By Dr. Alan Penney and Dr. Helen Zakour (Guest Authors)
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Core
Lifestyle medicine? Do you mean the opportunity to skip-over-and-move-onto-something-else medicine?
You wish!
Lifestyle medicine is on the rise and is fast spreading throughout the teaching agenda of the UK’s medical schools. In 2018, Leicester Medical School in the UK officially made it part of their curriculum. It is inevitable that other institutions will follow.
The purpose of this article is to cut out the waffle that topics related to the theme so often have. It promises to deliver what you need to know in a concise, efficient manner to aid as an invaluable revision tool. It is also here to help to educate you, the reader, a little more on things you might be able to do to help improve your lifestyle.
Lifestyle medicine is evidence-based clinical care that supports behaviour change (helping people change their habits) to prevent and manage long-term conditions. The British Society of Lifestyle Medicine describes 6 pillars: mental wellbeing, social connection, healthy eating, physical activity, sleep, and minimising harmful substances and behaviours. This article splits the topic into four areas.
Mental health. Exercise. Nutrition. Spirituality.
Let’s start with mental health.
Key Definitions:
Burnout - a syndrome caused by long-term workplace stress that has not been successfully managed. The World Health Organization (WHO) describes 3 features: exhaustion, feeling distant from or cynical about your job, and feeling less effective at work.
Mindfulness - paying attention in a particular way: on purpose, in the present moment and without judgement.
Cognitive behavioural therapy (CBT) - a talking therapy in which a therapist helps you change how you think and act. It is a recommended treatment for many mental health problems, such as depression and anxiety.
Allostatic load - wear and tear on the body caused by prolonged stress.
Motivational interviewing - a style of counselling that helps a person find their own reasons to change a behaviour, rather than being told what to do. It is used for lifestyle problems and disease.
Life in the medical field can be gruelling at the best of times. It is unsurprising that those in the medical profession are more likely than the general public to suffer from burnout and depression. This is especially alarming when you consider that this increases the risk of making medical errors by 6.2 fold. It is therefore really important to understand these feelings, be able to recognise them, and to be able to seek help. This applies to recognising these feelings in oneself, in colleagues, and in patients.
The Yerkes-Dodson Law describes the relationship between stress and performance (often called the stress-performance curve) as an inverted U shape. It shows how small amounts of stress can be helpful, increasing performance, but how higher levels of stress can impair performance. Sliding too far to the right of the curve is dangerous. Too much stress for too long causes allostatic load: physical wear and tear on the body.
The Yerkes-Dodson Law
Figure: The Yerkes-Dodson Law in graph form.
Public Domain Image
Mindfulness can be used as a tool to reduce stress and reach the optimum level of productivity. It involves paying attention to how your body and mind feel in the present moment, without judging these feelings or trying to change them. Mindfulness is a way to appreciate where the body and the mind are at now, to allow growth in the future.
When stress leads to a mental health problem such as depression or anxiety, cognitive behavioural therapy (CBT) may help. Motivational interviewing is used differently: it helps people find their own reasons to change a lifestyle behaviour. It is important that medical professionals have an awareness of these techniques so they are able to better offer support to patients, colleagues, and themselves.
Stress can sometimes present as a feeling of being overwhelmed, and a difficulty being productive. A part of helping to increase productivity involves setting goals. A goal can be said to be effective by following SMART:
S - specific - goals need to have a key aim which is clearly laid out.
M - measurable - goals need a measurement strategy to track progress.
A - achievable - goals need to be something you can actually do.
R - realistic / relevant - goals need to be possible and to matter to the person setting them.
T - timed - goals need to have a realistic time limit.
SMART goals make a change easier to plan and track. This may reduce the chance of missing the intended target and going round and round the Prochaska DiClemente cycle of behavioural change. This model (also called the transtheoretical model) describes the stages people pass through when changing a health behaviour. The stages include precontemplation (not yet thinking about change), contemplation (thinking about it), preparation (getting ready), action (making the change) and maintenance (keeping it up). People can relapse and go round the cycle again.
Figure: The Prochaska DiClemente Model of Behavioural Change.
SimpleMed Original by Alan Penney
Everyone knows that exercise is a fundamental component of ensuring quality physical and mental health. Yet in the 2021 Health Survey for England, only 33% of men and 26% of women aged 19 and over met both the aerobic and the muscle-strengthening guidelines:
NHS weekly guidelines for adults aged 19 to 64:
At least 150 mins of moderate aerobic activity + strength exercises on 2 or more days that work all the major muscle groups
Or
At least 75 mins of vigorous activity + strength exercises on 2 or more days that work all the major muscle groups
A mix of moderate, vigorous and very vigorous activity also counts. The NHS advises spreading activity evenly over 4 to 5 days a week, or every day, and reducing time spent sitting or lying down.
One side effect of doing minimal physical activity is the increased risk of sliding up the BMI scale.
BMI = weight (kg) / [height (m) x height (m)]
- Underweight: <18.5
- Healthy weight: 18.5 to 24.9
- Overweight: 25 to 29.9
- Obesity class 1: 30 to 34.9
- Obesity class 2: 35 to 39.9
- Obesity class 3: 40 or more
People from a South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean background are at risk of health problems at a lower BMI. For them, NICE uses lower thresholds: overweight is a BMI of 23 to 27.4, and obesity is a BMI of 27.5 or above.
For more information about BMI, please see our article on Nutrition, Diet and Body Weight.
With this in mind, why are so few people meeting the recommended weekly guidelines? The Theory of Planned Behaviour helps explain why people do not always act on their intentions. In this model, behaviour is predicted mainly by intention. Intention depends on 3 things: attitude towards the behaviour (whether you think it is good or bad), subjective norms (whether people who matter to you approve) and perceived behavioural control (how easy or hard you expect it to be). Perceived behavioural control can also affect behaviour directly, so someone who intends to exercise may still not do it if they feel unable to.
Figure: The Theory of Planned Behaviour modelled to show how eventual behaviour is based upon a number of factors.
SimpleMed Original by Alan Penney
Key Definitions:
Confounding factor - another factor, linked to both the thing being studied and the outcome, that can distort a study's result. For example, if people who exercise are younger than people who do not, a difference in heart disease could be due to age rather than exercise.
Weight stigmatisation - negative attitudes or stereotypes about people living with overweight or obesity, and the prejudice or discrimination that can follow
It is well documented that eating more calories than are burnt can increase BMI, but why do we eat so much? We eat for many reasons besides nutrition: hunger, boredom, comfort, conformity (fitting in with others), taste, impulse, time and cultural influences.
To control how much you’re eating, it can help to eat mindfully: eating slowly, removing distractions and paying attention to the taste of food and to feeling full. This can be combined with a SMART goal for weight management, a smaller plate and sensible portion sizes. A systematic review (a study that gathers and assesses all the research on a question) found that mindfulness meditation reduced binge eating (eating a very large amount in a short time) and emotional eating, but its effect on weight was mixed. Weight-focused advice like this is not a treatment for eating disorders (conditions such as anorexia and bulimia). NICE recommends specialist eating-disorder-focused therapy, and for binge eating disorder it says weight loss is not a therapy target in itself.
It is also important to ensure that all the nutrients that the body needs are being supplied by the diet: it is no use losing lots of weight if it makes the patient deficient in key vitamins or minerals. Eating a balanced diet is just as important as portion control.
Very brief advice from a GP can help. In a trial in England, GPs used 30 seconds at the end of a consultation to offer people with obesity a referral to a weight-management group. After 12 months, these patients had lost more weight on average (2.43 kg) than patients who were only told that losing weight would benefit their health (1.04 kg). Most patients (81%) found the conversation appropriate and helpful.
Key Definitions:
Transcendent - relating to the spiritual realm
Value-guidance - using your personal values to guide your choices and give structure to your life
Spirituality is about connecting to life on a deeper level than normally would occur day to day. It can help us find meaning and purpose in life, and it can be helpful when considering all of the other things mentioned previously in this article. A useful everyday framework is the NHS 5 steps to mental wellbeing, which evidence suggests can improve mental health and wellbeing:
- Connect (with other people)
- Keep learning (new skills)
- Take notice (pay attention to the present moment, also called mindfulness)
- Give (help other people)
- Be active (physically)
Public Domain Image
Even when a patient's physical health cannot be improved, spirituality may still help: it can give a sense of hope and support people through suffering and loss. A patient who cannot make big changes to, for example, their exercise levels can still change how they view themselves through spirituality. This may help them to make other changes in the future.
Maslow’s Hierarchy of Needs is a model that arranges human needs in levels, from the most basic to the highest: physiological needs (such as food, water and sleep), safety, love and belonging, esteem, and self-actualisation (reaching your full potential). It is a reminder that someone whose basic needs are not met may find the five steps above hard to manage.
Figure: Maslow's Hierarchy of Needs highlighting the categories of what people need each day.
SimpleMed Original by Alan Penney
Whilst it is important to recognise the importance of reaching out to patients, it is also important to appreciate the difference between isolation and solitude. Whilst we should always work against isolation, everyone needs some solitude, although the amount varies from person to person.
As May Sarton says, ‘Loneliness is the poverty of self; solitude is the richness of self’.
Spirituality is connected to the physical self in roots that we are only just starting to unravel. For example, low spirituality is related to decreased wound healing, sleep deprivation and cardiovascular stimulation. This means that being more connected to ones' spirituality can have wide-reaching effects, and drastically improve physical and mental health in the future.
This area of medicine will without doubt become a focus of attention over the near future. As clinicians it is vital that we stay updated and ensure that we are continuously learning about topics that may challenge us or slip under our view.
For now, though, be sure to stay mindful, and to look out for yourself!
Reviewed by: Dr. Marcus Judge
Edited by: Dr. Maddie Swannack
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