Abstract
‘As the US population continues to age, issues of cognitive impairment ranging from mild cognitive decline through dementia assume increasing importance.’
This issue marks the sixth year that the American Journal of Lifestyle Medicine (AJLM) has devoted an entire issue focusing on presentations made at the previous national conference of the American College of Lifestyle Medicine (ACLM). As always, an esteemed member of the ACLM serves a guest editor for these issues. This year, the task was admirably performed by Dr Deepa Sannidhi.
As the articles selected for this issue of AJLM demonstrate, the evidence supporting the field of lifestyle medicine continues to grow and prosper—in fact, the field has grown deeper, broader, and more precise. The articles contained in this issue investigate new areas of lifestyle medicine such as health equity, cognitive decline and Alzheimer disease, resilience, an approach to overcoming negative sequelae from adverse childhood experiences (ACEs), positive psychology, the economic case for lifestyle medicine for self-insured companies, lifestyle medicine for women and children, the role of positive psychology, and the importance of education in lifestyle medicine as a catalyst for change moving forward. Let us review each of the articles.
The article by Drs Sherzai and Sherzai offers a well-researched and persuasive framework for the use of lifestyle medicine practices as a means of delaying, mitigating, and perhaps even preventing Alzheimer disease. 1 The authors have developed a unique and well-researched acronym that they call NEURO, which stands for Nutrition, Exercise, Unwind (stress management), Restorative sleep, and Optimization of health. Their extensive review of the literature ties the approach that they offer to multiple randomized controlled trials and other well-designed research projects.
Interestingly, the major components of the plan outlined by these lifestyle medicine investigators are quite similar to the recommendations made in a recently released presidential advisory from the American Heart Association (AHA) and the American Stroke Association (ASA) titled, “Defining Optimal Brain Health in Adults.” 2 In this landmark document, the AHA and ASA define 4 ideal health behaviors (not smoking, physical activity at goal levels, healthy diet consistent with current guideline levels, and body mass index <25 kg/m2) and 3 ideal health factors (untreated blood pressure < 120 mm/Hg, < 80 mm/Hg, untreated total cholesterol < 200 mg/dL, and fasting blood glucose < 100 mg/dL) as the key components to lower the risk of cognitive decline and work toward achieving “optimal” brain health.
The AHA/ASA Presidential Advisory goes on to also recommend increased social engagement and other related strategies to enhance brain health. The recommended metrics to define optimal brain health are based on similar metrics that have been previously published by the AHA as part of its 2020 Strategic Plan for Lowering the Prevalence of Cardiac Disease in the United States. 3
The fact that lifestyle medicine practitioners are now focusing our efforts in the same direction that the AHA and ASA have also articulated in the area of brain health is significant. As the US population continues to age, issues of cognitive impairment ranging from mild cognitive decline through dementia assume increasing importance. Clearly, the modalities of lifestyle medicine will play an increasingly important role in helping mitigate this impending health crisis. Moreover, many of these habits and practices should be engaged in throughout a lifetime, thus extending the role of lifestyle medicine throughout the entire life cycle.
The article by Krishnaswami et al 4 as well as the companion piece by Krishnaswami and Colon-Gonzalez 5 offer important insights into the role of lifestyle medicine in underserved populations. The recommendation of what the authors describe as community-engaged lifestyle medicine is an important way for lifestyle medicine practitioners to engage their community particularly for the benefit of vulnerable populations. This represents an important step toward health equity.
The article by Krishnaswami and Colon-Gonzalez 5 explores another aspect of pursuing health equity—namely, using lifestyle medicine as a way to lower morbidity and mortality for mothers and infants. As the authors point out, as the richest nation in the world, it is not acceptable that the United States ranked 12th among developed countries in infant mortality. The burden of infant and maternal morbidity and mortality also falls disproportionately on the underserved and vulnerable populations. Lifestyle medicine can offer a cost-effective and potent way of dealing with these important issues.
The article by Ortiz 6 offers a fresh perspective that may not be familiar to many lifestyle medicine practitioners concerning the potential negative sequelae arising from ACEs. ACEs contribute to many of the root causes of chronic disease related to lifestyle. ACEs are extremely common among Americans, with the shocking finding that nearly 70% of Americans experience at least 1 ACE in their lifetime, and such exposures may be associated with the presence of multiple adverse sequelae, including mental health disorders, heart disease, cancer, and other chronic diseases. Ortiz 6 lays out a compelling approach for lifestyle medicine practitioners to combat the sequelae of ACEs and help both children and adults build higher levels of resilience.
The article by Lianov et al 7 outlines the rapidly emerging and important area of positive psychology in lifestyle medicine. Dr Lianov has been a leader in this field and has brought the study of positive psychology firmly into the mainstream of lifestyle medicine. As she points out in her article, positive psychology can help individuals overcome stress and anxiety as well as overcoming other risk factors for chronic disease such as heart disease, diabetes, and cancer. As defined by the World Health Organization, positive psychology is the “study of strength that enables people and communities to thrive.” This is an important reminder that health is more than the absence of disease. We are going to hear a great deal more about positive psychology as a component of lifestyle medicine in the years to come.
The economic case for lifestyle medicine also continues to grow. The article by Gulati and Delaney 8 presents a compelling case for why lifestyle medicine physicians have a great deal to offer to employers particularly those who are self-insured. They describe this as “value based insurance” and show that modalities skillfully delivered by lifestyle medicine practitioners can help companies ameliorate the trend of individuals moving from moderate to high risk and thereby not only harming their health but generating enormous increases in expense to their employers, particularly if they are self-insured.
The future of lifestyle medicine will certainly be in the hands of the next generation who will be trained by the current skillful practitioners of lifestyle medicine. The article by Mondala and Sannidhi 9 provides great insight and hope that programs such as professional in training and the Lifestyle Medicine Collaborative can rise to this challenge by providing an expanded array of materials and opportunities for the next generation of lifestyle medicine practitioners to gain the skills and the knowledge base necessary to move the field forward. These programs tap into the innate enthusiasm that young professionals bring to the practice of medicine and health care and help them focus this enthusiasm into the important areas of lifestyle medicine. It is impressive that Dr Sannidhi found the time to coauthor this article in addition to guest editing this entire issue of AJLM. Importantly, Dr Mondala also reviewed the available literature on trainee participation in lifestyle medicine, which underscores that a few years ago, there were no published articles on the work of trainees and their educational contributions. The growth of training programs that they document in their article demonstrates the enormous progress made in the ability of lifestyle medicine practitioners to influence the culture of medicine.
In addition to the 7 articles based on presentations from the national ACLM conference held in 2018 in Indianapolis, we have added 2 articles that had been previously accepted in AJLM but were due to be published in subsequent issues. We felt that these 2 articles continued to round out important areas of lifestyle medicine. The article by Egger et al 10 offers a simplified framework for how to use a “proof of concept” to the clinical processes of lifestyle medicine. Adherence to this framework will help lifestyle medicine practitioners focus their energies on lifestyle medicine practices that are highly likely to yield clinical benefit. This approach may also help distinguish true lifestyle medicine practices from non–evidence-based approaches, such as self-help websites, which may not be based on solid science, or nutritional websites, which may tout unproven approaches.
The article by Wilber et al 11 shows how a lifestyle walking program for African American women can result in significant lowering of blood pressure. This is important because the new, more stringent blood pressure guidelines announced in early 2018, dramatically expanded the pool of individuals who are now considered to have elevated blood pressure. This article also represents another example of the use of lifestyle medicine modalities to reach underserved and vulnerable populations.
Finally, in this issue, we are also including our regular “From the ACLM President’s Desk” column from Dr Dexter Shurney. This is part of a series of articles based on Dr Shurney’s exploration of the 4P strategy emphasizing “Policy, Partnership, Payment, and Public relations” as ways of further enhancing the ACLM’s mission and reach. For this column, Dr Shurney interviews Cathryn Couch who is the chief executive officer of the Ceres Community Project. This innovative project has provided numerous healthy meals and education in the areas of organic and plant-based nutrition. This type of initiative offers great promise in the area of “Partnership” as ACLM continues to grow and expand its reach.
More Evidence in Support of Lifestyle Medicine
A variety of documents, guidelines, and publications have been generated in the past few years, emphasizing the expanded role lifestyle medicine is playing throughout all of American medicine.
First, the most recent guidelines from the AHA and ACC is titled, “Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/AHA Task Force: Practice Guidelines.” 12 The fact that lifestyle management plays such a major role in the AHA/ACC practice guidelines is not by accident. This represents a recognition that lifestyle has now assumed a primary role in cardiovascular medicine.
Second, the Physical Activity Guidelines 2018 have now been released. 13 This document updates the Physical Activity Guidelines 2008 14 and offers abundant new evidence of the multiple benefits from even small amounts of regular physical activity. The data contained in this report should become part of the evidence base utilized by all lifestyle medicine practitioners.
Third, the AHA has recently released the 2018 Cholesterol Management Guidelines.
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These guidelines are extensive (over 500 pages). The AHA listed at the beginning some “tips” for how to implement these guidelines. The first and most important tip involves lifestyle management as indicated: A healthy lifestyle reduces atherosclerotic cardiovascular disease (ASCVD) risk at all ages. In younger individuals, healthy lifestyle can reduce development of risk factors and is the foundation of ASCVD risk reduction. In young adults 20 to 39 years of age, an assessment of lifetime risk facilitates the clinician-patient risk discussion and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome (p. 5).
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Fourth, in late 2017, the AHA and ACC issued new, more stringent blood pressure guidelines for Americans. 16 These guidelines now lower the threshold for hypertension to any readings >120 mm/Hg systolic and >80 mm/Hg diastolic. These stringent guidelines will require individuals to take a much more serious approach to managing their blood pressure, not only through medication (if needed), but also, importantly, through regular physical activity, proper nutrition, weight management, and of course, not smoking!
Fifth, in 2019, I am also proud to announce the publication of the third edition of my Lifestyle Medicine textbook. 17 This is a massive, 1800-page, evidence-based textbook with more than 180 contributors who are experts in various aspects of lifestyle medicine from around the world. Many members of the ACLM made significant contributions to this book. The intent of this authoritative book remains to provide the broadest possible academic underpinnings for the emerging field of lifestyle medicine.
Sixth, in 2018, the AJLM continued its robust growth. ALJM now has more than 10 000 subscribers of whom approximately 40% are institutions. Thus, the total number of health care workers reached by AJLM is undoubtedly probably much larger than the 10 000 listed subscribers. Significantly, in 2018, there were more than 120 000 downloads of AJLM articles, indicating a wide and deep interest in the content provided by AJLM in the area of lifestyle medicine. Furthermore, in 2018, AJLM was accepted in the PubMed database, thus making its content available across the wide spectrum of citations and audiences covered in PubMed Central.
Finally, I want to, once again, thank Dr Deepa Sannidhi for the outstanding work that she has completed to bring together an enormous body of information for the annual issue of AJLM devoted to the 2018 national conference of the ACLM. Editing an issue of AJLM takes a lot of hard work and attention to detail. Dr Sannidhi has performed in exemplary fashion to bring this issue together at the highest possible academic level!
In conclusion, when I survey lifestyle medicine in 2019, I am proud to reiterate that the field continues to expand and prosper and grow deeper, broader, and more precise. The future is bright because we bring the important messages of lifestyle medicine to an ever-growing audience across a wide range of conditions and practices.