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Lifestyle Medicine - The Future of Chronic Disease Management
Lifestyle Medicine - The Future of Chronic Disease Management
CURRENT
OPINION Lifestyle medicine: the future of chronic disease
management
Robert F. Kushner a,b and Kirsten Webb Sorensen b
Purpose of review
Lifestyle medicine is a new discipline that has recently emerged as a systematized approach for management
of chronic disease. The practice of lifestyle medicine requires skills and competency in addressing multiple
health risk behaviours and improving self-management. Targets include diet, physical activity, behaviour
change, body weight control, treatment plan adherence, stress and coping, spirituality, mind body
techniques, tobacco and substance abuse. This review focuses on the impact of a healthy lifestyle on chronic
disease, the rarity of good health and the challenges of implementing a lifestyle medicine programme.
Recent findings
Unhealthy lifestyle behaviours are at the root of the global burden of noncommunicable diseases and
account for about 63% of all deaths. Over the past several years, there has been an increased interest in
evaluating the benefit of adhering to ‘low-risk lifestyle’ behaviours and ideal ‘cardiovascular health metrics’.
Although a healthy lifestyle has repeatedly been shown to improve mortality, the population prevalence of
healthy living remains low.
Summary
Lifestyle medicine presents a new and challenging approach to address the prevention and treatment of
noncommunicable diseases, the most important and prevalent causes for increased morbidity and mortality
worldwide.
Keywords
lifestyle medicine, prevention, risk factor reduction
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Lifestyle medicine Kushner and Sorensen
Table 1. Distribution of risk factor exposure and percentage of attributable deaths from US population
Percentage of
Risk factor Exposure categories attributable deaths
the criteria for defining ‘low-risk lifestyle’ factors 0.08, respectively. The proportion of SCD attribu-
vary, these studies have shown that adherence table to smoking, inactivity, overweight and poor
to a healthy lifestyle is associated with improved diet was 81% [27].
health outcomes. In the European Prospective The Atherosclerosis Risk in Communities
Investigation Into Cancer and Nutrition (EPIC) Study (ARIC), a prospective epidemiological study
study, 23 153 German participants aged 35–65 years of 15 792 men and women of ages 44–64 years at
were followed up for a mean of 7.8 years. Adherence enrolment, demonstrated that adopting a healthy
to four health behaviours [not smoking, exercising lifestyle after age 45 results in substantial benefits
3.5 h per week, eating a healthy diet (high intake after only 4 years compared with people with less
of fruits, vegetables and whole-grain bread and low healthy lifestyles, reducing mortality and CVD
meat consumption) and having a BMI of <30 kg/m2] risk by 40 and 35%, respectively [28]. To further
at baseline was associated with 78% lower risk explore the relationship between change in
of developing chronic disease (diabetes 93%, myo- health behaviours, socioeconomic status and mort-
cardial infarction 81%, stoke 50% and cancer 36%) ality, Stringhini et al. [29] followed a cohort of
than participants without a healthy factor [5,26]. 10 308 civil servants from baseline examination
In the Nurses’ Health Study, a prospective cohort (1985–1988) to phase 7 (2002–2004) in the British
study of 81 722 US women from 1984 to 2010, a low- Whitehall II study. After adjusting for sex and year
risk lifestyle was defined at not smoking, BMI of less of birth, those with the lowest socioeconomic
than 25 kg/m2, exercise duration of 30 min/day or position had 1.60 times higher risk of death from
longer and top 40% of the alternate Mediterranean all causes than those with the highest socio-
diet score, which emphasizes high intake of economic position. However, this association was
vegetables, fruits, nuts, legumes, whole grains and attenuated by 72% when four health behaviours
fish and a moderate intake of alcohol. Compared (smoking, alcohol consumption, diet and physical
with women with zero low-risk factors, the multi- activity) were entered in the statistical model.
variate relative risk of sudden cardiac death (SCD) Another approach used to assess the burden
decreased progressively for women with one, two, of disease is to combine lifestyle and physiological
three and four low-risk factors to 0.54, 0.41, 0.33 and risk factors. This has been extensively applied to
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CVD. In the INTERHEART study, case–control study Examination Survey (NHANES). Compared with
of acute myocardial infarction across 52 countries, individuals with zero or one metric at ideal levels,
15 152 cases and 14 820 controls were enrolled those with six or more metrics at ideal level had 51,
between 1999 and 2003 to assess the effect of risk 76 and 70% lower adjusted hazards for all-cause, CVD
factors on development of coronary heart disease and ischemic heart disease mortality, respectively.
[30]. The study showed that over 90% of the
proportion of risk for an initial myocardial infarc-
tion is collectively attributable to nine measured THE RARITY OF GOOD HEALTH
and potentially modifiable risk factors: cigarette Despite the importance of following a healthy
smoking, raised ApoB/Apo A1 ratio, hypertension, life, multiple population studies have shown that
abdominal obesity, psychosocial factors, daily con- only a minority of individuals adhere to healthy
sumption of fruits and vegetables, regular alcohol lifestyle behaviours. In a comparative analysis of
consumption and regular physical activity. middle-aged adults aged 40–74 years participating
The concept of ‘cardiovascular health metrics’ in the NHANES III 1988–1994 and 2001–2006
has also emerged as a method to assess cardio- surveys, the proportion of adults who adhered to
vascular risk and coined as ‘Life’s Simple 7’ by all five healthy habits (at least five fruits and
the American Heart Disease (AHA) in their 2020 vegetables/day, regular exercise >12 times/month,
strategic impact goals to target a 20% relative maintaining a BMI between 18.5 and 29.9 kg/m2,
improvement in overall cardiovascular health moderate alcohol consumption and not smoking)
in all Americans [31]. The AHA combines four decreased from 15 to 8% [35]. The prevalence of
health behaviours (smoking, diet, physical activity meeting six or more cardiovascular health metrics
and body weight) with three health factors (plasma also decreased from 10.3% in NHANES 1988–1994
glucose, cholesterol and blood pressure) as their to 8.8% in NHANES 2005–2010 [33]. Adherence to
metrics and assesses adherence as poor, inter- the ideal health metrics was also analysed by Ford
&
mediate or ideal by distinct definitions (Table 2) et al. [36 ] using data from NHANES 1999–2002.
[32]. The AHA also recently published 11 compre- Overall, about 1.5% of participants met none of
hensive articles in a themed series titled ‘Recent the seven ideal cardiovascular health metrics, and
Advances in Preventive Cardiology and Lifestyle 1.1% of participants met all seven metrics; most
Medicine’ that emphasize the multiple deter- adults met two, three or four ideal health metrics.
minants of cardiovascular health [33]. Finally, On the basis of analysis of the NHANES data,
&& &&
Yang et al. [34 ] analysed the associations between Huffman et al. [37 ] projects that the AHA goal of
the number of ideal cardiovascular health metrics reducing CVD by 20% by 2020 will not be reached.
and mortality over a median follow-up of 14.5 years Poor health behaviours are not confined to the
using data from the National Health and Nutrition USA. In the recently published Prospective Urban
Table 2. Definitions of poor, intermediate and ideal cardiovascular health for each American Heart Association
(AHA) metric for adults >20 years of age
Goal/metric Poor health Intermediate health Ideal health
Current smoking Yes Former 12 months Never or quit >12 months
BMI (kg/m2) 30 25–29.9 <25
Physical activity None 1–149 min/week moderate intensity 150 min/week moderate
or 1–74 min/week vigorous intensity or 75 min/week
intensity or 1–149 min/week vigorous intensity or
moderate þ vigorous 150 min/week
moderate þ vigorous
Healthy diet scorea 0–1 components 2–3 components 4–5 components
Total cholesterol (mg/dl) >240 200–239, or treated to goal <200
Blood pressure (mm Hg) SBP 140 or DBP 90 SBP 120–139 or DBP 80–89 <120/<80
or treated to goal
Fasting plasma glucose (mg/dl) 126 100–125 or treated to goal <100
a
Healthy Diet Score is based on an overall dietary pattern that is consistent with a DASH (Dietary Approaches to Stop Hypertension)-type eating plan. Individual
components are fruits and vegetables: 4.5 cups per day; Fish: two 3.5 oz servings per week; Fibre-rich whole grains; three 1 oz equivalent servings per
day; Sodium: <1500 mg/day; Sugar-sweetened beverages: 450 kcal (36 oz) per week; nuts, legumes and seeds: 4 servings per week; processed meats: none
or 2 servings per week; saturated fat: <7% of total energy intake.
Adapted with permission from [32].
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Lifestyle medicine Kushner and Sorensen
Rural Epidemiology (PURE) Study, 153 996 adults, disease management: healthcare organization,
aged 35–70 years, from 17 low, middle and high- community resources, self-management support,
income countries of the world were surveyed for delivery system design, decision support and clinical
their health behaviours after a median of 5 years and information systems. Multiple studies suggest that
4 years after sustaining a coronary heart disease patients of practices implementing the CCM receive
event or stroke, respectively [38]. Despite having improved care [50]. A recent systematic review
known CVD, less than one in 20 individuals adhered found evidence that CCM approaches have been
to the three healthy lifestyle behaviours of avoiding effective in improving diabetes management in
cigarette smoking, undertaking regular physical US primary care settings [51]. Incorporation of the
activity and eating a healthy diet. The investigators patient-centred medical home [52] and enactment
also noted that, overall, individuals from upper of the Affordable Care Act (ACA) represent major
middle-income and low-income countries had a steps that will further increase access to preventive
lower prevalence of three of the healthy lifestyle services.
behaviours than those from high-income and lower However, existing evidence for implementing
middle-income countries. lifestyle medicine counselling in primary care is
There are multiple determinants of adherence mixed and limited. The US Preventive Services Task
to healthy lifestyle behaviours, including socio- Force (USPSTF) found that the health benefit for
economic forces, healthcare delivery and access diet, physical activity and behavioural counselling
and affordability issues among many others. to prevent CVD in the primary care setting is small
&
A population change in lifestyle habits will require (Grade C) [53,54 ]. In contrast, the USPSTF found
participation from multiple sectors of our society. stronger albeit modest evidence for behavioural
&
Structural interventions to facilitate increased counselling for obesity (Grade B) [55 ,56]. Nonethe-
physical activity, improved diet and decreased less, providers will need to acquire the skills and
cigarette smoking are needed [39–42]. Although competency necessary to address multiple health
controversial, changes in food taxation [43,44], risk behaviours and enhance self-management to
labelling [45] and regulation [46] have also been practice Lifestyle Medicine [57]. The AHA recom-
proposed. One programme that engages a broad mends that clinicians use counselling interventions
set of stakeholders involved with health and to promote healthy diet and physical activity that
healthcare, including clinicians, pharmacists, combine two or more of the following strategies:
insurers, healthcare systems, retailers, consumer set specific, proximal goals; provide feedback on
groups and others, is the Million Hearts Initiative progress; provide strategies for self-monitoring;
[47]. Launched in 2011 by the US Department of establish a plan for frequency and follow-up; use
Health and Human Services (HHS), Million Hearts is motivational interviewing; and build self-efficacy
a national initiative that aims to prevent one million [58]. Two recent studies that evaluated the health
heart attacks and strokes by 2017. Targets for outcomes from providing multiple behaviour change
the initiative are to improve patient adherence, counselling in primary care demonstrated limited
empower persons to make healthy choices, improve success [59,60]. Increased utilization of mobile
delivery of healthcare and focus on the ‘ABCS’ technology and other self-monitoring devices
(appropriate aspirin use for those at risk, blood may facilitate improved self-management, which
pressure control, cholesterol management and smok- is an important component for Lifestyle Medicine
ing cessation) [48]. [61].
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Obesity and nutrition
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Conflicts of interest vention on weight and cardiovascular risk factors in individuals with type 2
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