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Healthcare spending and reliance on single-agent approaches to cure disease and reduce disability are spiralling out of control in the USA.1,–,5 Meanwhile, sentinel health indicators such as mortality and incidence of many diseases are stagnating or, in many population subgroups, worsening.6,–,15 With the exception of cigarette smoking, where overall rates have fallen while becoming a habit concentrated in the poor and less educated, the underlying causes of most chronic diseases that constitute the bulk of both human suffering and healthcare spending have failed to improve much, if at all, over the past couple of generations.5 14 16 17 Obesity rates, inclusive of those in children, are the highest ever recorded in human history.11 17,–,19 Sedentariness has become the norm,18 20 21 and diets are increasingly nutrient sparse,22,–,26 especially in the majority of individuals who select calorie-dense, and shun whole-grain, foods.27,–,30
What is the typical American response to this? An article by Gardiner Harris in the 23 January 2011 New York Times entitled ‘New Federal Research Center Will Help Develop Medicines’ describes a plan to create a new US$1 billion centre on Advancing Translational Sciences at the National Institutes of Health (NIH). This plan typifies the search for a ‘magic bullet’, in pill form, that will cure all diseases and health problems.1 2 31
According to the article, large drug companies have spent ∼US$400 billion on drug research over the past 15 years. We should examine the effectiveness of this huge expenditure in terms of public health benefits. From previous works, done mainly over the period of demographic transition in the USA and elsewhere in the world where high-quality data exist, we can see that improvements in public health have explained the vast majority of improvements in life expectancy.32,–,37 Despite the development of effective new drugs approved in recent years, morbidity and mortality in USA over this period have been fairly stable,38 39 quality of life has also not improved40,–,43 and rates of mental illness are on the rise,44,–,49 including in those with weight- and physical activity-associated comorbidities.50,–,54 We should also consider the side effects of drug use and not just the more spectacular unintended effects of approved drugs, ranging from the psychotropic agents to cure depression (selective serotonin reuptake inhibitors)55,–,57 to anti-inflammatory agents such as Vioxx (manufactured by Merck, Whitehouse Station, New Jersey, USA).58 59 The relationship that exists between the pharmaceutical and healthcare industries further complicates matters.60 61 What happens in a society in which people are told that pills are available to put them to sleep, wake them up, stimulate them, calm them down and control appetite and body weight? We argue that the answer is in the growing number of people with mental disorders including depression and anxiety,44 46 47 49 51 sleep disorders,42 deteriorating nutritional status and increasing rates of obesity unprecedented in human history. The pills that have been developed, advertised on television and demanded by a desperate populace have been spectacular in their inability to address the major and growing public health problems of the USA. Not only do fundamental changes in things like tobacco use, diet and physical practices produce more impressive results, but they also lack the dangerous side effects of many drugs. Of course, they take effort, but with that effort also comes a sense of mastery that can lead to yet more personal and societal benefits. That these ominous public health trends and the ineffectual response of the pharmaceutical and healthcare industries are occurring in a country of >300 000 000 individuals is bad enough; but, for better and sometimes worse, the USA often leads the world in terms of its behaviours.
The major causes of disease, disability and death in the USA, and indeed around the world, are unhealthy lifestyles. These include smoking, sedentary habits and poor diets.21 35 62,–,65 Indeed, the recent modest reductions in cancer deaths in the USA result from behavioural changes, such as smoking cessation, reduction in the use of hormone replacement therapy and increased utilisation of colonoscopy to screen for colorectal cancers and precancers. This progress has virtually nothing to do with the basic science research that predominates in the NIH research portfolio, let alone the efforts of the drug industry. By contrast, if Americans were to adopt healthy lifestyles it would have substantial benefits, for individuals and for society as a whole. We recently published a report on a study in which we followed up 38 110 men for an average of 16 years after their initial examination.66 On a comparison of the lifestyles of the 2642 men who died with those who survived, we found that men who had even one of these positive health factors – not smoking, being physically active, not being overweight or obese, having moderate cardiorespiratory fitness and drinking 1–14 drinks/week of alcoholic beverages – had a 22% lower risk of dying. Men who had all five factors were 61% less likely to die during follow-up. It is highly unlikely that any regimen of drugs can even come close to these large reductions in risk of death. Likewise, in the Worcester Area Trial for Counseling in Hyperlipidemia, we found that hyperlipidaemic subjects who participated in just three or four sessions with a dietitian had a reduction in their total and low-density lipoprotein cholesterol, which is equivalent to the effect of taking statins (about 15 mg/dl over the course of the year).67 In men with biochemically recurrent prostate cancer, we showed that we could reverse disease with a combination of improving diet, reducing stress and increasing physical activity.68 Remarkable in their own right, these results were obtained without any drug side effects and with other benefits associated with eating more healthfully and getting in better physical shape. Many other evaluations of lifestyle have been published in recent years and with similar results.
There has been a direct comparison of lifestyle interventions and drugs in experimental studies. In 2002, the US Diabetes Prevention Program randomly assigned 3234 women and men at high risk for developing type 2 diabetes to a control group, a lifestyle intervention group or drug treatment group.69 Lifestyle intervention was approximately twice as effective as drugs in preventing diabetes. At about the same time, the Finnish Diabetes Study showed very similar results for lifestyle intervention for people at risk for diabetes.70 We are puzzled and concerned that these landmark findings have not been more widely promoted, including support of research focused on how to integrate these interventions to help high-risk individuals adopt and maintain healthful lifestyles.
Rather than continuing to pour more resources into developing single-agent, magic-bullet approaches intended to cure diseases that are easily prevented, we propose a radical idea: to develop means for disseminating and implementing programmes of lifestyle improvement proven to enhance individual and population-level health. We understand that while changes in diet and physical activity are conceptually easy, they are diabolically difficult to do in practice. The promise of even easier solutions to cure the consequences of years of sloth needs to be debunked. Societal changes that have co-occurred in the era of the search for the magic bullet have created environmental impediments (eg, widespread use of automobiles that have created environments hostile to pedestrians and cyclists) that need to be removed. Additionally, and perhaps more importantly, people have become convinced that they cannot do things to improve their own health. We need to usher in a new age of grand self-efficacy.
We propose that the health of the USA, and this is similar to most other countries, would experience major improvements if the NIH would create a new ‘National Institute for Improving Healthy Lifestyles’. Much of the current work of the National Center for Research Resources, which is mandated to address health disparities, would easily fit into this new institute. A billion dollars a year invested in this new institute is a much better bet to produce major improvements in the health of the people of the USA and would set a good example for the rest of the world.
Acknowledgments
The authors would like to acknowledge the support and assistance of their research groups in the Cancer Prevention and Control Program and the Department of Exercise Science at the University of South Carolina, especially Duck-chul Lee.
References
Footnotes
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.