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

17

00

17

50

18

00

18

50

19

00

19

50

20

00

20

20In

cid

en

ce o

f In

fect

iou

s D

ise

ase

s

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

17

00

17

50

18

00

18

50

19

00

19

50

20

00

20

20In

cid

en

ce o

f In

fect

iou

s D

ise

ase

s Incid

en

ce o

f Ch

ron

ic Dise

ases

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