Lifestyle medicine is evidence based medicine in which comprehensive lifestyle changes are used to prevent, to treat and even reverse the progression of chronic diseases by addressing underlying causes {1}.
LM is implemented through doctor directed interventions with patients. It is the role and responsibility of doctor to coordinate a team of health professionals to deliver on different aspects of patient lifestyle.
According to the World Health Organization 70% of global chronic diseases will be due to lifestyle by 2020. Currently the leading causes of death and disability in Ireland are due to poor diet, lack of exercise, obesity, smoking and alcohol. Lifestyle choices are the root cause of most disease, death and growing healthcare costs. The largest burden lies with weight management, nutrition, physical inactivity, stress and lack of patient insight into their own health risks {2}.
Some of those health conditions are listed below:
Diabetes
Hypertension
Hyperlipidemia / Cholesterol
Obesity
Heart Disease
Atrial Fibrillation
Strokes
Dementia
Mental health illnesses
Cancer
Arthritis, osteoporosis
Adverse surgical outcomes, prolonged hospital stays.
Lung diseases
Smoking related illnesses
Alcohol related illnesses
Gastrointestinal diseases
All of these conditions have some or all of their origins in poor lifestyle choices and in many cases these conditions are preventable and treatable by lifestyle interventions alone.
Lifestyle changes refer to:
Stopping smoking
Reducing alcohol intake
Physical activity / Exercise
Nutrition management (nutrition, diet, culinary medicine)
Stress resilience and emotion management (including happiness)
Sleep management
It is essential to tailor the approach to each individual patient. The success of this requires health coaching and motivation interviewing skills especially when 80% of people are often not “ready” to change at all. Several tools of intervention exist including VA model Whole Health Toolkit, lifestyle medicine programs and shared medical groups as examples {3,4}.
Why has Lifestyle Medicine taken on interest now? What about preventative care?
Lifestyle medicine is not just about prevention it is also about treatment and potentially reversal of chronic diseases.
LM is patient centered care; the patient is a partner in his or her own care. The patient needs to change. This requires a long-term plan and treatment. The patient is responsible for the outcomes. Medications may or may not be necessary {1}.
In a nutshell this is primary, secondary and tertiary prevention and treatment. Extra consideration has to be given to the environment that patient lives in or is exposed to.
The reasons why LM has emerged now include:
1. Cost of healthcare has risen exponentially and is not sustainable. Prevention and treatment with LM is relatively inexpensive with significant health and economic benefits for all stakeholders.
2. In USA, value based healthcare has lead to payments only when patients stay well and out of hospital for several weeks post discharge. If a patient is readmitted then payments to hospital are withheld. Payment structures are also moving to reward doctors based on patient health behavior and outcomes. SlainteCare for Ireland has identified same issues in Ireland and are encouraging society and doctors to do something about their own lifestyle to impact the health problems that exist in Ireland.
3. There are significant stress and mental health issues growing exponentially around the world. In healthcare the particular concern lies with staff burnout. In most cases stress is contributing to poor lifestyle and burnout. Doctors are leaving the profession. Suicide rates are extremely high and there is minimal support to deal with this potentially life threatening problem.
It is interesting that as doctors we are very slow to change our own habits, however we have an opportunity to adopt lifestyle medicine for ourselves in first instance and to communicate the same to all our patients: Physician self-care for health and happiness. This self-care may help us to prevent burnout and to deal more effectively with root causes {5}.
Gone are the days of smoking, drinking physicians sitting at desk and telling patients to exercise, diet and stop smoking and drinking. In fact, studies have showed that if doctors adopt lifestyle changes then their patients are 80% more likely to do the same. We are role models for our patients. We are also familiar with the challenges and rewards that change like this can bring.
Recent editorials from European Society of Cardiology, NEJM, AHA (American Heart Association), ACC (American College of Cardiology) have highlighted the importance of lifestyle medicine in medical care. Interestingly 85% of doctors claim “no one ever taught lifestyle to us in medical school”. Among Cardiology profession, AHA has told Cardiologists to take small steps with patients to encourage walking and to cut out sugar, eat more vegetables and mind their stress. But in Ireland there are few patients who are given any help to deal with these issues, except for lists of dos and don’ts and hope that they comply and get better. In all cases patients return needing more medication, more procedures, more surgeries and ultimately poorer outcomes {6-8}
There is enormous opportunity to positively impact all aspects of patient and personal health and disease risk by adopting and practicing LM. We all want to stay well, healthy and to live long. Nobody wants to end up in hospital unless absolutely necessary. Everyone wants accessible affordable healthcare that is more likely if 80% of people stay well and don’t get sick. It should be highlighted that several lifestyle medicine interventions have capacity to reverse disease at any age of life and so there is no reason for anybody to ignore this opportunity {9-12}.
The Evidence for lifestyle medicine benefit
A number of studies have shown the benefits of healthy lifestyle and lower heart disease risk factor burden on CAD outcomes and length of life. The Interheart study of over 10,000 MI patients found that risk factors accounted for 80% of risk for an MI {13}. In Chicago Heart Project over 30 years, the incidence of heart or cerebrovascular disease was rare in those with no risk factors {14}. The British Heart Foundation heart risk score (similar to Framingham) shows that less than 2 risk factors below 50 confers a 2% future MI risk compared with 65% risk if you have more than 2 risk factors {15}. Eliminating risk reduces future CV death. The same risk factors for heart disease are also a risk for non-cardiac death.
It is obvious that stopping smoking benefits all aspects of heath and reduces risk of heart, vascular, lung diseases, cancer and premature death. The same is true for lowering alcohol intake.
Physical Activity
Physical activity reduces risks for early death, colon cancer, coronary disease, breast cancer, strokes, T2 diabetes, hypertension, and metabolic syndrome. There is strong evidence that exercise prevents weight gain, reduces weight when combined with lowered calorie intake, improves lung and heart fitness, prevents falls, reduces depression, reduces anxiety and boosts cognitive function in the elderly. It also reduces lung and endometrial cancer occurrence, and improves bone density and insulin sensitivity. It betters sleep quality and improves work life balance and daily routine functioning {16,17}.
Physical activity is considered the best buy for public health (US Physical Activity Guidelines 2018). The recommended exercise is 150 -300 minutes of moderate physical activity per week {18}.
Physical inactivity is a major risk factor for disease. 50-60% of the population is affected (compared with 18% smoking, 30% cholesterol). Sitting is the new smoking! Inactivity causes 9% of premature mortality (5.3 million deaths) worldwide, compared with 5.1 million smoking related deaths {19}. Guidelines now recommend short bouts of standing and physical activity in between periods of sedentary activity even in physically active adults.
Prolonged sitting is associated with higher all cause mortality including heart and cancer {20}.
Resistance training improves muscular fitness. It is recommended to do 2 sessions per week. Better muscle function means fewer falls, better performance and less fatigue. It also reduces osteoporosis.
Emotion and mental health
Mind body medicine uses evidence-based effects of thoughts, beliefs and emotions to positively influence physical health. It employs relaxation exercises, meditation, biofeedback, hypnosis, yoga, tai chi and others to promote health and healing. The purpose is to provide for both primary and secondary prevention of disease rather than acute illnesses.
Stress is what the brain does to itself and other parts of the body when a stressor is perceived as a separation threat or challenge or even an attachment opportunity. This triggers the autonomic nervous system and inflammation response. The greatest sources of stress are due to separation such as death of spouse, divorce, jail, major personal illness etc.
Chronic stress increases risk for heart disease, strokes and cancer. It also increases the risk for lung, liver illness, STDs, mental health illnesses, autoimmune, metabolic syndrome. It leads to absenteeism, poor work performance and premature death {21}.
Dealing with stress is multifactorial, including stress management and resilience training. Life style changes are a key component of resilience as are positive psychology, mindfulness, relaxation response, coping skills, confidence, humor, altruism and strong social skills.
Stress management reduces cardiovascular disease, improves BP control, insomnia, low back pain, migraine frequency, arthritis + pain control, incontinence, disease management such as cancer treatment tolerance {1}.
Nutrition
Ireland is on its way to becoming the most obese population in world. Obesity is a condition that causes and contributes to multiple diseases and co-morbidities. It affects surgical outcomes. It leads to high rates of cancer, heart disease, strokes and falls – the 4 most common causes of death above 50 years of age in men and women.
What you eat affects your health. Changing what you eat can lower weight, offset disease risks and cure some (such as type 2 diabetes, coronary artery disease as examples) {9,12}. Lowering weight and normalizing BMI is associated with reduced risk of coronary artery disease in women. Not everyone loses weight and some may need medication and even surgery. But the benefits of changing poor nutrition habits have metabolic benefits for everyone and positively contribute to reduce cardiac risk. PURE trial found that diets including more vegetables, plants, legumes, lowered risk of heart disease and cancer. Plant based diets have also been shown to significantly lower risk for developing dementia {22}.
DIRECT trial in UK 2017 found that 12 week program of weight management (low carbohydrate diet) directed by nutrition coaching led to significant weight loss and cured diabetes in almost 60% of patients {23}. Similar studies exist in USA where successful diabetes prevention programs have been established using telehealth platforms (Fruit Street Health, Ohmada health, VitaHealth) {24}.
Ornish lifestyle program (Lifestyle Heart Trial) demonstrated reversal of coronary artery disease, improvement in angina scores and symptoms and reduction in risk with combination of diet, exercise, stress management and emotional wellbeing {11}. He also found these interventions reduced prostate cancer risk and was associated with longer life span compared with traditional western diet.
EPIC study of 23,000 people who exercised for 3.5 hours/week, not smoking, eating a healthy diet and keeping a healthy weight prevented 93% of diabetes, 81% of heart attacks, 50% of strokes and 36% of all cancers {25}.
Nutrition science shows huge variation in what is more or less healthy for the average person. In general plant based diets (lots of vegetables and greens) are associated with less heart events, strokes, and cancers {9,12}. The evidence for protein, carbohydrate, butter and fat varies depending on studies. More recent recommendations from AHA / ACC support the premise that a little bit of everything is good for you {26}. But too much of anything is bad for you, especially sugar, salt, red meat, butter, etc. Lower fat diets reduce risk of heart disease and some cancers. Value of additional supplements does not support any cardiovascular benefit at present.
Inadequate Sleep
Uninterrupted sleep of 7-9 hours is recommended for all adults over 18 years age. A poor sleep pattern is associated with increase risk for hypertension independent of diabetes and obesity {27}. Less sleep increases risk for weight gain among women. Poor sleep leads to more car accidents (22%). It doubles the risk of suicide. Poor sleep may be due to other medical conditions such as Sleep apnoea, Narcolepsy, Restless legs, Bruxism.
Regrettably most people do not consider sleep to be important so doctors are not aware of it unless they ask patients. Many factors such as mobile phone use, late nights, alcohol, and coffee consumption contribute to sleep patterns, as do medical issues such as reflux, pain and medications. Sleep hygiene is the practice of changing these habits, keeping to regular bedtime routine and going to bed at the same time every night, no gadgets in bedroom, get out of bed if not sleeping and only get back in when tired, are some options. Failing that, cognitive behaviour therapy or short-term medications are options. Latter is not as successful as people may think.
The real health benefits from LM come from addressing all risk areas and not just one. This takes time and effort to achieve best outcomes.
My interest in Lifestyle Medicine
I have worked as a Cardiology consultant for last 14 years and have always had an interest in understanding why patients develop heart disease and what is best way to deal with that. Like colleagues we put patients on tablets and do procedures but we really do very little to address underlying issues or causes of problem. High cholesterol, obesity, diabetes, uncontrolled BP, more heart disease means more tablets for patients.
Over time my patients have got more obese, less active and in general don’t really know what to do about this. I have referred several to dieticians and weight clinics but many do not attend.
Many younger patients are exercising; clean living and some have caught the attention of their parents to point where the latter have become more aware of need to change.
I too have taken on board this lifestyle mission at a personal level for weight, exercise, sleep, and stress and work life balance reasons. I feel much better and I am in better position to work with patients to empower them to do the same. It does require skills to be able to coach, motivate and empower patients to change; there are stress issues to be dealt with and the time to do this requires more than a cardiology consultation. But the real reward is seeing patients get better, lose weight, some reverse disease (as I have witnessed in diabetes patients who have lost significant weight on my clinic program). Most feel better, can exercise more, need less meds, look better, less stressed and get more positive attention from friends and family, which makes everyone happy. All these help you to live healthier and longer.
So after the recent launch of Slainte Care report, let us all acknowledge one critical aspect of its plan that lifestyle medicine is the future and we all need to learn about it for ourselves and implement it with our patients.
If you are interested in learning more for yourself or your patients please get in contact with me. Robert.kelly@beaconhospital.ie
Useful websites:
The European Society of Lifestyle Medicine
The American Society of Lifestyle Medicine
The Institute of Lifestyle Medicine
The American Board of Lifestyle Medicine
The Faculty of Sport and Exercise Medicine
References
1. Egger G, et al. Lifestyle Medicine. Third Edition Elsevier 2017.
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3. Ford ES et al. Healthy Living is the best revenge: EPIC study Arch Int Med 2009; 169(15): 1355-1362.
4. Passport to Whole Health Kit. (VA model of Whole Health Toolkit): a personal health planning reference manual. http://www.va.gov/patientcenteredcare/
5. Hill AB. breaking the stigma – a physician’s perspective on self-care and recovery. NEJM March 2017; 376 (12): 1103-05.
6. ESC August 2018.Do Cardiologists care about CV prevention? Www.medscape.com Based on EUROASPIRE V study.
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17. Lee et al. Effect of Physical inactivity on major non-communicable diseases worldwide. Lancet 2012
18. US Physical Activity Guidelines 2018 American College of Sports Medicine
19. Healy GN et al. Prolonged sitting and impact on mortality (NHANES data) Eur Heart J 2011.
20. Katzmazyk P et al. Sitting time and mortality from all causes, cardiovascular disease and cancer. Med Sci Sport Exer 2009
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22. Miller V et al. Fruit, vegetable and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study. Lancet 2017:390:2037-49.
23.Lean ME et al. Primary Care-led weight management remission for type 2 diabetes (DiRECT): an open label cluster randomized trial. Lancet December 2017.
25. Gonzalez CA et al. Diet and cancer prevention: Contributions from the European Prospective Investigation into Cancer and Nutrition study (EPIC). Eur J Cancer 2010.
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