Lifestyle medicine: a new medical specialty?BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4442 (Published 25 October 2018) Cite this as: BMJ 2018;363:k4442
Lifestyle medicine’s adherents talk enthusiastically of fixing the broken medical model and saving the NHS. Does the launch of a new diploma and its introduction to the curriculum at medical schools such as Cambridge University signal its emergence as a standalone specialty—and what might its impact be?
“Not just nutrition”
The Lifestyle Medicine Global Alliance, which lists 16 regional members from around the world and runs online training,1 defines lifestyle medicine as “an evidence based medical specialty” that uses “lifestyle therapeutic approaches” to prevent, treat, or modify non-communicable chronic disease2—the disease area that accounts for 71% of deaths worldwide.3
These approaches include “a predominantly whole food, plant based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substance use, and other non-drug modalities.”2
“Lifestyle medicine is not complementary or alternative—it’s mainstream,” says Rob Lawson, a retired NHS GP from East Lothian now working privately, who is chair of the British Society of Lifestyle Medicine (BSLM), founded in 2016. He says people need to realise it’s not just about nutrition. “You’ve got to get to the people who need it most. They’re not going to switch fish and chips for avocado and chia seeds,” he says. Helping people find a purpose in life and beat isolation can tackle the “upstream causes” of disease, he says.
Key to the delivery of lifestyle medicine is the ability to help people make sustainable lifestyle changes through behavioural change management techniques. “It’s all about behavioural psychology and buy-in,” says Alex Maxwell, a GP in Thornton Heath, south London, who is introducing lifestyle medicine into his practice.
Demand for education
In August, 40 healthcare professionals sat the first examination for the BSLM’s diploma in lifestyle medicine, which is certified by the International Board of Lifestyle Medicine. Lawson says the diploma will “set a common standard of lifestyle medicine protocols” and “differentiate between evidence based and otherwise.”
Medical schools are getting in on the act. Anne Swift, director of public health teaching at Cambridge University’s clinical school, has seen “quite a demand from students” for education about lifestyle medicine. “We’re going to introduce a new curriculum through public health teaching, which will educate students on nutrition, physical activity, and sleep, and give them skills in behavioural change.”
Theory and evidence will be taught in traditional lectures, while behavioural change techniques will be practised with role play. Students can train as health coaches, “so while still at medical school they have the opportunity to put those skills into practice with patients.” The changes will be introduced over the next two academic years.
Lawson is also working with BSLM on a “blueprint” lifestyle medicine curriculum to make available to other medical schools, and hopes it will become an integral part of the curriculum.
A standalone specialty?
One unresolved question is whether these students are training in a new specialty, or whether lifestyle medicine is, or should be, integrated into other medical specialties.
Lawson says he first expected it to be part of general practice. He has discovered, however, that “folk want to practise lifestyle medicine separately from general practice. I can see why and it reflects the pressure general practice is under.”
“In the long term, it’s got the ability to stand alone,” says Maxwell, “but that doesn’t stop the fact that the principles can be applied by any speciality.”
Helen Lawal, a GP who works across NHS and private sectors, says: “I’d like to see a time when lifestyle medicine doesn’t need a separate label, when it’s integral to the way we deliver healthcare.”
The diploma may encourage the development of a standalone specialty, Lawson accepts. “Now we have a global exam, you can work almost anywhere in the world as a healthcare professional in lifestyle medicine.”
Others consider lifestyle medicine to be the emeperor’s new clothes. Advising citizens and patients about evidence based alterations to diet or exercise to prevent and treat disease has been part of the medical curriculum and practice for decades,” says Glasgow GP Margaret McCartney.
How it works in practice
Maxwell says he uses the principles in every patient interaction, but his introduction of group lifestyle consultations is the most eye catching initiative.
He runs a lifestyle medicine group consulting session twice a month, where people review their biometric data and set lifestyle goals, then have sessions on food and activity. “That’s been getting fantastic feedback—80% of people say they prefer it to consulting on a one to one basis,” he reports.
Lawal has developed group consultations with One Medical Group, which runs walk-in centres and medical centres nationwide, and plans to establish NHS based lifestyle medicine clinics.
“We are still seeing the same patients with the same problems, but with a shift in the way you are approaching them: less of an emphasis on prescribing and more on taking a lifestyle history and helping them to create action steps they can take immediately,” she says.
The blame game
Some commissioning groups have refused people treatments—including routine surgery such as hip and knee replacements—until they’ve tackled lifestyle problems such as obesity or smoking.4 But Lawson is “vociferous” that lifestyle medicine does not involve blaming patients for their condition.
“To apportion blame is entirely the wrong thing.” He points to lower health inequalities in Nordic societies as an example of how wider societal determinants affect health.
For Swift, this is why lifestyle medicine sits within public health. “It’s really important to me that the course maintains the emphasis that the wider determinants of health are massively important.”
Maxwell argues that “getting people to take responsibility” for their health is crucial, whatever their situation. “I think there’s a big divide between those who are taking responsibility and those that aren’t.
“I’ve worked with lots of people in a deprived area and applying these principles to these guys I find far more satisfying than helping someone who knows they should be eating well to eat a bit better.”
However, Nick Summerton, an East Yorkshire GP and NICE adviser, says that doctors may have difficulties understanding patients’ lives. He says that as a new GP he used to lecture people about stopping smoking and couldn’t understand why they didn’t. “I realised their lives are not like mine and smoking was probably the one pleasure in their lives.”
A key question is how to get the message to those who need it most. While Lawson is sceptical of television shows’ ability to deliver behavioural change, Lawal, a media doctor on television lifestyle medicine shows such as Channel 4’s Food Unwrapped, disagrees.
“TV can be a powerful tool to bring people factual, evidence based information, or maybe expose them to other people that are going through similar experiences and be inspired by other people’s stories,” she says.
Saving the NHS?
The potential burden of chronic disease arising from lifestyle related causes is huge. With 26% of adults in the UK5 now classed as obese, and rates of type 2 diabetes still rising rapidly worldwide,6 NHS chief executive Nigel Stevens has warned that we need to “get serious about obesity or bankrupt the NHS.”7
While there’s a plethora of evidence that lifestyle can affect health,8 the evidence that doctors can bring about clinically meaningful lifestyle changes in patients is less plentiful.9 If this new movement is to establish itself as a useful new branch of medicine —never mind the saviour of the NHS—it will need to prove it can truly make a difference to patients’ lifestyles.
Both Lawal and Maxwell offer examples of patients who have benefited from a lifestyle medicine approach. One patient with intractable depression now plays football regularly, while another with chronic pain discovered purpose and companionship through cross stitch embroidery. In both cases, discovering an activity that gave them pleasure was key to patients making lifestyle changes that helped them to cope with their chronic conditions.
Lawal says, “I really do think this is the answer. Shifting towards this approach is the way we’re going to tackle public health problems and save the NHS.”
However, Summerton questions the sustainability and value of lifestyle interventions versus pharmacological options such as statins and smoking cessation therapies. “The evidence [for pharmacology] is usually very good, but there is this idea that it’s a bit grubby to use drugs for population health,” he says.
From a public health perspective, Swift sees the potential of lifestyle medicine to push disease prevention up the agenda. “Prevention has been given lip service since the 1970s but it’s never had momentum behind it,” she says.
The enthusiasm among medical students gives her optimism. “Students can see the impact on the NHS and it makes sense to change the way we think about these things. It’s just not feasible to use the traditional models any more. Students are of a generation who can envisage change and are willing to push for that.”
For Lawson, who spent decades trying to implement lifestyle principles in practice before lifestyle medicine was even a recognised term, the current interest in lifestyle medicine is cheering.
“The last [BSLM] conference [in June] was uplifting. It just shows: when you read about the state of the NHS and people put their heads in their hands, there are some people out there are trying to do something about it.”
Forging a career in lifestyle medicine: GP Helen Lawal
Lawal exemplifies the myriad roles that lifestyle medicine offers a doctor. Her qualifications include a degree in sports and exercise science, and she has previously worked in sexual health and family planning clinics. Current roles include:
NHS GP in Leeds
Lead GP on lifestyle medicine with One Medical Group, developing wellbeing and lifestyle clinics and services in the private sector and NHS
Health coach, working with private patients
Media doctor, with appearances on Channel 4’s Food Unwrapped and How to Stay Well
She says lifestyle medicine is good for doctors, as well as patients. “I have certainly experienced a significant improvement in job satisfaction by approaching my time with my patients in a lifestyle medicine way. To see patients actually make the changes and feel better —that’s a good feeling, that’s why we go into medicine.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare