Lifestyle medicine board practice questions, with answers

Answer: C. Mediterranean diet with extra-virgin olive oil or nuts

PREDIMED randomized about 7,400 Spanish adults at high cardiovascular risk but without established cardiovascular disease to a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with mixed nuts, or a control diet with advice to reduce dietary fat. Both Mediterranean arms had roughly a 30% relative reduction in the composite of myocardial infarction, stroke, and cardiovascular death. The original 2013 report was retracted and republished in 2018 after randomization irregularities were identified at some sites; the reanalysis gave similar results. The reduced-fat advice was the comparator that performed worse, and antioxidant vitamin supplementation trials have not shown cardiovascular benefit. Very-low-carbohydrate diets and intermittent fasting have no comparable hard-outcome trials.

Reference: PREDIMED (Estruch et al.), NEJM 2018

Answer: C. Add muscle-strengthening activity involving all major muscle groups on 2 or more days per week

His 200 minutes per week of moderate-intensity walking already falls within the adult aerobic target of 150–300 minutes of moderate-intensity (or 75–150 minutes of vigorous-intensity) activity. The remaining gap is the separate recommendation for moderate- or greater-intensity muscle-strengthening activity involving all major muscle groups on 2 or more days per week. More walking would add benefit but does not address the missing component, and there is no separate vigorous-intensity requirement because moderate and vigorous minutes are interchangeable (1 vigorous minute counts as about 2 moderate minutes). Flexibility work is not a key guideline for adults, and balance training is specifically emphasized for older adults as part of multicomponent activity.

Reference: Physical Activity Guidelines for Americans, 2nd ed. (2018)

Answer: B. Contemplation

Contemplation is defined by an intention to change within roughly the next 6 months, with awareness of the problem and ambivalence about acting. This patient acknowledges the need, expects to start within months, and cites a barrier that keeps him from committing. Precontemplation involves no intention to change in the foreseeable future. Preparation requires an intention to act within about the next 30 days, usually with small steps already taken, such as researching a gym or buying shoes. Action and maintenance require that the change has already begun, with maintenance starting after about 6 months of sustained change.

Reference: Prochaska & DiClemente, Transtheoretical Model of Health Behavior Change

Answer: B. Corticotropin-releasing hormone

In response to a stressor, neurons of the hypothalamic paraventricular nucleus release corticotropin-releasing hormone (CRH) into the hypophyseal portal circulation. CRH stimulates the anterior pituitary to secrete ACTH, which drives cortisol secretion from the adrenal cortex, and cortisol then exerts negative feedback on the hypothalamus and pituitary. ACTH and cortisol are downstream mediators rather than the initiating signal. Norepinephrine is the principal mediator of the sympathetic-adrenomedullary arm of the stress response, and GHRH regulates growth hormone rather than the HPA axis.

Reference: McEwen, N Engl J Med 1998; Chrousos, Nat Rev Endocrinol 2009

Answer: B. Ask him to explain in his own words what he will eat and when he will call about weight gain

Teach-back asks patients to restate, in their own words, what they need to know or do, so the clinician can confirm understanding and re-explain anything missed. It tests the clarity of the clinician's explanation rather than the patient, and it is a core health literacy universal precaution because limited health literacy is common and often not apparent. Closed questions such as asking whether there are questions or whether the plan makes sense usually draw a yes regardless of comprehension. Written materials are useful reinforcement but are often above patients' reading level and do not verify understanding, and a signed form documents the conversation without confirming that learning occurred. Plain language, a few key points per visit, and teach-back improve self-management in conditions such as heart failure.

Reference: AHRQ Health Literacy Universal Precautions Toolkit, Use the Teach-Back Method tool

Answer: B. 8 to 10 hours

The AASM pediatric consensus recommends 8 to 10 hours per 24 hours for teenagers aged 13 to 18 years. Children aged 6 to 12 years need 9 to 12 hours, children aged 3 to 5 years need 10 to 13 hours including naps, and children aged 1 to 2 years need 11 to 14 hours including naps. Adults should obtain 7 or more hours per night, so 7 to 8 hours understates the adolescent need. Large weekend catch-up sleep is a marker of chronic weekday sleep debt and worsens circadian misalignment rather than fully repaying it.

Reference: AASM pediatric sleep duration consensus, J Clin Sleep Med 2016

Answer: D. Refer the patient to a tobacco quitline

Ask-Advise-Refer is an abbreviated version of the 5 A's designed for clinicians with limited time. The clinician asks about tobacco use, advises quitting, and refers the patient to a quitline (1-800-QUIT-NOW in the United States) or another cessation service, ideally through a direct fax or electronic referral so the quitline contacts the patient. Quitline counseling increases quit rates, especially when combined with pharmacotherapy. Detailed assessment, quit planning, and follow-up belong to the full 5 A's and are provided by the referral resource in this model.

Reference: US PHS Clinical Practice Guideline, Treating Tobacco Use and Dependence 2008 update

Answer: E. 50%

The meta-analysis pooled 148 studies with about 308,000 participants followed for an average of 7.5 years and found a 50% increased likelihood of survival for people with stronger social relationships (odds ratio 1.50). The effect was consistent across age, sex, initial health status, and cause of death. Its magnitude was comparable to that of smoking and alcohol consumption and exceeded that of physical inactivity and obesity. Complex measures of social integration showed larger effects than simple measures such as living alone.

Reference: Holt-Lunstad, Smith & Layton, PLoS Med 2010

Answer: C. Positive social connection

The ACLM defines six pillars of lifestyle medicine: a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connection. Social connection is included because social isolation and loneliness are associated with higher mortality and cardiovascular risk. Supplementation and environmental toxin reduction are emphasized in some functional and integrative approaches but are not pillars. Spirituality can support stress management and meaning, and weight change is an outcome of the pillars rather than a separate pillar.

Reference: American College of Lifestyle Medicine, definition and six pillars of lifestyle medicine

Answer: C. Physicians with healthy habits counsel more often, and patients find their advice more credible.

Studies led by Erica Frank, including the Women Physicians' Health Study, found that physicians with healthier personal behaviours, such as regular exercise and healthy eating, were more likely to counsel patients about those behaviours. In a study in which patients viewed one of two versions of a health-education video, patients rated the physician who briefly disclosed personal healthy habits as more believable and more motivating. The association has been observed across several behaviours, including physical activity and diet, not only smoking. These findings are part of the rationale for including clinician personal health in lifestyle medicine competencies.

Reference: Frank et al., Physician disclosure of healthy personal behaviors improves credibility and ability to motivate (Archives of Family Medicine, 2000); Oberg & Frank, Physicians' health practices strongly influence patient health practices (2009)