Helen Salisbury: Is lifestyle a choice?BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2701 (Published 07 July 2020) Cite this as: BMJ 2020;370:m2701
All rapid responses
At this moment in the corona virus pandemic, I appreciate Dr Salisbury’s focus on the growing burden of noncommunicable diseases which is very much driven by unhealthy habits. In fact, conditions such as hypertension and diabetes affect populations worldwide and not only in the affluent nations. Guidelines for heart health, diabetes and many other conditions include recommendations for better nutrition and for physical activity. However, it seems that many doctors lack confidence as to how to convey these recommendations to specific patients. The subject of ‘lifestyle’ so called, remains in the peripheral vision instead of being in sharp focus at the centre of our visual field.
Fortunately, the founders of the lifestyle medicine movement have been thinking about this for a long time, and in 2010 JAMA published the article entitled Physician Competencies for Prescribing Lifestyle Medicine, which outlines recommendations for primary care physicians in terms of an expanded knowledge base and skills. These recommendations have evolved into the current curriculum of the American College of Lifestyle Medicine which can be learned on its own (30 hours of online learning), or as part of the preparation for the ACLM Certification Examination, which would then require a further 10 hours of live CPD and the submission of a case report. The lifestyle medicine qualification is now fully international and the exam is offered in many countries, including the UK, leading to the diploma of the International Board Lifestyle Medicine (IBLM). In the UK, there is also the excellent Plant Based Nutrition Course at Winchester University which is online and covers much of the same ground as the ACLM course, but with a primary emphasis on nutrition, as the name suggests.
Although too few of us acquired these skills in medical school or subsequent training, all physicians are lifelong learners and the corona virus pandemic has surely demonstrated the ability of doctors to learn new information very quickly, if it is perceived to be important. Now we even know that the underlying conditions that lifestyle medicine aims to address are extremely relevant to the risk of serious morbidity and even mortality from this virus.
I would like to suggest, with respect to the ‘choice’ of lifestyle medicine, that first and foremost, we physicians have a choice, to learn about it, and even practice some of its principles in our own lives. The ACLM course specifically addresses some of the communication and planning issues through a simplified coaching model where a doctor and patient collaborate to design behaviour change goals which are specific, measurable, achievable, realistic/relevant and time bound. These so-called SMART goals can help patients make small but meaningful changes that they are individually ready for, and achieving these goals may help to build confidence that will lead to more positive changes in the future. As doctors, we have to be ready to open the conversation with patients and offer them benign and effective options to improve health and well being. It could start with something as small as adding one vegetable or piece of fruit per day, or walking for ten minutes a few times a week. Offering such options can convey our confidence in the importance and efficacy of these interventions. It can show our confidence in the patient’s ability, to do something positive for themselves and perhaps reduce their pill burden, reduce their risk factors, and help improve how they feel both physically and mentally. We may even share some of our own lifestyle challenges or goals. For those patients who are less motivated, the ‘stages of change’ model developed by James Prochaska (and part of the ACLM course) can help us gain some skills in exploring motivation and leaving the door open to future change.
I think that offering such conversations is in fact a mark of respect for our patients.
It goes without saying that economic and social deprivation need to be addressed at the policy level and on many different fronts. Offering lifestyle consultations to individuals does not contradict or substitute for the systemic policy level.
I cannot think of any doctor in any speciality who would not benefit from learning the principles of lifestyle medicine. Any GP surgery would benefit from having at least one partner with skills and knowledge in this area, and who could perhaps have a specific session dedicated to lifestyle consultations. This could even reduce prescribing costs. Of course, in the current pandemic, this has real potential to address some of those risk factors which increase morbidity and mortality.
Dr Miriam Maisel dipIBLM is a GP, and writes and lectures on lifestyle medicine and plant based nutrition to professional and lay audiences. https://www.dr-maisel.co.il
Lianov, L, Johnson, M. Physician Competencies for Prescribing Lifestyle Medicine, JAMA, July 14, 2010, Vol 304, no 2.
Competing interests: No competing interests
Helen Salisbury’s recent view “Is lifestyle a choice?” lays out succinctly the tension between policy and clinical practice in this area. No one should doubt the link between a lack of “lifestyle choices” for those who live in food deserts and lack access to good quality green spaces. Equally I agree, that as clinicians, we cannot change our patient’s post-code nor their exposure to processed food, where as we can try to lead and educate to influence policy makers.
However, I think there is a need to name the work we can do to support our patients to change modifiable risk-factors; a name for being more ambitious and achieving long-term disease remission. Lifestyle Medicine is the name that is being used by a growing global, grass-roots clinician and patient movement that aims to use good quality evidence for what lifestyle changes improve health (improvements in diet, physical activity, sleep, social connection, stress and reduction in alcohol and smoking cessation) with tried and tested interventions for how people can be supported to change behavior (use of person-centred care and support planning, social prescribing, group consultations, health coaching, motivational interviewing etc). Examples of good quality evidence include The Direct Trial for Type-2 Diabetes remission (1), The SMILES Trial (2) for depression remission and The Lifestyle Heart Trial (3) for coronary arterial disease reversal. This approach has been shown to both prevent, treat and reverse long-term conditions, achieving far better outcomes than many of the burdensome medication regimes patients work so hard to take but often tell us they dislike.
Dr Salisbury asks for more evidence and skills. The British Society of Lifestyle Medicine (4) is an educational charity that is dedicated to exactly this. As a member I hope that by calling this supportive approach “Lifestyle Medicine” we could develop leaders who are strong enough to shape the future of medical practice and policy, face up to “Big Food” and “Big Pharma” and could call for the changes my patients are asking for. Similarly, I think naming the approach has the potential to create the space for good quality education and research that promotes clear messages in what can be a messy and controversial area. It could also help reclaim the word “lifestyle” from poorly evidenced advice from the food industry, social media “lifestyle gurus” or “glossy magazines” as the article suggests. It could also allow us to move away from the failed ideas of “lifestyle choice” where we give out simple “lifestyle advice” such as “eat less and move more”. This is important because those that face fewer choices through socioeconomic disadvantage need even more lifestyle medicine support from clinicians rather than us shying away from, or worse, using deprivation as an excuse not to offer this support. Importantly here, the evidence behind Patient Activation Measures (5) have shown that it is possible to target support to improve health outcomes through a lifestyle medicine approach, despite the health inequalities people face. There is no reason to assume that people are hopeless victims of socioeconomic factors.
Moving away from lifestyle choice and advice to “Lifestyle Medicine” suggests an approach that is as effective as medications and one that I can use to support my patients in a consultation. This has such a message of hope; my patient’s destiny isn’t fixed in their genes nor in their environment. With the use of evidence-based interventions, we can work together to live healthy lives despite the inequalities we might face.
1. Lean M et al, Primary care-lead weight management for remission of type-2 diabetes (DiRECT): an open-label, cluster-randomised trial, The Lancet (2018), 391; 10120, 541
2. Jacka et al, A randomised controlled trial of dietary improvement for adults with major depression (the SMILES trial), BMC Medicine (2017) 15:23
3. Ornish D, Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial, Lancet, 1990, Jul 21:336 (8708):129-33
5. Greene, J., Hibbard, J.H. Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes. J General Internal medicine (2012), 27, 520–526
Competing interests: No competing interests
Helen Salisbury discusses issues to do with lifestyle choices. The idea is that lifestyle choice is OK if you have a garden and decent salary and live in a leafy suburb. The experience and implication is that if you live on a seventh floor apartment block your choice is seriously limited. This has been the case and will be the case unless a concerted effort is made to help people to change.
The evidence for the beneficial and health promoting effects of the Big Five is enormous.1-6 They are exercise; healthy diet; adequate sleep; occupation or job; friends or social contacts. The literature is awash with good evidence showing that these interventions are the way to go. The problem is that you can't get people of modest means or those living in poverty to do these things. This is a world wide phenomenon and must be addressed by policy. The Greens are lobbying for renewables and biodiversity and clean water and air, and rightly so. However the population also needs to be greened - of toxins - sugars, diesel fumes, noise pollution, cramped housing, excess alcohol and tobacco, poverty, unemployment..., and given something useful and substantive to occupy them. Education but also restriction of harmful pollutants, be they cheap alcohol, junk food, congested cities, drugs, polypharmacy...the list goes on.
The health budget for most countries in the OECD for the past decades is of the order of 10 -20% of GDP. The public deserve more value for money. High tech medicine and pharma and insurers take the lion's share of the money - and meantime there is a token public health system exposed by the pandemic, little if any prevention and education programmes to teach and educate and encourage people to live healthier lives. Policy and structures need to actually empower those in high rises to make good lifestyle choices. The health system is skewed toward end organ disease - costing percentages of national budgets- while at the other end of the spectrum the very causes of these diseases are being ignored or actually promoted.
1. Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States. July 26, 2010. Available from: http://www.healthypeople.gov/2010/hp2020/advisory/SocietalDeterminantsHe...
2. World Health Organization, Commission on Social Determinants of Health. Closing the Gap in a Generation: Health equity through action on the social determinants of health. Available from: http://www.who.int/social_determinants/enExternal Web Site Policy
3. National Partnership for Action: HHS Action Plan to Reduce Racial and Ethnic Health Disparities, 2011; and The National Stakeholder Strategy for Achieving Health Equity, 2011. Available from: http://minorityhealth.hhs.gov/npa
4. The National Prevention and Health Promotion Strategy. The National Prevention Strategy: America’s Plan for Better Health and Wellness, June 2011. Available from: https://www.surgeongeneral.gov/priorities/prevention/strategy/index.html
5. The Institute of Medicine. Disparities in Health Care: Methods for Studying the Effects of Race, Ethnicity, and SES on Access, Use, and Quality of Health Care, 2002.
6. Health Impact Assessment: A Tool to Help Policy Makers Understand Health Beyond Health Care. Annual Review of Public Health 2007;28:393-412. Retrieved October 26, 2010. Available from: http://www.annualreviews.org/doi/abs/10.1146/annurev.publhealth.28.08300... Web Site Policy
Competing interests: No competing interests