Tools
Overview of Lifestyle Medicine
Definition/Introduction
Lifestyle medicine is a branch of evidence-based healthcare emphasizing disease prevention over curative medicine. Contemporary medicine follows the same basic approach to the clinical encounter: data-gathering, conducting any needed tests, providing the patient with a treatment plan, and possibly a referral or hospital admission. This approach can be described as essentially end-stage care. The modern character of healthcare has neglected prevention. Patients often receive little or no practical education on disease prevention. Studies employing direct observation of primary care practices have reported that preventive care has been underemphasized.[1]
The reasons for this may be varied, with some suggesting that too much time is required to provide the information needed by the typical patient visit.[2] This reactive, curative approach has important implications for healthcare financing.
The cost of healthcare in the United States has become prohibitive. At the time of this publication, it is estimated that the cost to provide care to the average adult is over $13,000 annually in the US.[3] The Centers for Disease Control (CDC) reports that six in ten Americans have a chronic disease, and two in four have two or more chronic diseases. These conditions account for approximately 75% of all healthcare costs.[4][5]
Chronic diseases include heart disease, Alzheimer disease, type II diabetes, cancer, stroke, and other similar disease processes. The United States is the outlier of all countries in healthcare expenditures, spending far more per capita as a function of GDP (gross domestic product).[6] Thus, if healthcare providers intervene to integrate prevention into their workflow, then we may see a significant decrease in the number of chronic diseases for individuals, the associated suffering, and healthcare costs for both individuals and the government.
Issues of Concern
Register For Free And Read The Full Article
Search engine and full access to all medical articles- 10 free questions in your specialty
- Free CME/CE Activities
- Free daily question in your email
- Save favorite articles to your dashboard
- Emails offering discounts
Learn more about a Subscription to StatPearls Point-of-Care
Issues of Concern
A major, compelling solution to the challenge of healthcare, both on the individual and collective levels, is to effect preventive change through lifestyle modification. This concept is not new: Hippocrates taught about the importance of prevention over 2000 years ago.[7] The medieval physician and philosopher Maimonides asserted that the most important cause of poor health is the food we choose to eat.[8]
It has been estimated that only one-fifth of the modifiable determinants of healthcare come from the care medical practitioners provide (see Image. Prevalence of Self-Reported Obesity, 2011).[9] Despite this, modern healthcare has heavily emphasized curative treatment over prevention. Preventing chronic disease may be the key to the healthcare financing crisis in the US and other nations and the overall improved health of the population taken as a whole.
In 2009, researchers analyzed lifestyle and body weight using pre-existing data from the large European Prospective Investigation Into Cancer and Nutrition–Potsdam study.[10][11][12] They identified four healthy lifestyle practices and body weight characteristics among German adults that predicted a composite healthy outcome. They noted a significant decrease in major chronic diseases for those with all four characteristics. The four predictive factors included having a body mass index (BMI) of less than 30 kg/m2, performing 3.5 h/wk of moderate physical activity, consuming a predominantly plant-based diet (whole-grain with low meat consumption), and never smoking.
Patients with these four characteristics had almost a four-fifths reduction in chronic disease (78%, 95% CI 27 to 83%) after adjusting for sex, age, occupational and educational status. A subsequent study using the National Health and Nutrition Examination Survey found that only 2.7% of Americans have a lifestyle that approximates the four factors mentioned in the previous study.[13] Although it is possible to avoid chronic disease through commonly attainable lifestyle changes, very few Americans take advantage of this opportunity.
Clinical Significance
Most people do not seek care until a disease process has already manifested, and this trend worsened with the COVID-19 pandemic.[14][15] Patients with diabetes or congestive heart failure (CHF) typically present for medical attention months after a symptom has been bothering them. Many of them have not seen a medical professional for months to years. Thus, how much time does a medical provider have to intervene before the disease process takes root? They may be presenting very late in the course of their illness. Obesity is also an important risk factor for many chronic diseases. Obesity rates have been increasing in the US, as evident in the CDC geographic data comparison of 1985 versus 1995 (see Images. Prevalence of Self-Reported Obesity, 2011 and Prevalence of Self-Reported Obesity, 2020). Based on the evidence presented in the studies mentioned above and others, prevention is key.
Evidence shows that the sequelae of adverse health behavioral choices can be partially corrected. In a non-controlled study from a single physician practice, Dr. Caldwell Esselstyn reported on patients who were rejected as candidates for bypass surgery and put on a lipid-lowering drug and a vegetarian diet with little vegetable oils. These patients demonstrated a subsequent widening of their coronary arteries.[16]
In 1998, a seminal study by Dr. Dean Ornish and collaborators was a landmark for initiating change. The article, entitled "Intensive Lifestyle Changes for Reversal of Coronary Heart Disease," compared 28 patients who had coronary artery disease and tried lifestyle intervention, compared to a cohort of patients who did not receive any intervention.[17] The study was conducted over five years. Lifestyle interventions included maintaining a primarily vegetarian diet emphasizing whole foods, exercise, smoking cessation, and counseling. A clinically and statistically significant reduction in the stenosis in coronary arteries was experienced in the intervention cohort versus those in the control group, who continued to use lipid-lowering pharmacotherapy. This seminal trial demonstrated that coronary artery disease could be reversed.
The American College of Lifestyle Medicine promulgates evidence that reinforces the importance of a diet containing fruits, vegetables, whole grains, unprocessed foods, and limited amounts of meat. These diet changes may have a substantial impact on obesity. A recent meta-analysis by Schlesinger et al. examined the risk of weight gain in relation to certain food groups.[18]
They saw a decreased relative risk of fat in muscle the more a vegetarian diet was invoked. This and other studies suggest that increasing vegetables in one's diet are associated with a decreased relative risk of obesity, and increasing red meat intake is associated with a greater risk. There are multiple reasons for this, one of them being that the saturated fat content in red meat is often neglected. Saturated fats exist not only in red meats but also in other foods such as butter and cheese. Therefore, through education in lifestyle choices, one can choose to avoid saturated fats, achieving less future chronic disease and the associated pain and suffering.
Diabetes mellitus is another chronic disease process that is very common and significantly affects a patient's health and lifestyle. In 2002, Knowler et al. demonstrated that lifestyle interventions focusing on weight loss outperformed metformin in patients with type II diabetes mellitus.[19]
They compared three interventional groups: lifestyle changes, metformin, and placebo. The lifestyle group was given a low-calorie & low-fat diet (almost vegetarian) and 150 minutes of physical activity per week. From this study, it is noteworthy that lifestyle changes outperformed metformin for preventing diabetes. Diabetes is also highly associated with obesity, and healthcare providers need improved strategies for weight loss. Obesity is increasing at alarming rates in the US. In 1985, no state had greater than a 14% prevalence of obesity. However, on the map 2010, greater than 30% of American adults are obese (see Images. Prevalence of Self-Reported Obesity, 2011 and Prevalence of Self-Reported Obesity, 2020). In 2005, Dansinger et al. compared four diets regarding weight loss and heart disease risk reduction: Atkins, Ornish, Weight Watchers(R), and Zone diets.[20][21]
All diets were noted to be successful at weight loss, directly related to regimen compliance. Ketogenic diets have become quite popular recently and often lead to successful weight loss. However, there is evidence that ketogenic diets (that encourage meat consumption) appear to be correlated with increased mortality.[21] This may be a result of the increase in saturated fats.[21]
In another study, the Portfolio diet (a diet of cholesterol-lowering foods) was administered to patients with high cholesterol levels.[22] The interventional group was compared to a control cohort taking lovastatin (a known cholesterol-lowering drug). In both groups, serum lipids and C-reactive protein were tracked. Cholesterol-lowering foods included whole grains, low-fat cereals, and increased use of vegetables. This study showed that it is possible to duplicate the benefits of statin with a targeted diet. The Adventist study was a large population-based longitudinal study of 96,000 patients, which compared vegetarians to meat-eaters.[23]
Over a decade of observation, vegetarians had lower all-cause mortality and lower ischemic heart disease, cardiovascular disease, and cancer incidence. Diabetes was also less prevalent among vegetarians. The article concluded that vegetarians were healthier. A subgroup analysis compared three groups: vegans, lacto-ovo vegetarians, and pescatarians. It was reported that the "pescatarian" group was associated with the lowest all-cause mortality rate and decreased incidence of type II diabetes mellitus. Studies like this one suggest that diet is generally the most crucial lifestyle modification.
Another important, well-established aspect of preventive health is exercise. The effect of decreasing mortality through exercise is greatest with the first 150-200 minutes of moderate exercise per week, with additional exertional duration providing incrementally less benefit.[24] According to the US Preventive Services Taskforce (USPSTF), almost 70% of mortality reduction benefit is achieved with 150 minutes of moderate exercise per week.[25][26] That roughly equals 30 minutes of moderate activity per day for five days a week. The talk test is a useful estimation of moderate exercise.[27] If one can talk but not sing, that can be considered moderate exercise to comply with the USPSTF recommendations for exercise. If one is exercising and cannot talk, that is considered vigorous.
Sleep is another area emphasized in lifestyle preventive health. Analyzing all-cause mortality in a sleep duration study published by the American Heart Journal, it is noted that mortality decreases as one approaches a daily sleep duration of seven hours and increases with sleep duration beyond eight hours.[28]
Sometimes societal constructs use lack of sleep as a feature of strength and "hard work," but it must be noted that this is not conducive to overall life performance. Lack of sleep is shown to decrease productivity and have consequences in the form of chronic diseases, including total cardiovascular disease and stroke.[28] Additionally, multiple studies suggest insufficient sleep is associated with Alzheimer disease.[29][30][31][32] Thus, current evidence suggests that achieving seven to eight hours of sleep is an appropriate lifestyle modification recommendation.
Smoking, if habitual, is another significant risk factor for disease and mortality.[33] Many well-documented dangers of addictive substances increase cancer risk and heart disease risk. Smoking is a more substantial risk factor for chronic disease than diet and exercise.[34] Thus, smoking must be eliminated from all lifestyles to avoid severe, predictable chronic diseases.
Stress and social isolation are other risk factors affecting chronic disease. Stress has been described as a risk factor for disease and overall mortality.[35][36] As such, stress management can aid in identifying positive and negative stress responses, identify coping mechanisms, and teach stress-reduction techniques for improved well-being. Social isolation has also been associated with increased mortality, so social connectedness as a preventive strategy is also an area of recent investigation, especially among the aging population.[37][38][39] Social connections can also aid in emotional resiliency and overall health.
The goal of lifestyle modification as a preventative medicine is to make daily changes that are relatively easy to perform, adjust to, and uphold in terms of future daily habits. By educating our patients about these preventative lifestyle modifications, we can help them understand the consequences and implications of poor choices. In this regard, one can minimize future pain and suffering caused by a chronic disease process that has poor prospects for a cure but appears to be preventative and/or reversible – such as strokes, heart attacks, kidney failure, and the use of chronic dialysis.
In summary, even though prevention is not a revolutionary topic in medicine, it is neglected in most modern medical practices. Evidence-based lifestyle changes must be increasingly emphasized in the practitioner-patient encounter. Nutrition and exercise are the most important lifestyle modifications for nonsmoking patients. Patients should be encouraged to choose a diet predominantly of fiber-filled, nutrient-dense foods, thus promoting health. Additionally, regular and consistent physical activity is essential to an optimal health equation. Lack of quality sleep can detrimentally impact both of these modifications mentioned above. Substance abuse must be considered an essential modification as well.
Nursing, Allied Health, and Interprofessional Team Interventions
The commercial media heavily promotes unhealthy lifestyle choices. Another popular example of a dangerous element of the western diet is bacon. Bacon is an example of processed meat that is now classified as a Group 1 carcinogen by the International Agency for Research on Cancer (IARC) list, the same as many more well-known carcinogens.[40][41] Yet, despite being known to cause cancer, bacon can be found at nearly every commercial fast food establishment across the U.S. and every grocery store.
There has also been some interest in making healthy food the default option in hospitals and medical centers. It is crucially important for these institutions to provide food prepared for patients based on a healthy lifestyle approach.[42]
All interprofessional healthcare team members should be included in the patient education and support process. Therefore, all healthcare team members must participate in preventive education and support of the patients in their care.
Media
(Click Image to Enlarge)
Prevalence of Self-Reported Obesity, 2011. Prevalence of self-reported obesity among U.S. adults by state and territory, BRFSS, 2011
Centers for Disease Control and Prevention. CC BY 3.0.
(Click Image to Enlarge)
Prevalence of Self-Reported Obesity, 2020. The prevalence of self-reported obesity among U.S. adults by state and territory, BRFSS, 2020
Centers for Disease Control and Prevention. CC BY 3.0.
References
Stange KC, Flocke SA, Goodwin MA, Kelly RB, Zyzanski SJ. Direct observation of rates of preventive service delivery in community family practice. Preventive medicine. 2000 Aug:31(2 Pt 1):167-76 [PubMed PMID: 10938218]
Level 2 (mid-level) evidenceYarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? American journal of public health. 2003 Apr:93(4):635-41 [PubMed PMID: 12660210]
Poisal JA, Sisko AM, Cuckler GA, Smith SD, Keehan SP, Fiore JA, Madison AJ, Rennie KE. National Health Expenditure Projections, 2021-30: Growth To Moderate As COVID-19 Impacts Wane. Health affairs (Project Hope). 2022 Apr:41(4):474-486. doi: 10.1377/hlthaff.2022.00113. Epub 2022 Mar 28 [PubMed PMID: 35344446]
Raghupathi W, Raghupathi V. An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach. International journal of environmental research and public health. 2018 Mar 1:15(3):. doi: 10.3390/ijerph15030431. Epub 2018 Mar 1 [PubMed PMID: 29494555]
. Tackling the burden of chronic diseases in the USA. Lancet (London, England). 2009 Jan 17:373(9659):185. doi: 10.1016/S0140-6736(09)60048-9. Epub [PubMed PMID: 19150686]
Chen S, Kuhn M, Prettner K, Bloom DE, Wang C. Macro-level efficiency of health expenditure: Estimates for 15 major economies. Social science & medicine (1982). 2021 Oct:287():114270. doi: 10.1016/j.socscimed.2021.114270. Epub 2021 Jul 24 [PubMed PMID: 34482274]
Marketos SG, Skiadas PK. The modern hippocratic tradition. Some messages for contemporary medicine. Spine. 1999 Jun 1:24(11):1159-63 [PubMed PMID: 10361669]
Segal I, Blazer S. The Maimonides Model for a Regimen of Health: A Comparison with the Contemporary Scenario. Rambam Maimonides medical journal. 2020 Oct 14:11(4):. doi: 10.5041/RMMJ.10396. Epub 2020 Oct 14 [PubMed PMID: 32213279]
Park H, Roubal AM, Jovaag A, Gennuso KP, Catlin BB. Relative Contributions of a Set of Health Factors to Selected Health Outcomes. American journal of preventive medicine. 2015 Dec:49(6):961-9. doi: 10.1016/j.amepre.2015.07.016. Epub [PubMed PMID: 26590942]
Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Archives of internal medicine. 2009 Aug 10:169(15):1355-62. doi: 10.1001/archinternmed.2009.237. Epub [PubMed PMID: 19667296]
Riboli E, Hunt KJ, Slimani N, Ferrari P, Norat T, Fahey M, Charrondière UR, Hémon B, Casagrande C, Vignat J, Overvad K, Tjønneland A, Clavel-Chapelon F, Thiébaut A, Wahrendorf J, Boeing H, Trichopoulos D, Trichopoulou A, Vineis P, Palli D, Bueno-De-Mesquita HB, Peeters PH, Lund E, Engeset D, González CA, Barricarte A, Berglund G, Hallmans G, Day NE, Key TJ, Kaaks R, Saracci R. European Prospective Investigation into Cancer and Nutrition (EPIC): study populations and data collection. Public health nutrition. 2002 Dec:5(6B):1113-24 [PubMed PMID: 12639222]
Riboli E, Nutrition and cancer: background and rationale of the European Prospective Investigation into Cancer and Nutrition (EPIC). Annals of oncology : official journal of the European Society for Medical Oncology. 1992 Dec; [PubMed PMID: 1286041]
Level 2 (mid-level) evidenceLoprinzi PD, Branscum A, Hanks J, Smit E. Healthy Lifestyle Characteristics and Their Joint Association With Cardiovascular Disease Biomarkers in US Adults. Mayo Clinic proceedings. 2016 Apr:91(4):432-42. doi: 10.1016/j.mayocp.2016.01.009. Epub 2016 Feb 20 [PubMed PMID: 26906650]
Czeisler MÉ, Marynak K, Clarke KEN, Salah Z, Shakya I, Thierry JM, Ali N, McMillan H, Wiley JF, Weaver MD, Czeisler CA, Rajaratnam SMW, Howard ME. Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns - United States, June 2020. MMWR. Morbidity and mortality weekly report. 2020 Sep 11:69(36):1250-1257. doi: 10.15585/mmwr.mm6936a4. Epub 2020 Sep 11 [PubMed PMID: 32915166]
Ni B, Gettler E, Stern R, Munro HM, Steinwandel M, Aldrich MC, Friedman DL, Sanderson M, Schlundt D, Aronoff DM, Gupta DK, Shrubsole MJ, Lipworth L. Disruption of medical care among individuals in the southeastern United States during the COVID-19 pandemic. Journal of public health research. 2021 Sep 24:11(1):. doi: 10.4081/jphr.2021.2497. Epub 2021 Sep 24 [PubMed PMID: 34558253]
Esselstyn CB Jr,Ellis SG,Medendorp SV,Crowe TD, A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician's practice. The Journal of family practice. 1995 Dec; [PubMed PMID: 7500065]
Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998 Dec 16:280(23):2001-7 [PubMed PMID: 9863851]
Level 1 (high-level) evidenceSchlesinger S, Neuenschwander M, Schwedhelm C, Hoffmann G, Bechthold A, Boeing H, Schwingshackl L. Food Groups and Risk of Overweight, Obesity, and Weight Gain: A Systematic Review and Dose-Response Meta-Analysis of Prospective Studies. Advances in nutrition (Bethesda, Md.). 2019 Mar 1:10(2):205-218. doi: 10.1093/advances/nmy092. Epub [PubMed PMID: 30801613]
Level 3 (low-level) evidenceKnowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM, Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England journal of medicine. 2002 Feb 7:346(6):393-403 [PubMed PMID: 11832527]
Level 1 (high-level) evidenceDansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA. 2005 Jan 5:293(1):43-53 [PubMed PMID: 15632335]
Level 1 (high-level) evidenceClemente Fuentes RW, Broszko CM, Pietralcyzk ES, Nashelsky J. Efficacy of a low-carbohydrate or ketogenic diet in preventing patient morbidity and mortality. Canadian family physician Medecin de famille canadien. 2020 Apr:66(4):262-263 [PubMed PMID: 32273411]
Jenkins DJ, Josse AR, Wong JM, Nguyen TH, Kendall CW. The portfolio diet for cardiovascular risk reduction. Current atherosclerosis reports. 2007 Dec:9(6):501-7 [PubMed PMID: 18377791]
Orlich MJ, Fraser GE. Vegetarian diets in the Adventist Health Study 2: a review of initial published findings. The American journal of clinical nutrition. 2014 Jul:100 Suppl 1(1):353S-8S. doi: 10.3945/ajcn.113.071233. Epub 2014 Jun 4 [PubMed PMID: 24898223]
Moore SC, Patel AV, Matthews CE, Berrington de Gonzalez A, Park Y, Katki HA, Linet MS, Weiderpass E, Visvanathan K, Helzlsouer KJ, Thun M, Gapstur SM, Hartge P, Lee IM. Leisure time physical activity of moderate to vigorous intensity and mortality: a large pooled cohort analysis. PLoS medicine. 2012:9(11):e1001335. doi: 10.1371/journal.pmed.1001335. Epub 2012 Nov 6 [PubMed PMID: 23139642]
Level 2 (mid-level) evidenceSingh R, Pattisapu A, Emery MS. US Physical Activity Guidelines: Current state, impact and future directions. Trends in cardiovascular medicine. 2020 Oct:30(7):407-412. doi: 10.1016/j.tcm.2019.10.002. Epub 2019 Oct 17 [PubMed PMID: 31677904]
Level 3 (low-level) evidenceRippe JM. Physical Activity and Health: Let's Talk the Talk and Walk the Walk. The American journal of medicine. 2021 Oct:134(10):1192-1194. doi: 10.1016/j.amjmed.2021.05.005. Epub 2021 May 25 [PubMed PMID: 34048720]
Foster C, Porcari JP, Anderson J, Paulson M, Smaczny D, Webber H, Doberstein ST, Udermann B. The talk test as a marker of exercise training intensity. Journal of cardiopulmonary rehabilitation and prevention. 2008 Jan-Feb:28(1):24-30; quiz 31-2. doi: 10.1097/01.HCR.0000311504.41775.78. Epub [PubMed PMID: 18277826]
Yin J, Jin X, Shan Z, Li S, Huang H, Li P, Peng X, Peng Z, Yu K, Bao W, Yang W, Chen X, Liu L. Relationship of Sleep Duration With All-Cause Mortality and Cardiovascular Events: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies. Journal of the American Heart Association. 2017 Sep 9:6(9):. doi: 10.1161/JAHA.117.005947. Epub 2017 Sep 9 [PubMed PMID: 28889101]
Level 1 (high-level) evidenceBubu OM, Brannick M, Mortimer J, Umasabor-Bubu O, Sebastião YV, Wen Y, Schwartz S, Borenstein AR, Wu Y, Morgan D, Anderson WM. Sleep, Cognitive impairment, and Alzheimer's disease: A Systematic Review and Meta-Analysis. Sleep. 2017 Jan 1:40(1):. doi: 10.1093/sleep/zsw032. Epub [PubMed PMID: 28364458]
Level 1 (high-level) evidenceMander BA, Winer JR, Jagust WJ, Walker MP. Sleep: A Novel Mechanistic Pathway, Biomarker, and Treatment Target in the Pathology of Alzheimer's Disease? Trends in neurosciences. 2016 Aug:39(8):552-566. doi: 10.1016/j.tins.2016.05.002. Epub 2016 Jun 17 [PubMed PMID: 27325209]
Shi L, Chen SJ, Ma MY, Bao YP, Han Y, Wang YM, Shi J, Vitiello MV, Lu L. Sleep disturbances increase the risk of dementia: A systematic review and meta-analysis. Sleep medicine reviews. 2018 Aug:40():4-16. doi: 10.1016/j.smrv.2017.06.010. Epub 2017 Jul 6 [PubMed PMID: 28890168]
Level 1 (high-level) evidenceWiner JR, Mander BA. Waking Up to the Importance of Sleep in the Pathogenesis of Alzheimer Disease. JAMA neurology. 2018 Jun 1:75(6):654-656. doi: 10.1001/jamaneurol.2018.0005. Epub [PubMed PMID: 29532083]
Jacobs DR Jr, Adachi H, Mulder I, Kromhout D, Menotti A, Nissinen A, Blackburn H. Cigarette smoking and mortality risk: twenty-five-year follow-up of the Seven Countries Study. Archives of internal medicine. 1999 Apr 12:159(7):733-40 [PubMed PMID: 10218754]
Ng R, Sutradhar R, Yao Z, Wodchis WP, Rosella LC. Smoking, drinking, diet and physical activity-modifiable lifestyle risk factors and their associations with age to first chronic disease. International journal of epidemiology. 2020 Feb 1:49(1):113-130. doi: 10.1093/ije/dyz078. Epub [PubMed PMID: 31329872]
Tian F, Shen Q, Hu Y, Ye W, Valdimarsdóttir UA, Song H, Fang F. Association of stress-related disorders with subsequent risk of all-cause and cause-specific mortality: A population-based and sibling-controlled cohort study. The Lancet regional health. Europe. 2022 Jul:18():100402. doi: 10.1016/j.lanepe.2022.100402. Epub 2022 May 28 [PubMed PMID: 35663363]
Song H, Fang F, Arnberg FK, Mataix-Cols D, Fernández de la Cruz L, Almqvist C, Fall K, Lichtenstein P, Thorgeirsson G, Valdimarsdóttir UA. Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study. BMJ (Clinical research ed.). 2019 Apr 10:365():l1255. doi: 10.1136/bmj.l1255. Epub 2019 Apr 10 [PubMed PMID: 30971390]
Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS medicine. 2010 Jul 27:7(7):e1000316. doi: 10.1371/journal.pmed.1000316. Epub 2010 Jul 27 [PubMed PMID: 20668659]
Level 1 (high-level) evidenceHouse JS, Landis KR, Umberson D. Social relationships and health. Science (New York, N.Y.). 1988 Jul 29:241(4865):540-5 [PubMed PMID: 3399889]
Sander R. Preventing social isolation and loneliness among older people: a systematic review of health promotion interventions. Nursing older people. 2005 Mar 1:17(1):40 [PubMed PMID: 27736564]
Level 1 (high-level) evidenceIARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Red Meat and Processed Meat. 2018:(): [PubMed PMID: 29949327]
Domingo JL, Nadal M. Carcinogenicity of consumption of red meat and processed meat: A review of scientific news since the IARC decision. Food and chemical toxicology : an international journal published for the British Industrial Biological Research Association. 2017 Jul:105():256-261. doi: 10.1016/j.fct.2017.04.028. Epub 2017 Apr 24 [PubMed PMID: 28450127]
Aggarwal M, Grady A, Desai D, Hartog K, Correa L, Ostfeld RJ, Freeman AM, McMacken M, Gianos E, Reddy K, Batiste C, Wenger C, Blankstein R, Williams K, Allen K, Seifried RM, Aspry K, Barnard ND. Successful Implementation of Healthful Nutrition Initiatives into Hospitals. The American journal of medicine. 2020 Jan:133(1):19-25. doi: 10.1016/j.amjmed.2019.08.019. Epub 2019 Sep 5 [PubMed PMID: 31494109]