Toward a roadmap for addressing today's health dilemma–The 101-statement consensus report

Importance: In recent decades there has been an expansion in the quantity and quality of scientific findings and guidelines on different health topics to promote individual and public health status. Reports also indicate that there has been a simultaneous increase in the financial burden of disease, including trillions spent on healthcare resources by governments worldwide (predominantly in developing countries) to address health concerns. At the same time, personal health behavior is well-known as efficient and cost-free, holding four times the potential to prevent early death compared to health care. Despite this knowledge, data show that the increasing prevalence of unhealthy lifestyles and the associated chronic diseases, especially in Western societies, still need to be controlled. This circumstance exemplifies today‘s global health dilemma, which alarms the inadequacy of ongoing efforts to address the existing health concerns worldwide.

Setting, insights, and observations: Three international, multidisciplinary, and inter-university events (two scientific conferences and one tertiary education symposium) were held in Austria (Innsbruck) between 2020 and 2022 to discourse, discuss, and debate these concerns. Two hundred eighty-four experts from 76 universities, organizations, and stakeholders spanning 31 nations and five continents participated in this international research and knowledge exchange to address today's global health dilemma. The latest scientific findings were discussed to develop practical strategies for improving lifestyle behavior and focus on the dual “Healthy Eating & Active Living” approach as a minimum recommendation for sustainable lifelong health and care. The expert panel debated crucial research priorities and future policies, identified gaps and untapped potential in basic health approaches that have been grossly neglected, and approved the evidence-based 101 consensus statements presented.

Conclusions and relevance: These endeavors aim to develop novel and effective interventions that address the needs of individuals and communities and promote optimal health status.

Highlights

• To address the global health dilemma of increasing non-communicable (chronic) diseases despite growing advances in health science and healthcare budgets, it is the consensus of the panel of experts that the power of Lifestyle Medicine has the potential to significantly contribute to the “Prevention First” appeal. The dual approach to sustainable and lifelong health—“Healthy Eating & Active Living”—is the minimum recommendation inclusive of every individual for better public health.

• To maximize health benefits for all, the permanent linkage of “Healthy Eating” is, at best, whole food plant-predominant, preferably vegetarian/vegan, and “Active Living” is, at best, daily and outdoors/in nature.

• This consensus statement aligns with the current trend towards de-medicalized and more holistic, personalized approaches to health and well-being, focusing on sustainable preventative policies.

1 Introduction, aims and methods

Despite groundbreaking accomplishments in science and technology over recent decades (1–4) health professionals currently face various challenges in addressing public health issues. These include financial interests, which can bias decision-making or priority-setting; difficulties in disseminating conclusive research to policy makers and the public in a timely and effective manner; and professional hubris, where overconfidence in expertise may hinder collaboration or the consideration of alternative approaches (5–9). Together, these factors have contributed to the increasing prevalence of non-communicable diseases (NCDs) and particularly their underlying risk factors (5–9). These challenges are primarily due to the broad and complex interface of health science disciplines and the contradictory viewpoints on health priorities. By bringing together experts and health professionals from diverse areas and communities through common ground, various foci could be openly linked in addressing current health issues of pressing concern.

The present paper reports the consensus and theme-specific results of three international, multidisciplinary, and cross-university events (10, 11) that hosted 284 internationally recognized experts from 76 universities, stakeholders, and organizations (including the WHO Regional Office for Europe) around the world (31 nations, five continents):

(1) “Health and Wellbeing: Addressing today's Global Paradox. Visioning an International Research and Knowledge Exchange”. 6. February 2020, 1-day hybrid conference, Innsbruck, Austria.

(2) “Improving Child and Adolescent Health for Better Public Health—Fiction or Within the Scope of Possibility? The perspective of a lifestyle-centered approach for Addressing Today's Global Health Paradox”. 10–11. November 2020, 2-day e-conference, Innsbruck, Austria.

(3) “The future in (y)our hands. Improved public health arises through better health of every individual. A tertiary education symposium about the future of human and planetary health”. 8. June 2022, 1-day hybrid conference, Innsbruck, Austria.

Through a consensus-generating approach (Figure 1, Supplementary Appendix S1), the experts (i) discussed the latest scientific findings including existing limitations in health approaches, (ii) identified gaps and untapped potentials in encouraging approaches that have been neglected, (iii) debated the necessity of specific and crucial research priorities, (iv) foresighted policies supporting novel and promising scientific and practical efforts, and (v) weighed on developing practical strategies to promote healthy lifestyle behaviors in everyday scenarios at different levels and settings with a specific emphasis on holistic and integrated health perspectives, particularly the preventative dual approach of “Healthy Eating & Active Living” (13–15) for sustainable, lifelong health and wellbeing.

Figure 1

Figure 1. Flow Chart of Consensus Exercise Process using the ACCORD-method “Consensus Meeting” for health-related activities and research, chaired by the first author, 64 experts (22.54 %) from 62 entities, 20 nations, and five continents formed the working group (main editorial board: of physicians, public health experts, sport scientists: KCW, MM, DRT, CD, and WKo) in accordance with ACCORD (12). © Katharina C. Wirnitzer.

The overarching aim of the congresses, within the context of an international research and knowledge exchange, was to establish direct statements to address today's global health dilemma—in the present context to be understood as a systemic paradox rather than a binary choice—which explores why growing advances in health science and increasing healthcare budgets do not adequately control the increasing prevalence of NCDs. This dilemma confronts policymakers and health care systems with competing, often undesirable trade-offs at the focal point of prevention, treatment, and long-term sustainability. Accordingly, it has been agreed that developing an evidence-based consensus statement outlining novel and effective intervention approaches to address the healthcare needs of individuals and communities is crucial for providing a scientific basis to promote an individual's optimal health status and improve the public health of nations worldwide. The aim was to focus on innovative interventions for improving the health outcomes of individuals and populations worldwide, which would reduce the social, ecological, and monetary burden of chronic diseases. As the German philosopher Arthur Schopenhauer (1788–1860) once famously exclaimed, “Health is not everything, but without health, everything is nothing.”

2 Background to the issue

2.1 Today's global health dilemma

Health is the natural aspiration of the human being from birth. Over the past few decades, the world has witnessed a shift in the primary focus of health concerns from infectious to chronic diseases, specifically NCDs (9, 16, 17). To control health problems, governments and international health organizations have established various policies over the past decades that have led to a general incline in healthcare budgets worldwide (18, 19) and are projected to cumulate to USD 15 trillion by 2050 (20). Accordingly, there has been rapid growth in the quantity and quality of health and medical investigations in recent decades (21, 22). Despite significant improvements in several areas of health sciences, such as sanitization/hygiene (23), neonatal health care practices (24), vaccination programs (25), and cancer screening (26), there are still gaps between the practical and applicable understanding of disease causes, the identification of biological markers of their presence and stage, and specific indicators influencing the effectiveness of potential remedies (27, 28). Therefore, the high-tech medicine of the 21st century has catalyzed today's global health dilemma, where despite significant advancements in health and healthcare, the world still experiences vast preventable deaths, high per-capita health burdens, and substantial financial costs.

In our technology-driven world, advanced and cutting-edge medicines are prioritized. It has been proposed that “omics” technologies, including proteomics, genomics, lipidomics, epigenomics, metabolomics, analysis of the microbiome, modern imaging methods, and physiological monitoring approaches, may once again play an important role, as they have already proven effective in fostering the implementation of precision medicine in daily practice (29–31). Based on this precision medical approach, specialists and physicians should ideally apply personalized treatment and consider the patient's unique physiology, microbial characteristics (viral, fungal, or bacterial properties), and the capacity to metabolize a particular medication and/or drug (31, 32). Contemporary advancements in science indicate the growing need to prioritize personalized approaches in medicine and expand our perspectives toward the person/patient as a whole organism. In 2022, NCDs accounted for 74% of all deaths globally (5); however, sustainably successful medicalized cures for preventable health conditions, particularly chronic health diseases with a more complex and multi-faceted etiology, such as obesity, diabetes type 2, cardiovascular diseases, and cancer, remain rare and elusive (33–36). While the theoretical aspects of modern medicine imply the necessity to apply three principles (diagnosis, therapy, and prognosis) to tackle the burden of diseases (37, 38), many current health approaches, specifically those to manage NCDs, are based on clear-cut diagnoses that often miss the underlying causes and subtler manifestations of illness (28, 39, 40). Such medical practice might lead to significant misinterpretation and may be—in some cases—significantly misleading.

The Continuum Concept, one of the most fundamental principles of physiology, biology, and disease, explains the status of an individual from optimal health to a hidden imbalance, progressing to severe dysfunction, ultimately leading to disease (41). A holistic and systematic approach to pathophysiology could shift models of disease in medicine away from simple associations rooted in empirical reductionism toward an appreciation of network-based models (42). An application of these systemic theoretical concepts in medicine can be seen, for instance, in the emerging field of psychoneuroimmunology, an interdisciplinary area of research exploring the complex interactions between psychological, neural, endocrine, and immune processes (43). While traditional medicine relies on specific regulatory types to handle treatment based on symptoms and the patient's general profile, it is also crucial to recognize cross-cultural factors in preventive and therapeutic approaches, particularly understanding shared and distinct pathological, physiological, and psychological features (44). It has been shown that personal behavior is the predominant determinant of health today, with four-fold the power to prevent premature death compared to healthcare (45, 46). Therefore, to promote overall health and wellness, it is essential to encourage behaviors that benefit the entire complex rather than isolating specific organs, tissues, cells, or structures. Unhealthy lifestyle behavior (e.g., physical inactivity, poor dietary habits, and substance abuse), along with overweight/obesity, is the primary mechanism of the pressing NCD challenge (5, 47, 48). To tackle these global health issues that predominantly track from childhood to old age (49, 50), it is crucial to address the pressing concerns identified by health organizations and experts worldwide (51, 52).

2.2 Health and the power of lifestyle

The desire for a happy and long life (with as few years lived with disability as possible–especially at the end of one's lifespan) has been a fundamental human aspiration and traces back to the beginning of humankind (53). In 1550, however, Luigi Cornaro (an Italian humanist, 1475–1566; Figure 2) reported for the first time that the human lifespan can be extended by making lifestyle modifications (54, 55). This idea is consistent with the current body of science, which indicates that genetics account for 20%−25% of an individual's lifespan, while the remaining 75%−80% is determined by various factors but principally lifestyle (56–58).

Figure 2

Figure 2. ‘The Art of Living Long”. A new and improved English version of the Treatise by the celebrated Venetian Centenarian Luigi Cornaro (Butler, 1917; without page) (54). Photography of the painting by Tintoretto of Luigi Cornaro (Fratelli Alinari, undated). Digitalized by the Internet Archive (2007). Digital reproduction: California Digital Library, Public Domain.

Today, the lifestyle medicine concept is a concrete, evidence-based, and comprehensive approach to preventing, treating, and even reversing various diseases by implementing health-promoting behaviors and replacing poor/unhealthy ones that are disadvantageous to health in daily routines. According to the American College of Lifestyle Medicine (ACLM), there are six pillars of lifestyle, including a whole-food, plant-predominant eating pattern, physical activity (PA), stress management, positive social relationships, restorative sleep, and the avoidance of risky substances (59, 60) (Figure 3). These six areas form the foundation of the recently designed “Lifestyle Medicine Curriculum,” which has been integrated into medical education (61). Lifestyle medicine aims to reduce dependence on medical treatments such as pharmaceutical therapy (prescribed medication) or surgical strategies by strongly emphasizing health-related behaviors. Instead, Lifestyle Medicine taps the potential of healthy dietary habits, regular PA, stress management techniques, positive relationship reinforcement (solid social support), improving sleep quality, and restricting smoking and alcohol intake (59, 60).

Figure 3

Figure 3. The six areas of lifestyle medicine – healthful eating, physical activity, stress, relationships, sleep, and substances – are complex and interconnected factors that substantially impact an individual's overall health and well-being. These areas, recommended briefly as healthy eating, keeping moving, sleeping well, avoiding substances, staying calm, and loving people (60), are influenced by various personal, environmental, and social factors contributing to their intricate nature. “Healthy Eating & Active Living” forms the minimum recommendation to start one's engagement toward better health. Adapted from (60) with permission from American College of Lifestyle Medicine (ACLM). Graphic modification: © Katharina C. Wirnitzer.

In line with and as an extension of lifestyle medicine, evidence suggests that Traditional, Complementary, and Integrative Medicine (TCIM) may significantly manage various health problems (62). TCIM is typically used alongside modern evidence-based medical approaches and is classified into five major categories: “whole medical systems,” “mind-body techniques,” “biologically based practices,” “manipulative and body-based therapies,” and “energy therapies” (63). TCIM (64), which is closely tied to cultural aspects, has received endorsement from the European Union (EU) (65), WHO (66), and other intergovernmental organizations (67–69). Considering that the cost-effectiveness of TCIM-based treatments is approved by the European Parliament (70) and may reduce concerns associated with the rising cost of modern medical practices, such health management approaches should be considered in future healthcare efforts worldwide.

2.3 “Healthy Eating & Active Living”

As one key component of a healthy lifestyle, a person's diet has the power of medicine and has thus been applied in treating various health conditions beyond preventative effects (71–76). Dietary patterns (e.g., type of diet: omnivorous, vegetarian) have always been influenced by food preferences and availabilities of geographical, sociocultural, economic, and religious factors (77–79), which have uncovered the complexity of defining a healthy diet (80–86). Available dietary guidelines have consistently emphasized replacing unhealthy food options with healthy ones (e.g., fruits, vegetables, whole grains, beans, legumes and pulses, nuts, and seeds) (81–91). While there are wide discrepancies in defining a healthy diet (71, 78), it has been well-documented that a whole-food plant-predominant (WFPP) diet (most significantly through a vegetarian or vegan pattern) is a general description for a healthy dietary approach (14, 84, 92–97). Notwithstanding the clarifications provided by scientific evidence, several misconceptions persist regarding the adverse health effects of transitioning to a vegetarian diet, especially a vegan one. However, such beliefs may lack scientific rigor, as they often result from a limited understanding of how to choose a diverse array of plant foods as substitutes for animal-sourced foods, as well as the potential for unbalanced and poorly planned dietary regimens, which can occur in any diet (93, 98). As so-called critical nutrients of the vegan diet (e.g., iron, iodine, calcium, vitamin D, vitamin B12) are not more problematic than any other diet type, it appears that vegans are at no exceptional risk for deficiency with a well-composed, wholesome diet appropriately supplemented by vitamin B12 (93). Hence, regardless of diet type, nutritional inadequacy usually emerges from other factors, primarily based on individually misapplied dietary behaviors (99–101).

A well-planned healthy diet has been documented as the most simple, safe, accessible, and affordable way to prevent and treat various diseases such as cardiovascular disease, type 2 diabetes, and the associated risk factors, including hypertension, hyperglycemia, and obesity (14, 88–90, 102, 103). Conversely, poor or unhealthy diets significantly contribute to global mortality, with dietary risks identified as one of the leading risk factors for death and disability, accounting for 20% of the cases worldwide (47, 104). For instance, data show that cardiovascular diseases, the world's leading causes of death over the past two decades (104, 105), are reversible by diet alone but only when adhering to a healthy, WFPP (especially vegan) diet (106–108). Healthcare approaches are highly connected to medical education. Nowadays, medical education and training seem to be primarily disease-centered, based on the specific knowledge of diseases and medical approaches. At the same time, health promotion is almost absent in curricular-determined learning and training content, which is a reflection of out-of-date education and practice (109–112). Results from a systematic review show that medical students lack the competence to provide high-quality, adequate nutrition and lifestyle care (113). Such circumstances have directed healthcare systems toward being more reactive than proactive, prioritizing treatment of illnesses over prevention, ultimately resulting in massive expenses to medically intervene (114–116). However, since 2019, policymakers in the EU emphasized the urgent need for more significant and more pressing efforts toward a shift to the prevention of ill health and disease and pose health promotion as a key pillar in ensuring future public health across nations (114). Accordingly, there has been an emphasis on lifestyle-based approaches that need to be included in the current healthcare system and the associated medication-based, disease-centered programs (117–119). The American Medical Association (AMA) consistently advocated for implementing plant-predominant meal options in hospitals and medical facilities (120). This initiative extends beyond merely improving the health of patients, staff, and visitors while encouraging the elimination of animal products from the menu (120). However, today's health dilemma has also raised concerns among primary care physicians and pediatricians regarding vegan/vegetarian nutrition, primarily due to a lack of detailed academic education on critical topics. The lack of compulsory education covering the depth of vegetarian dietary patterns and health makes it challenging for medical doctors to effectively support, recommend, or interact with individuals following non-omnivorous dietary patterns (98, 119, 121).

The history of reporting on plant-predominant diets dates back over 2,500 years, when Pythagoras introduced the philosophy of vegetarianism based on his observations (98). This nature-based philosophy, which generally prevailed until the 19th century, often recommended diets predominantly composed of plant foods to maintain health and wellbeing as well as alleviate and heal disorders and diseases (98, 122). However, during the past century (especially after World War II), profound changes in dietary habits have occurred worldwide: mainly including changes from (i) meals to snacks, (ii) eating at home to eating out, (iii) eating fruits and vegetables (plant-rich diets) to eating more animal foods; and (iv) eating intact, fresh, and organic foods to processed and industrialized products high in sugar, salt, (saturated) fats, and preservatives (78, 95, 123, 124). These changes, which have been associated with the increasing prevalence of NCDs and the risk factors for global mortality (5, 6, 125, 126), have led to the emergence of a vast number of research efforts since 1978, investigating and displaying evidence on the effectiveness of different types of diets, especially plant-predominant diets on sustainable health promotion (92, 100–103, 127–134) and longevity (108, 135, 136). Blue zones (specific locations around the world with populations living significantly longer and in good physical condition) are natural examples of the relationship between plant-predominant diets and healthy longevity (137, 138). Regarding the sustainability aspect of dietary maintenance, the EAT-Lancet Commission on healthy diets from sustainable food systems is considered a giant step (139). Even more recently, the European Commission (EC) has advocated Food 2030 as a framework for research and innovation policies, aiming to facilitate the transition toward sustainable, nutritious, and inclusive food systems (140). Furthermore, the latest Intergovernmental Panel on Climate Change (IPCC) summary report for policymakers highlights that shifting to a plant-predominant diet across all socio-ecological levels holds the most significant potential to protect individual and global health, promote human sustainability, including mitigating infectious diseases, epidemics, pandemics, and resource depletion along with increasing active mobility and other beneficial actions for health (141–143).

In parallel with the occurrence of dietary changes over the past century, the advancements and implications of technology in the daily routines of human beings have developed a new health concern worldwide called “sedentary lifestyle” (144). The effect of PA, sports, and exercise on NCDs has been widely studied over recent decades, and it has been proven that physical exercise is a versatile and effective treatment of NCDs, thus considered as medicine (145–151). As a crucial part of a healthy lifestyle nowadays, PA, sports, and exercise are critical factors in maintaining physical, physiological, and mental health and wellbeing across the life course, which is influenced by interpersonal and environmental factors (152–154). Rather than having specific and direct benefits for health, natural settings for performing PA, sports, and exercise promote health-enhancing behavior (155–160). There is scientific agreement that properly planned and regularly carried out PA (at best daily and outdoors/in nature) seems to act as a preventive measure, delaying or avoiding the onset of certain diseases, and as an effective treatment for subjects already affected by NCDs by increasing the quality of life, slowing down the progression of illness, and/or eradicating it (146–151, 158, 159). According to the general health guidelines of the World Health Organization (WHO) (145, 154), adults are recommended to comply with at least 150 min of moderate-intensity PA per week distributed over at least 3 days (at best, a minimum of 20 min daily) (161–163), while children and adolescents (aged 5–17 years) are advised to engage in at least 60 min of moderate-to-vigorous intensity PA daily, with mostly continuous activities involving large muscle groups.

Research advancements in health behavior have revealed the cumulative health benefits of PA and diet when applied simultaneously. Specifically, a healthy diet and regular PA, each as a single, 1-dimensional strategy, not only play independent roles in preventing and treating NCDs and associated risk factors per se, but their combination brings about additional synergistic benefits (164–166). This fact suggests the adoption and adherence of a holistic approach to health behavior by integrating all areas of lifestyle medicine, with a particular focus on the two main pillars of sustainable health–“Healthy Eating & Active Living”–forms the minimum recommendation to start one's engagement toward better health behaviors, habits, and patterns (Figure 3) (13–15, 165–172). This dual approach to sustainable and lifelong health is in line with contemporary views on human physiology and health (173–175), which requires a systemic perspective that integrates multimodal data from various entities to create a network functioning in health and disease and to explore its dynamic responses to disturbances (176). These integrative and multidimensional interactions shape the system's behavior and must be considered comprehensively over time, space, and the context of appearance (177, 178). Therefore, a holistic, de-medicalized, and systemic approach to health could move models of preventive and therapeutic strategies from simple associations rooted in empirical reductionism toward the appreciation of network-based models (29, 45, 179–182).

2.4 Environmental and ethical concerns in health promotion efforts

The benefits of healthy lifestyle behavior are not limited to the promotion of individual health or the public health of nations. Each component of a healthy lifestyle (e.g., consumption of plant foods, regular engagement in PA, sports, and exercise, etc.) considers ethical, social, and ecological aspects directly and indirectly (183–185). The United Nations' 17 Sustainable Development Goals (SDGs) mainly aim to end (#1) poverty and (#2) hunger globally (186). To do so, however, the most critical steps are achieving (#3) good health and wellbeing simultaneously with (#4) quality education (186), especially for women (187). From a broader perspective, personal health behavior is connected to planetary health and can significantly contribute to preserving and maintaining human development (185, 188). In parallel, ecosystem changes, particularly climate changes (primarily originating from human behavior over the past century), pose a significant threat to human health (188–191). In addition to increasing the likelihood of natural disasters (192), anthropogenic climate change has gradually led to environmental alterations, such as air pollution, loss of biodiversity, resource depletion, more frequent and heightened heatwaves, deforestation, and exacerbating water shortages, which may result in a wide range of health concerns, including instability and insecurity of resources, particularly food insecurity (180, 187, 188). However, the implementation of holistic solutions that consider synergies and trade-offs to target the United Nations' SDGs (181) and simultaneously address health and climate change challenges is restricted by the lack of action by decision-makers at both the national and global levels (189, 193–196). The WHO estimates that between 2030 and 2050, climate change will cause an additional 250,000 deaths globally each year due to malnutrition, infectious diseases, and heat stress (197). Children are among the most vulnerable populations, as recent reports from UNICEF indicate that about one billion children worldwide are at high risk of the impacts associated with climate change (198).

With a new and future-oriented holistic and de-medicalized lifestyle approach, critical concerns about animal testing in the pursuit of scientific progress could be addressed and tackled. Since the Medieval era, animal experimentation has driven medical research and justified medical progress. It is still considered the gold standard to advance knowledge in various fields, such as life science, medicine, agriculture, or product safety (199, 200). In 2012, almost half of the National Institute of Health's funding was allocated to testing that involved animal use (201). Today, however, there is ongoing questioning about the contemporaneity of vivisection and the utility and ethical acceptability of invasive animal research. Irrespective of ethical concerns regarding the justifiability of animal experiments in research activities, animal experimentation may not align with precision medicine approaches, which focus on the genetic diversity of human populations and inter-individual differences based on non-hereditary alterations during the life course (29, 30). This fact is evident, for example, in many human-specific diseases such as Alzheimer's, Parkinson's, multiple sclerosis, rheumatoid arthritis, type 1 diabetes, cystic fibrosis, and hemophilia A, which do not appear in animals (202, 203).

Furthermore, evidence shows that most (up to 95%) pharmaceutical drugs found effective and safe in animal studies fail in subsequent clinical phases in human populations, mainly due to insufficient efficacy, toxicity, and the emergence of unacceptable adverse drug reactions, raising significant concerns for ethical and economic reasons (204–211). This failure is predominantly attributed to the limitations of animal models in accurately representing human physiology during preclinical evaluations (211). It should also be considered that even if a drug is approved, safe use on humans is not guaranteed, as about one-third of the approved drugs are later withdrawn from sale or have warnings issued due to serious side effects (212). In September 2021, the European Parliament passed a resolution with 99% support to phase out animal testing across member countries, focusing on plans and actions to accelerate the transition to innovation without using animals in research, regulatory testing, and education (213). The EC is currently preparing a roadmap for phasing out animal studies for chemical safety testing in 15 legislative domains, which will be published at the beginning of 2026 (214). The EC responds to the European Parliament and the European Citizen Initiative to commit to a Europe without animal testing, collecting more than 1.2 million signatures from citizens (215). As a preparation, several transdisciplinary recommendations on how to become successful have already been published (216). Similarly, in December 2022, U.S. President Biden signed the FDA Modernization Act 2.0 into law, with strong bipartisan support, to speed up the discovery process, lower the costs of new life-saving treatments, and reduce animal testing (217). As a follow-up, an FDA roadmap has been published, stating that in 3–5 years time human-relevant testing methods (non-animal New Approach Methods) will be the default for safety/toxicity testing instead of animal studies (218). The National Institutes of Health in the US have followed suit in prioritizing the development and use of human-relevant testing methods by stating that projects only encompassing animal studies will no longer be funded (219).

2.5 Health education

Health education is not solely limited to the medical society, including healthcare practitioners. Children, adolescents, and young adults are widely recognized as vulnerable populations regarding health behavior, and promoting their health is crucial for their growth and future human development (220–223). Given that young people spend most of their daily activities in school as well as other educational contexts throughout a significant portion of their lifetime (224), it is essential to understand that schools and universities are vital settings for delivering health-related knowledge and developing competencies through adequate and effective education and training (220–222). Moving to a higher educational level may also bring about challenges regarding significant life changes in peer social circles and social pressures as well as educational environments, assignments, and facilities, thus permitting quick-fix, unhealthy lifestyle choices (225–227). However, the opportunity to provide education and training on healthy lifestyle behavior seamlessly linked from kindergarten, primary, and secondary school to college and university remains available according to national curricula, and it is yet to be fulfilled (221, 228). The WHO recommendations on health education emphasize that school and educational policies should support the adoption and maintenance of healthy lifestyle behaviors as a requirement for improving public health (220) and thus created the standard of “Health promoting schools” (WHO's Global School Health Initiative), launched in 1995 (229). Kindergartens, schools, and universities are living, working, and, at best, health-promoting environments that provide an optimal educational context for shaping lifelong healthy lifestyle behavior (230–232). Likewise, through educational efforts, the public is entitled to know about the controversy surrounding disease definitions and evaluations and the self-limiting and relatively benign natural course of many health conditions (233). Overall compulsory education is the optimum period (8–15 years in Europe) (234) in the life cycle where young people can be educated, trained, and empowered for healthy lifestyle behavior (234–236).

Nowadays, based on the overarching educational goal of “health promotion” as a curricular state mandate of many Western nations, it is therefore relevant that all compulsory subjects are competence-oriented and applied from the primary level to secondary level II (237–239). However, the central issue in translating conclusive, health-related scientific evidence into robust behaviors in adults and older adults is the reduced ability to learn new healthy behaviors after childhood and adolescence (240–243). Along with this, aptly formulated ancient wisdom was proclaimed by Confucius, a Chinese philosopher, politician, and educator: “If your plan is for 1 year, plant rice. If your plan is for 10 years, plant trees. If your plan is for 100 years, educate children.” Typically, compared to adults, health conditions may have a higher value in infancy, childhood, adolescence, and young adulthood, during which an individual faces several changes and transition phases. Outside of young people's family/guardianship and upbringing, it is generally recognized that early-stage education is critical for establishing long-term, health-related knowledge, skills, and competencies to achieve health policies. Developing a sustainable and lifelong health-related action readiness is essential, as well as the willingness to act wholesome; as the German writer Johann Wolfgang von Goethe (1749–1832) stated: “Knowing is not enough; we must apply. Willing is not enough; we must do.”

3 101 evidence-based consensus statements and research priorities

Table 1 presents a condensed overview of the 101 evidence-based consensus statements and research priorities along with respective rating the quality-level of evidence (Quality Rating Scheme for Studies and Other Evidence, modified from Oxford Center for Evidence-Based Medicine, with ratings from 1: properly powered and conducted randomized clinical trial/systematic review with meta-analysis; to 5: opinion of respected authorities; case reports).

Table 1

Table 1. Condensed overview of the 101 evidence-based consensus statements and research priorities along with respective rating the quality-level of evidence (Quality Rating Scheme for Studies and Other Evidence, modified from Oxford Center for Evidence-Based Medicine: 1 = properly powered and conducted RCT/systematic review with meta-analysis; 2 = lesser-quality RCT or high-quality cohort study; 3 = case-control or retrospective cohort study; 4 = case series or poor-quality cohort/case-control studies; 5 = opinion of respected authorities or case reports).

4 Overview and discussion

4.1 Summary

The three international congresses of research and knowledge exchanges between 2020 and 2022 aimed to contribute evidence-based consensus statements to address today's global health dilemma (rating quality of evidence see Table 1). These congresses were held to improve the individual's optimal state of health, which would cumulatively reduce the social, ecological, and monetary burden of chronic diseases in the mid- and long-term, ultimately resulting in better public health on a global scale. Considering the limitations and neglected gaps in current health-related approaches, this panel has proposed practical strategies that prioritize a holistic and integrated health perspective, specifically focusing on key elements of sustainable health behavior outlined in this report. Accordingly, research priorities and policies for future scientific and practical efforts have also been suggested.

The evidence-based statements developed by this consortium encompass various topics concerning sustainable health behavior and the improvement of global health, including general considerations on and approaches toward a good state of health (theme 1), the minimum (primary, key) behaviors associated with good health: “Healthy Eating & Active Living” (themes 2 and 3), other important, non-energy-balance-mediated lifestyle behaviors (theme 4), health education and literacy as critical aspects associated with good health and wellbeing (theme 5), and research priorities (theme 6). Regarding basic approaches, the statements (n = 22) generally emphasize the value of addressing health behavior as a complex and dynamic phenomenon shaped by individual, social, and environmental factors. This requires a focus from individual-level interventions, such as goal setting and self-monitoring, to broader population-level approaches that aim to change health-related social norms and policies concerning care. Regarding healthy eating, the statements (n = 19) highlight the importance of an adequate healthy diet considered medicine for various lifestyle disorders/conditions. Strategies for promoting healthy eating emphasize whole-food, plant-predominant diets and include nutrition education and policy initiatives such as subsidies for healthy foods and restrictions on marketing unhealthy products. For active living, the statements (n = 15) emphasize the importance of regular PA for improving and maintaining good health and reducing the likelihood of the associated risk factors. Strategies for promoting PA include environmental and policy changes, such as improving access to safe and convenient places for PA engagement. Other health behaviors addressed in the statements (n = 12) include sleep, stress management, relationships, and substance abuse. These areas highlight the need for a holistic and contemporary approach to health that addresses a cognizant range of lifestyle factors that contribute to overall health and wellbeing. In health education and literacy, the statements (n = 14) emphasize the need for effective communication and health literacy skills to promote behavior change and informed decision-making. This area includes the importance of tailoring evidence-based health information and messages to individual needs and preferences, ensuring its accessibility and distribution at all educational levels. Finally, the statements highlight the importance of research in advancing our understanding of health behavior and informing effective interventions (n = 19). This includes the need for interdisciplinary collaboration, rigorous methodology, and consideration of various critical factors in research designs and implementation. Overall, the 101 statements provide an in-depth overview of the essential de-medicalized factors involved in promoting and maintaining good health through behavior, with a particular focus on the dual approach of sustainable and lifelong health and wellbeing and the associated educational and communal considerations on the simple formula of “Healthy Eating & Active Living.” By addressing the complex and multi-faceted nature of health behavior and highlighting effective strategies for promoting behavior change, these statements offer valuable insights and guidance for researchers, practitioners, decision-makers, and policymakers in the field of public health.

4.2 From individual to public health

The dual approach of “Healthy Eating (at best, WFPP, and preferably vegetarian/vegan) and Active Living (at best daily and outdoors/in nature)” is a scientifically informed strategy that is well-known as promising due to its unique health benefits (13–15, 155–163, 165–172). The approach emphasizes the codependent and continuous application of healthy dietary patterns and regular engagement in PA, sports, and exercise, which serves to address the dynamic interplay between energy intake and expenditure (163, 238). By avoiding the development of NCDs and the risk factors, the dual approach is increasingly recognized as a cornerstone of preventive medicine, public health, and care practice. It highlights the significance of a holistic perspective that integrates various dimensions and interactions to generate network models of health and disease functioning (43, 45, 167, 273). Therefore, “Healthy Eating & Active Living” displays the minimum recommendation to unlock and begin tapping into the full potential of the power of lifestyle organization and change to improve one's health at the individual level from childhood into adulthood and old age (50). This, in turn, can contribute to prioritizing the person (and/or patient) centered approach over disease (and/or medication-) centered and thus shaping better public health of nations. Figure 4 displays the most relevant target groups in accordance with and derived from models of the determinants of health (29, 179, 180, 252, 268). With the potential to shift from a patient- and disease-centered approach to a preventive person-centered health approach, the model spans all levels and units of action to achieve better public health of nations that emerge from improved individual health.

Figure 4

Figure 4. Target groups considering personal and public health to be addressed, from the micro-level of individuals and families to the meso-level of communities (e.g., schools, universities, regions), to the macro-level determined by state and federal policies; in accordance with “The Main Health Determinants Model” by Dahlgren and Whitehead (252, 268). © Katharina C. Wirnitzer.

Consistent with the saying “you can't teach an old dog new tricks,” childhood, adolescence, and emerging adulthood are extremely sensitive life stages for ingraining healthy behavior. However, the challenge of the behavior change process remains significant for adults to cope with (Figure 5), and considering that relapses may occur (and at various stages), the successful adoption of new healthy behavior and the complete termination of previous unhealthy behavior is rare (Stage 6). Therefore, defining behavior change success is suggested to be any forward progression in the model rather than focusing solely on reaching the final stage of termination. Indeed, when the power of personal behavior at its lowest range estimate (the cause of 40% of all deaths) exceeds all other determinants of health (29, 30), including the health care system (10%), environment (5%), social circumstances (15%), and genetics (30%), the pursuit of addressing this challenge becomes even more crucial.

Figure 5

Figure 5. Stages of Behavior Change Theory Model within the challenge of the behavior change process of adulthood. Graphic illustration created on Raihan and Cogburn (181) and Prochaska and Velicer (182) © Derrick R. Tanous/Katharina C. Wirnitzer.

4.3 Current and future health approaches

The introduction of novel medications and drugs stimulates economic growth, creates employment opportunities, and contributes to the overall success of the capitalist system (274, 275). As a matter of fact, it is valuable for companies, especially in terms of profitability, to prioritize the continuous treatment of individuals with long-term health issues using modern medical products, rather than addressing preventive and sustainable health behavior across different societal levels—a challenge often encountered in the field of medicine (275–278). This consequence is especially apparent when comparing the impact of different health determinant domains on money spent in billions annually, e.g., behavior has a 38% annual impact (equivalent to USD 260 billion), while medical care has an 11% annual impact (or total USD 3,337 billion) (29). The mainstream media may play a key role in investigating and promoting contemporary medical activities while neglecting the primary mechanism of NCDs (274). In today's case, industrialization is successful with its crucial strategy of hidden and unregulated attempts to change public perceptions about health and illness (276–278). In Europe and the US, prescribed medications rank as the third leading cause of death right after heart disease and cancer, with approximately half of these deaths due to taking the medication correctly as prescribed, while the other half of these deaths are due to overdoses or drug abuse (274, 279). Interestingly, around 70%−80% of psychotropic (including antidepressant) medications are prescribed in primary care practices (280). The adverse combination of medical universities aligning closely with their university-industry partnerships, and the emphasis on patents rather than public-interest science, is quite evident (274). Often, the industry's conflict of interest is apparent rather than subtle since disease prevention, non-drug-dependent methods lack commercial interest, as healthy people have little-to-no dependency and are not lucrative clients for the medication industry (279). Healthcare and medicine must evolve into a proactive public health system that is predictive, preventive, personalized, and participatory (P4 model) (263). Therefore, it is crucial to step back from a fragmented and merely reactive health approach, which involves minimal interactions among specialists, often resulting in non-concerted prescriptions and scattered follow-ups. This approach also limits the information available to primary/family care physicians, therapists, and individuals/patients, ultimately leading to a suboptimal cost-effectiveness ratio. Along with the Hodges' model (a comprehensive framework offering a practical approach for learners and professionals considering health and aligned with the SDGs) that navigates healthcare complexities, transcends boundaries, encompasses various literacies, and fosters interdisciplinary connections (273), the integrated “P4 Health Spectrum” model promises to reduce the significant burden of NCDs and increase healthy aging and the health span (263).

Currently, the public health community partially relies on commercial determinants of health, specifically factors influenced by profit motives and monetary gain (281). In fact, many countries with tax-financed public health systems are increasingly facing social and health care inequalities due to profit and privatization-oriented health care reforms (282). In the ongoing conflict concerning the detrimental impact of commercial interests on health, particularly advertising strategies used by tobacco, alcohol, processed food, and sugary beverage entities, it's important to note that these influences drive (and often control) not only what to eat and drink but also individual access to health services (29, 180). It is well-documented that the process of ultra-processing food is predominantly associated with a loss of its nutritional value (283, 284). Currently, in the USA, Canada, and the UK, half or more of dietary energy comes from ultra-processed food products, and the production and consumption of these products are rapidly increasing worldwide (276–278). When introduced into young people's lives, for example, sugar-sweetened beverages contribute significantly to the development of overweight/obesity in children and adolescents (243, 285, 286). Obesity can cause severe diseases in childhood and adolescence and is a risk factor for obesity, cardiovascular morbidity and mortality, diabetes mellitus, and other chronic diseases in adulthood (287). Evidence indicates substantial health benefits associated with improving nutrition during the early stages of life, including the promotion of breastfeeding and the improvement of the quality of early childhood feeding (288). Eating habits, mainly shaped by the domestic environment, often persist throughout life (257). Adopting a healthy eating approach can positively affect other aspects of lifestyle, resulting in an overall healthier lifestyle, and can practically serve as a key factor in the transition to and adoption of other health-promoting behaviors, such as better sleep, increased PA/exercise levels, reduced stress levels/better resilience, and a lower likelihood of engaging in substance abuse (72, 76–78).

By embracing such an effective de-medicalized approach to health (i.e., “Healthy Eating & Active Living”), preventive and therapeutic models can surpass empirical reductionism (253, 289). To meet this, it seems crucial for any therapeutic approach to consider and effectively apply the three-to-one ratio (Figure 6): three competence-orientated areas of health-related actions, including—first and foremost—the prevention of diseases, maintenance of good health status, and promotion of health, followed by one, as a last resort, medicalized therapeutic strategies (as a fourth area of competence-orientated actions) to target specific health conditions, including curing and healing diseases. Consistent with this “prevention first” appeal (182, 184), EU policymakers have already identified and emphasized (i) the urgent need for greater and more pressing efforts toward a shift to the prevention of ill-health and disease with health promotion as a key pillar in ensuring future public health (114, 118), and (ii) the cross-European need to focus on changes in future medical and health pedagogy to address the current public health gaps (262, 290).

Figure 6

Figure 6. Four areas of action comprising health-oriented action, competence, and readiness in order to achieve sustainable and lifelong health and wellbeing. © Katharina C. Wirnitzer.

In line with the statement of Dr. Anthony Fauci, the chief medical advisor of the US, “the first thing is to stick with the science” (interviewed by the NEJM); therefore, it is imperative to follow the conclusive evidence on healthy lifestyle behavior when considering disease prevention, health maintenance, and the promotion of good health altogether (291). Sticking to the science, however, is long overdue in the promotion of better public health of nations worldwide, except for the science of a specialized therapy, especially when dealing with preventable diseases, which, in such cases, intervention is often too little, too late. A current Lancet comment states that it is not enough to talk about change, and thus tertiary entities need to act in helping society to grow and tap its potential for change (292). As crucial platform not only to empower future health-professionals but individuals for a healthier life, too, colleges and universities play a pivotal role in establishing the provision and transition to evidence-based information about the health-related power of lifestyle medicine and lifestyle behaviors as foundation for informed lifestyle choices. In this regard, universities must advocate for the plant-predominant dietary transition as one key pillar of empowering people for a healthy life, starting with students and academic staff (292, 293). Since the COVID-19 pandemic, there is an ongoing debate regarding the question of how firmly scientific findings and recommendations for primary care practice are rooted in high-quality, research-based evidence (294–296). It has been reported that only 18% of the recommendations for primary care practice are based on patient-oriented evidence from consistent, high-quality studies (294). Consistently, findings from a study assessing changes in the quality of evidence in updates of Cochrane reviews indicate that only a minority of outcomes for healthcare interventions are backed by high-quality evidence (9.9%), and the quality of the evidence does not consistently show improvement or deterioration in updated reviews (251). Another study indicates that over 90% of healthcare interventions examined in recent Cochrane Reviews lack robust support from high-quality evidence, and there is insufficient reporting of associated harms (297). Moreover, in various scientific domains, research findings are frequently presumed to reflect the prevailing bias (298), and a significant number of published results may be false or exaggerated (277, 278, 299–301), with an estimated 85% of research resources being wasted (302). However, it is inconceivable to envision modern healthcare without considering evidence-based medicine (269), and readers of journals should exercise caution when interpreting research findings (303). The adoption of large-scale collaborative research, standardization of definitions and analyses, pilot examination of interventions, and improvement in study design standards, peer review, reporting, and dissemination of research have been identified as crucial actions to enhance the validity of scientific works (302). The recent planning of the Evidence Synthesis Infrastructure Collaborative is a great example of aiming to combine evidence synthesis from all fields of research and all countries globally (304). The planning phase was run by Cochrane, Campbell and the Joanna Briggs Institute (Australia) and the execution will start in the fall of 2025 by Wellcome UK, investing 45 million GBP in establishing this global infrastructure. The aim is to work toward better informed decision and policy-making, with the Global South in the lead and sustainability as the major focus point.

4.4 Scientific and educational animal use

Since “man is not a mouse” (305, 306), an advanced, fit-for-future, holistic, and de-medicalized health and care approach requires methods free of animal testing, as animal experiments no longer meet today's bio-technological standards regarding the advancement of medical and human sciences. In line with the well-documented incompatibility between animal experiments and human trials (209, 307, 308), current evidence from systematic reviews identified significant limitations in preclinical animal research, encompassing both the quality of publications and translational value (209, 210). Translational percentages (concordance rates) of results exhibit a wide range from 0–100% with no predictable factors for translational success or failure in humans (309), and even multiple experiments fail to significantly contribute to improving the reproducibility of animal testing, accounting for 41%−72% of the observed total variance (310, 311). These results show how misleading animal experimentation can be in terms of human health and emphasize the necessity to study the specific human disease in detail first and, on this basis, select the cost-appropriate, technologically advanced human-relevant model or method (e.g., use of isolated cells and tissues, organoids, robotics, computer bio-modeling) and system of testing before starting the research (312).

Recent decades have shown a tremendous development in science and technology, which have also made it possible to move to more human-centered science. Despite the challenges of the COVID-19 pandemic, it was possible to develop reliable vaccines for the market within 1 year, with fewer animal studies, increased use of alternatives, and expedited movement to clinical trials (272, 313). It should also be considered that legislative requirements for animal studies lack a solid, evidence-based foundation (314). In addition, there is a special need to entrench advanced alternatives across tertiary curricula and training for medical students, as well as students of relevant life and health sciences. Results from a systematic review on the educational efficacy of humane teaching methods indicate that learning outcomes are superior (30%), equivalent (60%), or inferior (10%) to those produced by traditional animal use (315). The review concludes that widespread implementation of humane teaching methods would preserve learning outcomes and may provide additional benefits for students and educators, tertiary institutions, and entities, with a particular focus on the wellbeing of animals (315). Animal-free methods in educational training and research, as part of de-medicalized future approaches to health, are on the pulse of time, indeed. With this, humane teaching methods have already been implemented within life and health sciences education and in many countries. Nowadays, ethically motivated students are able to pursue their studies in tertiary education and training without harming animals (316–318).

Over the past two decades, funding agencies have launched opportunities and specific calls for innovative projects across various disciplines to develop alternative methods replacing animal experiments (319–322). These initiatives and programs, often backed not only by national funding agencies and/or corresponding federal ministries but also increasingly on a European and world-wide level, aim to support the development of effective, efficient, human-relevant and human-centric technologies and tools in sustainable biomedical research (319–321). The recent launch of the new Ombion Center for animal-free biomedical innovations is a demonstration of major investments by the Dutch government to build an infrastructure offering research, education, training, advice and support to enhance the acceptance and use of animal-free biomedical innovations (323).

In this regard, innovative and award-winning databases provide transparent information, helping to avoid or at least reduce the use of animals in experiments characterized by repeated trials and multiple testing (324, 325). A recent survey commissioned by the Eurogroup for Animals, polled approximately 11,000 EU citizens from eight member states on the abolition of animal testing in research, testing, and education, with 77% of EU citizens in favor of phasing out animal testing (326). This outcome is in line with a registered 2023 European Citizens' Initiative advocating for a Europe without animal testing, supported by more than 1.2 million valid signatures from citizens of all 27 EU member states (327, 328), providing a strong indication of the shift away from animal testing.

4.5 The COVID-19 pandemic

Opportunities to follow healthy lifestyle behavior may be influenced by limiting factors and acute events that are beyond an individual's intention and control. During the past 5 years, COVID-19, as a magnifying glass of public health problems, posed an unprecedented worldwide challenge and evolved into a sudden public health emergency overnight, which is unparalleled in contemporary history (329, 330). To control the spread of the pandemic, social contact restrictions (e.g., encouraging people to stay at home, avoid non-essential travel, and maintain social distance) and lockdowns with (self-)quarantine (e.g., closure of public gardens, educational and recreational services and utilities) have been frequently implemented (331, 332). Regardless of the health-related problems associated with direct infection with SARS-CoV-2, data show that the pandemic has had unfavorable impacts on lifestyle behaviors (including dietary and activity patterns) and health status (including mental health) of various populations worldwide (333–335), which have gradually become more common than the outbreak itself. Additionally, education and community life have also been markedly affected by the COVID-19 pandemic and associated restrictions (336, 337), which may potentially result in further detrimental health effects from a long-term viewpoint (although this is currently hidden). Evidence indicates that healthy lifestyle behaviors, particularly regular engagement in PA, sports, and exercise alongside a healthy (particularly, WFPP, preferably vegetarian/vegan) diet can strengthen the immune system and reduce the likelihood of COVID-19 infection (338–344). Additionally, an active lifestyle is considered an effective strategy to reduce the psychological distress associated with the pandemic and lockdowns (345–347). During such an unprecedented pandemic, where medical and/or pharmacological treatments are not yet available to effectively manage its spread, a collaborative effort between health organizations and governmental decision-makers is necessary to promote evidence-based, de-medicalized approaches, such as “Healthy Eating & Active Living,” to prioritize providing practical incentives for people to consume healthier food options and engage in desirable PA, sports, and exercise opportunities (348–351).

Currently, although it appears that the world is in the final stages of the COVID-19 pandemic, there exists no guarantee that hidden health-related concerns (especially those associated with psychosocial health) will not potentially appear or develop in the form of post-pandemic consequences, or that the world will not experience a similar health tragedy in the future. While current global policies face challenges in effectively proposing and addressing Earth's overpopulation as a general approach to mitigate most global pandemics, there appears to be a further emphasis on the fundamental adoption of healthy lifestyle behaviors as a key factor in modern and sustainable health and care practices for better public health outcomes to address existing public health concerns. Nevertheless, the COVID-19 pandemic revealed that the health of the individual is not equal to the health of the community. Therefore, at the very least, benefits from behavioral change occur across societal levels. From the perspective of the unenthusiastic population health developments worldwide, as well as the COVID-19 crisis recently passed, the public health community urgently needs advice-focused, hands-on actions along with the drivers of those generating increasing social, health, and care inequalities. It requires the willingness to act from professionals of all health-related areas and spheres of influence to tackle inequalities and strive for fairer treatment in the post-pandemic world (180, 191).

Due to the positive health effects in the promotion and maintenance of health over the life course, the following observations shall be considered for the protection against moderate-to-severe COVID-19 infections during situations of severe health conditions (although they were not entirely present in the public mass media as general recommendation to aid in one's state of health or even to support vaccine efficacy): the risk for severe COVID-19 outcomes and the associated death was lower (i) in active people meeting the PA, sports, and exercise guidelines during the COVID-19 situation compared to inactive people (338, 352–362), (ii) in people following dietary patterns characterized by high-quality choices, especially through healthy plant foods as “best buys” (339) compared to those did not prioritize their diet quality, and (iii) in people following vegetarian and vegan diets, which were associated with lower risk and severity of COVID-19 (reduction of up to 73%) compared to those following omnivorous diets (339, 340, 359–367). To reduce the likelihood of future epidemics, positive lifestyle changes (i.e., toward healthy eating habits) must be reflected since evidence indicates that slaughterhouse cooling chambers provide an optimum environment to preserve highly infectious viruses, like SARS-CoV-2, which further raises the need to talk about meat (368, 369). When a high-quality diet (indicated by a high percentage of plant foods or entirely WFPP diets at best) is supported by regular PA, sports, and exercise (daily outdoors/in nature at best), the unique synergistic effects improve the cardiovascular, metabolic, and immune systems, which ultimately benefits immune-surveillance and has the potential to counter similar virus infections and symptoms at three preventative levels: (1) strengthening immune system in combating infections; (2) increasing vaccine-efficacy via responses from other types of infections (e.g., influenza); (3) improving physical fitness and quality of life. Thus, PA, sports, and exercise combined with a healthy diet serves as an effective and promising dual approach to protect the human body from similar viral infections and symptoms (338–365). Since current policies have insufficiently addressed people's willingness to change, it is time for public-health communities, decision-makers, and health experts to encourage people and patients on “Healthy Eating & Active Living” through professional guidance (370, 371). From this perspective, it is any physician's responsibility to prioritize individual, public, and global health issues (191, 246), as basal and permanent moral drivers in medical and health-related professions, not only limited to times of severe crisis.

4.6 Closing remarks

According to the ACLM (60), there are several key behaviors, including core competencies with the minimum of the dual approach to sustainable health:

• Eating healthy food before taking medication (i.e., Food over Medicine), and continuously linked to

• Moderate-to-high levels of day-to-day PA, sports, and exercise (i.e., Exercise over Medicine).

There is no evidence-supported doubt that diet is a major determinant of health and wellbeing (for good) or disease (for worse) (27, 372, 373). Although analyses and recommendations of renowned studies like The Multiple Risk Factor Intervention Trial (270), the North Karelia Project (374) and The China Study (375, 376) vary, the general conclusions of these and many other conclusive publications usually state that healthy dietary patterns are mainly plant-predominant. Regarding Food over Medicine, the term WFPP diet has been coined by pioneers in the field of healthy eating (95, 377–379), as plant foods are believed to be even more effective than medicine (103). Exercise over Medicine, however, shows that healthy diet also has limitations, as other aspects of life and behavior fulfill the holistic concept (172, 183, 380, 381). Physical education as a compulsory school subject, therefore, plays a greater role in school health promotion than any other school subject such as science, history, or math. From a developmental perspective, PA requires children to have competence in motor skills to be able to move effectively and safely (382), and therefore, it requires fitness development (266, 267). Indeed, the integration of school subjects as a cohesive body of knowledge emphasizes the significance of their interactions, reflecting the potential to promote healthy behavior (383, 384).

Data from epidemiological evidence, such as the EPIC-Oxford Study or the Adventist cohorts, show quite broadly how a healthy lifestyle, including PA and exercise, along with plant-predominant (including vegan) diets, can contribute to long-term sustainable health (100, 385, 386). That is to say that these populations have provided a basic example of a healthy aging lifestyle, which has been shown to expand the lifespan from 10–17 years (91, 387, 388). Nearly 700 million years lived with disability were caused by NCDs in 2013, which constitute 9 out of the 10 leading causes of years lived with disability (389). NCD-caused years lived with disability contribute to most of the disease burden in many countries (389–391) and insurance groups are advocating for healthier behaviors, especially vegan nutrition, due to the exceptional characteristics (392–398). Many countries are now spending 30%−86% of their health care budgets on the medical management and symptomatic relief of NCDs and other chronic conditions (18, 20, 254, 399). Times of increased stress levels come and go but remain prevalent for specific populations, as not all diseases are preventable (e.g., due to genetics or that many people currently live with NCDs/chronic conditions), and therefore stress management and relief practices (e.g., Red Noses Clowndoctors, Sensory Room Therapy, yoga) hold precious value (400–402). These holistic practices are closely tied to our interpersonal relationships, which profoundly contributes to mental health (264). Happiness, after all, is the highest goal for many people in life (403), with much to learn from the circumstances in Bhutan, the one and only country with a federal ministry on happiness (404). Without health, considered the greatest wealth, the potential for happiness experienced over a lifetime is restricted (405). Therefore, it is especially important to consider the scale of misery for individuals as well as nations (403). In the best-case scenario for individuals, starting from natural health at birth to the full extent of leading a complete, healthy lifespan, the end of the aging process almost guarantees discomfort and/or some degree of suffering (388, 390, 406), while the choices to behave accordingly to avoid additional problems remain. The development and implementation of comprehensive public metrics to evaluate healthy lifestyle behaviors, along with offering financial incentives, compensation, or bonuses from statutory health insurance funds to families, educational entities at all levels, employees, and businesses that adopt health-promoting behaviors, could be effective toward fostering a culture of health and wellbeing within society and across nations (8, 10, 146, 230, 231).

Considering the “prevention first” appeal (that has been acknowledged across many global health policies but has deficient implementation) and given the importance of informed lifestyle choices as a practical step (114, 172), health experts, policymakers, journalists, and patients should be conscious of corporate-sponsored material regarding the nature or prevalence of the disease. Instead, they should rely on publicly funded sources that provide information on the de-medicalized treatment of common health problems as a primary preventive course of action. Likewise, rather than relying solely on prescribed medication, it is essential to consider the power of lifestyle medicine and health behavior, prioritizing a person-centered approach to health over a disease-centered one (15, 167). This involves making healthy lifestyle choices as the first line of intervention, placing them above the immediate prescription of medications to address unhealthy behaviors. Collectively, it is also essential for politicians, physicians, and the public to address the disparities and conflicts between public health and private health, including issues like the right to health, a patient's bill of rights, and patient autonomy. Rather than debating slogans, it is crucial to identify tailored solutions to the pressing health issues and challenges (407).

In the context of holistic support of personal health (particularly the de-medicalized evidence-based concept of lifestyle medicine) and based on consensus that food and physical exercise are considered medicines, the basic and simultaneously sound dual approach that forms the foundation to sustainable and lifelong health and wellbeing is “Healthy Eating & Active Living.” Based on the interwoven, related, and integrated nature from both the key pillars of health, (1) healthy–at best WFPP, preferably vegetarian/vegan–diets permanently linked to (2) regular–at best daily and outdoors/in nature–PA, sports, and exercise (13–15, 155–159, 161, 162, 165–172) is the minimum recommendation to start tapping the full potential of the power of lifestyle to improve one's health on an individual level. “Healthy Eating & Active Living” must come first in school education and be seamlessly linked with college and university education to promote the health and wellbeing of nations; person- (or patient-) centered approaches trumps disease- (medication-) centered approaches.

5 Conclusions

Despite increased healthcare budgets and improved quality of scientific data resulting in the development of evidence-based guidelines and recommendations aimed at promoting better individual health outcomes, the prevalence of unhealthy lifestyles, chronic conditions, and environmental challenges continues to accelerate. This is particularly evident in industrial nations and Western societies, but it is also becoming more prevalent and alarming in developing countries. These trends suggest that global health efforts may not be as effective as intended in promoting better individual health outcomes to improve public health. The overemphasis on medicalization and the limitations of current treatment methods in modern, high-tech medicine in tackling NCDs raise serious concerns and pose major challenges in achieving sustainable healthcare in an increasingly digitalized world. Additionally, various perspectives on scientific conclusions in the commercialized areas and fields of the global health sector can further complicate the understanding and dissemination of appropriate health information. These perspectives may be influenced by interests that do not always prioritize people's health and can damage the credibility of experts, reduce patient confidence, and create significant obstacles to public health promotion efforts. As a result, it is important to recognize and address these challenges to ensure that accurate and reliable health information is accessible to all.

The present consensus paper summarizes the findings and conclusions of three multidisciplinary meetings held in Innsbruck, Austria from 2020–2022, which collectively hosted 284 internationally recognized experts from 76 universities, stakeholders, and organizations from five continents. The aim of these research and knowledge exchange events was to address today's unenthusiastic and challenging global health dilemma by sharing practical and purposeful strategies to develop healthy lifestyle behaviors and habits, with a special focus on the evidence-base of “Healthy Eating & Active Living,” at best WFPP, preferably vegetarian/vegan diets permanently linked to PA, sports, and exercise at best daily and outdoors/in nature, as the minimum recommendation for initiating advantageous personal lifestyle changes for health. The goal was to motivate and empower individuals, general populations, as well as health, education, and policymaking experts alike to tap a huge intrapersonal potential often neglected or ignored. The experts identified gaps in health-related approaches, addressed how to tackle and bridge these, and debated research priorities and necessary policies for future efforts. The consortium of authors made and approved a significant number of consensus statements (N = 101) spanning across six specific themes based on sound and robust scientific evidence.

In conclusion, to address the current global health dilemma of today's high-tech medicine, multiple strategies are necessary, including establishing innovative curricula at all educational levels for children/adolescents, future teachers, pedagogics, and healthcare professionals. This should be accompanied by increased stakeholder participation from policymakers, health authorities, and public bodies, tackling organizational challenges related to multidisciplinary collaborations, addressing infrastructure requirements, revising disease classification systems, updating testing models, establishing regulatory frameworks and reimbursement models, and addressing potential ethical, legal, and social concerns. Moreover, it is crucial to evaluate the monetary and health-related effectiveness of specific health programs, interventions, and measures in terms of their impact on public health outcomes and thus budgets scaling vs. factual health of the public in being able to rate their return on investment, considering the different settings of nations' health care systems.

The presented consensus statements, though perhaps not immediately implementable worldwide, can serve as a crucial step toward establishing a roadmap for best practices in health science. To facilitate practical application, certain initial entry points can help guide implementation. Promoting “Healthy Eating & Active Living” (through well-planned wholefood, plant-predominant diets and regular PA) provides a foundational approach to prevent NCDs and improve overall health and well-being. Early interventions targeting children and adolescents, alongside personalized health behavior programs for adults, can foster sustainable lifestyle habits. In parallel, enhancing health education and literacy across all educational levels equips individuals with the knowledge, skills, and motivation to adopt and maintain healthier behaviors throughout life. Together, these strategies offer a pragmatic starting framework for translating the broader 101 consensus statements into actionable measures and to ensure optimal vertical permeability at all relevant levels and settings. This approach aims to address today's public health challenges, particularly in the increasing prevalence of NCDs and their underlying mechanisms, that are often neglected and/or forgotten, yet often need to be addressed despite growing advance in health science and increasing healthcare budgets. By providing practical strategies and highlighting research priorities and policies, the present consensus report and its detailed statements can assist in developing up-to-date and effective approaches that emphasize de-medicalized, holistic, and integrated health perspectives. They hold the potential to bridge existing gaps and limitations in health-related approaches and ensure that future efforts are aligned with the latest scientific findings.

The present consensus statements can contribute to the development of effective approaches, aiming for the overall improvement of individual and public health. This is especially relevant for policy and decision-makers, as well as various stakeholders, including NGOs, globally acting organizations, research funding agencies, health experts, scientists, healthcare and educational professionals, educational entities and institutions, and health-related industries.

Author contributions

KW: Resources, Writing – review & editing, Visualization, Project administration, Supervision, Writing – original draft, Methodology, Conceptualization. MMot: Resources, Conceptualization, Writing – review & editing, Methodology, Writing – original draft. DT: Resources, Conceptualization, Writing – review & editing, Methodology, Writing – original draft. CDr: Methodology, Conceptualization, Writing – original draft, Resources, Writing – review & editing. MMos: Resources, Writing – review & editing, Writing – original draft. HC: Writing – review & editing, Writing – original draft, Resources. TR: Writing – review & editing, Writing – original draft, Resources. K-HW: Writing – original draft, Writing – review & editing, Resources. AMi: Resources, Writing – review & editing, Writing – original draft. BK: Resources, Writing – original draft, Writing – review & editing. ZF: Writing – review & editing, Writing – original draft, Resources. MR-H: Writing – review & editing, Writing – original draft, Resources. AMa: Writing – review & editing, Writing – original draft, Resources. NM: Resources, Writing – review & editing, Writing – original draft. FS: Writing – original draft, Resources, Writing – review & editing. CS: Writing – review & editing, Writing – original draft, Resources. NG: Writing – review & editing, Resources, Writing – original draft. CL: Writing – review & editing, Writing – original draft, Resources. PF: Writing – review & editing, Writing – original draft, Resources. GR: Writing – original draft, Resources, Writing – review & editing. DW: Resources, Writing – review & editing, Writing – original draft. RL: Writing – review & editing, Resources, Writing – original draft. CK: Writing – review & editing, Resources, Writing – original draft. MJ: Writing – original draft, Writing – review & editing, Resources. NK: Resources, Writing – review & editing, Writing – original draft. HJ: Resources, Writing – review & editing, Writing – original draft. MF: Writing – original draft, Resources, Writing – review & editing. AKn: Resources, Writing – review & editing, Writing – original draft. KK: Writing – review & editing, Writing – original draft, Resources. KP: Resources, Writing – review & editing, Writing – original draft. BH: Writing – original draft, Resources, Writing – review & editing. BJ: Resources, Writing – original draft, Writing – review & editing. WK: Resources, Conceptualization, Methodology, Writing – review & editing, Writing – original draft. TP: Resources, Writing – review & editing, Writing – original draft. KC-P: Writing – original draft, Resources, Writing – review & editing. PT: Writing – review & editing, Writing – original draft, Resources. SS: Resources, Writing – original draft, Writing – review & editing. HL: Writing – original draft, Writing – review & editing, Resources. MS: Writing – review & editing, Resources, Writing – original draft. AKr: Resources, Writing – review & editing, Writing – original draft. SF: Resources, Writing – original draft, Writing – review & editing. LG: Writing – review & editing, Resources, Writing – original draft. FK: Writing – review & editing, Writing – original draft, Resources. MA: Writing – original draft, Writing – review & editing, Resources. HN: Writing – original draft, Resources, Writing – review & editing. SN: Writing – original draft, Resources, Writing – review & editing. AOA: Writing – review & editing, Resources, Writing – original draft. JH: Writing – original draft, Writing – review & editing, Resources. CG: Resources, Writing – original draft, Writing – review & editing. GN: Resources, Writing – original draft, Writing – review & editing. AA: Writing – original draft, Resources, Writing – review & editing. AR: Writing – review & editing, Resources, Writing – original draft. MT: Writing – original draft, Resources, Writing – review & editing. GN: Resources, Writing – review & editing, Writing – original draft. ÉP: Writing – review & editing, Resources, Writing – original draft. MK: Writing – review & editing, Resources, Writing – original draft. BB: Resources, Writing – review & editing, Writing – original draft. WK: Writing – review & editing, Resources, Writing – original draft. KB: Resources, Writing – review & editing, Writing – original draft. PJ: Resources, Writing – original draft, Writing – review & editing. GP: Writing – review & editing, Writing – original draft, Resources. RB: Writing – review & editing, Writing – original draft, Resources. CDu: Writing – review & editing, Writing – original draft, Resources. GS: Writing – review & editing, Writing – original draft, Resources.

Funding

The author(s) declare that no financial support was received for the research and/or publication of this article.

Acknowledgments

We would like to express our profound gratitude to all the individuals and institutions that have made this international collaboration possible. Our heartfelt thanks go out to our colleagues and peers across the globe whose invaluable contributions, insights, and expertise have significantly enriched this manuscript. We acknowledge the diverse cultural, geographical, and institutional perspectives that have been brought together in this work, fostering a spirit of cooperation and mutual respect. This collaborative effort has not only enhanced the quality of our research but also reinforced the importance of global unity in the pursuit of knowledge. This work testifies to the power of international collaboration, and we look forward to future partnerships that will continue to push the boundaries of our collective knowledge. There are no professional relationships with companies or manufacturers who will benefit from the results of the present research work. Moreover, this research did not receive any specific grant or funding from funding agencies in the public, commercial, or non-profit sectors. However, we would like to acknowledge the following authors for their funding, grant, scholarship, financial compensation/honoraria or other involvement and declare that the bodies listed were and are not involved. There is no impact from any agencies on drafting and writing, presentation, critical review, commenting and editing, and publication of the present manuscript: Katharina C. Wirnitzer: This research work is part of both the Austria nationwide school study (https://www.science2.school/en/; TWF – Tiroler Wissenschaftsförderung ID: UNI-0404/2413) as well as the college and university study (https://uni.science2.school/en/; TWF – Tiroler Wissenschaftsförderung ID: F.30976/6-2021), which are supported by the Austrian Federal Ministry of Education, Science, and Research (BMBWF), all Austrian Federal Education Authorities, as well as the Austrian Students' Union (ÖH). She also would like to acknowledge being PI of the GHRDA – Good Health Retrospective Data Analysis with the funder (Biogena GmbH & Co KG, Austria) has had no role in the procedures and conduction of this study, study design, data analysis, presentation, or publication of the findings. Holger Cramer is Editor-in-Chief of the Journal of Integrative and Complementary Medicine (JICM), President of the International Society for Traditional, Complementary, & Integrative Medicine Research (ISMCR), and Chair of the Deutsche Gesellschaft für Naturheilkunde e.V. (DGNHK) His work is supported by the Robert Bosch Stiftung, Stuttgart, Germany. Thomas Rosemann is Chair of Primary Care at the University of Zurich and Director of the Institute for Primary Care at the University Hospital, Zurich (USZ); on his initiative, the National Research Program (NRP) 74 was established for the Health Services Research area in Switzerland in 2017. Karl-Heinz Wagner is President of the Austrian Nutrition Society and in the Scientific Board of the German Nutrition Society. Andreas Michaelsen, would like to acknowledge the DBU Deutsche Bundesstiftung Umwelt (ID: 37986/01 for Nutrition for Planetary Health in der Schule), along with having authored several books considering treatment, cure and heal with the power of intermittent fasting, nutrition and nature. Merel Ritskes-Hoitinga acknowledges the support of the research by the SAFE project (SAFE – Safety Assessment through Animal-Free Evolution; NWA.1395.20.004 funding Netherlands). Fatima C. Stanford is funded by the National Institutes of Health NIDDK U24 DK132733, UE5 DK137285, and P30 DK040561. Nataša Fidler Mis would like to acknowledge the Slovenian Research Agency (P3-0395: Nutrition and Public Health). Claus Leitzmann is a pioneer in the area of and conducted research projects (funds from local and federal agencies) on vegetarian, vegan, raw and whole food nutrition, and acknowledges having authored hundreds of scientific papers and more than 40 books. Doris Wilflingseder initiated the MUI AnimalFree Research Cluster at the Medical University of Innsbruck (MUI). Moreover, she is part of the Animal welfare committee and the senate of MUI. Rodrigo Antunes Lima is funded by the Project “IHMC22/00003”, funded by Instituto de Salud Carlos III and funds Next Generation Eu, which finances the actions of the Recovery and Recovery Mechanism Resilience (MRR). Christian Kessler is a member of the scientific advisory board of the company Bruno Zimmer. He is board member of the German Medical Doctors' Association for Ayurveda-Medicine (DÄGAM e.V.). Naim A. Khan is the Editor of several Journals: Nutrients, PlosOne and J Clin Med. Karl W. Kratky would like to acknowledge having edited and authored several books – some on systemic thinking, others on complementary medicine. Bostjan Jakse is a member and vice-president of the Slovenian Strategic Council for Nutrition (2022–2024). He is also a member of the working group that prepares Slovenian national guidelines 2025: Eating for health and the planet, based on food groups. Walter Kofler is President International Academy of Sciences - Health & Ecology. Tomas Pfeiffer is President of the Institute for TCIM/CAM, the Professional Chamber Sanator, and the Foundation of Josef Zezulka; he is organizer of the World Health Congress Prague, which is a non-profit event. Tomas Pfeiffer did not receive any external funding from any international agency. Manuel Schätzer works for SIPCAN – Special Institute for Preventive Cardiology and Nutrition, an NGO working in preventative healthcare. Abhishek Mittal is a PhD Scholar at Amity Institute of Public Health, Amity University, Noida, India. Corina Gericke and Gaby Neumann are employees of the non-profit organization DAAE – Doctors Against Animal Experiments. Aysha Akhtar is employed at the non-profit organization CCS – Center for Contemporary Sciences. Madan Thangavelu is International President at Ayush Valley Foundation, a non-profit organization. Éva Perpék received funding from the National Research, Development and Innovation Office (Hungary, grant number FK 138315, PI: Ágnes Győri) to study the mental health of social workers. Éva Perpék also acknowledges funding from the János Bolyai Research Scholarship of the Hungarian Academy of Sciences (BO/484/25). Michael Klaper is a speaker and author of several books focusing upon proper nutrition and a balanced lifestyle. Bhaswati Bhattacharya is book author. She is Director of the non-profit Center for Ayurveda Studies, Indic Academy, India. Georg Seifert would like to acknowledge the DBU Deutsche Bundesstiftung Umwelt (ID: 37986/01 for Nutrition for Planetary Health in der Schule).

Conflict of interest

FS has been an advisor/consultant for Calibrate, GoodRx, Pfizer, Eli Lilly, Boehringer Ingelheim, Gelesis, Vida Health, Life Force, Ilant Health, Melli Cell, Sweetch, Clearmind, and Novo Nordisk. CK receives honoraria for lecturing Ayurveda at Sonne und Mond, Berlin. BJ is receiving compensation at Herbalife Nutrition. CDu has been an advisor/consultant for Eli-Lilly, Pfizer, UCB scientific grants, consultancy/speaker fees and travel expenses or financial support for by CDu organized scientific meetings/workshops from Abbvie, Amgen, AOP Orphan, Astrazeneca, Bristol-Myers-Squibb, Eli-Lilly, Janssen, Galapagos, Merck-Sharp-Dohme, Novartis, Pfizer, Roche, Sandoz, STADA, UCB, and Vifor. FK was employed by Tirol Kliniken GmbH. SN was employed by Hands On Therapy Concepts Pvt. Ltd.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Author disclaimer

The views, opinions, and findings expressed within this multidisciplinary consensus statement paper and contained in this report are those of the authors and should not be construed or interpreted as representing the official viewpoint, guideline or decision of the Department of Research and Development in Teacher Education of the University College of Teacher Education Tyrol, Innsbruck, Austria, or representing exhaustingly the state-of-the-art science from the cross-cut area at the interface of or overlapping/inter-disciplinary areas medicine and health sciences, life sciences, sport science, and nutrition science, respectively. Approved for public release; distribution unlimited.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fnut.2025.1676080/full#supplementary-material

Abbreviations

ACLM, American College of Lifestyle Medicine; AMA, American Medical Association; COVID-19, Corona Virus Disease 2019; EU, European Union; GBP, Great Britain Pounds; IPCC, Intergovernmental Panel on Climate Change; PA, physical activity; NCDs, non-communicable diseases; WFPP, whole food plant-predominant; RCTs, randomized controlled trials; SARS-CoV-2, Severe Acute Respiratory Syndrome Coronavirus Type 2; SDGs, Sustainable Development Goals; TCIM, Traditional, Complementary, and Integrative Medicine; USD, United States Dollar; WHO, World Health Organization.

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