AMA Journal of Ethics^®

As our understanding of the broad range of factors that affect health grows, our health care system must align with this knowledge—researching, teaching about, and striving to prevent the many chronic diseases to which lifestyle contributes. Enormous amounts of time, money, and energy are spent on largely preventable illnesses that stem at least in part from lifestyle choices, behaviors, and environmental influences; it is well understood, for example, that many pervasive chronic diseases are related to nutrition, physical activity, sleep, environmental exposures, and other lifestyle influences. Such conditions have a profound effect on health care finance, with 75 percent of medical costs in the U.S. spent on care of individuals with chronic illnesses and 25 cents of every health care dollar spent on the treatment of diseases or disabilities that result from potentially changeable behavior [1].

As former secretary of the U.S. Department of Health and Human Services Tommy G. Thompson said a decade ago, “So many of our health problems can be avoided through diet, exercise and making sure we take care of ourselves. By promoting healthy lifestyles, we can improve the quality of life for all Americans, and reduce health care costs dramatically” [2]. This issue of Virtual Mentor centers on efforts to do just that.

According to the lifestyle medicine consensus panel, lifestyle medicine is “the evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life” [3] and encompasses nutrition, physical activity, stress reduction, rest, and social support systems. Wayne Dysinger, MD, MPH, gives a brief overview of the skills and knowledge needed to practice lifestyle medicine. This focus on prevention may feel like a change from the treatment-focused medical culture of our time, and, as Jed W. Fahey, MS, ScD, and Dr. Thomas W. Kensler, PhD, indicate in their piece on dietary phytochemicals and chemoprevention, there is indeed cutting-edge work being done in the field. But thinking and talking about the connection between the body, the surroundings, and the mind is part of a long medical tradition, which Micah R. Sadigh, PhD, reviews in his history of medicine piece.

Looking at the role that individual decisions in lifestyles and behaviors play in determining risk for and experience of disease raises thorny ethical dilemmas. As illustrated in the second case commentary by Mark T. Hughes, MD, MA, many factors shape each individual’s health, including medical care, social circumstances, genetics, environmental circumstances, and lifestyle factors, of which behavioral choices are only one—albeit a key—element. Dr. Hughes points out that physicians and other health care professionals can guide and coach the patient in making health-promoting decisions, while respecting the patient’s self-determination and stage of readiness to change. This powerful form of medicine is only effective when the patient embraces it, and therefore the physician must respect the patient’s autonomy and empower him to take responsibility for his health. In his commentary on the first case, David Katz, MD, MPH, explores what happens if a patient requests pharmacological intervention when lifestyle changes would be equally or more beneficial and have fewer side effects. Amireh Ghorob, MPH, Rachel Willard-Grace, MHD, and Thomas Bodenheimer, MD, explain how health coaching satisfies ethical principles by promoting a process of shared decision making and improving patients’ understanding of and participation in their health care plans.

Health coaching is not all we can do, however. In this issue’s op-ed, Neal D. Barnard, MD, takes us beyond the narrow, individual scope of one-on-one counseling, proposing a range of physician responsibilities related to promoting beneficial lifestyle, from counseling to public advocacy to attention to doctors’ own health. The third case commentary, by Lenard I. Lesser, MD, MSHS, and Sean C. Lucan, MD, MPH, brings to light the ways in which the provision of healthy food in hospital cafeterias can uphold an institution’s ethical obligations while sending a broader message about the importance of proper nutrition.

Anthony L. Schlaff, MD, MPH, looks at how health-related counseling came to be widely embraced, exploring its relationship to medicine and public health in the United States. He explains that, despite our society’s focus on interventions that assume individual responsibility, public health research over the past half century has shown that behavior can be most effectively changed not by education or counseling but by altering the conditions in which the behavior occurs.

Such efforts tend to target populations rather than individual patients, working to protect the public while imposing limitations or regulation on everyone and utilizing scarce medical resources for prevention of disease for which not everyone is at risk. Andrew W. Brown, PhD, and David B. Allison, PhD, challenge the fairness of such programs, exploring the unintended adverse consequences of health policies that aim to reduce obesity and strategies that may minimize unintended ethical and other impacts.

Valarie Blake reviews recent policy efforts to bring about behavior change, including the contested New York City ban on sodas over 16 ounces. Andrew A. Strasser, PhD, and Lynn T. Kozlowski, PhD, look at the graphic cigarette warning labels required under the Family Smoking Prevention and Tobacco Control Act as an example of health policy and regulation that has shown to be effective yet faces intense legal and ethical scrutiny. Kristina H. Lewis, MD, MPH, SM, considers the use of such methods to improve individuals’ diets and nutritional choices. As she points out, such policy brings up complicated ethical considerations, since the effectiveness of these measures—the degree to which they benefit the public’s health—often corresponds to the extent to which they intrude on personal rights and liberties.

Death and comorbidity from infectious disease are decreasing, only to be replaced by the greater toll on our health of chronic diseases, many of which are lifestyle-related. Our health care system must evolve in ways that address individual choice, acknowledge the impact of various lifestyle behaviors on health, and strive to prevent chronic disease rather than solely react to it.