Lifestyle medicine in practice
The problem for clinicians is how to facilitate patient receptiveness and long-term adherence to therapeutic lifestyle change. From the beginning of this century attempts have been made to develop a structure and pedagogy for lifestyle medicine that define its operational processes. In Australia, this is a four-tiered approach (discussed in more detail in the next section) involving the:
- determinants of lifestyle-related disease (the ‘science’)
- skills required for clinical practice (the ‘art’)
- use of technology to assist behaviour change (the ‘tools’)
- procedures applicable for a lifestyle and environmental approach to care (the ‘actions’).
Several draft practice principles have also been formulated by the Australasian Society of Lifestyle Medicine and some are documented in the Box.3 These principles may change with time, but they offer a starting point for practice in the field.
Four-tiered approach of lifestyle medicine
By determinants we mean the ‘causes of the causes’. Fifteen key determinants for chronic disease (often incorrectly called ‘causes’) have been identified in previous publications.3,17 Suffice to say that in the mainstream literature these are usually confined to a few behavioural ‘causes’, namely poor nutrition, inactivity, smoking, excessive alcohol intake and stress. However, these ‘causes’ are also the product of societal and environmental factors. We have provided evidence for at least 11 other determinants for chronic disease, including inadequate sleep, the environment, a loss of purpose or identity and social inequity. All these determinants interact with each other in a ‘systems’ fashion as illustrated in Figure 1. This suggests that a total approach to management is needed that avoids simplistic linear approaches such as a lone diet or an exercise program.
Lifestyle medicine skills
The skills involved in conventional medical practice including diagnosis, prescription and counselling, are also appropriate and necessary for any practice of lifestyle medicine. However, the reach is a little wider when considering upstream behavioural and environmental determinants of disease in lifestyle medicine. Obesity for example, is clearly a function of energy imbalance. However, energy intake (food and drink) and components of energy expenditure (metabolism, physical activity) can be influenced by a range of other, less obvious factors, which should be considered in any ‘systems model’ approach. Stress, for example, can influence energy intake and metabolism positively or negatively as well as activity levels. Inadequate sleep can lead to low activity levels during the day, which can then impact on diet and relationships, which can ultimately affect body weight outcomes.
Chronic disease diagnosis depends on the identification of the underlying determinants and social mechanisms that are driving unhealthy behaviours as much as the disease itself. In clinical practice most chronic diseases share common dysfunctions or mechanisms (e.g. low-grade inflammation also called ‘metaflammation’) and signs (e.g. elevated inflammatory markers, gut dysbiosis).18 Addressing the upstream determinants causing these dysfunctions can often alter the outcomes of several chronic disease processes.
Prescription and deprescription
Prescriptions can be for both pharmacological and nonpharmacological interventions, but in lifestyle medicine they are used more as an adjunct to a therapeutic lifestyle intervention than as a primary treatment. Medications are directed more upstream to the cause and the ‘cause of the cause’ rather than aimed at disease or risk modification, which is generally the medication focus of conventional medicine. Deprescription, in response to the frequent overuse of polypharmacy that may cause harm but also result in limited benefit–cost outcome, is also likely to become a standard procedure in managing lifestyle-related problems in the future.19
Counselling in lifestyle medicine involves the usual array of skills, but potentially draws more from the behavioural and environmental literature. This includes a greater reliance on motivational interviewing and principles; mechanisms of influence as used by advertising and social marketing; and the arts of coaching, coaxing and nudging patients from extrinsic (external) to intrinsic (internal) motivation to drive long-term behaviour change. There is also a greater reliance on public health and health promotion for major environmental change as an upstream determinant, like those used in the anti-smoking and now obesity debates.