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Lifestyle medicine in Latin America and the Caribbean as prevention and treatment for non-communicable diseases

By Prof Robert Kelly - 01st Mar 2024


Reference: March 2024 | Issue 3 | Vol 10 | Page 42


I was invited to give a talk at the Inaugural Conference on Lifestyle Medicine in Latin America and the Caribbean that took place 23-25 February 2024 in Curacoa. This is in the south Caribbean, and is part of the Dutch Antilles, 50km north of Venezuela. The Caribbean has a population of 40 million people between all the islands. They are blessed with year-round sunny weather, but their health situation is not so good.

The primary health concern in this part of the world lies in non-communicable diseases (NCDs), such as cardiovascular disease (CVD), hypertension, obesity, diabetes, lung disease, and cancer. NCDs affect around two billion people all over the world and cause three quarters of all deaths globally.

CVDs account for most NCD deaths, or 17.9 million people annually, followed by cancer (9 million), respiratory diseases (3.9 million) and diabetes (1.6 million). These four groups of diseases account for over 80 per cent of all premature deaths worldwide.

Around 15 million people die prematurely between the ages of 30 and 69 years from a NCD. Over 85 per cent of these premature deaths occur in low- and middle-income countries. Smoking, physical inactivity, excess alcohol consumption, and unhealthy diets all increase the risk of dying from a NCD.

In the South Americas region, 5.5 million deaths are from NCDs, and 2.2 million of these are premature deaths. Some 85 per cent of those occur in low- and middle-income countries in the region. Evidence is increasing that in low-income countries, NCDs are following the social gradient seen in middle- and high-income countries. Social determinants of health account for a major part of the distribution of disability and mortality from NCDs.

In CVD those socioeconomic factors include:

  • Environmental factors;
  • Employment status;
  • Income level;
  • Educational attainment.

In Curacao, the island is dependent on tourism. It has food shortages, primarily due to weather, and imports food from the US and other developed countries. Most of those foods are ultraprocessed and unhealthy. Fast food and sugary drinks industries have expanded into this region and offer less expensive food options that are easy to access and eat. The imported foods are also cheaper than local options as inflation pushes those prices up at local supermarkets, which makes unhealthy alternatives even more affordable.

Curacao has a socialised health system, and every islander is entitled to free care and medication. Certain cancer chemotherapy treatments and cardiac bypass surgery are not available, so patients travel to Colombia or Holland. Sourcing chemotherapy for certain cancers is more difficult because of cost.

Income, poverty, education, and local culture affect cardiovascular health. Unfortunately, an unhealthy diet is driving increases in obesity, hypertension, diabetes, heart disease, strokes, and premature death. The same picture exists across the entire region of the Caribbean and is worse in places like Haiti.

On one island, however, Martinique (French Caribbean), scientists have discovered a Blue Zone – where hundreds of inhabitants are living to over 100 years of age in good health. The reason for this is not entirely clear. Islanders who moved to France die several decades earlier in life compared to those who stayed in Martinique.

The World Health Organisation and Pan American Health Organisation have engaged with this region and identified the following specific goals to achieve a 25 per cent reduction in premature mortality by 2025 (NCD Global Monitoring Framework):

  • 30 per cent reduction in salt intake;
  • 10 per cent reduction in physical inactivity;
  • 30 per cent reduction in cigarette smoking;
  • 10 per cent reduction in excess alcohol consumption;
  • Improvement in blood pressure detection and treatment;
  • Improvement in medication access and delivery to patients;
  • Increase physical activity.

Several initiatives have been put in place to help achieve these goals, including ‘SAFER’ to address alcohol misuse, ‘SHAKE’ to address salt reduction, ‘REPLACE’ to reduce trans-fat intake, ‘MPOWER’ for smoking cessation, and ‘HEARTS’ for cardiology disease reduction.

Leaders in this field agree that “NCDs will only be controlled, and their prevalence and early lethality reduced, if society confronts them with well-formulated programmes implemented by health systems, combined with actions on the social determinants of health and the socio-economic and environmental inequalities.”

Last week The Lancet reported that one billion people around the world are obese. The most obese countries include Latin America and the Caribbean. Obesity is a very complex disease – there are several biological pieces that may be addressed by new drugs, but a huge part of obesity is down to what is going on in the Caribbean (and elsewhere in the world) – social and commercial determinants of health.

The American Heart Association has identified the importance of a lifestyle-based approach in preventing, treating, and potentially reversing chronic diseases including CVD. This is now part of cardiology and diabetes guidelines.

What are the determinants of health?

  • Genetic (20 per cent);
  • Access to healthcare (10 per cent);
  • Social (20 per cent);
  • Human behaviour (50 per cent).

These determinants of health are inter-related.

The causes of heart disease and determinants of health overlap with most NCDs, and they are all linked through the field of lifestyle medicine. Lifestyle medicine is evidence-based, doctor-delivered, and uses lifestyle-related therapeutic approaches to prevent, treat, and potentially reverse lifestyle-related chronic diseases. It encompasses the application of medical, behavioural, motivational, and environmental principles in a clinical setting, and teaches self-care and self-management.

The pillars of lifestyle medicine

The pillars of lifestyle medicine include:

  • Addictions (no smoking/alcohol in moderation);
  • Nutrition;
  • Physical activity;
  • Sleep;
  • Stress/emotional wellbeing/connectedness.

Day one sessions

The meeting sought to explore the concept that lifestyle medicine could be applied to prevent NCDs around the world. My invitation to this summit was to talk about nutritional approaches that help to prevent CVD in our populations. In summary, a balanced, whole food plant-based or Mediterranean diet with salt intake of no more than 6g/day had the most evidence of benefit to prevent CVD and most NCDs.

The challenge is accessing this food. Recently, the US adopted a Food as Medicine initiative with presidential, government, and multiple stakeholder involvement. This includes prescribing healthy food meals to patients.

In Ireland, our issue is not so much access to food. The quality and cost of healthy foods are determinants of healthy nutrition, but so is human behaviour and each individual’s choice to eat the correct food instead of unhealthy, packet, processed, fat, sugary alternatives.

Intensive lifestyle medicine programmes have been highly effective at preventing, reversing, and treating CVD and other issues, including those shown to reverse diabetes, reduce CVD by 50 per cent, and reduce chronic kidney disease to a similar degree at 12 years of follow-up. This is evident in the Look Ahead study, among others, where patients reversed diabetes with dietary intervention early on, having entered an intensive lifestyle medicine programme to achieve this enormous risk reduction in NCD.

The conclusion of my talk was that nutrition approaches can help prevent CVD and reverse NCDs such as diabetes and hypertension. In the panel discussion for this session, we also looked at the HEARTS initiatives in South America. These include studies that implement care delivery in the community among low economic populations. One example includes a blood pressure (BP) study, where patients are unhealthy, poorly educated, and do not get access to care and medications.

This project was initiated to educate community volunteers to run a clinic to measure BP; to give patients information; to ensure they got medications from a doctor and were taking them; and then to follow up and monitor responses. This approach significantly reduced BP within the study cohort. The approach has now been rolled out across Argentina and Central America.

At the end of day one, Professor Barry Popkin from North Carolina gave a keynote talk titled: ‘The nutrition transition: Dynamics and potential for slowing down or reversing the current pattern.’ He highlighted that one way to reverse the current obesity and food equity issues is by teaching people small steps towards change and working with government and policy makers to make healthy food available.

Day one left me with the sense that many of the health problems of our world remain enormous, but there are also opportunities to tackle them collectively. While a simple approach of helping patients to change personal lifestyle behaviours is critical to everyone’s health, we all need to help people make healthier decisions. It is really important not to lose sight of the bigger picture, primarily the social determinants of health and the need to address those issues as part of the solution for NCDs. This Caribbean insight taught me that the same issues, of differing degrees, are evident throughout the world.

Day two sessions

Day two addressed the specialty of lifestyle medicine, with representatives from the American College of Lifestyle Medicine and the European Lifestyle Medicine Organisation giving specialised talks, including those entitled ‘Exercise is medicine and sexual health (including erectile dysfunction) in lifestyle medicine’. Many men in Curacao refuse to take blood pressure medication because they are afraid of getting erectile dysfunction.

The focus then switched to chronic obstructive pulmonary and other chronic lung diseases. Lifestyle factors identified include smoking, climate change, and air pollution. Interestingly, local South American traditions also emerged as a risk factor. In Central America biomass fuels are used in homes to cook food as tradition. These fuels appear to increase the risk of, and exacerbate, lung conditions.

Another stimulating topic of conversation looked at environmental contributions to cancer and considered how modern food may be harming human health. The latter formed a presentation from Singapore about the gut microbiome, and how it has been damaged since the mass industrialisation of food processing. An altered microbiome has been linked to multiple diseases (dysbiosis) including NCDs, cancer, and heart disease.

The afternoon sessions focused on cancer. The meeting organisers included Prof Bob Pinedo, Prof David Khayat, and Dr Peter Harper, three of the world’s most eminent cancer leaders from the Netherlands, France, and UK. These three pioneers have given much of their lives to addressing cancer on a global scale and helping disadvantaged regions, such as parts of Latin America and the Caribbean.

Prof Pinedo is originally from Curacoa, and went on to become a leader in oncology in the Netherlands, where he still sees patients at 80 years of age. He set up the Caribbean Cancer Prevention Centre to help islanders screen for, and manage, cancers. The service has encountered several problems with patients not attending for visits. Local culture and body image again appear to pay a role, whereby women who have larger breasts and curves (Chi Chi) are viewed as strong, attractive, and feminine. Thinner women are generally considered weak and sick, which has implications for breast cancer care. Many women will not seek medical attention for breast lumps as they are afraid that having a mastectomy will result in their husband leaving them.

Day three sessions

The third day of the meeting focused on obesity, nutrition, diabetes, and the social-environmental determinants of heart disease in Latin America and the Caribbean. This day highlighted the innovative work that many regions have implemented to prevent NCDs, including obesity.

In Barbados, the government has introduced the Barbados School Nutrition Policy to create healthy food and physical activity for school children. Like the rest of the world, children bring unhealthy food to school and get lots of parental letters excusing them from gym classes. Barbados has opted to tackle that issue and has involved all stakeholders, including children, teachers, parents, and industry. They provide water and healthy food free to all children, they provide healthy food, and they educate all stakeholders. In Aruba a local paediatrician introduced the JUMP18 initiative to empower children and their parents to improve their health and wellbeing.

Data from Mexico and Chile was presented to show how sugar taxes are effective ways of reducing sugar consumption, and how food labelling, when presented very simply instead of the generally scientific food labelling practices across the globe, enables everyone to understand what healthy or unhealthy food is. These labels are now mandatory in Chile and food companies can be fined and lose business for breaking the rules. Other South American countries are following Chile’s initiative.

In Mexico, a toolkit is being created for obesity and NCD prevention. This includes diet, food systems, public health, social, and commercial determinants of health (Rivera JA. Science 2024). Mexico has also been at the forefront of launching a position statement for health professionals around the world to become better: ‘The need for immediate action to address obesity’.

Two major health initiatives particularly stood out – a Dutch initiative and the SALURBAL study. The Dutch approach to weight management has designed a multi-city approach to make cities healthier, to ensure the health of children and future generations. It has achieved wide stakeholder support, and its focus is to make Amsterdam a healthy city for children growing up there. This initiative is being replicated across other cities in the Netherlands.

The Drexel University in Philadelphia, US, is collecting data to help make Latin American cities (and others) healthier, more equitable, and environmentally sustainable as part of the SALURBAL study. It engages policy makers and the public about urban health, sustainability, and implications for societal action. The group has built a platform and network to ensure continued learning and translation.

Data collection includes health (death, cause of death, life expectancy, behaviour, biomedical risk factors, and violence); physical environment (transportation, congestion, air pollution, green areas, access to water, and sanitation); social and economic environment (poverty, income inequality, segregation, race and ethnicity, housing, education, GDP, and employment).

SALURBAL runs a portal that is accessible to everyone. There are fascinating health and social insights, with huge variations in different cities and countries. Most interesting is the data on the impact of climate change and sustainability, and how they relate to health. Investigators have found that high exposure to air pollution directly impacts NCD in some regions, and have suggested that urban policies can be changed to address these health issues.

In terms of climate change, rising temperatures are an important contributor to NCD mortality and morbidity in the region. Like other parts of the world, including Europe, many exposures and pathways are important, including air quality, wildfires, storms, and floods. However, more evidence is needed to support action.

The talk summarised that societal and environmental factors are very underappreciated as contributors to NCDs. There are major implications for policies outside the healthcare sector. The SALURBAL team has recently expanded their research – looking closer at actions to prevent any further health impacts of climate change, and also to protect from changes that have already occurred, as well as generating new knowledge and building regional capacity for continued learning and action into the future.

The environment issue is again highlighted recently in a New England Journal of Medicine publication showing that microparticles and neoplastics (in air and water) are getting into carotid artery plaques (58 per cent of samples detected from surgical carotid endarterectomy tissue), and that is leading to a 4.5-fold increase in the risk of heart attack, stroke, and premature death for patients.

The final session of the summit discussed diabetes and diabesity. Colleagues from the Netherlands gave an overview of a simple, individual approach to kick starting lifestyle medicine for everyone:

  • Avoid ultraprocessed food;
  • Vegetables and fruit should be a part of daily diet;
  • Eat a handful of nuts as a snack;
  • Eat fatty fish once or twice a week;
  • Eat lean meat only (poultry or game) and in moderation;
  • Eat only wholegrain produce (and not too much of it);
  • Full fat (fermented) mild products are allowed;
  • Use extra virgin olive oil for dressing salad;
  • Use air fryer cooking to avoid cooking oil use;
  • Drink water, coffee, or tea instead of fruit juice or soft drinks;
  • Stand up from behind your desk at least once an hour;
  • Take a bike instead of car/motorbike;
  • Take the stairs instead of lift/elevator;
  • Go for a walk for at least half an hour each day (moderate pace);
  • Get a good night’s sleep;
  • Make and spend time with family and friends.

These steps can reverse diabetes and reduce the need for multiple medications. In truth, medication is unlikely to work for individuals without also taking lifestyle medicine. The same applies to most NCDs.

One recurrent theme of the meeting highlighted how diseases of traditionally middle socio-economic classes (due to consumption) are increasing among lower socioeconomic groups. Malnutrition is being replaced by obesity. In some parts of the world (sub-Saharan Africa), there is malnutrition and obesity in parts of the same country.

Type 2 diabetes is now seen in much younger generations, where childhood eating habits and obesity are driving type 2 instead of type 1 disease. The social and commercial determinants of health are also playing a part in this worrying trend. This does not fare well for NCD risk to younger people unless actions are taken.

Conclusion

This summit really opened my eyes to the bigger picture of world health: Preventing NCDs with lifestyle measures; the real-life challenges for patients; social and commercial determinants of health that we can all relate to; the health concerns arising from environment, food, climate change; and the enormous need for everyone to participate in making our planet a healthier world where children and future generations can live long and healthy lives.

In terms of my clinical practice, I am driven to bring lifestyle medicine into everyone’s lives, because without changes in our eating, physical activity, stress, sleep, and social connection, the initial benefits of medications, stents, and surgery will not last, and people will continue to have more heart attacks, strokes, and premature death.

I am grateful to the organisers of this summit for revealing the greater complexities of health challenges worldwide. My burning desire to make a difference in patients’ lives continues.

The views in this article are personal interpretations based on LMLAC Summit 2024 – www.lmlac.org). I have withheld the references and encourage interested readers to reach out to me directly if you would like to learn more and get involved. Email:robert.kelly@beaconhospital.ie

Author Bios

Prof Robert Kelly MD MBA FRCPI FACC FESC FFSEM, Associate Professor of Clinical Sciences UCD Beacon Hospital, Senior Lecturer Lifestyle Medicine RCSI University of Health Sciences, Medical Director of Lifestyle Health and Wellbeing, Beacon Hospital, Board Member of European Society of Lifestyle Medicine, Co-founder Irish Society of Lifestyle Medicine, Consultant Cardiology and Lifestyle Medicine, Beacon Hospital, Dublin


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