Lifestyle Medicine: Have Hammer, See Nails, Seeking Spoon

Famously, when you have a hammer, you tend to see nails everywhere you look. As president of the American College of Lifestyle Medicine, then, perhaps it's no surprise that I see opportunity to apply this remedy everywhere I look. Lifestyle medicine is my hammer.
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Lifestyle is the best medicine. The perennial challenge is figuring out what makes the best spoon.

I suppose I might be prone to bias on this topic. Famously, when you have a hammer, you tend to see nails everywhere you look. As president of the American College of Lifestyle Medicine, then, perhaps it's no surprise that I see opportunity to apply this remedy everywhere I look. Lifestyle medicine is my hammer.

But to throw one more metaphor into the mix, that really puts the cart before the horse. I am not looking for evidence in support of lifestyle medicine because I lead the professional college devoted to that cause; I lead the college because I have long been devoted to that cause, and for the best of reasons: evidence.

The evidence that lifestyle is the best medicine is vast, consistent, generalizable, time-honored, and robust. We need a variety of other medicines, of course, to treat the wide variety of ways our health can break -- although lifestyle interventions figure in that mix as well. But when the goal is optimizing health rather than opposing disease, lifestyle has no rival. The artful practice of lifestyle medicine is the best chance each of us has to add years to our lives and life to our years.

Yet that medicine may not go down easily. The short list of salient priorities -- eating well, being active, avoiding tobacco, sleeping enough, controlling stress, and connecting with other people -- lies on the road seldom taken in some cultures, and on a path of much lesser resistance in others. Where lifestyle exerts the greatest net benefit on bodies, the body politic has had a lot to do with it. Blue Zones result where the prevailing norms facilitate health and vitality.

That is why context is critical to the examination of lifestyle as medicine, and why the benefits in the context of modern American culture can only be seen as through a lens, darkly. Those benefits are visible, as highlighted in a series of articles in the current issue of the Annals of Internal Medicine online, but somewhat overcast with shadow.

A group of researchers, reviewing the literature on behalf of the United States Preventive Services Task Force, concluded that: "Intensive diet and physical activity behavioral counseling in persons with risk factors for cardiovascular disease resulted in consistent improvements across various important intermediate health outcomes up to 2 years." Those intermediate health outcomes included LDL, blood pressure, fasting blood glucose, and weight. On the basis of this evidence review, the Task Force now formally recommends lifestyle counseling to modify cardiovascular risk.

The relevant shadows are the kind of counseling, and the enthusiasm for it. The kind of counseling recommended is "intensive," suggesting that lesser interventions just won't get the job done. The Task Force gave this recommendation a "B" grade, meaning: "There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial." In contrast, an "A" grade indicates high certainty in substantial benefit.

Why only "B" level enthusiasm for intensive counseling? Because the evidence evaluated is, for the most part, the evidence of what clinical interventions can do. That they can be helpful at all is perhaps surprising in a culture that conspires directly against them. Physicians and other health care professionals offer advice about healthful eating, for instance, while Big Food companies engineer irresistible junk. Two steps forward, three steps back is not a great formula for progress.

And yet we are making some in spite of it all. Recent evidence from the Look AHEAD Trial indicates that intensive lifestyle counseling can both improve outcomes and lower costs in the management of Type 2 diabetes. Perhaps that isn't the final nail clinching the argument for routine application of lifestyle medicine, but it certainly argues strongly in favor of applying the hammer. Which leads us back to that elusive spoon.

For Mary Poppins, it was famously a spoonful of sugar that helped the medicine go down. These days, more spoons full of sugar are about the last thing we need. Clinicians can, and should, play an important role in the administration of lifestyle as medicine. By acquiring and practicing the relevant skills, we can play an even bigger role, defending and cultivating our own health, and that of our families.

But around the globe and across the decades, bodies benefit the most when the body politic gets involved and aligns the propagation of health with the propositions of culture. Lifestyle is the best medicine, and culture is the spoon.

That spoon could help the medicine go down, all but universally, and with stunning benefit. But for now, it is missing from our silverware drawer. Until we find it, it's back to the harder work, and lesser benefits, of pounding those nails.


David L. Katz, MD, MPH, FACPM, FACP is the founding director of Yale University's Prevention Research Center, President of the American College of Lifestyle Medicine, and author of Disease Proof - which preaches what he practices. Hammer not included.