The BSLM supports a critical and evidence-based adoption of “lifestyle medicine”
By Dr Ellen Fallows
6th May, 2021
The British Society of Lifestyle Medicine (BSLM) welcomes the BJGP article, ‘Exemplary medical care or Trojan horse? An analysis of the ‘lifestyle medicine’ movement’ (1), in that it highlights the importance of the drivers of non-communicable disease through lifestyle factors such as smoking, alcohol, poor diet and physical activity. The BSLM would also consider sleep, social connection, connection with nature and relaxation as less well studied but equally important contributors to health outcomes for some people.
The article supports many of the aims of the British Society of Lifestyle Medicine. For example, it suggests that “translation of guidelines into achievable real-world benefits outside clinical trials is challenging”. BSLM is working to bring evidence and guidelines regarding lifestyle interventions to the attention of clinicians. It currently provides training in the use of group consultations and will shortly be providing training in the use of skills to support lifestyle change that include health coaching, person-centred care, motivational interviewing, use of social prescribing and shared decision making. The BSLM diploma and curriculum does not include any teaching on “reflexology, homeopathy, herbalism or naturopathy”, nor does it associate with any pharmaceutical, nutraceutical or cosmetic organisations.
The BSLM is not affiliated with the British Association for Nutrition and Lifestyle Medicine (BANT), functional medicine nor integrated medicine and does not endorse any alternative medical practice. The aim of the BSLM is to equip as many people as possible, whether patients, professionals, or practitioners of any background, with evidence-based knowledge about the effects of lifestyle on health. It will provide training in the tools to support people who want to use lifestyle change alongside traditional pharmaceutical and surgical interventions to improve their health, no matter what disadvantages people face.
The author’s main areas of concern are around three important issues that merit further discussion:
- A lack of evidence base (uncritical endorsement, infiltration of pseudoscience).
- The potential for profiteering.
- The potential for widening health inequalities through a focus on individuals.
Some issues regarding the first two points apply to that of medical practice in general. Clinicians from all disciplines can practice medicine privately and therefore profit from their knowledge and skills. The unique issue around profiteering and evidence-base surrounds regulation of the use of the term lifestyle medicine in that it can be used by non-regulated professionals. The BSLM was founded to address these concerns regarding evidence base and quality. It aims to reclaim the “lifestyle arena” from quacks and gurus, growing to become an organisation that sets standards, accredits practice, and provides good quality evidence-based education.
The BSLM agrees that there is a need to set standards for lifestyle medicine practice and it will continue to discuss regulation with the GMC, but until lifestyle medicine is a regulated medical speciality, the BSLM will continue to teach and promote evidence-based practice through its qualifications and publications.
The argument then follows; why do we need to call this practice anything at all other than medicine in its currently regulated format? The authors list the current evidence-based “individual-level” interventions that medicine is meant to promote such as “advice and support, exercise prescription, referral to weight management”. However, the evidence suggests that in clinical practice there is little training of medical professionals to discuss and use these types of intervention, particularly in the field of nutrition (2), and that provision of this type of information and support to patients is not widespread practice (3, 4). When given at all, “reasons behind the lifestyle and dietary advice had not been adequately explained” and “dietary advice was vague” (5).
Further highlighting the need to name and promote this approach, is the clear disparity in funding to research lifestyle interventions – nutrition research being again a good example (6). For example, most research funding is spent on pharmaceutical interventions (7, 8), despite evidence suggesting that patients would prefer more research to focus on evaluating lifestyle interventions, according to the top 10 research priorities for most long-term conditions by the James Lind Foundation (9). Similarly, in one study, when given a choice between a preventive medication or lifestyle change, 90% of patients expressed a preference for lifestyle change (10).
By giving lifestyle medicine a name and raising its profile, the BSLM will be able to address these issues and support the use of more and better-quality individual level interventions. In doing so the BSLM hopes to reduce the impact of “too much medicine” and the harms of over-medicalising issues which may be driven by social and lifestyle issues (11).
Finally, the article suggests that clinicians should avoid using the “individual level interventions” that are promoted by lifestyle medicine as these could widen health inequalities. The international lifestyle medicine community has also recognised this challenge (12) and review evidence that those facing socio-economic disadvantage find it much harder to make changes to their lifestyle. The BJGP article points out for example, that health education and dietary counselling interventions are much less likely to improve the eating habits of more deprived groups (13). However, the same relationship is seen in preventive medicine interventions (14) and in adherence to medications for many long-term conditions, with no call for clinicians to abandon prevention or prescribing for these conditions (15, 16). Similarly, there is a socioeconomic inequality of access to healthcare in general (17). These issues, now worsened by the Covid pandemic, are a challenge for all of healthcare. We will need both individual level interventions (lifestyle, pharmaceutical and surgical interventions) and policy/public health interventions; they are not mutually exclusive. The balance of resource allocation for both intervention types should be constantly scrutinised. The BSLM would agree that there is too much focus on health care provision and insufficient efforts to create healthy living spaces, equal access to healthy food, enable people to obtain sufficient sleep and create meaningful relationships etc. However, where we are providing healthcare and if these issues are modifiable, we should not neglect them in the consulting room.
Rather than clinicians avoiding supporting the patient in front of them with behaviour and lifestyle changes for fear the wealthier might fare better, we must focus on creating, delivering, and researching better interventions and more intensive support for those who need it most. Professor Sir Michael Marmot concluded in his review ‘Fair Society; Healthy Lives’, that health inequality could be addressed through, “strengthening the role and impact of ill-health prevention” and advised providing care “with a scale and intensity that is proportionate to the level of disadvantage” (18). This approach applies to all medical practice – whether using lifestyle and behaviour change techniques, prevention or medications and surgery.
To deliver this as clinicians (rather than policy makers), we need to identify patients who are most deprived and better engage them in person-centred healthcare. Alongside deprivation scores, wider measures of needs such as the Patient Activation Measure (PAM) could be used by clinicians to achieve this (19). For example, studies have suggested that interventions to improve activation can improve health outcomes, despite socioeconomic inequalities (20, 21, 22).
Supporting clinicians to help individual patients with lifestyle change is not mutually exclusive to the BSLM working with public health (many of whom are members of the society). The article is right to point out the well-recognised risks of “lifestyle drift” in policy making (23) and how this can allow politicians and industry to blame the individual who “chooses” a certain lifestyle, when these choices are not freely made. However, by clarifying the different needs of policy making versus the clinical encounter, the BSLM is confident that when the evidence for lifestyle interventions is given level footing with pharmaceutical and surgical approaches (in regard to funding, inclusion in medical training and focus in a consultation), then these tensions can be better understood.
The authors suggest that lifestyle medicine needs a “clear consensus on what constitutes evidence-based practice with organisational standards and leadership commitment to the removal of bad science and of financial and ideological conflicts”. The BSLM agrees and is the only lifestyle medicine organisation in the UK to set itself apart from the alternative medicine community, be free from pharmaceutical or nutraceutical sponsorship and is setting up a learning academy to deliver its own diploma, maintenance of certification programme, fellowship and CPD opportunities to ensure we have evidence-based, medical education available to all.
It is also collaborating with academic partners and NHS care providers to ensure that future work is rigorous and can be used to address health inequalities. The use of effective approaches to support people with lifestyle change has been neglected by the medical profession and must not be left in the hands of social media influencers and “lifestyle gurus” nor only accessible to the wealthy; the BSLM is helping to grow the knowledge and skills needed to address the issues raised by the authors and welcomes those who wish to support us to work on these challenges by joining the organisation.
As a society the BSLM works with a broad range of partners who have a number of different views, when doing this we strive to work with transparency and ensure that the pillars of lifestyle medicine, and change for all, are at the forefront of all we do.
Dr Ellen Fallows.
BSLM Learning Academy Director, Trustee and General Practitioner
- Nunan D, Blane DN, McCartney M, 2021, Exemplary medical care or Trojan Horse? An analysis of the “lifestyle movement”, BJGP; 71 (706): 229-232
- Macaninch E, Buckner L, Amin P, et al, (2020), Time for nutrition in medical education, BMJ Nutrition, Prevention & Health; 0
- Phillips K et al, (2012), Counselling patients about behaviour change: the challenge of talking about diet. Br J Gen Pract., 62, e13–21.
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- Jarbøl DE, et al. (2017), Determinants of preferences for lifestyle changes versus medication and beliefs in ability to maintain lifestyle changes. A population-based survey. Prev Med Rep., 6, 66-73
- Moynihan R, Smith R. (2002), Too much medicine? Almost certainly, BMJ; 324 : 859
- Krishnaswami J, Sardana J, Daxini A. (2019); Community-Engaged Lifestyle Medicine as a Framework for Health Equity: Principles for Lifestyle Medicine in Low-Resource Settings. Am J Lifestyle Med. 13(5):443-450
- McGill R, Anwar E, Orton L, et al. (2015), Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact. BMC Public Health; 15: 457
- Riley R, Coghill N, Montgomery A, et al, (2016), Experiences of patients and healthcare professionals of NHS cardiovascular health checks: a qualitative study. J Public Health (Oxf). 38, 3, 543-551
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- Hokyou Lee et al, (2019), Combined Effect of Income and Medication Adherence on Mortality in Newly Treated Hypertension: Nationwide Study of 16 Million Person-Years, JAHA, 8, 16
- Giuseppe M, et al, (2018), Socioeconomic inequality of access to healthcare: Does choice explain the gradient?, Journal of Health Economics, 57, 290-314
- Marmot M, (2010), Fair Society Healthy lives (The Marmot Review), Institute of Health Equity, http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review accessed 6/5/21
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- Williams, O. and Fullagar, S. (2019), Lifestyle drift and the phenomenon of ‘citizen shift’ in contemporary UK health policy. Sociol Health Illn, 41: 20-35