If it works, why don’t we do it?
More on obstacles to public policy application of clinically significant lifestyle changes
“Cozinha solidária” (“solidary kitchen”), a program by the MST (the Brazilian Landlass Rural Workers Movement), where balanced, nutritious, plant-based food is offered to families in need.
Last week I told you about my newly acquired and very welcome heat tolerance, as a result of calorie restriction (CR), a clinical dietary strategy with an impact on chronic non-transmissible diseases and longevity. I listed evidence about the many other beneficial effects and advantages of CR. I wondered why it wasn’t as sought, prescribed, and adopted as something affordable and effective would be expected to be. For several non-transmissible and chronic diseases, CR is the only intervention with clinically relevant outcomes, and, for others, it is the only affordable alternative.
The first and obvious reason I thought of was that this is very recent research. The fact that CR increases the lifespan of certain invertebrates was known since the 1930s, but what this meant for inflammation and all the chronic metabolic disorders was unknown, and was only evidenced and systematically studied in the past few years (here and here for a history of calorie restriction research).
As I mentioned last week, I extracted five classes of reasons for not widely adopting CR from the literature: the lack of conclusive human studies, challenges with adherence and sustainability, potential risks and side effects, ethical and practical considerations, and the need for further research.
The lack of conclusive human studies and the need for further research are one class. Potential risks and side effects are relevant only for what is known as extreme calorie restriction, which involves restricting total daily energy intake to a level below basal metabolic rate. Otherwise, the literature is unanimous in pointing out that there are few contraindications, and it is generally safe.
Ethical considerations refer to bringing up the subject of dieting to overweight and obese individuals which, according to some non-medical “fat scholars” as well as “fat activists”, is emotionally traumatizing, especially because it confronts their deeply held belief that intentional weight loss is necessarily harmful and, ultimately, impossible because there would be a necessary supercompensatory rebound weight gain after the intervention. This is not true, and not supported by science, but this movement exists and exerts significant pressure on the medical establishment, and fat scholars are not interested in science as an institution, which they frequently criticize. It’s a serious situation and, indeed, it can certainly be an important reason for not prescribing CR to obese patients, even if they are diabetic, hypertensive, and seriously ill. I would, however, alternatively classify this reason as “political/ideological” rather than ethical.
That leaves us with challenges with adherence and sustainability, and this is a medically relevant factor. CR is not a substance that can be swallowed or injected, nor is it equipment to be worn. It’s a behavior. Prescribing behaviors is always tricky. Whoever is prescribing it is suggesting the patient alter their behavior consistently in a way that influences their whole life. That’s not just a minor behavioral change - say, learn and clean the cat’s litter box every day, or brew coffee in an Italian coffee press instead of an electric coffee maker. CR implies a set of behavioral changes that alter the person’s entire relationship with food and their digestion, which has the potential to transform the person’s life at a much deeper level.
The term can be misleading since “CR” means just limiting food. “Just eat less”. Less than what? A very simple recommendation for obese people struggling is “less than now”. When delivered this way, it’s usually useless. But if “less than now” is detailed with the patient, and the patient identifies one measurable habit - “I buy a large latte and a cinnamon roll on my way to work every single day” - that they can alter, and later associate whatever result they get with that small action, it can be quite effective. It’s about segmenting a big task - returning an obese individual to health and normal weight - in order to make it manageable. Losing 192 lbs is insanely difficult, complex, and long-term, but getting a less caloric coffee and skipping the cinnamon roll is not that hard. In a month, maybe the patient will be breathing better. This is a weight loss strategy. CR as a clinical approach to chronic disease is a very different thing: CR is defined as reducing one’s average daily calorie intake below the person’s calculated energy requirements, without malnutrition or deprivation of important nutrients. The intensity of CR is defined by the average calorie deficit in the diet. Most interventions are around 20-30%.
Unlike the approach used with the obese individual with an excess of 192 lbs who was recommended to start his diet focusing only on two habitual items to change, the CR patient has some serious investment to make: he needs to collect and process quantitative data, to begin with. Everyone collects and processes some biometric data - weight, height, waist circumference - but here we are talking about listing all the food that is eaten and counting their calories, weighing in regularly, calculating the daily energy intake, the calorie-reduced projected energy intake, and budgeting every meal to stay within the calculated calorie limit. They don’t have to weigh in every day, but they do have to do it enough to update the daily energy requirement value. There is a more rigid alternative where the patient depends on a health professional who weighs the patient, calculates their maximum calorie consumption for a CR, and hands the patient a basic food plan that respects that limit. This last approach is less time-consuming and possibly less anxiety-triggering, but it also creates a dependency on the health professional and potentially leads to a diet that is harder to follow for its rigidity. Both approaches represent some discomfort and a lot of change in the person’s management of their eating.
Collecting and processing data involves added demand on the patient’s executive functions, and this is always a concern in behavior change: the degree of effort involved in self-awareness and self-control may be beyond what the patient has available.
A daily calorie deficit can be achieved either by reducing the amount of calories in each meal, without changing the number or time of the meals, or by restricting the feeding time (also known as time-restricted intermittent fasting). Restricting the calories in each meal is the traditional approach and the one that most depends on a lot of planning and calculating. Restricting time is expected to result in a calorie deficit because the feeding window is smaller.
Several authors suggest that time restricted eating/fasting is less demanding and therefore potentially encourages more adherence than CR proper. Time-restricted eating would involve less counting and monitoring, for example, and could work for the patient if he adjusts to a restricted feeding window and a smaller number of meals. Studies also show that time-restricted eating causes less emotional distress from hunger.
Both approaches involve regulating one’s behavior, both approaches potentially involve accepting the discomfort of hunger or cravings, and both approaches certainly involve nutritional re-education and food substitutions. They are both strategies of behavior change necessary to create a lifestyle change.
CR is a lifestyle intervention, and lifestyle interventions constitute the field of the specialty “Lifestyle Medicine.”
The following conceptualization of lifestyle attributed to the WHO defines it as: “a general way of life, as the interaction of living conditions and the individual's standards of conduct determined by socio-cultural factors and personal characteristics”. It’s a balanced definition with an equivalent weight for agency and structure: the repertoire of possible behaviors is determined by society, with its culture and its socioeconomic structure, but ultimately the individual makes the choices. I couldn’t find the original: just this citation, and it’s a good version of a pretty consensual idea.
I expected to find most of the content on lifestyle and health with the WHO, and I was surprised to find this new medical specialty. Lifestyle medicine is deeply rooted in that historical moment when the critical mass about the weight of physical activity and nutrition on the global burden of morbidity and mortality reached the point of institutionalization, in the early 2000s. For a couple of decades, the major killer in the world has been the industrial lifestyle (I’m calling the current dominant lifestyle this way in analogy to the current industrial food system). Today, 74% of all deaths worldwide can ultimately be traced down to - let's call it as it is - pathogenic nutritional habits, pathogenic physical (in)activity levels, and pathogenic substance use habits. A pathogenic lifestyle.
The Global Strategy on Diet, Physical Activity and Health was released in May 2004. That same year I was assigned, by the BIREME, the task of elaborating a project for assessing the technical information needs, and creating a system to improve the access and practical use of evidence-based research information, by front-line health practitioners in the fields of physical activity and nutrition. That was my first professional contact with this wide, ill-defined, interdisciplinary field. The two areas that make it, exercise science and nutrition, are very different in content and study/intervention objects, but they are complementary and can hardly be understood without the other. Under this program, they were associated under the umbrellas of international and domestic public policies in preventive health (or lifestyle).
For completely different reasons, I had actually dealt before with the newly identified and acknowledged primary role of nutrition in health and disease. I studied the historical and policy aspects of prostate cancer research, and how nutrition had emerged as a primary target for intervention in the 1990s. That was when the role of the Western diet on the “hormone cancers” (prostate, breast, and colon) was finally recognized, and dietary interventions were taken very seriously by the prostate cancer patient community. This same line of research fueled a more fundamental debate on public policy and epidemiology, since these cancers kept rising. It became clear that dietary interventions were the only instruments in their prevention.
A healthy lifestyle, as defined by the World Health Organization (WHO), is “... a way of living that lowers the risk of being seriously ill or dying early. Not all diseases are preventable, but a large proportion of deaths, particularly those from coronary heart disease and lung cancer, can be avoided. Scientific studies have identified certain types of behaviour that contribute to the development of noncommunicable diseases and early death. Health is not just about avoiding disease. It is also about physical, mental, and social well-being. When a healthy lifestyle is adopted, a more positive role model is provided to other people in the family, particularly children.” Lifestyle interventions are usually described as what they intervene in, and the concept of a healthy lifestyle is implied. For example, the set of behaviors and conditions that sustain and optimize the main health pillars, including nutrition, physical activity, mental well-being, and social connectedness. They are hard to implement at any level, whether constructed within the patient-doctor relationship or within the community.
The way most interventions are formatted, they approach lifestyle as a set of individual behaviors to be modified according to individually assessed factors such as self-efficacy, motivation, control, and subjective beliefs, refraining from pursuing the stronger, societal level influences that ultimately sustain or compromise the former. But that is the problem, isn’t it? Consider the case in question that brought me here: calorie restriction as an intervention for chronic disease. The first obstacle is the obesogenic environment: the existence of feeding cues all around (visual, olfactory), the omnipresence of hyperpalatable, addictive ultra-processed food, the prevalence of pathogenic eating habits among friends, family members, and co-workers, and an overwhelming marketing aggressively promoting that food. Then there is the lack of social support. Several authors suggest that health-related behavioral changes and health behaviors are deeply interconnected with the wider communities, and there they gain their meaning. It’s no surprise that individualized approaches face serious obstacles.
In many target behaviors, the patient’s journey can be uncomfortable and even painful at several levels. Hunger and cravings can be physically unpleasant, and can bring to the surface traumatic memories, background, and semi-conscious assumptions. Why, really, do I want to eat these cookies, for example? What do I need to fill or satisfy? There are empty spaces in one’s soul that we do our best to keep hidden and shut. The proportion of patients with a pathogenic eating behavior that is a consequence of emotional trauma, particularly childhood family trauma, is high (here, specifically on overweight and obesity). Approximately 64% of adults in the United States have experienced at least one form of adverse childhood experience (ACE), according to the Centers for Disease Control and Prevention, and 17.3% of adults report experiencing four or more ACEs. ACEs don’t just influence people’s eating habits: they basically determine the person’s whole response system. It’s no surprise that they are also the main factor in adult addictive behavior and criminality.
Treating this particular lifestyle implies uncomfortable confrontations with the patient’s emotional difficulties and trauma, and also the material circumstances of their behavior. That might be the first time that the patient will be forced to take inventory of the highly obesogenic environment outfitted by the food industry, retail commerce, and an overwhelming marketing drive from both. Their public, work, and domestic environments are conducive to overeating, and harmful food choices. The lower the income, the more toxic the obesogenic environment. All this involves effort, sometimes too much effort, to overcome. Yet, it is our only hope, as a society, to deal with the virtual pandemic of inflammatory chronic disorders. If the dominant (industrial, urban) lifestyle is the ultimate cause of the major burden of mortality and of human suffering in health, then it probably shouldn’t be handled by a medical specialty, but by medicine as a whole, as well as government organizations and civil society’s institutions.
That leads us to the conclusion that clinical interventions with preventive effectiveness as well as management success for the non-communicable diseases must aim at the community. That, and the fact that such diseases are affecting the majority of adults today, by far the most important of health concerns, makes me critical of the new specialty: are we ok with cornering the knowledge and skill necessary to treat the majority of adults today (so that they don’t become part of the 74% who die of non-communicable diseases and their consequences) into an optional content in medical education? Isn’t it obvious that the ability to handle - identify, educate, prevent, treat - widely distributed pathogenic factors that sooner or later will affect most patients is mandatory for the practice of medicine, any medicine, anywhere? And now this is “protected” under a gatekept certification, for which the professional must pay other professionals who just invented the field?
There is one final consideration about lifestyle that reframes this entire discussion: the industrial lifestyle is not sustainable long-term. It’s where lifestyle meets environmental concerns and the larger economy. It’s almost an unspoken consensus among food and nutrition researchers that the food industry works like a social and economic parasite and, left unchecked, will eventually kill the host: humanity. Yet, it’s one of the major industries of the global economy, and its presence is pervasive at all levels of social life.
One of the characteristics of a healthy lifestyle is being sustainable, and sustainability is given by local, regional food systems and social support networks. It is at this level that lifestyle interventions have actual epidemiologically relevant preventive potential. At this level, they necessarily cover from “womb to tomb”: “to grow up healthy, children need to sit less and play more”, says a headline at the WHO website concerning healthy lifestyles.
It seems to me that we will go on having two categories of clinical lifestyle interventions, one of them now “protected” under specialty certification: the poor and the rich, the sustainable and the unaffordable. At one level, it is about seeking health as conceptualized by the WHO and other socially committed organizations. A "socially anchored" definition recognizes that health is not solely an individual's biological (or mental) state but is also profoundly influenced by social and environmental factors. Interventions aligned with this perspective involve local food initiatives like collective gardens, community and family health agents, incentives to local organic farmers, and subsistence agriculture/horticulture, as well as grassroots organizations and health structures. At the other level, we have fancy boutique “biohacks” that tap into aging and inflammation research.
I can employ many of the methods for successful lifestyle intervention because I am short-circuiting the social chain of service supply: I access science and medical databases, make my own diagnostic hypotheses, provide the clinical diagnosis, select the measures, and the treatment. I also provide the prescription, the “doctor’s/professional’s education”, the patient education (where I play both), and the blueprint to navigate social structures and markets. I implement the guidelines and fill in every other service that should exist between decision-making and adoption of a major lifestyle change. All of this except for the social network, which, like most people, I don’t have, and that is a setback, but I still have all the other “services” in my favor. I can do it.
That’s not available for the dozens of millions of people in this country alone suffering from similar conditions. This is the exact opposite of a rare disease: it is the most common class of diseases. The class where pharmacological treatment is non-existent or ineffective, and where the only prevention is lifestyle change.
Not all is lost, though, and friends in Brazil tell me that family medicine as practiced within the SUS, Brazil’s Unified Health System, which is entirely free and universal, is pretty well done, given all the difficulties. Facing the preventive and treatment challenges of non-transmissible (“lifestyle-related”) chronic illness means addressing the pathogenic factors of society and its culture at all levels. It means assisting patients in, collectively and individually, avoiding each one and, instead, adopting a decision in full agency and mastery of their goals. But it also means confronting an economic structure that allows predatory industries, such as the food industry, full, unregulated access to people. It means ending unjustified agricultural incentives for that industry, strongly regulating food marketing, and several other measures.
The answer to my original question, then, is that the reason why lifestyle interventions, from the easiest and most superficial to the most profound, are not more sought, prescribed, and employed is probably because there isn’t enough institutional and network social support available. These measures are, in fact, the only ones effectively preventive and treatment as well, they are cheap at the user end, but they strongly depend on solid social health policies, social programs, and political will.