A shift in prevalence from infectious to lifestyle-related chronic diseases in developed societies requires a modified approach to clinical management and health policy. The emerging practice of lifestyle medicine draws on existing strategies as well as developing new knowledge, skills, procedures and tools to help manage the modern tsunami of lifestyle-related chronic diseases. It bridges clinical practice and public health using a four-tiered, multisystem approach.
- Lifestyle medicine extends current medical principles by striving to modify the behavioural, environmental and social determinants of lifestyle-related chronic disease rather than just the risk factors and symptoms of the disease.
- Crucial to achieving this is establishing the determinants (‘cause of the causes’ or ‘upstream determinants’) of lifestyle-related disease as the first step in a four-tiered approach.
- The remaining three steps involve: developing the skills required for clinical practice; using technology to assist behaviour change; and applying procedures that are specific to a lifestyle/environmental approach to care.
Picture credit: © ratmaner/Depositphotos
The 20th and 21st centuries have seen big changes in the nature and prevalence of disease. In developed countries like Australia, the shift has been from a predominance of infectious diseases to a predominance of noncommunicable, chronic diseases;1 a cross-over now accepted as an almost inevitable ‘rite of passage’ in developing countries. This disease cross-over, called the ‘epidemiological transition’,2 occurred in the third quarter of the 20th century in Australia, heralded by the rise in overweight and obesity at population levels.
Clinical practices and healthcare systems, however, have been unprepared for dealing with these changes and remain largely unchanged. In a medical benefits environment that rewards quick consultations between a single ‘expert’ and the patient, the chronic disease problem is not being optimally managed. Tinkering around the edges, such as through the chronic disease management system introduced in Australia in 1999, has failed to arrest the problem. Hence, alternative approaches need to be considered. To this end, since its genesis towards the end of the millennium, over a dozen professional colleges and societies in lifestyle medicine have arisen around the world. Postgraduate training is currently offered in several tertiary institutions worldwide, and a growing number of texts are now available.3-6
Here we discuss a four-tiered approach used in the developing discipline of lifestyle medicine for dealing with chronic diseases related to lifestyle, society and the environment. We hope this provides direction for clinicians when managing the modern tsunami of lifestyle-related chronic disease.
Lifestyle modification in chronic disease
The value of a healthy lifestyle for the primary prevention of chronic disease has been demonstrated in large-scale epidemiological studies including the Framingham Heart Study, the Nurses’ Health Study and the European Prospective Study into Cancer and Nutrition.7-9 Indeed, an estimated 90% of cardiovascular disease and type 2 diabetes mellitus, as well as one in three cancers, have been estimated to be at least somewhat preventable through healthy lifestyle practices.10,11
But while primary prevention is most desirable, patients are often not motivated by the possibility of future pain (physical or emotional), which may account for why lifestyle as ‘medicine’ has not been historically emphasised. However, individuals are motivated by present pain, and a growing body of evidence is showing lifestyle interventions to be efficacious for the management and, in some instances, treatment of chronic conditions – that is, for secondary prevention. Indeed, intensive lifestyle change has been shown to:
- reduce vascular stenosis and associated disorders12
- normalise blood sugar levels without the need for medication13
- regress markers of early stage prostate cancer.14
Hence, the view of therapeutic lifestyle change is shifting from that of a nicety – something that might produce better health in years to come – to a necessity. Of course, facilitating patient receptiveness and long-term adherence to therapeutic lifestyle change can be challenging. However, comprehensive lifestyle interventions have reported high levels of engagement and low levels of recidivism by applying an array of strategies for behaviour change including education, social support, self-monitoring, problem solving and nurturing self-efficacy.14-16
Role of lifestyle medicine
Lifestyle medicine has been defined as: ‘The application of environmental, behavioural, medical and motivational principles to the management (including self-care and self-management) of lifestyle-related health problems in a clinical and/or public health setting.’3
Lifestyle medicine adds to conventional medicine in that it focuses on the upstream and midstream conditions for disease, as well as proximal risk factors and the disease itself. It differs from nonmedical clinical practice, that is, practice by clinical allied health professionals, in that it may include medication (e.g. for smoking cessation or hunger control) and even surgery where appropriate (e.g. for weight control) as in standard medical care. It also differs from purely behavioural approaches in that it examines the social and environmental aetiologies as well as individual behaviours. Some of the other main differences between the two approaches are shown in Table 1.3