By Liora Engel-Smith

Carolyn Nicholson has been on the diet treadmill for much of her life. The so-called “ketogenic” diet, one low in carbs and high in fat and protein, was the latest diet the 64-year-old was on.

Nicholson, who lives on the Outer Banks’ Roanoke Island, said that approach served her well for a time, she lost weight and kept it off. But the high-fat diet made her cholesterol levels climb, first a little, then enough for her doctor to recommend cholesterol medication.

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Nicholson was hesitant — she didn’t want a prescription. There had to be another way, she thought. That’s when Nicholson met Christina Bowen, a family doctor who specializes in lifestyle medicine. A relatively new specialty that emerged in recent decades, lifestyle medicine doctors help patients get a handle on healthy behaviors, from getting enough sleep to reducing stress, developing an exercise routine and eating more fruits and vegetables.

Doctors and public health practitioners know that health behaviors are an important component of health. A 2007 paper in the influential New England Journal of Medicine ranks health behaviors as far more important than access to medical care when it comes to mortality and morbidity. Behavior even trumps genetics and social characteristics in its degree of influence over health outcomes.

Focusing on that behavior component, Bowen said, can have powerful results, not only in preventing and reversing diabetes and heart disease but also in preventing cancer in high-risk patients. These diseases have a couple of things in common: They disproportionately affect rural populations, and lifestyle modifications can reduce the risk of getting them.

“We know that cancer prevention is not something that people talk about from a lifestyle modification perspective,” Bowen said.

But the link between obesity and a higher cancer risk is well-established for breast, ovarian and colorectal cancers, to name a few.

And Bowen’s Outer Banks Hospital Center for Healthy Living is in the middle of an area of the state where some of these cancers strike all too frequently.

A cancer hot zone

Eastern North Carolina has some of the highest cancer rates in North Carolina, and residents from several area counties, including Washington, Halifax and Pasquotank, are among the top 10 counties with the highest cancer deaths in the state. The picture isn’t much better when it comes to breast cancer. Several eastern North Carolina counties, including Martin, Vance and Nash have higher breast cancer death rates than other North Carolina counties.

A map of cancer incidence rates by county in 2017
Source: NCDHHS.

That’s why Bowen set her sights on working with breast cancer survivors, through an initiative that refers oncology patients to her center after an evaluation of their risk. These high-risk patients — more than 60 to date — arrive at Bowen’s practice through a referral from Charles Shelton after a genetic screening and an initial evaluation for cancer risk, with the goal of preventing a second cancer.

Two doctors in white coats stand in a hallway of a center where they address cancer risk with lifestyle change
Doctors Christina Bowen and Charles Shelton. Photo credit: Vidant Health

“We don’t tell you what you need to change,” said Shelton. “We tell you, ‘Look, here are 10 things you do that we know are bad, you could pick any one of those and make a difference.’”

Bowen then meets with the patients and helps them set goals that would reduce their risk — including incorporating more plant products into their diets, increasing exercise, losing weight and quitting smoking.

Bowen sees relationships with patients as one of collaboration, mentoring and support. The lifestyle physician provides resources and encouragement as patients take steps to change their lifestyles.

Bowen uses the same approach with the breast cancer cohort as she does with other patients, including Nicholson, the 64-year-old who had high cholesterol. Bowen helped Nicholson move from her high-protein diet to a plant-based way of eating — concentrating on whole foods, fruits and vegetables and minimizing animal products. Nicholson was apprehensive about that overhaul at first.

“I was kind of scared about it,” Nicholson said. “This is totally different. Am I going to be able to do it?”

‘Change their lives for the better’ 

Health behaviors are notoriously difficult to influence in a clinical setting. Medical providers spend an average of 15 minutes or less with their patients. Providers may spend as little as five minutes to one minute per topic, hardly enough time to talk about lifestyle choices, beyond the basics.

But Shelton and Bowen’s approach relies on in-depth conversations with patients. And it seems to be working. The two recently published a paper in the journal Oncology Issues that shows all patients in the cancer cohort met one health goal that lowered their risk of a second cancer. Most patients — 80 percent — met all of their health goals.

“We partner with our patients, it’s not a hierarchy,” Bowen said of the reasons for the program’s success. “I’m here to help them change their lives for the better.”

A physician sits behind a desk talking to an older woman
Dr. Christina Bowen of Outer Banks Hospital. Photo credit: Vidant Health

Bowen and Shelton are looking to expand the program to other areas of eastern North Carolina, and to other types of chronic diseases.

“Our goal is to really pilot this locally and then magnify [this approach] to the rest of North Carolina,” Shelton said.

One habit at a time

Nicholson, the patient from Roanoke Island, may have not been confident in her ability to change her diet at first, but she’s made progress in the three months she’s worked with Bowen.

Nicholson added more salads to her meals. She’s tried new plant-based recipes Bowen shared with her. Gradually, Nicholson amassed a collection of cookbooks and go-to recipes. She’s learned to substitute high-fat dairy sauces with cream sauces made of cashews, for instance.

The results soon followed. Nicholson’s cholesterol dropped to normal levels. Her energy levels also increased. Bowen’s greatest power is her enthusiasm and her ability to help people unstick old habits, Nicholson said.

“We can get stuck in our routine and our lifestyle, and we just need someone that knows a lot and is encouraging,” she said.

With her new way of eating firmly established, Nicholson now has a new goal. As Bowen put it to Nicholson in one meeting, the next new habit is “exercise, exercise, exercise.”

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Liora Engel-Smith joined NC Health News in July 2019 and covers policies, programs and issues that affect rural areas. She has previously worked for the The Keene Sentinel in New Hampshire and the Muscatine...

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