An easy-to-remember formula for good health (0, 5, 10, 30, 150) is proposed in a wonderful editorial in American Family Physician titled “Preventive Health: Time for Change.” The author suggests this formula to physicians to “help patients achieve healthy lifestyle goals”:
- 0 = no cigarettes or tobacco products
- 5 = five servings of fruits and vegetables per day
- 10 = ten minutes of silence, relaxation, prayer, or meditation per day
- 30 = keep your BMI (body mass index) below 30
- 150 = number of minutes of exercise per week (e.g., brisk walking or equivalent)
The editorial is penned y Colin Kopes-Kerr, MD, from the Santa Rosa Family Medicine Residency in Santa Rosa, California:
It is time to make a decision. Which will be our health promotion strategy—primary prevention or secondary prevention?
Traditionally, the only one available to us was secondary prevention. Medicine consisted of a one-on-one physician-patient relationship, and taking care of patients meant minimizing the impact of any diseases the patient had. We did not have the time or tools to do anything else. More recently, we have been able to reduce a patient’s mortality by 20 to 30 percent by treating heart disease with a statin or beta blocker. These two medications have had the most dramatic effects in secondary prevention.
But now, the way we practice medicine has changed. We have a real choice to make. According to recent literature, primary prevention appears to work better than any other strategy in medicine. So why do some physicians not implement primary prevention? Despite the literature, maybe physicians are not getting the news. We need to keep repeating the message to physicians and patients that primary prevention is simple and effective. Next, we need to take a look at our own behavior as physicians and determine if it makes sense in the context of primary prevention.
There are 10 major studies on the effects of primary prevention.(1–15) These studies demonstrate very large correlations between specific healthy lifestyle behaviors and decreases in major chronic diseases (e.g., diabetes mellitus, heart disease, stroke, cancer) and all-cause mortality.
Although these studies offer a complex array of data to sift through, the elements of a healthy lifestyle are clear: not smoking, regular exercise, healthy diet, healthy body weight, and reduced stress.
Although exercise guidelines vary, I ascribe to the U.S. Department of Health and Human Services’ Physical Activity Guidelines for Americans, which recommends at least 150 minutes of brisk walking or the equivalent per week.(16) For the diet criterion, the Atherosclerosis Risk in Communities study illustrates that merely consuming five servings of fruits and vegetables per day is associated with the same benefits as consumption of a Mediterranean-style diet.(11) A standard of five servings of fruits and vegetables is much easier to remember and adhere to.
There is strong support for at least one weight-related variable in a healthy lifestyle. This may include body weight, body mass index (BMI), waist circumference, or waist:hip ratio. The INTERHEART study showed waist:hip ratio to be the most predictive of cardiovascular disease.(6) However, unlike BMI calculation, measurement of weight:hip ratio has not yet become standard in U.S. practices. I use BMI as the metric, and a value less than 30 kg per m2 as the cutoff between a healthy and unhealthy lifestyle. The goal is to move away from this outer limit toward a more ideal parameter, such as less than 25 kg per m2.
The final variable of a healthy lifestyle, which has strong support from the INTERHEART study, is stress reduction.(7) The INTERHEART study offers useful suggestions for measuring stress—perception of severe stress at home or at work, financial stress, or major life events.(7)
The minimal lifestyle intervention that would be beneficial is not defined. However, 15 to 20 minutes of silence, relaxation, or meditation appears to be a common interval.(17) To be more inclusive of patients, I set the criterion to an even less restrictive amount, about 10 minutes per day.(17) This is enough time to produce a change in biorhythms and is achievable for most patients.
Information alone does not lead to behavior change, however. Motivational interviewing or brief negotiation is a new framework that can close the gap between knowledge of available lifestyle interventions and changing behaviors. The framework has already been proven markedly effective for tobacco, drug, and alcohol addiction.(18) Few physicians have received the training necessary to implement motivational interviewing or brief negotiation. Resources for learning about these skills include the Kaiser Permanente Medical Group Web site and the book Motivational Interviewing in Health Care: Helping Patients Change Behavior.(18)
In terms of health, we can have it all. We have the requisite tools to convert knowledge into healthy behaviors. This newfound power to reduce diabetes, heart disease, stroke, cancer, and all-cause mortality with primary prevention strategies should impel us to change how we counsel patients. Research is needed to explore why some physicians are not making this change.
Address correspondence to Colin Kopes-Kerr, MD, at email@example.com. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
- Stampfer MJ, Hu FB, Manson JE, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000;343(1):16–22. View here
- Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 2001;345(11):790–797. View here
- Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA. 2009;302(4):401–411. View here
- Knowler WC, Barrett-Connor E, Fowler SE, et al.; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403. View here
- Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004;292(12):1433–1439. View here
- Yusuf S, Hawken S, Ounpuu S, et al.; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infraction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937–952. View here
- Rosengren A, Hawken S, Ounpuu S, et al.; INTERHEART Investigators. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):953–962. View here
- Chiuve SE, McCullough ML, Sacks FM, et al. Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation. 2006;114(2):160–167. View here
- Chiuve SE, Rexrode KM, Spiegelman D, et al. Primary prevention of stroke by healthy lifestyle. Circulation. 2008;118(9):947–954. View here
- Kurth T, Moore SC, Gaziano JM, et al. Healthy lifestyle and the risk of stroke in women. Arch Intern Med. 2006;166(13):1403–1409. View here
- King DE, Mainous AG III, Geesey ME. Turning back the clock: adopting a healthy lifestyle in middle age. Am J Med. 2007;120(7):598–603. View here
- Khaw KT, Wareham N, Bingham S, et al. Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study [published correction appears in PLoS Med. 2008;5(3):e70]. PLoS Med. 2008;5(1):e12. View here
- Ford ES, Bergmann MM, Kröger J, et al. Healthy living is the best revenge: findings from the European Prospective Investigation into Cancer and nutrition–Potsdam study. Arch Intern Med. 2009;169(15):1355–1362. View here
- Lee CD, Sui X, Blair SN. Combined effects of cardiorespiratory fitness, not smoking, and normal waist girth on morbidity and mortality in men. Arch Intern Med. 2009;169(22):2096–2101. View here
- Djoussé L, Driver JA, Gaziano JM. Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA. 2009;302(4):394–400. View here
- U.S. Department of Health and Human Services. 2008 physical activity guidelines for Americans. View here.
- Dialogue Partner. View here
- Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press; 2008. View here