There is no longer any serious doubt that what each of us does in our daily lives profoundly affects our short- and long-term health and quality of life. An overwhelming body of scientific and medical literature supports this idea. But are we really utilizing this evidence to help achieve better health and quality of life for our patients and in our own lives?
Hundreds, if not thousands, of studies provide evidence that regular physical activity, maintenance of a healthy weight, not smoking cigarettes, and following sound nutritional and other health promoting practices all profoundly impact health. The strength of the literature supporting the positive effects of daily habits and actions is underscored by their incorporation in virtually every evidence-based clinical guideline addressing the prevention and treatment of metabolic diseases. For example, the following guidelines and consensus statements all incorporate significant emphasis on lifestyle medicine principles and practices as a key component of either the prevention or the treatment of disease:
- 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults1
- 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults2
- 2015-2020 Dietary Guidelines for Americans3
- American Heart Association Strategic Plan for 20204
- Preventing Cancer, Cardiovascular Disease and Diabetes: A Common Agenda for the American Cancer Society, the American Diabetes Association and the American Heart Association5
- 2018 Physical Activity Advisory Committee Scientific Report6
The power of daily practices, when incorporated into a positive lifestyle, has been demonstrated in multiple randomized controlled trials and cohort studies. For example, the Nurses’ Health Study concluded that >80% of all heart disease and >91% of all diabetes in women could be eliminated if they would adopt a cluster of positive practices, including maintenance of a healthy body weight (body mass index of 19–25 kg/m2); regular physical activity (30 minutes or more on most days); avoiding tobacco products; following a few, simple nutritional practices, such as increasing whole grains and consuming more fruits and vegetables; and consuming 1 alcoholic beverage per day.7 The US Health Professionals Study8 showed similar, dramatic risk reductions in men from adopting these same lifestyle behaviors. Multiple randomized controlled trials also support the health benefits of positive lifestyle habits.
Many physicians are surprised to learn that negative lifestyle practices profoundly increase the risk of cancer. Of course, physicians recognize that cigarette smoking is the leading cause of lung and some other cancers.9However, the American Institute for Cancer Research10 and the International Agency for Research on Cancer11concluded that there is sufficient evidence to link 13 human malignancies to excess body fatness. Excess body fat is the second leading cause of preventable cancer, following only cigarette smoking. An inactive lifestyle has also been linked to increased risk of cancer.
With all of these powerful examples of the profound impact of lifestyle on health, how are we in the medical community doing at helping our patients adopt positive lifestyle habits? Sadly, very poorly. Less than half of the adult population in the United States meet minimum requirements for aerobic exercise12 Less than 20% of adolescents get enough physical activity to result in health benefits.13 More than two-thirds of the adult population in the United States is either overweight or obese. Less than one-third of the population consumes adequate servings of fruits and vegetables and follows other simple evidence-based nutritional principles related to good health. The prevalence of diabetes has doubled in the United States in the past 20 years. More than one-third of the adult population in the United States has high blood pressure, and if the new blood pressure guidelines from the American Heart Association and American College of Cardiology are widely adopted, the number reaches a staggering 46%.1
How can we explain these grim statistics? The answer is both simple and complex. The simple answer is that very few people are taking positive steps in their daily lives to lower their risks of chronic disease. In fact, when the American Heart Association published its Strategic Plan for 2020, which outlined a series of lifestyle steps to lower the likelihood of developing heart disease, only 5% of people achieved what the American Heart Association has classified as “optimal cardiovascular health.” This abysmally low finding has been replicated in numerous other studies.
But the answer is also complex. Behavior change is hard, and there are multiple factors in our daily lives that mitigate against it. Increased screen time has clearly lowered levels of physical activity and increased sedentary living. Abundant, calorie-laden food is readily available and has resulted in an increase of >450 daily calories for every man, woman, and child in the United States over the past 30 years.14
What should we in the medical community be doing? Once again, the answer is both simple and complex. The simple answer is that we need to discuss positive lifestyle measures and their impact on health with every patient we see. The complex answer is that many aspects of medical practice make such discussions difficult, including time demands, lack of reimbursement, lack of knowledge and education in these areas among physicians, and perhaps most disturbing, skepticism that our patients will truly change their behavior. Unfortunately, <40% of physicians routinely counsel their patients on lifestyle issues.15 This represents a squandered opportunity, because >70% of adults see a primary care physician on at least an annual basis.16 Furthermore, physician recommendation has been shown to be one of the most powerful predictors of behavior change.
We need to launch an emphasis on the health-promoting benefits of lifestyle habits and put these habits into practice for our patients and in our daily lives. If we are truly going to practice evidence-based medicine, we (and our country) can no longer afford to ignore the overwhelming evidence that daily habits and actions profoundly impact not only health outcomes but also cost of care.
Although many investigators have been active in this broad area over the past few decades and many constructs have been developed to promote the concept of the power of habits and actions, I believe that this field will coalesce under the rubric of “lifestyle medicine.” I have been making this argument for >20 years. In fact, the field of lifestyle medicine was first named in the academic literature with the publication of the first edition of my comprehensive textbook of that name in 1999.17 The basic concept of incorporating lifestyle in both the prevention and treatment of disease has become even more urgent in the past 20 years. I am hopeful that the publication of the third edition of my textbook (due Spring, 2019) may have a greater impact!18
There are signs that the concept of lifestyle medicine is beginning to take hold. As a cardiologist, I was pleased that the council within the American Heart Association that I sit on changed its name in 2013 from the Council on Nutrition, Physical Activity, and Metabolism to the Council on Lifestyle and Cardiometabolic Health. The American Academy of Family Practice has inaugurated a study track in lifestyle medicine, as has the American College of Preventive Medicine. A fledgling healthcare organization, the American College of Lifestyle Medicine has been launched and has doubled its membership each year for the past 5 years.
One final plea—physician heal thyself! A distinct minority of physicians practice the components of positive lifestyle in their own lives. Yet we know that those physicians who engage in regular physical activity and follow sound nutritional principles while maintaining a healthy body weight are much more likely to counsel their patients in these areas than those who do not. Furthermore, such practices as regular physical activity may help ameliorate the increasingly worrisome problem of physician burnout.
Employing the principles of lifestyle medicine in the daily practice of medicine represents a substantial opportunity to enhance the value equation in medicine by improving outcomes for our patients and simultaneously controlling costs.19 The time has come to truly practice lifestyle medicine and encourage positive lifestyle decisions for our patients and adopt them in our own lives. Our patients and our country should demand nothing less.
To read this article in its entirety please visit our website.
-James M. Rippe, MD
This article originally appeared in the January issue of The American Journal of Medicine.
