My first reaction to the COVID pandemic, actually just months but seemingly lifetimes ago, was not about social determinants of health.
It was not about total harm minimization, vertical interdiction, or the context of other casualty counts. Rather, it was about the pandemic we already had, hiding in plain sight- the pandemic of chronic, degenerative, cardiometabolic diseases fueled overwhelmingly by another pandemic entirely of our own devising, a pandemic of lifestyle at odds with vitality, and in particular, of poor quality diets and junk impersonating food.
Hard as it may be to accept right now, the COVID pandemic will end, and before all that long in the grand scheme of things. It will have come and gone in a vividly memorable but ultimately short span of our lives. In contrast, the pandemic of cardiometabolic disease of our own entirely unnecessary manufacture has been siphoning years from lives and life from years all around us, every day that every one of us has been alive. In fact, over the lifespans of those reading this near the time I write it- these contrived pandemics have been worsening every year.
The toll is staggering. As I had cause to note in response to the COVID risk distortions that persist even now, and that I have largely lost hope of rectifying until the competing passions, dogma-induced selective deafness, and inflamed anxieties abate - heart disease alone kills 650,000 Americans every year. That’s 1800 of us… every day. Most of these deaths are premature, and indeed most come at the cost of more years from life than the casualties to COVID.
Poor diet alone stands out among the behavioral, root causes of premature death as the now undisputed number one. Poor diet- something to which we do not accidentally fall victim, but something we engineer and market for the sake of profit at the expense of public health- kills 500,000 of us prematurely every year. That is far more than twice the toll of COVID to date in the United States.
Perhaps your thoughts turn quickly to the other harms of the pandemic- to complications, and “long-haulers.” Right they should, but this offers no rebuttal to the carnage of bad diet, for it too takes life from years when not taking years from life. Every case of coronary disease, diabetes, heart failure, stroke, dementia, or disabling obesity is a “long haul” cardiometabolic affliction we know full well how to avoid in most, if not all, cases.
So this far into the pandemic, let’s go back to before the beginning- and revisit the outsized role of diet, and the native state of our prevailing health.
Colleagues and I have published on this matter more than once, and the mainstream media have made note of it, more than once- but not nearly enough. More than 60% of American adults have at least one of the conditions that makes a bad COVID outcome many multiples more likely, and more than 40% of us have two or more of these conditions, elevating our personal and communal risk astronomically.
Drugs and bariatric surgery can attenuate this toll, but they are- as we in Preventive Medicine like to point out- efforts to mop a flooded floor while failing to turn off the spigot. Lifestyle is the remedy here. An overhaul of personal, communal, and ultimately the national pattern of diet and activity is the foundational fix. Lifestyle at odds with longevity and vitality is what corrodes the foundations of our health out from under us.
I will be privileged this coming week to address my Lifestyle Medicine colleagues as we convene in the hundreds or even thousands, albeit virtually in deference to the pandemic. I will espouse to them what I am espousing to you now: the acute case for chronic health.
We speak routinely of “chronic disease.” We rarely refer as explicitly to the obvious remedy, “chronic health.” Were we to do so, we might recognize the shared liability of the two. “Chronic” means sustained, but also hints at slow, gradual, and delayed. We are a people famously intolerant of gratification delayed.
Enter COVID. All of the gradual advantages of health and vitality are now acute defenses against SARS-CoV-2 as well. There is, all around us now, an acute danger making the case for self-defense in the form of chronic health. This confluence of the sustained and the immediate is parent to an indelibly teachable moment. I say: let’s use it.
I am not alone. Even before all this began, diet had been highlighted as the leading cause of premature death in America, and a call issued for corrective action. More recently- during the pandemic- a committee of the American Heart Association recognized the significance of diet as a veritable vital sign, calling for its assessment with every patient.
At this advanced stage of my career- after some 30 years of teaching, research, and patient care- that is now my day job: making diet the vital sign it deserves to be. We have the tool to do it, the first major re-conception of dietary assessment in our lifetimes. We can capture full dietary details- type, quality (objectively measured), servings, nutrient levels- in roughly 60 seconds. This has the potential to revolutionize every aspect of dietary intervention, from disease management, health promotion, risk assessment, population level trend analysis, to nutrient supplementation- where we can, at last, answer the neglected question: supplemental to what? Learn more as the spirit moves you at DietID.com.
With regard to COVID, diet quality exerts an outsized influence- both directly on immune system responses, and indirectly via cardiometabolic conditions and their degree of control. Studies show, for instance, that good as compared to poor glycemic control in type 2 diabetes can reduce COVID mortality risk by a factor of four. Similar benefits relate to control of blood pressure.
In some number of interviews since the onslaught of COVID, I have been asked to explain the diversion of my professional focus from diet, nutrition, and lifestyle, to the pandemic. The answer comes readily, and extends well beyond my training in preventive medicine, public health, and epidemiology. I am not generally focused on diet and lifestyle interventions because I like food more than most people. I have focused my career on what matters most to years in lives, and life in years, in the hopes of making the greatest possible positive contribution. Diet and lifestyle are perennially the most important means to the most important ends.
During the pandemic, however, a devotion to years in life and life in years demands an accommodating detour. To do otherwise would be to overlook the proverbial elephant in the room, something to which I have a somewhat famous antipathy.
I have felt obligated to channel my focus on the same ends- years in life, life in years- through the prism of alternative means, notably SARS-CoV-2, and the fallout of our societal responses to it. But as with all detours, the fundamentals of my route, journey, and destination are as they ever were.
COVID makes an acute case for chronic health. We are living in a teachable moment. Good may yet come of all this if it finds us…willing to learn.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.