Lifestyle Medicine and the Far Horizon: Before, Since, and Beyond.

“Lifestyle behaviors are choices, and the choices people make are subsumed within the choices people have.” We refer in the vernacular, perhaps blithely, to a “healthcare” system, while what actually prevails in that space is a “disease care” system. 1 That system is reactive, rather than proactive, responsive to illness and injury, but inattentive to vitality and wellbeing at their origins. Among the many consequences of this now oft-lamented divide are staggeringly high disease-care costs; a shameful gap between lifespan and healthspan 2; and widespread frustration among clinicians charged, essentially, with putting Humpty Dumpty back together again, 3 under ever increasing constraints and burdensome oversight, without ever the option of providing balance training or doing anything about the perils of that wall. We are obliged to await the next fall in an unending sequence, and send in the ambulance, yet again. These liabilities have long prevailed, and worsened, despite our knowledge of how to prevent most, even nearly all, premature death and chronic disease. 4 These liabilities have prevailed despite clear evidence that lifestyle interventions can treat and reverse disease as well as cultivate health. In this context, the establishment of Lifestyle Medicine as a field, and the founding of the American College of Lifestyle Medicine as its vehicle, created a welcome alternative. The opportunity to address the “root causes” of most chronic disease and premature death and to blend the proactive stewardship of vitality with reactive treatment of illness attracted a following. Small at first, that following has swelled over the years, and growth has accelerated briskly. Today, ACLM is among the fastest growing professional societies in the House of Medicine. The opportunity introduced was not unencumbered. New practice models were required to support the effective delivery of lifestyle medicine, and while suitable approaches have been devised, the effort to optimize and scale these continues to this day. Lifestyle is more cultural than clinical enterprise, 5 and living in a society that conspires mightily against health 6 impedes what clinicians can accomplish. This, in turn, makes it challenging to corroborate in data the full potential of lifestyle medicine as a clinical advance. 7 More challenging still, new reimbursement models valuing prevention and wellbeing rather than remuneration for filled hospital beds and fees for services rendered were, and to this day still are, required as well (a topic addressed in a parallel talk/article by my colleague, Dr Dexter Shurney). Progress has been made in this area, too, and the advance of value-based care is promising, but the value proposition of lifestyle medicine and the prevailing business model of medicine align thus far only with considerable friction. We might examine our progress through lenses fashioned to gauge the quality of system performance. In particular, the model developed by Donabedian 8 invites consideration of structures, processes, and outcomes. The structural underpinnings of lifestyle medicine have advanced tremendously in tandem with the growth of ACLM. Noteworthy among them are the College membership at large, now at over 13,000, as well as its diverse member groups; partnerships and councils; staffing and educational content. The large and ever-growing inventory of assets is enumerated and routinely updated online (see https://lifestylemedicine.org/). So, too, has progress been impressive in the area of processes. The College has established and scaled both training and credentialing; facilitated and diversified means of communication, networking, and professional exchange; grown, diversified, and refined its annual conference. To varying degrees, these advances have been shared with sibling organizations and effectively globalized (see https://lifestylemedicineglobal.org/). The view of outcomes depends on where one looks at the flow from intention and effort to accomplishments. The standards of practice advance before outcomes improve, and those standards are in turn anticipated by advances in evidence and attendant knowledge. Thus, evidence might be considered an “upstream” outcome, relative to the impacts of that knowledge on population health, which reside downstream. Advances in research and evidence to guide the practice and affirm the value of lifestyle medicine have been considerable. Peer-reviewed publications have spanned impacts and insights from the epigenome to the microbiome; diabetes to dementia; hypertension to endometriosis; coronary disease to cancer; standards of practice to sleep physiology; all-cause mortality to nutrigenomics; research methods to cell biology. 9-38 Lifestyle has been shown to rival the best of pharmacotherapy for a range of conditions without the liabilities of cost and adverse side effects. Methodologic advances include tailored means of synthesizing evidence, 39 and scalable means of assessing diet. 40 The opportunity to advance both public and planetary health with lifestyle medicine, and dietary change in particular, has been detailed, highlighting an important distinction for the field. 41-43 Most medical activity occurs at some cost to planetary health; only lifestyle medicine may function in the service of it. This is crucial, because we have some hope of being healthy, vital people on a healthy, vital planet—or we have no hope of being healthy, vital people. The downstream view of outcomes, however, is less encouraging. The global burden of lifestyle-responsive chronic disease continues to rise. Health disparities in the United States are stark, as is the gap between lifespan and healthspan. 2 The pandemics of obesity and type 2 diabetes continue their relentless advances. The opportunity to mitigate the toll of the COVID-19 pandemic by means of lifestyle medicine was all but entirely neglected. 44-46 Dedicated efforts to propagate a universal understanding of fundamental truths about healthful eating and living 47 are impeded by tidal waves of misinformation, disinformation, and malinformation. 48The view ahead encompasses an array of obstacles. Lifestyle medicine interventions of a “too little, too late” variety resulting in negative or trivial outcome effects are periodically published and invoked to cast doubt on the enterprise. 49 The medical establishment is apt to define any adverse effects of lifestyle gone awry as a disease, inviting the inevitable prioritization of drugs and surgery in treatment. 50 Elements of our society, and food supply in particular, that directly sabotage health 6 are unconstrained and seemingly condoned in the service of corporate profits and political capital. All of which brings us to this juncture and the vantage point it affords us. The establishment of lifestyle medicine as a discipline, and the advent of ACLM as its flagship vehicle, effectively blazed a new course through the landscape of modern medicine—directed at the implicit promise of genuine “health” care. Where at first were only the footprints of a few visionaries and innovators, a legion has followed—appending their own vision and diverse innovations, and the strength of unity. Needed, still, are the means of translating accumulated knowledge into the power of routine, and effective action; the food-as-medicine domain is an encouraging example. 51,52 Also needed is the integration of clinic-based and culture/community-based efforts to promote health, as lifestyle, ultimately, is more a matter of culture than clinic. 53,54 In this area, the recently announced partnership between ACLM and Blue Zones, and the foundation of Blue Zones Health, shines the light of bright promise. A difference, to be a difference, must make a difference 55—and to make the differences that matter most, innovation, adaptation, and ingenuity will be required. So, too, will be the political will to make policy changes. Lifestyle behaviors are choices, and the choices people make are subsumed within the choices people have. Across the expanse of 2 decades, a foundation has been laid of practical structures, robust processes, and a trove of empirical evidence underlying expert knowledge. Despite these noteworthy advances, the burden of preventable disease has mostly only grown; the preventable, and thus shameful, divide between lifespan and healthspan has mostly only widened. We stand now on that foundation, and gaze at a light on the far horizon—beckoning us to translate what we know and learn into meaningful, measurable improvements in modern epidemiology and the human condition. 56 The full promise of lifestyle medicine—of lifestyle in medicine, conjoined to lifestyle as medicine 5—is the routine addition of years to lives, and of life to years—and contributions to planetary health into the bargain. The fulfillment of that promise lies ahead, as do the miles of effort separating us from it. We may celebrate our advances to date, but not sleep on them—for we have those miles to go, and those promises to keep. But at least from here, we can discern and follow the light. -fin Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.