Abstract
“Health equity is an issue of great importance in American medicine and an area where lifestyle medicine can play a significant role.”
This issue of the American Journal of Lifestyle Medicine marks the 8th year that we have had the pleasure of publishing articles based on some of the presentations made at the previous national meeting of the American College of Lifestyle Medicine. As always, these articles are impressive and demonstrate the expanded breath of interest and intellectual ferment in the area of lifestyle medicine. While the articles contained in this issue demonstrate important examples of how lifestyle medicine has progressed, they also underscore remaining challenges.
Drs. Reddy and Beg, did an outstanding job of curating articles and coordinating their production with the various authors as Guest Editors. Upon reviewing the grouping of articles selected by Drs. Reddy and Beg, several recurrent themes stand out. First, an ongoing emphasis on behavior change remains which, of course, is the holy grail of lifestyle medicine. In this area, the article by Moore underscores that it is important to consider starting from “ground zero” by changing mindsets which is the key to ultimately changing behaviors. 1 The article by Bharati et al. also emphasizes how rapidly the field of lifestyle medicine has permeated primary care practice and the perceptions and practices of family physicians. 2 This is indeed gratifying.
Secondly, I am struck that models continue to be developed and “fine-tuned” to show how lifestyle medicine can be incorporated into various practice settings and healthcare delivery organizations.
The article by Annam et al. shows the significant development of the lifestyle medicine inpatient consultation services at Loma Linda University Health. 3 As the authors point out, their experience can serve as a transformative model for how lifestyle medicine can be utilized as a key component of chronic disease management in a tertiary care facility.
The article on Omega-3 fatty acids and cognitive outcomes in neurodevelopment by Drs. Sherzai, Moness, Sherzai and Sherzai emphasizes how nutrition can play a critical role in lowering the risk of Alzheimer’s disease. 5 Drs. Dean and Ayesha Sherzai have been leaders in the area of preventive neurology and have published important work in this area related to how daily habits and actions can reduce the risk of Alzheimer’s disease. I am delighted that they have now joined the Editorial Board of AJLM in the area of preventive neurology.
While it is important to underscore the multiple advances in the area of lifestyle medicine, it is also important not to ignore ongoing challenges. These are well articulated in the article by Dr. Robert Pearl who emphasizes that while lifestyle medicine can truly play a significant role in mainstream medicine, it will be essential to overcome longstanding cultural and structural issues which are currently retarding this progress. 6
The article by Artz and Weaver makes the very interesting and important point that as lifestyle medicine continues to grow and thrive, there is a parallel path in the area of value-based medicine. 7 There is a natural synergy between lifestyle medicine and value-based medicine. It is, however, important to underscore precisely what is meant by the term “value” in medicine and healthcare. “Value” cannot just be another way of cutting down on the expense of medical care. It needs to incorporate the underlying values that we all hold so dear as practitioners of medicine. The issue of value-based care reminded me of a wonderful article written many years ago by a professor at Harvard Business School, Michael Porter, entitled “A strategy for health care reform--toward a value-based system.” 8 Professor Porter points out that individuals in the public truly understand the issue of “value” in almost every aspect of their lives. In medicine we have somehow gotten away from a framework where individuals can truly assess the value that our efforts bring. Re-establishing “value” in medicine represents an incredible opportunity for lifestyle medicine. It should remind us all of the very reason why we all went into medicine—namely, to promote the high value of our patients’ health. There is an incredible opportunity to blend lifestyle medicine with value-based care as long as we do not forget the underlying values which brought us to medicine in the first place.
The article by Sundermann, Chielli and Spell offers a comprehensive and authoritative review of an area that is emerging in lifestyle medicine—namely, the powerful role of nature as a component of healing. 9 I have been personally interested in this area for many years. We are now seeing more articles submitted to the American Journal of Lifestyle Medicine in nature and health. Indeed, we named “The Healing Power of Nature” as the theme for the July-August 2023 issue of AJLM. I was delighted to write an Editorial entitled “The Healing Power of Nature” 10 to accompany an article on wilderness medicine written by Moore 11 and an Editorial by Dr. John La Puma on “Nature-based Medicine.” 12 The current article by Sundermann et al. provides much more detailed background on the health benefits of nature and is loaded with practical tips to help practitioners incorporate recommendations about outdoor activities and health to all of their patients.
Of note, several investigators have become so concerned about the negative health effects of not engaging with nature that they have coined the term “nature deficit disorder” to describe the adverse psychological impact of spending over 90% of our time indoors.
The profound emotional benefits of experiencing nature have been discussed for over a century. The brilliant landscape architect Frederick Law Olmstead, who is considered the father of modern American landscape architecture felt that his landscape designs should provide a respite and antidote to the stresses and strains of urban living, and this was almost 100 years ago! His notable landscape projects including Central Park in New York City, the Emerald Necklace around Boston, Yosemite National Park, and many others were designed to inspire people and promote health.
It seems like a natural connection to utilize the fundamental precepts of lifestyle medicine and combine them with outdoor physical activity or meditation. This is the point that Sundermann et al. make persuasively in their article.
Health equity is an issue of great importance in American medicine and an area where lifestyle medicine can play a significant role. The article by Davis, Shurney, Stone and Bowman makes a compelling case for why lifestyle medicine can make major contributions in this area. 13 The authors also conducted an interesting and informative interview with former Attorney General Jerome Adams who emphasized that racial discrimination plays a central role in inequities in the American health system.
The article also contains background information on how the American College of Lifestyle Medicine (ACLM) has taken a very aggressive and appropriate role in delving into the topic of health equity. Early efforts in this area included the Health Disparities Solution Summit. We were pleased to publish the proceedings of this summit in AJLM which contained numerous recommendations from ACLM in this important area moving forward. 14
Other organizations within mainstream medicine have also played significant roles in health equity which has clearly been underestimated in the past. Both the American College of Physicians and the American Heart Association15,16 have issued recent position papers on health equity and food security. I hope and believe that the article by Davis et al. will further encourage ACLM to issue a position statement in this area.
Furthermore, the recently completed White House Conference on Hunger, Nutrition and Health emphasized the current problems of inequities in the health care system and offered a path toward helping to correct some of these historic injustices. 17
This year has also been one of great growth and excitement for the American College of Lifestyle Medicine! Membership in ACLM continues to rapidly accelerate. This year ACLM crossed the 10,000-member mark—an important milestone which underscores the fact that lifestyle medicine continues to be the most rapidly growing specialty within the field of medicine. ACLM also continues to foster multiple efforts in the area of medical education and public policy, including a major presence at the White House Conference on Hunger, Nutrition, and Health. An important follow-up sponsored by ACLM is a provision of the “Food is Medicine” curriculum free of charge to multiple physicians around the country.
I was pleased to note that the person who played a leading role in driving the White House Conference was Congressman Jim McGovern, who has had a longstanding and passionate history of advocacy for more nutrition education for healthcare workers in general and physicians in particular. Congressman McGovern’s District contains the UMass Chan Medical School where I serve as a Professor of Medicine on the faculty. I have had an important ongoing dialogue with Congressman McGovern about how we can incorporate some of his concepts more fully in the medical school curriculum at all levels at UMass Chan Medical School. Congressman McGovern wrote a persuasive article in the American Journal of Clinical Nutrition arguing the urgent need to improve medical education in the area of nutrition. 18 I believe this has important implications for congressional districts and medical schools throughout our country.
This year has also been a banner year for the American Journal of Lifestyle Medicine. This year we crossed the 16,000-subscriber mark and had over 200,000 downloads of full-text articles! It is clear that lifestyle medicine is a worldwide phenomenon since many of these articles were downloaded in various countries around the world.
Many years ago, when I edited the first edition of my multi-authored textbook which named the field of lifestyle medicine in the academic literature, my vision was to emphasize to the medical community the overwhelming evidence which underscores the importance of daily habits and actions and health. 19 I felt, and continue to feel, that lifestyle medicine is the ideal vehicle to assemble the thousands of studies that have clearly demonstrated the health promoting value of sound nutrition, regular physical activity, weight management, avoiding tobacco, etc. Since that time, the literature supporting the power of these daily habits and actions has continued to expand and deepen.20,21 We have now added sleep and positive relationships with other people to complete the “Six Pillars of Lifestyle Medicine.”
As a cardiologist, I was delighted to see that the initial rubric established by the American Heart Association for cardiovascular disease reduction which had been called “Life’s Simple Seven” incorporated many of the concepts of lifestyle medicine. Over the past year this framework was expanded to now be entitled “Life’s Essential Eight” with the addition of healthy sleep. 22 The lifestyle medicine community can take significant credit for bringing forth this concept and the literature of the powerful, health promoting habit of restorative sleep.
My interest in continuing to expand the evidence-base of lifestyle medicine, has largely been focused over the past few years in generating single topic volumes in the Lifestyle Medicine Series where I have the honor of serving as the Series Editor. In the past 18 months, we have published six volumes in the Series including ones on obesity management, physical activity, women’s health, cardiovascular disease, and a Manual of Lifestyle Medicine. Over the next 12-18 months, six more books are scheduled in the Lifestyle Medicine Series including volumes on diabetes and pre-diabetes, behavioral counseling, psychiatry, mental health and behavior, geriatrics, family practice and lifestyle nutrition.
I have challenged the editors of all of these volumes to continue to expand the evidence-base of lifestyle medicine so that these books can not only serve as important guidelines for primary care physicians, but also expand the knowledge of lifestyle medicine into the various subspecialties within mainstream medicine. In addition, I am pleased to announce that the 4th edition of my Lifestyle Medicine multi-authored textbook is completed and in manuscript form. It should be published within the next few months.
As I survey the field of lifestyle medicine, it is clear that while great challenges remain, enormous progress continues to occur. The passionate and committed members of ACLM represent the “tip of the spear” in lifestyle medicine. It is clear that ACLM is pushing the envelope to incorporate lifestyle medicine into all aspects of healthcare. Each year the publication of this issue, devoted to the previous national meeting of ACLM, gives me an opportunity to reflect on the substantial progress that continues to occur in lifestyle medicine. I am always left with the feeling that, for lifestyle medicine and its passionate and committed practitioners, the future is indeed bright!
James M. Rippe, MD Editor in Chief, AJLM
Professor of Medicine
UMass Chan Medical School, Worcester, MA