The interaction between
lifestyle and chronic disease
Garry Egger AM MPH PhDSouthern Cross University
Australasian Society for Lifestyle MedicineCentre for Health Promotion and Research
Outline
1. Chronic diseases are on the rise world-wide and are signaled by, and often attributed to, obesity …… but……
2. …obesity is more of a ‘canary in a coal mine’, than it is a ‘cause’ of chronic diseases.
3. Lifestyle and environmental factors, with or without obesity, are the main determinants of chronic disease
4. Lifestyle Medicine offers some different procedures for managing modern chronic diseases
Outline
1. Chronic diseases are on the rise world-wide and are signaled by, and often attributed to, obesity .
“We shape our environments, then our environments shape us.”
Adapted from Winston Churchill
The Integrated Approach to Infectious Diseases
‘Germ Theory’
• Immunization
• Hygiene
• Public Health
• Anti-biotics
Shen S, Wong C. Clinical & Translational Immunology (2016) 5, e72; doi:10.1038/cti.2016.12
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Infectious Disease Incidence over time
Chronic (Non-Communicable) Disease Era: 1980 - ?
(1) Cardio and cerebro-vascular disease(2) Cancers with lifestyle component(3) Endocrine/metabolic disorders(4) Gastrointestinal diseases(5) Kidney disease(6) Mental/CNS health(7) Musculoskeletal disorders(8) Respiratory diseases(9) Reproductive disorders(10) Dermatological disorders
Chronic disease categories with
lifestyle/environmental determinants
Ref: King D et al. JAMA Intern Med. 2013;():1-2.
Health Status of Baby Boomers vs Parents in the US(NHANES 1988-1994 vs 2007-2010)
% of each cohort with disease/risks
Infectious vs Chronic Diseases Incidence over time
Shen S, Wong C. Clinical & Translational Immunology (2016) 5, e72; doi:10.1038/cti.2016.12
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Two categories of disease: multiple causes
Infectious Diseases
‘Germ Theory’
100,000 BP 200BP TIMELINE Present
Hygiene & Public health
Antibiotics/Immunisation
Chronic Disease
???????
??????????
Outline
2. …obesity is more of a ‘canary in a coal mine’, than it is a ‘cause’ of chronic diseases.
“Any important disease whose causality is murky, and for which treatment is ineffectualtends to be awash in significance.”
Susan Sontag, ‘Illness as metaphor’
Growth in Overweight and Obesity Worldwide
World Health Organisation 2014
Association of body-mass index with all-cause mortality, by sex
The Global BMI Mortality Collaboration. Lancet July 13, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30175-1t
Leanand metabolically
healthy
Leanbut metabolically
unhealthy(NOMOI/TOFI)
Overweightbut metabolically
normal(OBMNI/FOTI)
Overweightand metabolically
unhealthy
30% 31%
29%
10%
Forms of Obesity
Normal weight obesity(NWO) M =<1%; F=1-24%)Eur J Nutr 2008;47(5):251-7
Mechanisms of Increased Ectopic Deposition in Liver and Muscle
Ref: Schulman G. NEJM 2014; 371:1131-41.
LeptinAdiponectinObesity
No ‘spill-over’No MetS
Healthy
Ref: Kim et al., J Clin Invest 2007;117(9):2621-2637
Fat ‘Spill-Over’: Transgenic Obese Mice
LeptinObesity
‘Spill-over’MetS
Unhealthy
The Hierarchy of Drivers in Modern Diseases
Disease
Proximal(‘ ’)Determinants
Medial(‘midstream’)
Distal(‘upstream’)
RiskFactors/Markers
OBESITYBPLipids
-Apos-Tg-LDL-C-HDL-C
High FPGIGTCRPHBA1C
NutritionInactivitySmokingSun exposPollution
StressAnxietyDepressionDrugs/alcoholSleepRelationshipsInequality
Environment(macro & Micro)(Physical/Socio-Cultural/Political/Economic)
CHDDiabetesStrokeCancersInjurySTDsPCOSInfertilityCOPDGallstones
‘Cause’
PUBLIC HEALTH CONVENTIONAL MEDICINELIFESTYLE MEDICINE
‘Penicillin of LM’
‘Cause of thecause’’
‘Cause of thecause of thecause ….’’
•Czech Republic
30
29
28
27
26
25
24
23
22
21
20
19
Per capita GDP ($,000)
Me
an B
od
y M
ass
Ind
ex (
kg/m
2)
5 10 15 20 30 50
• USA
• NZ•Australia
• CanadaUK •
•Sweden
• Finland
•Columbia•S. Africa
• Denmark
•Ireland
• Germany
• Brazil
•Indonesia
•Philippines
•Mongolia
• Japan
•Egypt
• Cameroon
• India
• Bangladesh
Norway•
• China•Malaysia
‘Hap
pin
ess
’
Sustain
able C
O2
•Angola
•Thailand
•
• Romania
• Estonia
• Hungary
• Poland
• Barbados
•
• Uganda
• Liberia
• Burundi
•
• Mexico
• Singapore
•Samoa
•
• South Korea
Greece•
• Switzerland
•
•Italy
• • •
Health
y BM
I
BMI by Gross Domestic Product
Ref: Egger G, Swinburn B, Islam A. Ec & Hum Biol, 2012; 10:147-153
ENGLISH SPEAKING
NON- ENGLISH SPEAKING
THE ’SWEET SPOT’
Outline
3. Lifestyle and environmental factors, with or without obesity, are the main determinants of chronic disease
Classical Inflammation vs ‘Metaflammation’
Inflammation
ImmuneDefense
Resolution
Basal Homeostasis
Classical, Acute,Infectious Response
Imm
un
e R
eac
tio
n
ChronicAllostasis
Modern, Chronic.Non-infectious Response
Disease‘Dys-MetabOlism’
‘Meta-flammation’
Oxidativestress
InsulinResistance
Lifestyle/Environmental‘Inducer’
MicrobialPathogen/‘Antigen’
Ref: Egger G, Dixon J. Obes Rev 2009 (in press)
Crosstalk between gut microbiota and host in ‘metaflammation’ and metabolism
Ref: Boulange CL et al. Genome Med 2016;8:42
E N V I R O N M E N T
Metaflammation
Chronic (Non-Communicable) Disease
LifestyleSmoking Over-
Nutrition
Starvation
DietStress/Depression
Inactivity Drug use
Over-exercise
Inadequate
Sleep
Obesity
ExcessAlcohol
E N V I R O N M E N T
Pollution
+ Other Mechanisms(eg. oxidative stress, insulin resistance etc)
Ref: Egger G, Dixon J. Brit J Nutr 2009;18:1-5
‘E C T O P I C’ F A T
G U T M I C R O B I O T A
Two categories of disease: multiple causes
Infectious Diseases
‘Germ Theory’
100,000 BP 200BP TIMELINE Present
Hygiene & Public health
Antibiotics/Immunisation
Chronic Disease
‘Anthropogens’ Hypothesis
Lifestyle Medicine including Public Health &
Environmental Modifications
“Anthropogens”:
‘Man-made environments, their bi-products and lifestyles encouraged by these, some of which may be detrimental to human health.’
Source: Egger G. Preventing Chronic Disease, 2012
Outline
4. Lifestyle Medicine offers a different, and adjunct approach to managing modern chronic disease
Lifestyle Medicine
“A form of health promotion and branch of medicine targeting prevention and management of lifestyle-related diseases) .”
(Global Lifestyle Medicine Association 2014)
www.lifestylemedicine.org.au
Components of Lifestyle Medicine
• Knowledge (science)(ie. what are the lifestyle/environmental ‘determinants of chronic disease?)
• Skills (art)(ie. what are the skills/practices for changing unhealthy lifestyles/ environments?)
• Tools (aids)
(ie. what tests/devices/equipment can be used to assist changes towards a healthy lifestyle and/or environment)
• Procedures (actions)(ie. what sequence of steps needs to be taken to establish a course of action to improve unhealthy lifestyles/environments)
Clinicalcare(1:1)1 Doc; 1 Patient
Shared MedicalAppointment
1 Doc; 1 Facilitator6-12 patients
Groupeducation
(1:X)1 Educator;
15-20 patients
Where SMAs Fit
Facilitator Practice NurseDoctor
SMA TEAM
Documenter
Shared Medical Appointments (SMAs)
DoctorFacilitator
Medical Records
Shared Medical Appointment (SMAs) – Bourke NSW, May 2014
Doctor
Facilitator
Consulting Rooms
Documenter
White Board
SMA Trial Evaluation Preliminary Results
How do you rate SMAs for Type 2 Diabetes?
1______________2_____________3______________4______________5
Poor Fair OK Good Great 4.55
Would you continue to come to SMAs if these were availableat your centre?
1______________2_____________3______________4______________5
Definitely not Probably not Perhaps Probably Definitely
4.86
Do you think SMAs would reduce the number of other visits you would need with your doctor alone?
1______________2_____________3______________4______________5
Definitely not Probably not Perhaps Probably Definitely 3.81
SMA Trial Evaluation Preliminary Results (cont)What did you enjoy most about SMAs?
1______________2_____________3______________4______________5
Did not enjoy at all Enjoyed very much
Having more time for asking questions 4.84
1______________2_____________3______________4______________5
Did not enjoy at all Enjoyed very much
Hearing experiences of other patients 4.90
1______________2_____________3______________4______________5
Did not enjoy at all Enjoyed very much
Getting information from others 4.97
1______________2_____________3______________4______________5
Did not enjoy at all Enjoyed very much
Getting support from others 4.77
1______________2_____________3______________4______________5
Seeing the doctor more relaxed4.64
Did not enjoy at all Enjoyed very much
“It’s good to hear other people’s issues. It makes you realise you’re not alone and you’re not as bad off as you think.” 42 man with HIV, scrotum removed, cancer, etc.
“ As a result of this group I’m more aware of my condition and therefore managing it with more confidence.” 70- y.o. ex-Nurse.
“ I got so much out of this because I heard answers to questions that I always forgetto ask the doctor.” Indigenous man
“For me it just feels so much more relaxed than an individual consultation.” GP Adelaide
“It’s novel and breathing life in to my practice and desire to improve my knowledge and skills for real. I like the spotlight on me – it energizes me to perform better.”
Patient Evaluations
Provider Evaluations
“SMAs have given me a comfortable push to increase my knowledge. I talk withpatients one to one. And while you always do your best it doesn’t matter that much if I get my facts wrong or advice slightly off, as I won’t see them again for ages –and they have no one to check with anyway. In the SMA situation you can’t do that.Someone in your patient group or team are going to know more than you aboutsome things –you can’t fudge it! After the 2nd SMA I read deeply about diabetes and am continuing to do so in preparation.”
Advantages of SMAs
A. For Patients• Extra time with own doctor and morerelaxed pace of care;• Peer support and feedback from patients with similar conditions;• Answers to questions they might not havethought to ask (because others in the group ask)• Greater self-management education and attention to psychosocial issues
B. For Clinicians• Better management of waiting lists;• Reduced repetition of information/advice;• Can contain costs while increasing clinicalincome;• A chance to get to know patients better in an interactive setting;
Advantages of SMAs
Approaches to Managing Chronic Diseases
PUBLIC/PERSONAL HEALTH
Regulatory (‘Top Down’)
“Legislate and regulate if you can…. • Legislative approaches (eg. seat belts; smoking;)
“…educate and motivate if you can’t.• Health promotion/social marketing approaches(eg. ;
• ‘Stealth Approaches’‘Making healthy choices the easy choices” (eg. NZ food outlets)
Community (‘Bottom Up’)• Big picture advocacy approaches (eg. Public funding for elections; bike paths; eliminate limitedliability in corporations etc)
CLINICAL HEALTH
Mono-causal focus
(Lifestyle Medicine)
• Multi-disciplinary teamwork √
• Self management training √
• Telephone triaging x
• Community referrals √x
• Shared Medical Appointments x