At the end of last week’s wellbeing round-up I touched upon the growing interest in lifestyle medicine within my profession and the opportunities that exist to develop knowledge, experience and qualifications in this area. I described the impact it had upon my professional and personal life and promised to return to this topic in more detail. Since I am a man of my word, I thought I would devote this week’s post to it. This is driven partly out of my own passion for the subject, and partly because of some interesting debates on the subject via social media in the last week or so.
Is Lifestyle Medicine a thing…and if so, how should we be doing it?
Wikipedia defines lifestyle medicine as “a branch of medicine dealing with research, prevention and treatment of disorders caused by lifestyle factors such as nutrition, physical inactivity, and chronic stress”. It’s a reasonable enough definition. I would add that, if done properly, it is also an evidence based speciality. No one is disputing that prevention is better than cure and that reducing risk factors for wellbeing such as weight, blood pressure, smoking, excess alcohol, sleep deprivation, anxiety and social isolation will result in better wellbeing for individuals and the population as a whole. If the term “lifestyle medicine” can be used to cover interventions which address this, then clearly it is not just a thing but a really good thing. The question is more over what it means to practise it, particularly who should be doing it and how.
What is a Lifestyle Medicine specialist?
There has been much debate in the internet shouting factory of late (particularly the Twitter part of it) about whether there is or should be such a thing as a lifestyle medicine specialist. Doctors can do courses (such as the Prescribing Lifestyle Medicine offered by Lobe Medical ) and even obtain a diploma in it from the British Society of Lifestyle Medicine. It certainly seems to be gaining traction as an idea. General practice is the most obvious setting to practise it in, as we know our patients, have plenty of information about many different aspects of their lives and aspire to practise in a holistic way. It could be any member of the primary care team, most obviously a doctor or a nurse. GP’s often sub-specialise within practices (for example in dermatology, women’s health or cardiovascular medicine) – so why not in this area?
There are of course different views on this. The concerns I have heard raised can be philosophical (i.e. we should all be doing this all the time, let’s not call it a speciality), pragmatic (i.e. we don’t have doctor time to spare on this, you don’t need a medical qualification so let’s give it to someone else to do) or around the issues of equity (i.e. for all the patients who aren’t acutely unwell that you spend time with, others end up seeing people who are sicker and pose a greater clinical risk). The last one was summed up by my colleague who said over a pint in the pub the other day “No one’s going to sue you for telling them to lose weight and exercise more”.
My responses to these issues are as follows:
- Yes, we should all be doing this but for whatever reason, we clearly aren’t. Not consistently. The fact that discussing lifestyle medicine seems to be a novel if not entirely alien concept to some clinicians shows how far we have to go.
- The relationship between a patient and their doctor/nurse/pharmacist/physio etc can be very helpful and powerful in at least starting these conversations. Priests are not just allowed to talk about God at funerals but are actually expected to. If they don’t, they are doing those they have a duty of care towards a disservice. In primary and care we are perfectly placed to start these conversations with a patient who trusts us and needs help. The term “doctor as drug” is often used to describe the reason that patients keep attending their GP surgery even though we can actually do very little for them. Why wouldn’t we value this when we can actually help them to make a big difference to their lives?
- I agree that appropriate use of resources, including doctor time, is key. Not all lifestyle medicine-based conversations need to take place with a doctor. The follow up conversations could be with a nurse, health care assistant, dietician or social prescriber. After all, we don’t want patients to become dependent on us for this too…it’s all about encouraging them to take ownership of this for themselves.
- I believe that practices or practice networks will benefit from having clinical practitioners for whom this is a special interest. We cannot expect every doctor or nurse to have all the facts and expertise at their fingertips, or to be up to date with behavioural psychology and the latest research. Of course such specialists can cascade their expertise down to their colleagues, offering themselves as available for referral up occasionally if required. And before anyone gets too snooty about how important such a special interest is and whether those who are doing it are pulling their weight or have a diploma in it, we could consider the fact that sub-specialisation has been going on ever since the inception of general practice and particularly over the last 20 years or so. GP’s are used to referring to each other internally if required. This need be no exception. With regard to workload and equity, GP’s also vary widely in how closely they follow up patients in terms of how often they are seen and for how long. There is generally an environment of high trust and a degree of individual autonomy and freedom within GP partnerships, as long as it isn’t being taken to extremes.
Does Lifestyle Medicine mean “victim” blaming?
This is one of the weirder arguments that seem to have arisen out of the subject, certainly on social media. Some people seem to have it in their heads that by raising the issues of lifestyle medicine and personal responsibility, as opposed to patting patients on the head with a prescription for statins, an antihypertensive, an oral hypoglycaemic and a referral for bariatric surgery, we are victim-blaming. I’m genuinely puzzled by this view. I have two issues with accusations of victim-blaming, namely the use of each of those words. It is right that we acknowledge that life is not a level playing field and that some people will face many challenges, and perhaps not have as many opportunities, purely because of where they are born and in what environment they are raised. However, to label a large proportion of the population as “victims” is depressing, patronising and nihilistic. People born into similar environments can make different decisions about their lifestyle and experience different outcomes as results. To label them as victims suggests they are powerless, can’t be helped and face inevitable poor health and wellbeing. With regard to the second word, there is no reason at all that having a careful and sensitive discussion with a person about the positive ways in which they can take control of their lives and transform their future need be viewed as blaming them. It’s about moving people on from where they are at present. I’m not as bothered about producing lycra-clad, fitbit-wearing, dairy-free, goji berry-gobbling triathletes as I am about people getting off the couch, eating a few more vegetables and being able to walk to the end of the street without going a dusky blue colour.
Individual Versus Population lifestyle medicine.
I read a thought-provoking post from Greg Fell, Director of Public Health for Sheffield, this week. It’s about the challenge of obesity and whether interventions should take place on an individual or population scale. You can read it here. It makes a number of important points including how much money has to be spent on weight management services to help a small part of the population lose weight and keep it off, and that the current obesity epidemic is not driven by greed or laziness but other socio-economic and environmental factors. I agree with Greg about the importance of the bigger picture stuff. We need to think much more carefully about public policy, how we design our cities and housing developments, good transport links, making cities safer for cycling, education in schools, legislating on what food labelling and on the presence of fast food outlets on our high streets and near our schools.
However, taking off my hat that I wear when considering issues of public health and commissioning, and putting back on my hat as a GP who has one to one interactions with patients every day, I do just need to point out a couple of things:
Firstly, all the admirable big picture stuff is just that…admirable. When the government comes up with the money and the local authority budget is no longer being slashed but actually increased, all will, eventually, be well. I’m sure there are examples of these helpful positive changes already existing and producing tangible results, just not anywhere near me.
Secondly, the view from parliament or county hall is somewhat different from the view on the ground from general practice. If I have a patient in front of me who needs to be supported in making some significant lifestyle changes, one of which includes referral to weight management, I would prefer to be able to do this rather only being able to put my arm around them, advise them simply to eat fewer pies and reassuring them that the picture will probably be a bit rosier for their kids. Ok, maybe their grandkids. Definitely their great, great grandkids.
My Lifestyle Medicine utopia
Allow me if you will to summarise by describing my vision of the sunlit uplands of wellbeing and of practising lifestyle medicine.
To start with, we will all be living in a society that is much more equal in terms of life chances, as politicians of whatever political hue have finally got the importance of the determinants of wellbeing and invested heavily in this. Infrastructure in our society will have been developed to make it easier for people to live connected, meaningful, active lives. Education in schools will have resulted in parents and children alike making as healthy a choice as they can within their means. Wellbeing Centres will be competing on the high street with fast food outlets, demonstrating that understanding and practising lifestyle medicine is not just confined to medical professionals or a privileged few. In primary care, GP’s will be providing a properly funded service as part of their core general medical services contract which identifies people at higher risk of wellbeing issues and gives them the appropriate support and education, signposting them on to lifestyle services to help them make the changes that they need to for themselves. Just as people have asthma plans or birthing plans, it will be considered routine for them to have a wellbeing plan, which a lifestyle medicine practitioner (of whatever variety) has helped them put together. Those same practitioners will be available to support their colleagues to give extra advice and input when required but this won’t needed all that often because the importance of lifestyle medicine has been understood and embraced and become an integral part of the core of primary care. All of this will be properly paid for by the government who have put their money where their mouth is as they too recognise that lifestyle medicine is indeed a thing.
I hope that you have enjoyed this week’s post. Both your feedback and sharing this with others would be much appreciated. The weekly wellbeing round-up will be back next week. Until then, take care of yourselves!
Dr Richard Pile