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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
- 4. Goals • Define LifestyleMedicine • 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 goingon How we got here What WE can do about it
- 6.
- 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 responseto 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
- 11. Characteristics • Preventive/ Proactive •Associative model of care • Empowering/Optimistic • Wholistic
- 12. “It is timewe 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
- 13. Classic Medical Model Surgery Pharmaceuticals
- 14. Enlightened Medical Model Surgery Pharmaceuticals Botanicals Physical Modalities Mind-Body Interventions
- 15. Ideal Medical Model Surgery Pharmaceuticals Botanicals Physical Modalities Lifestyle Interventions
- 16. The function ofprotecting and developing health must rank even above that of restoring it when it is impaired. -Hippocrates-
- 17.
- 19.
- 20. Leading Causes ofDeath in US
- 21. Top Ten Causesof Death for Men in the United States
- 22. Actual Causes ofDeath in US
- 23.
- 24. Associated Pathology • CVD: • Obtstetrics: – Hypertension – Gestational DM – Congestive Heart Failure – Macrosomia – PVD – Inc. C Section rate – Impotence – Inc. Perinatal Morbidity DIABETES – Inc. Pre/Eclampsia – Claudication • Cancer: • Endocrine: – Prostate – Diabetes – Colon – PCOS – Breast Metabolic Syndrome – Hypothyroidism – Infertility – Endometrial – Renal Cell – Gallbladder • Orthopedics: – Esophageal Adeno. – Osteoarthritis • Other: – AVN • Hyperuricemia, Pancreatitis, • Hepatic: Gallstones, Sleep Apnea, Alzheimer’s, – #1 cause of liver dz in US Dyslipidemia, Metabolic Syndrome
- 25. Overweight ↑ riskof DM2 by 3 fold Obesity ↑ risk by 9 fold
- 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
- 31. Financial Expenditures • ChronicDz ≈ 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 • $4of 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!
- 36. How did thishappen?
- 42. Genetic Shift or Lifestyle Choices?
- 43. They did notdisplay their parent’s susceptibility to cancer and diabetes…. ……..the effects of the agouti gene had been virtually erased.
- 44.
- 46. ↑39% Av. of 52tsp added sugar/person/day in 2000
- 47. •IOM: (UL) forsalt is 5.8 g/day > 95 percent US Males 31 - 50 > 75 percent of US females 31- 50 regularly in excess of the UL.
- 48.
- 49.
- 50.
- 51. Michelangelo’s David: 12 month20 city tour of the US
- 52.
- 54. US Gov. Reccomendations 150 minutes per wk 30 minutes/day + 2-3 days/Strength Tr. 4-5 days a week
- 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 inactivityis more common in: Women > Men African American > Whites Hispanic > Whites Older > Younger Less affluent > More Affluent
- 58. Exercise • Reduces riskof – 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 eatmore – Sugar, Salt, Meat, Dairy, Fat – 1970-2000: • ↑ 24.5 % C/day ≈ 530K/day • We get less then ideal – Exercise
- 60. We have a problem of epidemic proportions!
- 62. What can wedo?
- 63. What if We ate less fat, salt and sugar and more fruits, vegetables and grains & increased our exercise habits????
- 64. Some Say….. – If10% 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
- 65.
- 66. Common Misconceptions 1. # There is no evidence that a healthy lifestyle decreases M&M or extends a healthy lifespan.
- 69. 12 year CohortStudy 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 dopersons 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
- 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 PreventionTrial 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
- 75. Misconception 3 # PrescriptionMedications are more effective.
- 76. Multi-Center Randomized ControlledTrial 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
- 78. Misconception 4 # The benefits of lifestyle interventions don’t last.
- 80. Misconception 5 # Lifestyle Interventions are too expensive.
- 81. “Compared with theplacebo 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 fordifferences 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.”
- 83.
- 84. Perspectives • There issignificant evidence that: – Lifestyle dramatically impacts M&M – Organized Lifestyle Interventions are: • Effective • Cost Efficient • Feasible • Sustainable
- 85.
- 86. Duke Rice DietProgram
- 87.
- 89.
- 95. Perspective • Lifestyle-Associated Diseasesare the leading expenditure and cause of mortality in the western world • Personal choices can alter this trajectory • We can transform lives
- 96.
- 97. Challenge 1# Lifestyle Medicineis not paid for by many insurance companies.
- 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 responseto 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.
- 103. What can wedo?
- 104. Foremost • Lead byexample • Identify personal lifestyle goals • Optimize our own health • Encourage family and friends to do likewise
- 105. Then • Seek toeducate and empower • Through transmission of knowledge and motivation • Get involved in your circle of influence
- 106. Finally • Advance healthon the national and global level through political action • Get involved
- 107. Conclusion • America isfacing an epidemic of disease fostered by lifestyle choices • Lifestyle interventions are the answer • Plant Based Nutrition is central
- 108. Together we canmake a difference
- 109.
Editor's Notes
- #8 http://www.cc.gatech.edu/cpl/projects/graphcuttextures/data/rotation-perspective/people-out-persp.gif
- #9 graphicfreebie.com http://www.howtodraw.ca/images/076fig.png Sodahead.com
- #10 -- Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al
- #11 http://www.lifestylemedicine.net.au/health-professionals/index.htm
- #18 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.
- #20 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
- #21 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/
- #22 www.cdc.gov/cancer/ breast/statistics/ http://www.cdc.gov/cancer/Prostate/publications/decisionguide/
- #24 --http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/obesity.pdf --http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm
- #25 --http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/obesity.pdf
- #26 Fox, Caroline. Et al. Trends in the Incidence of Type 2 Diabetes Mellitus: Circulation 2006:113;2914-2918.
- #27 http://health.ucsd.edu/news/images/DPP1.jpg
- #30 -- 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/
- #31 --AJCN 2007; 85: 1169-1170
- #32 --http://www.healthierus.gov/STEPS/summit/prevportfolio/power/index.html#we
- #33 -- Medco Health Solutions
- #34 --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?
- #35 --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
- #42 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.
- #44 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
- #45 Gila Reservation Arizona Maycoba, Mexico
- #46 World’s smallest island country just 8.s sq miles 95% are overweight/obese and 50% have diabetes
- #47 -- http://www.ers.usda.gov/briefing/consumption/Effects.htm
- #48 --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
- #50 --http://www.ers.usda.gov/publications/foodreview/jan1996/frjan96a.pdf
- #52 http://static.howstuffworks.com/gif/michelangelo-1.jpg
- #55 -- http://www.cdc.gov/nccdphp/dnpa/physical/index.htm -- http://www.cnn.com/2003/HEALTH/diet.fitness/08/15/cdc.exercise.ap/
- #57 ----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.
- #58 ----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
- #61 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.
- #62 http://www.google.com/imgres?imgurl=http://www.deliverfreedom.com/blog/wp-content/uploads/2009/11/happy-dog.jpg&imgrefurl=http://www.deliverfreedom.com/blog/lessons-you-can-learn-from-a-dog-to-live-a-fulfilling-life/&usg=__P9wGV1Z55MqChCMQSB9j3Zw-KiE=&h=522&w=522&sz=49&hl=en&start=0&zoom=1&tbnid=pntaOysLWeGPqM:&tbnh=131&tbnw=131&prev=/images%3Fq%3Ddog%26um%3D1%26hl%3Den%26safe%3Dactive%26client%3Dsafari%26sa%3DN%26rls%3Den%26biw%3D1407%26bih%3D681%26tbs%3Disch:1&um=1&itbs=1&iact=hc&vpx=783&vpy=207&dur=1418&hovh=225&hovw=225&tx=97&ty=68&ei=DkHHTKeqB8L68AbBh4yhDw&oei=DkHHTKeqB8L68AbBh4yhDw&esq=1&page=1&ndsp=31&ved=1t:429,r:12,s:0 mixxbuzzers.com http://www.psychologytoday.com/files/u107/cigarette.jpg businesspundit.com
- #65 -- 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.
- #69 --Am J Clin Nutr. 1999 Sep;70(3 Suppl):532S-538S.
- #70 Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project.
- #71 -- 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.
- #72 --Annals of Internal Medicine 2003: 139:455-459
- #73 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
- #75 --FDDP (N Engl J Med 2001;344:1343-50.)
- #78 -- J Gerontol A Biol Sci Med Sci. 2006 Oct;61(10):1075-81.
- #80 ..Intervention group with a 43% reduction in risk P value .0001
- #82 -- Ann Intern Med. 2005 Mar 1;142(5):323-32.
- #83 -- Value Health. 2007 Nov-Dec;10(6):443-50. PMID: 17970926 Overweight/Obese/HTN/Hyperlipidemia/Diabetes
- #84 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.
- #99 --American College of Lifestyle Medicine and ACPM call for preventive…lifestyle med. training
- #101 --
- #103 -- Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al