Key Points
Lifestyle Medicine is a modern medical discipline that supports behaviour change through evidence-based, person-centred techniques that improve mental wellbeing, healthy relationships, healthy eating, physical activity, good quality sleep, and avoidance of harmful substances and behaviours (the six pillars of Lifestyle Medicine).
The three core domains of Lifestyle Medicine are Foundation Knowledge, Lifestyle Pillars, and Clinical Skills.
Lifestyle Medicine can be practised in one-to-one clinical settings or in small groups; these interventions have the potential to prevent, treat and – in some instances – reverse disease.
Lifestyle Medicine is an important tool alongside Public Health to address long-term conditions and improve resilience to emerging and re-emerging infectious diseases.
Lifestyle Medicine mitigates against the harms arising from over-medicalisation and over-reliance on pharmaceutical and surgical approaches.
1.1 The Discipline of Lifestyle Medicine
Lifestyle Medicine is a modern medical discipline applicable to all medical, allied specialities and healthcare practices. Definitions of Lifestyle Medicine vary according to social and cultural norms. In the United Kingdom (UK), Lifestyle Medicine has been defined as ‘evidence-based clinical care that supports behaviour change through person-centred techniques to improve mental wellbeing, social connection, healthy eating, physical activity, sleep and minimisation of harmful substances and behaviours’ [1].
Lifestyle Medicine is practised by clinicians in a one-to-one setting or in small groups. The discipline can be conceptualised as a bridge bringing together current clinical practice with interventions which might have conventionally been ascribed solely to Public Health. Traditionally, Public Health has leveraged larger-scale interventions addressing similar lifestyle factors (as well as their underlying socio-economic factors) through policy at population level.
1.1.1 Prevention, Treatment, and Remission
Lifestyle Medicine can prevent, treat, and – in some instances – reverse, or put into remission, the disease processes underlying chronic diseases (which we will term long-term conditions). Examples include interventions to support healthy dietary changes that can reduce blood pressure [Reference Appel, Moore and Obarzanek2]; a comprehensive lifestyle intervention, including dietary changes, stress management, and physical activity-reversed coronary atherosclerosis when compared to medication approaches [Reference Ornish, Scherwitz and Billings3]; weight loss with calorie restriction supported by a lifestyle change programme was found to put type II diabetes mellitus into remission in 40% of trial participants after one year [Reference Lean, Leslie and Barnes4]; and a trial to support a Mediterranean dietary intervention found depression significantly improved or resolved [Reference Jacka, O’Neil and Opie5].
1.1.2 The domains of Lifestyle Medicine
The domains of Lifestyle Medicine knowledge are Foundation Knowledge, Lifestyle Pillars, and Clinical Skills (Figure 1.1):
1. Foundation Knowledge of person-centred, evidence-based medicine, physiological mechanisms, health behaviour, socio-economic determinants, the role of the built environment, nature and planetary health
2. Lifestyle Pillars: The key lifestyle factors impacting health outcomes which include mental wellbeing, healthy relationships, healthy eating, physical activity, good quality sleep, and avoidance of harmful substances and behaviours
3. Clinical Skills for the practice of Lifestyle Medicine, including taking a lifestyle history, using person-centred care, and supporting behaviour change. Behaviour change can be achieved by supporting self-care, social prescribing, brief advice and sign-posting, coaching and psychological approaches, as well as group care.
These domains of knowledge reflect the three core principles of Lifestyle Medicine practice which are to acknowledge and understand the socio-economic determinants of health (SDH); to deploy behaviour change skills; and understanding of lifestyle change around the six pillars of Lifestyle Medicine [Reference Fallows6].
1.1.2.1 Foundation Knowledge of Evidence-Based Medicine, the Social, Economic, and Commercial Determinants of Health, Cellular Mechanisms, Environmental and Planetary Health
Application of the best quality and most up-to-date research findings on lifestyle interventions, in addition to using clinical expertise and understanding patient values, will result in a Lifestyle Medicine practice that is evidence-based (Chapter 4).
Lifestyle Medicine considers the impact of environmental, commercial, and social determinants of health. These include ‘the factors that drive the conditions in which people are born, grow, live, work, and age and the fundamental drivers of these conditions’ [7], for example our income, work, education, access to food, housing, social inclusion, and environment (Chapter 6). Understanding how these upstream factors affect lifestyle and, in turn, cellular mechanisms driving health outcomes (Chapter 5), is critical for the effective practice of Lifestyle Medicine as it is these determinants that have the greatest impact on health [Reference Braveman and Gottlieb8]. With this knowledge, those practising Lifestyle Medicine will support action outside of the clinical consultation: for example, within population health, government policy and wider society to support the creation of environment and a society that enables healthy living. Therefore, Lifestyle Medicine is additional to – and not a substitute of – policy-level and population-based approaches.
1.1.2.2 Lifestyle Pillars: the Key Lifestyle Factors Impacting Health Outcomes
Mental Wellbeing
Lifestyle Medicine prioritises the assessment of mental wellbeing in all health conditions (Chapter 9), rather than focusing on the presence or absence of mental illness. This practice can include using a ‘positive psychology’ approach to care that helps people to work towards meaning, purpose, and connection in their lives [Reference Lianov9]. Lifestyle Medicine also supports the use of techniques to reduce the impact of stress, such as mindfulness-based stress-reduction techniques, meditation, breathing exercises, physical activity, improving social connection, increasing connection with nature, improving sleep quality, healthy eating, and avoiding harmful substances and behaviours. For example, this could involve prioritising discussions in a consultation around finding meaning and purpose in life and connecting more with nature, friends, and family.
Healthy Relationships
Lifestyle Medicine uses assessments of loneliness, social isolation, and the quality of relationships (Chapter 10). In a consultation this may mean discussions around how to develop and sustain healthy, meaningful relationships and increase social connection, or it could involve referral to a social prescriber or community project.
Physical Activity
Lifestyle Medicine assesses and addresses physical activity (aerobic, balance, and resistance activity) as well as sedentary behaviour (Chapter 11). Clinicians can then support people to access green spaces, incorporate more physical activity in their lives, as well as reducing time spent sitting down.
Healthy Eating
Lifestyle Medicine assesses and addresses dietary quality through simple screening tools such as routinely asking patients a 24-hour dietary recall such as ‘what did you eat yesterday?’ and ‘was this a typical day?’ (Chapter 12). Lifestyle Medicine focuses on supporting people to improve food quality by reducing the consumption of ultra-processed foods and increasing intake of whole vegetables, fruits, and nuts. These healthier eating patterns may include Mediterranean, ‘whole-food, plant-based’, or lower-processed carbohydrate diets, as well as other evidence-based eating patterns. Healthy eating approaches aim to support people to reduce snacking, adjust the times they are eating, and increase the period during which they fast.
The choice of healthy eating pattern is driven by patient preferences and circumstances; therefore, it will be suited to their culture as well as being practical, locally available, and affordable.
Sleep
Lifestyle Medicine assesses and addresses sleep quality and supports people to achieve better quality sleep and avoid behaviours which can impair sleep quality (Chapter 13).
Minimising Harmful Substances or Behaviours
Lifestyle Medicine assesses and addresses the use of harmful substances or behaviours (Chapter 14). Its practice includes supporting people to stop smoking, reduce excessive alcohol consumption, and avoid addictive substances and behaviours such as gambling or harmful excessive internet or social media use. It also raises awareness of avoidable environmental pollutants, and the risks associated with polypharmacy (Chapter 22). Lifestyle Medicine often supports or requires deprescribing.
1.1.2.3 Clinical Skills for Practice, including Taking a Lifestyle History, Using Person-Centred Care, and Supporting Behaviour Change
The patient is an active partner in the practice of Lifestyle Medicine; this approach avoids paternalistic ideas of the healthcare professional as the sole holder of all the knowledge and skills required to achieve health. By encouraging a more equal partnership, Lifestyle Medicine employs a person-centred approach. This means considering people’s values alongside their wider family and community during a consultation. A key question is, ‘what matters most to you about your health?’ This type of person-centred care (Chapter 7) includes sharing decision making, and using a coaching approach (Chapter 16) with patient-led goal setting and supported self-care. Evidence suggests that people are much more likely to make and sustain behaviour changes if this type of approach is used (Chapter 15).
Lifestyle Medicine employs a multidisciplinary healthcare team to deliver more-complex and longer-term support required for lifestyle change. This may involve health coaches, social prescribers, mental health workers, dieticians, physiotherapists, social workers, health visitors, nurses, psychotherapists, and many others. It also links people into services in their own community that can support them to sustain healthy lifestyle changes.
Lifestyle Medicine is used alongside medication prescribing and surgical interventions. In some instances, lifestyle changes can be supported using medications if a patient wishes to use them: for example, the use of Varenicline to support smoking cessation or a Glucagon-like Peptide-1 Receptor Agonist (GLP-1) to reduce appetite. If significant lifestyle changes are made, medications for long-term conditions often need to be down-titrated or stopped entirely – this can be important for some medications which can have serious side effects if no longer needed, for example the risk of hypoglycaemia with insulin for type II diabetes mellitus when blood sugar levels have improved through lifestyle changes. Deprescribing is therefore a key skill in the practice of Lifestyle Medicine (Chapter 22).
1.1.3 A Clinical Example Comparing Lifestyle Medicine to Traditional Approaches
In Table 1.1, a contemporary medical model can be contrasted with Lifestyle Medicine practice. More often, our current medical model focuses on downstream clinical biomarkers such as lipids or blood pressure, for example, which are caused in-part by upstream modifiable factors such as what we eat, physical activity, stress, mental wellbeing, our relationships, sleep, alcohol, smoking, and harmful technology use. A Lifestyle Medicine approach puts equal emphasis on considering addressing these upstream modifiable factors as it does to medication approaches. In this case (Box 1.1), seeking more detailed information about lifestyle prioritises this agenda in a short consultation and allows support to be tailored to what matters to the patient, in contrast to providing generic advice, often as an afterthought.
Mr Jones, a 65-year-old man, attends his General Practitioner (GP) concerned that his local gym has told him that he cannot start exercising because his blood pressure is 162/100 mmHg. His medical records show that his last BMI was 36 kg/m2. He has previously consulted about gout and feeling tired all the time. Blood samples taken after his appointment for gout show that he had raised urate, a raised average blood sugar (HbA1c) of 44 mmol/mol, a higher-risk lipid profile (non-fasted triglycerides of 5 mmol/l, non-HDL cholesterol of 5.4 mmol/l, HDL cholesterol of 0.6 mmol/l), and a marginally raised liver enzyme (ALT), all suggestive of metabolic syndrome.
1.2 Why Do We Need Lifestyle Medicine?
We must ‘reduce the level of exposure of individuals and populations to the common modifiable risk factors for non-communicable diseases, namely tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol and their determinants while at the same time strengthening the capacity of individuals and populations to make healthier choices and follow lifestyle patterns that foster good health.’
1.2.1 Addressing Modern Epidemiological Challenges
Modern medicine has made tremendous progress in addressing communicable disease, including through vaccination programmes, antibiotics, and antiviral treatments. Lifestyle Medicine has developed in response to the comparatively slower progress achieved in addressing the twenty-first century’s rise in non-communicable diseases (NCDs). Prior to the COVID-19 pandemic, the World Health Organization attributed 74% of all deaths globally to NCDs, with cardiovascular and metabolic diseases contributing to most deaths [10]. Non-communicable diseases are long-term conditions that require complex and longer-term interventions to improve health outcomes [Reference Budreviciute, Damiati and Sabir11] (see Figure 1.2). Providing these interventions are challenging for health services and systems that were first developed primarily to treat episodic communicable diseases and trauma.
Lifestyle Medicine provides more options to address the root causes of the twenty-first-century non-communicable disease burden
Adding to the challenge now facing our healthcare systems, multiple long-term conditions also often coexist and contribute to multi-morbidity. For example, people commonly suffer from type II diabetes mellitus, metabolic liver disease, cardiovascular and chronic kidney disease, and depression and obesity. This multi-morbidity requires personalised support during one-to-one clinical interventions such as those used in Lifestyle Medicine, which can address lifestyle factors [Reference Hurst, Dickhaus and Maulik12] alongside population-level interventions used by Public Health and government policymakers.
1.2.2 Lifestyle Medicine Addresses the Rising Threat of Communicable Disease Outbreaks
Up until recently, the number of people dying from infectious diseases has precipitously fallen, even with sporadic outbreaks of novel infections such as HIV and SARS-CoV-2 [Reference Smith, Goldberg and Rosenthal13]. The challenge of COVID-19 may be partly attributed to deteriorating planetary health, with new diseases emerging from areas with poorer socio-economic, environmental, and ecological conditions [Reference Jones, Patel and Levy14]. Alongside these outbreaks, people with long-term conditions, such as hypertension, cardiovascular disease, chronic respiratory disease, type II diabetes mellitus, and cancer, are more susceptible to such infections [Reference Kompaniyets, Pennington and Goodman15]. For example, a UK Biobank study demonstrated that the underlying drivers of long-term conditions, such as obesity, physical inactivity, smoking, and increased alcohol intake, accounted for up to 51% of the population attributable fraction of severe COVID-19 outcomes [Reference Hamer, Kivimäki, Gale and Batty16]. The combination of a pandemic of infectious disease and long-term conditions [Reference Sheldon and Wright17] has been called a ‘syndemic’; Lifestyle Medicine has the potential to increase the resilience of individuals to this combination of future novel infectious disease outbreaks and increasing long-term disease burden [Reference Kluge, Wickramasinghe and Rippin18]. Unfortunately, our past continuous growth in life expectancy in the western world is now faltering and more of our additional years are spent with ill health and disability due to long-term conditions. Modern medicine will need to address the root causes of non-communicable and infectious disease outbreaks both in the consulting room with Lifestyle Medicine and at a wider environmental and social level with Public Health and policy-level measures.
1.2.3 Lifestyle Medicine Mitigates against the Consequences of Over-Medicalisation
Scientific advances in pharmacotherapies and surgery have been central to the success of modern medicine. Yet evidence suggests that we are prone to overestimate the effectiveness of our pharmaceutical and surgical interventions for long-term conditions. For example, GPs [Reference Treadwell, Wong, Milburn-Curtis, Feakins and Greenhalgh19] and their patients [Reference Hoffmann and Del Mar20] have been found to significantly overestimate the benefits and underestimate the harms from many frequently prescribed long-term medications. The over-reliance on medications to address long-term conditions has led to concerns about harms from ‘too much medicine’ [21] and ‘over-prescribing’ [Reference Rudge22]. For example, the average number of repeat medications in England has risen from 10 per person to 20 in just 10 years [Reference Rudge22]. This is despite patient preference for research into non-medication options [23] (Chapter 22).
An inappropriate over-reliance on pharmaceutical options for long-term conditions is also unsustainable and risks a disempowering message to patients that they may be powerless to change future health outcomes. In some instances, this over-reliance on pharmaceuticals particularly for long-term conditions, may falsely reassure people about current health behaviours, resulting in worsening health behaviours. For example, people taking preventive medications for raised cardiovascular risk (hypertension or dyslipidaemia) were less likely to make lifestyle changes than those who opted not to take medications [Reference Sugiyama, Tsugawa, Tseng, Kobayashi and Shapiro24]. An over-emphasis on pharmaceutical treatments rather than supporting self-care and lifestyle approaches also risks overwhelming healthcare systems with already high levels of practitioner burnout [Reference Karuna, Palmer, Scott and Gunn25].
1.2.4 A New Medical Paradigm
A greater understanding of the cellular mechanisms, including the impact of lifestyle factors on the microbiome, [Reference Rodriguez-Castaño, Caro-Quintero, Reyes and Lizcano26] epigenetic mechanisms, [Reference Alegría-Torres, Baccarelli and Bollati27] and immune system regulation [Reference Furman, Campisi and Verdin28] (Chapter 5), is shaping a new healthcare paradigm. This new paradigm moves away from the deterministic view that our destiny is predicted predominantly by our genes [Reference Silverman29] to one where we understand that gene expression is significantly modifiable and that treatment options also, including supporting people to improve lifestyle factors, are just as effective and valid as medication and surgical options. Lifestyle Medicine also asserts that support for lifestyle change can be effective in the consulting room at an individual level and not just at Public Health or policy levels.
All major international guidelines (e.g. SIGN, NICE, and WHO guidelines) have always recommended that long-term condition management starts with ‘lifestyle advice’. The discipline of Lifestyle Medicine takes this a step further, to lay out the evidence-based tools and knowledge required by clinicians to provide individually tailored behaviour change support rather than simple advice. Lifestyle Medicine also acknowledges that some people will need more support than others due to socio-economic barriers to change, and the discipline describes how to provide this support through person-centred care.
Lifestyle Medicine can be understood as a natural progression to a modern model of medical practice that encompasses the evidence around socio-economic, environmental, lifestyle, and genetic factors to deliver a holistic, collaborative, and person-centred model of care where the practitioner is an enabler of change (see Figure 1.3).
At the time of writing, organisations that promote the teaching of Lifestyle Medicine are growing in number and size and the discipline is part of the core curriculum in an increasing number of medical schools as well as being recognised as an area of expertise for GPs with an ‘extended role’ in practice by the Royal College of General Practitioners [Reference Nunan, David, Blane and McCartney30]. Lifestyle Medicine’s agenda of addressing the root causes of ill health by focusing on ‘health at home’ delivers on NHS policy to integrate and personalise care around people’s own goals and values [Reference Fallows31]; this is now leading to organisational changes in healthcare delivery, including the creation of Integrated Care Systems in the UK [32] that bring hospital providers together with networks of GP surgeries, community teams, social care, and voluntary organisations to address the root causes of ill health and move away from our historically pharmaceutical and hospital specialist focus to care.
In this textbook, we will explore each of these topics in greater detail, providing learners with a conceptual and practical guide to Lifestyle Medicine today.
