Australian doctors are introduced to the evidence for lifestyle medicine
The current issue of the Medical Journal of Australia includes a “lifestyle medicine” section, featuring an article by Garry J Egger, Andrew F Binns and Stephan R Rossner. They literally wrote the book on Lifestyle Medicine. Their book is the core curriculum for the postgraduate Master of Clinical Science in Lifestyle Medicine program at Southern Cross University in Lismore, NSW, and forms the guiding principles used by the Australian Lifestyle Medicine Association (ALMA).
As they explain, lifestyle medicine is not conventional medicine, it’s the latest alternative modality sweeping the world. Alternative medicine is becoming mainstream.
What is Lifestyle Medicine? You won’t want to miss the essential background on the new field of lifestyle medicine in Australia, and the origins of the ALMA, here. It tells the story of the government advisor who wrote the national clinical guidelines for weight control and obesity, the GutBuster’s Waist Loss diet doctor, Professor Trim, who also promotes personal carbon credit cards to fix global warming and the obesity epidemic at the same time. He started the lifestyle medicine degree program at Southern Cross University and established ALMA at his department.
The term “lifestyle medicine” goes back even earlier, of course, and originated with Dr. Ernst L. Wynder, M.D., who believed that most cancers, heart disease and chronic diseases of aging are our own fault and caused by bad diets and lifestyles. This story was covered here. Dr. Wynder promoted this new field of lifestyle medicine as essential for governments and society to address, and as offering a new role for public health: population medicine. The American Health Foundation he founded went on to become the Institute for Cancer Prevention (IFCP). For decades, IFCP had been recognized by the National Cancer Institute at the National Institutes of Health as the only center in the country devoted to studying the relationship between cancer and diet and lifestyle behaviors. It’s the source for much of the lifestyle-associated risk factors and beliefs that make up preventive medicine today — surrounding veggies, antioxidants, weight loss, organics, detoxification, garlic and low-fat foods.
These associations have not been credibly replicated, however, and even the world’s largest report of epidemiological studies of cancers had been unable to find tenable correlations between 17 cancers and BMIs, diets people are eating or lifestyles. Nor have credible links between heart disease and western diets and lifestyles been shown.
The field of preventive-lifestyle medicine has had a checkered past, as readers may remember. IFCP’s been involved in some of the biggest scandals in clinical research. FBI investigations found millions of dollars of government research grants had been misused by IFCP, even after it had been in trouble for embezzling grant money just years earlier, and the CFO was criminally prosecuted after lying to federal agents to cover it up. Of course, IFCP is not the only cancer center devoted to lifestyle medicine today, nor is NIH the only funder. The Robert Wood Johnson Foundation, for example, recently gave the Cancer Institute of New Jersey and RWJ Medical School $12 million to create a large collection of data on lifestyle, diet, genetic and environmental associations (risk factors) with cancer.
Most important to fair tests of possible causes are the gold standards of medical research: randomized, placebo-controlled, double-blind clinical trials. As clinical trial evidence is steadily failing to support most of the alternative beliefs behind lifestyle medicine, they are increasingly finding their way into mainstream medicine, academia and public health policies. This isn’t meant to scare you about the reasoning skills of medical professionals or anything. But it may help provide some grounding as you read the incredible claims in the MJA article.
In their article, “The emergence of ‘lifestyle medicine’ as a structured approach for management of chronic disease,” professor Egger and colleagues introduced this new modality to Australian Medical Association readers, telling them that its popularity is growing. There’s at least three universities in the United States offering postgraduate medical specialties in lifestyle medicine (Harvard, University of Florida and Loma Linda); Lifestyle Medicine Associations; and even its own journal, the American Journal of Lifestyle Medicine.
This journal is edited by Dr. James M. Rippe, M.D., who heads the Lifestyle Medicine Initiative and chairs the Center for Lifestyle Medicine at the University of Central Florida. As these sites note, the marketing potential of lifestyle medicine is abundant, with a wide variety of corporate partnerships and sponsorships interested, from pharmaceutical and supplement companies, disease management organizations, weight loss programs and products, health food, fitness products and equipment suppliers, and wellness programs and coaching.
While medical professionals are ideally immune to bandwagon marketing and, instead, follow sound science-based medicine, the clinical evidence to support of lifestyle medicine that was presented in this article was thin. The authors repeated the lifestyle medicine adage that 60-70% of all chronic diseases treated in developed countries are lifestyle-based and, therefore, preventable. They advocated lifestyle medicine as a new approach to population-based priorities for public health and “a more comprehensive approach to the management of chronic disease [that] would consider not only risk factors, but also a range of antecedent factors from all levels of causality.” For example, they said:
Treatment would ultimately employ a combination of clinical and public-health interventions, which may not always seem intuitive. For example, population rates of obesity could be reduced by not only implementing personal weight-loss programs at the clinical level, but also highlighting the environmental effects of burning fossil-fuel instead of personal energy for transport.
Several large-scale prospective studies have now shown the benefits of lifestyle change in preventing progression from pre-diabetes to type 2 diabetes, with effects lasting for up to 20 years. Cost-effectiveness has also been demonstrated.
Calorie credit cards have already been covered here. The study the authors cited to support the assertion that lifestyle interventions can prevent type 2 diabetes was the China Da Qing Diabetes Prevention Study. But how many medical professionals followed the link to see what the study actually found and what those 20-year effects really were?
This study had recruited 577 adults already diagnosed with impaired glucose tolerance from 33 Chinese clinics in 1986 and randomly assigned the patients to either a control group or a diet, exercise or diet and exercise intervention. The endocrinologists found: “There was no significant difference between the intervention and control groups in the rate of first CVD events, CVD mortality, and all-cause mortality.” The Beijing authors concluded that “whether lifestyle intervention leads to reduced cardiovascular disease and mortality remains unclear.
Despite the widespread marketing and beliefs that “healthy” diets and lifestyles can prevent or delay type 2 diabetes, such views have not been supported in the body of quality evidence, as reported. Cochrane Collaborative conducted a comprehensive systematic review and QUOROM (evaluation of the quality of the studies) of 8,675 studies, after searching for all of the randomized, controlled clinical trials of dietary advice and interventions in type 2 diabetes that had lasted at least six months. It had found no evidence to support dietary interventions. A recent update included background research and reviewed another 1,413 studies to determine if any type of dietary advice or weight loss, with or without other lifestyle interventions, could be shown to improve morbidity, total mortality, or quality of life. They found none.
Nor has cost effectiveness been shown. The study that professor Egger and colleagues used to support this claim was not actual patient data, but a Markov model and a “probabilistic sensitivity analysis” by Swiss economists. Their model had used secondary data and been based on assumptions that treating risk factors, namely weight loss for obesity, would result in longer life over standard care. In a meta-analysis by the same authors in the same issue of the International Journal of Public Health, they examined 13 studies of lifestyle interventions in obese patients lasting 1-3 years. They reported an average weight loss of 2.93kg, but no clinically meaningful change in health indices (cholesterols, fasting blood sugars or HbA1c, and blood pressures). The authors didn’t report any actual clinical outcomes or mortality data at all.
The MJA authors went on to describe how lifestyle medicine differs in orientation to conventional medical practice. “Exercise and nutrition are the penicillin of lifestyle medicine; psychology the ‘syringe’ through which these are delivered,” they said. From their book, they listed the most significant differences. Lifestyle medicine “treats lifestyle causes” and the “patient is required to make big changes,” with the “emphasis is on motivation and compliance.” Rather than doctors treating patients on a one-to-one basis, they said, in lifestyle medicine doctors act as a coordinator of a team of professionals.
The ambit of lifestyle medicine includes the management of obesity, sleep, mood states (anxiety, depression), addictions, sexual behaviour, skin health, oral and auditory health, pain, iatrogenic illness, and many types of injury. Typically, each of these conditions requires the input of a specialist discipline (eg, a dietitian, an exercise physiologist, a psychologist). However, a new generation of graduates from multidisciplinary allied-health vocational programs now being offered at several universities will change this in the future. The availability of non-medical specialties reduces the involvement required of general practitioners, who often lack the time to personally provide these services to their patients.
They didn’t define the non-medical personnel who will reduce the need for doctors. Perhaps, it’s believed that having the right diet and lifestyle will mean 60-70% of us will never get old or sick and need doctors.