Lifestyle medicine is a rapidly growing global discipline that offers people more options to achieve better health before and alongside medication or surgical options. It describes approaches that nurses and other health professionals can use to support people to improve their sleep, mental wellbeing, relationships, reduce isolation, eat better quality food, increase activity levels, and avoid overusing technology, as well as the use of harmful substances such as alcohol and tobacco.
These concepts are not new – they have roots in ancient medical practice. However, discussion and support for lifestyle factors have been sidelined by an overemphasis on technology and pharmaceuticals in modern medicine. Medications can do great good, but repeated calls have been made to stem the risks from ‘overprescribing’, with the average number of repeat medications in England rising from 10 to 20 per person in just 10 years (Ridge, 2021). This is despite a patient preference for research into non-medication alternatives and for greater support to make lifestyle changes, particularly with regard to long-term conditions (Jarbøl et al, 2017). Healthcare providers and their patients have been found to overestimate the benefits and underestimate the harms from many frequently prescribed medications (Treadwell et al, 2020).
A focus on pharmaceutical options is costly, it sends a disempowering message to patients and can place a burden healthcare systems due to monitoring requirements, while also often failing to treat the root cause of a patient's problem.
Non-pharmaceutical alternatives
Science is moving away from the determinism of genetics. In other words, away from the suggestion that our destiny is written exclusively in our DNA, that our health is unmodifiable and can be impacted only by medications.
Modern medical disciplines, such as lifestyle medicine, teach that wider factors such as the environment, society and lifestyle can have a profound impact on health outcomes. This is an optimistic message: that our destiny is in our hands and, with the right support – which is essential – we can also modify our health without resorting to medications or surgery. Lifestyle medicine is not about blaming or shaming, it is about:
- Supporting and empowering people
- Using behaviour change techniques
- Group clinics
- Linking into community groups through social prescribing.
Lifestyle medicine provides person-centred and values-based care that works to overcome socioeconomic disadvantages. This still requires huge policy initiatives and public health support to promote and foster healthy communities.
Research and health care
A paradigm shift has happened in scientific research that supports this approach. Discoveries have suggested that a significant factor influencing much ill health, including cancer, depression, heart disease and even COVID-19, is an inflammatory process termed ‘systemic chronic inflammation’ that is attributable to environmental, social and lifestyle issues (Furman et al, 2019).
Whereas a healthy immune response causes short-term activation in the immune system and is critical for survival, ‘chronic inflammation’ is a phrase used to describe the process wherein immune cells remain activated at a low level over many months or years, causing damage to organs and blood vessels. This results in high blood pressure, an incorrect balance of blood fats, raised blood sugar levels, potentially leading to conditions such as type 2 diabetes, depression, heart disease and even cancer.
Research (Srour et al, 2022) has also found that chronic inflammation is worsened by consumption of ultra-processed food (food that has had much of its fibre removed and substances added such as emulsifiers, sugar, salt and cheap fats), lack of sleep, social isolation, stress, inactivity, mental ill health, and alcohol and tobacco use.
A key modulator of the immune system and inflammation is our microbiome (the collection of viruses, bacteria that live within and on our body). There is evidence, examples which were presented at the British Society of Lifestyle Medicine's (BSLM) sixth annual conference in London last year, that it is through this microbiome that our sleep, physical activity, stress and social connection impact our health (Rodriguez-Castaño et al, 2017).
Studies into gene expression (epigenetics) have also found that genes can be turned off and on by these same factors (Alegría-Torres et al, 2011). Most importantly, major clinical trials (Ornish, 1998; Saneei et al, 2014; Jacka et al, 2017; Lean et al, 2018) have demonstrated that providing adequate support for patients to help them improve lifestyle factors is achievable in clinical practice and delivers health improvements. It does not simply help prevent, but can also treat and put into remission some long-term conditions such as depression, type 2 diabetes, high blood pressure and heart disease.
The BSLM is turning this research into clinical practice through its network of thousands of clinicians. The increasing interest in this approach was evident at the society's recent conference in London recently. More than 1000 healthcare practitioners from all backgrounds (nurses, physiotherapists, GPs and hospital consultants) came together, along with patients and researchers, to share the science behind this powerful new approach and how it is being used to transform health care in the NHS.
Delivering at scale
Nursing education, policy and the delivery of care is only just catching up with this liberating shift from solely medication-based solutions to supporting people with the additional option of helping them make and sustain lifestyle changes.
Lifestyle medicine interventions involve the assessment of the key pillars underpinning health. This includes taking an overview of a person's mental wellbeing, relationships, eating habits, sleep, activity levels and consumption of harmful substances, such as smoking/alcohol, or unhealthy behaviours, such as excessive social media use or harmful gambling.
This assessment enables practitioners to take a person-centred – rather than a guideline-driven – approach and to use behaviour change techniques, such as health coaching, goal-setting and social prescribing in small groups or in a one-to one-setting, to help people set health goals and work towards them to improve health.
This might, for example, supporting an individual to increase consumption of green leafy vegetables, stop smoking or connect with their community through social prescribing initiatives. Follow-up is provided to help sustain and build on these changes in the same way that a medication prescription might be reviewed.
Critically, our environments continue to be degraded at the same time as inequality and deprivation grow worse: these are factors that have a major influence on people's lifestyles and behaviours. Despite this, last year's BSLM conference was buzzing with examples from frontline clinicians and other speakers who presented results demonstrating good practices that have supported not simply preventive health practices, but in some instances the reversal of long-term conditions, even in the most deprived areas of the UK (Saneei et al, 2014; Jacka et al, 2017; Lean et al, 2018).
Clinicians attending the conference were joined by policymakers and healthcare leaders such as influential proponent of preventive healthcare practices physician Professor Sir John Armstrong Muir Gray and Crystal Oldman of the Queen's Nursing Institute. There was a consensus that lifestyle medicine this is where the future of medicine lies: that the health of patients is in their own hands, supported by clinicians.
Dr Oldman specifically described the role of nurses in lifestyle medicine. She said that, nurses often have longer and more longitudinal relationships with patients, this placed them in an ideal position to scale up the use of a lifestyle-medicine approach in consultations. This would include assessment of a wide range of lifestyle factors and providing support using brief health coaching techniques. The BSLM now calls on policymakers and healthcare organisations to support the growing movement to deliver lifestyle medicine at scale.
Professor Garry Egger, one of the pioneers of lifestyle medicine, has stated: ‘We need to legislate, regulate and advocate where we can; to educate, motivate and instigate where we can't; medicate, operate and palliate, if all else fails’ (Egger et al, 2017).
There must be a joined-up approach to bridge the gaps between clinical medicine and public health, between supply and demand, between equity and inequity of health.
Lifestyle medicine is ‘optimistic medicine’ that can deliver excellent health outcomes, efficiency, patient and clinician satisfaction, and adds educational value. When scaled up across the NHS, with nurses leading the way, it could help lift the NHS off its knees.
PUTTING THE CONCEPT OF LIFESTYLE MEDICINE INTO PRACTICE
- Have you cared for a patient where you have felt that wider factors such as poor sleep, nutrition, stress, isolation, alcohol, smoking or harmful technology use has contributed to their admission or presentation?
- Are you addressing lifestyle factors with your patients, taking time to address what matters most to them?
- How could you start to incorporate the principles of lifestyle medicine in your nursing practice?
- What barriers are there in your practice or hospital to incorporating lifestyle medicine practice?
- What is the first next step you could take to learn more or start to implement lifestyle medicine in your practice?