Lifestyle principles have been advocated for the promotion of health and prevention of disease since antiquity. More than 2000 years ago, Hippocrates asserted, ‘Let food be thy medicine and medicine be thy food’. Predating Hippocrates, Levitical health laws mandated lifestyle practices such as hand washing after touching dead bodies or diseased animals, and avoiding pathogenic substances such as blood and mould. The consumption of animal fat was also forbidden, which is intriguing given that chronic disease was not the major health threat at the time.
Notwithstanding the developments in pharmacological and surgical technologies that have profoundly enhanced healthcare, the authors propose that the historical practice of ‘lifestyle as medicine’ will become increasingly re-emphasised in future healthcare for mitigating and/or managing contemporary concerns relating to chronic and infectious diseases.
Lifestyle as medicine for chronic disease
The value of a healthy lifestyle for primary prevention of chronic disease has been unequivocally demonstrated in large-scale epidemiological studies, including the Framingham Heart Study, Nurses Health Study, and European Prospective Study into Cancer and Nutrition (EPIC). Indeed, an estimated 90% of cardiovascular disease and type 2 diabetes mellitus, as well as one in three cancers, are preventable through healthy lifestyle practices.1,2
While primary prevention is most desirable, patients are often not motivated by the possibility of future pain (physical or emotional), which may account for why lifestyle as a medicine has not been historically emphasised. However, individuals are motivated by present pain, and a growing body of evidence is showing lifestyle interventions to be efficacious for the management and, in some instances, treatment of chronic conditions. Indeed, intensive lifestyle change has been shown to reduce vascular stenosis and associated disorders,3 normalise blood sugar levels without the need for medication,4 and even regress markers of early stage prostate cancer.5 Hence, the view of therapeutic lifestyle change is shifting from that of a nicety – something that might produce better health in years to come – to a necessity. Of course, facilitating patient receptiveness and long-term adherence to therapeutic lifestyle change can be challenging. However, comprehensive lifestyle interventions have reported high levels of engagement and low levels of recidivism5–8 by applying an array of behavioural-change strategies, including education, social support, self-monitoring, problem solving and nurturing self-efficacy.
The application of therapeutic lifestyle interventions to influence chronic disease prevention and progression is being referred to as ‘lifestyle medicine’,9 promoted by professional organisations such as the Australasian Society of Lifestyle Medicine, American College of Lifestyle Medicine and European Society of Lifestyle Medicine.
The scope of lifestyle medicine is broad and emphasises not only traditionally identified lifestyle factors such as diet, physical activity and smoking, but also other lifestyle-related health determinants such as stress management, social connectedness and environmental factors.10,11 With growing evidence that the application of lifestyle medicine interventions can be cost-effective12 and yield long-term benefits,13 it seems apparent that lifestyle as medicine will be increasingly relied upon as a countermeasure to combat the burgeoning rise and skyrocketing costs of modern chronic diseases.
Lifestyle as medicine for infectious disease
Despite advances in the treatment of infectious diseases during the 20th century, they remain among the leading causes of death worldwide. Concerns exist about an escalation in mortality related to infectious disease,14 especially in the wake of antibiotic resistance.15 Lifestyle principles, especially hygiene-related practices, have underpinned the management of infectious diseases in healthcare. However, recent evidence suggests that other lifestyle factors, including diet, physical activity and stress, may play an important role in infection susceptibility.16–19
In particular, the Western diet – characterised by a high consumption of refined foods that are low in fibre and phytonutrients, but high in saturated fats, sugar and salt – may predispose individuals to infection and illness by affecting the immune system directly and/or through deleterious effects on the gut microbiome.16,20 Low diversity and composition of gut microbiota can result in pro-inflammatory responses that have been linked to obesity, diabetes, cardiovascular disease and cancers,18,21 as well as to a compromised ability to resist colonisation by invasive pathogens.16 Emerging evidence suggests that adopting a more whole food eating pattern, which is common practice in lifestyle medicine interventions, promotes a commensal gut flora that protects the host from infection.17
We argue that lifestyle as medicine will be increasingly emphasised in the future as awareness grows of its merits to address 21st century health concerns. These merits are especially attractive in view of the general lack of iatrogenic outcomes associated with applying lifestyle as medicine, in contrast to medication-based therapies where the ancient dictum that ‘the dose is the poison’ still applies. Only in extreme cases of excess do health problems occur as a result of lifestyle-based treatments.
If the age-old benefits of lifestyle as medicine are to be more effectively used in general practice into the future, modifications are needed in medical training and clinical practice. A century ago, Thomas Edison asserted, ‘the doctor of the future … will interest his patient in the care of the human frame, in proper diet and the cause and prevention of disease’.22 For these words to become prophetic, the teachers must be taught23 and, presently, most medical training programs place little emphasis on lifestyle education.24,25
Lifestyle as medicine is an old concept, but still a good one that has a lot to offer if it is given the opportunity.
Darren Morton PhD, Senior Lecturer, Avondale College of Higher Education, Lifestyle Research Centre, Cooranbong, NSW. firstname.lastname@example.org
Brett Mitchell PhD, Director, Avondale College of Higher Education, Lifestyle Research Centre, Cooranbong, NSW; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Dickson, ACT
Lillian Kent PhD, Lecturer, Avondale College of Higher Education, Lifestyle Research Centre, Cooranbong, NSW
Garry Egger PhD, Director, Centre for Health Promotion and Research, NSW
Trevor Hurlow MD, General Practitioner, Waratah Medical Services, Morisset, NSW
Competing interests: Darren Morton has, outside this work, received payment from Sanitarium Health Food Company for development of a lifestyle education program. Brett Mitchell is paid for board membership of Australasian College for Infection Prevention and Control, receives consultancy fees from Australian Commission on Safety and Quality in Health Care, and has received grants from Covidien Pty Ltd.
Provenance and peer review: Not commissioned, externally peer reviewed.
- Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:937–52.
- Ford ES, Bergmann MM, Kroger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: Findings from the European Prospective Investigation Into Cancer and Nutrition – Potsdam study. Arch Intern Med 2009;169:1355–62.
- Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990;336:129–33.
- Barnard R, Jung T, Inkeles S. Diet and exercise in the treatment of NIDDM: The need for early emphasis. Diabetes Care 1994;17:1469–72.
- Ornish D, Magbanua MJ, Weidner G, et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Natl Acad Sci USA 2008;105:8369–74.
- Esselstyn CB Jr, Gendy G, Doyle J, Golubic M, Roizen MF. A way to reverse CAD? J Fam Pract 2014;63:356–364b.
- Rankin P, Morton DP, Diehl H, Gobble J, Morey P, Chang E. Effectiveness of a volunteer-delivered lifestyle modification program for reducing cardiovascular disease risk factors. Am J Cardiol 2012;109:82–86.
- Morton DP, Rankin P, Kent L, Dysinger W. The Complete Health Improvement Program (CHIP): History, evaluation and outcomes. Am J Lifestyle Med 2014; Published online before print.
- Egger GJ, Binns AF, Rossner SR. The emergence of ‘lifestyle medicine’ as a structured approach for management of chronic disease. Med J Aust 2009;190:143–45.
- Kushner RF, Sorensen KW. Lifestyle medicine: The future of chronic disease management. Curr Opin Endocrinol Diabetes Obes 2013;20:389–95.
- Egger G, Dixon J. Beyond obesity and lifestyle: A review of 21st century chronic disease determinants. Biomed Res Int 2014;2014:731685.
- Palmer AJ, Roze S, Valentine WJ. Intensive lifestyle changes or metformin in patients with impaired glucose tolerance: Modeling the long-term health economic implications of the diabetes prevention program in Australia, France, Germany, Switzerland, and the United Kingdom. Clinical Therapeutics 2004;26:304–21.
- Diabetes Prevention Program Research G, Knowler WC, Fowler SE, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374:1677–86.
- National Institute of Allergy and Infectious Diseases. Emerging infectious diseases/pathogens introduction/goals. Available at www.niaid.nih.gov/topics/emerging/pages/introduction.aspx [Accessed 5 February 2016].
- World Health Organization. Antimicrobial resistance: Global report on surveillance. Geneva: WHO, 2014.
- Myles IA. Fast food fever: Reviewing the impacts of the Western diet on immunity. Nutr J 2014;13:61.
- Kau AL, Ahern PP, Griffin NW, Goodman AL, Gordon JI. Human nutrition, the gut microbiome and the immune system. Nature 2011;474:327–36.
- Simpson RJ, Bosch JA. Special issue on exercise immunology: Current perspectives on aging, health and extreme performance. Brain Behav Immun 2014;39:1–7.
- Knowles SR, Nelson EA, Palombo EA. Investigating the role of perceived stress on bacterial flora activity and salivary cortisol secretion: A possible mechanism underlying susceptibility to illness. Biol Psychol 2008;77:132–37.
- Honda K, Littman DR. The microbiome in infectious disease and inflammation. Annu Rev Immunol 2012;30:759–95.
- Trinchieri G. Cancer and inflammation: An old intuition with rapidly evolving new concepts. Annu Rev Immunol 2012;30:677–706.
- Edison T. Quoted in Wizard Edison. The Newark Advocate. 2 January 1903:1.
- Lianov L, Johnson M. Physician competencies for prescribing lifestyle medicine. JAMA 2010;304:202–03.
- Adams KM, Lindell KC, Kohlmeier M, Zeisel SH. Status of nutrition education in medical schools. Am J Clin Nutr 2006;83:941–44S.
- Hyman MA, Ornish D, Roizen M. Lifestyle medicine: Treating the causes of disease. Altern Ther Health Med 2009;15:12–14.