What's In a Lifestyle?

    No matter what your overall cardiovascular risk profile looks like, diet and lifestyle influence illness and death rates throughout life. The $64,000 question has been–“By how much?” This question had gone unanswered until 2004.
    The study is known as “The HALE Project,” and it was published in the Journal of the American Medical Association in 2004.¹ The study attempted to quantitate the effect of a healthy lifestyle in terms of overall mortality and mortality from cancer and heart disease, which together comprise up to 75% of all deaths in persons older than 65 years in industrialized countries. The study focused on a large population of 1507 healthy elderly men and 832 healthy elderly women between the ages of 70 and 90 years from 11 different countries. None of the subjects had any known diagnoses of heart disease, cancer, or diabetes at the start of the study. The advanced age of these subjects, however, meant that they were all at very high risk for death and other adverse health events. The researchers monitored the outcomes of this group for a period of ten years.
    For the purposes of the study a healthy lifestyle was specifically defined by 4 characteristics–not smoking, exercise, eating a Mediterranean-like diet, and any regular use of alcohol. Not smoking meant either never having smoked or having quit at least 15 years prior to the beginning of the study. To be considered an ‘exerciser’ subjects had to engage in approximately 30 minutes of activity per day equivalent to at least a brisk walk. Regular use of alcohol (remember this is a European population) was defined as any consumption of alcohol greater than zero grams per day. The average alcohol intake was 17-21 grams per day for men and 5-6 grams per day for women. The most complex variable was the diet component. The modified Mediterranean diet was assessed by means of an 8-point score. One point was scored for each of the 8 major food groups–monounsaturated fat, legumes (including nuts and seeds), grains, fruit, vegetables (and potatoes); fish; dairy products; and meat products. The first six of these were considered desirable items for consumption, and the last two (meats and dairy products) were considered foods to be avoided as much as possible. To receive a point for the 6 healthy groups a subject had to consume more than the ‘average’ amount for someone his or her age according to epidemiological nutrition studies. To receive a point for the 2 undesirable food groups a subject had to eat less than the average amount for his or her age. Finally, in order to receive the overall point for the Mediterranean-like diet a subject needed to score all 8 points on the individual components.
    Thus, the composite lifestyle score consisted of 4 possible points–one each for exercise, smoking status, diet, and alcohol use.
    After 10 years of follow-up, men and women between the ages of 70 and 90 years who had adhered to a Mediterranean diet, were nonsmokers, or had stopped smoking more than 15 years ago, were physically active, and used alcohol moderately had less than half the mortality rate from all causes, heart disease, and cancer than those who did not. For the subjects that had just 2 of the lifestyle characteristics all-cause mortality was reduced by 38%. For individuals with 3 of the characteristics all-cause mortality was reduced by 55%, and for individuals with all 4 of the positive lifestyle characteristics, all-cause mortality was reduced by 65%! The specific reductions associated with all 4 characteristics were 73% for coronary heart disease, 67% for all cardiovascular diseases together, 69% for cancer, and 67% for all other causes. To put this into perspective, there are no drug treatment studies for any disease that achieve comparable reductions in all-cause mortality. There are no studies of other specific preventive health measures that achieve comparable results. None of the widely familiar interventions for the prevention or early detection of cancer (such as Pap smears, mammograms, fecal occult blood testing, colonoscopy, or PSA blood tests for prostate cancer) achieve anything close to this; in fact, none of these measures has been demonstrated to have any effect on all-cause mortality at all! They only reduce your chance of dying of a specific cancer, but they do not extend your lifetime.
    The primary point of this web site is that, if you are going to invest energy and money in your health, there are certain key targets that will get you the most benefit. Why spend your resources on anything else? These targets are not the ones that you hear about all the time in the newspapers or on TV. The highest yield targets are relatively free (or cost saving) and are not advertised much, since no particular companies (except health care plans) will make money from them. There simply is no higher yielding target in all of medicine except a healthy lifestyle. To the extent that you have any energy or money that you want to invest in your health, this is where to spend it. And it won’t cost you a whole lot. And it will get you dramatic results. It just takes work–every day.
    The conversation you need to have with yourself is about the question, “Are you serious about doing something for your health?” Are you willing to do something proactive and effective for yourself, or do you just want to go on using the traditional model whereby, after you have suffered the consequences of not taking care of yourself, you experience some symptoms or disease and then go to the doctor for symptomatic relief, but not for prevention or for cure. What does health mean to you? What is it worth to you? Are you truly comfortable with an after-the-fact band-aid style approach? Do you accept the fundamental illogic of that position? Many do. What this means for them is that their visits to the doctor are largely wasted. They are coming too late to do much good. They are asking someone else to do for them what they have been unwilling to do for themselves, and that doesn’t work. Health is work. Work that only you can do. Your doctor should be your advisor and your coach. Your doctor does not have any magic cure-all. Most tests that are offered barely do more good than harm, and most pills offer only symptom relief without having any effect on overall mortality.
The exception are cholesterol lowering medications known as statins, like Lipitor and Crestor. These have been shown to lower all-cause mortality for high-risk individuals by about 33%, which is only half the benefit of a healthy lifestyle. But this leads to another approach. What if you combined a healthy lifestyle with the most effective of our available modern medications? This might be the healthiest strategy of all. Take a look at the possibilities.

1. [Mediterranean diet, Lifestyle factors, and 10-year mortality in elderly European Men and Women: The HALE Project. Knoops KTB et al. JAMA 2004; 292 No 12: 1433-9]