Is ‘Lifestyle Medicine’ effective? Considering The Wider Determinants of Disease.

Lifestyle medicine is the growing ‘movement’ to improve health by promoting an understanding of the wider causes of disease, such as food, exercise, environment, community and stress, etc.
Lifestyle medicine (LM) is interesting because it focuses on interventions that are so simple, and that we all already know are ‘good’ for us. The LM that I see is delivered by doctors who work hard in their clinics or by using their public presence to motivate health behaviour changes – with differing degrees and types of successes.
The delivery of Lifestyle Medicine as a way to promote health and prevent disease and to unburden the western world of its growing chronic disease problem is not going to be easily achieved, and perhaps we are not currently going about solving this problem in the most effective way.
These thoughts were developed out of certain frustrations that I have felt as someone who reads, lives and promotes LM – and I hope it is of interest to you, or at least displays a problem that I am facing that I think needs to be considered and fixed.

The wider causes of disease. The population carries the burden of the wider causes of disease. Who carries responsibility?
Is it the individual? Is it the doctor? Is it the department of health? Is it all of the wider arms of government, controlling taxes, education, infrastructure, agriculture?
Here is a LM story.
Imagine that you walk into a fast food restaurant. There are customers tapping on the computer screens to order their burger and fries. Customers from all walks of life, representing the vast variety of socioeconomic backgrounds in the UK. City slickers, rural dwellers, plumbers, builders, road-layers, doctors, lawyers, bankers. They order their food, sit down at a table and pull out their phone to start working on some task of life – organising car shares for kids at school, consulting with patient blood tests, finishing up client emails or financial documents. The food comes, but they don’t concentrate upon it. ‘That was delicious!’ they exclaim, it tastes good, is easy to hold, is cheap. They are there to get fed, a quick pit-stop, their focus on their phones allowing life to never be interrupted. They get back into their cars and drive on to their next destination.
Imagine also that in the corner of the fast food restaurant there is a narrow booth inhabited by a doctor who believes in lifestyle medicine. There are 100 customers in the fast food shop. The doctor sits in his booth, which has room for maybe only one or two patients, and is otherwise surrounded by an arsenal of leaflets and hefty diet and exercise popular science books. A big poster is strung up above him FREE LIFESTYLE MEDICINE CONSULTS.
The doctor tries to do good work.  Waiting for patients to present, just as in the GP practice, the doctor shuffles the leaflets on the desk. When the patients are waiting for their food to be collected they might squeeze into the uncomfortable booth – the doctor preaches ‘try this; eat fewer calories, change your macronutrients, do some resistance training, get some morning sunlight’. Have a leaflet. Again mirroring a normal consultation, the doctor doesn’t have much time. The doctor tries to use some motivational interviewing to stimulate some behaviour change, but before you can say carrots the patient’s burger number pops up on the screen and the patients move out to the pick up area and are whisked away back into their busy lives.
Occasionally the doctor strikes lucky and manages to have a solid conversation with a patient whom the doctor really believes will be a good lifestyle medicine follower. Unfortunately, more often than not, the patient wears yoga leggings, is social media literate, takes a multivitamin and only found themselves in the fast food restaurant by accident after mistaking it for a whole foods grocery store.
The doctor works all day – getting in early and leaving later than the shift rota required. Still, leaving as the business world closes, the doctor sees the fast food restaurant become even more busy as the business workers catch some food after a hard days work. The doctor is frustrated – leaving now means that the doctor misses many possible opportunities to teach lifestyle medicine and enact behaviour change. But the doctor needs to eat, sleep and exercise too, so the doctor leaves a note – follow me on Instagram #healthydoc .
The doctor walks out into the carpark, and before getting into the car turns around to look at the restaurant. The restaurants glowing logo illuminates the forecourt of the restaurant, the doctor sees more people, children and the elderly, poor and the rich, all cast upon by the yellow light.
The doctor sighs. Although equipped with the best of intentions, the doctor cannot be the primary fighter in this battle. A flicker of blame crosses the doctor’s mind. Why can’t the people just choose the right option? Why do they come to this place? Why can’t they see that cheap fast food is poisoning them? Do they not understand the concept of ‘return on investment’? What about their current and future health? What about the health of their children!? Can’t they see that diabetes is a horrible disease?
UGH they should all be as conscientious of lifestyle medicine! Each individual should be empowered to make their own best decisions, they should be able to identify, create and engineer their best health!!
A truck pulls up into the forecourt, delivering beef from the midlands, chicken from the south, bread from the north, pickles from the east, vegetable oils from the west. A moment of wider realisation strikes – Perhaps the doctor has wild fantasy of sabotaging the delivery truck, insulting the fast food business, hammering on the sides of the truck with protest signs. Maybe if this happens, the supply chain will break and the public will no longer be shackled by the fast food industry!
But indeed, protesting against one truck will not stop the fleet of other trucks. The farms have been working to produce the beef, oil and bread. The farms chose to produce these crops because of demand and subsidy. The doctor baulks at the idea of challenging the Farmers’ unions.

This little parable was borne out of an argument with my sister.  These were the conclusions. She made the better points and I learned from them. Also contains questions I’m hung up on.
  • Why are the people buying their food there?
  • Food isn’t important. Lives are busy. Insurmountably busy. Unfathomably busy. So busy that people like the doctor can never truly understand how busy they are.
  • When family, employment and other matters are pressing, why would an individual worry about something so trivial as a single meal? When 99% of a person’s bandwidth is focused on getting through the day, what are the chances that ‘lifestyle change’ will get in? Do we blame the individual?
    • No. Other people don’t share all the luxuries some of us have been shaped by. Other people have hardships that others do not understand.
  • So do we blame the farmer?
    • No. The farmer only follows the same rules that the customers inside the fast food restaurant also follow – a grind in life, profit to make, debts to pay, childcare to organise, marriages to maintain. For the farmer, worrying about the implications of supply, demand and subsidy are not conducive to a happy life. Why would they worry?
  • So who do we blame?
  • We believe that we are all have an equal ability to live an optimal life, but currently we do not. An ability to do so is not the fault of the individual but is a product of the true wider determinants of health – policy governing education, food, taxes, socioeconomic policy. Government policy that cuts good school meals, makes quality food more expensive than a gas station packaged hamburger or makes golden lit fast food restaurants more prominent in the food landscape than cheap whole food in supermarkets or farmers markets.
  • Empowering people to become their own ‘health engineer’ is an ideal, but to do so is not possible by focusing on the individual. People are too busy and do not have the base level of education to make ‘health engineering’ an easy, thus realistic prospect.
  • The government cannot take burden of population health forever, but it should take steps to build education as a long term investment to promote empowerment of the individual.
  • So what is the role of Medicine in informing the public about ‘Lifestyle’? Should it be called lifestyle medicine if we want nonmedics to embrace and own it?
  • Social media based lifestyle medicine suffers from selection bias and I don’t believe it adequately reaches the people who would benefit from lifestyle medicine most.
  • Likewise, focusing on any single group of people does not address the three tiers involved in population health – pubic, medicine, government. Each tier should acknowledge that they hold responsibility. Next is to understand which tier holds the levers to change population health. I say it is the government who can change the landscape for the public, and both the government and public liase with medicine.
  • But we’ve hammered on this for ages. Public health efforts are a prominent feature. What can we change?
  • How can we use social media effectively?
  • Some programmes are really good!
  • The conviction the doctor holds about the severity of disease is a product of the doctor’s education that has been amassed over years of schooling and life experience. From the day that this doctor set foot in the nice school, with a wholesome family and a regular supply of food and sport – health education has been in some way valued.
  • I was fortunate to grow up in the south of England, live in a stable home with health oriented family members, go to a good school and to get a loan to fund myself through medical school. My opinion of what is possible is different to what someone else, from an unlimited lottery of different circumstances, believes is possible.
  • Medicine is deeply human. Be more human.
NB The problems of government is that there is a chasm between academia and policy. Both roles are so intensive that there will not be an effective combination of the two – to have an actively campaigning politician who is also waist deep in performing and analysing new public health research. All in all, this doctor sighs at the huge complexity of linking government to the population via population health. Perhaps an easier solution is to have communities engage their own health-promotion initiatives, building their sense of belonging around education, elderly care, healthcare, food and recreation – a la health hub.
Trying to confront the problem of the chronic disease burden is massive. Trying to think about both the magnitude of it and the complexity of its internal networks is almost enough to send one into career burnout (irony). The way that large problems have been tackled in the past is by slicing the problem up and dealing with each slice by prioritising importance.
To protect us all from burnout and to establish some progress, which aspect of ‘lifestyle medicine’ ‘population health’ and ‘health engineering’ should be tackled first, and by who? Or if we have multiple parties – various governments, international lifestyle medicine or public health societies aimed at doctors and public, student focused campaigns such as the BSLM or ULMS and Nutritank or policy focused groups such as the Obesity Action Campaign – where do they all start and how do they all share effort and work in the same direction?
What ya think?

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