In Conversation with Randall Stafford: Global and Personal Prevention Strategies and Lifestyle Choices that Exemplify Healthy Living

FOREWORD With a fondness for all creatures in the world and a vision for a holistic management of health care and public health, Prof. Randall Stafford accepted the interview invitation on a lovely summer night in Beijing, China. Prof. Stafford is a Professor of Medicine at the Stanford University School of Medicine where he directs the Program on Prevention Outcomes and Practices and a Fellow of the Stanford Center at Peking University. While he first trained in public health, including health administration and epidemiology, his clinical training is in primary care internal medicine, which gives him a broad overview of patients and population health. With a successful career in research and academic medicine at Massachusetts General Hospital and Stanford University, Prof. Stafford has directed his attention to contemplating needed changes in the direction of modern medicine and medical education. Heart and Mind explores these questions in conversation with Prof. Stafford with many tangents into his lived experiences. Dear readers, we hope you enjoy the conversation as much as we did. QUESTION 1 As a world-renowned expert, you have been dedicated to population health outcomes for decades and have published more than 200 peer-reviewed papers, with an h-index on Scopus of 72. Among all of your excellent publications and achievements, what are the most important to you? Prof. Stafford Three clusters of scientific papers are especially important to me. First, many of my early articles focused on how the US health-care system does not work well to provide evidence-based care. Even though this conclusion may seem obvious now, this was not as widely acknowledged when I began my research. Among my early articles, several indicated that the use of cesarean section was highly influenced by nonclinical factors, including patient income, patient race/ethnicity, insurance status, type of hospital, and time of day.R1-R4 This success while still in medical school demonstrated the potential impact of examining clinical practice patterns for both quality of care and health disparities. Second, many of my more recent articles focus on new ways of providing prevention and chronic disease management to improve the quality of care and patients’ medical care experience. My clinical trials over the past two decades have rigorously tested new approaches to delivering health care. These trials have examined reengineering health care through new digital applications,5,6 reporting practice data to providers,7 nonphysician health professionals,8 community health workers,9 and patient self-management.10 Finally, I have been vocal in editorials promoting major reforms in health-care systems in both the US and globally. Many nations, including China, have been overly eager to adopt features of the US health-care system despite its inherent problems with quality of care, inefficient resource use, and health disparities. I have been vocal in calling for a prevention perspective in health care,11 better comparative effectiveness analyses of the quality and cost of new drugs and devices,R12-R14 and a more comprehensive approach to chronic disease treatment.15 QUESTION 2 Can you discuss your model of how the prevention and treatment of chronic diseases should fit together? How can public health and health-care systems as well as citizens work together to do a better job of preventing and treating disease? Prof. Stafford Population members, public health systems, and medical care systems all need to be accountable for the prevention of chronic disease, whether it is diabetes, coronary artery disease, hypertension, or atrial fibrillation. Our first goal should always be to prevent or forestall the first occurrence of disease. Much more can be done by public health systems to better facilitate healthy behaviors. We already have well-defined, evidence-based goals around physical activity, dietary practices, weight management, sleep, stress, social networks, and substance use. We need a better-funded and more vibrant public health system that facilitates healthy behaviors at both an individual and societal level. This needs to include investment to overcome significant socioeconomic barriers to improved health behaviors. Greater responsibility for health also needs to be placed on patients themselves because otherwise the strategies suggested by health care and public health systems will not be adopted. As a doctor, I can only recommend, I cannot mandate. Hence, frequently, my first step is to engage and empower patients through the idea that they can and should help manage their own conditions. Effective use of health behavior change can prevent a multitude of downstream problems, including cardiovascular disease, metabolic conditions, and mental health disorders. Many other conditions show promising prevention results, including cancer, cognitive decline, susceptibility to infections (like COVID-19), and fertility problems. Once individuals have developed clinical conditions, we need to continue with the initial therapies. The strategies that work for prevention can also contribute to treatment. All too often, however, current models of treatment often abandon health behavior change strategies in favor of drug treatments. Not only do we need to continue standard prevention approaches as part of treatment but we also need to add more intensive, patient-specific health behavior approaches. For example, patients can help manage their high blood pressure by maintaining a healthy weight, eating a healthy, largely plant-based diet, reducing sodium intake, engaging in regular physical activity, and managing their sleep, stress, and social networks. Or, for example, greater attention to diet and weight management should be recommended for people with newly diagnosed Type 2 diabetes. Those with chronic conditions may also benefit from specific mind–body strategies. For example, walking meditation could be suggested for those with depression and/or anxiety. Only after basic and more intensive health behavior strategies have been fully deployed, we should reach for the prescription pad. At this point, all of the previously deployed strategies should be maintained or intensified. Health behavior strategies can reduce the number and doses of medications needed. In addition, many health behavior approaches help increase the biological effectiveness of drug treatments. Finally, health behavior approaches may be critical in reducing disease progression better than drug treatment, as is well known in heart failure and chronic kidney disease. The typical use of drugs alone as treatment is not only short-sighted but it also reduces effectiveness. Treatment should be comprehensive and include multiple strategies simultaneously. This model of prevention and treatment is illustrated in Central Illustration. QUESTION 3 What led you to become an ovo-lacto vegetarian? Would you like to share your favorite recipe? Prof. Stafford I appreciate your question. I have been an ovo-lacto vegetarian for my entire adult life, now for 48 years. I came to be a vegetarian for multiple reasons: (1) Health benefits: Eliminating meat from my diet made me feel better, and I knew it was healthier for my long-term health. Even in 1976, research studies indicated this; (2) Less environmental impact: The book, Diet for a Small Planet by Frances Moore Lappé,16 shaped my thinking. We know much more now, but even 50 years ago, there was good evidence that the environmental damage from a meat-centered diet is much more than that of a plant-based diet; (3) More efficient worldwide food production: I also knew that a vegetarian diet was better suited for providing adequate nutrition to the entire planet’s population. This remains true, even with the dramatic increases in agricultural productivity and the shift in global diets toward more meat; and (4) Care for other living beings: I feel strongly we need to care about other living beings on the planet. From a very young age, I felt a close kinship with nature and all animals. Eating a vegetarian diet honors animals and is a mode of doing less harm in the world. Many of my favorite recipes include eggplant. Eggplant is one of those versatile vegetables that is high in fiber and nutrients. I very much enjoy the taste of eggplant, although I know that not everyone agrees. A few of my favorite dishes include: (1) Chinese-style stir-fry with eggplant, (2) vegetarian Greek moussaka with eggplant and zucchini squash, and (3) Baba Ganoush, a Middle Eastern spread with roasted eggplant. QUESTION 4 The Wellness Living Laboratory (WELL)-China initiative, part of Stanford’s WELL, investigates the interplay among health behaviors, well-being, and the development of chronic disease. As the founding director of the project, you have been to China many times. Could you please share your insights from these visits? Prof. Stafford I have long been interested in China and its public health. In 2012, I was selected to develop and initiate a partnership between Stanford University and a Chinese academic institution. My goal was to create a living laboratory where the issues of well-being, health behaviors, and disease development could be rigorously studied in a large population. My first travel to China involved a 2-month visit to several leading Chinese universities. At each location, there was a vigorous exchange of ideas about population health and wellness. I presented my viewpoint that ultimately population member well-being should be the goal of a combined public health and medical care system. From my very welcoming hosts, I learned so much about Chinese health care and public health, Chinese health policy strategies, traditional Chinese medicine, and Chinese culture and politics. As in many other countries, it was clear that China’s incredible success with economic development had created a rising tide of noncommunicable diseases that required new approaches. I witnessed this firsthand in traveling to Beijing, Shanghai, Suzhou, Nanjing, Hangzhou, and Xi’an. I was constantly impressed by my Chinese counterparts’ collegiality, frankness in acknowledging the rise of cardiometabolic diseases, and creativity in contemplating solutions. Furthermore, 2013 was a time of increased openness between the US and China, which I sincerely hope will return in the near future. Ultimately, we created the WELL-China Project in collaboration with Zhejiang University in Hangzhou. The Stanford-Zhejiang initiative worked closely with neighborhood health centers in Hangzhou as well as the city government to create a WELL-China cohort of 10,000 residents who completed a standardized examination and questionnaire.17 While I reluctantly needed to step away from leading this project, I remain proud of my role in initiating the project. Since starting the WELL-China Project, I have also collaborated with other Chinese health-care researchers. For example, I am deeply involved in work with Prof. Yi Song, who directs the Institute for Child and Adolescent Health at Peking University’s School of Public Health. This has led to many key studies on patterns of obesity, physical inactivity, and myopia among Chinese schoolchildren.R18-R20 QUESTION 5 In your clinical and teaching experience, are there patients or cases that impressed you? Prof. Stafford Throughout my career, I have been equally involved in practicing clinical internal medicine and conducting public health research. The clinical experience of providing chronic disease treatment and teaching clinical trainees remains extremely significant to me. My favorite days of the week are going into the clinic to see patients and to help train the Stanford internal medicine residents. My early clinical training in medical school began in the late 1980s. At that time, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) were very prominent problems within the US, particularly in San Francisco. I saw firsthand how the medical community came together to ensure that we were providing high-quality, compassionate, and evidence-based care to people with HIV/AIDS. It was an example of physicians prioritizing doing the right thing by caring about their patients. I saw the courage of patients and doctors working together to cope with a disease that seemingly came out of nowhere. My experience with HIV/AIDS contrasts with the dynamics of the COVID-19 pandemic. In many countries, health-care systems, clinicians, and population members have yet to develop a coherent approach to the realities of COVID-19. This continues today with resistance to public health measures, vaccine hesitancy, uncertainty about social distancing and isolation measures, and profiteering on testing and vaccine sales. As a clinician, I have personally struggled with the conundrum of taking care of patients who acquire COVID-19 because they were not vaccinated and/or did not take appropriate transmission reduction measures. QUESTION 6 What kind of physician, cardiologist in particular, do you expect in the future? What professional skills and medical literacy are necessary for a qualified cardiologist? Prof. Stafford My own training is in general internal medicine. I chose such broad training because it provides me with an overview of the patient population. I chose not to go into cardiology, even though much of my research focuses on cardiovascular disease. For both cardiologists and internal medicine physicians, three new skills are needed in the coming years that medical schools and residency programs are not doing enough to foster. Ability to communicate in plain language with patients Clinicians need the ability to communicate with patients in a way that patients truly understand and can engage with. This skill is separate from the technical expertise of clinicians which is often prioritized in medical training. We are in an era where we have very sophisticated drugs, devices, and procedures that help us take better care of patients. However, many patients often feel alienated by the complexity of the health-care system and need physicians who can play the role of coach, guide, and advocate. In particular, clinicians must recognize that different patients will require different approaches to communication, which in most cases are distinct from what the doctor might prefer for herself or himself. Ability to think statistically and explain probabilities Health-care systems tend to offer patients procedures without necessarily ensuring that patients fully understand what they are getting into. In the future, clinicians will have to be much more statistically literate. They will need to think in statistical terms and explain probabilities to patients in plain language. Hopefully, physicians will begin to use new digital tools to help present complicated data in ways that patients can readily comprehend. Ability to use whole-person thinking that accounts for both mind and body functioning together This is central to the World Health Organization’s definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”21 Clinical subspecialization often leads us to think of diseases in very mechanistic and/or biochemical terms. In heart disease, for example, when we are not using analogies to plumbing, we tend to focus on the biochemistry of the arterial endothelium. We sometimes forget that the whole person experiences the state of disease, not just the coronary arteries. Due to the bidirectional influences that mind and body have on each other, we need to treat and empower the “mind–body.”22 QUESTION 7 You have served on a number of expert committees, including for the California’s Medicaid program, the National Committee on Quality Assurance, the American Heart Association, and the American College of Preventive Medicine. In consideration of your extensive experience of dealing with organizations and journals, could you please give some advice for the development of Heart and Mind? Prof. Stafford I very much agree with the basic concepts on which Heart and Mind was founded.22 There are strong, often bidirectional connections between heart health and our subjective, cognitive, social, and emotional lives. I see several major tasks ahead in making this insight more central to health care and public health. First, we need to articulate why it is that clinicians ought to adopt this broader view of human disease. Heart and Mind should advocate for this viewpoint not only for patients but also for clinicians. I feel that it is vital to communicate how a broader conceptualization of mind and body can make clinicians more effective at helping patients. This is particularly the case because so much chronic disease depends on health behaviors that themselves depend on how we think about our health and our environment. Second, much can be done to different models of health care. In the US, there is a very prominent toward the of medicine strategies in health care. often, medicine, however, is by those who have by disease. It be better to offer other health strategies within medicine. This be especially for those conditions where medicine often such as and not by practices, such as and should be and studied as part of clinical care. I have these help people better health and health behaviors. However, more evidence is needed about which work and how they can be into medical For example, a is needed in a population with high blood pressure to the that the of could have an in blood In each of these three we need to expect some of resistance from cardiologists and other clinicians who are not to thinking in a mind–body I am very that over the however, we will have both the evidence and the will to medicine in this which can to better patient outcomes and greater for clinicians. QUESTION How do you personally approach your own health and Prof. Stafford My own is very much toward healthy I feel that it is critical for physicians and health to the Chinese or as we in practice what we need to the health behaviors and strategies that we our patients to take I have lived my with kidney disease, which was years I was on for a and have two kidney from With this medical it has always been vital for me to be an of my own I a largely plant-based diet, with only and I vegetables and as well as whole while my of and My use of is to a of week such as when with or I of physical I a of and through and and on have me to travel enough to in the and culture of I am This has been especially of my in China. several I have had a much at Zhejiang and than I have For example, in I my as part of my Chinese that completed the My is also I especially when I am more Finally, I am to that I feel improve my well-being, and work Living a that can be an example for patients is important to me. has been the not only the interview but also the of Prof. Randall for the the health of and the whole and the of other living In the Prof. Stafford on ways to improve the health-care system and the general health of the are significant in and change are for both health care and public health systems to provide better chronic disease and prevention approaches have been the potential of health-care including using digital nonphysician health-care and strategies. 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