Future Directions for Health Equity and Lifestyle Medicine: Insights from Former US Surgeons General

Abstract

Lifestyle medicine practices address root causes in the realm of patient care, healthcare systems, community health, and public health policy. It often takes consistent messaging and robust scientific evidence to buy in support of patients, health administrators, community leaders, and government officials. Four former U.S. surgeons general—the Honorable Admiral David Satcher, MD; Vice Admiral M. Joycelyn Elders, MS; Vice Admiral Antonia Novella, MD; and Vice Admiral Richard Carmona, MD, MPH, FACS—participated in a town hall during the American College of Lifestyle Medicine’s 2021 annual conference to discuss health equity and its relationship to LM. Moderated by Dexter Shurney, MD, MBA, MPH, immediate-past president of the American College of Lifestyle Medicine and president of the Blue Zones Well-Being Institute, the discussion also explored the challenging role and responsibilities of the nation’s top medical officer, the emergence of LM as an undervalued but high-potential tool for addressing complex issues such as health disparities, and specific actions—especially related to leadership—that would accelerate wider adoption of LM. In this article, Drs. Shurney and Carmona share their insights and highlights from the conversation and consider future directions of LM.

Using approaches such as lifestyle medicine will transform the nation’s ailing health system while continuing to address individual patient health needs.

Discussion around lifestyle medicine (LM) has been building for decades, led, in part, by the work of “America’s doctor,” the U.S. surgeon general. Health equity and its relationship to LM have been a high priority for many of the U.S. surgeon generals as they have been, in practice, lifestyle medicine practitioners. Admiral David Satcher, MD, the 16th surgeon general, and his team demonstrated to the nation the impacts of social determinants of health (SDoH). ¹ Social determinants—the conditions in which we are born, grow, work, and age as shaped by the distribution of money and resources at the global, national, and local levels—have now become part of the medical and policy community vernacular.

Today, researchers, policy makers, the health community, and the public are paying attention—some for the first time—to SDoH and health equity. Health equity is being able to control all those elements in an environment that allows us to optimize our health, and this is important because all populations should be able to optimize their health in everything they do—however, that process and potential depend on zip code, education, parental influence and habits, and other influences. ²

This paper will review key points discussed during a town hall discussion between former US Surgeons General—the Honorable Admiral David Satcher, MD; Vice Admiral M. Joycelyn Elders, MS; Vice Admiral Antonia Novella, MD; and Vice Admiral Richard Carmona, MD, MPH, FACS—during the 2021 American College of Lifestyle Medicine’s annual conference. Long after their tenures in the Office of the Surgeon General, these leaders continue to advocate for lifestyle medicine and health equity.

Dr. Satcher, for instance, used his national platform from 1998 to 2002 to introduce and greatly expand LM to a global audience, later founding the Satcher Health Leadership Institute at the Morehouse School of Medicine around LM’s core elements of disease prevention, health leadership development, and evidence-based policies and practices that help people live better longer.

His institute builds on what he called his “Surgeon General’s Prescription,” a list of five actions that people should incorporate into their daily lives.

1. Engage in moderate physical activity at least five days a week for 30 minutes a day.

2. Eat at least five servings of fruits and vegetables per day.

3. Avoid toxic substances such as tobacco, illicit drugs, and overuse of alcohol.

4. Conduct sexual behavior responsibly.

5. Participate in relaxing, stress-reducing activities with adequate sleep.

These remain some of the key components of LM today and are especially critical when prescribing ways to address health disparities. Dr. Satcher has often referenced them when promoting LM as an approach to changing disparate realities around Alzheimer’s disease. He notes that the Centers for Disease Control (CDC) estimate 5.8 million U.S. resident currently suffer from Alzheimer’s disease, and 1.1 million of them are African American. ³ Alzheimer’s is now the sixth leading cause of death for all Americans, but the disease may be two to three times higher among older African Americans than in older non-Hispanic whites. ³ Satcher also emphasizes that while Alzheimer’s disease increases with age, it is not a normal part of aging, and with the steady aging of the nation’s population, especially among minority groups, the burden of care for Alzheimer’s patients is a growing problem.

Only recently, in 2020, with release of research by the Lancet Commission has it emerged that a lot of the deterioration of Alzheimer’s disease is preventable, bolstering attention to the possible connection between brain health and LM. ⁴ Like diabetes, heart disease, hypertension, and many other chronic conditions, lifestyle medicine is finally providing an opportunity for the medical community to do more to decrease the impact of Alzheimer’s disease.

Such data support a town hall observation made by Dr. M. Joycelyn Elders, who in 1993 became the first African American to serve as surgeon general: The medical community is seeing a shift from primarily acute care to chronic medicine and treatments. This raises the urgency for much wider adoption of LM. As an example, the Green House Project, which collaborates with senior living providers to build houses for older adults that demonstrate LM elements that can boost brain health and overall well-being by offering senior citizens more socially and physically engaging opportunities for housing than traditional nursing homes. ⁵

This example speaks to what we have often heard at work and in research related to Blue Zones, areas where people live to be 100 or older while still enjoying a high quality of life. In short, it is called “living longer, better.” ⁶ In practice, Blue Zones are demonstration sites for the power of LM, the potential to make individuals and communities healthier for the long-term. Blue Zones research has shown that lifestyle enables better health for more than the elite and privileged. The inextricable link between the tenets of public health and those of LM is clear.

The Mayhem of Poor Messaging—Lessons from COVID-19

From the perspective of Antonia Novella, MD, the first woman and Hispanic person to hold the position of U.S. surgeon general, low health literacy and poor messaging, particularly within groups who are historically marginalized, can add to the mayhem of improving health at the population level. Novella shared her experiences as one who herself has overcome systems of health and social inequity. Personally and professional, Novella shared how she understands the need firsthand for LM at all population levels due to her dedicated longtime work in Puerto Rico. COVID-19 has brought to the forefront the injustice of the healthcare system and the exaggeration of who suffers more than the rest, including under-resourced Hispanic communities. Due to potentially low health literacy and limited health information for some Hispanic/Latinx and Black communities, the deficiency of translated public health information surrounding COVID-19 prevention and other health issues, as well as social determinants, adhering to public health guidance has been even more difficult. For example, it is nearly impossible to physically distance in small homes with multi-generational residential living, while preventative tools, such as masks also remain costly to many Hispanic/Latinx families.

In addition, health messaging about LM or COVID-19 has not been adequately diffused via the most-preferred Hispanic communication outlets such as on Spanish television or through trusted physicians. According to Dr. Novella, although 6 in 10 American Hispanics speak English, 18 million others do not understand anything but Spanish. ⁷ This language barrier and educational gap can cause terrible harm and death. These health disparities are new only in the sense that the virus is a recent anomaly. Hispanics have long experienced higher rates of acute and chronic diseases such as diabetes. ⁸ The heartbreaking reality is that the life expectancy of all Americans dropped by one year due to the pandemic in 2020, but by 3 years for Hispanics and nearly two years (1.9) for Black Americans. ⁹ During the discussion, Novella described that in the Hispanic community, for instance, many sick patients are extremely reluctant to go to the emergency room, even when experiencing chest pain or respiratory problems, for fear of infection or high costs.

Worsening the situation has been not only language barriers, but also ineffective messaging about COVID-19 and LM, a point to be acknowledged. Healthcare providers and government agencies need to draft “better lifetime messages” for citizens, especially minority populations, and find new ways to make healthcare information available. Effective messaging that is culturally sensitive is critical to any successful healthcare and prevention campaign, especially those directed at communities carrying the highest risks, and that will be important to the future of LM, too.

When the public hears that 80% of chronic diseases are resolved or avoided through simple actions such as physically moving more and eating fruits and vegetables, the information often does not influence people to act. Currently, with America so sick, the simplicity of this life-saving message must be disbursed in more rigorous and highly repetitive forms. Only then will the information be absorbed, processed, and translated into actions. More than anything, though, patients must have trusted advisors, such as family physicians, who share the best evidence-based advice and simple actions needed to achieve good health for them as individuals and in general. This trust-building advocacy remains an underleveraged opportunity to educate patients about LM and its benefits.

Telehealth may help change that. The pandemic generated a dramatic pivot to telehealth care, and Hispanics are its largest users. ¹⁰ The shift has prompted many patients to talk to their medical professionals about non–COVID-19 mental and physical conditions such as depression, hypertension, and especially diabetes. This deeper conversation has generated high support among many healthcare providers for making telehealth regulations—relaxed during the pandemic emergency—permanent and more reimbursable.

Telehealth is not a panacea, though. In rural areas, internet access is often unavailable, making video and even audio access impossible or unstable, and families—especially older Americans—may not have money for computers, smart phones, and other technical devices. However, broadband accessibility is improving rapidly, bolstered in large part by federal COVID-19 relief funds disbursed to states specifically to speed internet connectivity. The other concern raised by the group on the issue of messaging is that we live in an era of increasing disinformation which has led to a crisis of distrust in public health and facts in general.

Maintaining Momentum for Lifestyle Medicine Post–COVID-19

While the pandemic has revealed the ugly truths around health disparities, can this awareness provide long-lasting momentum for lifestyle medicine once the virus becomes better manageable, possibly prompting people to relax their current preventative practices? “Fixing” the COVID-19 problem is one thing; fixing America’s overall public health is quite another. As former surgeons, many worked to show that most chronic diseases were preventable. Their work as clinicians in the trenches gave them the passion to drive toward greater preventative actions because they lived through all that pain, suffering, death, and economic burden that could largely have been avoided.

The same is true for those U.S. Surgeons General and medical leaders who grew up in marginalized, low-wealth communities and witnessed the detrimental physical and mental outcomes of a biased healthcare system and systemic racism. Approximately 40% of our nation’s children grow up in poverty, unable to be the people they could be, because of inequities that exist in every state, every community. ¹¹ We as practitioners and researchers see in our own work—and remember ourselves—why LM is so important, along with the need for organizations such as ACLM that champion simple lifestyle changes.

Additionally, we can now look at these outcomes from a micro level, how these factors affect epigenetic inputs and impact health and disease. People may remember that as youngsters, our parents would say, “Eat your greens. Go out and play. Be nice to other people, so you have friends.” Those were each epigenetic inputs that enhanced gene expression across the board in almost everything we did on a daily basis. On a molecular basis, we can today show that the directives of our loved ones were right. We can determine the actions that give us a better outcome or at least a better chance of disease prevention. The LM work today—and what many former surgeons general continue to do—must give new life to what we have all been preaching for decades but that people are finally understanding in a rare a-ha moment.

Raising the Profile of Lifestyle Medicine

The position of surgeon general is unique and provides the ability unity to speak on opportunities to improve health, safety, and security in ways that amplify evidence-based recommendations by the government and healthcare community. COVID-19 prevention has been an excellent example of that unity. Lifestyle medicine is another.

Lifestyle medicine is one such topic that needs a high-level platform like that of the Office of the Surgeon General. We all want to live longer, happier, younger, and cheaper, but we must understand that we cannot afford our current collective lifestyle. According to the Centers for Medicare & Medicaid Services (CMS), national health spending will grow at an estimated 5.4% annually and reach $6.2 trillion by 2028—nearly 20% (19.7%) of the nation’s Gross Domestic Product spent on what we call healthcare. ¹² It is not healthcare; it is sick care. Seventy-five cents of every healthcare dollar is spent on chronic diseases caused by unhealthy behaviors.

Therein lies the value proposition for why organizations such as ACLM are so important and why surgeons general continue to speak out about this issue. As an old television ad used to tout, “You can pay me now, or you can pay me later,” and we all know that when you pay later, costs are usually much higher than today’s sticker price.

Unfortunately, the pandemic has led to greater public mistrust regarding public health and the Office of the Surgeon General. The science behind their guidance is no longer believed by everyone, which harms the impact of all public health messages, even those related to LM that have nothing to do with COVID-19. To find our way back, Surgeons General must continue to use their position to get the country moving together on some high-priority healthcare strategies. We must change the dialogue to ensure that evidence-based science is always out there to counter misinformation and disinformation as the foundation of appropriate policy.

The moment also has come not to fight health disparities. We must unite to push past SDOH barriers, systemic racism, and bias to advocate for LM. ¹³

A Call for Lifestyle Medicine Leadership

As health professionals, we must change the focus of our medical education and practice. Currently, board exams do not routinely include LM elements such as nutrition and issues such as addressing health disparities—and unfortunately many schools teach only to the boards. So we must move to change what is featured on board exams. But we cannot wait for certification board exams to catch up. Sustainable change starts with education, so we must continue to advocate to our colleagues in the medical education field that due to the country’s poor health, their students need more information in the curriculum regarding LM—even when information is not labeled clearly as “lifestyle medicine.”

Although institutional conversations are advancing at a slow rate, we believe change is moving in that direction. Many in the health field are seeing that the next generation of healthcare professionals views its future differently. We see the proliferation of farmers markets, the popularity of urban trail systems and parks, and the choices of healthier foods and exercise by young people. Next-gen healthcare practitioners seem to be looking at the world through a “whole-person” lens and understanding that adopting lifestyle changes early in life can have tremendous health and healthcare cost benefits. The job of healthcare leaders then is to push to ensure that LM is integrated into all curricula for medical students.

Moving forward, we all agree on the importance of upstream tactics such as “starting early” by teaching LM habits to youth and young families so they can reduce illness and acute health crises later. Early childhood education is not too early to start teaching comprehensive health information and to ensure parents understand what they can do to protect their children’s daily and long-term health. As research has shown, family physicians and other trusted medical and mental health professionals play critical roles in inspiring patients to make simple health changes, so the former need to become more involved in the LM community and commit to educating patients, despite possible political or public pushback.

America cannot afford the trajectory we are on and the diseases and economic burden that are burying us right now. We appeal to all stakeholders to reach out and ask all practitioners to join us in seeing the value of prevention and LM because that is our future. ACLM has done tremendous work keeping LM on the forefront, especially as it extends more effort into LM’s relationship to health disparities. But it cannot carry out this mission alone.

The most important thing we as medical professionals can do is lead at all levels, not only in the settings of clinical practice but in the larger landscape of the healthcare community where we can serve as opinion leaders as well.

Leaders also must recognize that scientific research has strengthened the shift healthcare into a new direction of treatments, practices, and disease prevention. As Dr. Satcher has noted, “When it comes to the whole issue of lifestyle, we've come to a reckoning point in our country. If we are not helping people change their lifestyle, then we're not making the kind of contribution that needs to be made.”

Only through courageous leadership can these messages of change be perpetuated, so we can optimize the well-being of our nation, distribute health equally across all ethnicities and genders, and ensure SDoHs are addressed. We must level that playing field, whereby every child born today—regardless of background—can have the best life. People should not be slowed or prevented from enjoying the myriad benefits of good health because of the zip code in which they live or the social and economic headwinds they face. That is the world we want to get to—and leadership is the key to its achievement.

A popular mantra in America’s Special Forces is “The only easy day was yesterday.” The healthcare community should echo that as they shake their heads at the staggering statistics showing the discouraging scale and diversity of healthcare disparities. We cannot give up. We must collectively light the way using approaches such as lifestyle medicine to transform the nation’s ailing health system at the macro level while continuing to address our patients’ individual health needs at the micro level. What none of us can do alone, when we are united as a galvanized force for change, anything is possible.