercola
Chris Kresser, an acupuncturist, licensed integrative medicine clinician and co-director of the California Center for Functional Medicine, is widely recognized for his contributions to the ancestral nutrition movement. As many leaders in and promoters of functional medicine, Kresser is a wounded healer, whose interest in alternative disciplines developed because conventional medicine failed him.
“In my early 20s, I took off on an around-the-world trip. I was surfing in Indonesia [when] I got an acute tropical illness — fever, chills, diarrhea, delirium. I don’t really remember much of what happened during those few days. But there was an Australian staying in the little village that I was in who happened to have some antibiotics that brought me back from the brink,” Kresser says.
“That evolved into a decadelong journey back to health … I came home and … proceeded to see probably no fewer than 20 or 25 doctors over the course of the next several years, in three different countries, hoping they would be able to help me. Most of the doctors I saw meant well.
They tried their best to help, but I quickly found out that conventional medicine, while it’s fantastic at dealing with trauma and emergencies, it was really miserable at dealing with the kind of complex chronic illness that I had developed.
Despite everyone’s best efforts, nobody was able to help. I eventually decided there was no one that was more deeply invested in my own healing than myself. I started my own exploration, which eventually led to returning to school to study Chinese medicine and acupuncture.
I chose that because of all the modalities I tried along my journey, that was what has been most helpful to me. But then, even before I graduated from school, I realized I wasn’t going to end up practicing Chinese medicine. I discovered functional medicine and kind of moved in that direction.”
Unconventional Medicine
Kresser has written a number of books, the latest one of which is “Unconventional Medicine: Join the Revolution to Reinvent Healthcare, Reverse Chronic Disease, and Create a Practice You Love.” In the beginning of the book, he discusses the impact of conventional medicine on chronic disease, and why it so rarely works.
When modern medicine as we know it was developed, the primary challenges were acute problems, and this is one of the reasons why conventional medicine lacks the tools and know-how to address the many chronic ailments facing us today.
The landscape of health and disease has changed rather dramatically, and acute care medicine doesn’t work well for chronic problems. In 1900, the top three causes of death were all acute infectious diseases: typhoid, tuberculosis and pneumonia. Other common reasons for medical visits included broken limbs, gallbladder attacks, appendicitis and similar problems.
“The treatment for those problems was relatively straightforward. You put the arm in a cast or remove the gallbladder,” Kresser says. “It was one doctor, one problem, one treatment and that was the end of the story.”
Today, 7 of the 10 top causes of death are chronic diseases rather than acute diseases and, unlike acute problems, chronic diseases tend to be complex, difficult to manage and often last a lifetime. In short, the model of care that was developed for treating acute problems doesn’t work for chronic disease. As noted by Kresser, “That explains why 1 in 2 Americans now has a chronic disease, and 1 in 4 has multiple chronic diseases, including almost 30 percent of kids. We’ve just been using the wrong tool for the job.”
Chronic Disease Has Become an Existential Threat
This is also why the health care debate, which is really focused on the availability of insurance, is completely missing the point.
“If we don’t get a handle on chronic disease, there’s no method of paying for health care that will be sufficient,” he says. “A simple thought experiment will show this. It costs $14,000 a year to treat the average patient with Type 2 diabetes.
The most recent statistics by the Centers for Disease Control and Prevention suggests that 100 million Americans now either have prediabetes or full-fledged Type 2 diabetes. You don’t have to be a math genius to multiply 100 million times $14,000. You get a number so big that it’s absolutely impossible to generate the money we would need to cover that.”
The situation is actually far worse than that, because insulin resistance likely affects upward of 250 million Americans, and insulin resistance is a foundational core of prediabetes and diabetes. Work by the late Dr. Joseph Kraft, author of “Diabetes Epidemic and You: Should Everyone Be Tested?” suggests that 80 percent — 8 out of 10 — of Americans are insulin-resistant.1,2
Statistics also reveal opioid overdoses are now a leading cause of death among Americans under the age of 50, and two separate studies have confirmed that conventional medical care is the third leading cause of death in the U.S. As noted by Kresser:
“It’s not an exaggeration to say that chronic disease is an existential threat to society and humanity at the same level as nuclear weapons, warfare and other things that we typically worry about and concern ourselves with. I don’t think that chronic disease gets the attention that it should get as a threat to our health, well-being and longevity as a species.”
Doctors Are Victims of the System Too
Doctors are also hogtied by a medical system that doesn’t allow them to really invest sufficient time. Most physicians genuinely want to help people. But how much can you really accomplish in mere minutes? The average primary care visit is eight to 12 minutes. Most primary care doctors have 2,500 patients on their roster and see an average of 25 patients a day.
The incentives for physicians are based on how many patients they’re seeing each day, and with an average debt of $200,000 for medical school, doctors have to play this numbers game to pay off their debt and still make a living. Add to those pressures the interests and incentives of the drug and insurance industries, which rarely align with the best interest of patients or even doctors.
“You end up reimbursement-based medicine, where the treatment chosen is based on what will be reimbursed by the insurance company, not on what the evidence suggests is the best option. You’ve got all these misaligned incentives, which almost guarantee that the type of care that’s offered to patients is not in their best interest,” Kresser says.
“To clarify, there are three issues here. 1) There’s a mismatch between what our bodies are hardwired for and the way that we’re living now. 2) The medical paradigm is totally mismatched with what we need for chronic disease, and 3) The way care is delivered is mismatched [to our true needs] …
If we recognize that diet and lifestyle is a primary driver of chronic disease ... then we need to acknowledge that changing our behavior, our diet and our lifestyle, is one of the most important steps we can take to prevent and reverse chronic disease. And yet our medical system just pays the briefest lip service to that. It’s not at all set up to actually deliver that kind of care.”
The ADAPT Framework
Kresser has developed a program called the ADAPT Framework, referring to the need for adaptation to our environment (which has dramatically changed from what it was for most of our evolutionary history), adaptation of our medical paradigm to one suited for the prevention and treatment of chronic disease, and adaptation of our health care delivery methods.
“Those are really the three separate elements of the framework: realigning our diet, behavior and lifestyle with what our bodies are hardwired for; changing the medical paradigm to one that prevents and reverses chronic disease instead of just trying to manage it for the whole patient’s life; and updating the way we deliver care, so it supports the most important interventions which, again, are diet, lifestyle and behavior changes,” Kresser says.
Case Sample: Prediabetes
As a hypothetical example, take an individual who is diagnosed with prediabetes, meaning he has a fasting glucose level above 100 milligrams per deciliter but not high enough to qualify as diabetes. The current medical paradigm has nothing to offer at this point, because his glucose level is not high enough to start prescribing medication. In essence, the patient is simply told to wait until full-blown Type 2 diabetes develops, at which point treatment can commence.
“What could happen in that situation would look something like this: ‘The good news is we’ve discovered that your blood sugar is high. It’s not full-fledged Type 2 diabetes yet, and the earlier we intervene, the better prognosis you’re going to have, the more chances that we have of preventing or reversing it,’” Kresser says.
“To do that, we need to address your diet and your lifestyle, because we know that’s the primary driver of this condition. So, we’re going to set you up with a health coach, who is going to come to your house and do a pantry cleanout. They’re going to take you shopping.
They’re going to give you recipes and meal plans. They’re going to work intensively with you to adopt this diet, because we know that information is not enough to change behavior. If it was, we wouldn’t be in the situation that we’re in now. I can’t just tell you to eat well. I have to actually give you some support in order to do that.
Then we’re going to set you up with a personal trainer at the gym. They’re going to get you on an exercise and physical activity program that’s going to also support these efforts.
The good news is your insurance company is going to cover all of that, because they recognize they could save potentially half a million dollars over the course of your lifetime just by preventing you from getting this one single disease. They’re going to spend a few thousand dollars now to save a half-million dollars over the course of your lifetime.
That’s just one small example of how this model could work, because it’s actually focusing on preventing the disease before it happens or reversing it once it started to progress. Nothing that I just said is not possible, given our current technology, resources, and even the system as it currently exists. This could happen tomorrow if it was the way we decided to offer care.”
A Collaborative Practice Model
To facilitate this kind of switchover, Kresser has developed a powerful collaborative practice model that embraces streamlined operation and reduced overhead bureaucracy, and that really cuts to the core of what needs to be done to address chronic illness. One of the key changes is allowing for more time with each patient. You simply cannot cover diet, exercise, sleep and stress management in a 10-minute appointment. For that, we really need a team-based approach.
Patients need support to implement diet and lifestyle changes. They need medical experts to help them understand the significance of their test results.
Kresser’s collaborative practice model integrates physicians and other licensed providers such as nurse practitioners, physician assistants, health or wellness coaches and nutritionists trained in functional medicine, who can provide specific guidance related to diet and lifestyle changes. “Ultimately, I would say the proper ratio of health coaches to doctors would be probably five or six [per] doctor in each practice, depending on the patient load,” Kresser says.
This model also requires the elimination of red tape bureaucracy and bloated, inefficient electronic medical record systems that simply get in the way. Technology should be used to automate things that create more time for what should never be automated — the face-to-face direct patient care. Community can also be built around online and in-person classes, video meetings and group care, where people with similar condition get together and actually connect with and support each other.
“There are some electric medical records that are actually designed for this type of medicine that we’re talking about. They strip out all of the stuff that you don’t really need. They focus on only what you do need. The one that we use has features that make it really easy to quickly enter what you need to enter so that I can focus on the patient. But I also have a nurse practitioner with me, and she does all the note taking.
I can just work and maintain eye contact with the patient and do what I need to do. That’s part of this team-based approach to care as well,” Kresser says. “We’re moving toward [this] program at our clinic. When the patient comes in, they work intensively with the health coach and nutritionist for several months before they even see the doctor.
Now, of course, you can’t make hard and fast rules. Some people need to see the doctor right away if they have a more serious issue that needs to be dealt with.
But in general, if someone has what we could call a lifestyle disease, which is most chronic diseases, and they haven’t yet taken the steps to address their diet and lifestyle, what’s the point of them even working with the doctor until they get that stuff under control? In many cases, if once they get that stuff under control, they may never even need to see the doctor.”
New Payment Models Are Also Needed
Naturally, someone’s going to have to pay for this care model. Health coaches typically bill by the hour, and few insurance companies presently offer reimbursement for this kind of care. There are signs of change, however. Iora Health,3 for example, a Denver-based primary care facility, is currently addressing Type 2 diabetes using health coaches.
“They use something called capitated payments, where they go to the insurance companies and say, ‘Give us your patients with Type 2 diabetes. We will reverse Type 2 diabetes … or at least get your diabetics back to prediabetes. We’re going to do this mostly with health coaches. If we are successful, you pay us this much. If we’re not successful, you pay us less. If we are more successful than we said we would be, pay us more.’ That’s an attempt to realign incentives.
It’s actually performance-based compensation instead of the way it usually works in medicine, where the compensation happens no matter what. That system has been pretty successful. I think it’s a good proof of concept that that could actually work, even within our current system.
But this is just one company in one area. That will need to roll out on a wider scale for it to be successful. Whether or not that happens goes back to that other question: Is it going to happen voluntarily, or is it going to happen because it has to happen?”
The National Board of Medical Examiners also recently teamed up with the International Consortium for Health and Wellness Coaching (ICHWC) to create standards for health coaches. This too is a step in the right direction in terms of legitimizing health coaching in the eyes of medical professionals, with the goal of incorporating them into the health care system and provide reimbursement for their services.
The U.S. Centers for Disease Control and Prevention, which is not known as a particularly progressive organization, has also publicly recognized the need for health coaching. “Even without the full collapse of our health care system, I think we will see more integration of health coaching in the next decade,” Kresser says. “Whether we can get all the way to where we need to get to is another question.”
The Importance of the Basics
It’s hard to overstate the importance of basic lifestyle strategies when it comes to protecting and optimizing your health. Take sleep for example. One-third of Americans get less than six hours of sleep per night. Fifty-five years ago, that number was only 2 percent. This upshot of sleep deprivation is undoubtedly having an impact on public health these days, as lack of sleep has been linked to weight gain, diabetes, cognitive impairment and reduced immune function, just to name a few.
For example, most obesity researchers now agree that sleep is the second most important factor beyond diet for maintaining healthy body weight. Even a single night of sleep deprivation has been shown to cause insulin resistance in healthy people with no pre-existing insulin resistance. “Sleep is where we rejuvenate and regenerate our mind, our body and our spirit. If we don’t get enough sleep, that doesn’t happen. We basically start to fall apart in every area of our life,” Kresser says.
Electromagnetic field (EMF) exposures, especially electrical fields generated by electrical wiring, is a related issue, as these fields have been shown to impair biological function and disrupt sleep. For most people, it would therefore be wise to shut down the electrical circuit in your bedroom at night, to allow your body to recuperate and regenerate optimally.
More Information
At present, the ADAPT Program has trained over 400 clinicians, and in June the ADAPT Health Coach Training Program will be launched. The training has been submitted for approval by the ICHWC. If approved, anyone who graduates from the Health Coach Training Program and completes the requirements will be eligible to sit for the ICHWC accreditation, which will be internationally recognized.
“We’re really excited about that. I view that as the next step in this collaborative practice model, because we’re training the practitioners and we’re training them on why they need health coaches and nutritionists, and then we’re training the nutritionists and the health coaches on how to work effectively with licensed clinicians,” Kresser explains. “We really want to create that synergy, all under this ADAPT Framework umbrella …
Part of what differentiates our program from most others is its emphasis on practical application. You can’t learn to be a good coach by reading books or watching PowerPoint presentations. The ADAPT program focuses heavily on skills development, mentor coaching and supervision, and practice coaching sessions with real clients to ensure that our students are well-prepared when they graduate.”
To learn more, and to sign up for the ADAPT training for clinicians and health coaches, please visit KresserInstitute.com. There you can also find a list of providers who have finished the training program. Also be sure to pick up a copy of Kresser’s book, “Unconventional Medicine: Join the Revolution to Reinvent Healthcare, Reverse Chronic Disease, and Create a Practice You Love.”