August 2017 - NON-MEDICATED LIFE
The Role of Lifestyle Medicine in Reducing Healthcare Cost
By Paul E. Lemanski, MD, MS, FACP
Editor’s Note: This is the 78th in a series on optimal diet and lifestyle to help prevent and treat disease. Any planned change in diet, exercise or treatment should be discussed with and approved by your personal physician before implementation. The help of a registered dietitian in the implementation of dietary changes is strongly recommended.
Medicines are a mainstay of American life and the healthcare system not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death, while others may reduce certain types of cancer.
In the first 77 installments of the Non-Medicated Life, informed diet and lifestyle have been shown to accomplish naturally for the majority of individuals most of the benefits of medications in the treatment of chronic medical conditions such as hypertension, high cholesterol, diabetes and heart disease. As a medical intervention, lifestyle may accomplish such benefits with fewer side effects, may reduce the number and amount of medication, and may allow actual discontinuation of medication. It seems self-evident that decreasing reliance on medications needed to treat chronic conditions has the potential to reduce healthcare costs.
What is becoming increasingly apparent is the power of lifestyle, not only to treat existing medical conditions, but also to prevent their development. In this way, lifestyle as a medical intervention may be an effective strategy to prevent the development of conditions, such as coronary heart disease, that typically require high cost procedures in their management. In a time in our history when the cost of healthcare has become central to the delivery of that care, a review of the role of lifestyle as medical intervention, and the conditions that can be prevented and treated in an increasingly cost effective manner is in order.
I will use the term “lifestyle medicine” to indicate lifestyle as medical intervention including the use of diet, exercise, and certain behaviors to prevent and treat medical conditions that result in human disease. Lifestyle medicine as a concept had its foundation in the work of Michael McGinnis and others, who identified and quantified the major non-genetic factors that contributed to death in the United States during the 1980s. They suggested that disease was not a root cause of death in the United States, but rather a consequence of chronic conditions contributed to by behavioral factors. Indeed, three of those factors: tobacco use, dietary pattern and physical activity, accounted for 80% of chronic diseases.
Later, in an epidemiological study, Daniel Ford and others showed that individuals who ate well, exercised, avoided tobacco and controlled body weight had an 80% lower probability of developing chronic disease than those who did not.
Lifestyle medicine clinical trials further supported the epidemiological studies. In his seminal 1991 Lifestyle Heart Trial, Dean Ornish, MD, showed for the first time that lifestyle alone through diet, exercise and relaxation techniques could slow, stop and on average reduce cholesterol plaques in arteries of individuals with coronary heart disease. In 2001, the Lyon Diet Heart Study showed that a high omega-3 Mediterranean diet could reduce cardiac death and nonfatal heart attack by 70%. Up to this time, the accepted approach in the treatment of coronary artery disease was bypass surgery, coronary stents, or powerful cholesterol lowering drugs. With the current cost of surgery and stents amounting to $28 billion per year using lower cost lifestyle medicine to prevent and treat heart disease would seem cost effective.
In 2006, the Diabetes Prevention Study proved that in overweight/obese pre-diabetic individuals a lifestyle medicine intervention resulting in the loss of just 5-7% of bodyweight could decrease conversion from pre-diabetes to diabetes by 57%. This has profound implications on the cost of care. Currently there are about 25 million Americans with diabetes and about 65 million with pre-diabetes. Those with pre-diabetes are converting to diabetes at the rate of 11% per year. Without intervention, within 9-10 years, 90 million Americans will suffer from diabetes – less the ones who die.
Moreover, at least 68% of those over 65 with diabetes will die from heart disease and a majority will be treated with the high cost procedures described above to improve their quality of life. Preventing diabetes with lower cost lifestyle medicine would again seem cost effective.
In addition to preventing and treating heart disease and diabetes, lifestyle medicine may be used to effectively treat elevated blood pressure, elevated cholesterol, gastroesophageal reflux, sleep apnea and obesity, all without medication or high cost procedures. For example:
• Systolic blood pressure (e.g., for a blood pressure of 140/90 the 140 is the systolic pressure) may be lowered 4.5 mmHg with 10 pounds of weight loss, 4 mmHg by reducing sodium to 2 grams per day, 10 mmHg on the DASH diet, 4-9 mmHg with regular aerobic exercise, 5 mmHg by reducing alcohol intake, and 10 mmHg with programmed isometric hand exercises, with reductions additive.
• LDL (bad) cholesterol may be decreased 11-15% on a low saturated fat diet (generally less than 15 grams of saturated fat per day) and up to 20-30% on a vegan diet.
• Reducing caffeine, alcohol and chocolate, along with modest weight loss may resolve reflux symptoms and allow discontinuation of powerful, expensive reflux medications
• Moderate weight loss, reductions in alcohol, and changes in sleep position may resolve sleep apnea.
• Avoiding processed foods, slowing the eating process, decreasing the caloric density of foods consumed, and eating a predominately plant-based diet – while getting daily exercise – can reduce and maintain a healthy bodyweight.
• Finally, the lifestyle intervention of smoking cessation and tobacco use prevention will dramatically reduce the rate of heart attack, stroke, emphysema, head and neck cancer, lung cancer, cervical cancer and bladder cancer.
In summary, lifestyle medicine defined as the use of diet, exercise and behavior to prevent and treat medical conditions that result in disease, can be shown to be a cost effective intervention, compared to the cost of medication and high tech procedures.
Moreover, lifestyle medicine may duplicate the benefits of medication without the side effects. Lifestyle medicine holds the promise of holding down the cost of heath care while improving the health of our population. It is an approach whose time has come.
Paul E. Lemanski, MD, MS, FACP (firstname.lastname@example.org) is a board certified internist at the Center for Preventive Medicine, CapitalCare Medical Group in Albany. He is a medical director of the Department of Community Medicine and Population Health at CapitalCare Medical Group. Paul has a master’s degree in human nutrition. He is an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.