Lifestyle Medicine Interventions for Personal and Planetary Health: The Urgent Need for Action

Introduction

SARS-CoV-2, the virus that causes COVID-19, has been particularly adept at exploiting the pre-existing crisis of chronic disease. ¹ A crisis disproportionally shouldered by those also suffering from social and environmental injustice. ²

Increasingly, health professionals are recognizing that the climate crisis is poised to exploit the same vulnerabilities. ³ Again, the people most at risk from climate change-related heat waves, extreme weather events, and worsened air quality are those with chronic conditions like heart disease, diabetes, and respiratory conditions. ⁴ Chronic disease already affects six in ten adults in the United States. ⁵ Climate threats pose an added danger to those with chronic disease because these conditions, and some medications for these conditions can impact the ability to dissipate heat or maintain hydration during periods of higher temperatures.^3,6,7 Access to necessary follow-up care for chronic conditions can also be hindered by extreme weather events.^3,6,7

In a vicious cycle, climate change and the deterioration of planetary health from other threats such as environmental pollution, biodiversity loss, and ocean acidification also threaten the very foundation of health and the “healthspan.”^6,7 Access to healthy foods, safe places for outdoor activity, clean air and water, stress management, restorative sleep and social connection are all threatened—putting more and more people at risk for developing chronic disease in the first place, especially those in already marginalized communities.^6-8

In the setting of these colliding threats, we are in the midst of a health emergency. The 2021–2022 Intergovernmental Panel on Climate Change (IPCC) reports demonstrate that aggressive action must be taken within the next 10 years in order to limit the most deadly health dangers of climate change. ⁹ Though health professionals train to address chronic disease prevention and management, many are not equipped to bring the overlapping health risks of the climate crisis into the exam room. ¹⁰

Here, we discuss the proceedings of our workshop at the American College of Lifestyle Medicine (ACLM) annual conference LM2021, “Lifestyle Medicine for Personal and Planetary Health.” We examine how lifestyle medicine (LM) interventions can be a prescription for individual, community, and planetary health. Our prescriptions can work to not only restore the health of individuals and families, but also bolster health equity while allowing us to help mitigate and adapt to the health impacts of the climate crisis.^6,8

Pillars of Lifestyle Medicine and Planetary Health

Below, we outline the six pillars of lifestyle medicine as defined by ACLM, and describe how “climate-healthy” prescriptions aligned with each pillar are beneficial for individual and planetary health. We also address health equity considerations, as LM prescriptions can optimally protect people and planet when used effectively as “community-level prescriptions.”

Nutrition

A shift toward plant-based diets has major health benefits and the potential to make a significant dent in the 31% of greenhouse gas (GHG) emissions that come from the global food system.^11,12 From deforestation, fertilizer use, processing, packaging, and transport, our food system adds to emissions as well as the pollution of air, water, and soil. ⁷

Critically, total GHG emissions to produce animal foods are generally much higher than plant-based food.^7,13 Beef is at the highest end of the spectrum (the production of 1 kg contributes about 60 kg of GHG emissions while plant-based food like many fruits, vegetables, and nuts contribute closer to 1 kg of GHG emissions or less for every 1 kg produced). ¹⁴

The health benefits of a plant-predominant dietary shift are equally important. Poor diets, low in whole grains, vegetables, fruits, nuts, and high in red meat, salt, and processed foods, kill 11 million people a year across the globe every year. ¹⁵ Almost 50% of Americans have poor-quality diets, and 90% do not meet daily recommendations for fruit or vegetable intake.^16,17

A whole-food plant-predominant diet made up of whole grains, legumes, fruits, vegetables, nuts, and seeds and that minimizes or eliminates processed foods is optimal for individual and planetary health. ⁸ Data from the EAT-Lancet Commission, show that prescribing a sustainable, health whole-food plant-based diet could reduce the burden of chronic disease globally and prevent close to 11 million deaths per year while also protecting planetary health.^7,8,18

Physical Activity

Active transport, meaning walking or bicycling where possible, is another lifestyle medicine prescription that can be “multi-solving,” addressing multiple issues with one intervention. Sedentary lifestyles kill over 4 million people globally. ¹⁹ According to the most recent data, only about 23% of Americans meet physical activity guidelines for strength and aerobic activity and 25% classify as physically inactive.^20,21 At the same time, about 29% of GHG emissions come from the US transportation sector. ²²

Outdoor physical activity is at risk from climate change. Climate disasters can threaten the ability to perform physical activity outdoors. Additionally, air pollution and higher temperatures also threaten limit safe outdoor activity. ²³

By prescribing physical activity, especially as a substitute for short-distance traveling in vehicles using fossil fuels, we can lower the risk for chronic disease and curb local air pollution. According to data from one study, over 1200 deaths a year could be avoided by substituting active transport for short car rides—less than 4 km. ²⁴

Avoiding Toxic Substances

Though all health professionals are trained to address toxic exposures such as alcohol, tobacco, opioids, and illegal substance abuse, many of us are not trained to discuss the health threats of toxic air, water, and soil pollution. We believe that pollution exposures should also fall under the pillar of toxic substance exposure and therefore should be routinely discussed in the clinical setting. ⁶

By some estimates, air pollution, caused in part by the burning of fossil fuels, is responsible for over 4 million deaths annually, with some estimates placing the number of deaths as high as 8 million.^25,26 It also increases the burden of chronic disease from chronic conditions such as dementia, heart, and lung disease. ²⁷

LM providers can prescribe ways to monitor air pollution to patients by recommending that they regularly review sites such as AirNow.gov. On days when air quality is poor, they can limit pollution exposure by wearing N95 masks or avoiding outdoor activity.^6,8,27 Similarly, discussions about monitoring local water quality and information about toxic contaminants in food products can also be offered to protect health.

Sleep Disturbance

The link between poor-quality sleep and many chronic mental and physical health conditions continues to increase.^28-30 Critically, climate change–related impacts pose a hazard to both sleep quantity and quality. For example, displacement resulting from climate-related weather disasters threaten healthy sleep patterns.^6,7 Long periods of elevated temperatures and noise pollution can also affect sleep, particularly in neighborhoods that have lost protective tree canopies.^31-35

Prescriptions for restorative sleep help patients link the importance of sleep to prevent chronic disease and maintain resilience in the face of emerging health threats. Interventions like tree planting in urban areas and park prescriptions can help reduce urban heat along with light and noise pollution, which can improve sleep quality.^6-8,35 Additionally, tree canopies can protect local air quality, helping with adaptation to predicted climate threats.^6-8,34

Stress Management

Patients and health professionals increasingly recognize climate-related threats to mental health.^6,36 These threats include eco-anxiety, post-traumatic stress disorder—or PTSD—related to climate disasters, and mental-health stress linked to higher temperatures.^6,7,36 In the long-term, chronic stress not only affects health but makes it harder for people to make healthy lifestyle choices. ³⁷

Here again is a “multi-solving” opportunity. Lifestyle medicine practitioners can encourage the use of green space, nature, and parks for stress management and mental and physical health. ³⁸ These prescriptions can also help address “thermal inequities,” a critical intervention, as more evidence links higher temperatures with worse mental health outcomes.^6,35 With racist redlining practices leaving many communities devoid of tree cover, the heat impacts can be much greater for these communities.^6,35 By encouraging tree planting, health professionals can address mental health and heat resilience with one prescription.

Social Connection

Beyond the individual health benefits, shared green spaces and parks can enhance social connection and happiness within communities. Though social connection has not traditionally been thought of as medicine, the health effects of isolation have helped doctors see the importance of community ties for health.^39-42

With the increasing threats posed by climate disruption and lessons learned from isolation during the COVID-19 pandemic, LM health professionals must recognize that prescriptions for social connection are even more critical. Disruptions to health and healthcare access may be limited by helping patients find community support in the lead-up to, and aftermath of, extreme weather events, as isolated patients tend to have a harder time getting care and services after disasters.^43,44 Researchers recently found that higher levels of social support helped people cope and reduced the risk for mental health conditions after Hurricane Maria devastated Puerto Rico. ⁴⁴

Health Equity

Ultimately, our hope is that LM prescriptions to improve individual health may also drive action to limit inequities in access to healthy foods, safe spaces for outdoor activities, protective tree canopies, and clean air for entire communities.

As LM providers, we have a role in advocating for community-engaged LM (CELM), an approach discussed elsewhere, but critical to address the intersection of climate change, chronic disease, and health equity. ⁴⁵

Health equity paired with climate action is of utmost importance because marginalized communities suffer disproportionately from the impacts of air pollution (due to siting of polluting roadways and industries), food desserts, destruction of green space, and other threats that make it more difficult to adapts to climate threats.^6-8,46

Conclusion

Climate change, among other planetary threats, is an urgent risk to human health and the “healthspan.” In the setting of a global population that is both aging and suffering from greater burdens of chronic disease, climate change may cause even greater health harms. Lifestyle medicine prescriptions are critical interventions that help to prevent and treat chronic disease, build community health and resilience, and mitigate climate change. We must help our patients and communities make “climate-healthy” behavior changes that can heal both people and the planet.