Wouldn't we all like another tool in our toolkit for helping our patients? Especially in the current climate with so much pressure on us, and so many people feeling unwell and unhappy. ‘Lifestyle medicine’ is concerned with non-pharmaceutical interventions which can help our patients. Despite the somewhat medicalised name, this area has historically been the bread and butter of nurses, who have long been trained to approach the patient holistically. We have generally been the ones to have conversations about ‘diet and exercise’ and nurses have done fantastic work in this area. But do we all really appreciate the power of these interventions, and the broader scope of lifestyle factors such as sleep and relaxation/stress control, to impact on peoples' physical and mental health?
Following clinical guidelines
Most clinical guidelines for managing long-term conditions, both physical and mental, suggest addressing lifestyle/modifiable factors as the first step of treatment. But in practice, this is often only given brief attention, before thinking about which pharmaceutical intervention to try. This is probably due to a few factors, including the unrealistic time constraints of appointments, the sheer workload in primary care, financially incentivised clinical targets, the difficulty of engaging patients in behaviour change, and possibly a lack of appreciation by both health professionals and patients themselves of the genuine potential power of these factors for improving medical conditions.
The benefits of lifestyle interventions on health
Until recently, there has been a lack of high quality research in this area of health care. Some of the more cynical might argue that this is because a lot of medical research is funded by pharmaceutical companies and there is no profit for them in, for example, helping someone to sleep better through natural means or reduce their blood pressure through relaxation techniques.
Now, however, we are getting the books, articles and discussion that we need to highlight the real potential benefits of the following factors, to name a few:
- A healthy diet comprised of unprocessed foods, healthy fats and lots of fibre from plant foods
- The impact of poor quality/duration of sleep on blood sugar levels, blood pressure, mood and anxiety, weight management (NHS, 2018)
- The role of the gut microbiome in just about everything to do with our physical and mental health (Valdes et al, 2018)
- The huge impact that stress and anxiety, human connection, loneliness (Holt-Lunstad et al, 2015), and our living environment/connection with nature can have on our health.
This is before we have even considered the potential benefits of physical activity/movement on all aspects of our physical health, mood, cognition, anxiety levels, strength, balance and neurological function.
Empowering our patients
While developing an interest in lifestyle medicine over the last few years, I have found it is a resource I can turn to when the pharmaceutical options seem to have been used up or perhaps do not seem appropriate. Having a discussion about the impact of lifestyle factors can help to empower patients who may have become used to relying on health professionals to point them in the direction of the next drug every time they attend – an unsustainable option.
Our national guidelines can seem to place patients on a pathway which gradually adds or strengthens drug treatments whenever the ‘right’ results are not achieved, but most of these guidelines will actually recommend revisiting or reviewing the lifestyle basics whenever considering a step-up in treatment. Perhaps we do not always have time to do this in our current system?
The NHS Long Term Plan (2019) aims to increase the personalisation of patient care, and make health care more of a partnership between health professional and patient, utilising the patient's expertise in their own health. By working with our patients to support lifestyle changes we can improve their skills, knowledge and confidence in managing their own health, potentially reducing their reliance on formal health care services and reducing pressure on the NHS.
How many of our patients, and in fact our health professionals, know that there is an evidence-based link (Firth et al, 2020) between what they eat and drink, and their mood, concentration, cognition and risk of depression and anxiety? The effect of processed foods containing high levels of sugar and fat, lack of plant foods containing fibre and phytonutrients, and the impact of artificial sweeteners and flavourings could all have an adverse effect on our gut microbiomes, which, in turn, can lead to dysregulation of our physiological processes, leading to poor physical and mental health.
Many patients with mental health problems might have been advised by a health professional to take some exercise to improve their condition but may think of it more as a distraction technique or a psychological effect rather than appreciating the profound chemical and physiological changes which can occur in their bodies and brains as a result of regular movement (which doesn't have to be attending the gym or going running).
The power of a good night's sleep
Although it is generally accepted that a good night's sleep is helpful, how many of us fully appreciate just how important the correct amount and quality of sleep can be for how well our bodies and brains function? Until the publication of books such as Professor Matthew Walker's Why we sleep, the exact science of how important our sleep is for all our physiological functions had not been widely understood, and the potential adverse impact of so many aspects of our modern lifestyle not recognised.
Behaviours such as using electronic devices, which emit blue light before we go to sleep, eating and drinking at all hours of the day and night, never mentally switching off from our work and stresses, and consuming caffeine and alcohol prior to sleep can all impact negatively on how restorative and beneficial our sleep is. All of these factors are things that a patient can potentially address and improve themselves, without any need for medical treatment.
Separation of physical and mental health
Stress is recognised as a modern health epidemic and contributes to many health problems and chronic diseases. Fortunately, the growing recognition of the problem has led to the development of NHS services such as IAPT (Improving Access to Psychological Therapies). However, the separation of physical and mental health, and the their treatment, could be argued to be a move in the wrong direction, because our mental and emotional health have such a profound impact on our physical health and wellbeing.
Specific mental health services are vital and we currently need much more capacity; however, there is an argument for better training and education for all front-line health workers in order to improve their understanding of the lifestyle factors which can impact on mental health and open up the opportunities for brief but effective interventions and support to be provided whenever patients attend for review. This could leave more time available with the specialist services for those with more severe problems. If frontline primary care staff had the time and the tools to talk to patients about strategies for reducing stress, such as modifying their diet and alcohol intake, modifying their access to digital devices and social media, practising mindfulness and meditation practices, expanding activities and social connections, contact with nature etc, they could empower these patients to have an impact on their own health, while waiting for more specialised services in cases where these were appropriate.
Useful resources:
- British Society of Lifestyle Medicine: https://bslm.org.uk/
Podcasts:
- https://drchatterjee.com/blog/category/podcast/
- https://thedoctorskitchen.com/podcasts
Books
- Matthew Walker. Why we sleep. The new science of sleep and dreams. 2018. Penguin.
- Dr Rupy Aujla. The Doctor's Kitchen – Eat to Beat Illness: A simple way to cook and live the healthiest, happiest life. 2019. Thorsons
- Dr Rangan Chatterjee. The 4 Pillar Plan: How to Relax, Eat, Move and Sleep Your Way to a Longer, Healthier Life. 2017. Penguin.
- Dr Rangan Chatterjee. Feel Better In 5. 2019. Penguin.
Accessing resources
There is an RCGP accredited course accessible to any health professional called ‘Prescribing Lifestyle Medicine’, which is a wonderful resource of evidence-based information about the benefits of lifestyle factors in health. It attempts to provide a clinical framework within which health professionals can more holistically assess and address their patient's needs. There are also helpful podcasts hosted by GPs such as Rupy Aujla and Rangan Chatterjee, who interview experts in the fields of research and medicine on the health benefits of nutrition and lifestyle. These are highly accessible forms of evidence-based information for both health professionals and patients alike.
Conclusion
All practice nurses will be able to recall certain patients who took it upon themselves to make some serious changes to some aspect, or aspects, of their lifestyle and achieved amazing results, whether that was a person with type 2 diabetes, hypertension, obesity or possibly someone suffering from depression. We know it can work, but do all our patients realise that? It is not sustainable for the NHS to continue with the current model of care in the face of the massive rise in preventable, lifestyle-driven diseases. The only option is to harness the power of the changes people can make in their own lives with relatively modest actions and behaviour adjustments. By providing them with evidence-based information and supporting them with a coaching approach to focus on the areas which matter most to them, we can empower our patients to improve their own health and wellbeing. It is time to remember this very important tool in our clinical toolkit which can provide hope and autonomy for our patients in the face of deteriorating public health due to the modern western lifestyle.