Dr. David Donohue Grand Rounds at Christiana Care December 2019
It was a great privilege to speak to the faculty and residents and medical students at Christiana Hospital on December 19, 2019.
My talk was a bit controversial, so as to not be boring. :-)
I make some rather dramatic points, not customary for a typical medical presentation.
Earth is in dire trouble, with ice melting at a pace more in line with our worst case scenarios. Tipping points and runaway warming are close at hand.
Animal agriculture is a large part of our footprint, accounting for #3 and #4 largest sources of carbon emissions and a host of other impacts (water use, land use and degradation, collapse of marine life, etc.
99% of our meat comes from factory farms, which have massive environmental and climate footprint.
7 billion humans exert a huge footprint, but the 70 billion land animals that we raise and slaughter each year have a vast footprint as well.
In the last 10 years, the US has experienced a decrease in life expectancy. This is mainly due to younger people dying from substances like heroin, and also due to rising rates of chronic disease like obesity and diabetes.
The US health care system is the most costly in the world, and much of the reason for this is our high and growing rate of chronic diseases like obesity and diabetes.
Our private system of financing sick care is convoluted and inefficient. However, the bigger source of cost in the US health care system is our high rate of chronic diseases.
Roughly 80% of our health care dollars are spent on people with chronic diseases and roughly 80% of those diseases could be prevented with healthy lifestyle change.
Why do we develop chronic disease and die young? The western diet is the #1, #3, #4, and #6 underlying contributor.
Medical error is (by some estimates) our #3 cause of early death. Less chronic disease means less exposure to our risky health care system.
It is commonplace for patients to develop 5 or more chronic diseases and engage with our health care system to a high degree. You would think this should translate to a significant boost in health and vitality. However, despite all this engagement and the use of the very best we treatments that allopthic medicine has to offer, most people with chronic disease will live shortened lives of disability and sickness.
In fact, when science has looked at the absolute benefit of our best interventions for chronic diseases (like statins, blood pressure drugs) they are only marginally effective.
By comparison, lifestyle interventions can be far cheaper and far more effective, even improving longevity of populations (something no drug can do).
A standard allopathic treatment for atherosclerotic blockage of the coronaries is angioplasty and stent. Most stents are done for people with chronic stable angina (that is, people not having a heart attack). That research has been done and stents do not prevent heart attacks or death or chest pain. Yet we still do them.
Lifestyle medicine programs like the Ornish program deliver more significant benefits, with 80% of participants able to avoid getting a subsequent procedure (stent or bypass surgery) that they would otherwise have had.
Dietary changes alone to a low fat whole foods plant based diet can be just as effective as Ornish’s lifestyle program, with a high adherence rate (89% in Esselstyn’s report).
The standard/only allopathic answer to breast cancer prevention is mammography. Mammography does not prevent breast cancer, but rather it “causes” breast cancer in that people who undergo mammography are more likely to be diagnosed with breast cancer. But mammography is only marginally effective, saving 0.3 to 3.2 women in their 50s the misery of dying from breast cancer. This comes at a massive cost of overdiagnosis, unnecessary procedures, and large amounts of radiation delivered to a population. Mammography confers no improvement to overall longevity.
By comparison, lifestyle medicine can prevent breast cancer in the first place. Research on the American Institute for Cancer Research (AICR) guidelines for healthy lifestyle show improved life expectancy and as much as a 40% reduction in the incidence of breast cancer.
Most chronic diseases, from head (brain diseases) to toe (gout) have a strong lifestyle component. Clinicians should be thinking lifestyle first and foremost when they address every chronic disease for every patient.
Comparing allopathic medicine to lifestyle medicine, we find most allopathic medicine treatments amount to disease “management” analogous to mopping up the overflowing water on the floor whereas lifestyle medicine treatments address the underlying cause of disease, analogous to turning off the faucet.
Allopathic dietetics focuses on macronutrients and counts grams of carbohydrate, fat, and protein. Lifestyle medicine focuses on whole foods and recipes and skill building around foods.
The more dietary fiber a population eats, the less obesity, diabetes, heart disease, breast cancer, diabetes, dementia, and early death they experience.
The single best educational resource I have found to teach yourself nutrition science is nutritionfacts.org. I tell my patients that if you spend an hour on that website, you will know more nutrition than most doctors. I highly recommend you sign up for their daily alerts.
I recommend clinicians should join the American College of Lifestyle Medicine. They are an effective and growing advocacy organization, doubling in membership every 1.5 to 2 years. Their annual conference is free of commercial bias or excessive corporate influence, as opposed to the major allopathic medical organizations.
Diabetes is where lifestyle medicine really shines. We in lifestyle medicine are not afraid to use the “C” word (“cure) regarding type 2 diabetes. Progressive Health of Delaware has run its own diabetes reversal program since 2016.
Whereas there are many who believe that reversing type 2 diabetes comes down to how much weight you are able to lose and maintain, there is considerable science suggesting that reversal of diabetes is largely a function of your dietary fat and fiber. Eat fiber (and reduce fat) enough and you likely have the power to reverse diabetes.
One study found that when people with diabetes switch to a high fiber diet (65 grams per day of fiber), the majority were diabetes free in an average of 16 days.
The allopathic medicine algorithm to treating diabetes is roughly (1) metformin, (2) a second, newer drug, (3) insulin. The lifestyle medicine algorithm to treating diabetes is (1) educate, motivate, coach on lifestyle, (2) enroll in disease reversal program or see a plant-based dietitian, (3) start metformin.
I very seldom start insulin on type 2 diabetes patients. Usually this can be avoided by addressing the underlying cause of diabetes with dietary fiber and exercise.
The same algorithm for healthy lifestyle is ideal for most of our chronic diseases including lung disease, cognitive impairment
The lungs are a vascular organ and whole foods plant based nutrition can improve lung function just as it can improve the heart, kidneys, and other organs.
The 1 main reason why YOU should try LM on yourself is: Healthy doctors spread healthy behaviors. You will be less effective in counseling your patients until you make the changes yourself.
Why wasn’t I taught any of this stuff?! Good question. We in allopathic health care get precious little education in nutrition.
We should have gotten extensive education in nutrition and sustainability K-12 but we did not. The world desperately needs our students to learn these sustainability skills.
We definitely should have been taught healthy lifestyle and nutrition science in college or med school as it is fundamental to human health. But current medical education excludes such education, focusing instead on useless skills like calculus, physics, and organic chemistry.
You might think there is not much to study but it turns out there are 99,000 research studies published annually in nutrition science. This is a rich body of science that we in allopathic medicine have little knowledge of.
What are my 7 recommendations for large health systems?
Create combined Lifestyle Medicine residency tracks with Internal Medicine and with Family Medicine. You will attract forward thinking and passionate and talented residents
Deploy a employee health program for your own employees, modeled after the one done in Arizona by Joel Fuhrman and colleagues. They achieved a 66% reduction in depression scores, improvement in most every biometric tested, and 42% reduction in subsequent health care costs.
Overhaul most service lines to align with a “Lifestyle First” approach to most chronic diseases. Whereas this sounds radical, it is the very recommendation from most every major medical body for most chronic diseases.
Run disease reversal group programs at all facilities.
Hire or train plant-based dietitians. Yes that is a thing (or person!) and their skills are quite different than allopathic dietitians. They do more focus on foods, recipes, cooking demos, and food samples. Because of the primacy of whole foods plant based nutrition in disease reversal, your plant based dietitians are generally the most important member of your treatment team.
Advocate for state legislation to fully cover disease reversal programs, with incentive payments for long term success.
Form an Institute of Lifestyle Medicine to facilitate and study implementation of Lifestyle Medicine across the health system.
In summary, Lifestyle Medicine and a healthy lifestyle is not just a nice-to-have, something our health system should start doing more of in the future. Rather, it is critical to the long term health of our planet, our country, our patients, and ourselves.