The Power of Lifestyle as Medicine Gentry Dodd, MD, FAAPMR, DipABLM - - PowerPoint PPT Presentation

The Power of Lifestyle as Medicine

Gentry Dodd, MD, FAAPMR, DipABLM 9/13/2019

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Learning objectives

• Discuss and define Lifestyle Medicine
• Focus on the impact of Lifestyle Medicine on the nation’s number one

killer, heart disease

• Review the economic impact of chronic disease on US healthcare and

how to become involved in Lifestyle Medicine

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My background

• Indiana University School of Medicine
• Physical Medicine and Rehabilitation residency
• Occupational Medicine as a means of promoting wellbeing
• Lifestyle Medicine as the key to a healthy and productive workplace

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4

Cholesterol

• Dietary cholesterol has a limited

impact on blood cholesterol levels in humans

• Maybe a high cholesterol diet is

indicative of other unhealthy lifestyle behaviors

Cholesterol

• 27-OH cholesterol “can function

as an estrogen and increase the proliferation” of most breast cancer cells

• Pro-oxidative
• Pro-inflammatory
• Pro-estrogenic
• Explains the finding that women with

heart disease risk factors are more likely to develop breast cancer

• Oxycholesterols also related to the

development of Alzheimer’s

• Can be involved in all stages of

cancer development

• Initiation
• Promotion
• Progression
• Potentially facilitating their

metastasis

• Stimulates angiogenesis for tumor

blood supply

Cholesterol

• More aggressive tumors have

higher levels of enzyme converting cholesterol à 27HC

• ER+ tumors à 27HC content is

increased in the breast overall

• Women with low levels of the

enzyme that degrades 27HC don’t live as long

• “some estrogen-driven breast

tumors may rely on 27HC to grow when estrogen isn’t available”

Cholesterol

• >80% of breast cancers start out

responding to estrogen

• Rationale for the use of
• aromatase inhibitors (anastrozole,

letrozole, exemestane)

• Inhibit conversion of androgens to

estrogen

• Common occurrence of diffuse MSK

pain

• SERMs (tamoxifen, raloxifene)
• Risk for thromboembolic events and

endometrial cancer

• Many ER+ tumors will relapse

with resistant tumors despite hormone therapy

• 27HC fuels breast ca growth

without estrogen

• The good news is that

cholesterol is a highly amenable risk factor à diet and lifestyle

Soy

• Controversial topic
• Exacerbated by misinformation

found on Dr. Google

• “Soy foods promote breast cancer”
• Thought to be 2/2 phytoestrogen

compounds called isoflavones

• Estrogens stimulate breast ca

growth, so must phytoestrogens

Soy

• Two types of estrogen receptors
• Alpha
• Beta
• Two receptors
• Different tissue distributions
• Often have different/opposite

functions

• Alpha in the breast à pro-estrogenic
• Beta in the breast à anti-estrogenic
• Soy phytoestrogens preferentially

bind to and activate estrogen receptor beta

• Antiproliferative effects on breast

cancer cells

• Found even after just a few servings of

soy foods

Soy

• Misconception stems from mice

studies

• The main phytoestrogen (genistein)

stimulates mammary tumors in mice

• Humans metabolize soy isoflavones

(subgroup of phytoestrogens that bind to ER) differently

• The same amount of soy will result in

20-150x higher concentrations in mice

• If we ate 20-150 cups of soybeans

daily, we would have some alpha activation…..

Soy

• Just a few servings per day

results in excess beta activation

• Actively helps prevent breast ca
• Soy intake during childhood,

adolescence, and adult life is associated with decreased risk of breast ca

• Women who eat the most soy in

their youth have less than ½ the risk

• Rates are much lower in Asia

compared to the US

• …..until they move to the US and

adopt the Western lifestyle

Soy

• What about those that already

have the disease?

• JAMA 2009, soy food intake and

breast ca survival

• “soy food consumption was

significantly associated with decreased risk of death and [breast cancer] recurrence.”

• This has been repeated multiple

times, with the same conclusion

• Nutrition guidelines
• American Cancer Society
• Soy foods are beneficial for survival
• Five out of five studies, tracking

>10,000 breast cancer patient, have confirmed the benefit of adding soy for survival

• Reduced mortality
• Reduced recurrence
• For ER+ and ER- tumors, young

women and older women

Fiber

• Case control studies (retrospective)

at Yale

• Premenopausal women who ate

more than 6g fiber/day had 62% lower odds of developing breast ca than those who ate <4g/day

• The fiber came from plant sources,

not supplements

• Dozen or so other studies
• Higher fruit and vegetable intake à

lower breast ca risk

• Higher saturated fat (meat, cheese,

dairy) à increased risk

• Every 20g fiber per day associated

with 15% lower risk

• Prospective cohort studies
• 14% lower risk for every 20g fiber

consumed per day

• Risk doesn’t really fall until 25g/day is

consumed

Flaxseeds

• One of the richest plant sources
• f Omega 3 FAs
• 100x more lignans than other

foods

• Lignans are phytoestrogens that

dampen the effect of estrogen in the body

• Flaxseeds contain the lignan

precursors which are activated by the good bacteria in the gut

Flaxseeds

• Breast ca survivors with higher

levels of lignans have been shown to survive longer

• Double-blind, placebo-controlled

randomized intervention à flax muffins

• Breast cancer patient who

regularly consumed flaxseeds had:

• Decreased tumor cell proliferation
• Increased cancer cell death rates
• Decreased cancer cell aggressiveness

scores

• “dietary flaxseed has the

potential to reduce tumor growth in patients with breast cancer…[F]laxseed, which is inexpensive and readily available, may be a potential dietary alternative or adjunct to currently used breast cancer drugs.”

Take home points

• Dr. Dodd’s

Breast cancer Obviating and Operational Banishment System

• Increase soy based food

consumption

• Does not necessarily need to be

every day

• Flax seed daily
• Must be ground
• Eat a diet to lower cholesterol
• Minimal to no animal based foods

Coronary artery disease

• #1 killer of men and women in

Western civilizations

• 596,339 in 2011
• Treated with 40 years of

aggressive drug and surgical interventions

• Risk factors:
• Age, gender
• DM
• HTN
• Lipids
• Goal lipid levels often targeted with

statins

• Cochrane Database Review 2011
• Reduced all cause mortality by

16% à Absolute reduction 0.45% à NNT 222

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Coronary artery disease

• J Family Practice 2014
• Whole, plant-based diet
• Moderate sized, compliant

population, self selected

• NNT = 2

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What’s the point?

• Where’s the hammer?
• Infectious disease used to be our

largest health threat

• Chronic diseases are our biggest

danger presently

• DM
• HTN
• CAD
• HLD
• All have underlying

metainflammation

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Anthropogens

• “man made environments, their by-products, and/or lifestyles

encouraged by these, some of which may be detrimental to human health”

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Pro-inflammatory “inducers” of chronic disease

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The cause of the cause

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The cause of the cause of the cause

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Behavioral determinants of health

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• 1 in 5 smokes
• 4 out of 5 need to significantly

improve their diet

• 3 out of 4 do not get enough

physical activity

CDC, Morbidity Mortality Weekly Report AHA, Heart disease and stroke stats, 2008

Behavioral determinants of health

• Few people demonstrate

multiple healthy behaviors

• 3% have healthy levels of 4

lifestyle behaviors

• Non-smoking
• Healthy weight
• 5 fruits/vegetables per day
• Regular physical activity
• Multiple studies have shown

benefits to lifestyle changes

• Framingham Heart 2006 – optimal

risk factors leads to 10 year longer life span than those with at least two risk factors

• Multiple Risk Factor Intervention

Trial (MRFIT) 1999 – those with low risk factor status had 73-85% lower risk for CVD mortality and 40-60% lower mortality rate

Reeves and Rafferty, Arch Int Med, 2005

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Additional studies

• Nurses’ Health Study 2000
• 5/5 healthy lifestyle factors (diet,

exercise, BMI, smoking, EtOH) à 83% risk reduction for CVD

• 91% of DM cases could be eliminated
• 3/5 à 57% reduction
• 4/5 à 66% reduction
• Health Professionals Follow Up

Study

• All five healthy lifestyle factors

compared to none à 87% lower risk for CVD

• 2/5 à 27% lower risk

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Additional studies

Interheart study 2004

52 countries Smoking, lipids, HTN, DM, obesity accounted for 80% of the attributable risk for AMI 9 modifiable risk factors account for >90% of first MI risk worldwide

Risk factors are the same despite geographic region and racial/ethnic group 28

Summary of studies

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Leading causes of US deaths 2016

1. Heart disease: 633,842 2. Cancer: 595,930 3. Chronic lower respiratory diseases: 155,041 4. Accidents (unintentional injuries): 146,571 5. Stroke (cerebrovascular diseases): 140,323 6. Alzheimer’s disease: 110,561 7. Diabetes: 79,535 8. Influenza and pneumonia: 57,062 9. Nephritis, nephrotic syndrome, and nephrosis: 49,959

• 10. Intentional self-harm (suicide): 44,193

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• 80% of premature deaths are attributable to three factors:
• Tobacco
• Diet
• Physical activity levels

“How we use our feet, our forks, and our fingers”

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Katz DK et al. Jekel’s Epidemiology, Biostatistics, and Prev Med, 2013.

Common diseases are uncommon in Blue Zones

• The world’s longest living

cohorts

• Okinawa, Japan
• Sardinia, Italy
• Loma Linda, California
• Ikaria, Greece
• Nicoya Peninsula, Costa Rica

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Lifestyle practices common to all Blue Zones

• Family
• No smoking
• Socially engaged
• Constant, moderate physical

activity

• Plant-based diet
• Legumes

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Okinawa centenarian

Adventist health study 2

• >96,000 SDAs from North America
• Entire cohort considered to health-conscious
• Die at about half the rate of the general population
• 2002-present
• 8% vegan
• 28% lacto-ovo vegetarian
• 10% pesco-vegetarian
• 6% semi-vegetarian
• 48% non-vegetarian

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AHS 2

• Mortality rates reduced
• 28% vegan men
• 15% vegans
• 9% LOV
• CV disease reduced
• 42% reduction vegan men
• 23% lower in LOV men
• Hypertension
• 75% lower among vegans
• 55% lower LOV
• Diabetes
• 62% lower in vegans
• 38% lower in LOV

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AHS 2

Cancer

16% lower vegans 8% lower LOV

• Breast cancer
• Increased with obesity, meat

intake

• Decreased with fruit and veggie

intake

• Prostate cancer
• Improved with food sources of

lycopene and selenium

• Possibly helped with whole food

soy

• Colon cancer
• Worse with red meat
• Improved with high fiber, calcium,

folate

• Gastric cancer
• Worse with increased salt
• Improved with fruit and veggie

consumption

• Others
• No clear connection for nutrition and

pancreas, ovarian, endometrial, and

• ther types

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AHS 2

• Vegans continued to demonstrate lower risk of chronic disease
• Cataracts
• 40% lower
• Diverticular disease
• 72% lower
• Renal disease
• 52% lower

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Diseases have changed over the years

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Anderson G and Horvath J. The growing burden of chronic disease in America. Public Health Reports. 2004. 119: 263-269.

Chronic disease development blamed on diet

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“The major dietary changes that followed the Industrial Revolution were a reduction in starch foods and in fiber intake, and a great increase in consumption of animal fats, salt, and sugar.”

1987

• “Many of the major and commonest diseases in modern Western

culture are universally rare in third-world communities, were uncommon even in the United States until after World War I, yet have comparable prevalence today in both black and white Americans. This finding compels the conclusion that these diseases must be due not to our genetic inheritance but to our life-style.”

• DP Burkitt

Western diseases and their emergence related to diet

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Our biggest killer is almost non-existent in areas focusing on plant-based diets

• Tarahumara Indians of Northern Mexico
• Beans and corn
• Papua New Guinea highlanders
• Diet largely based on sweet potatoes
• Inhabitants of rural Africa
• Starchy vegetables and tubers
• Inhabitants of rural China
• Rice and vegetables

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Rural China CAD levels very low

42

South African Bantu – less than 1:1000

• CAD rate less than 1%
• Over five years, 1328 necropsies were performed
• 7 cases of coronary thrombosis or MI

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More than 100x the rate in American patients versus Uganda patients

• Among 632 age and gender matched autopsies
• 1 MI among black Ugandans (0.2%)
• 136 MIs in Caucasian Americans (22%)
• 800 subsequent autopsies in Uganda, East Africa and St. Louis, USA
• Only one healed infarct in Ugandan patients >40 yoa out of >1400 individuals
• All autopsies performed by US trained surgeons

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Thomas WA et al. Incidence of myocardial infarction correlated with venous and pulmonary thrombosis and embolism. Am J Card, 1960. 5: 41-7.

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• Main risk factor for heart disease is cholesterol
• “If the serum total cholesterol is 90 to 140 mg/dL, there is no evidence that

cigarette smoking, systemic hypertension, diabetes mellitus, inactivity, or

• besity produces atherosclerotic plaques. Hypercholesterolemia is the only

direct atherosclerotic risk factor; the others are indirect.”

2013 conference on heart disease, Baylor

46

Benjamin MM and Roberts WC. Facts and principles learned at the 39th annual Williamsburg Conference on Heart Disease. Proc (Bayl Univ Med Cent), 2013. 26(2): 124-36.

Optimal LDL is between 50-70

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Regression studies suggest atherosclerosis does not progress when LDL ≤70mg/dL

“Almost 75% of heart attack patients fell within recommended targets for LDL cholesterol, demonstrating that the current guidelines may not be low enough to cut heart attack risk in most.”

Normal cholesterol, in a country where heart disease is prevalent, is not low enough

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Our guidelines are too high for a reason

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Esselstyn CB and Favaloro RG. Introduction: more than coronary artery disease. Am J Cardiol. 82(10): 5-9.

“For plaque progression to cease, it appears that the serum total cholesterol need to be lowered to the 150 mg/dL area. In

• ther words the serum total cholesterol must be lowered to

that of the average pure vegetarian. Because relatively few persons are willing to abide by the vegetarian lifestyle, lipid- lowering drugs are required in most to reach the 150 mg/dL level.”

But is this even achievable?

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(Editor-in-Chief of the American Journal of Cardiology)

Optimal cholesterol levels can be achieved with diet alone

• Average serum LDL cholesterol
• Omnivores

123.43 +/- 42.67

• Lacto-ovo vegetarians

101.47 +/- 28.07

• Lacto vegetarians

87.71 +/- 41.67

• Vegans

69.28 +/- 29.53

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DeBiase SG et al. Vegetarian diet and cholesterol and triglycerides levels. Arq Bras Cardiol. 2007. 88(1): 35-9.

Lower cholesterol levels found in those eating plant- based diets

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Effects of plant-based diets

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Ferdowsian HR and Barnard ND. Effects of plant-based diets on plasma lipids. Am J Card.

• 2009. 104(7): 947-56.

The effects of plant based diets are multifactorial

• Plant based diets are low in fat, saturated fat, and dietary cholesterol
• Fiber and plant sterols bind bile acids and cholesterol, enhancing their

removal

• Increases in soy may decrease cholesterol synthesis
• Also increases resistance to LDL oxidation
• Increased intake of monounsaturated fats, nuts, and fruits and

vegetables decreases CRP levels, LDL particle size, and resist LDL

• xidation

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55

Esselstyn CB and Favaloro RG. Introduction: more than coronary artery disease. Am J Cardiol. 82(10): 5-9.

Prev Med 2012: 80

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Lifestyle Medicine

Lifestyle Medicine involves the use of evidence- based lifestyle therapeutic approaches, such as a predominantly whole food, plant-based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substance use, and pursuit of other non-drug modalities, to treat, reverse and prevent chronic disease.

• Validated as highly effective
• Addresses the root-cause of disease
• Simple and efficient …cost-effective
• Engaging / patient-centered / healing

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Simple, Powerful Therapy

Choose predominantly whole, plant-based foods that are fiber- filled, nutrient dense, health-promoting and disease-fighting Identify dietary, environmental and coping behaviors to improve sleep health Regular and consistent physical activity is an essential piece of an

• ptimal health

equation The well- documented dangers

• f any addictive

substance use can increase risk for many cancers and heart disease Identify both positive and negative stress responses with coping mechanisms and reduction techniques for improved wellbeing Social connectedness is essential to emotional resiliency and overall health

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Chronic Disease Epidemic:

• Healthcare in US costs $3.3 trillion annually
• This represents 18% of the US GDP
• 70% of these costs are attributed to the treatment of chronic

conditions

• Lifestyle Medicine addresses the root cause to both improve health

& reduce costs

WHY NOW

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Unsustainable Economics

WHY NOW

• US Healthcare Spend = $3.5 trillion ($10,739 per person)

17.9% of US Gross Domestic Product

• 75% of this spend is on chronic disease. Nearly half of all

Americans live with one or more chronic disease.

• Lifestyle Medicine is the cost- and life-saving foundation
• f all healthcare - in clinical practice, as well as in worksite

health promotion.

• Proof – Launched in Nov 2018, LMERC Advisory Board

Members: economists, research physicians, health care consultants, actuaries, data analysts and public health professionals LMeconomicresearch.org

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Education Imperative

Average physician receives less than 3 hours of lifestyle training in medical school

WHY NOW

LifestyleMedicineEducation.org

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Clinical guidelines state that diet changes are a critical first line treatment for many chronic conditions (e.g., diabetes, obesity, hypertension), often before any medication is prescribed. This is reinforced by leading national and international organizations, and based on innumerable evidence-based studies showing dietary change has an “A” rating on patient impact.

Lancet Commission

Systems of Change

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#RealHealthcareReform

• Team-Based Care
• Group Visits & Support Groups
• Value-Based Care
• Proven Outcomes
• Improved Patient Satisfaction
• Renewed Physician Passion
• Jonathan Bonnet, MD

“We have long known what behaviors promote health and prevent disease. Lifestyle medicine embodies this idea of true 'health' care. Rather than pills and procedures, the focus is on the lifestyle choices we make every day.”

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Medical Discipline Key Care Approach

Lifestyle Medicine Use 7-9 key lifestyle modalities to treat/reverse/prevent disease; Promotes a predominantly WFPB diet Preventive Medicine Early detection/Screening; Environmental safety/public health Functional Medicine Emerging diagnostics; Gut health; Nutraceuticals/Supplements Naturopathic Medicine Manipulation; Herbal remedies Integrative Medicine Combined use of complementary & conventional medicine approaches to care & treatment

Different Disciplines

“One of the most powerful aspects

• f Lifestyle Medicine is that patients

become more engaged, active participants in their own self-care, disease prevention and management, and overall well- being.”

• Cindy Geyer, MD

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The American College of Lifestyle Medicine (ACLM) is the medical professional society for physicians, clinicians, allied health professionals, and all those in professions devoted to advancing lifestyle medicine as the foundation of a transformed and sustainable healthcare system.

CME & CEUs Board Certification – ABLM/IBLM Media Programming American Journal of Lifestyle Medicine Speaker’s Bureau Policy & Practice Toolkits Consumer Awareness Corporate Roundtable

The Lifestyle Medicine Global Alliance represents the convergence of lifestyle medicine professional associations from around the world, uniting under one banner for the purpose of collaboration, shared knowledge and best practices, to manifest the vision of a world without non- communicable disease

BENEFITS

LEARN & DO MORE

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