Position Paper

Purpose

For my candidacy for the office of Young Leader Director of the Asian Society of Lifestyle Medicine (ASLM)

Introduction

Asia is the largest of earth’s seven defined continents with a colourful population of 4.15 billion [1] and, diverse value systems, faiths, beliefs, customs and economies [2, 3]. Similarly, its healthcare systems; ranging from tax-based financing to social insurance and high-out-of-pocket payment [3]. Asia is also known to be burdened with an array of unique health related problems which are scattered in different regions in sundry patterns [4]. Increasing healthcare costs, ageing populations, healthcare access and quality, communicable diseases and non-communicable diseases (NCDs) are some key health problems to mention. Out of which, NCDs are rising in tandem with increased prosperity and urbanisation promoting sedentary lifestyle, in the region [5, 6]. Unhealthy lifestyle behaviours are at the root of the burden of NCDs, which are now the leading cause of disability- adjusted life years (DALYs) [7 ,8] and the most prevalent cause for increased morbidity and mortality worldwide [9]. In fact, NCDs are strongly related to poverty and are major drain on the economy [6]. On the whole, ageing populations with an increasing burden of NCDs could be catastrophic to thriving economies in Asia.

Background

Lifestyle Medicine

Lifestyle Medicine emphasises on promoting behaviour changes that allows the body to heal itself and focuses on evidence based practice of helping individuals and families, adopt and sustain healthy behaviours that affect health and quality of life (optimal nutrition, physical activity, cessation of tobacco, sleep, stress management and healthy relationships) [10]. There is a strong body of evidence demonstrating that healthy behaviours reduce the risk of chronic disease. A comprehensive review of scientific evidence affirmed the utilisation of Lifestyle Medicine both for the prevention and treatment of chronic disease [11]. However, it presents a challenging yet a pragmatic approach, especially in the settings of Asia [9]. Furthermore, it is considered a sustainable solution for ever increasing cost of healthcare.

Planetary Health

Radical and wide-ranging changes to the structure and function of the Earth’s ecological systems represent a growing threat to human health [12]. “Planetary health is an attitude towards life and a philosophy for living”. Its vision is for a planet that nourishes and sustains the diversity of life with which we coexist and on which we depend. This process includes all relevant stakeholders and most importantly, every human being who has an interest in their own health, in the health of their fellow human beings, and that of future generations [13]. Our endeavour to propagate the practice of Lifestyle Medicine indirectly and completely supports the creation of a movement for planetary health.

I support knowledge and access to knowledge as one source of social transformation. Making the message of Lifestyle Medicine freely available to public could certainly be another stepping stone to eradication of widely prevalent NCDs while ensuring sustainability of our planet.

Asia as a Region

Asia could be geographically subdivided in to four main regions; East Asia (EA), South-east Asia (SEA), South Asia (SA) and West Asia. However, provided established agencies and treaties for Asian regional cooperation and the membership of ASLM; EA, SEA and SA are discussed in detail throughout this paper. South Asian Association for Regional Cooperation (SAARC) for SA and Association of South East Asian Nations (ASEAN) for SEA are international relations and regional cooperation coalitions established between the nations. SAARC, EA and ASEAN countries contribute towards 44.09%, 39.96% and 15.92% of the Asian population respectively [1], while leaving out East Timor [14].

East Asia’s healthcare challenges include large inequalities that are observed between the poor and the prosperous in their access to healthcare financing mechanisms [15]. Japan has achieved success in reduction of alcohol consumption, transport accident deaths, communicable diseases and NCDs during the past decades, though the pace of reduction has stagnated since 2005 for NCDs. Its health struggle also includes tobacco control, low birth rate, ageing population and Alzheimer’s disease [16]. China on the other hand has successfully mitigated the crises of communicable diseases over the last few decades but it is facing a significant burden of chronic NCDs today [17]. This epidemiological transition in China is attributed to both heavy environmental pollution resulting from industrialisation and changing lifestyles and consumption patterns [18]. South Korea has made progress in its health status through economic development and universal health coverage through national health insurance, but NCDs continue to be the top causes of mortality.

Similarly, but as profoundly evident, in South Asia almost half of the adult disease burden is attributable to NCDs [19]. Particularly, Indian subcontinent has among the highest rates of cardiovascular disease globally, largely driven by urbanisation [20]. Cardiovascular disease with stroke being the major cause of mortality while being accountable to a large proportion of DALYs, hypertension and diabetes mellitus which had risen more rapidly than in any other region in the world constitutes part of the struggle in SA [19]. Metabolic syndrome and abdominal obesity among urban adults are observed in India and in countries such as Pakistan, Bangladesh and Sri Lanka [19, 21]. Moreover, indoor air pollution, tobacco consumption (smoking and chewing), excessive alcohol consumption and related cancers (lung cancers and oropharyngeal cancer) are major health concerns in the region [5, 19].

South-East Asia, a collection of island fragments large and small makes the foundation of wide variation in history and, social/ cultural heterogeneity. Globalisation and technological advances have brought these nations closer together. This convergence, manifested reduction in deaths from communicable diseases and increase in average life expectancy with an epidemic rise in chronic NCDs [3]. Furthermore, ageing populations and low birth rates in Thailand and Singapore, immigration/ emigration patterns across SEA, diminishing trends of communicable diseases in most countries except Cambodia, Myanmar and Laos, natural disasters, effects of climate change and increasing trends of NCDs particularly in cardiovascular disease and cancer have defined current and near-future trends of public health interests in SEA [6]. In addition, Myanmar and Thailand suffer from high per capita intake of alcohol in par with some countries in SA region such as India and Sri Lanka [5].

Striking a balance between different healthcare stakeholders; taking into account overall resource constraints, efficacy of service delivery and welfare gains, is a key challenge for many countries in the region. However, on the bright side, aforementioned growing health concerns could be effectively addressed by relatively low-cost preventive and curative interventions [18], including approaches such as Lifestyle Medicine in this large and intricate task.

Actions with an Empirical Approach

Working hand-in-hand with multiple stakeholders would play a key role in optimising the outcomes. Therefore, understanding our stakeholders is vital for the viability and propagation of this movement. Medical/ allied health students, university lecturers/ medical educationists, government bodies, policy makers, academic/ training institutions, general public and corporates are key parties in the mission of establishing Special Interest Groups across sundry strata. The threefold action plan proposed below is an attempt to blend pragmatic approach with special considerations of the region.

1st Establishing Special Interest Groups (SIGs)

Creating SIGs of Lifestyle Medicine could be an effective way forward in addressing the health issues with a view to a future free of current struggles of health in Asia. This approach is threefold: SIGs building, lobbying and media campaign. Tools such as East Asian Medical Students’ Conference 2020, Medical Students International Conference 2020, Conference of International Federation of Medical Students’ Association 2019 and 10th Asian Medical Education Symposium 2019 shall be cardinal platforms for collaboration, brief training sessions for SIG building and obtaining feedback for ongoing SIGs in order to tweak SIG approach to match cultural barriers and processes. Ultimate goal of this exercise is to develop a strong, tested, culturally appropriate framework and an ecosystem that works for all of Asia and has properties of self-propagation; training modules, ample online resources [22], foster and support the exchange of information between SIGs, equipped for quality maintenance, protocols to ensure adherence/ compliance, provision of opportunities to learn from the best practices, rewarding schemes for regions, online registration modules, information systems for quarterly or annual returns [to be decided following a feasibility assessment] and sharing stories across the Globe via various platforms (E.g.: Lifestyle Medicine SIGs – Asia blog, social media platforms and scientific conferences).

Furthermore, reaching out to universities and medical/ allied health training institutions through members of ASLM by the means of promoting research in Lifestyle Medicine is another, yet an important portal of entry.

The goal is to establish SIGs in all three regions of Asia at a ratio of 1 per 30 million populations [>50% countries in Asia have a population more than 30 million people, hence this number was chosen for convenient sampling for a pragmatic action plan] per country except for China and India, while ensuring at least one SIG in all the countries with less than 30 million populations, within a course of two years, covering medical and allied health faculties/ universities. [A feasible and an achievable number of SIGs to be established in China and India to be discussed with country representatives.]

2nd Raising Awareness

Raising public awareness would serve as a corner stone to the sustainability of this movement, in my opinion. As we progress, certain social groups/ regions becoming articulate about the reasons underlying disengagement and being conscious of their lack of involvement in the movement is crucial for change. On the other hand, the need for higher income has been an important consideration when choosing certain medical disciplines among medical undergraduates, particularly the highly sought after medical specialties such as gastroenterology, nephrology, and cardiology [23], which may in turn call for raising awareness on Lifestyle Medicine and its utility among the general public in order to ensure a sustainably rising demand. These converging trends would eventually influence government policy makers and corporations/ insurance companies to advocate better budgetary allocations for the practice of Lifestyle Medicine.

This goal could be achieved with a strong body of scientific evidence to support the effectiveness of Lifestyle Medicine interventions in Asia and promoting it through social media and mass media communications. On-going public health/ health promotions interventions might as well serve as avenues for creating public awareness.

3rd Building Research Collaborations

Promotion of collaborative research among medical and allied health students/ professionals and thereby finding better evidence in local context to support the approach.

In this venture, it is pivotal that we understand the status quo among medical specialties in Asia. Lifestyle friendliness has been well-documented in the medical literature as a factor that influences medical students’ choice of specialisation/ training [24]. A recent study elaborated that basic medical subjects and service-oriented (lifestyle-related) and preventive medical specialties were found to be less attractive to medical students [25]. However, interestingly a study conducted in Japan revealed that preclinical and clinical experiences as well as role models are influential factors when formulating their specialty preferences [26], which may suggest that revamping medical education and incorporation of concepts of Lifestyle Medicine in the medical curriculum (E.g. Medical curriculum of the College of Medicine, Adventist University of the Philippines) is likely a promising way ahead. Collaborative research in medical education involving Lifestyle Medicine could most likely bring this to a reality by convincing medical educationists and policy makers.

All in all, I assume that the mainstay at this stage of the movement promoting Lifestyle Medicine is to invest time and energy in establishment of SIGs, raising awareness among students, professionals and the general public, and research collaborations in order to build a solid body of evidence locally and thereby influencing education curricula in medical and allied health universities/ institutions. It will invariably lead us towards better health policies through strong and sustainable collaborations with all stakeholders, with Lifestyle Medicine as the paradigm shift in all aspects of delivery of preventive medicine, primary care, as well as tertiary care.

Samandika Saparamadu’s Profile

I am a Medical Doctor, 31, who is currently based in Singapore (Country of Origin: Sri Lanka). Passionate in making the society a better place through our medical profession. I have been a social activist and a public speaker as a medical undergraduate. My interests and experience spans across clinical medicine, clinical research, public health research and movement building. Currently, I am continuing my research work at MOHH Singapore and completing my British Internal Medicine Board Exams (MRCP) while waiting to embark on my career in Public Health. My resume submitted to ASLM will provide more insight into my profile.

References

  1. Worldometers.info. Asian Populations by Country [internet] Dover, Delaware, U.S.A; 2019 [Accessed 2019 Feb 27]. Available from: http://www.worldometers.info/population/countries-in- asia-by-population/
  2. Fawcett J, Arnold E. Explaining Diversity: Asian and Pacific Immigration Systems. In Pacific Bridges: The New Immigration from Asia and the Pacific Islands. New York: Center for Migration Studies. 1987:453-73.
  3. Chongsuvivatwong V et al. Health and health-care systems in southeast Asia: diversity and transitions. Lancet 2011;377:429–37
  4. Key health challenges in the asia pacific region [internet]. WHO Western Pacific Region;2018 [Accessed 2019 Feb 25] Available from: http://www.wpro.who.int/health_research/documents/ dhs_hr_health_in_asia_and_the_pacific_18_chapter_13_key_health_challenges_in_the_asia_pacifi c_region.pdf
  5. World health statistics 2018: monitoring health for the SDGs, sustainable development goals [internet] Geneva: World Health Organization;2018. [Accessed 2019 Feb 25] Available from: https://apps.who.int/iris/bitstream/handle/10665/272596/9789241565585-eng.pdf?ua=1
  6. Dans A, Ng N, Varghese C, Tai ES, Firestone R, Bonita R.The rise of chronic non- communicable diseases in southeast Asia: time for action. Lancet 2011;337:680–9.
  7. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990 – 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224 – 60.
  8. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270(18): 2207-12.
  9. Kushner RF, Sorensen KW. Lifestyle medicine: the future of chronic disease management. Curr Opin Endocrinol Diabetes Obes 2013;20:389 – 95
  10. ASLM. Lifestyle Medicine Standards [internet]. Lifestyle Medicine Standards Taskforce [Accessed 2019 Feb 28] Available from: https://www.lifestylemedicine.org/ACLM-Standards
  11. American College of Preventive Medicine. Lifestyle medicine: evidence review. 30 June 2009. http://c.ymcdn.com/sites/www.acpm.org/resource/ resmgr/lmi-files/lifestylemedicine- literature.pdf [Accessed 01 Jan 2019]
  12. Whitmee S, Haines A, Beyrer C at al. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. The Lancet 2015;386:1973-2027
  13. Horton R, Beaglehole R, Bonita, Raeburn J, McKee M, Wall S. From public to planetary health: a manifesto. The Lancet 2014;383:847
  14. Simonsen SG. The Authoritarian Temptation in East Timor: Nationbuilding and the Need for Inclusive Governance. Asian Survey 2006;46(4):575-96
  15. Langenbrunner JC, Somanathan A. Financing Health Care in East Asia and the Pacific: Best Practices and Remaining Challenges. World Bank Group 2011. Available from: https:// elibrary.worldbank.org/doi/pdf/10.1596/978-0-8213-8682-8
  16. Health systems in transition: Japan Health System Review [internet] Geneva: World Health Organization; 2018. [Accessed 2019 Feb 25] Available from: https://apps.who.int/iris/bitstream/ handle/10665/259941/9789290226260- eng.pdf;jsessionid=BD717D314228B762B19C24C5D7DAB681?sequence=1
  17. Yang G, Kong L, Zhao W, et al. Emergence of chronic non-communicable diseases in China. Lancet 2008;372:1697-705.
  18. Bandara A. Emerging health issues in asia and the pacific: Implications for public health policy. Asia-Pacific Development Journal 2015;12(2):33-58
  19. Ghaffar A, K Srinath Reddy, Monica Singhi. Burden of non-communicable diseases in South Asia. BMJ 2004;328:807-10
  20. Goyal A, Yusuf S. The burden of cardiovascular disease in the Indian subcontinent. Indian J Med Res 2006;124:235-44
  21. Misra A, Khurana L. Obesity-related non-communicable diseases: South Asians vs White Caucasians. International Journal of Obesity 2011;35:167–87
  22. American College of Lifestyle Medicine [internet] Lifestyle Medicine Interest Groups [Accessed 2 March 2019] Available from: https://lifestylemedicine.org/ACLM/About/ Student___Trainee/Interest_Groups/ACLM/About/Student_Trainee/Interest_Group.aspx? hkey=497cf687-3196-4e23-a354-5f55aa6b44b0
  23. Garibaldi RA, Popkave CMA, Bylsma W. Career Plans for Trainees in Internal Medicine Residency Programs. Academic Medicine 2005;80(5):507-12
  24. Creed PA., Searle J, Rogers ME. Medical specialty prestige and lifestyle preferences for medical students. Social Science & Medicine 2010;71(6):1084–8
  25. Ahmed SM, Majumdar MA, Karim R, Rahman S, Rahman N. Career choices among medical students in Bangladesh. Adv Med Educ Pract. 2011;2:51-8
  26. Saigal P, Takemura Y, Nishiue T, Fetters MD. Factors considered by medical students when formulating their specialty preferences in Japan: findings from a qualitative study. BMC Med Educ. 2007;7:31

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