Lifestyle medicine: a cultural shift in medicine that can drive integration of care

ABSTRACT

Our traditional medical mindset and healthcare culture are being severely challenged. In the face of novel infectious diseases, such as Coronavirus 2019 (COVID-19), along with rising levels of chronic diseases, such as obesity, type 2 diabetes mellitus, psychiatric illness, cardiovascular disease and cancer, many argue that current healthcare practices are failing to meet our needs. Energy and vision for a new way of practicing medicine are colliding, from both top-down, driven by policy, and bottom-up, driven by clinicians and patients. Policy makers have laid out the need for integration of healthcare delivery to address the complex chronic disease burden; creating integrated care partnerships, health and wellbeing boards and primary care networks to bring together ‘at the place level’ primary and secondary care, mental and public health services, social care and the voluntary sector. In practice, this is starting to build lasting working relationships between previously siloed services, to address the complex environmental, social, cultural, lifestyle and biopsychosocial drivers of ill health rather than simply providing access to hospitals, doctors and medication. Similarly, out of frustration with our traditional pharmaceutically driven medical model, grass-roots clinicians have built a new vision for their role in this better integrated health system, with the discipline of lifestyle medicine.

Our traditional medical mindset and healthcare culture are being severely challenged. In the face of novel infectious diseases, such as Coronavirus 2019 (COVID-19), along with rising levels of chronic diseases, such as obesity, type 2 diabetes mellitus, psychiatric illness, cardiovascular disease and cancer, many argue that current healthcare practices are failing to meet our needs.

The case for change has long been overwhelming, with decades of evidence demonstrating that socioeconomic and lifestyle factors have the greatest impact on health outcomes.¹ Despite this evidence, NHS funding has stubbornly focussed on the so-called ‘curative and rehabilitation care’ provided by acute hospitals, where pharmacological and doctor-driven care is the priority.² Report after report have raised alarm about overprescribing³ and the use of too much medicine,⁴ while the latest data find that, despite this proliferation of medicine, we are living shorter and less healthy lives.⁵

As a clinician, it is possible to sense a quiet re-evaluation of medical paradigms. This re-evaluation is born from necessity, as many in the NHS, particularly those in primary care, hit ‘rock-bottom’.⁶ Clinicians will recognise, as with patients, that reaching ‘rock bottom’ can trigger a crisis in belief that acts as a catalyst for change.⁷ Evidence showing the inadequacy of our current medical model is seen daily through the harms of too much medicine, polypharmacy, unsustainable practice, growing patient dissatisfaction and clinician burn-out. As belief and power in the traditional medical model fall away, space has been created for a paradigm change. Energy and vision for new ways of practicing medicine are colliding, from both the top down, driven by policy, and the bottom up, driven by clinicians and patients. From the top, policy makers have laid out the need for integration of healthcare delivery to address the complex chronic disease burden,⁸ creating integrated care partnerships, health and wellbeing boards and primary care networks to bring together ‘at the place level’ primary and secondary care, mental and public health services, social care and the voluntary sector. In practice, this is starting to build lasting working relationships between previously siloed services, to address the complex environmental, social, cultural, lifestyle and biopsychosocial drivers of ill health rather than simply providing access to hospitals, doctors and medications. Similarly, from the bottom up, out of frustration with the traditional pharmaceutically driven medical model, grass-roots clinicians have built a new vision for their role in this better integrated health system with the discipline of lifestyle medicine. An increased awareness of the limits of pharmaceutical interventions, the importance of lifestyle factors and the concept of lifestyle change as medicine is also reaching the general public through popular media.

The evolution of lifestyle medicine

Lifestyle medicine was coined as a concept during the 1980s by epidemiologist Ernst Wynder during his work proving the link between smoking and lung cancer. However, its roots are as old as medicine itself, evolving when Hippocrates liberated medical practice from superstition and religion to focus on secular approaches to diet, exercise, rest and wellbeing. By the late 1990s, the discipline was formally defined in the first textbook of lifestyle medicine by American physician James Rippe. The American College of lifestyle medicine was founded in 2004 and established speciality training. In the UK, the British Society of lifestyle medicine (BSLM) was established in 2006, developing a curriculum, qualification, journal and conferences. Several medical schools now include lifestyle medicine teaching. As interest in this field has grown rapidly, many other aligned organisations have been set up in the UK, such as the Personalised Care Institute and the National Academy of Social Prescribing, while established medical bodies, such as the Royal College of General Practitioners, are developing definitions for GPs with extended roles in lifestyle medicine.

The BSLM defines lifestyle medicine, as ‘evidence-based clinical care that supports behaviour change through person-centred techniques to improve the six pillars of mental wellbeing, social connection, healthy eating, physical activity, sleep and minimisation of harmful substances and behaviours’.⁹ The practice of lifestyle medicine in the UK teaches about the influence of the socioeconomic determinants of health, the use of behaviour change techniques and knowledge of the six pillars (Fig 1). Cultural factors have influenced various definitions of lifestyle medicine around the world, but the six pillars remain central to the concept.

Fig 1.

The three core principles in the practice of Lifestyle Medicine.

Lifestyle medicine describes a medical discipline that is practised by clinicians of all backgrounds at a personal level within one-to-one consultations or small groups of patients. It is most effective with strong public health policies. In contrast to lifestyle medicine, public health often uses larger-scale interventions or influences policy changes to address the underlying socioeconomic drivers of lifestyle behaviours. Although public health remains the most effective and equitable way to improve health, lifestyle medicine can act as a bridge between population-level activity and smaller-scale interactions. Training clinicians to use support for lifestyle change as medicine means that they can skilfully offer all evidence-based treatment options, rather than over-rely on, or potentially overemphasise, medication or surgical treatment options.

Although ‘lifestyle advice’ has long been listed in major guidelines, this advice has often lacked detail and failed to recognise the skills and infrastructure that clinicians and patients need to achieve sustained lifestyle change. These skills include the use of behaviour change techniques along with compassionate, personalised care that involves the patient as an active partner. This moves away from paternalistic care, where clinicians are assumed to hold all the knowledge and skills. Personalising care using enquiries, such as ‘what do you feel is most important to your health right now?’, is central to the practice of lifestyle medicine. Equally, new healthcare systems, as provided in integrated care models, are needed that support patients to make and sustain lifestyle changes. For example, this involves integration of care providers from many different backgrounds, such as social prescribing, dietetics and health coaching.

Lifestyle medicine addresses the neglected and outdated concepts of ‘lifestyle advice’ and the failure of medical and allied health curricula to provide any teaching on physical activity for health,¹⁰ let alone the skills to support behaviour change, nutrition, sleep science, mental wellbeing (as opposed to just mental illness) and how to improve social connection for health. It formalises this gap in training by providing an evidence-based discipline that addresses the overfocus on pharmaceutical and hospital-based solutions. Senior medical educators are now calling for this teaching to be embedded urgently in all undergraduate medical education,¹¹ while trail-blazing medical schools, such as Imperial College London and Oxford University, now include lifestyle medicine in their core curriculum.

Challenging the status quo; a framework for prevention, treatment and remission of chronic disease

Lifestyle medicine provides an evidenced, intellectual framework that challenges the concept of a ‘pill for every ill’. Most importantly, as a discipline, it provides an easily understood ‘lifestyle as medicine’ focus within consultations with patients. This focus does not apport blame and instead takes a supportive approach, while also allowing for all therapeutic options to be offered, including medication and surgery if appropriate. From basic physiology to interventional trials, the concept of lifestyle medicine can explain the why and how for a new way of working that can pave the way for integrated care.

The discipline has been shaped, for example, by the latest research into the role of epigenetic factors regulating gene expression. The Human Genome project dominated the 1980s and 1990s, promising to be the greatest breakthrough in medicine following James Watson's proclamation in Time magazine in 1989 that ‘we used to think our fate was in our stars, now we know in large measure our fate is in our genes’.¹² This fatalistic mind-set fed into the narrative that we are defined by our parents' health and, consequently, medication or surgery are the only feasible interventions to alter the hand we are dealt. Research showing that gene expression is powerfully modulated by lifestyle has challenged this concept of genetic determinism, which still looms large in the minds of clinicians and patients. We now know, for example, that even those who carry BRCA genes for breast cancer risk can significantly modify their individual risk with lifestyle changes, such as physical activity and eating patterns.¹³ Research by those including Nobel prize-winner Professor Elizabeth Blackburn, shows that many surprising factors, including stress, sleep and social isolation, can change our DNA length (through the action of telomerase activity),¹⁴ leading to trials of lifestyle interventions demonstrating associated DNA changes.¹⁵ Even more revolutionary is the latest research into the role of mitochondria, which suggests that they are the ultimate control centre of gene expression, cell differentiation and death with a key role in inflammation and ageing.¹⁶ Tantalising research suggests that nutrition, fasting, sleep, stress, physical activity and social connection exert powerful effects on mitochondrial function and, in turn, gene expression, with implications for chronic diseases¹⁷ as well as COVID-19 risk.¹⁸ Clinical applications of this knowledge include initial small randomised controlled trials of, for example, ‘fasting-mimicking diets' to promote ‘mitophagy’, the breakdown of old dysfunctional mitochondria,¹⁹ with the potential to put metabolic diseases and even autoimmune conditions, such as multiple sclerosis, into remission.²⁰ New theories have also emerged around the role of mitochondria in brain health and how lifestyle interventions could be used to not only prevent, but also treat dementia.²¹

Similarly, few people will have avoided the exponential research into, and increasing awareness of, the human microbiome, particularly the gut microbiome and its crucial role in immune regulation.²² We can now explain the mechanisms behind how poor-quality food, sleep, physical activity and stress impact the gut microbiome, resulting in low-grade, chronic activity in the immune system that is now thought to drive a so-called ‘inflammaging’ process associated with chronic disease.²³ For example, ultraprocessed foods disturb gut microbiome health and are associated with obesity.²⁴ This could explain why our previous focus on calories over quality of food in particular, has failed to make any dent in the increasing levels of obesity and metabolic disease prevalence.

Crucially, our improved understanding of epigenetics, inflammation, mitochondrial function and the microbiome can be applied to clinical practice without the need for medication. Approaches taught in lifestyle medicine can prevent, treat and, in some instances, reverse disturbances in immune function, microbiome and gene expression that drive chronic diseases. For example, eating the so-called ‘DASH diet’ can treat blood pressure,²⁵ combined stress management, dietary changes and physical activity have the potential to reverse coronary atherosclerosis and prevent cardiovascular disease²⁶ and, in the DiRECT trial, caloric restriction and subsequent lifestyle changes put type 2 diabetes mellitus into remission for many,²⁷ whereas, in the SMILES trial, support to change to a Mediterranean diet significantly improved and even resolved all depression symptoms for 30% of those receiving the intervention.²⁸ The ability for lifestyle medicine approaches to treat and even remit diseases previously considered to be irreversible, still remains largely unrecognised by the policy makers who relegate these approaches to prevention.

Addressing up-stream, modifiable lifestyle factors, not only for prevention, but also as treatment of established disease, can have wider downstream health effects than simply focusing on single traditional biometrics, such as blood sugar, cholesterol, body mass index (BMI) or blood pressure. For example, when considering the treatment of hypertension, an antihypertensive medication might lower blood pressure, but supporting a patient to make lifestyle changes is likely to have multiple downstream effects, on not only blood pressure, but also weight, blood sugar, cancer risk, cardiovascular risk, brain health and mood. Both treatment options should be given equal attention in a consultation and, depending on patient preferences, support should be provided for both.

A framework for coordination of care

Lifestyle medicine reasserts the effectiveness of simple patient-driven, community or home-based interventions in the face of the irresistible draw toward the new, technical and seemingly simple solutions offered by precision medicine, robotics, genomics and artificial intelligence (AI). In our rush to embrace these new technologies, we risk greater fragmentation and specialisation of care. The mindset shift in clinicians who are trained in lifestyle medicine can help bring us back to basics, while the integration agenda will help deliver the healthcare structure that is needed to support patients who chose to use lifestyle as medicine.

Central to the integration agenda is coordination of clinical care, around which there are many competing agendas, including those of the clinician, healthcare system, medical guidelines and even pharmaceutical industries and governments. NHS policy is clear that, through the personalised care agenda, healthcare systems and clinicians must integrate care around patient goals.²⁹ Lifestyle medicine teaches clinicians the skills needed to support patients to voice their own priorities around which their care should be integrated. Some patients are activated, motivated and have high levels of health awareness. Others, often those facing challenging circumstances, might be less activated or motivated to engage in healthcare and have low levels of health literacy.³⁰ Lifestyle medicine teaches clinicians about the socioeconomic drivers of health behaviours so they can engage and support even the least-activate patients through personalised care.

Lifestyle medicine also promotes better integration of care by moving the focus away from our traditional single biometric measurements or organ-based disease states. For example, its practice supports patients and clinicians to come up with goals informed from wider range of factors. Consider the example of the traditional assessment of chronic diseases, which includes a history, examination and biometric investigations, such as weight, blood pressure and blood tests, possibly resulting in a referral to a single-organ/system specialist in a hospital setting (Fig 2). A wider assessment, as taught in lifestyle medicine, would include seeking information about a patient's own goals and values, their understanding of the role of self-care, lifestyle, medication and surgery, the influence of local socioeconomic factors on their lives, their own lifestyle factors (including eating habits, activity levels, sleep, stress, relationships, etc) and their ability to make changes to how they live. This might result in sign-posting or referring to wider community services that can support lifestyle changes and can even involve reducing or stopping medication (Fig 3). This wider assessment embraces the concept that ‘health starts at home’ as described in The Fuller Stocktake report on integrated care.³¹ Lifestyle medicine teaches clinicians to assess the lives of patients as lived at home, such as what they eat, how active they are, how they sleep, their relationships and exposure to harmful substances.

Fig 2.

A simplified example of a traditional medical care pathway for people with chronic disease.

Fig 3.

A simplified example of an integrated care pathway involving a physician with Lifestyle Medicine skills for people with chronic disease.

The Fuller Stocktake report also recognised that the introduction of new roles, such as health coaches and social prescribing link workers, were supporting a crucial change in the culture within clinical teams. Valuing lifestyle change as much as medication is part of this cultural shift, with training in lifestyle medicine ideally suiting those working in these new roles. Some of the skills taught in lifestyle medicine include the use of group consultations (or shared medical appointments) to bring patients with similar health conditions together with the use of health coaches, link workers and psychologists working with a traditional clinician. Group consultations could be an effective way to offer more time to support patients to come up with health goals, explore a wider range of lifestyle factors and provide education, motivation and support by connecting patients to wider healthcare and community services.³² They also have potential to physically integrate care in the community around a patient while multiple clinical roles work together in the group consultation.

Informing a shift in public perception of the drivers of health

Whether using the language of lifestyle medicine, behaviour change, supported self-care or ‘health at home’, these are all attempts to move the focus of healthcare activities away from hospitals, medication and surgery. The concept of ‘lifestyle as medicine’ has entered popular culture and could support a timely shift in patient expectations of healthcare. For example, media doctors, such as Dr Michael Mosely, Drs Chris and Xand Van-Tullekan, Professor Tim Spector and Dr Rangan Chaterjee, provide popular content on lifestyle medicine. Although the quality of reporting around health and lifestyle has traditionally been poor,³³ clinicians, particularly those with training in lifestyle medicine, are better able to communicate the nuances around socioeconomic drivers of health, individual behaviours and which interventions are evidence based. With over half of young people using social media to access lifestyle-health information and reporting change in health behaviours as a result,³⁴ it is these media doctors, rather than traditional public health messaging, who likely hold the greatest potential to bring people on board with this cultural shift to address lifestyle factors and integrate healthcare around the home.

Addressing health inequity with personalised support

Well-designed public health and policy interventions to improve the socioeconomic determinants of health can be the most effective way to address health inequity. However, generic population awareness-raising campaigns around lifestyle, such as smoking cessation campaigns, have been found to worsen inequalities. This might be because wealthier individuals are already activated and more able to afford the support to make changes.³⁵ By contrast, lifestyle medicine, with personalised support tailored to the challenges in people's lives, could deliver more successful interventions for those facing deprivation.³⁶ For example, lifestyle medicine teaches clinicians to support patients to change potentially modifiable drivers of disease, rather than to medicate them. This avoids the harms of polypharmacy, which is significantly associated with deprivation³⁷ and is particularly the case when addressing mental health and pain issues, for which there are 56% more prescriptions for dependence-forming medication in the most deprived compared with the least deprived areas of the UK.³⁸

Those living in deprived circumstances do face greater challenges when making lifestyle changes; for example, they are more likely to have limited access to healthy affordable food, work shifts that do not allow good quality sleep and might have little access to safe, green spaces. However, the assumption that those facing greater deprivation might be ‘resistant to’ or ‘unable to’ make lifestyle changes when offered well-delivered personalised support is not founded in good evidence. These beliefs can also lead to prejudiced behaviour in a consulting room, where clinicians avoid offering support or information about lifestyle to these groups of patients when they often have the most to gain. For example, individuals from deprived groups have an increased risk of harm from the same amount of alcohol consumed by those from less deprived groups, even after controlling for drinking patterns, BMI and smoking.³⁹ Similarly, deprived populations are disproportionately affected by the harmful effects of smoking and physical inactivity.⁴⁰ However, there is evidence that those from deprived communities can be supported by well-designed lifestyle interventions. For example, the DiRECT trial, demonstrating the effectiveness of a dietary and behaviour change intervention for type 2 diabetes mellitus remission, recruited nearly half of its participants from the most deprived quartiles of Glasgow, with significant complex chronic disease burden and polypharmacy⁴¹ and differences in the chances of remission were not statistically significant between demographic groups.⁴² In fact, well-designed interventions can have the greatest impact on those from the most deprived communities, for example a nutrition coaching intervention for pregnant women in the Netherlands found that the most deprived women made the most healthy changes to their diet⁴³ and a lifestyle intervention for cardiovascular disease in America was found to be as impactful for those from more deprived backgrounds as it was for those from wealthier backgrounds.⁴⁴ More research is needed to find out which types of intervention work best and which skills are needed within integrated teams to help people from more deprived backgrounds engage and be supported to make and sustain healthy lifestyle changes.

Driving an optimistic medical cultural shift

The discipline of lifestyle medicine now has global spread with a strong UK vision that can drive better integrated care and shift the unwarranted focus on hospitals and medication-based approaches. Change is happening at an individual level, with patients gaining knowledge from better quality media, clinicians up-skilling with lifestyle medicine qualifications, adding lifestyle medicine to their tool-box in appointments and setting up their own lifestyle medicine clinics and group clinics. These clinicians are also involved in change within healthcare systems as clinical leaders and within research. Despite challenging times, trail-blazing organisations, such as the British Society of lifestyle medicine, the Personalised Care Institute⁴⁵ and the National Academy of Social Prescribing,⁴⁶ will continue to drive a revolutionary and optimistic cultural shift within healthcare.