Author: Dr Roxanne Becker

Introduction

We know about the global pandemic of Covid-19 that has dominated our lives for the past 2 years, but did you know about the pandemic of non-communicable (or non-infectious) diseases that is responsible for 71% of all deaths globally, and 80% of premature deaths (deaths <70 years old)?(1) According to a study published in 2018, (2) 80% of chronic disease and premature death could be avoided if we implemented 4 healthy lifestyle habits: a healthy diet, regular physical activity, abstinence from tobacco smoking, and avoiding excessive alcohol consumption.

Context

The Nurses Health and Health Professionals Follow Up Studies showed that of the >170 000 participants that were followed up for 34 years, those who adhered to the above 4 healthy lifestyle habits and had a normal BMI, had a 74% lower risk of death from all causes, as well as an 82% reduced risk of cardiovascular disease, and a 65% reduced risk of cancer. (3) And the European Prospective Investigation into Cancer and Nutrition estimated lifestyle changes could potentially prevent 93% of diabetes cases, 81% of heart attacks, 50% of strokes and 36% of all cancers. (4) The 2021 Global Nutrition report states that 20-25% of adult deaths are associated with an imbalanced diet. (5)

South Africa is a complex country in a health crisis, with a quadruple burden of disease including non-communicable diseases, communicable diseases, perinatal and maternal morbidity and mortality, and injury-related disorders. (6) Over 10 years, from 2009 to 2019, South Africa went from have 3 communicable diseases as the leading causes of death, namely human immunodeficiency virus (HIV), lower respiratory tract infections and tuberculosis, to having two non-communicable diseases in the top three causes of death. HIV is still rife in our country and is still the leading killer, but ischaemic heart disease (IHD) and cerebrovascular disease (CVA) or stroke, moved up to the second and third causes, and diabetes moved up from the seventh leading cause of death, to the fifth. (7)

Another important consideration is that high body mass index (BMI), high fasting plasma glucose, high blood pressure and tobacco smoking are the third to sixth risk factors that are driving the most death and disability in the country, beaten only by unsafe sex (increasing transmission of HIV) and malnutrition. (7)

Since we have established a clear trend in South Africa towards non-communicable diseases, mainly diseases of lifestyle, what is lifestyle medicine and why is it needed in our country?

Though lifestyle medicine has been practiced for hundreds to thousands of years, many still consider it a relatively new sub-specialty. Lifestyle medicine has been described by the American College of Lifestyle Medicine as “a medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions including, but not limited to, cardiovascular diseases, type 2 diabetes, and obesity.” (8) It focuses on 6 pillars; a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, avoidance of risky substances and positive social connections. And it’s important to note that lifestyle medicine aims not to replace medication and surgery entirely, as lifestyle medicine practitioners are aware that in some cases medication or surgery is necessary, but rather to compliment Western medicine with the aim of addressing the cause of disease, promoting overall well being, and reducing/eliminating medication where possible.

Lifestyle medicine for specific diseases

Obesity. Adiposity-Based Chronic Disease (ABCD) was proposed as the new diagnostic term for obesity a few years ago, as a means to reduce stigma attached to the word “obesity”. In a position statement from the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE), it was suggested that Lifestyle Medicine be the central key to addressing this disease. (9) Obesity is not a benign condition; it is associated with chronic inflammation due to the adipokines released from visceral fat which has been linked to an increase in risk of several diseases. (10) Obesity is the leading risk factor for diabetes, increasing a person’s risk of diabetes by 93 times if their BMI is greater than 35, and both obesity and diabetes increase the risk of cardiovascular disease (CVD) substantially. (11) An estimated 6% of all cancers are attributable to obesity, including breast, colorectal and ovarian cancers. (12)

During the Covid-19 pandemic, we also saw that the rates of severe covid-19 disease, as well as the need for ventilation, increased as BMI increased. (13) A systematic review of nearly 2000 individuals with a BMI between 35-48, classified as having severe obesity or ABCD, underwent lifestyle interventions including dietary modification, physical activity goals, and behavioural interventions all of which showed significant reductions in body weight. (14) However, a common issue today is that doctors either do not have time to address these interventions with their patients, due to high patient burden, particularly common in public hospitals, or they do not have the knowledge or skills to address these topics with their patients.

Diabetes. Many patients and doctors see diabetes as an irreversible diagnosis that progressively worsens and believe that diabetic control can only be managed and controlled and not improved or reversed. Plant-based diets have been shown to both prevent and treat type 2 diabetes (DMII), and have also been shown to reduce the risk of diabetes-associated complications such as chronic kidney disease (CKD), CVD, and peripheral neuropathy (PN), as well as to reduce the severity of proteinuria in patients with CKD (a poor prognostic feature) and to reduce subjective pain due to PN. (15) The Reverse Diabetes 2 Now trial, which used a Mediterranean diet, regular exercise and stress management as interventions, found that 71% of participants who were taking insulin at baseline were able to come off it completely, and 67% were able to lower their oral diabetic medications. Not to mention, their subjective health and quality of life improved. (16) But Lifestyle Medicine should also be used in prediabetic patients, as dietary and exercise interventions have been shown to dramatically reduce the risk of prediabetic patients from developing diabetes. (17)

Cardiovascular disease. As early as 1990, we’ve seen that lifestyle modification might be able to reverse cardiovascular disease. The Lifestyle Heart Trial was a prospective, randomised control trial that found through a low-fat vegetarian diet, regular exercise, smoking cessation and stress management, 80% of participants in the experimental group had some extent of regression of their atherosclerosis on their coronary angiograms. (18) The Mount Abu Open Heart Trial also found that through a low-fat vegetarian diet, regular exercise and stress management through meditation, 91% of participants were found to have regression of their atherosclerosis, as well as a reduction in cardiac events. (19) And finally another study published in 2014 found that a whole food plant-based diet resulted in reversal of coronary artery disease on angiogram, as well as improved myocardial perfusion, and reduced cardiac events. (20)

Hypertension. Several meta-analyses have shown that reducing salt intake, regular exercise, reducing alcohol, weight loss, and reduced alcohol consumption all reduced blood pressures in hypertensive patients. (21) The Nurses Health Studies I and II, the Health Professionals Follow Up Study and the EPIC-Oxford study all found that vegan diets were associated with the lowest incidence of hypertension, and that omnivorous diets were associated with the highest incidences, with vegetarian and pescatarian diets in the middle. (22,23) The Dietary Approaches to Stop Hypertension (DASH) diet, which focuses on whole foods, while limiting meat and processed foods, as well as the Mediterranean diet, which is similar to the DASH diet but with less dairy, and more olive oil, have both been shown to improve blood pressure control in hypertensive patients. (24,25)

Conclusion

Lifestyle Medicine has the potential to drastically reduce the morbidity and mortality in this country, while simultaneously improving quality of life. It can also reduce the health care expenditure and reduce the patient burden on health care professionals. Lifestyle Medicine has the potential to be as effective, if not more effective, than medication at managing some of these diseases mentioned, and we urgently need more healthcare professionals to be trained in and to practice this subspecialty.