The Six Pillars

These pillars define a relatively new branch of medicine, Lifestyle Medicine (LM), which is acting in the field of prevention. They comprise nutrition, physical activity, sleep, stress management, avoidance of risky substances and social connection.

Using these pillars and not based on pharmacotherapy, LM applies the principles of prevention mainly for cardiovascular disease, diabetes and obesity, but may be used in other specialties as well.

Life Medicine modern history probably began in 2004 (1), when The American College of Lifestyle Medicine (ACLM) was founded in the United States. In 2022, already 9000 members in 30 medical communities were activating (1). In the last decades, the theory and practice in LM have developed enormously (2, 3).

However, the roots of LM are very far beyond. Thus, five centuries before Christ, Hippocrates, considered the father of medicine, stated that in the description of pathology it was necessary to note what was the amount of food eaten by patients every day, what type of wine and how much they used daily, if they exercised and if their sleep was adequate. Differrent lifestyle patterns were described in this way.

Around the same time, the Chinese philosopher Confucius recognized the impact of diet and alcohol as well as that of mindfulness and meditation on people’s health (1).

Coming to our times, diet is one of the most important components of the six pillars. A relevant study published in 2019 (4) analyzed the effect of diet on longevity in 195 countries during a 27-year (1990–2017) follow-up. Its authors believed that the most important diet risk factors were 1) the high intake of sodium (in their study accounting for three million deaths); 2) the low intake of whole grains (also accounting of three million deaths); and 3) the low intake of fruits (another two million deaths). A total of 11 million deaths could be attributable to dietary risk factors (4). Therefore, I cannot abstain from citing one of their conclusions (4): “Our findings show that suboptimal diet is responsible for more deaths than any other risks globally, including tobacco smoking, highlighting the urgent need for improving human diet across nations.” Some of the most outstanding studies in the field can be further mentioned.

PREDIMEDstudy (primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts), which enrolled a total number of 7447 patients, was stopped early because the primary end-point (myocardial infarction, stroke, or death from cardiovascular causes) was reduced by about 30% in the study group at 4.8 years (5).

Lyon Heartstudy evaluated over 600 patients who had a myocardial infarction and showed a 50-70% reduction in secondary prevention of heart attacks in the group with mediterranean diet (6).

Based on the findings of the above-mentioned studies and on many other large trials, official medical bodies introduced the importance of a heart-healthy diet in their educational programs (7). This was included in guidelines too (8). It is to be noted that not all plant-based diets may be considered healthy.

The authors of a study published in 2017 created a plant-based diet index (PDI) and distinguished between healthful plant-based diet (hPDI) (whole grains, fruits/vegetables, nuts oils, tea/coffee) and less-healthy plant diet [unhealthful PDI (uPDI) (juices/sweetened beverages, refined grains, potatoes/fries, sweets]. Animal foods were considered unhealthful. The 4,833,042 person-years follow-up revealed a strong inverse association between hDPI and coronary heart disease, while uPDI and animal food diet were directly associated with heart ischemia (9).

Physical activityis very important for longevity. A study on 4800 individuals, who were followed- up for more than 10 years, found a 70% decrease in death rate for the individuals who used to walk 10,000 steps or more compared with those who walked only 2000 steps or less (10). Among those aged over 65 years there was an 80% decrease in mortality, irrespective of how fast they walked. This increase in longevity was greater than any pharmacological therapy (10).

Restorative sleep has profound impacts on health across the lifespan. Sleep is related to the repair processes needed to correct and prevent neuronal damage. Disordered sleep has an influence not only on cognitive impairment but also on cardiovascular disease and premature mortality (11).

Stress reduction (12).is equally important. Physiologic consequences of stress are activation of the sympathetic nervous system and elevated levels of cortisol. These bring cardiovascular changes and downregulation of immune function. Proposed modalities to reduce stress include spending more time in nature and practicing meditation or some mindful movement such as yoga

Cigarette smoking is still considered to be responsible of one in five deaths in the USA.

Alcohol abuse and illicit drug use have a comparable negative impact on longevity (1).

Social connectivity was recently highlighted during the COVID-19 pandemic (13). It was shown that social isolation increased the risk of coronary heart disease and stroke by about 30% and 32%, respectively, while in patients with heart failure it was associated with a 400% risk of death (13). One of the important conclusions of this study was that “social connectivity is vital for human health” . One of the most interesting findings on lifestyle is that it not only prevents, but may reverse some chronic illnesses like coronary artery disease.

The Lifestyle Heart Trial, .published in The Lancet in 1990 and JAMA in 1995 and 1998, demonstrated that intensive therapeutic lifestyle changing reversed the progression of coronary artery disease, as measured by quantitative coronary angiography (14). In the lifestyle intervention group there were 2.5 times fewer cardiac events than the control group

Any clinician should probably obtain, together with her/his degree in specialty, the degree in Lifestyle Medicine. Knowledge in this field should be applied day by day all year round.

However, a good piece of time should be added to doctors activity, in order to explain to their pacients the six pillars and monitor their implementation in patients’ daily life.

A good piece of time…