Lifestyle+ — 1

When we get into discussions of “healthy lifestyle,” it usually refers to diet, exercise, sleep, and intake of alcohol, coffee, and tobacco. My much broader definition, lifestyle+, adds environmental conditions such as exposure to toxins including air pollution, microplastics, forever chemicals, socioeconomic status, loneliness, and social isolation. Thinking about diet must now include consideration of ultra-processed food, time-restricted eating, and the optimum amount of daily protein for you specifically. Exercise means more than aerobic fitness; it includes good posture, resistance weight training, and that which maintains your sense of balance along with more standard notions. The reason to address this dimension first is that many more healthy years can be added to our lives without fancy, expensive technology.

The studies that have been done on diet, exercise, and sleep are predominantly observational studies from large cohorts. Why? It is extremely difficult to randomly assign a lifestyle to a person and expect compliance for many years going forward. Instead, we observe “real-life” statistics in the wild rather than contrived experimentally focused studies. But these large real-life cohorts rely on imprecise data, such as food diaries or self-reported memory for nutritional intake, physical activity, or sleep. Nonetheless, collectively they comprise an enormous body of evidence that can illuminate an “association” when there is a consistent pattern of benefit or harm, often with respect to magnitude of effect, across multiple reports. This does not establish a cause-and-effect relationship but merely a link that is supported by analytics adjusting for any confounding factors. The problem with such adjustments is that even the cumulative, small effects of confounding factors can be important, and some factors are simply overlooked. Many such studies suggest there is an effect on “all-cause mortality,” meaning it doesn’t matter what exactly a person died of—their heart condition, cancer, or some other disease. Nevertheless, all-cause mortality numbers are meaningful because they suggest there are real negative health effects via yet undiscovered pathways. Evidence from randomized trials, which are typically much smaller with more limited follow-up, deserve extra credence because they can provide a causal relationship about the intervention.

DIET

The aphorisms “You are what you eat,” which dates to 1826, and “Let food be thy medicine and medicine be thy food,” misattributed to Hippocrates, reflect the long-standing belief in the vital importance of diet. A systematic assessment across 195 countries concluded that a poor diet is linked to 22 percent of all deaths, which accounts for more deaths around the world than tobacco, cancer, hypertension, or any other medical condition or health risk. So, what is a healthy diet? There are over sixty thousand diet books on Amazon, yet the evidence remains thin for what constitutes the best healthy diet, no less the presumption that it should be the same for all people. The global diabesity epidemic has been fueled, at least in part, by our diet, but the often-overlooked heavy influence of Big Food, an oligopoly of multinational corporations, must be recognized.