What is lifestyle medicine? – Articles

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A promise to address most modifiable risk factors for diabetes mellitus, cardiovascular and cerebrovascular diseases, and cognitive decline

Highlights

• Chronic non-communicable diseases (specifically diabetes mellitus, cardiovascular diseases and cerebrovascular diseases (stroke and vascular cognitive impairment)) have significant and negative consequences for individuals, health care systems and economies around the world. chronic non-communicable diseases share modifiable risk factors (FRM), such as hypertension, hyperlipidemia, smoking, poor diet, and low physical activity; hypertension being the most prevalent FRM.
• Most FRMs can be successfully addressed through lifestyle medicine, which is an evidence-based medical specialty that addresses the underlying causes of chronic diseases through its primary, secondary and tertiary preventive approach.
• Lifestyle medicine includes 6 pillars: nutrition, physical activity, sleep health, stress reduction, social connections and substance use. Addressing habits and lifestyle factors through these pillars has the potential to address and reduce modifiable risk factors (MRFs), which may moderate the overall burden of disease.
• It is imperative that clinicians take into account the unique circumstances and inextricably interrelated aspects of lifestyle and social determinants of health at the micro, macro, and meso levels.
• Lifestyle medicine has the potential to contribute to the restoration of health by modifying behaviors that have contributed to the global burden of disease. The adoption of lifestyle medicine requires a multifaceted approach to support this paradigm shift and achieve health equity.

Epidemiological burden of chronic diseases

Diseases have significant consequences on people, healthcare systems and economies around the world, making them challenging, and their prevention and management is a global priority. The chronic diseases They are the main cause of disability and mortality, representing 74% of deaths worldwide, and their increase continues in parallel with the increase in health spending. Chronic diseases are responsible for 90% of annual healthcare spending.

The most common chronic diseases are diabetes mellitus (DM) (96%, type 2 DM [DM2]), cardiovascular diseases (CVD) and cerebrovascular diseases (stroke [ACV)] and vascular cognitive impairment [DCV)]). Globally, 1 in 3 adults lives with >1 chronic disease.

Between 1990 and 2019, all CVDs (e.g., coronary artery disease, peripheral artery disease, and rheumatic heart disease) nearly doubled, with ischemic heart disease comprising the majority of CVDs. The global trend of increasing mortality also increased. In parallel, stroke and vascular cognitive impairment [DCV)] emerge as important global public health challenges. Strokes represent >40% of cases.

The global burden of all neurological diseases is equivalent to 1 stroke every 3 seconds.

This is in conjunction with a dramatic increase in stroke among younger adults. That is, almost 40% of strokes occur in workers and the middle-aged population (<65 years). More importantly, 50% of people with stroke develop some cognitive impairment and meet the clinical and radiographic definitions of VCI (representing 30% of all dementia diagnoses). The presence of vascular cognitive impairment [DCV)] It affects at least 1 cognitive domain and includes a spectrum of vascular brain pathologies (not just stroke) that contribute to any cognitive impairment, from mild cognitive impairment to dementia. The burden of all chronic diseases mentioned above is on a steep rise, probably due to current lifestyles in modern society, or lack of access to care in the developing world.

The global burden of disease, specifically for diabetes mellitus (DM), CVD and cerebrovascular disease (stroke and CVD) is attributed to modifiable risk factors (FRM). Approximately 90% of strokes, almost 70% of cardiovascular diseases, approximately 70% of CVD or T2DM and almost 40% of dementia have been linked to shared DRFs. These factors are common to all and include hypertension, hyperlipidemia, hyperglycemia, alcohol consumption, smoking, poor diet and little physical activity; High blood pressure being the most important factor of all (40%-60%). Currently, high blood pressure, as an FRM and independent chronic disease, affects one billion people worldwide; 1 in 3 middle-aged adults live with HTN. It is estimated that there will be an approximately 60% increase in cases globally by 2025. The risks of DM, CVD, stroke and VCI are shared across FRMs, many of which can be managed through a Lifestyle Medicine (MEV).

Lifestyle Medicine

Definition

The Lifestyle Medicine (MEV), is defined by the American College of Lifestyle Medicine as a medical specialty that applies behaviors, motivations, environmental and clinical principles to prevent, treat or manage chronic diseases. Addresses the underlying causes of chronic diseases through their primary and secondary forms, and tertiary preventive approach; with direct and indirect multiscale effects on general health, quality of life, well-being, and health care expenditures. It consists of 6 pillars: nutrition, physical activity, sleep health, stress reduction, social connections and substance use.

Nutrition. Nutrition is a fundamental component of the lifestyle habits that affect DM, CVD, stroke and DCV. It is estimated that 1 in 5 premature deaths worldwide are due to a suboptimal diet.

Diabetes. One of the most essential components of lifestyle therapy for T2DM is supporting people to adopt a healthy lifestyle and a healthy diet (with appropriate calorie restrictions). Weight loss >10%-15% of body weight and implementation of a weight-focused approach to the treatment of T2DM are recommended as an important goal to reverse underlying metabolic abnormalities, improve glycemic control and CVD risk factors, and achieve remission of DM2. This remission It is defined as the return of hemoglobin A1C (HbA1c) to <6.5%, spontaneously or after an intervention, with 3 months without the consumption of usual hypoglycemic agents. In the case of inaccuracy or unreliability of A1c, remission can be defined as fasting blood glucose <126 mg/dl or estimated HbA1c <6.5%, calculated from continuous glucose monitoring values.

He Diabetes Remission Clinical Trial examined the effect of a structured and intensive weight management program and compared it with usual management of DM and obesity, which was applied in primary care to achieve remission of T2DM. At 2 years, 36% of intervention group participants (n=194) remained in remission, experienced a 50% reduction in T2DM medication use, and showed greater weight loss with higher rates of remission of T2DM; 86% of patients with T2DM lost 15 kg of body weight before remission. The study also found that the proportion of participants with T2DM who were still in remission after 5 years was 3 times higher than those in the control arm who were still in remission, with an average weight loss at 5 years of 8.9 kg. .

Lifestyle. Medicine for the treatment of DM emphasizes incorporating more nutrients and dense fiber sources and foods such as non-starchy vegetables, whole grains, legumes, nuts, seeds, with limitation of calorie-dense, highly palatable, nutrient-poor food groups. such as ultra-processed foods and red and processed meats.

Cardiovascular diseases and stroke

Based on the Global Burden of CVD 2022 and the NHLBI (National Heart, Lung, and Blood Institute)-Risos Collaboration study, it has been established that ischemic heart disease represents the majority of risk-associated CVDs. In the Framingham cohort study, each additional serving of ultra-processed foods was associated with a 5% and 9% increase in overall CVD risk and mortality, respectively.

Of all the FRMs, the arterial hypertension It is the most prevalent vascular risk for all CVD and all cerebrovascular diseases. Healthy dietary patterns, such as the Dietary Approaches to Stopping Hypertension diet, the Mediterranean Diet, and other plant-based diets, show promise in reducing this risk, with several randomized controlled trials confirming the effectiveness of dietary interventions in lowering blood pressure. arterial and the management of hypertension. General recommendations on these dietary patterns also include a higher intake of whole grains, legumes, fruits, vegetables, fish, vegetable (olive) oils, seeds and nuts and a lower intake of low-fat dairy products and poultry. All of this results in a diet with an optimal fiber content, but also macro and micronutrients (specifically low sodium content in relation to potassium).

In a meta-analysis of 30 randomized controlled studies, the the DASH diet (low sodium, high potassium, with a predominance of whole plant-based foods) significantly reduced blood pressure with a net effect on both systolic and diastolic blood pressure (5.5 and 3.0 mm Hg), respectively, which was achieved in the second week of the introduction of the diet. When combined with additional sodium reduction (1,500 mg/day vs. 2,300 mg), the DASH diet was associated with a more potent reduction in systolic blood pressure (approximately 20 mm Hg).

Although the DASH study did not include CVD outcomes, other studies have shown that lowering blood pressure can markedly lower the risk of congestive heart disease and stroke. Such findings are consistent with a large meta-analysis that also found a blood pressure reduction of only 10 mm Hg in systolic pressure and 5 mm Hg in diastolic pressure, associated with a 41% reduction in stroke across all trials: 46 % in primary prevention, 44% in secondary prevention, and 35% in trials that included participants with a history of coronary artery disease. Although the effect of low sodium in proportion to potassium may explain part of the effects of the DASH diet on blood pressure reduction, other studies explored these associations through consumption and measurements of different foods.

In the Danish study on diet, cancer and health (N = 53,150 people), after a 23-year follow-up, participants who consumed the most plant nitrates (141 mg/day) had lower systolic and diastolic blood pressures. A modest intake of 60 mg/d (1 cup of green leafy vegetables) was associated with a 15% and 17% lower risk of CVD and ischemic stroke, respectively.

In the PREDIMED trial, the Mediterranean Diet supplemented with extra virgin olive oil or nuts vs. controls (low-fat diet) was associated with almost 40% relative reduction in stroke risk, while the consumption pattern of provegetarian foods compared to the diet, including animal products, eggs, dairy or meat, reported almost 40% % reduction in mortality rate from all causes.

Vascular cognitive impairment (VCI). Although there are no studies of the effects of dietary patterns specifically on VCD, the most convincing evidence of the effect of diet on the vascular mediation of dementia risk comes from studies related to increased consumption of foods rich in vitamin E (walnuts ), which act as antioxidants, fish, polyunsaturated fats, vitamin B12 and folates, as part of the Mediterranean Diet, showing a 20% to 40% reduction in the risk of dementia in the upper quartiles of consumption of that diet. However, in a systematic review of 56 randomized controlled trials, greater adherence to all plant-rich dietary patterns, such as the DASH, Mediterranean, and Mediterranean-DASH diets, Intervention for Neurodegenerative Delay (MIND), was significantly associated with a lower risk of dementia (approximately 50%). Even moderate adherence to the MIND diet reduced the risk of dementia by 35%.

Key Message on Lifestyle Medicine and Nutrition

Currently, to prevent CVD and stroke, several important clinical practice guidelines support a predominantly plant-rich diet and low sodium intake (<2400 mg/day). However, globally reducing the consumption of ultra-processed foods This is easier said than done without strong public health policies and synchronized intersectoral efforts. Health promotion experts advocate for broader evidence-based policies, providing clearer dietary guidelines, promoting correct food labeling, oversight, restricting fast food establishments near schools, and reducing the size and the appeal of food portions and packages, along with fresh food recipe for everyone.

The most effective tools to combat global burden diseases (DM, CVD, stroke or DCV) are simple and profitable lifestyle strategies with implementation of whole foods, with a predominance of foods rich in vegetables, together with effective advice with MEV specialists or nutritionists. Behavioral change and consumption of plant-rich dietary foods along with addressing the root causes of lifestyle-related chronic diseases are very important.

Physical activity

Physical activity is essential for general health and quality of life, in addition to its important effect on multiple organ systems and the risk of developing DM, CVD, stroke or CCI. The direct and indirect effects of physical activity are broad, complex and poorly understood at the molecular level. However, numerous signaling pathways and molecules have been identified that have been related to exercise, called exercise. The immune, nervous and cardiometabolic systems produce and are influenced by exercins, contributing to the response to physical activity. The biological effects of physical activity vary and include improved energy utilization, angiogenesis, neurogenesis, endothelial and immune function, increased skeletal muscle mass, and mediation of mitochondria and inflammation.

The benefits of physical activity in the primary and secondary prevention of DM, CVD, stroke and cognitive function are undeniable.

Diabetes and cardiovascular diseases

Globally, 7.2% of CVD deaths are attributed to physical inactivity. Physical inactivity also substantially affects the risk of developing coronary heart disease, stroke, high blood pressure and T2DM, in both people from low- and high-income countries.

Both the aerobic exercises Like the ones of force They lower blood pressure and improve lipid levels. The benefits of exercise interventions are comparable to those of medication, as seen in mortality, secondary prevention of heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of DM.

These findings are consistent with a meta-epidemiological study of 305 randomized controlled trials that showed that physical exercise interventions were more effective in reducing mortality than pharmacological intervention in patients with stroke, although such an effect was not significant for congestive heart disease. or prediabetes. Making a switch from medication to medical procedures, physical exercise has been shown to be superior to percutaneous coronary intervention (PCI) in patients with stable CVD.

A 12-month randomized controlled trial (n=101) comparing an exercise training program (20 minutes of daily bicycle ergometer) with PCI in patients with stable coronary artery disease found significantly greater event-free survival (88% vs. 70%). % in the PCI group), increased maximum oxygen consumption and lower cost, in those who followed a physical training program compared to percutaneous coronary intervention (PCI).

Cerebrovascular accident or vascular cognitive impairment. Participation in any type of physical activity has been shown to not only reduce the risk of stroke but also the progression of cognitive decline and dementia, including VCI.

Physical activity can improve neuronal connections, maintain neuronal plasticity and improve the release of neurotrophic factors.

Although randomized controlled trials have not yet been carried out, a meta-analysis of 18 cohorts and a study of 5 cases and controls showed that moderate to high physical activity was associated with a lower incidence of stroke and mortality (approximately 30%) while a level of High occupational physical activity reduced the risk of stroke by 43%; High levels of leisure-time physical activity reduced stroke risk by 20% to 25% compared with inactivity. Similar findings were observed in a systematic review on physical activity and VCI: the overall effect of physical activity reduced VCI by 30%; Higher levels of physical activity were associated with a lower risk of VCI over time, in addition to supporting the recommendations of the American Heart Association for the prevention of stroke and VCD.

Key message for Lifestyle Medicine and physical activity. Physical activity is a highly beneficial lifestyle approach in the prevention, management or long-term treatment of chronic diseases such as DM, CVD, stroke and VCI. The dosage of physical activity (frequency, intensity, duration, and type of activity) to achieve specific health outcomes varies. Currently, clinical guidelines recommend that adults with or without chronic disease perform ≥150-300 min/week of moderate-intensity physical activity or 75-150 minutes of vigorous-intensity aerobic activity, combined with ≥2 sessions of weight training. resistance per week. The older adults They should also incorporate physical activity that includes a balance component. Clinicians should encourage physical activity at each clinic visit, with advice on physical activity guidelines and possible referral to rehabilitation or exercise specialists within the community, as appropriate.

Sleep health

Sleep is an integral contributor to cardiometabolic metabolism and brain health.

Sleep is also a foundation for overall improvement in other pillars of lifestyle. The evidence on sleep health and DM, CVD, stroke, and VCI is increasing, with most research coming from observational studies.

Diabetes mellitus, cardiovascular diseases, cerebrovascular accidents or vascular cognitive impairment. Poor sleep has been consistently identified as a risk factor for poor glycemic control in T2DM. Total sleep duration and subjective sleep quality, (measured by the Pittsburgh Sleep Quality Index ≥6 indicating poor sleep), were significantly associated with higher HbA1c. A review of studies published between 2015 and 2020 also showed a consistent association of sleep variability with an increased risk of adiposity, glucose dysregulation, and T2DM.

Sleep disturbances also have a negative effect on CVD and cardiometabolic health. In a systematic review and meta-analysis of 15 prospective studies (N =¨474,684), short sleep duration was associated with a higher risk of developing coronary heart disease and stroke or death. Similarly, long sleep duration was also associated with increased risk of coronary heart disease, stroke, and total CVD. The findings on the negative effects of sleep on CVD risk are also consistent with a population-based study that found that people who slept <6 hours had a higher risk of possible CVD and a 30% higher risk of future dementia. respectively.

Key Message from Lifestyle Medicine and Sleep. Sleep disturbance has harmful consequences on DM, CVD, stroke or VCD. The importance of VME interventions and preventive approaches (e.g., sleep hygiene, sleep education, relaxation techniques, and cognitive behavioral therapy) is highlighted to promote healthy sleep, specifically with improved duration and quality. cardiovascular health and neurocognitive outcomes. Sleep health should be assessed during clinical visits and referred to MEV or referred to a sleep specialist if indicated.