Biohacking our Best: Lifestyle & Performance Medicine for the Aviator

Abstract

Aviators are a unique population of individuals who often thrive in environments with high operational tempo and a mission-centric culture. However, the combination of occupational and life stressors can put aviators at risk over time of developing preventable health conditions, including chronic pain, hypertension, elevated body mass index, and type 2 diabetes. This article will discuss lifestyle and performance medicine in the context of aviation. It will include a review of high-impact ways the USAF Lifestyle and Performance Working Group is incorporating the pillars of lifestyle medicine into the United States military healthcare system. 

USAF Thunderbirds at Sunrise, by Master Sgt. Matt Hecht

Introduction

Aviators are a selected population of high performers with excellent baseline health. However,  chronic stress associated with intense operations, training, and deployment cycles can lead to high allostatic load. Allostatic load was first described in 1994 by Schulkin et al. as “the price the body pays for containing the effects of arousing stimuli and the expectation of negative consequences.”1 This has also been termed operator syndrome, where high allostatic load leads to a constellation of interrelated suboptimal health patterns and functional impairments.2 These can include sleep disturbances, substance abuse, endocrine dysfunction, headaches, stress reactivity, and marital, family, and community dysfunction.2 Aviators are at risk of developing the same types of health conditions, which can be largely prevented, treated and, in many cases, reversed through lifestyle medicine (LM). This article will review LM, or lifestyle & performance medicine (L&PM), as it is referred to in the U.S. Air Force (USAF) and Department of Defense (DoD). It will introduce the six pillars of LM, review a case study in LM, and provide a strategic review of expanding efforts across the DoD to integrate LM across the spectrum of healthcare delivery. As described in Air Force Instruction 48-101, “Personnel are the most important and valuable resource for the Air Force.”3 By focusing on L&PM, we ensure Airmen and Guardians in aviation are well positioned to optimize their target performance and prevent lifelong adverse health outcomes.

Background

Devolving health trends and increased chronic disease burdens have been common trends throughout the civilian sector and DoD for several decades.4 In the United States, total healthcare spending in 2019 was estimated to be $3.6 trillion, which accounts for 16.8% of the national gross domestic product.5 Yet, 86% of all healthcare dollars are spent on chronic diseases, many of which are preventable through lifestyle choices.4 Americans who have five or more chronic conditions make up 12% of the population, although they account for 41% of the total healthcare spending.4  Service members are also impacted by risky health behaviors including tobacco use, excessive alcohol consumption, poor nutrition, and lack of physical activity.6 Diagnoses of overweight and obesity in active duty service members rose 73% between 2011-2018, and individuals with these diagnoses are less likely to be medically ready to deploy.6 Obesity also predisposes individuals to serious diseases such as type 2 diabetes, high blood pressure, coronary heart disease, and multiple types of mental illness.7 The DoD spends $1.5 billion annually on obesity-related healthcare costs for current and former service members and their families.8 According to the Centers for Disease Control and Prevention data from 2020, more than 33% of Americans (over 88 million people) are pre-diabetic, and over 10% of Americans have diabetes.9 As of June 2021, there are over 1.3 million service members and nearly 800,000 Guard/Reserve members within the DoD.10 Health data trending would suggest that nearly 720,000 uniformed service members currently have prediabetes, but only 16% of them know they have it.10 The incidence of diabetes in the U.S. military is known to be similar to that of the civilian population (1.6 vs. 1.9 cases per 1,000 person-years) despite fitness standards.11 

In addition to contributing to common chronic diseases, unhealthy lifestyle factors increase the risk of many forms of cancer and all-cause mortality.12,13 Yet, prevention and reversal of lifestyle-related disease are underemphasized in primary care. Patients often express frustration regarding what changes to make and the expected outcomes. Physicians, and other healthcare professionals, also struggle with patient expectation management, noncompliance, and a medical system that focuses largely on disease management rather than realizing and sustaining health maintenance. LM focuses on addressing the root causes of diseases. LM educates and empowers patients to make meaningful changes in their daily habits that have a significant impact on lifelong health.
 

Lifestyle Medicine

LM utilizes six pillars of wellness, which are first-line interventions to prevent and reverse many chronic diseases as well as to optimize human performance. These focus areas are evidence based and include predominantly whole food/plant-based nutrition, engaging in routine physical activity, obtaining restorative sleep, managing stress, maintaining social support, and mitigating risky substance use. LM includes expanding fields of study such as the gut microbiome, epigenetics, and the impact of lifestyle changes on telomere length and aging. 

Specialists in LM consistently utilize therapeutic lifestyle interventions as the foundation to their conventional healthcare practice. LM specialists contribute to the field of lifestyle medicine through multiple avenues, which include direct patient care, research, training, education, performance improvement, and population health. They also participate in lifestyle medicine forums and academic associations that seek to improve and advance the practice of LM.

Lifestyle Medicine Certification

Certification in LM is possible for most healthcare providers, but the pathways are slightly different depending on baseline education and training. The American Board of Lifestyle Medicine (ABLM) certifies physicians in LM. Allied healthcare professionals are certified by the American College of Lifestyle Medicine. The International Board of Lifestyle Medicine certifies physicians and allied healthcare providers who train and practice outside of the United States.  These pathways include continuing medical education specific to the six pillars of wellness accomplished through a combination of in-person and virtual training. 

Physicians also complete a case study. Recertification is required every 10 years, and maintenance of certification pathways is available. The ABLM is currently in the process of becoming formally recognized by the American Board of Medical Specialties, and despite this standard process, most of the education and training in LM provides category 1 AMA certified medical education. Expertise in LM supports the Defense Health Agency’s Quadruple Aim, which drives critical initiatives focused on better care, encouraging healthy behaviors, improving medical force readiness, and lowering costs.

Case Study

Here is an overview of one patient’s encounter with an LM-trained physician and the significant impact it had on his health. This patient has provided consent and permission to share medical information/health history. Maj LJ is a 35-year-old black male flyer who voluntarily elected to participate in an L&PM consultation in an effort to improve his health, evaluate his current health status, and improve his energy. During this L&PM session, LJ was identified by his primary care/L&PM provider as having type 2 diabetes (hemoglobin A1C 6.9% after repeat testing), hypercholesteremia (LDL: 223 mg/dL), hypertension (stage I), impaired fasting insulin, an unhealthy body mass index (BMI) (28.6) with excess central adiposity, chronic fatigue, low energy, brain fog, poor sleep habits, and suffering performance at work. As a result of these underlying health issues, LJ was medically disqualified, grounded from flying duties, required a health waiver and a medical profile, and was forced to forego his upcoming deployment. He was provided with the options for how he could approach his current medical diagnoses: through strategic lifestyle changes or pharmaceutical management. He elected a trial of strategic lifestyle changes. During this process, LJ accomplished the following baseline LM metrics, which included a combination of screening items that encompass the six pillars:

• BMI
• Body fat composition
• Blood pressure
• Total natural fiber intake (fruit/vegetable/whole grain portions daily)
• Sugar-sweetened beverage intake and frequency
• Caffeine, alcohol, and tobacco (intake/frequency)
• Stress scale and modification assessment
• Physical activity 
• Sleep quality assessment
• Cognitive wellness
• Quality of life assessment
• Occupational performance and satisfaction assessment
• Deployment readiness assessment

He received counseling in the six pillars of LM and set his own personal SMART goals: lose weight, drop LDL cholesterol, and improve hemoglobin A1C and fasting blood glucose. Perhaps, most important, he chose to have an open mind when approaching L&PM. Maj LJ received standard diabetic screenings as well as education in whole food/plant-based nutrition. For his first L&PM intervention, he decided to commit to a simple nutritional change in his lifestyle that involved starting with a 7-day whole food/plant-based challenge. He was closely followed by his physician, who utilized the stages of change model, motivational interviewing, and health coaching techniques to provide support, build confidence, and set accountability. 

After a 3-month intervention, his hemoglobin A1C dropped from 6.9% to 6.3%, his fasting blood glucose dropped 10 points, and his LDL dropped from 223 to 138. His BMI also decreased from 28.6 to 26.7, and he lost 35 pounds. LJ was amazed and became fully committed to maintaining this healthy lifestyle. Three years later, LJ has kept his hemoglobin A1C trending downward, and his diabetes remains in remission through sustainable lifestyle choices. He successfully controls his medical diagnoses without medication, is fully deployable, and serves on active duty. Most importantly, LJ has showcased and modeled his own health victories for his children and family members, who have subsequently changed their own lifestyle habits. 

Maj LJ reported that it was the simple act of a medical professional giving him the option regarding how he could address his own health that ignited his drive to take matters into his own hands. He reports being about 80-90% plant based as is his family, and his health is progressing in a favorable trajectory. LJ’s story is not an anomaly or a one-off health victory in flight medicine. Since 2017, hundreds of similar health successes have been documented within that operational medical readiness L&PM clinic.

USAF Lifestyle & Performance Medicine Working Group 

The USAF Lifestyle & Performance Medicine Working Group (L&PM WG) was chartered in 2019 to align and expand the L&PM initiative across the Air Force Medical Service. It has grown from the original 10 core members to include a coalition of the interested that has more than 175 joint service and civilian members. The L&PM WG focuses on seven lines of effort: research, education, key leader engagement, grass-roots initiatives, clinical implementation, policy and advocacy, and building a culture of health. Recent lifestyle medicine publications include original research on BMI in active duty military14 and the association between health-related behaviors and the odds of hospitalization for COVID-19.15 

USAF L&PM WG Highlights

• Incorporated lifestyle medicine into 19 DoD clinical sites (CONUS and OCONUS) 
• Participated in 50 healthcare education events including the CHAMP TFF Summit and the Romanian Society of LM Inaugural Congress reaching over 2,000 personnel 
• Implemented the multi-year LM residency curriculum training at five DoD Accreditation Council for Graduate Medical Education residencies
• Over 100 LM-certified military-affiliated healthcare professionals since 2017
• Published nine evidence-based articles on L&PM
• Established five L&PM medical subspecialty champion representatives 
• Received approval for USAF LM special experience identifier designation for physicians and other medical professionals (available 30 April 2022)

Conclusions

Lifestyle medicine focuses on prevention, treatment, and reversal of lifestyle-related disease. Through implementing the LM model of care delivery, patients become their own agent of change with guidance from LM-trained healthcare professionals. LM-certified professionals offer medical expertise along with strategic recommendations and encouragement throughout the process. There is a growing body of medical literature that supports LM and many case studies that demonstrate its potential to improve the health of patients. The USAF L&PM WG is a multi-disciplinary community of medical professionals dedicated to incorporating L&PM into military medicine. With successful integration of L&PM, the DoD will appreciate a significant decrease in chronic disease risk, burden, and comorbidity sequelae, as well as minimized profile metrics for optimal readiness, deployability, and lethality. Flight surgeons and other healthcare professions who participate in the care of aviators are uniquely positioned to provide root-cause analysis of human performance shortfalls and apply clinical skills in L&PM. The practice of L&PM provides healthcare professionals with the skills to help facilitate the prevention and reversal of today’s health threats in an effort to optimize the wellbeing of tomorrow’s aviators. 

References

1. Schulkin J, McEwen BS, Gold PW. Allostasis, amygdala, and anticipatory angst. Neurosci Biobehav Rev. 1994; 18(3):385-396.
2. Frueh BC, Madan A, Fowler JC, Stomberg S, Bradshaw M, et al. “Operator syndrome”: a unique constellation of medical and behavioral health-care needs of military special operation forces. Int J Psychiatry Med. 2020; 55(4):281-295.
3. U.S. Air Force. Aerospace medicine enterprise. Washington (DC): Department of the Air Force; 2014. Air Force Instruction 48-101. [Accessed 19 Jan 2022]. Available from https://static.e-publishing.af.mil/production/1/af_sg/publication/afi48-101/afi48-101.pdf.
4. Buttorff C, Ruder T, Bauman M. Multiple chronic conditions in the United States. Santa Monica (CA): RAND Corporation; 2017. 
5. Congressional Research Service. U.S. health care coverage and spending. Updated 2021 January 26. [Accessed 19 Jan 2022]. Available from https://sgp.fas.org/crs/misc/IF10830.pdf.
6. Centers for Disease Control and Prevention. Chronic diseases and military readiness. 2021 November 8. [Accessed 19 Jan 2022]. Available from https://www.cdc.gov/chronicdisease/resources/publications/factsheets/military-readiness.htm. 
7. Centers for Disease Control and Prevention. The health effects of overweight and obesity. 2020 September 17. [Accessed 19 Jan 2022]. Available from www.cdc.gov/healthyweight/effects/index.html.
8. Meadows SO, Engel CC, Collins RL, Beckman RL, Cefalu M, et al. 2015 Health Related Behaviors Survey: health promotion and disease prevention among U.S. active-duty service members. Santa Monica (CA): RAND Corporation; 2018. [Accessed 2 Nov 2021]. Available from https://www.rand.org/pubs/research_briefs/RB9955z2.html.
9. Centers for Disease Control and Prevention. Prediabetes – your chance to prevent type 2 diabetes. Updated 2020 Jun 11. [Accessed 2 Nov 2021]. Available from https://www.cdc.gov/diabetes/basics/prediabetes.html#:~:text=Approximately
   %2088%20million%20American%20adults,t%20know%20they%20have%20it.
10. Defense Manpower Data Center. DoD personnel, workforce reports & publications. Military and Civilian Personnel by Service/Agency by State/Country: June 2021. [Accessed 2 Nov 2021]. Available from https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports.
11. Paris RM, Bedno SA, Krauss MR, Keep LW, Rubertone MV. Weighing in on type 2 diabetes in the military: characteristics of U.S. military personnel at entry who develop type 2 diabetes. Diabetes Care. 2001; 24(11):1894-1898.
12. American College of Lifestyle Medicine. Evidence overwhelmingly supports efficacy of lifestyle medicine. (n.d.). [Accessed 6 Nov 2021]. Available from https://www.lifestylemedicine.org/Scientific-Evidence. 
13. Liu L, Wang S, Liu J. Fiber consumption and all-cause, cardiovascular, and cancer mortalities: a systematic review and meta-analysis of cohort studies. Mol Nutr Food Res. 2015; 59(1):139-146.
14. Clerc PG, Mayer SB, Graybill S. Overweight BMI (25-29) in active duty military: excess fat or more lean mass? A look at the evidence. Mil Med. 2021; usab447. Online ahead of print. 
15. Webber BJ, Lang MA, Stuever DM, Escobar JD, Bylsma VF, Wolff GG. Health-related behaviors and odds of COVID-19 hospitalization in a military population. Prev Chronic Dis.  2021; 18:E96. 

Authors

Regan A. Stiegmann, Maj, USAF, MC, FS, DipABLM
Flight Surgeon, Lifestyle & Performance Medicine Specialist
U.S. Air Force Academy
Vice Chair, USAF Lifestyle & Performance Medicine Working Group

Chelsea B. Payne, Lt Col, USAF, MC, FS, DipABLM
Command Preventive Medicine Physician
U.S. Africa Command

Date: 04/29/2022

Source: Lt Col Chelsea B. Payne