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President's Desk, December 2015
David L. Katz, MD, MPH

Accord for the Future

‘Tis, as the saying goes, the season.  As I write this, if not necessarily as you read it, ‘tis the season of rhetorical flourish, soaring aspirations.  Even if often wrapped in crass commercialism, or delivered in the lyrics of a particularly corny carol, the sentiments are real, the yearning- perennial and fervent.  We feel it always, I believe- but only allow ourselves to express it so freely in this annual interregnum.

Yes, we want a world of peace and harmony.  Damn it, we do!  Yet, how elusive it is.  And of course, the enemy to what we would so ardently celebrate, so eagerly bequeath to our children is…us.  Who else?

As we revisit again this year the jarring contrast between what we desire and what we devise, images of Paris beckon.  Paris, where terrorists so recently sprayed bullets and cast their fetid shadow over the City of Light.  Paris, where only weeks later, a world of nations gathered to defend our common treasure from shortsighted profiteering, and address climate change at last.  The Paris Accord, though doubtless bedeviled by operational details, and perhaps somewhat too late, and almost surely too little, is historic just the same.  And, whatever its deficiencies, so much better than discord.

How right, too, that Paris should symbolize the triumph of accord in the aftermath of mayhem born of discord, however murky and inscrutable its particular origins.  In French, “I agree” is “d’accord,” and the expression figures frequently in the flow of that mellifluous language.

Accord, then, is today’s theme.  There, and only there, resides the answer to these seasonal hopes.   Only in unity is the strength to shrug off the discordant status quo that bides its time while we are busy buying presents.

The Paris Climate Accord shows the capacity of nations to agree on our common interest in the fate of the planet.  Closer to home, we had a recent and vivid, if much humbler demonstration of the capacity of nutrition experts to agree on common interest in the fare on our plates. 

The Oldways Common Ground conference was remarkable for the diverging implications of its product, and its process.  The product, as in Paris, showed the possibility of accord at the outer limits of hope and expectation alike.  The process showed how readily discord prevails when given the least quarter.

I have reflected on this recently, more than once.  At times, of course, we truly disagree.   We may disagree on what should be done, or even more likely, how.  There is room for real disagreement.  We can, as the saying goes, agree to disagree.

But we often fail even to agree to disagree, and disagree about disagreeing instead.  And much of that deeper discord is the stuff of smoke and fog, shadow and misapprehension.

In the case of diet, all experts I’ve met around the world eat much more like one another than any eats like the typical member of their native population.  Yet, these same experts populate journals and airwaves alike with seemingly mutually exclusive claims.  How can practice be so confluent, the related preaching so cacophonous?

For one thing, our answers follow our questions, and our questions are all too often the thin edge of a divisive wedge.  In the case of guns, they pose as choices between rights and controls.  In the case of climate they pose as choices between the environment and the economy.  In the case of diet, they masquerade as choices between this claimant to the best diet laurels, and that.

The ramifications of our tendency to ask divisive questions in the first place are massively amplified in cyberspace, where anonymity and a boundless expanse serve to stoke our primal xenophobia, even as they embolden our stridor.  Echo chambers prevail, empathy erodes, and extremes of opinion obscure the common ground.

But then there is this timely, seasonal reminder that we want that common ground.  In the mists of Christmas future, we see our children playing together on it.

We see them healthy as well, of course.  So it is genuinely meaningful and comforting to know that a who’s who in lifestyle medicine around the world agree on how to make that most likely for their own children.  It is meaningful and comforting as well that the communal recipe addresses the critical needs of our overtaxed planet. 

There is massive environmental benefit in lifestyle as medicine.  Water consumption to produce beef calories is in general an order of magnitude greater than that required to produce corresponding plant-food calories.  Water consumption to produce soda pop, the drinking of which redounds only to the benefit of the sellers, is nothing less than astounding.  In Marion Nestle’s new book, Soda Politics, we learn that some 500 liters of water are consumed to produce one liter of Coke or Pepsi.  We might all imagine dumping 499 bottles of water down a drain as the prelude to drinking one bottle of soda, and wince accordingly.

There is, in fact, a massive global accord about the fundamentals of healthy eating.  Fortuitously, those same fundamentals are as germane to the fate of the planet, from aquifers to biodiversity, as they are to the fate of our families.  The argument for a less processed, more plant-based diet is solid, and sound; rooted in science and sense; time-tested, and real-world relevant.  The very formula that prevails for chronic disease reduction pertains to the preservation of planetary treasure.  Beneath the veil of apparent din and discord, there isn’t just accord; there is concordant accords across disciplines, and domains.

We in Lifestyle Medicine are natural emissaries of this truth.  We have the kinder, gentler means to prevent, treat, and reverse disease.  We can add years to lives, and life to years.  We can, as well, contribute something substantive to the stabilization of climate, the sustainability of our food systems, and the defense of natural resources- one thoughtfully provisioned plate at a time.

We are invited, then, to do all we can to ensure accord is on the menu.  All that is required is the strength unique to unity.  All that is needed is the declaration of common cause, on the solid substrate of common ground.

Alas, such things are easier said than done.  But ‘tis the season that invites us to indulge in our most hopeful reflections, and perhaps to recall that the best way to predict the future- is to create it.

Preventive Medicine, Lifestyle Medicine, and Functional Medicine all profess to target the true causes of disease, and there is a valid basis for each such claim.  The specific contentions of each enterprise are the substance of that manuscript now in the works; it’s not my place here to preempt those better arguments, by better sources.

I can, however, illustrate the effort by noting the pedigree of Lifestyle Medicine’s claim.

We might trace the origins of our mantle to Hippocrates, who famously advanced the cause of lifestyle medicine with such admonishment as: “let food be thy medicine.”  There is little left to append there other than: amen.

We might, alternatively, constrain our timeline to the modern era, in which case McGinnis and Foege, rather than Hippocrates, are parents to our cause, flag bearers in our forward progress.  Their seminal publication in JAMA in 1993 made the case for causes not only explicit, but even eponymous: “Actual causes of death in the United States.”

Those “causes” extended to a list of ten factors.  Most noteworthy for our camp is the overwhelming predominance of lifestyle on that list.  The first three entries, accounting for 80% of premature deaths in 1990, and reaffirmed in diverse publications since and current to this day, were tobacco use, dietary pattern, and physical activity.  As this readership likely knows, I refer to those routinely as our daily applications of feet, forks, and fingers.  The evidence base substantiating these as master levers of medical destiny is little short of irrefutable.

So the legitimacy of our claim to causal devotion is not to be trifled with; it is not to be discredited.  But there is perhaps some danger in the very blatancy of that legitimacy. 

We in Lifestyle Medicine may be overly inclined to invoke that robust and riveting literature.  We might get carried away with the idea that lifestyle practices are, indeed, the actual causes of most of what ails us in modern society- or the remedy to that very problem.  We are right to do so, up to a point.  Beyond that point, though, the claim may make us proud, and insular.  It may isolate us.  It might make us exclusive.

But in fact, our claim, however legitimate, cannot be exclusive; for it is contingent on a more nuanced reality.  Even causes have causes.

The treatment of an effect we can administer may be better than the treatment of its cause we cannot.  The closer we get to bedrock, the better – but whatever we do in the neighborhood of roots will reverberate far more profoundly than the pruning of peccant branches in the canopy.

Consider, for instance, the social determinants of health.  We in lifestyle medicine are not prone, I trust, to dismiss the fundamental importance of poverty versus privilege; of environmental security versus squalor.  Poverty is not a lifestyle choice, however; it is a circumstance in which lifestyle choices play out.  The choices we make are, ultimately, subordinate to the choices we have.  Some lives are so focused on the immediate exigencies of survival, there is no place for “style.”  The appendage of “style” to life is, itself, something of a privilege.  Perhaps we focus on lifestyle because the deeper layers of causality are beyond our reach.

There is a need to highlight the primacy of causes, to rally in defense of the respect they warrant, to allocate more resources in their direction.  Modern, conventional medicine is routinely, if inadvertently neglectful of causes, in its preferential attention to effects.  This was elaborated recently and well by our colleague from South Africa, Dr. Derek Yach, and his co-authors writing in the American Journal of Preventive Medicine.

If we are to change something so formidable as the established allocations of the NIH, it will require a considerable counterforce.  Such strength is unlikely in the absence of unity.

If we can allow that lifestyle factors have causes upstream, and effects downstream that matter; if we can acknowledge that none of us has a monopoly on best methods; if we can concede that the “good” we can do may trump the “better” we cannot- it has the potential to illuminate common ground.  If we can recognize that even causes have causes, it may unite us in common cause.

Therein lies the best way forward, for there are arduous miles to go – and only, I think, in unity, the strength to go the distance.

As I write this, the American College of Lifestyle Medicine and the American College of Preventive Medicine have made considerable progress toward a prenuptial agreement that may allow for the mutual rewards of marriage in the foreseeable future.  As I write this, those two entities along with the Institute for Functional Medicine have made considerable progress toward the drafting and submission of a joint manuscript elucidating the perhaps overlooked architecture of our native alignment.

The former endeavor is, ultimately, much about the details of practice, and the practicalities of administration.  The latter is all about principles.  The first principle underlying a mutual devotion to causes is this: even causes have causes.

Preventive Medicine, Lifestyle Medicine, and Functional Medicine all profess to target the true causes of disease, and there is a valid basis for each such claim.  The specific contentions of each enterprise are the substance of that manuscript now in the works; it’s not my place here to preempt those better arguments, by better sources.

I can, however, illustrate the effort by noting the pedigree of Lifestyle Medicine’s claim.

We might trace the origins of our mantle to Hippocrates, who famously advanced the cause of lifestyle medicine with such admonishment as: “let food be thy medicine.”  There is little left to append there other than: amen.

We might, alternatively, constrain our timeline to the modern era, in which case McGinnis and Foege, rather than Hippocrates, are parents to our cause, flag bearers in our forward progress.  Their seminal publication in JAMA in 1993 made the case for causes not only explicit, but even eponymous: “Actual causes of death in the United States.”

Those “causes” extended to a list of ten factors.  Most noteworthy for our camp is the overwhelming predominance of lifestyle on that list.  The first three entries, accounting for 80% of premature deaths in 1990, and reaffirmed in diverse publications since and current to this day, were tobacco use, dietary pattern, and physical activity.  As this readership likely knows, I refer to those routinely as our daily applications of feet, forks, and fingers.  The evidence base substantiating these as master levers of medical destiny is little short of irrefutable.

So the legitimacy of our claim to causal devotion is not to be trifled with; it is not to be discredited.  But there is perhaps some danger in the very blatancy of that legitimacy. 

We in Lifestyle Medicine may be overly inclined to invoke that robust and riveting literature.  We might get carried away with the idea that lifestyle practices are, indeed, the actual causes of most of what ails us in modern society- or the remedy to that very problem.  We are right to do so, up to a point.  Beyond that point, though, the claim may make us proud, and insular.  It may isolate us.  It might make us exclusive.

But in fact, our claim, however legitimate, cannot be exclusive; for it is contingent on a more nuanced reality.  Even causes have causes.

The treatment of an effect we can administer may be better than the treatment of its cause we cannot.  The closer we get to bedrock, the better – but whatever we do in the neighborhood of roots will reverberate far more profoundly than the pruning of peccant branches in the canopy.

Consider, for instance, the social determinants of health.  We in lifestyle medicine are not prone, I trust, to dismiss the fundamental importance of poverty versus privilege; of environmental security versus squalor.  Poverty is not a lifestyle choice, however; it is a circumstance in which lifestyle choices play out.  The choices we make are, ultimately, subordinate to the choices we have.  Some lives are so focused on the immediate exigencies of survival, there is no place for “style.”  The appendage of “style” to life is, itself, something of a privilege.  Perhaps we focus on lifestyle because the deeper layers of causality are beyond our reach.

There is a need to highlight the primacy of causes, to rally in defense of the respect they warrant, to allocate more resources in their direction.  Modern, conventional medicine is routinely, if inadvertently neglectful of causes, in its preferential attention to effects.  This was elaborated recently and well by our colleague from South Africa, Dr. Derek Yach, and his co-authors writing in the American Journal of Preventive Medicine.

If we are to change something so formidable as the established allocations of the NIH, it will require a considerable counterforce.  Such strength is unlikely in the absence of unity.

If we can allow that lifestyle factors have causes upstream, and effects downstream that matter; if we can acknowledge that none of us has a monopoly on best methods; if we can concede that the “good” we can do may trump the “better” we cannot- it has the potential to illuminate common ground.  If we can recognize that even causes have causes, it may unite us in common cause.

Therein lies the best way forward, for there are arduous miles to go – and only, I think, in unity, the strength to go the distance.

As I write this, the American College of Lifestyle Medicine and the American College of Preventive Medicine have made considerable progress toward a prenuptial agreement that may allow for the mutual rewards of marriage in the foreseeable future.  As I write this, those two entities along with the Institute for Functional Medicine have made considerable progress toward the drafting and submission of a joint manuscript elucidating the perhaps overlooked architecture of our native alignment.

The former endeavor is, ultimately, much about the details of practice, and the practicalities of administration.  The latter is all about principles.  The first principle underlying a mutual devotion to causes is this: even causes have causes.

Preventive Medicine, Lifestyle Medicine, and Functional Medicine all profess to target the true causes of disease, and there is a valid basis for each such claim.  The specific contentions of each enterprise are the substance of that manuscript now in the works; it’s not my place here to preempt those better arguments, by better sources.

I can, however, illustrate the effort by noting the pedigree of Lifestyle Medicine’s claim.

We might trace the origins of our mantle to Hippocrates, who famously advanced the cause of lifestyle medicine with such admonishment as: “let food be thy medicine.”  There is little left to append there other than: amen.

We might, alternatively, constrain our timeline to the modern era, in which case McGinnis and Foege, rather than Hippocrates, are parents to our cause, flag bearers in our forward progress.  Their seminal publication in JAMA in 1993 made the case for causes not only explicit, but even eponymous: “Actual causes of death in the United States.”

Those “causes” extended to a list of ten factors.  Most noteworthy for our camp is the overwhelming predominance of lifestyle on that list.  The first three entries, accounting for 80% of premature deaths in 1990, and reaffirmed in diverse publications since and current to this day, were tobacco use, dietary pattern, and physical activity.  As this readership likely knows, I refer to those routinely as our daily applications of feet, forks, and fingers.  The evidence base substantiating these as master levers of medical destiny is little short of irrefutable.

So the legitimacy of our claim to causal devotion is not to be trifled with; it is not to be discredited.  But there is perhaps some danger in the very blatancy of that legitimacy. 

We in Lifestyle Medicine may be overly inclined to invoke that robust and riveting literature.  We might get carried away with the idea that lifestyle practices are, indeed, the actual causes of most of what ails us in modern society- or the remedy to that very problem.  We are right to do so, up to a point.  Beyond that point, though, the claim may make us proud, and insular.  It may isolate us.  It might make us exclusive.

But in fact, our claim, however legitimate, cannot be exclusive; for it is contingent on a more nuanced reality.  Even causes have causes.

The treatment of an effect we can administer may be better than the treatment of its cause we cannot.  The closer we get to bedrock, the better – but whatever we do in the neighborhood of roots will reverberate far more profoundly than the pruning of peccant branches in the canopy.

Consider, for instance, the social determinants of health.  We in lifestyle medicine are not prone, I trust, to dismiss the fundamental importance of poverty versus privilege; of environmental security versus squalor.  Poverty is not a lifestyle choice, however; it is a circumstance in which lifestyle choices play out.  The choices we make are, ultimately, subordinate to the choices we have.  Some lives are so focused on the immediate exigencies of survival, there is no place for “style.”  The appendage of “style” to life is, itself, something of a privilege.  Perhaps we focus on lifestyle because the deeper layers of causality are beyond our reach.

There is a need to highlight the primacy of causes, to rally in defense of the respect they warrant, to allocate more resources in their direction.  Modern, conventional medicine is routinely, if inadvertently neglectful of causes, in its preferential attention to effects.  This was elaborated recently and well by our colleague from South Africa, Dr. Derek Yach, and his co-authors writing in the American Journal of Preventive Medicine.

If we are to change something so formidable as the established allocations of the NIH, it will require a considerable counterforce.  Such strength is unlikely in the absence of unity.

If we can allow that lifestyle factors have causes upstream, and effects downstream that matter; if we can acknowledge that none of us has a monopoly on best methods; if we can concede that the “good” we can do may trump the “better” we cannot- it has the potential to illuminate common ground.  If we can recognize that even causes have causes, it may unite us in common cause.

Therein lies the best way forward, for there are arduous miles to go – and only, I think, in unity, the strength to go the distance.

As I write this, the American College of Lifestyle Medicine and the American College of Preventive Medicine have made considerable progress toward a prenuptial agreement that may allow for the mutual rewards of marriage in the foreseeable future.  As I write this, those two entities along with the Institute for Functional Medicine have made considerable progress toward the drafting and submission of a joint manuscript elucidating the perhaps overlooked architecture of our native alignment.

The former endeavor is, ultimately, much about the details of practice, and the practicalities of administration.  The latter is all about principles.  The first principle underlying a mutual devotion to causes is this: even causes have causes.

Preventive Medicine, Lifestyle Medicine, and Functional Medicine all profess to target the true causes of disease, and there is a valid basis for each such claim.  The specific contentions of each enterprise are the substance of that manuscript now in the works; it’s not my place here to preempt those better arguments, by better sources.

I can, however, illustrate the effort by noting the pedigree of Lifestyle Medicine’s claim.

We might trace the origins of our mantle to Hippocrates, who famously advanced the cause of lifestyle medicine with such admonishment as: “let food be thy medicine.”  There is little left to append there other than: amen.

We might, alternatively, constrain our timeline to the modern era, in which case McGinnis and Foege, rather than Hippocrates, are parents to our cause, flag bearers in our forward progress.  Their seminal publication in JAMA in 1993 made the case for causes not only explicit, but even eponymous: “Actual causes of death in the United States.”

Those “causes” extended to a list of ten factors.  Most noteworthy for our camp is the overwhelming predominance of lifestyle on that list.  The first three entries, accounting for 80% of premature deaths in 1990, and reaffirmed in diverse publications since and current to this day, were tobacco use, dietary pattern, and physical activity.  As this readership likely knows, I refer to those routinely as our daily applications of feet, forks, and fingers.  The evidence base substantiating these as master levers of medical destiny is little short of irrefutable.

So the legitimacy of our claim to causal devotion is not to be trifled with; it is not to be discredited.  But there is perhaps some danger in the very blatancy of that legitimacy. 

We in Lifestyle Medicine may be overly inclined to invoke that robust and riveting literature.  We might get carried away with the idea that lifestyle practices are, indeed, the actual causes of most of what ails us in modern society- or the remedy to that very problem.  We are right to do so, up to a point.  Beyond that point, though, the claim may make us proud, and insular.  It may isolate us.  It might make us exclusive.

But in fact, our claim, however legitimate, cannot be exclusive; for it is contingent on a more nuanced reality.  Even causes have causes.

The treatment of an effect we can administer may be better than the treatment of its cause we cannot.  The closer we get to bedrock, the better – but whatever we do in the neighborhood of roots will reverberate far more profoundly than the pruning of peccant branches in the canopy.

Consider, for instance, the social determinants of health.  We in lifestyle medicine are not prone, I trust, to dismiss the fundamental importance of poverty versus privilege; of environmental security versus squalor.  Poverty is not a lifestyle choice, however; it is a circumstance in which lifestyle choices play out.  The choices we make are, ultimately, subordinate to the choices we have.  Some lives are so focused on the immediate exigencies of survival, there is no place for “style.”  The appendage of “style” to life is, itself, something of a privilege.  Perhaps we focus on lifestyle because the deeper layers of causality are beyond our reach.

There is a need to highlight the primacy of causes, to rally in defense of the respect they warrant, to allocate more resources in their direction.  Modern, conventional medicine is routinely, if inadvertently neglectful of causes, in its preferential attention to effects.  This was elaborated recently and well by our colleague from South Africa, Dr. Derek Yach, and his co-authors writing in the American Journal of Preventive Medicine.

If we are to change something so formidable as the established allocations of the NIH, it will require a considerable counterforce.  Such strength is unlikely in the absence of unity.

If we can allow that lifestyle factors have causes upstream, and effects downstream that matter; if we can acknowledge that none of us has a monopoly on best methods; if we can concede that the “good” we can do may trump the “better” we cannot- it has the potential to illuminate common ground.  If we can recognize that even causes have causes, it may unite us in common cause.

Therein lies the best way forward, for there are arduous miles to go – and only, I think, in unity, the strength to go the distance.


AMERICAN COLLEGE OF LIFESTYLE MEDICINE

The American College of Lifestyle Medicine (ACLM) is the world's flagship professional medical association for physicians, clinicians and allied health professionals, as well as those in professions devoted to advancing the mission of lifestyle medicine.

       

© 2015 American College of Lifestyle Medicine

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