The Silent Epidemic.

The Coronavirus Disease 2019 (COVID-19) pandemic has forever altered the world that we live and practice in. Each of us has needed to make significant changes in our lives and the way we work. We have experienced stay-at-home orders, mask wearing, as well as sanitizing surfaces and scrupulous handwashing practices. Yet, this deadly virus continues to spread. Experts now estimate that there may be over 400,000 fatalities from COVID-19 in the United States by December 31, 2020.

The widespread devastation from the COVID-19 virus has disrupted every aspect of our lives. We see tragic examples of people dying alone with family members unable to be there to comfort them due to the virus. We also see health care workers who have risen to the challenge of treating these desperately ill people while often feeling overwhelmed by the magnitude of the problem and even the lack of proper protective equipment.

The COVID-19 virus has rightly taken center stage for our entire nation. Despite the devastating consequences of COVID-19 I believe there may be a silver lining for the medical community. The COVID-19 pandemic has caused us to stop and consider how precious life is and what we are called upon to do as physicians. With this in mind, I believe that this may be a propitious time to examine what I refer to as “America's Silent Epidemic.” For example, the Centers for Disease Control and Prevention estimates that over 650,000 individuals in the United States will die of heart disease this year. The National Institutes of Health estimates that obesity each year causes over 300,000 fatalities. Diabetes is listed as the cause of death for over 270,000 individuals each year. Over 480,000 people in the United States die each year from cigarette smoking or passive exposure to cigarette smoke. When you add up these largely preventable diseases, this silent epidemic takes over 4 times as many American lives each year as COVID-19.

While most physicians would agree that these lifestyle-related diseases are important and largely preventable, unfortunately the medical community has been largely absent from the battle to ameliorate these conditions. In fact, numerous studies show that physicians typically discuss weight management, physical activity, or proper nutrition in <40% of the individuals that they see in their practices.

There is another important reason for physicians to address issues related to lifestyle habits and practices with all of their patients but particularly with disadvantaged populations. Health disparities have played a role in the alarming racial and ethnic disparities related to COVID-19. Age-adjusted hospitalization rates for COVID-19 among native Americans and black Americans are between 4 1/2 and 5 times that of white Americans. Hispanic Americans have also been disproportionately affected. Hispanic Americans are hospitalized at a rate approximately 4 times that of white Americans. Moreover, the mortality of black Americans in a number of cities has been more than twice as high as the proportion of black residents in their geographic area. Both obesity and poor nutritional habits have contributed significantly to the disparities in how COVID-19 has affected Americans. Both obesity and poor nutrition are more common in disadvantaged populations than they are in more affluent ones. Thus, COVID-19 has underscored issues of health equity in our country, an area that physicians need to seriously address. A number of medical organizations such as the American College of Physicians and the American Heart Association have already articulated positions on health equity.

The public generally understands the value of these positive lifestyle measures, yet their actions speak louder than their words. The Physical Activity Guidelines 2018 Scientific Report, for example, presents overwhelming evidence of the multiple benefits of regular physical activity, yet, reports that <25% of adults participate in the 150 minutes of moderate to vigorous physical activity that the report recommends. The National Health and Nutrition Examination Survey reports that <9% of adults consume the recommended daily serving of vegetables and only 12% consume the recommended servings of fruit. The Dietary Guidelines for Americas 2020-2025 reports that Americans are not consuming enough whole grains, fruits, and vegetables, while consuming too much salt and sugar. In fact, poor diet has now surpassed tobacco use as the leading cause of preventable death. Between 30% and 40% of adults and children report inadequate sleep, and over 40% of adults in the United States experience enough stress in their daily lives to impair function at home or work.

These problems are not confined only to the United States. In fact, the World Health Organization has launched a major international initiative to combat noncommunicable diseases, stating that such diseases kill 41 million people each year—the equivalent of 71% of all deaths globally.

In medicine we pride ourselves on practicing based on evidence. Yet, in the area of lifestyle habits and actions there is overwhelming evidence that we have largely ignored. For example, the Nurses’ Health Study showed that over 80% of all heart disease and 91% of all diabetes could be eliminated if women followed a few simple lifestyle measures such as regular physical activity (30 minutes or more a day), weight management (body mass index >19 and <24.9 kg/m2), proper diet (more fruits and vegetables and whole grains), and avoiding tobacco products.

The US Male Professional Study showed similar findings. Numerous other studies have supported these findings. Yet, sadly, only 5% of adults in the United States follow all of these lifestyle practices.

The enormous toll of adverse health consequences from failure to follow simple lifestyle practices will not be reversed overnight. Yet, we in the medical community have an obligation to sound the alarm both to the public at large and each of our individual patients. It is time to make this epidemic of lifestyle-related diseases no longer “silent.”

The pain and suffering caused by the COVID-19 pandemic reminded me of the profound message of Viktor Frankl writing during the madness of the Holocaust when he wrote that we do not get to choose our difficulties but we have the freedom to select our responses. Meaning, he argued, comes from 3 things: the work we offer in times of crisis, the love we give, and our ability to display courage in the face of suffering.

There is enormous human suffering, not only from the COVID-19 pandemic, but also the silent epidemic of lifestyle-related diseases that rob many individuals of their health and life itself. Let's use the lessons from the COVID-19 pandemic as an impetus to reconsider how we can reverse the silent epidemic of adverse health choices that currently prevails in the United States.