Printed on: May 18th, 2024

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Lifestyle (as) medicine: Why? What? How?

Lifestyle (as) medicine: Why? What? How?

Is primary care equipped to handle today's health challenges and plan for the future?

With a surge in workload, staff shortages, increased wait times and practitioner burnout on the rise, it often does not seem that way (BJGP 2023;73:3).

Why is our health service in crisis? The answer is not simple (it never is!).

This crisis is fuelled by many factors, including:

• Increasing medical and social complexity.
• Declining funding as a proportion of GDP.
• An aging population.
• Rising comorbidity and multimorbidity with long-term conditions such as type 2 diabetes, cardiovascular disease, obesity, cancer and psychiatric illness (Kings Fund 2016 Understanding pressures in general practice).

The COVID-19 pandemic further exacerbated these issues (BJGP 2022;72:e325).

Long-term conditions are escalating due to changing lifestyles, including:

• Modern nutrition, e.g. the increased consumption of calorie-dense ultra-processed foods.
• Sedentary behaviour.
• Loneliness and social isolation.
• Increasing stress levels and mental health burden.
• The obesity crisis. 76% of men and 60% of women are currently overweight or obese in the UK.
• Numerous other risk factors, including pollution, loss of natural spaces and excess alcohol consumption, driven by industrialisation, urbanisation, population growth and trade in harmful substances.

The World Health Organization (WHO) estimates that 71% of premature death is related to four common long-term conditions. These are often referred to in the literature as the four horsemen (BMC Public Health.2021;21:2163):

• Cardiovascular disease.
• Cancer.
• Chronic respiratory disease.
• Type 2 diabetes.

The WHO explored the impact of healthy lifestyles on quality of life and individual health across 35 countries. It found that 60% of long-term conditions were related to unhealthy lifestyles (J School Health, 2004;74(6):204–206). However, it is important to acknowledge that our ability to adopt a healthy lifestyle is not equal across society. A study in the Lancet found that 1 in 3 premature deaths were related to socioeconomic status (Lancet Public Health 2020;5(1):e33-41).

Given all this, could ‘lifestyle medicine’ make up part of the solution?

• Historically, acute illnesses, particularly infectious diseases, dominated the medical landscape.
• Now, as discussed above, this has been replaced by ill health due to long-term conditions.  
• Given the connection between lifestyle behaviours and long-term conditions, there is a compelling need to reconsider our approach to medicine.

Treating complications and trying to slow down the progression of long-term conditions through medication and surgical procedures often has less impact on the patient’s physical and mental health than effective lifestyle changes. However, supporting patients to make these lifestyle changes is a skilled job, and many of us lack confidence in moving away from simply offering advice to more effective communication models. We perhaps also lack the knowledge of what we should be ‘advising’.  

This is important because even celebrated new drugs such the GLP-1 mimetics, e.g. semaglutide (Wegovy), have been shown to be effective when combined with lifestyle changes (JAMA 2022;327:138).

The siloed nature of healthcare means that patients are often managed by numerous specialities and clinicians. This can lead to overprescribing, and missing the overall picture and impact of each intervention. Personalised care was therefore selected as one of the NHS Long term plan 2019 five major practical changes to the NHS, with an aim to reach 5 million people by 2034.

The Comprehensive Model of Personalised Care encompasses six elements:

• Collaborative decision-making.
• Tailored care and support planning.
• Empowering choice.
• Social prescribing.
• Fostering supported self-management.
• Incorporating personal health budgets.

You can read more about how this works in practice in the case study of the Leamington Spa Personalised Care Team, a collaborative team of GPwER in lifestyle medicine, social prescribers, dieticians, mental health workers and health coaches. See useful resources box.

We think so!

The relatively recent introduction of the concept of lifestyle medicine reflects this changing perspective, and it is likely to become a pivotal and influential domain in the future of healthcare.

It is now being incorporated into medical school curricula in the UK, e.g. Imperial College London and Oxford University (Future Healthcare Journal 2023;10(3):226).

In 2024, the RCGP published the General Practitioners with Extended Roles Framework in lifestyle medicine (GPwERLM), co-authored by Dr Hussain Al-Zubaidi (Red Whale team member) and Dr Callum Leese, Dr Ellen Fallows and Dr Rob Lawson, to support the growing interest in the field among primary care clinicians (see useful resources box).

Lifestyle medicine can and should be applied by ALL clinicians (within their scope of practice), including doctors of other specialities, social prescribers, health coaches, dieticians and physiotherapists.

Some people find the term ‘lifestyle medicine’ difficult. They may equate it with blame for lifestyle ‘choices’ that are part of a wider socioeconomic picture, or associate it with ‘the worried well’ seeking nutraceuticals (or even a denial of the benefits of pharmacological or surgical interventions). This is not the intention.

Dr Ellen Fallows, Vice-President of BSLM, states: “This focus does not apport blame and instead takes a supportive approach, whilst also allowing for all therapeutic options to be offered, including medication and surgery if necessary” (Future Healthcare Journal 2023;10:226).

This is the approach we aspire to at Red Whale.

Lifestyle medicine is a globally recognised medical discipline defined as: “Evidence-based healthcare that supports behaviour change through person-centred techniques to improve mental wellbeing, healthy relationships, physical activity, healthy eating, sleep and minimisation of harmful substances or behaviours” (British Society of Lifestyle Medicine).

It is based around 3 core principles:

• The social determinants of health: awareness of and action to improve these.
• Behaviour change skills: proven techniques to support people in sustaining lifestyle changes (see our article on Motivating behaviour change).
• The 6 pillars of lifestyle medicine:
  • Healthy eating.
  • Mental wellbeing.
  • Health relationships.
  • Physical activity.
  • Minimising harmful substances.
  • Restorative sleep.  

Let’s consider here ‘lifestyle medicine’ as a skill that we can add to our toolbox. This can be used alongside our existing skillset, including prescribing and deprescribing, or can be used as standalone.

If you are a GP considering doing this as part of an extended role, you can find more details of the RCGP recommendations at RCGP GPwERLM Framework 2024.

Let’s consider the 3 key areas we need to develop if we want to use lifestyle medicine effectively (BSLM accessed March 2024, RCGP GPwERLM Framework).

This might be an attitude shift. The truth is that ‘medical’ intervention has a relatively small effect on health (as opposed to disease). Socioeconomic factors, including lifestyle behaviours, are more important (adapted from Dahlgren-Whitehead model 1991 and WHO Commission on Social Determinants of Health 2005–2008).

While strong public health and progressive economic policies will produce the greatest impact, most of us cannot influence population-level policy (the big white circle and the arrows). However, we can, potentially, impact the areas shaded in grey.

There are two exciting things to consider when comparing lifestyle change with drugs. The following uses smoking as an example, but evidence also exists for weight management and physical activity.

While a blood pressure tablet will reduce blood pressure (and possibly the risk of adverse cardiovascular outcomes), smoking cessation will reduce blood pressure and the risk of adverse cardiovascular outcomes, cancer, COPD and diabetes. It may also improve mental wellbeing and reduce financial outlay.

Unlike medication, lifestyle change can impact not just the person undertaking it, but also their wider family. There is evidence that children tend to mimic their parents' smoking and quitting behaviours (Nicotine Tob Res. 2014;16(1):11). Removing smoking from the household can also reduce the risk of childhood respiratory disease and SIDS.

This is a significant move away from ‘giving lifestyle advice’ – telling people what to do is rarely effective!

To increase the effectiveness of lifestyle-focused interactions, we can (BSLM accessed March 2024):

• Use a person-centred approach: this means finding out what matters to this person about their health, and helping them to integrate this and their values with the evidence and available options for management. This is sometimes called personalised care.
• Use supported self-care: empower and activate people to manage ongoing health conditions themselves outside of the immediate consultation or intervention (this is essential if we think about how much clinical contact time we have with each person!).
• Use specific communication skills/coaching tools that have been demonstrated to be more effective than giving advice. This might include:

This is key to being able to share information with patients seeking support.

You will find articles to support your learning in these areas on Red Whale Knowledge and as part of our Lifestyle Medicine course. If you want to study this in more depth, the RCGP GPwERLM Framework outlines a wide range of detailed CPD opportunities.

Please follow the link for a PDF version of the GEMS for download/printing: Lifestyle medicine: GEMS

This evolving area of evidence is often rather different from what many of us are used to with ‘simpler’ drug-based interventions.

This evolving area of evidence is often rather different from what many of us are used to with ‘simpler’ drug-based interventions.

Lifestyle medicine presents challenges in conducting double-blinded randomised controlled trials (RCTs) because of: 

• Cost implications (and limited incentives for many usual funders of research).
• The impossible challenge of blinding participants to, for example, nutrition or physical activity interventions.
• The complexity of standardising lifestyle interventions across groups.

"Prevention is better than cure."

This well-known saying is one I suspect ALL clinicians and patients would agree with.

However, most developed nations’ healthcare systems and funding structures do not reflect this, with most financial and workforce resource dedicated to managing disease once it’s established. In the UK, most NHS funding is spent on ‘curative and rehabilitation’ care delivered in acute hospitals (ONS Healthcare expenditure, UK Health Accounts 2021).

Traditionally, health prevention is divided into primary, secondary and tertiary, referring to distinct levels of healthcare intervention aimed at preventing and managing health issues at various stages (J Prim Care Community Health. 2023;14:21501319231186500, Mayo Clin Proc Inn Qual Out 2024;8:151).

Some newer concepts are coming into play:

• Primordial prevention: this comes before primary prevention, and aims to reduce the risk of risk factors (e.g. hypertension, overweight, starting smoking) by intervening through public health, school-based and socioeconomic initiatives.
• Quaternary prevention: this is at the other end of the scale, and focuses on prevention of iatrogenic harm from overdiagnosis, overmedicalisation, polypharmacy, etc. Strategies include avoiding over-investigation of medically-unexplained symptoms, facilitating continuity of care, and empowering patients to understand their health conditions and the relative benefits and harms of a range of treatment options.

There are, of course, medical and surgical options for primary, secondary and tertiary prevention. However, drugs or surgery are generally targeted at a single condition, and may exacerbate other co-existing conditions. Only lifestyle measures and a personalised care approach work across the WHOLE spectrum, with cumulative benefits across multimorbidity. Lifestyle medicine emphasises the integration of evidence-based care, behaviour change and patient empowerment to foster healthier lives.

There is no one formula for delivering a lifestyle medicine approach. It is of course possible to incorporate the attitudes, skills and knowledge into ANY consultation or interaction in primary care, and, for some of us, that will be where we focus our efforts. When considering wider and more intentional applications, here are some suggestions from the 2024 RCCP GPwERLM Framework:

• Discussing the potential of lifestyle interventions as part of medication reviews, instead of escalating therapy.
• Careful assessment and potential adjustment of medications based on lifestyle changes. 
• See our article Deprescribing after lifestyle intervention. 

• Integrating with primary care chronic disease nurses, health coaches, social prescribing link workers, dieticians, physiotherapists, pharmacists and mental health workers.
• Where needed, referring to secondary care and specialist input.

• Designed to address lifestyle factors in specific populations; continues to use an individual approach, while fostering a culture of peer-to-peer support and learning.
• See our article Group care and group consultations, which includes some examples from across the UK.

• Look to address societal and cultural practices that may negatively affect lifestyle and contribute to poorer health outcomes.
• Join advisory boards, council meetings or policy discussions.

• Whole-person approach integrating lifestyle change with conventional evidence-based treatments; embraces a biopsychosocial perspective within patient interactions.
• The assessment typically includes:
  • Ascertaining the patient’s needs.
  • Detailed lifestyle history exploring the six pillars (see our article The six pillars of lifestyle medicine).
  • Clinical assessment of their lifestyle factors.
  • Co-creation of a lifestyle treatment plan with goal-setting, supporting behaviour change and follow-up.
• Patients must be partners in the treatment rather than passive recipients.
• Typically, no extra risk factor testing or prescription of nutritional supplements beyond primary care norms. Nutritional needs are achieved through the adoption of a predominantly whole food balanced diet.

This is taking place in some NHS settings. GPs involved in this work estimate that an assessment of this type can be done in 20 minutes if we know the person, or 30 minutes for a new patient. Follow-up can then be done in 15 minutes. This is food for thought.

You may be thinking, “How do we fit this in and fund it within NHS services?”. Good question!

Many of us worry that offering lifestyle medicine opportunities at a practice level is not financially possible or sustainable, but there are routes to funding that can make this a sustainable and rewarding path.

Who in your practice might have the skillset and time to apply for funding? This could include the practice manager, social prescriber or health coach. This will involve creating a business case for the proposed project.

.If this is the first time you are doing this, starting small will help, e.g. initiatives aligned with the Active Practice Charter and Parkrun Practice scheme. This could sow the seeds of a culture change within your PCN, and provide quick wins that will motivate the team to do more.

You could then build a collaborative group that includes (where possible) roles funded through the ARRS scheme who have strong skills in this area, e.g. health and wellbeing coaches, dieticians, social prescribers and care coordinators. This will help focus on a specific initiative important to your population; this might involve offering group care.

When completing business cases, focus on the opportunities for patient engagement, staff development and potential cost savings to increase the chance of success.

This model could help secure external funding from sources such as local councils, active partnerships and sport legacy funding.

If you can identify PCN/cluster agreed Key Performance Indicators, aligning your proposed outcome measurements to these will also help strengthen the case for funding.  

Nine years ago, something struck me – I was experiencing burnout. It took a sonographer unveiling the presence of non-alcoholic fatty liver disease, my GP confirming hypertension, and the growing burden of 10-minute patient interactions to underscore the toll modern lifestyle had taken on my health and wellbeing.  

It was around this time that I stumbled on the TV show 'Doctor in the House'. Dr Chatterjee showcased transformative journeys using lifestyle medicine with patients grappling with various long-term health conditions.

I was intrigued by the positive outcomes. Some of the highlighted evidence was entirely novel to me, absent from both my undergraduate and postgraduate training. Over the following years, I achieved substantial weight loss, experienced enhanced physical and mental wellbeing, and gained a fresh perspective. This personal transformation spilled over into my clinical practice, rejuvenating my satisfaction with my job. I started to really appreciate how my environment had been controlling so much of my behaviour.

I became passionate about supportngi both my colleagues and patients on a similar journey to health. I have not looked back since and feel more fulfilled and satisfied with my work. Dr Hussain Al-Zubaidi.

Lifestyle (as) medicine: Why? What? How? Lifestyle medicine is evidence-based healthcare based on 3 principles: Awareness of and action to improve the socioeconomic determinants of health. Using proven behaviour change skills to support people in sustaining lifestyle changes. Using the 6 pillars of lifestyle medicine (nutrition, mental wellbeing, healthy relationships, physical activity, minimising harmful substances and restorative sleep) to assess and support individuals to make positive changes.

Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) RCGP - physical activity hub British Society of Lifestyle Medicine RCGP GP with an extended role in lifestyle medicine framework Personalised care delivery in primary care – Leamington case study Books The 4 Pillar Plan: How to Relax, Eat, Move and Sleep Your Way to a Longer, Healthier Life, Dr Rangan Chatterjee (Penguin, 2018)