Inaugural Lifestyle Medicine Editorial

When first drafting this inaugural editorial in November 2019, events were already starting to unfold on the other side of the world, which would lead to the current pandemic, transform all of our lives and cause a still-mounting death toll. We now know that the first case of what is now named COVID-19 was traced back to 17 November 2019 in Wuhan, Hubei province, China and that at least 266 people were infected last year,1 despite initial reports suggesting the very end of December for case zero. However, this version of events was inconsistent with a case identified retrospectively from a retained swab in France taken 27 December 2019 (BBC, 2020)2, although this report is awaiting confirmation from the French Government. Sequencing supports a current scientific consensus that the SARS-CoV2 coronavirus is of natural origin, with 96% homology with a bat coronavirus (RaTG13) and all six key residues from the pangolin spike receptorbinding domain.3 We know the SARS virus had further outbreaks after the initial outbreak on at least four occasions at three labs in China, Taiwan, and Singapore.4 However, in May 2020 speculation continues about whether patterns ofmobile phone activity inOctober 2019 indicate a “hazardous event” between 6 and 11 October causing a shutdown of theWuhan Institute of Virology.5 There have been a variety of commentators, with academic leadership from the New England Journal,6 JAMA,7 and Lancet,8 with Richard Horton critical about the unheeded timely warnings about testing and personal protective equipment (PPE) requirements. Changes in UK advice on staff use of PPE in hospital outpatients in May, plus patients and other visitors and public transport users using face coverings from June have brought guidance in line with the practice of those of us informed by both the ecological evidence from countries who have coped well with the pandemic and the precautionary principle. Trish Greenhalgh has been highly influential on Twitter and in print on the revision of this guidance (Greenhalgh et al, 2020).8 However, some of the most useful literature has been open access and online. For example, Tomas Pueyo is a Silicon Valley online educator, who rose to international prominence with a razor-sharp, insightful, comparative international analysis on the causes and consequences of failing to arrest spread of such an infectious and relatively deadly pathogen10 and the subsequent impact of relaxing control measures.11 As I write the first revision, these articles have been viewed 40 million and 10 million times, respectively, with a total of 60 million by the time of publica-

supports a current scientific consensus that the SARS-CoV2 coronavirus is of natural origin, with 96% homology with a bat coronavirus (RaTG13) and all six key residues from the pangolin spike receptorbinding domain. 3 We know the SARS virus had further outbreaks after the initial outbreak on at least four occasions at three labs in China, Taiwan, and Singapore. 4 However, in May 2020 speculation continues about whether patterns of mobile phone activity in October 2019 indicate a "hazardous event" between 6 and 11 October causing a shutdown of the Wuhan Institute of Virology. 5 There have been a variety of commentators, with academic leadership from the New England Journal, 6 JAMA, 7 and Lancet, 8

with Richard
Horton critical about the unheeded timely warnings about testing and personal protective equipment (PPE) requirements. Changes in UK advice on staff use of PPE in hospital outpatients in May, plus patients and other visitors and public transport users using face coverings from June have brought guidance in line with the practice of those of us informed by both the ecological evidence from countries who have coped well with the pandemic and the precautionary principle. Trish Greenhalgh has been highly influential on Twitter and in print on the revision of this guidance (Greenhalgh et al, 2020). 8 However, some of the most useful literature has been open access and online. For example, Tomas Pueyo is a Silicon Valley online educator, who rose to international prominence with a razor-sharp, insightful, comparative international analysis on the causes and consequences of failing to arrest spread of such an infectious and relatively deadly pathogen 10 and the subsequent impact of relaxing control measures. 11 As I write the first revision, these articles have been viewed 40 million and 10 million times, respectively, with a total of 60 million by the time of publica-tion. The reasons why this was so powerful include it being a fresh perspective, an honest broker calling the politicians to account and relating, despite chagrin and shame, how quickly our health systems would and have been overwhelmed, especially in Italy, Spain, and the United States. However, social media also had an important bearing with Trish Greenhalgh and many others tweeting the link and there can be no doubt that policy has been both formed and changed as a result.
The publication in The Observer newspaper of the full Imperial College modeling paper 12 that had informed government policy and projected around the 500 000 UK deaths and the 2. Clinical Trial after a registry analysis was published showing higher mortality from hydroxychloroquine and chloroquine with and without macrolides was published in the Lancet (Mehra et al, 2020). 16 However, inconsistencies in the data have already led to publication of an 'expression of concern' (Lancet, 2020), 17 swiftly followed by retraction (Mehra, Ruschitzka & Patel, 2020) 18 when Surgisphere would not comply with a full independent data review. The efficacy and any major toxicity of hydroxychloroquine has been rapidly more definitely addressed by interim analysis of the ongoing RECOVERY randomised controlled trial, which has recruited 11,000 COVID-19 patients. Due to this furore, their independent monitoring board were asked by MHRA to review the hydroxychloroquine data, which confirmed the 1542 subjects already randomised to that arm did not benefit-25.7% dying compared to 23.5% deaths with usual care. While some commentators have criticised the Lancet and New England Journal, who also published another Surgisphere paper that has now been retracted (NEJM, 2020), 19 this is actually an excellent example of the full ongoing peer review process, which does not end with publication.
In the time of COVID-19, some of the things that we need to reconsider are as follows: We have known for a decade that "eating a healthy diet, increasing physical activity, and avoiding tobacco use can prevent 80% of premature heart disease, 80% of type 2 diabetes cases, and 40% of cancers." 20,21 However, the trends for these key pillars of lifestyle are disturbing: rising obesity is associated with lack of improvements in diet and activity and mortality, and the percentage of global total deaths per annum are increasing from ischemic heart disease (9.4 million deaths, 17%), diabetes mellitus (1.6 million deaths, 3%), and cancer (4.1 million deaths, 7%). Even tobacco use, which has declined substantially in most countries globally, is increasing in certain post-Soviet Commonwealth of Independent States countries, with rates above 40% in men and attributable cardiac, respiratory, and cancer disabled life burden increasing in Eastern Europe as a whole. 22,23 There has been precious little interest in public health and scant regard for funding or implementation.
However, this pandemic has changed our approach to everything and that includes a heightened understanding of the importance of exercise-one of very few valid reasons to leave the house-nutrition, stress, and social relationships. Add in sleep and avoiding smoking plus other toxins and the six main pillars of lifestyle medicine are suddenly at the center of public consciousness, along with new insights into the scientific method, vaccine development, and clinical trials. There is substantial interest in virtual group consultations (https://bslm.org. uk/vgc/), as that seems to be an innovation whose time has come and may yet become a default in these times of self-isolation and social distancing.
The response from the public has been exceptional and it is at times like this that we are reminded that our society is both real

WHY IS PROGRESS SO SLOW AND HOW CAN WE MAKE A DIFFERENCE?
There have certainly been vested interests, including corporations whose profits depend on undesirable lifestyles. Governments have also not been equally proactive in making changes that may undermine revenue from "sin taxes," making lobbying more effective. However, there have also been barriers to sharing evidence, building scientific consensus, and empowering people to make positive lifestyle choices. Importantly, there is now a groundswell: a grassroots zeal for change in the  your table of contents alerts, read it, submit high-quality articles, and consider reviewing or joining the editorial board. We want to build the evidence base for lifestyle medicine, so will welcome articles from all disciplines that improve our understanding of the effects of lifestyle interventions, including exercise, nutrition, sleep, stress management, relationships, and avoidance of toxins, as well as interventions that support or enable lifestyle changes like group consultations, 25 whether or not they are compared to drugs or other interventions. 26 We have seen how powerful open access publication can be but would argue that rapid, robust peer review is highly desirable to ensure that decisions are made on the best evidence.
The final two questions-on COVID-19 and the relationship to Lifestyle Medicine-are eloquently addressed in the accompanying editorial, 27 which draws together a large amount of very recent work to explain how inflammation from ageing and chronic disease provides a unifying mechanism to explain much of the COVID-19 risk. The positive message is that many of these risks are modifiable using lifestyle