Lifestyle Medicine focuses on applying behavioral and environmental principles to managing lifestyle-related health problems. Chronic diseases now account for 75% of healthcare costs in the US, many of which are strongly associated with diet and physical inactivity. While genetics play a role, the rise of these "lifestyle diseases" correlates with changes in American diets and exercise patterns over recent decades. Prospective randomized studies demonstrate that organized lifestyle interventions can significantly reduce disease incidence and healthcare costs compared to prescription medications. Lifestyle Medicine aims to educate and empower individuals to make personal choices that can transform health outcomes on both individual and societal levels.
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Lifestyle Medicine: The Power of Personal Choices, North American Vegetarian Society 2011
1. Lifestyle Medicine
The power
of
personal choices!
Stephan Esser USPTA, MD
Institute of Lifestyle Medicine
2011
2.
3.
4. Goals
• Define Lifestyle Medicine
• Explore the growth of “lifestyle diseases” in
America today
• Evaluate the potential of LM interventions
• Review some ‘Opport-unacles’
• What can we do!
5. What is going on
How we got here
What WE can do about it
8. 56 y/o male Joe
High Blood Pressure
Obese
High
High Blood Cholestero
Sugars l
Depression Arthritis of
Fatigue the knees
9. “A global response to a
global problem: the epidemic
of overnutrition.” WHO
It is estimated that by 2020 2/3 rds of the global burden
of disease will be attributable to chronic non-
communicable diseases, most of them strongly
associated with diet. The nutrition transition towards
refined foods, foods of animal origin, and increased
fats plays a major role in the current global
epidemics of obesity, diabetes and cardiovascular
diseases, among other non-communicable conditions.
Sedentary lifestyles and the use of tobacco are also significant
risk factors. …….. A concerted multi-sectoral approach,
involving the use of policy, education and trade mechanisms,
is necessary to address these matters.
10. Lifestyle Medicine
Finger s, Feet , For ks:
– the application of environmental, behavioral,
medical and motivational principles to the
management of lifestyle-related health problems
The M er Lever s of
ast
in a clinical setting.
– Modalities:
•
•
Dest iny!
Diet
Exercise
• Sleep
• Emotional Poise
• Reduced toxic exposures
12. “It is time we descended from Olympus
and began to address the people….
to educate them about the realities of health and
disease, to teach them what they can do to help
themselves and what we cannot do. They must be
taught about the marvelous capabilities and
the serious limitations of medicine.”
Moser, R.H
“Knowledge is not Enough.” NEJM 1977
29. Total Healthcare Spending
• $2 TRILLION in 2005, or $6,700 per person
• >16.2% of the gross domestic product (GDP)
• Projected to exceed $4 TRILLION by 2015
30.
31. Financial Expenditures
• Chronic Dz ≈ 75% of health care costs
– Acc. to Dept of HHS:
• CVD and CVA $351.8 billion (2003)
• Cancer $171.6 billion (2002)
• Diabetes $132 billion (2002)
• Obesity $117 billion (2000)
• Arthritis $82 billion (1995)
• Smoking DMC $75 billion
LP $80 billion
• Physical Inactivity $76 billion (2000)
• Poor Nutrition DMC $33 billion
LP $9 billion
32. Metabolic Costs
• $4 of every $10 spent on prescription drugs
is spent to tx symptoms of
Metabolic Syndrome
– ↑ Cholesterol/LDL
– ↑ BP
– ↑ Blood Sugar
33. Waist Circumference > 40” M > 35” W
> 25%
of Americans
Triglycerides > 150 HDL < 40 M or < 50 W
BP ≥ 130/85 Fasting Glucose of ≥ 100
34. Obesity
Waist Circumference > 40” M > 35” W
Triglycerides >Dyslipidemia < 40 M or < 50 W
150 HDL
HTN/CVD
BP ≥ 130/85 Fasting Glucose of ≥ 100
Diabetes
35. We spend more
yet
we are one of the
sickest
most obese
societies on Earth!
54. US Gov. Reccomendations
150 minutes per wk
30 minutes/day
+
2-3 days/Strength Tr.
4-5 days a week
55.
56. CDC Exercise Stats
• > 60% of adults are not regularly active
• 25% are not active at all
• 50% of all youth ages 12-21 are not vigorously
active on a regular basis
• By age 75 1:3 men and 1:2 women engage in NO
physical exercise
57. • Physical inactivity is more common in:
Women > Men
African American > Whites
Hispanic > Whites
Older > Younger
Less affluent > More Affluent
58. Exercise
• Reduces risk of
– Heart Disease ≈ 40%
– Obesity: ≈ 30-100%
– Stroke ≈ 50%
– Type 2 Diabetes ≈ 50%
– Hypertension ≈ 50%
– Disability delayed ≈15 years
– Colon Cancer ≈ 25-40%
– Breast Cancer ≈ 20%-44%
– Osteoporosis ≈ 20+%
59. Perspective
• We eat more
– Sugar, Salt, Meat, Dairy, Fat
– 1970-2000:
• ↑ 24.5 % C/day ≈
530K/day
• We get less then ideal
– Exercise
63. What if
We ate
less fat, salt and sugar
and
more fruits, vegetables and grains
&
increased our exercise habits????
64. Some Say…..
– If 10% of adults began a regular walking program,
$5.6 billion in heart disease costs could be saved.
– If Americans↓ Na intake by 2300mg/day = 3-6 mm Hg ↓
in SBP
• 11 % ↓ strokes
• 7 % ↓ coronary events
• 5 % ↓ total mortality
66. Common Misconceptions
1.
#
There is no
evidence that a healthy lifestyle decreases
M&M or
extends a healthy lifespan.
67.
68.
69. 12 year Cohort Study
1507 men 832 Women
Ages 70-90 years
50% ↓ in all-cause
Outcomes: 10 yr all cause mortality
4 Factors: Med. diet, Moderate EtOH, physical exercise
and non-smoking were ass. w ↓ in ACM
and cause specific
mortality
70. “Not only do persons with better health habits
survive longer, but in such persons, disability is
postponed and compressed into fewer years
at the end of life.”
Vita, AJ et al. NEJM 1998; 338:1035-1041
71.
72. Retrospective Cohort Study
Outcomes: Incidence of CVD events
379,0003 Diabetics to 9 Million non-DM2
Diabetics four times more likely to have CVD
“Diabetes confers an
equivalent risk to
ageing 15 years!”
73. Misconception 2 #
There are no good
prospective, randomized trials
to prove that
Organized Lifestyle Interventions
are effective.
74. Finnish Diabetes Prevention Trial
Total 522: 172M 350W
Av. age 55
Risk of
Av. BMI 31
Randomized to standard of care or
individualized lifestyle counseling
Diabetes ↓ 58 %
Av. f/u 3.2 yrs
(P<0.001)
“The reduction in the incidence of diabetes was
directly associated with changesN in lifestyle”
Engl J Med 2001;344:1343-50
76. Multi-Center Randomized Controlled Trial
n=3234 non-diabetics w/ ↑plasma glucose
3 Arms: placebo, Metformin (850BID), Lifestyle
Intervention
Lifestyle =7% weight loss/ healthy diet/150min wk exercise
Av. f/u = 2.8yrs
↓ 58%
Diabetes Incidence ↓’d by 31% in Metformin
and by 58% in Lifestyle Intervention
NEJM:2002
77.
78. Misconception 4 #
The benefits of lifestyle interventions
don’t last.
79.
80. Misconception 5 #
Lifestyle Interventions
are
too expensive.
81. “Compared with the placebo intervention,
the cost per QALY was approximately
$1100 for the lifestyle intervention and
$31300 for the metformin intervention.
From a societal perspective, the
interventions cost approximately 8800
dollars and 29,900 dollars per QALY,
respectively. From both perspectives,
the lifestyle intervention dominated
the metformin intervention.”2005
intervention
82. “After controlling for differences in
sociodemographics, smoking and comorbidity,
individuals with cardiometabolic risk factor
clusters missed 179% more work days and
spent 147% more days in bed (in addition to
lost work days) than those without. Lost work
days and bed days resulted in $17.3 billion
annually in lost productivity.”
95. Perspective
• Lifestyle-Associated Diseases are the leading
expenditure and cause of mortality in the
western world
• Personal choices can alter this trajectory
• We can transform lives
98. Challenge 2
#
Lifestyle Medicine is not a
respected field of medical
research or practice.
99. Challenge 3
#
In clinical training today,
students receive insufficient
education on lifestyle medicine.
100. Challenge 4
#
The individual
adds an extra variable to
medical care in LM…
……each of us has to perform the
treatment.
101. Challenge 5#
You have to walk the talk.
An advocate for a healthy diet and
exercise must do both.
102. “A global response to a
global problem: the epidemic
of overnutrition.” WHO
It is estimated that by 2020 2/3 rds of the global burden of
disease will be attributable to chronic noncommunicable
……if…….Lifestyle is the
diseases, most of them strongly associated with diet.
Problem
The nutrition transition towards refined foods, foods of
animal origin, and increased fats plays a major role in the
current global epidemics of obesity, diabetes and
cardiovascular diseases, among other noncommunicable
We Have the Answer
conditions. Sedentary lifestyles and the use of
What is risk factors. …….. A concerted
tobacco are also significant
the answer……..?
multi-sectoral approach, involving the use of policy, education
and trade mechanisms, is necessary to address these matters.
104. Foremost
• Lead by example
• Identify personal lifestyle goals
• Optimize our own health
• Encourage family and friends to do likewise
105. Then
• Seek to educate and empower
• Through transmission of knowledge and
motivation
• Get involved in your circle of influence
106. Finally
• Advance health on the national and global
level through political action
• Get involved
107. Conclusion
• America is facing an epidemic of disease
fostered by lifestyle choices
• Lifestyle interventions are the answer
• Plant Based Nutrition is central
The faucet of preventable disease is overflowing on the floor and as we respond with an acute care, emergent response very few people are reaching for the faucet.
Approx. 1,300,000 new cases per year www.cdc.gov/.../mmwrhtml/ figures/m846qsf.gif www.ncbi.nlm.nih.gov/ bookshelf/picrender.fcgi.. http://www.ctahr.hawaii.edu/CS/blogs/sustainable_agriculture/cdc_logo(2).jpg
Modifiable behavioral risk factors are leading causes of mortality in the United States. (JAMA, 2000 Mokdad et al. CDC) www.cdc.gov/cancer/ breast/statistics/ http://www.cdc.gov/cancer/Prostate/publications/decisionguide/
Fox, Caroline. Et al. Trends in the Incidence of Type 2 Diabetes Mellitus: Circulation 2006:113;2914-2918.
http://health.ucsd.edu/news/images/DPP1.jpg
-- 6/22/02 radio address :Americans who are obese spend approximately 36 percent more on health care services than the general population. They spend 77 percent more on medications. --Catlin, A, C. Cowan, S. Heffler, et al, &quot;National Health Spending in 2005.&quot; Health Affairs 26:1 (2006): 142-153.2.Borger, C., et al., &quot;Health Spending Projections Through 2015: Changes on the Horizon,&quot; Health Affairs Web Exclusive W61: 22 February 2006. -- http://www.mathematica-mpr.com/health/
--AHA 2004 --States if you have 2 of characteristics =‘s 2 times risk of death from coronary heart dz, if you have 4 of these =‘s you have 3.5 times the risk?
--AHA 2004 --States if you have 2 of characteristics =‘s 2 times risk of death from coronary heart dz, if you have 4 of these =‘s you have 3.5 times the risk? -Dysglycemia, HTN, Obesity, and Dyslipidemia
6/22/02 radio address :Americans who are obese spend approximately 36 percent more on health care services than the general population. They spend 77 percent more on medications.
Agouti = defect in alpha melanocyte stimulating hormone a secondary molecule increased by increasing leptin levels. Early nutrition can influence DNA methylation because mammalian one-carbon metabolism, which ultimately provides the methyl groups for all biological methylation reactions, is highly dependent on dietary methyl donors and cofactors.[ 21 ] For example, dietary methionine and choline are major sources of one-carbon units, and folic acid, vitamin B 12 , and pyridoxal phosphate are critical cofactors in methyl metabolism. The genome of the preimplantation mammalian embryo undergoes extensive demethylation, and appropriate patterns of cytosine methylation are re-established after implantation.[ 4 ] These DNA methylation patterns must then be maintained over many rounds of rapid cellular proliferation during fetal and early postnatal development. Availability of dietary methyl donors and cofactors during critical ontogenic periods therefore might influence DNA methylation patterns. [ 10 and 16 ] Hence, early methyl donor malnutrition (i.e., overnutrition or undernutrition) could effectively lead to premature “epigenetic aging,” [ 22 ] thereby contributing to an enhanced susceptibility to chronic disease in later life. Vitamin B12, choline, Vitamin B6
Gila Reservation Arizona Maycoba, Mexico
World’s smallest island country just 8.s sq miles 95% are overweight/obese and 50% have diabetes
--IOM rec on Na: AI 1.5g/d UL 2.3g/d --http://www.cspinet.org/ --http://www.ama-assn.org/ama/pub/category/16461.html -- http://www.iom.edu/?id=18495&redirect=0 -- Dr. Heikki Karppanen of the University of Helsinki and Dr. Eero Mervaala of the University of Kuopio report that an average 30-35 % reduction in salt intake during 30 years in Finland was associated with a dramatic 75 % to 80 % decrease in both stroke and coronary heart disease mortality in the population under 65 years. During the same period the life expectancy of both male and female Finns increased by 6 to 7 years.The most powerful explaining factor for the favorable changes was the more than 10 mmHg (&quot;point&quot;) decrease in the average blood pressure of the population. A marked decrease in the average cholesterol levels of the population also remarkably contributed to the decrease of heart diseases. The extensive use of drugs contributed less than 10 % of the observed decreases in blood pressure, cholesterol, and cardiovascular diseases. -- http://www.iom.edu/Object.File/Master/20/004/0.pdf http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=3&tax_subject=256&topic_id=1342&level3_id=5140
----http://www.cdc.gov/nccdphp/dnpa/physical/health_professionals/index.htm over half of US adults do not engage in physical activity at levels consistent with public health --http://books.nap.edu/openbook.php?record_id=1627&page=118 IOM: Greater then 1/2 of all US children do not get enough exercise to develop a healthy heart and lungs --http://www.cdc.gov/nccdphp/sgr/intro.htm Daily enrollment in physical education classes has declined among high school students from 42 percent in 1991 to 25 percent in 1995. --Only 19 percent of all high school students are physically active for 20 minutes or more, five days a week, in physical education classes. high school students are physically active for 20 minutes or more, five days a week, in physical education classes.
----http://www.cdc.gov/nccdphp/dnpa/physical/health_professionals/index.htm over half of US adults do not engage in physical activity at levels consistent with public health --http://books.nap.edu/openbook.php?record_id=1627&page=118 IOM: Greater then 1/2 of all US children do not get enough exercise to develop a healthy heart and lungs --http://www.cdc.gov/nccdphp/sgr/intro.htm
6/22/02 radio address :Americans who are obese spend approximately 36 percent more on health care services than the general population. They spend 77 percent more on medications.
-- http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm --http://www.nhlbi.nih.gov/health/prof/heart/hbp/salt_upd.pdf --http://www.nhlbi.nih.gov/health/prof/heart/hbp/salt_upd.pdf --http://www.usatoday.com/news/health/2008-02-10-salt-dangers_N.htm -- Intersalt Cooperative Research Group (1988). Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. BMJ . 297 : 319–328. --The contradictory nature of these findings accords with the unreliability of the methods used in NHANES III and IV (ie, 24-h dietary recall). Twenty-four-hour urinary sodium from complete urine samples is the only accurate way to estimate dietary salt intake, and this was not measured in NHANES III and IV. The large international study—INTERSALT, 2 which had 24-h urinary sodium and BP measured, showed that salt intake is directly associated with BP and the increase in BP with age in more than 10,000 individuals including both hypertensives and normotensives. -- -- http://www.nhlbi.nih.gov/new/press/nov30a99.htm -- Healthy adults living in a temperate climate can maintain a normal sodium balance with as little as 115 mg of dietary sodium per day. In consideration of the wide variation in Americans’ physical activity and climatic exposure, a safe minimum of 500 mg of sodium per day has been recommended.
--Am J Clin Nutr. 1999 Sep;70(3 Suppl):532S-538S.
Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project.
-- compression-of-morbidity hypothesis predicts that the age at the time of initial disability will increase more than the gain in longevity, resulting in fewer years of disability and a lower level of cumulative lifetime disability.
--Annals of Internal Medicine 2003: 139:455-459
Diabetes confers an equivalent risk to aging 15 years. Due to earlier transition to a high risk category of CVD and other health concerns --Diabetics are 4 times more likely to have CVD --Diabetics have a similar risk of Coronary Heart Disease to those without diabetes who have had an MI
--FDDP (N Engl J Med 2001;344:1343-50.)
-- J Gerontol A Biol Sci Med Sci. 2006 Oct;61(10):1075-81.
..Intervention group with a 43% reduction in risk P value .0001
-- Ann Intern Med. 2005 Mar 1;142(5):323-32.
-- Value Health. 2007 Nov-Dec;10(6):443-50. PMID: 17970926 Overweight/Obese/HTN/Hyperlipidemia/Diabetes
http://www.newschannel9.com/pictures/s-layoffs.jpg We are all painfully aware of the ongoing challenges in our economy; the subprime mortgage market, job losses, questionable solvency of the SSA, and even fortune 500 companies suffering from excess costs and reduced margins. In fact according to Business week, the only new job market has been the industrial medical complex.
--American College of Lifestyle Medicine and ACPM call for preventive…lifestyle med. training
--
-- Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al
