An article in the British Journal of General Practice published online, on the 29th April 2021, sets out a mixture of support, disdain and implied ineffectiveness of the role that lifestyle medicine[1] has in the restoration and generation of human health. The direct journal response online allows only for 350 words. A fuller response is found below.
Response to: Exemplary medical care or Trojan horse? An analysis of the ‘lifestyle medicine’ movement.
Dr McCartney and colleagues raise numerous points, some of which are helpful. But also disingenuously imply that the ‘benefits’ of lifestyle medicine are being subjugated on the application of inadequate critique, the inclusion of pseudoscience and ‘alternative medicine’, profiteering and an absence of focus on social and political reduction of poverty and other societal drivers of health inequality by the related beneficial behavioural changes being individualised in their application.
It is of course their remit and character to challenge the spectrum of therapeutic interventions included in lifestyle medicine. They further impugn that as many of these therapeutic applications and related training courses are fee or reward based, they are ideologically unsuitable and refer to evidence-based medicine (EBM) compliant related data sets as the only valid determinant of therapeutic inclusion criteria. This, despite the long history of financial incentives offered by the pharmaceutical industry to physicians, highlighted in the 2020 Independent Medicines and Medical Devices Safety Review report suggesting their posturing is highly nuanced[2],[3].
Simply put, the aim of EBM is to introduce scientific coherence into what clinical epidemiologists characterise as the unscientific practice of medicine and in particular variations in diagnoses, treatment, and prescribing. Then, if the evidence presented is important enough to change practice, the quality of research should be as high as possible, the analysis well determined, the conclusions reasonable and the relevance current, safe, and applicable. If clinicians such as the respective authors choose to ignore the conclusions or guideline recommendations generated by lifestyle medicine[4], and the application of one to one, group and community-based approaches the onus is on them to prove without bias why this should be[5].
Obviously, their position is founded in an environment in which Primary Care is available at no direct cost to the recipient, but whilst tying their critique points to the UK model alone they miss many valuable determinants of inherent capability and delivery. Including, that the fully qualified UK GP workforce remains in decline – with a drop of 339 FTE fully qualified GPs between December 2019 and December 2020 according to NHS Digital data and that medical undergraduate training does not adequately prepare GPs for translating these lifestyle options in a format that meets time constraints and willingness to employ, despite their demands for it to be included[6].
We live our lives in a socio-economic and environmental context over which we have, often, limited or no control. And lifestyle medicine does not just acknowledge this, it proactively advocates for changes at these levels to improve people’s health and wellbeing.
Examples of good quality lifestyle-based evidence include The Direct Trial for Type-2 Diabetes remission[7], The SMILES Trial [8] for depression remission and The Lifestyle Heart Trial [9] and related follow ups [10],[11], for coronary arterial disease reversal. Further qualified research published in this area is presented by the Preventative Medicine Research Institute.
The central core of lifestyle medicine is about supported behaviour change at individual and community levels. Until clinicians operate at the level of policy and legislation, their primary focus is on meeting the needs of their patients and community within their scope of capability.
Food, alcohol, drugs, smoking and medication choice, trauma (including psyche) and infection are all primary drivers of inflammation, oxidation and increased immune activity, which in turn are the sine qua non of non-communicable disease development [12]. Many of these are rooted in behaviours, that are the result of the interplay between habit, often well-established automatic responses to the immediate and wider environments, conscious choice and calculation, and are located and determined in complex social environments and cultures. Moreover, the very behaviours which need to be changed are sustained and nurtured by highly profitable industries selling goods which make people ill – sugar-rich, nutrient-poor, energy-dense fatty foods and alcoholic beverages as well of course tobacco, legal and illegal drugs.
There is another related common mistake of which the behavioural science literature warns the unwary, but which the authors tend to favour. This is to overly privilege the role of information from ‘expert sources’ as a driver of behaviour change. Reflecting the traditional medical models of the doctor-patient relationship, the basis of which is that patients have an information deficit and come to see medical practitioners to consult them for their expertise to remedy their deficiency in knowledge and understanding. In return, they get information in the form of a diagnosis from which treatment proceeds.
This is a model that was designed for, and works pretty well, for patients with acute conditions. It tends to work less well for the chronic conditions that are the great contemporary medical challenge and where patients often have very high degrees of information and expertise in place or seek qualification of existing opportunities for change, or are so far removed from the concept of personal capacity for improvement that the connection seems almost unbridgeable.
Since for many practitioners, passing on expertise means passing on information, what this model has tended to assume is that if we tell people the negative consequences of eating too much/little of keystone foods or exercising too little, or other health generating lifestyle determinants they will change their behaviour accordingly. This is clearly not true, and every front-line clinician and practitioner knows it is not true.
To motivate change requires a different thought process, meaning the shared decision making needs to be embedded in the understanding of the mechanisms which might be disconnected and the networks that need to be disrupted in order that an evolved agreement about what can be done will determine guidance on the type of interventions/exclusions which might be applied.
Treating the people embedded in dysfunctional (from a health generation perspective) behaviours, not as cultural dopes, but as knowledgeable actors whose understanding and interpretation of their own conduct is as important, is the nexus of unravelling the connections.
Prescribing Lifestyle Medicine (supplied by Clinical Education & Practice Unbound) provides a format that allows clinicians to use a tried and tested methodology of applying individual support for patients and clients of health and social care services that steer away from solely information giving and towards empowering and motivating individuals to generate their own solutions to their problems i.e the journey and responsibility become shared individually and in community.
Medicine is a highly adaptable profession, with new studies constantly challenging the conventional wisdom. But some of the most important changes, including the evidence-based medicine movement[13] of the 1990s, have been cultural ones, based on moments of self-reflection that led the medical community to think differently about its role. Lifestyle Medicine could prove to be one of those moments. When doctors talk about treating the patient’s “body, mind, and spirit,” via lifestyle change it can sound like a feel-good catchphrase. But in fact, there may be no other way to treat diseases that take years to develop and are intimately tied to the ways people think, feel, and live their everyday lives.
As Steven Sloman and Philip Fernbach argue in their 2017 book, The Knowledge Illusion, “We live with the belief that we understand more than we do.” When groups of people depend on others for information and advice, they seem to be as vulnerable to error as individuals. However, this
should not make us smirk with smug superiority but heighten our awareness that we, too, are trapped within our bubble of beliefs. Consensus of beliefs does not automatically make them correct, something the authors of the British Journal of General Practice article may choose to reflect on.
References
[1] Rippe JM. Lifestyle Medicine: The Health Promoting Power of Daily Habits and Practices. Am J Lifestyle Med. 2018;12(6):499-512. Published 2018 Jul 20.
[2] Independent Medicines and Medical Devices Safety Review report https://www.gov.uk/government/publications/independent-medicines-and-medical-devices-safety-review-report (accessed 3.5.21)
[3] Written statement to Parliament: Update on the government’s response to the Independent Medicines and Medical Devices Safety Review. https://www.gov.uk/government/speeches/update-on-the-governments-response-to-the-independent-medicines-and-medical-devices-safety-review (accessed 3.5.2021)
[4] Schuller-Goetzburg P, Plakys G, Katileviciute A, Khoja S, Kodzius R. Management and Prevention Strategies for Non-communicable Diseases (NCDs) and Their Risk Factors. Front Public Health. 2020 Nov 26;8:574111.
[5] Tomlinson, S. Lifestyle medicine in community-engaged health promotion. J Public Health (Berl.) (2020).
[6] Radenkovic D, Aswani R, Ahmad I, et al Lifestyle medicine and physical activity knowledge of final year UK medical students BMJ Open Sport & Exercise Medicine 2019;5:e000518
[7] 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
[8] Jacka et al, A randomised controlled trial of dietary improvement for adults with major depression (the SMILES trial), BMC Medicine (2017) 15:23
[9] Ornish D, et al, Intensive lifestyle changes for reversal of coronary heart disease, JAMA (1998), 16;280(23):2001-7
[10] Pischke CR, Scherwitz L, Weidner G, Ornish D. Long-term effects of lifestyle changes on well-being and cardiac variables among coronary heart disease patients. Health Psychol. 2008 Sep;27(5):584-92
[11] Razavi M, Fournier S, Shepard DS, Ritter G, Strickler GK, Stason WB. Effects of lifestyle modification programs on cardiac risk factors. PLoS One. 2014 Dec 9;9(12):e114772.
[12] Seyedsadjadi N, Grant R. The Potential Benefit of Monitoring Oxidative Stress and Inflammation in the Prevention of Non-Communicable Diseases (NCDs). Antioxidants (Basel). 2020;10(1):15. Published 2020 Dec 27.
[13] Djulbegovic B, Guyatt GH. Progress in evidence-based medicine: a quarter century on. Lancet. 2017 Jul 22;390(10092):415-423.