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The Golden Age
of Medicine

 

 

E-Newsletter No. 85

Golden Age of Medicine 2.0: Lifestyle Medicine and
Planetary Health Prioritized

Alan C. Logan1, Susan L. Prescott1,2,*, David L. Katz3

1in-VIVO Planetary Health, West New York, NJ, USA, 2School of Medicine, University of Western Australia, Perth, WA, Australia, 3Yale University, Prevention Research Center, Griffin Hospital, Derby, CT, USA

The ‘golden age of medicine’ - the first half of the 20th century, reaching its zenith with Jonas Salk’s 1955 polio vaccine - was a time of profound advances in surgical techniques, immunization, drug discovery, and the control of infectious disease; however, when the burden of disease shifted to lifestyle-driven, chronic, non-communicable diseases, the golden era slipped away. Although modifiable lifestyle practices now account for some 80% of premature mortality, medicine remains loathe to embrace lifestyle interventions as medicine Here, we argue that a 21st century golden age of medicine can be realized; the path to this era requires a transformation of medical school recruitment and training in ways that prioritize a broad view of lifestyle medicine. Moving beyond the basic principles of modifiable lifestyle practices as therapeutic interventions, each person/community should be viewed as a biological manifestation of accumulated experiences (and choices) made within the dynamic social, political, economic and cultural ecosystems that comprise their total life history. This requires an understanding that powerful forces operate within these ecosystems; marketing and neoliberal forces push an exclusive ‘personal responsibility’ view of health - blaming the individual, and deflecting from the large-scale influences that maintain health inequalities and threaten planetary health. The latter term denotes the interconnections between the sustainable vitality of person and place at all scales. We emphasize that barriers to planetary health and the clinical application of lifestyle medicine - including authoritarianism and social dominance orientation - are maintaining an unhealthy status quo.

Key Words: Lifestyle, Health disparities, Medical education, Authoritarianism, Social dominance orientation, Non-communicable disease

Received: December 28, 2018, Accepted: February 22, 2019

*Corresponding author: Susan L. Prescott School of Medicine, University of Western Australia, c/o Perth Children's Hospital, Perth, WA 6001, Australia Tel: 61-8-9340-8171, Fax: 61-8-9388-2097 E-mail: susan.prescott@uwa.edu.au

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION

“Lifestyle health risks represent a bottomless pit of incipient disease in family practice...in the well-organized office, no matter how busy, there are various strategies and methods by which physicians can raise their patients’ awareness of lifestyle risks and deal with them during the average office visit”

    Shires and Hayward. Canadian Family Physician, 1979 [1].

Although infectious diseases remain a looming threat to humanity, the weathervane of global disease burden is pointing steadfastly in the direction of the chronic noncommunicable diseases (NCDs); as stated by experts in global health, the term NCDs may obscure the socially-transmitted, pandemic nature of these conditions [2]; the vectors include urbanization, industrialization, poverty, the widespread availability (and marketing) of unhealthy goods, and the often unjust structure of society [3]. The direct and indirect NCD-related costs to society–both financial and in loss of human potential—remain untold. Moreover, NCDs are part of grotesque socioeconomic inequalities, neoliberal philosophies, environmental degradation, disconnection from the natural environment, biodiversity losses, and climate change [4,5].

The dominance of lifestyle driven, socially-transmitted diseases over the last half-century has not been met with an adequate, responsive shift in the training and practice of physicians in western nations; despite awareness of this ‘inconvenient truth’ [6], institutional medicine (that is, medical schools and the representative organizational structures of ‘medicine’) remains committed to the primacy of biomedicines and technology. The response to the crisis of NCDs is found in the promise of ‘omics’, ‘precision’ and ‘personalized’ medicine. In North American medical training, the biopsychosocial model isn’t taught from a utility perspective [7].

Coincident with the rise in interest in preventive medicine and a holistic form of health which considers root causes, the 1980-1990s witnessed an increased awareness of how individual and collective lifestyles (and the social forces which shape those lifestyles) impact the health of the planet. For example, Jonas Salk, famous for his groundbreaking polio vaccine, argued that the human body was an extension of the functioning whole of the external environments - including its biodiversity, social policies, and cultural practices; since humans are vitally dependent upon the health of the Earth’s natural systems (which are, in turn, deeply impacted by human lifestyles), there is an urgent need to discuss the biological, social and cultural aspects of health from the planetary health perspective [8]. Thanks in part to the highly-publicized 2015 Lancet Commission on Planetary Health Report [9], the term planetary health has entered the mainstream lexicon; however, as with lifestyle medicine, the saliency of planetary health to 21st century healthcare remains distant from current medical training and practice.

Here, we will explore the history of the growing movement of lifestyle medicine and the related concept of planetary health. The latter term—defined as the interdependent, sustainable vitality of all natural and anthropogenic ecosystems (social, political and otherwise) —should be of highlevel relevance to the goals of lifestyle medicine. Indeed, although lifestyle medicine and planetary health have not yet reliably found their common ground (certainly a work in progress [10]), we make the case that both are an ethical imperative.

ROADMAP TO THE CURRENT REVIEW

Here in our narrative review and commentary, we will focus on the importance of lifestyle medicine within in the context of planetary health (which we view as one-inthe-same). In order to emphasize this connection, we first explore the foundations of medicine’s 20th century golden age, the history of contemporary lifestyle medicine, and the coincident rise of the planetary health concept. Next, as a surrogate marker of overall lifestyle medicine knowledge and active promotion of its tenets, we summarize recent studies which have examined nutritional (and physical activity) competency and/or consistent use in practice among medical students and physicians in western nations. It is easy to demonstrate that current physician preparedness and application of knowledge pertaining to the lifestyle aspects of NCDs is woefully inadequate; however, we argue that this fact is shrouded by the stubborn desire for institutional medicine to assure the public that medical doctors are trusted experts in all matters pertaining to health.

After briefly referencing the oft-discussed barriers to the uptake of lifestyle medicine and planetary health, we will turn our attention to an area of research—authoritarianism, social dominance orientation, Machiavellianism and threat to status—which has largely escaped discourse. We describe the ways in which these psychological constructs—individually and collectively—could permeate the power structures of western medicine; we argue that these constructs maintain a status quo which favors biomedicine (and relegates non-technical subjects considered ‘soft’) while at the same time vigorously protects the idea of physician as lifestyle authority and sees any challenge to this idea as a threat to status. It is not our contention that these psychological constructs (at individual and larger scales) are the primary reason for the status quo; inertia and the daunting prospect of truly transforming medical training is likely a major contributor.

MEDICINE’S GOLDEN AGE

“We now live in a golden age of treatment and a dark age of preventive medicine. It is time that we express our national interest in efforts that will reduce the price we pay for permitting disease to debilitate its victim before we finally deal with it”

    Senator Maureen Neuberger. 1966 [11].

In the quote above, taken from Senate Committee hearings on illness through the aging process, Senator Neuberger was referring to the inadequate prevention of chronic NCDs. Media reports on the 1966 hearings made note of the progress in conquering of infectious disease through sanitation, immunization and effective drugs, but pondered the inability of modern medicine to tackle the growing numbers of chronic, non-infectious diseases [12]. At a time of great social change, it was the beginning of the end of medicine’s golden age.

In the first half of the 20th century, and especially during the 1950s, physicians described themselves as being in the golden age of medicine [13,14]; given the relatively rapid advances in surgical techniques, the development of antimicrobials and other drugs, and the 1955 announcement of the polio vaccine success (a zenith moment which galvanized the public), this golden age view, mixed in as it was with other remarkable scientific achievements, seemed entirely justifiable [15]. While institutional medicine-at-large basked in the glow of these achievements (and as we argue, still does to a degree), other discoveries (including Henry Beecher’s landmark 1955 placebo research - the public revelation that “Many a drug has been extolled on the basis of clinical impression when the only power it had was that of a placebo” [16]), healthcare realities (the cost of an impending epidemic of ‘diseases of civilization’) and social currents (the questioning of institutions in general) were flowing below the surface. By the mid-1960s, a few ‘rogue’ physicians challenged the infatuation with the previous decades; distinguished cardiologist Wilhelm Raab MD provided the following admonishment: “It is only natural that the contemporary medical students’ preceptors, whose generation had sponsored and created such dramatic developments, are still fully pre-occupied with the exciting achievements of their era. Thus, only little thought and even less action was and is being devoted by them to the comparatively dull subject of the mere maintenance of such an apparently commonplace thing as “health”...our future practicing physicians, whatever their special interests, will have to insist upon receiving instruction in the basic principles and techniques of practical prevention of the diseases of civilization - even at the expense of some less important theoretical and ultra-sophisticated diagnostic and therapeutic details. They must learn to preach, on every suitable occasion, the plain, common sense elements of health maintenance, and they must take upon themselves the difficult, but rewarding, ethical obligation to practice themselves what they preach” [17].

Dr Raab’s courage to speak out was notable; he organized the first international preventive cardiology conference in 1964 (focusing on sedentary behavior, high calorie diets, smoking and psychological distress) [18]. He advocated for a plant-based diet, outdoor exercise in natural environments and limitation of screen time [19]. Dr Raab was described as tenacious “in pursuing his work in spite of the opposition and active resistance of numerous influential critics” (we will focus on the continued ‘active resistance’ against lifestyle medicine below) [20].

Golden ages are typically viewed as golden because of  technological advances; while many promissory notes have been written on the technological sides of precision (personalized) medicine (that is, the predictive potential and clinical relevance of the so-called ‘omics’ revolution and microbiome science), their fullest potential is still predicated upon physician-delivery. Thus, the technological sides of 21st century personalized medicine cannot be extracted from lifestyle (and its psychosocial determinants) and the contextual complexities of an individual’s environment and total lived experiences. While the 20th century golden age of medicine addressed infectious disease, we argue for a 21st century golden age where the prevention and treatment of  NCDs is prioritized by the implementation of knowledge that already exists. Described below, the principles of lifestyle medicine and planetary health are actionable (and evidence-based) right now [21].

LIFESTYLE MEDICINE,
PLANETARY HEALTH

The importance of lifestyle as a general theme—diet, exercise, sleep, mental ‘hygiene’ and climate exposure—has resonated within most medical systems through recorded history. In the latter half of the 20th century researchers and policymakers began to use the term ‘lifestyle’ in relation to health and disease; for example, in 1979, the United States (US) Surgeon General’s Report on Health Promotion & Disease Prevention (Healthy People) estimated that lifestyle accounted for the cause of mortality in half of cases, while environmental factors (especially airborne pollution) was estimated to account for a further 20% of the annual mortality. The Report mentioned lifestyle(s) eleven times and reframed the meaning of mortality causes and complexities [22].

Fourteen years later, US government scientist J. Michael McGinnis and colleague William Foege  published their landmark study; once again, smoking, dietary choices, lack of physical activity and excess alcohol were the primary factors in the annual burden of mortality and chronic disease [23].

Put simply, modifiable lifestyle practices account for 80% or more of premature death in modern society. The findings of McGinnis and Foege have been replicated by other groups over the years [24]. In 2018, high BMI, smoking, and high fasting plasma glucose remain the three most important risk factors in the United States; while there have been some gains in smoking cessation efforts, substance abuse is on the rise, physical activity remains far from sufficient and an unhealthy diet remains the status quo [25].

Mortality from NCDs is a surrogate marker of preceding loss of quality of life—the root causes are taking both years from life, and life from years. In sum, there is little question that lifestyle is the corridor through which humans can either promote the sustainable vitality of person, place and planet, or conversely, detract from health at each of these scales. Lifestyle medicine, inclusive of attention to planetary health, is a modern imperative across all fields of medicine/health professions (for definitions of lifestyle medicine and planetary health, see references [26,27]). Since physicians maintain a very high level of trust in society—and multiple opportunities exist in which physicians can educate and advocate for lifestyle factors which promote health at all scales—it would be expected that medical training and knowledge concerning lifestyle and health in the 21st century would be commensurate with the burden of disease and the urgency of planetary ill-health. However, as we describe below, such is not the case.

NUTRITION, LIFESTYLE TRAINING

“Most physicians care little about diet and care less. And our best medical schools continue to turn out graduates unable to write even a quantitative dietetic prescription, which is an elementary matter, to say nothing of writing one which shall also be balanced and qualitatively appropriate. The recent graduate, as well as the old practitioner, is still apt to confuse the practice of medicine with the use of drugs to an extent which I feel sure will soon be universally recognized as unduly large”

    Edward C. Cornwall, MD 1919 [28].

As evidenced by Dr Cornwall’s frustration a century ago, the relegation of nutrition in training and  practice has been a persistent theme in post-industrial medicine; he correctly predicted that drugs would have an unduly large place in 20th century medicine, but the justification for a pharmaceutical-minded medicine was warranted, especially with the profound advances in antimicrobials, vaccines and other highly-effective medicines. Science discovered, clinical/public health medicine implemented, and society benefited immensely—particularly in regard to infectious disease control.

However, as the 20th century passed its mid-point, it was clear that the laboratory medicine set in motion by Abraham Flexner’s report was leveraged by commercial interests to mold a medical training dominated by biomedicine (as opposed to psychosocial and lifestyle approaches) [29,30].

Although there have been changes to western medical school curriculum over the decades, the lack of plasticity and rigid nature of medical training - reform without meaningful transformation [31]—is an ongoing problem (explored in detail elsewhere [32-34]). As described below, the available literature would suggest that the mismatch between medical education and preparedness for the epidemic of NCDs cannot be solved by tinkering around the edges of the curriculum. Indeed, individual medical students - those with the least power in the structures of institutional medicine - are taking to the pages of medical journals to express their displeasure with the absence of lifestyle medicine in curriculum [35].

The concerns of students are backed up by many published studies. First, we can look at the current state of nutrition education in westernized medical programs; the majority (70%) of US medical schools are unable to meet the 25 hours minimum nutrition education. Didactic training largely escapes clinical training for preparedness for NCDs and remains largely devoted to preclinical (e.g., biochemistry) contexts [36-38]. As a result, the majority of students report that they are ill-prepared for clinical nutrition counseling [39-41] and poor scores on clinical nutrition exams reflect such self-disclosures by students [42].

On the other hand the medical school educators report that nutrition education is satisfactory [43].

Among North American cardiologists, 90% report nutrition education was either absent or parse during fellowship training, 59% reported no nutrition education during internal medicine training and 1/3 reported receiving no nutrition education at all during in medical school training [44]. Absence of nutritional training translates into lack of knowledge; a variety of studies have shown that practicing physicians struggle with tests querying even basic knowledge on micro/macronutrients, dietary influences on lipids, the ability of soluble fiber to influence cholesterol, etc. [45-48]. These are not passing grades; indeed, one recent study involving pediatrics residents found that average number of correct answers (52%) on basic nutrition knowledge [49] was comparable to patient groups who completed the same 18-question test [50,51].

Recent studies on knowledge and preparedness for physical activity counseling among medical students shows that this, too, is subpar. For example, in the United Kingdom, medical students report lack of familiarity with established physical activity guidelines and underestimate the role of physical activity in the global disease burden [52]; schools devote a total of 4.2 hours of physical activity training (vs. 109 hours average on pharmaceutical knowledge) throughout the entire curriculum [53]. In North American research, one study showed that vast majority of graduating medical students felt unprepared to provide appropriate exercise counseling [54]; primary care residency programs provide only 2.8 hours of didactic training on obesity, nutrition, and physical activity combined [55]. Most students acknowledge that they are unaware of current physical activity recommendations, but among those claiming to have awareness, only 2% correctly identified national guidelines [56]. Voids in physical activity training and knowledge (particularly with strength training guidelines) have also been reported in Australian medical schools [57]. In the United States, formal training on physical activity is absent from the curriculum in most medical schools [58].

These pronounced voids in training are reflected outside the walls of medical schools; although majority of patients are interested in receiving lifestyle guidance [59], practicing physicians are often unaware of specific lifestyle guidelines and are not actively engaging with patients on the important aspects of lifestyle medicine [60,61]. Consider that most (60%) office visits by obese patients involve a complete absence of physician engagement with lifestyle counseling/health education [62]; more specifically, only about half of overweight/obese patients with ≥ 1 cardiovascular disease risk factor (and currently not meeting physical activity guidelines) receive advice to increase physical activity [63].

Despite the American College of Rheumatology’s osteoarthritis management guidelines recommend exercise as a first-line, nonpharmacologic strategy to manage arthritis symptoms, 40% of patients receive no such counseling [64].

Alarmingly, among those with arthritis and overweight or obesity, approximately 75% of adults with overweight and 50% of those with moderate obesity (BMI 30 to < 35) are not receiving any provider weight-loss counseling [65]. The Royal College of Ophthalmologists maintains specific lifestyle counseling criterion for age-related macular degeneration, yet patients report that physicians rarely discuss the major portions of the guidelines [66]. Evidence also indicates that whether or not a physician engages in lifestyle

Fig. 1. Dysbiosis of Scale. Neoliberalism promotes the goods and services which contribute to literal and metaphorical dysbiosis (Greek = life in distress); it blames the individual, offers solutions in the form of supplements/medications/gadgets, and deflects from the large-scale forces which maintain health inequalities and threaten planetary health. guidance is a product of their own belief systems; that is, regardless of existing evidence supporting the importance of lifestyle, if a physician maintains the belief that lifestyle will not affect outcomes, they are unlikely to engage in such counseling [67].

Perhaps most concerning are the lifestyle counseling gaps in pregnancy; physicians are not providing thorough lifestyle guidance during prenatal visits [68,69]. Lifestyle medicine involves more than merely asking about smoking during pregnancy; rather, it means following clinical guidelines concerning specific referral, assisting and following up on smoking cessation care. On this score, opportunities are missed and performance in providing appropriate smoking cessation care to pregnant women is low [70]. Indeed, effective approaches in lifestyle medicine cannot be equated to simple check-off boxes advising patients to “eat less fat and cholesterol” and “exercise more” [71-73].

This background becomes all the more disconcerting when viewed through the prism of planetary health; since physicians hold the trust of society, it is incumbent on the medical schools to educate its students on the realities of lifestyle vis à vis the health of person, place and planet. For example, the healthy, nutritionally-dense, plant-based diets that favor health promotion are also (due to their lower greenhouse gas emissions and environmental impact) those which support planetary health [74-77]; the conclusions of the Dietary Guidelines Advisory Committee (which independently critiqued the 2015 US Department of Agriculture and US Department of Health and Human Services Dietary Guidelines for Americans) were clear: “a dietary pattern that is higher in plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts, and seeds, and lower in animal-based foods is more health promoting and is associated with lesser environmental impact than is the current average US diet” [78]. Modifying the Mediterranean diet and opting for plant-based proteins and eggs (vs. meats) improves sustainability and reduces environmental impact by up to 86% (based on multiple indicators), and still provides adequate nutrients [79]. On the other hand, if the global expansion of western-style dietary patterns rich in animal products continues unabated through 2050, it would increase global greenhouse gas emissions by 80% and require an extra 740 million hectares of additional cropland (that is, compared to a healthy diet modeled as an average of Mediterranean, pescetarian and vegetarian diets) [80].

Thus far we have been using voids in nutritional knowledge as a surrogate marker for the larger aspects of lifestyle medicine in the anthropocene (Fig. 1); best practices in lifestyle medicine will require a deep understanding of the interconnectivity of many variables influencing individual and community lifestyle choices; this includes, but is not limited to, screen media use, sleep quality, psychological distress (and perhaps more importantly, the presence of positive emotions such as optimism), socioeconomic  disadvantage, personal/community resources, availability of safe/usable green space (natural environments), concentration of fast-food/convenience stores (and their targeted marketing) and food deserts, allostatic load, and the presence of airborne toxins and/or environmental degradation [81-83].

Others have called attention to the complete absence of required environmental education in North American medical schools (some offer electives); given the realities of climate change and environmental degradation, the authors ponder how future physicians can provide expert guidance to individuals and the public without adequate training and accountability for competence [84].

In sum, although there has been a good deal of research demonstrating that medical students are not being prepared to be experts on lifestyle vis à vis the epidemic of NCDs - and that most practicing physicians cannot be considered as experts in lifestyle guidance - there has been little formal recognition (by institutional medicine) of this reality. Of course, the potential of newly trained physicians as trusted authorities in matters of lifestyle as they pertain to health and disease is enormous, but the evidence shows that at this time lifestyle medicine remains, absurdly, its own ‘branch’ of medicine. The absence of lifestyle training is a matter of ethics; educators and clinicians can, and should, be held to ethical account for incompetency and an inability to address the lifestyle matters of NCDs in a reliable, evidence-informed manner [85,86].

BARRIERS TO CHANGE -
AUTHORITARIANISM,SOCIAL
DOMINANCE

“Given the benefits of lifestyle medicine interventions, it would seem that our health care system would rush to embrace this movement; however, nothing could be further from the truth. Through the decades, leading proponents of lifestyle interventions have faced resistance or marginalization”

     Balazs I. Bodai, MD, et al. 2018 [87].

Today, the evidence surrounding lifestyle factors in prevention, treatment and health promotion is robust. Thus, in the contemporary medical environment where evidence-informed practice is the basis of care, lack of evidence cannot be cited as the barrier to transform medical training. Physicians have oft-described persistent barriers to the adoption and institutionalization of preventive treatment, education and counseling practices in clinic - described in detail elsewhere, these include lack of time, pressures to handle more pressing issues, lack of resources and perceptions of lack of (convenient) evidence- informed materials, lack of reimbursement or financial incentives, low expectations of benefit, concern about offending patients (e.g. suggesting weight loss), lack of confidence in outcome benefits, and low self-efficacy (confidence in delivering preventive/lifestyle care) [88].

These oft-mentioned barriers to the widespread uptake of lifestyle medicine into clinical care are salient, but they do not provide a rationale as to why medical schools refuse to do more than tinker around the edges, and they cannot explain why the champions of lifestyle medicine have been marginalized and made to feel an ‘out-group’ within institutionalized medicine. Inertia might explain avoidance of the daunting task of deep, Flexner-like revisions to the medical curriculum but it cannot provide a rationale for deprecation. We provide a different perspective on the 5-decades-old status quo. We suggest that an exploration of authoritarianism and social dominance orientation (plus the related construct of Machiavellianism) might provide insight into the institutional resistance and marginalization faced by lifestyle medicine.

The roots of our argument can be traced to public health physician and biostatistician Halbert L. Dunn (1896-1975) who promoted the idea high-level wellness; Dunn contended that the prerequisite to individual and societal high-level wellness (vitality) is the opportunity to maintain a healthy lifestyle which includes a sense of purpose and creative expression [89,90]. The barriers to high-level wellness, Dunn argued, were institutional authoritarianism, clinging to dogma, lack of critical analysis skills (manifest in uncritical allegiance to “teams” in political, economic, occupational, academic and other social spheres), and the inability “to re-examine previous beliefs in the face of new facts or situations which bring to light contradictions” [89]. In particular, he was concerned that scientific findings could be selectively used/misused/ignored by socially-dominant elites (individual leaders, dominant organizations, or self-appointed experts) and authoritarians to the detriment of human wellness [91].

Although recent elections in North America and Europe have underscored the ways in which public and planetary health is threatened by political authoritarianism and elitism [92-94], the topics of social dominance orientation and authoritarianism aren’t restricted to political parties and their operatives; these psychological constructs are of relevance to all institutions, including those which maintain dominant ‘in-group’ status such as westernized medicine [95] and science [96]. Authoritarianism is described as  expecting or requiring people to obey; favoring a concentration of power; limitation of personal freedoms. Several authoritarianism scales have been validated, and higher scores on such instruments are associated with broad aspects of prejudice, rigid adherence to mainstream convention, and stigmatization of out-groups; furthermore, authoritarianism predicts aggression toward out-group members, hyper-vigilance to threats against non-conformism, and an intolerance to diversity and the viewpoints of differing cultures [97-99]. The authoritarian cognitive style is devoid of nuance and fine-grained discourse; out-groups are generically painted with broad-brush strokes in simplistic, all-or-none fashion [100].

Researchers have noted that authoritarianism often runs hand-in-hand with the related psychological construct of social dominance orientation (SDO); indeed, the tandem of authoritarianism and SDO is so potent that researchers refer to combination as the “lethal union” [101]. Higher levels of SDO reflect attraction to prestige and hierarchy within social structures; higher scores on SDO instruments predict the entitlement and acceptability of high-status groups to dominate other groups, and reflect the degree to which an individual accepts the maintenance of social and economic inequality. SDO scores also predict prejudice and obscure awareness that powers gained from dominant social positions are being used for personal gains [102,103]. On the other hand, lower scores on SDO scales predicts empathy, and greater concern for matters of social justice and inequalities [104]; since SDO reflects a desire to gain and maintain status, the construct is characterized by a hypervigilance against any challenges to privileged status and the associated benefits [105].

Separate but related to authoritarianism is Machiavellianism; higher scores on Machiavellianism scales typically reflect lower levels of empathy, conscientiousness, agreeableness and emotional intelligence, and higher levels of cynical beliefs [106]. Of relevance to our present discourse concerning the intentional marginalization of the less powerful (or the aforementioned “opposition and active resistance of numerous influential critics” faced by lifestyle medicine pioneer Dr Wilhelm Raab), Machiavellianism is also associated with the derogation of others who violate preconceived standards and intentional induction of shame and embarrassment in the target [107,108]. The detrimental consequences of Machiavellianism (at various scales - individual and group) is currently the subject of intense research within business and other organizational structures [109].

The idea that authoritarianism, SDO and Machiavellianism might permeate medical institutions to a degree that it interferes with global health concerns (our focus here on the interrelated priority of lifestyle medicine and planetary health) has escaped discourse. However, there is a body of research (albeit rarely cited in the mainstream) which demonstrates authoritarianism and/or SDO is at concerning levels among students upon entrance to western medical schools, that such levels are increased through medical education and then reinforced through the institutional levels of medicine [110-115]; levels of authoritarianism and/or Machiavellianism in medicine predicts judgment on certain patients for making unhealthy lifestyle choices, and is associated with negative attitudes toward those with chronic pain, substance abuse and unexplained symptoms [111,116,117].

Older research has demonstrated that medical students scoring high in authoritarianism are less likely to have accumulated undergraduate courses in sociology, anthropology and psychology, are uncomfortable with topics that are not concrete and precisely delineated, more likely to view psychiatry as a low prestige specialty, and the least likely to take a ‘whole person’ (patient-oriented) perspective in regard to the physician’s role [118]. Interestingly, the technical specialties (surgery, anesthesia, or those with low patient discourse) score higher on SDO, authoritarianism and/or Machiavellianism vs. general practitioners, pediatricians and/or psychiatrists [118]. Inside medicine itself, the gradient of bullying, unprofessional behavior and dominance has been reported to be from the technical specialties toward general practitioners and other disciplines with high patient engagement [119-121].

There have been very few plausible reasons for medicine’s decades-old evasion of lifestyle medicine; the most reasonable one takes us back to the 20th century golden age and the desire to replicate the model of its bench-side successes. Medical science is intrinsically reductionistic and we are all beneficiaries of the massive investments in the reductionist scientific methods (and its application in clinical settings). The painstaking toil of reductionist science continues to provide untold benefits to humankind. But so does painstaking public health research; the magnetic lure of reductionism may obscure that the active  ingredient in broccoli is simply broccoli. The sophistication of reductionist science shores up the social status of medical expertise - Nobel Prizes aren’t the domain of public health and lifestyle medicine; even without bringing financial incentives into the equation, the system is geared toward the silver bullet and ‘active ingredient’ solutions [122]. Lifestyle medicine isn’t a shiny, glittery object. In Dr Raab’s words:

“Part of the blame belongs to the average American physician. Fascinated by dramatic new diagnostic methods, scrambling to keep up with the proliferation of new therapies, [the physician] has little time to concentrate on the comparatively dull and nebulous subject of disease prevention...nor should the often-heard cry for “more research” ever serve as a mere excuse for not doing something - and soon - about our grave national health emergency. For when a house is on fire, those who live in it do not sit down amid the smoke and flames to discuss the need for more research into the chemical and physical laws of combustion.  They call the fire department” [123].

Medicine-at-large is sensitive to criticism [124]; it is likely that the resistance to Dr Raab’s criticisms is similar to the barriers encountered by contemporary physicians who advocate for lifestyle medicine. We posit that authoritarianism, SDO and Machiavellianism may be at play. This can explain why lifestyle medicine advocates are (despite their adherence to evidence) cast as ‘out-groups’ and justifies the view that it is unnecessary to truly transform the training of physicians commensurate with healthcare needs in the 21st century. To admit otherwise - that is, to expressly concede that the physician as currently trained is not an expert in all matters of health, including lifestyle and environmental variables - would be a threat to status. Rigid thinking may also be preventing the emergence from the mid-20th-century modern paternalistic infectious-disease model of teaching; in the late 1970s, when lifestyle medicine was a sapling, a commentary in the New England Journal of Medicine postulated that the field of lifestyle medicine was wide open for magic (as in pseudoscience): “The new theory is that most of today’s human illness, the infections aside, are multifactorial in nature, caused by two great arrays of causative mechanisms; the influence of things in the environment; and one’s personal lifestyle...it has become common belief that the environment will have to be changed, and personal ways of living will have to be changed, and radically. These things may turn out to be true...but it will take a long time to get the necessary proofs. Meanwhile, the field is wide open for magic” [125]. The same author pejoratively pinned lifestyle with holistic medicine: “Science is especially endangered these days...the most magical of all is the new discipline known as holistic medicine. All you have to do is live right and you can become indestructible” [126].

Four decades later—with plenty of ‘necessary proofs’ concerning lifestyle, the environment, and NCDs—we argue that medicine’s unwillingness to take charge of ‘the field’ has only left a larger void to be filled in by the magicians who operate outside the bounds of evidence-based lifestyle medicine. To what extent are fad diets, exercise substitutes in a pill - and all manner of gadgets - merely a space to be filled by medicine’s vacuum? On the other hand, the authoritarian who claims that lifestyle medicine is already ‘just medicine’ (inferring that its already being taken care of by contemporary medicine-at-large)—or insinuates that it isn’t a high-level concern—is, in our opinion, no less a charlatan or magician.

ACTION ORIENTATION AND
RESEARCH PRIORITIES

“Application of the biomedical model outside its limits is unscientific; advocacy of such application promotes dogma and is antiscientific”

   George L. Engel, MD, 1996 [29].

As western medicine marches deeper into the 21st century, its golden era of infectious disease control and scientific miracles now in the cultural rear-view mirror [127], it is increasingly evident that the health of person, place and planet are inseparable. In order to address this ‘new reality’, nothing short of a Flexnarian transformation of medical education will suffice. Of course, there have been many calls for adding some additional hours in nutrition or exercise counseling to an already-crowded medical curriculum; such small steps are obviously important but run the danger of acting as check-off boxes that mask the deeper mismatch between medical education and 21st century needs.

In the so-called post-truth world, filled with medical misinformation, the first steps to recovery entail an earnest and unqualified admission on the part of institutional medicine that it has a problem; just as public health acknowledged, two decades ago, that “we need a little humility, we need to recognize that the environmental movement has been doing public health’s work for the past 20 years or more in drawing public attention to the health effects of environmental problems” [128], medicine, too, might concede that some experts in evidence-informed lifestyle medicine/holistic health have been doing clinical medicine’s work in promoting a lifestyle for personal, public and planetary health for nearly half-a-century. Recovery requires an admission that very few medical doctors are currently experts in lifestyle as it pertains to health. Flexner went to work with the understanding that medical training was in disarray; he was assessing the damage with an eye toward remediation.

The academic transformation of 21st century medical education must include lifestyle medicine and planetary health perspectives throughout the training and continuing medical education processes; a single module will not suffice.

Students and resident physicians require exposure to lifestyle medicine in community practices as formalized extensions of the university-based medical schools; such experience within affiliated, multispecialty clinics can immediately demonstrate the value of reducing health disparities and ecological injustices via lifestyle interventions [129]. Of course, like any other aspect of scientific medicine, lifestyle factors in health - and the efforts of lifestyle medicine to address them - will always be a moving target; there is much known [130], but also much to be discovered concerning best practices [131]. However, there is little in the way of student accountability concerning the established evidence; only a small fraction of board/licensing questions involve detailed clinically-relevant nutrition and other lifestyle knowledge [132].

In addition to the incorporation of further scientific (lifestyle-related) knowledge into course curriculum, we argue that medicine-at-large needs to reevaluate its criteria for medical school entrance; interestingly, Joseph Merrill, MD, (who published several studies on authoritarianism in medicine) found that those who had the highest scores on the ‘science’ portion of the Medical Colleges Admission Test were more likely to hold antipathy toward patients, have higher need for dominance and had stronger opinions on the Totalitarian-Authoritarian-Dogmatism questionnaire [117].

There seems to be an urgent need to explore authoritarianism, SDO and Machiavellianism at entrance, throughout training and in later physician performance. Surprisingly little is known concerning the motivations of those who ‘win’ the highly competitive spots in medical school. Who is in it for the status and financial rewards? Some research shows that medical students with an overt dislike of integrative medicine score higher on status motivations and lower on agreeableness [133] (of relevance here because lower agreeableness often correlates with higher authoritarianism, SDO and Machiavellianism [134]); at some point we need to start weighing the candidate’s organic chemistry and physics scores vs. attributes which favor humanism in medical care in the anthropocene [135].

Progress in lifestyle medicine and planetary health requires interdisciplinary perspectives and inter-professional training which underscores that ‘leadership’ in the broad field of health (wellness/vitality) doesn’t belong to medical doctors by default [32]; however, higher SDO is associated with an unwillingness to engage in inter-professional education [136]. Machiavellianism also requires study in this context; for example, higher scores are associated with problematic work behavior among physicians [137], greater awareness of academic incivility (meaning they are cognizant of the disruption), and such individuals are more likely to perceive academic incivility as appropriate behavior [138]. Machiavellianism is also linked to excess social media use, cybertrolling and cyberbullying [139,140]; does collective narcissism - the unrealistic belief in the greatness of one’s particular group [141] - exist with certain sectors of medicine, is it impeding progress, and if so, how can it be addressed?

Movements toward lifestyle medicine with planetary health in mind will require knowledge on the extent to which physicians bring preformed opinions and dogma (especially political) into clinical settings. Authoritarianism and/or SDO predict lower levels of environmental concern (including the serious realities of climate change), and a hierarchical, human dominated view of nature [142-145]. The fact that human health is dependent upon planetary health leaves no room for opinions which contrast with scientific consensus concerning climate change; while most physicians agree that climate change is ongoing and that human activity plays a role, almost half of physicians (polled by the American Academy of Allergy, Asthma and Immunology, published Dec 2015) are at odds with the single correct scientific consensus (that is, climate change is ongoing and it is caused mostly by human activity) [146].

CONCLUSION

“Society granted physicians status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectation that physicians would be competent, altruistic, moral, and would address the health care needs of individuals and society. This arrangement remains the essence of the social contract”

   Sylvia R. Cruess, MD and Richard L. Cruess, MD, 2004 [147].

If medicine-at-large continues to neglect competency in lifestyle medicine it will risk rendering the social contract null and void. The gravitational tug of ever more science, specialization and personalization can certainly provide potential benefits; however, it can pull medical practice away from the grand confluence of ‘good for people, good for the planet’. We have posited that progress in lifestyle medicine (in the context of planetary health) requires a more fine-grained understanding of the ways in which authoritarianism and social dominance orientation (at individual, institutional and other scales) could support the status quo and/or interfere with meaningful solutions to serious global health problems.

The fallacious idea - maintained by medicine-at-large - that most physicians in western nations are currently lifestyle ‘experts’, or that it is “just medicine” (an oft-used statement that infers evidence-based lifestyle medicine is both widely taught and frequently deployed), is, in our opinion, at odds with the social contract and an important barrier to change. Whether or not this is a conscious process or simply inertia is a matter of debate and a suitable subject for research. In any case, the seriousness of global health problems - at scales of person, place and planet - force medicine-at-large to reevaluate its current medical school recruitment strategies and required prerequisites.

Medical practice of a given age has only ever been a ‘form.’ The function has always been to add years to human lives, and life (vitality) to human years, while minimizing the imposition of harm. The form of medicine should follow its defining function; today, the preponderance of chronic disease and premature death is preventable by lifestyle means, and thus, medicine is duty bound to address this fact.

Moreover, healthy people cannot reside on an uninhabitable planet, and thus medicine is also duty bound to address the confluence of human and planetary health; in sum, there is no medical discipline that can contribute meaningfully to the health of people and planet alike other than lifestyle medicine. The 21st century golden age of medicine awaits.

ACKNOWLEDGEMENTS

Conflicts: SLP reports the following: Scientific Advisory Board and speakers fees from Danone Nutricia, Schiphol, Netherlands and Nestlé Nutrition Institute, Lausanne, Switzerland; consultancy fees from Bayer Dietary Supplements Division, Whippany, NJ, USA; speakers fees from Health World Inc, Queensland, Australia; royalties from a trade paperback which discusses the microbiome.

ACL has received consultancy fees from Genuine Health, Toronto, Canada; speakers fees from Health World Inc, Queensland, Australia; royalties from a trade paperback which discusses the microbiome. DLK reports no competing interests.

REFERENCES

1. Shires DB, Hayward W. Prospecting in your practice.  Can Fam Physican 1979;25:934-6.

2. Allen L. Are we facing a noncommunicable disease pandemic? J Epidemiol Glob Health 2017;7:5-9.

3. Allen LN, Feigl AB. Reframing non-communicable diseases as socially transmitted conditions. Lancet Glob Health 2017;5:e644-6.

4. Prescott SL, Wegienka G, Logan AC, Katz DL. Dysbiotic drift and biopsychosocial medicine: How the microbiome links personal, public and planetary health. Biopsychosoc Med 2018;12:7.

5. Benatar S, Upshur R, Gill S. Understanding the relationship between ethics, neoliberalism and power as a step towards improving the health of people and our planet. Anthropocene Review 2018;5:155-76.

6. Rippe JM, Angelopoulos TJ. The American Journal of Lifestyle Medicine: A forum, a vision, and a mandate. Am J Lifestyle Med 2007;1:7-9.

7. Jaini PA, Lee JS. A review of 21st century utility of a biopsychosocial model in United States medical school education. J Lifestyle Med 2015;5:49-59.

8. Logan AC, Prescott SL, Haahtela T, Katz DL. The importance of the exposome and allostatic load in the planetary health paradigm. J Physiol Anthropol 2018; 37:15.

9. Whitmee S, Haines A, Beyrer C, Boltz F, Capon AG, de Souza Dias BF, Ezeh A, Frumkin H, Gong P, Head P, Horton R, Mace GM, Marten R, Myers SS, Nishtar S, et al. Safeguarding human health in the Anthropocene epoch: Report of The Rockefeller Foundation-Lancet Commission on planetary health. Lancet 2015;386: 1973-2028.

10. Rizvi S, Pagnutti C, Fraser E, Bauch CT, Anand M. Global land use implications of dietary trends. PLoS One 2018;13:e0200781.

11. Rice DP. Detection and prevention of chronic disease utilizing multiphasic health screening techniques: Hearings before the Subcommittee on the Health of the Elderly of the Special Committee on Aging. U.S. Government Printing Office; Washington, DC. 1966.

12. Beckman RO. Preventicare introduced to senators. Fort Lauderdale News. 1966, 29 Sep:10D. Print.

13. Turner EL. The changing panorama of medical care and some if its implications in medical care. Northwest Med 1953;52:295-8.

14. Allen EV. The golden age of medicine. Nebr State Med J 1950;35:307-9.

15. Brandt AM, Gardner M. The golden age of medicine? In: Cooter R, Pickstone JV, editors. Companion to medicine in the twentieth century. Routledge; London (UK). 2003. pp21-37.

16. Beecher HK. The powerful placebo. J Am Med Assoc 1955;159:1602-6.

17. Raab W. Golden age of medicine--Dark age of prevention. New Physician 1964;13:125-7.

18. Lepeschkin E. On the occasion of the 70th birthday of Dr. Wilhelm Raab. Cardiologia 1964;45:383-4.

19. Claffey CE. Center to end tired feeling. Boston Globe. 1961, 27th Aug:A8. Print.

20. Surawicz B. Profiles in cardiology: Wilhelm Raab. Clin Cardiol 1997;20:310-1.

21. Reddy KR, Freeman AM, Esselstyn CB. An urgent need to incorporate evidence-based nutrition and lifestyle medicine into medical training. Am J Lifestyle Med 2018. http://dx.doi.org/10.1177/1559827618781764.

22. U.S. Department of Health, Education and Welfare. Healthy people: The surgeon general’s report on health promotion & disease prevention. U.S. Government Printing Office; Washington DC. 1979.

23. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12.

24. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-45.

25. Collaborators USBoD, Mokdad AH, Ballestros K, Echko M, Glenn S, Olsen HE, Mullany E, Lee A, Khan AR, Ahmadi A, Ferrari AJ, Kasaeian A, Werdecker A, Carter A, Zipkin B, et al. The state of US health, 1990-2016: Burden of diseases, injuries, and risk factors among US states. JAMA 2018;319:1444-72.

26. Sagner M, Katz D, Egger G, Lianov L, Schulz KH, Braman M, Behbod B, Phillips E, Dysinger W, Ornish D. Lifestyle medicine potential for reversing a world of chronic disease epidemics: From cell to community. Int J Clin Pract 2014;68:1289-92.

27. Prescott SL, Logan AC, Albrecht G, Campbell DE, Crane J, Cunsolo A, Holloway JW, Kozyrskyj A, Lowry CA, Penders J, Redvers N, Renz H, Stokholm J, Svanes C, Wegienka G, et al. The Canmore declaration: Statement of principles for planetary health. Challenges 2018;9:31.

28. Cornwall EC. Some facts and principles of dietotherapy. Med Record 1919;96:181-86.

29. Engel GL. Biomedicine’s failure to achieve Flexnerian standards of education. J Med Educ 1978;53:387-92.

30. Brown ER. Rockefeller medicine men. University of California Press; Berkeley (CA). 1979.

31. Bloom SW. The medical school as a social organization: The sources of resistance to change. Med Educ 1989; 23:228-41.

32. Wilkes M, Kennedy R. Interprofessional health sciences education: It’s time to overcome barriers and excuses. J Gen Intern Med 2017;32:858-9.

33. Whitehead CR, Hodges BD, Austin Z. Captive on a carousel: Discourses of ‘new’ in medical education 1910-2010. Adv Health Sci Educ Theory Pract 2013;

18:755-68.

34. Skochelak SE. A decade of reports calling for change in medical education: What do they say? Acad Med 2010;85:S26-33.

35. Womersley K, Ripullone K. Medical schools should be prioritising nutrition and lifestyle education. Br J Sports Med 2018;52:e6.

36. Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools: Latest update of a national survey. Acad Med 2010;85:1537-42.

37. Cuerda C, Schneider SM, Van Gossum A. Clinical nutrition education in medical schools: Results of an ESPEN survey. Clin Nutr 2017;36:915-6.

38. Kahan S, Kushner RF. Nutrition in clinical medicine: A core competency for healthcare providers. Med Clin North Am 2016;100:xvii-xx.

39. Baute V, Carr AD, Blackwell JNt, Carstensen ER, Chhabra Pt, Porter LC, Cartwright MS. Incorporating formal nutrition education into a medical school curriculum: A student-initiated lecture series. Am J Med 2017;130:623-5.

40. Mogre V, Stevens FCJ, Aryee PA, Amalba A, Scherpbier A. Why nutrition education is inadequate in the medical curriculum: A qualitative study of students’ perspectives on barriers and strategies. BMC Med Educ 2018;18:26.

41. Gramlich LM, Olstad DL, Nasser R, Goonewardene L, Raman M, Innis S, Wicklum S, Duerksen D, Rashid M, Heyland D, Armstrong D, Roy C. Medical students’ perceptions of nutrition education in Canadian universities. Appl Physiol Nutr Metab 2010;35:336-43.

42. Hargrove EJ, Berryman DE, Yoder JM, Beverly EA. Assessment of nutrition knowledge and attitudes in preclinical osteopathic medical students. J Am Osteopath Assoc 2017;117:622-33.

43. Chung M, van Buul VJ, Wilms E, Nellessen N, Brouns FJ. Nutrition education in European medical schools: Results of an international survey. Eur J Clin Nutr 2014;68:844-6.

44. Devries S, Agatston A, Aggarwal M, Aspry KE, Esselstyn CB, Kris-Etherton P, Miller M, O’Keefe JH, Ros E, Rzeszut AK, White BA, Williams KA, Freeman AM. A deficiency of nutrition education and practice in cardiology. Am J Med 2017;130:1298-305.

45. Temple NJ. Survey of nutrition knowledge of Canadian physicians. J Am Coll Nutr 1999;18:26-9.

46. Raman M, Violato C, Coderre S. How much do gastroenterology fellows know about nutrition? J Clin Gastroenterol 2009;43:559-64.

47. Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. What do resident physicians know about nutrition? An evaluation of attitudes, self-perceived proficiency and knowledge. J Am Coll Nutr 2008;27:287-98.

48. Flynn M, Sciamanna C, Vigilante K. Inadequate physician knowledge of the effects of diet on blood lipids and lipoproteins. Nutr J 2003;2:19.

49. Castillo M, Feinstein R, Tsang J, Fisher M. Basic nutrition knowledge of recent medical graduates entering a pediatric residency program. Int J Adolesc Med Health 2016;28:357-61.

50. Castillo M, Feinstein R, Tsang J, Fisher M. An assessment of basic nutrition knowledge of adolescents with eating disorders and their parents. Int J Adolesc Med Health 2015;27:11-7.

51. Castillo M, Feinstein R, Fischer M. Nutrition knowledge of medical graduates. J Adv Nutr Hum Metab 2016;2:e1188:357-61.

52. Dunlop M, Murray AD. Major limitations in knowledge of physical activity guidelines among UK medical students revealed: Implications for the undergraduate medical curriculum. Br J Sports Med 2013;47:718-20.

53. Weiler R, Chew S, Coombs N, Hamer M, Stamatakis E. Physical activity education in the undergraduate curricula of all UK medical schools: Are tomorrow’s doctors equipped to follow clinical guidelines? Br J Sports Med 2012;46:1024-6.

54. Holtz KA, Kokotilo KJ, Fitzgerald BE, Frank E. Exercise behaviour and attitudes among fourth-year medical students at the University of British Columbia. Can Fam Physician 2013;59:e26-32.

55. Antognoli EL, Seeholzer EL, Gullett H, Jackson B, Smith S, Flocke SA. Primary care resident training for obesity, nutrition, and physical activity counseling: A mixed-methods study. Health Promot Pract 2017;18: 672-80.

56. Guseman EH, Whipps J, Howe CA, Beverly EA. First-year osteopathic medical students’ knowledge of and attitudes toward physical activity. J Am Osteopath Assoc 2018;118:389-95.

57. Strong A, Stoutenberg M, Hobson-Powell A, Hargreaves M, Beeler H, Stamatakis E. An evaluation of physical activity training in Australian medical school curricula. J Sci Med Sport 2017;20:534-8.

58. Cardinal BJ, Park EA, Kim M, Cardinal MK. If exercise is medicine, where is exercise in medicine?  Review of US medical education curricula for physical activity-related content. J Phys Act Health 2015;12: 1336-43.

59. Stevens C, Vrinten C, Smith SG, Waller J, Beeken RJ. Determinants of willingness to receive healthy lifestyle advice in the context of cancer screening. Br J Cancer 2018;119:251-7.

60. Kraschnewski JL, Sciamanna CN, Stuckey HL, Chuang CH, Lehman EB, Hwang KO, Sherwood LL, Nembhard HB. A silent response to the obesity epidemic: Decline in US physician weight counseling. Med Care 2013;51:186-92.

61. Chatterjee R, Chapman T, Brannan MG, Varney J. GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: A questionnaire-based survey of general practice in England. Br J Gen Pract 2017;67:668-75.

62. Talwalkar A, McCarty F. Characteristics of physician office visits for obesity by adults aged 20 and over: United States, 2012. NCHS Data Brief 2016.1-8.

63. Sreedhara M, Silfee VJ, Rosal MC, Waring ME, Lemon SC. Does provider advice to increase physical activity differ by activity level among US adults with cardiovascular disease risk factors? Fam Pract 2018;35: 420-5.

64. Hootman JM, Murphy LB, Omura JD, Brady TJ,  Boring M, Barbour KE, Helmick CG. Health care provider counseling for physical activity or exercise among adults with arthritis—United States, 2002 and 2014. MMWR Morb Mortal Wkly Rep 2018;66: 1398-401.

65. Guglielmo D, Hootman JM, Murphy LB, Boring MA, Theis KA, Belay B, Barbour KE, Cisternas MG, Helmick CG. Health care provider counseling for weight loss among adults with arthritis and overweight or obesity—United States, 2002–2014. MMWR Morb Mortal Wkly Rep 2018;67:485-90.

66. Bott D, Huntjens B, Binns A. Nutritional and smoking advice recalled by patients attending a UK age-related macular degeneration clinic. J Public Health (Oxf) 2017;40:1-9.

67. Williams K, Beeken RJ, Fisher A, Wardle J. Health professionals’ provision of lifestyle advice in the oncology context in the United Kingdom. Eur J Cancer Care (Engl) 2015;24:522-30.

68. Whitaker KM, Wilcox S, Liu J, Blair SN, Pate RR. Provider advice and women’s intentions to meet weight gain, physical activity, and nutrition guidelines during pregnancy. Matern Child Health J 2016;20: 2309-17.

69. Lee A, Belski R, Radcliffe J, Newton M. What do pregnant women know about the healthy eating guidelines for pregnancy? A web-based questionnaire. Matern Child Health J 2016;20:2179-88.

70. Zeev YB, Bonevski B, Twyman L, Watt K, Atkins L, Palazzi K, Oldmeadow C, Gould GS.  opportunities missed: A cross-sectional survey of the provision of smoking cessation care to pregnant women by Australian general practitioners and obstetricians. Nicotine Tob Res 2017;19:636-41.

71. Yang HY, Chen HJ, Hsu YJ, Cheskin LJ, Wang Y. Impact of weight-related advice from healthcare professionals on body mass index of patients in the USA. Public Health 2018;159:50-7.

72. Kushner RF, Ryan DH. Assessment and lifestyle management of patients with obesity: Clinical recommendations from systematic reviews. JAMA 2014;312: 943-52.

73. Stengel MR, Kraschnewski JL, Hwang SW, Kjerulff KH, Chuang CH. “What my doctor didn’t tell me”: Examining health care provider advice to overweight and obese pregnant women on gestational weight gain and physical activity. Womens Health Issues 2012;22: e535-40.

74. van Dooren C, Keuchenius C, de Vries J, de Boer JD, Aiking H. Unsustainable dietary habits of specific subgroups require dedicated transition strategies: Evidence from the Netherlands. Food Policy 2018;79:44-57.

75. Seconda L, Baudry J, Alles B, Boizot-Szantai C, Soler LG, Galan P, Hercberg S, Langevin B, Lairon D, Pointereau P, Kesse-Guyot E. Comparing nutritional, economic, and environmental performances of diets according to their levels of greenhouse gas emissions. Clim Change 2018;148:155-72.

76. van de Kamp ME, Seves SM, Temme EHM. Reducing GHG emissions while improving diet quality: Exploring the potential of reduced meat, cheese and alcoholic and soft drinks consumption at specific moments during the day. BMC Public Health 2018;18:264.

77. Hendrie GA, Baird D, Ridoutt B, Hadjikakou M, Noakes M. Overconsumption of energy and excessive discretionary food intake inflates dietary greenhouse gas emissions in Australia. Nutrients 2016;8:690.

78. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture. US Department of Agriculture, Agricultural Research Service; Washington, DC. 2015.

79. Blackstone NT, El-Abbadi NH, McCabe MS, Griffin TS, Nelson ME. Linking sustainability to the healthy eating patterns of the Dietary Guidelines for Americans: A modelling study. Lancet Planet Health 2018;2: 344-52.

80. Tilman D, Clark M. Global diets link environmental sustainability and human health. Nature 2014;515: 518-22.

81. Logan AC, Prescott SL. Astrofood, priorities and pandemics: Reflections of an ultra-processed breakfast program and contemporary dysbiotic drift. Challenges 2017;8:24.

82. Prescott SL, Logan AC. Transforming life: A broad view of the developmental origins of health and disease concept from an ecological justice perspective. Int J Environ Res Public Health 2016;13:1075.

83. Prescott SL, Logan AC. Each meal matters in the exposome: Biological and community considerations in fast-food-socioeconomic associations. Econ Hum Biol 2017;27:328-35.

84. Gomez A, Balsari S, Nusbaum J, Heerboth A, Lemery J. Perspective: Environment, biodiversity, and the education of the physician of the future. Acad Med 2013;88:168-72.

85. Katz DL. The medical ethics of food. AMA J Ethics 2018;20: E994-1000.

86. Weiler R, Feldschreiber P, Stamatakis E. Medicolegal neglect? The case for physical activity promotion and exercise medicine. Br J Sports Med 2012;46:228-32.

87. Bodai BI, Nakata TE, Wong WT, Clark DR, Lawenda S, Tsou C, Liu R, Shiue L, Cooper N, Rehbein M, Ha BP, McKeirnan A, Misquitta R, Vij P, Klonecke A, et al. Lifestyle medicine: A brief review of its dra-matic impact on health and survival. Perm J 2017;22: 17-025.

88. McDonnell LA, Turek M, Coutinho T, Nerenberg K, de Margerie M, Perron S, Reid RD, Pipe AL. Women’s heart health: Knowledge, beliefs, and practices of Canadian physicians. J Womens Health (Larchmt) 2018;27:72-82.

89. Dunn HL. High-level wellness for man and society. Am J Public Health Nations Health 1959;49:786-92.

90. Dunn HL. What high-level wellness means. Can J Public Health 1959;50:447-57.

91. Dunn HL. High-level wellness: A collection of twenty-nine short talks on different aspects of the theme “High-level wellness for man and society”. Slack Publishing; Thorofare (NJ). 1977. p189.

92. McKee M. Health professionals must uphold truth and human rights. Eur J Public Health 2017;27:6-7.

93. Greer SL. Medicine, public health and the populist radical right. J R Soc Med 2017;110:305-8.

94. Horton R. Offline: Planetary health-worth everything. Lancet 2018;391:2307.

95. Prescott SL, Logan AC. From authoritarianism to advocacy: Lifestyle-driven, socially-transmitted conditions require a transformation in medical training and practice. Challenges 2018;9:10.

96. Lemaitre B. Science, narcissism and the quest for visibility. FEBS J 2017;284:875-82.

97. Adorno TW, Frenkel-Brunswik E, Levinson DJ, Sanford RN. The authoritarian personality. Harper;

New York (NY). 1950.

98. Stenner K. The authoritarian dynamic. Cambridge University Press; Cambridge (UK). 2005.

99. Martinez-Zambrano F, Garcia-Morales E, Garcia-Franco M, Miguel J, Villellas R, Pascual G, Arenas O, Ochoa S. Intervention for reducing stigma: Assessing the influence of gender and knowledge. World J Psychiatry 2013;3:18-24.

100. Hammond MD, Cimpian A. Investigating the cognitive structure of stereotypes: Generic beliefs about groups predict social judgments better than statistical beliefs. J Exp Psychol Gen 2017;146:607-14.

101. McFarland S. Authoritarianism, social dominance, and other roots of generalized prejudice. Pol Psychol 2010;453-77:453-77.

102. Guimond S, Dambrun M, Michinov N, Duarte S. Does social dominance generate prejudice? Integrating individual and contextual determinants of intergroup cognitions. J Pers Soc Psychol 2003;84:697-721.

103. Tan X, Liu L, Huang Z, Zheng W. The dampening effect of social dominance orientation on awareness of corruption: Moral outrage as an indicator. Soc Indic Res 2016;125:89-102.

104. Pratto F, Sidanius J, Stallworth LM, Malle BF. Social dominance orientation: A personality variable predicting social and political attitudes. J Pers Soc Psychol 1994;67:741-63.

105. Sidanius J, Cotterill S, Sheehy-Skeffington J, Kteily N, Carvacho H. Social dominance theory: Explorations in the psychology of oppression. In: Barlow FK, Sibley CG, editors. The Cambridge Handbook of the Psychology of Prejudice. Cambridge University Press, ; Cambridge (UK). 2016. pp149-87.

106. Abell L, Qualter P, Brewer G, Barlow A, Stylianou M, Henzi P, Barrett L. Why Machiavellianism matters in childhood: The relationship between children’s Machiavellian traits and their peer interactions in a natural setting. Eur J Psychol 2015;11:484-93.

107. Schriber RA, Chung JM, Sorensen KS, Robins RW. Dispositional contempt: A first look at the contemptuous person. J Pers Soc Psychol 2016;113: 280-309.

108. Austin EJ, Farrelly D, Black C, Moore H. Emotional intelligence, Machiavellianism and emotional manipulation: Does EI have a dark side? Pers Individ Dif 2007;43:179-89.

109. Wisse B, Seebos E. When the dark ones gain power: Perceived position power strengthens the effect of supervisor Machiavellianism on abusive supervision in work teams. Personality Indiv Diff 2016;99:122-6.

110. Merrill JM, Camacho Z, Laux LF, Thornby JI, Vallbona C. How medical school shapes students’ orientation to patients’ psychological problems. Acad Med 1991;66:S4-6.

111. Merrill JM, Laux LF, Lorimor R, Thornby JI, Vallbona C. Authoritarianism’s role in medicine. Am J Med Sci 1995;310:87-90.

112. Lepiece B, Reynaert C, van Meerbeeck P, Dory V. Social dominance theory and medical specialty choice. Adv Health Sci Educ Theory Pract 2016;21:79-92.

113. Tsimtsiou Z, Kerasidou O, Efstathiou N, Papaharitou S, Hatzimouratidis K, Hatzichristou D. Medical students’ attitudes toward patient-centred care: A longitudinal survey. Med Educ 2007;41:146-53.

114. Lavin B, Haug M, Belgrave LL, Breslau N. Change in student physicians’ views on authority relationships with patients. J Health Soc Behav 1987;28: 258-72.

115. van Ryn M, Hardeman RR, Phelan SM, Burke SE, Przedworski J, Allen ML, Burgess DJ, Ridgeway J, White RO, Dovidio JF. Psychosocial predictors of attitudes toward physician empathy in clinical encounters among 4732 1st year medical students: A report from the CHANGES study. Patient Educ Couns 2014;96: 367-75.

116. Merrill JM, Camacho Z, Laux LF, Thornby JI, Vallbona C. Machiavellianism in medical students. Am J Med Sci 1993;305:285-8.

117. Merrill JM, Laux L, Thornby JI. Troublesome aspects of the patient-physician relationship: A study of human factors. South Med J 1987;80:1211-5.

118. Parker S. Personality factors among medical students as related to their predisposition to view the patient as a whole man. J Med Educ 1958;33:736-44.

119. Roberts NK, Dorsey JK, Wold B. Unprofessional behavior by specialty: A qualitative analysis of six years of student perceptions of medical school faculty. Med Teach 2014;36:621-5.

120. Bradley V, Liddle S, Shaw R, Savage E, Rabbitts R, Trim C, Lasoye TA, Whitelaw BC. Sticks and stones: Investigating rude, dismissive and aggressive communication between doctors. Clin Med (Lond) 2015;15: 541-5.

121. Baker M, Wessely S, Openshaw D. Not such friendly banter? GPs and psychiatrists against the systematic denigration of their specialties. Br J Gen Pract 2016; 66:508-9.

122. Katz DL: HuffPost Q&A: Reductionists missing the forest for the trees? [Internet]. The Huffington Post; 2013 [updated March 18, 2013; cited 2019 Aug 19]. Available from: https://www.huffingtonpost.com/david-katz-md/huffpost-qa-david-katz_b_2473574.html.

123. Raab W. Heart attack - number one killer of Americans. In: Williams RL, editor. The healthy life: How diet and exercise affect your hearth and vigor. Time, Inc; New York (NY). 1966. pp18-23.

124. Anderson OW. The medical profession and the public: An examination of interrelationships. Mich Med 1968; 67:455-63.

125. Thomas L. Notes of a biology-watcher. On magic in medicine. N Engl J Med 1978;299:461-3.

126. Thomas L. Science and the future of medicine: Future prospects. Trans Assoc Am Physicians 1978;91:72-9.

127. Burnham JC. American medicine’s golden age: What happened to it? Science 1982;215:1474-9.

128. Hancock T. Ecosystem health, ecological iatrogenesis, and sustainable human development. Ecosystem Health 1997;3:229-34.

129. Rooke J. Advancing health equity with lifestyle medicine. Am J Lifestyle Med 2018;12:472-5.

130. Katz DL, Meller S. Can we say what diet is best for health? Annu Rev Public Health 2014;35:83-103.

131. Doughty KN, Del Pilar NX, Audette A, Katz DL. Lifestyle medicine and the management of cardiovascular disease. Curr Cardiol Rep 2017;19:116.

132. Patel S, Taylor KH, Berlin KL, Geib RW, Robin Danek R, Waite GN. Nutrition education in U.S. medical schools: An assessment of nutrition content in USMLE STEP preparation materials. J Curriculum Teaching 2015;4:108-13.

133. Jocham A, Kriston L, Berberat PO, Schneider A, Linde K. How do medical students engaging in elective courses on acupuncture and homeopathy differ from unselected students? A survey. BMC Complement Altern Med 2017;17:148.

134. Ekehammar B, Akrami N, Gylje M, Zakrisson I. What matters most to prejudice: Big five personality, social dominance orientation, or right-wing authoritarianism? Eur J Personality 2004;18:463-82.

135. Gaufberg E, Dunham L, Krupat E, Stansfield B, Christianson C, Skochelak S. Do gold humanism honor society inductees differ from their peers in empathy, patient-centeredness, tolerance of ambiguity, coping style, and perception of the learning environment? Teach Learn Med 2018;30:284-93.

136. Sollami A, Caricati L, Mancini T. Does the readiness for interprofessional education reflect students’ dominance orientation and professional commitment? Evidence from a sample of nursing students. Nurse Educ Today 2018;68:141-5.

137. Ying L, Cohen A. Dark triad personalities and counterproductive work behaviors among physicians in China. Int J Health Plann Manage 2018;33:e985-98.

138. Turnipseed DL, Landay K. The role of the dark triad in perceptions of academic incivility. Personality Indiv Diff 2018;135:286-91.

139. Kircaburun K, Jonason PK, Griffiths MD. The Dark Tetrad traits and problematic social media use: The mediating role of cyberbullying and cyberstalking. Personal Individ Diff 2018;135:264-9.

140. Wang X, Lei L, Liu D, Hu H. Moderating effects of moral reasoning and gender on the relation between moral disengagement and cyberbullying in adolescents. Personal Individ Diff 2016;98:244–9.

141. Putnam AL, Ross MQ, Soter LK, Roediger HL. Collective narcissism: Americans exaggerate the role of their home state in appraising U.S. history. Psychol Sci 2018. http://dx.doi.org/10.1177/0956797618772504.

142. Carrus G, Panno A, Leone L. The moderating role of interest in politics on the relations between conservative political orientation and denial of climate change. Soc Nat Resour 2018;31:1103-17.

143. Milfont TL, Richter I, Sibley CG, Wilson MS, Fischer R. Environmental consequences of the desire to dominate and be superior. Pers Soc Psychol Bull 2013;39: 1127-38.

144. Panno A, Giacomantonio M, Carrus G, Maricchiolo F, Pirchio S, Mannetti L. Mindfulness, pro-environmental behavior, and belief in climate change: The mediating role of social dominance. Environ Behav 2018;50:864-88.

145. Jylha KM, Akrami N. Social dominance orientation and climate change denial: The role of dominance and system justification. Pers Individ Dif 2015;86:108–11.

146. Sarfaty M, Kreslake JM, Bloodhart B, Price K, Montoro M, Casale TB, Folstein S, Maibach EW:

George Mason University Centre for Climate Change Communication: Views of allergy specialists on health effects of climate change [Internet]. Milwaukee (WI): American Academy of Allergy, Asthma & Immunology; 2015 [cited 2016 Aug 29]. Available from: https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/ Libraries/Climate-Change-Survey.pdf

147. Cruess SR, Cruess RL. Professionalism and medicine’s social contract with society. Virtual Mentor 2004;6: 185-8

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