“The last of human freedoms - the ability to choose one's attitude in a given set of circumstances.” Victor Frankl
What is the right lifestyle that keeps us fit and healthy? Since 2/3 of all diseases worldwide are the result of lifestyle choices, we are approaching a turning point when it comes to lifestyle interventions. The World Health Organisation explains that three of four people over the age of 65 live with at least one chronic disease like prediabetes, diabetes, heart disease, cancer or the Alzheimer's disease.
The American Heart Association has come up with seven basic metrics defining our physical health. These are: normal weight (Body Mass Index, BMI), physical activity, healthy diet, normal blood cholesterol level, normal blood pressure, normal fasting plasma glucose and not smoking. All these metrics are modifiable meaning our health is in our hands.
A well designed Norwegian research study has concluded that people who met five of the seven metrics mentioned above had up to 78% reduced a risk of all-cause mortality including heart disease, diabetes, high blood pressure and heart failure.
Another large Swedish study on 20,721 men aged between 45 and 79 aimed to examine the benefits of combined low-risk diet, alcohol consumption and physically active lifestyle practices on the incidence of a heart attack. The study has shown that a healthy diet and moderate alcohol consumption were associated with a lower risk of a heart attack. The researchers concluded that four of five heart attacks could be avoided by modifying only three lifestyle metrics.
Detailed research has been carried out over the last two decades to measure the impact of both lifestyle choices and lifestyle interventions on various groups of people. One of the largest clinical trials, INTERHEART has shown that simple daily choices make a big difference for our health. For example, having a sweet snack and sugar-sweetened beverage a day was associated with weight gain in 90% of men and 94% of women.
Fig.1. Mechanisms linking sugar sweetened beverages intake to weight gain.
Independently of weight gain, soft drinks being high in glucose and fructose, contribute to insulin resistance, inflammation and high blood pressure. All of the above increase the risk of metabolic syndrome, type 2 diabetes and cardiovascular disease.More evidence comes from a large multiethnic study on atherosclerosis. The study has concluded that four lifestyle metrics (regular exercises, healthy diet, healthy weight and not smoking) have the power to reduce all-cause mortality by 81%.
Even though a few studies have shown no benefit in lifestyle intervention in particular groups of patients, they have proven positive results in high-risk groups of patients. For example, the Look-AHEAD trial has failed to demonstrate the benefits of lifestyle interventions in reducing the risk of cardiovascular disease in people with diabetes, but it has shown a significant improvement in this group manifested in reduction in haemoglobin A1C level (a common blood test used to diagnose diabetes and to observe how well it's being managed), blood pressure, HDL cholesterol and albuminuria (the presence of albumin in the urine, usually a symptom of a kidney disease).
Researchers also noted a significant reduction in medications for diabetes, hypertension, and high cholesterol and significant improvements in the quality of life and depression. So, ultimately the results of the study weren't poor. Although the study initially aimed to measure the benefits of a lifestyle intervention in people with cardiovascular disease, it turned out that people who benefited the most were actually those with type 2 diabetes.
How does "eat less and exercise more" approach work for us?
The major challenge in any lifestyle intervention is to implement what we already know; we must break bad habits, introduce good habits, stop smoking, eat less and exercise more. The question remains, how to do it in practice and how to ensure that the changes are sustainable?
Most people who have tried any diet know how difficult it is to lose extra pounds and how easy it is to regain weight within the next few months. In fact, most diets result in a temporary weight loss, usually around six months, with the weight being regained on average 1-2 kg by 12 months.
The same applies to physical exercise programmes. In the Women's Health Initiative study, participants signed up for a low-fat diet that supposed to cut fat intake from 30% to 20% of daily calories. By six months, the 20% went up to 24%, and by one year it had come back up to 29%.
Many clinical trials have shown similar results, proving that lifestyle interventions bring only temporary results and are not sustainable in the long run. The major reason these programmes fail is the fact, that both the time frame and the goals of the lifestyle interventions are artificially created for the sake of "becoming healthier." Also, the goals are hardly ever aligned with people's core values and the life they genuinely want to live. Instead, they put up with a temporary struggle knowing that this sacrifice will soon end and they will go back to a normal life.
Public policy change
Although there is no real empirical data available as all public policy studies to date are only model based simulations, the results are quite inspiring. A review of a few American studies has shown that increased fast food prices were related to a lower consumption of unhealthy foods. Similarly, higher prices on fast food, combined with lower prices for fruit and vegetables, were associated with lower weight and lower BMI.
Fig.4. Trends in Selected Food and Beverage Prices and Obesity Rates among Children and Adults in the U.S., 1980–2011
Another study suggests that a 20% tax on sugar-sweetened beverages would prevent 95,000 coronary events, 8,000 strokes, and 2,600 premature deaths in the United States alone over a period of ten years. It would also save $17 billion in medical costs and generate $13 billion in annual tax revenue.
Implementing behavioural changes is challenging and usually not sustainable in our increasingly sedentary and ageing population. Moreover, a recently published research from the Stanford University has shown that change in behaviour doesn't predict improvement in health outcome anyway.
Becoming more knowledgeable and self-aware of the choices we make is the first step towards living a better life for longer.