President's Desk, February 2015
David L. Katz, MD, MPH
Lifestyle Medicine, and Common Cause: Even Causes Have Causes
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.