Leveraging Lifestyle as Medicine: How to Fire on All Cylinders

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Throughout my recently completed tenure as President of the American College of Lifestyle Medicine, I encouraged my colleagues to think of our product as a six-cylinder engine. The six cylinders of lifestyle as medicine are, in my view: feet, forks, fingers, sleep, stress, and love. Allow me to explain.

Disease as Cause or Effect?

It has long been clear that a slightly longer list of factors—ten, to be exact—accounts for almost all of the premature deaths that occur each year in the U.S. and other developed countries. Understanding this requires thinking about the true, or “root” causes of premature death. For instance, even as I write this, federal data just released indicate that diabetes has moved up as the third leading “cause” of death in the United States, behind heart disease and cancer.

But the reality is, most diabetes is type 2, and nearly all type 2 diabetes is preventable through a combination of eating well, being active, and controlling weight. In other words, type 2 diabetes is not a cause; it’s an effect.  So, too, for heart disease, cancer, stroke, dementia, most lung disease, and so on.​​​

That epiphany—that the diseases we tend to think of as the causes of chronic misery and premature death are effects—was a key determinant of the path my career took. The scientific paper that made that case most decisively, entitled “Actual Causes of Death in the United States,” came out in 1993, just as I was completing my training in Preventive Medicine. The rest, as they say, is history.

The causes of premature death have causes, and the beauty in that simple revelation is that those underlying causes can be modified. By modifying them, we can live both longer, and better. We can add years to our lives, and life to our years. There is proof of that.

Focusing on Modifiable Risk Factors: Feet, Forks, and Fingers

One of my favorite studies on the topic, published in 2009, showed that those people who didn’t smoke, ate vegetables, fruits, whole grains, and little meat routinely, were physically active, and had a healthy weight, were 80 percent less likely to develop ANY major chronic disease than those who went the other way. Just four modifiable factors could explain away 80 percent of the risk for getting ANY major chronic disease. That’s a very big deal.

That original list of ten factors from 1993 included items that any one of us could potentially modify, like physical activity, and also some items that can only be changed with collective action, like the risk of exposure to environmental toxins and firearms. Sometimes the best defense of the human body resides with the body politic taking action.

But the most potent influences on health outcomes at the level of the population, and in terms of our risk, are the factors each of us can modify on our own, at least in principle. In that original paper 24 years ago, fully 80 percent of the premature deaths each year in the U.S. were explained by just three factors: tobacco use, poor diet, and lack of physical activity. These, then, are the first three of my six cylinders: feet (being physically active); forks (eating optimally); and fingers (not holding cigarettes).

Taking Charge of Sleep, Stress, and Love

Other studies, and the experience of whole populations have established the importance of the other three cylinders: sleep (getting enough of it); stress (not getting too much of it, or managing it well); and love (strong social connections). There is an extensive literature on the profound health effects of all three of these.

Sleep influences everything from hormonal balance to immune system function. Much the same is true of psychological stress—which generally cannot be avoided, but can be managed effectively. And it is well established that Homo sapiens are social animals and need one another.

John Donne said no one is an island a long time ago, and we now have modern research to show that bad outcomes attach to those who succumb to such isolation and loneliness. By “love,” I don’t mean just romantic love; I mean solid connections to others. Family, friends, and a strong sense of community are all medicinal.

How Do You Make the Best Choices for You?

While others may use different terminology, the simple fact is that where people live the longest and the best around the world, they are firing on these six cylinders every time. They eat well, are active, tend not to smoke, get enough sleep, aren’t overwhelmed by stress, and have strong social ties. Fire on those six cylinders and the path to more years in life and more life in years is the open road before you.

But of course, firing on those six cylinders is easier said than done, for a number of reasons. Given all the competing messages out there, it may be hard to know, for instance, what an optimal diet is. Even if you are among those who do know, it may be hard to make it work for you and your family.

The True Health Initiative exists to help make sure everyone does, indeed, know “what.” Experts around the world agree about the fundamentals of lifestyle as medicine, including the key and consistent features of an “optimal” diet—and if experts know, then everyone should know. The True Health Initiative exists to turn the global consensus among experts, and the weight of evidence, into common knowledge.

Verywell, in turn, is a daily source of practical information about health—including frequent guidance about these very factors, and how to put them to use in your own life.

Verywell and the True Health Initiative represent a powerful combination in the service of better health, more years in life, and more life in years. Lifestyle as medicine is a six-cylinder engine. The prize— longevity and vitality—is up ahead, along a road open to you and those you love. With expert guidance about where to go and a bounty of tips about how to fire on all six of those cylinders, you can get there from here!

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