Lifestyle as medicine should get respect

Lifestyle medicine is undermined by those profiting from the propagation of lifestyle disease.

Among the predominant themes of modern medicine is a consistent emphasis on high standards of evidence. There are many subtleties involved in producing high-quality evidence as the foundation of something nearing certainty about the effects of X on Y, with many of them well established and universally acclaimed, others more controversial.

There is, however, a considerably larger potential problem than the reliability of any given p value (calculated probability), and that is the matter of parity in what research gets done, how it is reported, and what becomes of the results. From my vantage point — more than 20 years running a clinical research lab, over 25 years of clinical care — I see a very unlevel playing field. I am concerned in particular that lifestyle as medicine gets all too little respect.

A study was just published in JAMA comparing a lifestyle intervention comprising both dietary modification and exercise, to standard care relying principally on drugs for blood glucose control in type 2 diabetes. The primary outcome measure was change in glycohemoglobin (HgbA1c), a kind of “weighted average” of blood sugar over time, and the participants were followed for a year.

There was an unusual element in the study design that hints already at the biomedical biases of modern society. Since standard care that relies preferentially on medication is, indeed, “standard,” the researchers designed a “non-inferiority” study, otherwise known as an equivalence study. The statistical techniques were chosen to show that the lifestyle intervention was as good as standard care; most studies are designed to show that treatments differ.

At 12 months, the treatment assignments were not equivalent. HgbA1c had improved more in the lifestyle treatment group than the standard care group, despite what the authors described as a “substantial and parallel reduction in glucose-lowering medication” in that group. In plain words, with the lifestyle intervention, participants had better blood glucose despite taking less medication. In this “lifestyle as medicine” versus “medicine as medicine” contest, lifestyle won, reminding us all of the same result when lifestyle was compared to medication in a much larger, and rather famous study of diabetes prevention.

The new study made the medical news, but that’s where things took an odd turn. The headline at MedPage Today, since changed (at my request), was originally: “Exercise Not on Par with Meds for Glucose Control in T2D.” That’s true — it was “not on par” because it was better!

The headline in the American College of Physician’s JournalWise newsletter, widely distributed to physicians, was: “In adults with type 2 diabetes for < 10 y, a lifestyle intervention was not equivalent to standard care for glycemic control.” Again, that is technically true; it was “not equivalent” because … it was better.

Admittedly the odd reporting in this case had much to do with the investigators’ choice of an equivalence design, and with the very tempered language the investigators themselves used in their paper. But still, it’s hard to imagine a drug study showing effects greater than the control group being reported as “failure to show equivalence” under any circumstances. There is a ubiquitous bias at play.

While we generally use the term “standard of care” to imply state of the art, the standard may refer more reliably to the state of the status quo, the nature of which is to defend itself.

Some years back, I was working as themedical director at a boarding school for adolescents with severe obesity. The results achieved were stunning in every way. But the school has since folded because the kids who most needed the help came from families that could least afford it, and the third-party payers who will, as a matter of routine, cover bariatric surgery for a 17-year-old, don’t have policies to cover the even better results intensive lifestyle medicine can achieve.

Lifestyle as medicine is the best medicine we have, the only one appropriate for universal application, suitable for children and octogenarians and breastfeeding mothers; the only one that can add years to almost everyone’s life, add life to almost everyone’s years. But lifestyle medicine is undermined by those profiting from the propagation of lifestyle disease, and gets too little respect from those selling the standard remedies of modern medicine.

In other words, those holding the silver spoons may not want you to have the spoon you need to help lifestyle as medicine go down. That just means it’s time to invent new spoons.

Lifestyle as medicine is the best medicine we have ... the onlyone that can add years to almost everyone’s life, add life to almost everyone’s years.