Written by: Dr. Simon Poole
Major Principles of Lifestyle Medicine
Health and wellness are inextricably linked to the way we live our lives.
Although in recent years we have often come to rely on drugs and medical interventions to treat illness and disease, it has long been understood that the maintenance of a state of good health is dependent to a very large extent on our lifestyle choices. Peoples of ancient cultures were well aware of this relationship and we can read descriptions of lifestyle medicine in early works of philosophy and religion.
Modern lifestyle medicine is broadly defined as an evidence based approach to the advancement of health and wellbeing through promoting the prevention of avoidable lifestyle-related diseases.
“The application of environmental, behavioural, medical and motivational principles to the management (including self care and self-management) of lifestyle-related health problems in a clinical and/or public health setting”1
Health professionals are increasingly advocating the principles of lifestyle medicine as epidemiologists predict a dramatic rise in the burden of chronic illnesses including cardiovascular disease, cancers, hypertension, strokes and obesity. In recognition of this, The World Health Organisation in 2005 called for investment in health promotion to stem the rise in premature deaths and avoid unnecessary disability due to chronic diseases.2
Lifestyle measures which can be advocated with evidence to support healthier lives include good nutrition, physical activity, stress reduction, rest, smoking cessation, and avoidance of alcohol abuse
Wellness is a term which was used in the World Health Organisation’s 1948 Constitution which described health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The pursuit of wellness is regarded as being an active and dynamic process of making choices to achieve the goal of a healthy and fulfilling life. Wellness is not confined to a physical state, but also refers to mind and spirit. Promoting wellness deserves the same scientific rigour as the founding principles of evidence-based lifestyle medicine.
Wellness is dependent on good nutrition but is also supported by regular physical activity, engagement in family and community life, stress reduction and a sense of purpose. The word “diet” is derived from the Greek word “diaita” which means “way of life”. It is useful to think of a diet in this much more holistic way as a means to achieve wellness, rather than as a restrictive way of eating designed to lose weight.
The evidence supporting the benefits of lifestyle choices is well established. More than 90 percent of type 2 diabetes, 80 percent of cardiovascular disease, 70 percent of stroke, and 70 percent of colon cancer cases are potentially preventable by a combination of non-smoking, avoidance of being overweight, moderate physical activity, healthy diet, and moderate alcohol consumption.3
In particular, a Mediterranean style diet rich in Extra Virgin Olive Oil has been shown to be exactly the sort of diet which can provide these benefits.
The Mediterranean Diet was first described by Professor Ancel Keys in research showing lower rates of mortality in communities that adhered to a traditional diet rich in extra virgin olive oil, vegetables, fruit and nuts, wholegrains and legumes with moderate consumption of alcohol and low amounts of red meat.4
The Lyon Heart study demonstrated significantly better outcomes for people with heart disease who adopted a Mediterranean style diet, and the large Greek EPIC study showed further evidence for reduced mortality with higher Mediterranean Diet adherence scores.5,6
Research now demonstrates reduced risk of many diseases including cardiovascular disease, cancers, dementia, parkinsons disease, diabetes and obesity as well as overall mortality with the Mediterranean Diet.7–47
The diet is now widely recommended as a healthy eating pattern. The 2015 US Dietary Guidelines Advisory Committee specifically cited it as a diet of choice and it is advised by governments and public health bodies across the world.48
Extra Virgin Olive Oil and olives contain numerous compounds which have been shown to have powerful antioxidant and anti-inflammatory effects. As an individual component inseparable from the Mediterranean Diet, higher consumption of Extra Virgin Olive Oil has been associated with, a reduction in risk of stroke by as much as 73% and with a 26% and 44% reduction in overall mortality and cardiovascular mortality respectively.49,50
First published in 2013, the Predimed study (Prevención con Dieta Mediterránea), a high quality randomised controlled study compared a Mediterranean Diet supplemented with Extra Virgin Olive Oil with a low-fat diet. The results were compelling, revealing a thirty percent reduction in cardiovascular disease and stroke and the trial was stopped after seven years for ethical reasons when the advantages of the Mediterranean Diet oil became clear. The low fat cohort was recommended to adopt the more healthy Mediterranean diet supplemented with Extra Virgin Olive Oil. Further subset data are emerging showing benefits for other conditions.51
The European Food Safety Authority has recognised the significance of the compound hydroxytyrosol and its derivatives in the protection of LDL cholesterol from oxidative stress, a process considered to be fundamental to the development of symptomatic cardiovascular disease. This has resulted in the acceptance that Extra Virgin Olive Oils with a certain quantity of these compounds are able to carry a specific health claim.52 This claim is: ‘Olive oil polyphenols contribute to the protection of blood lipids from oxidative stress’. Note: The claim may be used only for olive oil which contains at least 5 mg of hydroxytyrosol and its derivatives (e.g. oleuropein complex and tyrosol) per 20 g of olive oil. In order to bear the claim information shall be given to the consumer that the beneficial effect is obtained with a daily intake of 20 g of olive oil.52
- Egger G, Binns A, Rossner S. Lifestyle medicine: managing diseases of lifestyle in the 21st century. 2011. McGraw-Hill: North Ryde, NSW.
- World Health Organization. Preventing Chronic Diseases – A Vital Investment, World Health Organisation 2005.
- Willett WC, Koplan JP, Nugent R, et al. Prevention of Chronic Disease by Means of Diet and Lifestyle Changes. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 44.
- Keys A, Menotti A, Karvonen M, et al The diet and 15-year death rate in the seven countries study. Am J Epidermiol. 1986;124(6):903–15.
- De Lorgeril M, Salen P, Martin J, et al. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999(6):779–85.
- Trichopoulou A. Bamia C, Trichopoulos D. Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ 2009;338:b2337.
- Sofi F, Macchi C, Abbate R, et al. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr. 17(12):2769–82. doi: 10.1017/S1368980013003169. Epub 2013 Nov 29.
- Dinu M, Pagliai G, Casini A et al. Mediterranean diet and multiple health outcomes: an umbrella review of meta-analyses of observational studies and randomised trials. Eur J Clin Nutr. 2017;27(1):doi:10.1038/ejcn.2017.58.
- Sofi F, Cesari F, Abbate R, Gensini G, et al. Adherence to Mediterranean diet and health status: meta-analysis. BMJ. 2008;337: doi.org/10.1136/bmj.a1344.
- Sofi F, Abbate R, Gensini G et al. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr. 2010;92(5):1189–96.
- Widmer R, Flammer A, Lerman L et al. The Mediterranean diet, it’s components, and cardiovascular disease. Am J Med. 2015;128(3):229–38.
- Estruch R, Ros E, Sala-Salvao J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Eng J Med. 2013;368(14):1279–90.
- Tresserra-Rimbau A, Rimm E, Medina-Ramon A et al. Polyphenol intake and mortality risk: a re-analysis of the PREDIMED trial. BMC Med. 2014;12: doi: 10.1186/1741-7015-12-77.
- Harriss L, English D, Powles P et al. Dietary patterns and cardiovascular mortality in the Melbourne Collaborative Cohort Study 1’2’3. Am J Clin Med. 2007;86(1):221–9.
- Dontas A, Zerefos N, Panagiotakos D et al. Mediterranean diet and prevention of coronary heart disease in the elderly. Clin Interv Aging. 2007;2(1):109– 16.
- Keys A. Coronary heart disease in seven countries. Circulation. 1970;40:Supp 1– 211.
- Hernaez A, Fernandez-Castillejo S, Ferries M et al. Olive oil biophenols enhance high-density lipoprotein function in humans: a randomized controlled trial. Arteriosclerosis, Thrombosis, and Vascular Biology Journal of the American Heart Association. 2014;34:2115–9.
- Covas M, Nyyssonen K, Poulsen H, et al. The effect of biophenols in olive oil on heart disease risk factors: a randomized trial. Ann Intern Med. 2006;145:333– 41.
- Fito M, Cladellas M, de la Torre R, et al. Antioxidant effect of virgin olive oil in patients with stable coronary heart disease: a randomized, crossover, controlled, clinical trial. Atherosclerosis. 2005;181:149– 58.
- Moreno-Luna R, Munoz-Hernandez R, Miranda ML, et al. Olive oil biophenols decrease blood pressure and improve endothelial function in young women with mild hypertension. Am J Hypertens. 2012;25:1299–304.
- Widmer R, Freund M, Flammer A et al. Beneficial effects of polyphenol-rich olive oil in patients with early atherosclerosis. Eur J Nutr. 2013;52:1223–31.
- Ferrara L, Raimondi A, d’Episcopo L, et al. Olive oil and reduced need for antihypertensive medications. Arch Intern Med. 2000;160:837–42.
- Perona J, Canizares J, Montero E, et al. Virgin olive oil reduces blood pressure in hypertensive elderly subjects. Clin Nutr. 2004;23:1113–21.
- Larsen L, Jespersen J, Marckmann P. Are olive oil diets antithrombotic? Diets enriched with olive, rapeseed, or sunflower oil affect postprandial factor VII differently. Am J Clin Nutr. 1999;70:976–82.
- Harper C, Edwards M, Jacobson T. Flaxseed oil supplementation does not affect plasma lipoprotein concentration or particle size in human subjects. J Nutr. 2006;136:2844–8.
- Aguilera C, Mesa M, Ramirez-Tortosa, et al. Sunflower oil does not protect against LDL oxidation as virgin olive oil does in patients with peripheral vascular disease. Clin Nutr. 2004;23:673–81.
- UC Davis Olive Centre. Olive oil as medicine: the effect on blood lipids and lipoproteins.
- UC Davis Olive Centre. Olive oil as medicine: the effect on blood pressure. UC Davis.
- Lasa A, Miranda J, Bullo M, et al. Comparative effect of two Mediterranean diets versus a low-fat diet on glycaemic control in individuals with type 2 diabetes. Eur J Clin Nutr. 2014;68:762–72.
- Escrich E, Moral R, Grau L, et al. Molecular mechanisms of the effects of olive oil and other dietary lipids on cancer. Mol Nutr Food Res. 2007;51:1279–92.
- Salvini S, Sera F, Caruso D, et al. Daily consumption of a high-phenol extra-virgin olive oil reduces oxidative DNA damage in postmenopausal women. Br J Clin Nutr. 2006;95:742–51.
- Perez-Herrara A, Rangel-Zuninga OA, Delgado-Lista J, et al. The antioxidants in oils heated at frying temperature, whether natural or added, could protect against oxidative stress in obese people. Food Chem. 2013;138: 2250–59.
- Valls-Pedret C, Sala-Vila A, Serra-Mir A, et al. Mediterranean diet and age-related cognitive decline: a randomized clinical trial. JAMA Intern Med. 2015;175(7):1084–1103.
- Schroder H, Marrugat J, Vila J, et al. Adherence to the traditional Mediterranean diet is inversely associated with body mass index and obesity in a Spanish population. J Nutr. 2004;134:3355–61.
- Panagiotakos DB, Chrysohoou C, Piassavas C, et al. Association between the prevalence of obesity and adherence to the Mediterranean diet: the ATTICA study. Nutr. 2006;22:449–56.
- Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008;359:229–41.
- Trichopoulou, A. Naska A, Orfanos P, et al. Mediterranean diet in relation to body mass index and waist-to-hip ratio: the Greek European prospective investigation into cancer and nutrition study. Am J Clin Nutr. 2015;82(5): 935–40.
- Sánchez-Villegas A, Bes-Rastrollo M, Martinez-Gonzalez M, et al. Adherence to a Mediterranean dietary pattern and weight gain in a follow-up study: the SUN cohort. Int J Obes. 2005;30(2):350–8.
- Flynn MM, Reinert SE. Comparing an olive oil-enriched diet to a standard lower-fat diet for weight loss in breast cancer survivors: a pilot study. J Women Health. 2010;19:1155–61.
- Bes-Rastrollo M, Sanchez-Villegas A, de la Fuente C, et al. Olive oil consumption and weight change: the SUN prospective cohort study. Lipids. 2006;41:249–56.
- Soriguer F, Rojo-Martínez G, Goday A et al. Olive oil has a beneficial effect on impaired glucose regulation and other cardiometabolic risk factors. Di@bet.es study. Eur J Clin Nutr. 2013;67:911–6.
- Soriguer F, Almaraz m, et al. Incidence of obesity is lower in persons who consume olive oil. Eur J Clin Nutr. 2009;63(11):1371–4.
- Mennella I, Savarese M, Ferracane R et al. Oleic acid content of a meal promotes oleoylethanolamide response and reduces subsequent energy intake in human. Food Funct. 2015;6(1):204–10.
- Haro-Mora, J, Garcia-Escobar E, Alcazar P, et al. Children whose diet contained olive oil had a lower likelihood of increasing their body mass index Z-score over 1 year. Eur J Endocrinol. 2011;165(3):435–9.
- Perez-Martinez P, Garcia-Rios A, Degaldo-Lista J, et al. Mediterranean diet rich in olive oil and obesity, metabolic syndrome and diabetes mellitus. Curr Pharm Des. 2011;17(8):769–77.
- Razquin C, Marinez J, Martinez-Gonzalez M, et al. A 3 years follow-up of a Mediterranean diet rich in virgin olive oil is associated with high plasma antioxidant capacity and reduced body weight gain. Eur J Clin Nutr. 2009;63(12):1387–93.
- Romaguera D, Norat T, Mouw N, et al. Adherence to the Mediterranean diet is associated with lower abdominal adiposity in European men and women. J Nutr. 2009;139(9): 1728–37.
- Office of Disease Prevention and Health Promotion. 2015 US Dietary Guidelines Advisory Committee Report.
- Samieri C, Feart C, Proust-Lima C, et al.Olive oil consumption, plasma oleic acid, and stroke incidence: the Three-City Study. Neurology 77(5):418–25. doi: 10.1212/WNL.0b013e318220abeb. Epub 2011 Jun 15.
- Buckland G, Mayen A, Agudo A, et al. Olive oil intake and mortality within the Spanish population (EPIC-Spain) Am J Clin Nutr. 2012. 96(1):142–9. doi: 3945/ajcn.111.024216. Epub 2012 May 30.
- Estruch R, Ros E, Salas-Salvado J, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med. 2013;368:1279–90. DOI: 10.1056/NEJMoa1200303.
- EFSA Journal. Opinion on the substantiation of health claims related to polyphenols in olive and protection of LDL particles from oxidative stress.