Lifestyle Medicine: The missing puzzle piece for community pharmacy
Community pharmacists are medication experts and are usually the health professional that people see most often. The foundation of our role is making sure medications are used appropriately, which means no medicine is overused, underused or misused.
How this looks in practice varies wildly depending on the community a pharmacist serves. A day’s work can include:
- provision of health advice and triaging of acute demand (often free of charge to patients)
- diagnosing and treating minor ailments (from allergies to acne and everything in between)
- prescribing pharmacist-only medications
- dispensing and checking prescriptions
- administering vaccinations
- reviewing medication treatment plans, and
- collaborating with other members of the mutli-disciplinary health team, including pharmacist colleagues working in hospital, GP or other settings.
All this is done to optimise therapy and improve health outcomes, for dozens or even hundreds of people each day.
In the face of multiple health crises, the profession is continuously designing and advocating ways to deliver better, safer, more equitable person-centered care. Furthermore, the recent Aotearoa New Zealand Health and Disability Review called for prevention of illness needs to become a fundamental part of how ‘Tier 1’ services (including community pharmacy) operate. Likewise in Australia, the draft National Preventive Health Strategy emphasises the need for a rebalancing of health action towards preventive health and health promotion.
The future of pharmacy is being crafted. Will Lifestyle Medicine form part of the puzzle?
Lifestyle interventions can be more effective than medication
Many health conditions respond surprisingly well to improvements in nutrition, movement, stress management, better sleep, cessation of smoking or alcohol, and improved social connections. But how does lifestyle change stack up against medicine?
In 2002, a clinical trial was published in the New England Journal of Medicine comparing the impact of metformin (850 mg twice daily) and a lifestyle intervention on reduction of incidence of type two diabetes in patients with impaired glucose tolerance. After an average follow-up of 2.8 years, the lifestyle intervention – involving a low-fat diet and moderate physical activity – reduced the incidence of diabetes by 58% and metformin reduced incidence by 31%, as compared with placebo. The NNT (number needed to treat) to prevent one case of diabetes was 6.9 for the lifestyle intervention compared with 13.9 for metformin1.
The number of New Zealanders with type 2 diabetes is expected to increase by 70-90% in 20 years, and diabetes is the fastest growing chronic disease in Australia, so shifting focus towards preventing disease is vital. To help support that shift, pharmacists will need to focus on more than medication. It’s not just diabetes that would benefit.
Lifestyle Medicine can help manage and reverse the world’s biggest killer, heart disease. For example, in a 1998 study, an intensive lifestyle intervention including a low-fat whole food plant-based diet was shown to significantly reduce the incidence of secondary cardiac events compared to usual care (risk ratio for usual care=2.47). Furthermore, 82% of patients in the lifestyle intervention group showed regression of stenosis, compared to progression of stenosis in the usual care group2.
Lifestyle interventions have been shown to lead to significant and wide ranging beneficial outcomes whilst having few or no negative side effects. For those looking to delve deeper, the American College of Lifestyle Medicine has collated a wide range of evidence on various health conditions.
Lifestyle Medicine complements pharmaceutical therapy
Six key areas of Lifestyle Medicine include a plant-predominant diet, regular exercise, sleeping well, stress management, strong social connections, and avoiding tobacco, alcohol and illicit drugs. The practice of Lifestyle Medicine is complementary to pharmaceuticals – it does not need to be one or the other.
For example, pharmacists can counsel patients about starting newly prescribed medication for diabetes, but also offer information and advice about the benefits of adopting a whole food plant-based eating pattern and increasing movement as appropriate. When fully informed about appropriate treatment options, patients may agree a plan with their doctor to take medicines and make lifestyle changes simultaneously. In many cases where intensive lifestyle change is adopted, medication may cease to be indicated (highlighting the importance of medical supervision).
While there is no denying that pharmaceuticals can have huge benefits, such as reducing symptoms of disease and helping patients avoid long-term complications or undesirable health events. However, medications can have serious or even fatal side effects. Adverse drug events (ADEs) and adverse drug reactions are major causes of patient morbidity and mortality, and a source of significant costs for both organisations and patients3,4.
In the case of chronic diseases such as type two diabetes, medications have not been shown to reverse disease so may be required ‘life-long’. It’s common for pharmacists to see the number and dosage of ‘long-term medications’ for patients escalate over time. Many members of my community walk out of our pharmacy with large bags full of tablets. The New Zealand Health Quality and Safety Commission found that in 2017, on average, 34% of New Zealanders aged 65 and over received five or more long-term medicines. Māori and Pacific peoples received more medicines at a younger age compared with those identifying as Asian or European/Other5. This is a potentially disheartening experience for patients and health professionals alike.
On the other hand, the efficacy of Lifestyle Medicine and potential for it to lead to wellness offers an empowering option for patients and can significantly increase job satisfaction for pharmacists. Witnessing patients come off medications when they are no longer needed is an incredible experience. In an often challenging and stressful workplace, the value of this cannot be underestimated.
Reducing disease incidence and progression will save money
Aotearoa’s District Health Boards’ combined pharmaceutical expenditure in the 2019/20 year was $1.04 billion. In 2020, the New Zealand government spent NZ$34.15 million on insulin glargine, just one type of insulin. Taking a broader view beyond just medications, the estimated annual cost of diabetes in New Zealand is currently $2.1 billion, and is projected to increase by 63% to $3.5 billion in 20 years6. The figures in Australia are similarly concerning, with estimates in 2010 exceeding AU$14.6 billion.
Imagine if 1 in 7 cases of diabetes could be prevented by implementing a Lifestyle Medicine intervention such as that published in 2002 (which showed a NNT of 6.9). In Aotearoa, reducing diabetes costs by 1/7 could potentially free up NZ$300 million annually or NZ$500 million per year in 20 years.
By preventing or reversing disease and avoiding expensive medications, hospital admissions and procedures, resources will be freed up to be redirected to preventative or health-promoting interventions.
Community pharmacies can promote Lifestyle Medicine in flexible, impactful ways
Pharmacies can give greater attention to the domains of Lifestyle Medicine in a variety of ways that suit staff and patients. Three approaches below highlight options for differing levels of expertise.
- Referring patients to other community services that support lifestyle change
For pharmacists who are not confident directly providing evidence-based lifestyle support, referral offers a way to ensure patients can access beneficial information and assistance. Referral is also recommended for complex patients who require specialist advice,
- Incorporate Lifestyle Medicine principles into current pharmacy services
Many areas of pharmacy can benefit from a component of Lifestyle Medicine, from advice on common complaints such as constipation or lethargy, to comprehensive medication therapy assessments.
Medication optimisation services become more holistic with evidence-based lifestyle recommendations provided. It is crucial that such recommendations are accompanied by a plan for ongoing practical support or referrals to services that assist with the targeted behaviour change. Point of care testing for blood pressure, blood sugar or cholesterol can also be paired with lifestyle counselling and written action plans to help people improve risk factors for disease.
- New services may also be designed for delivery by pharmacists qualified in domains of Lifestyle Medicine or in collaboration with multidisciplinary colleagues.
Pharmacists overseas have been offering lifestyle services for many years7,8. In Aotearoa, funding for community-based services that focus on prevention may become more accessible for ‘Tier 1’ providers (including community pharmacy), with health system changes on the horizon.
The recent Aotearoa New Zealand Health and Disability System Review report called for “the long talked about move to give more emphasis to preventive care and the promotion of wellness needs to become a reality” and recommended formal ringfencing of Tier 1 funding within DHB budgets. The review also recommended building illness prevention and wellbeing promotion into every part of the health and disability system. Likewise, Australia’s draft National Preventive Health Strategy emphasises the need for increased prevention funding.
Getting started with Lifestyle Medicine in practice
Lifestyle Medicine can help patients get well, stay well and avoid unnecessary use of medication. So what steps can pharmacists take to start incorporating it in day-to-day work?
1. Begin developing knowledge and practical skills for implementing Lifestyle Medicine
Explore the resources and education pathways available on the websites of the Australasian Society of Lifestyle Medicine (ASLM) and American College of Lifestyle Medicine (ACLM). Better still, become a member of your regional Society of Lifestyle Medicine and attend their workshops and conferences.
2. Gain a more in-depth understanding of Lifestyle Medicine and a formal qualification
Register to undertake Certification in Lifestyle Medicine. This involves completing an online course, submitting a written case study, achieving a set number of ‘in-person’ education hours and sitting a formal exam. Find more information here.
3. Ask patients if they would like to talk about recommended lifestyle changes
Could your patient potentially benefit from a lifestyle change? If so, invite a conversation with them. A great opportunity for this is the ‘teachable moment’ when patients are collecting a new medication, but you can raise it at any appropriate opportunity. If patients do not want to discuss lifestyle, then let them know you are available should they change their mind. If they are open to a chat, aim to figure out their stage of ‘readiness for change’ and offer tailored advice to match.
4. Map local or online services and resources that could support patients with lifestyle change
Understanding what options are available to help with behaviour modification ensures pharmacists can signpost patients to the most suitable services to match their needs. These may include, but are not limited to:
- subsidised or fully-funded consultations with a dietitian, exercise physiologist or counsellor
- services to support cessation of smoking or reduce abuse of drugs and alcohol,
- intensive therapeutic lifestyle therapy treatment programmes, such as the Complete Health Improvement Programme (CHIP) which is offered in person or online)
- credible sources of online information and events to increase health literacy and boost confidence in taking steps towards health goals
- online fora where patients can access peer-support from others making positive lifestyle changes
Providing printed handouts may be helpful – many exist online or you can design your own for your local community including local services. ASLM members can access a range of lifestyle handouts via the members’ area of the website and Doctors For Nutrition offer free printable handouts on shifting towards a healthy plant-based diet.
5. Connect with local health professionals who support the domains of Lifestyle Medicine
Through the Australasian Society of Lifestyle Medicine or via local networks, you’ll likely be able to find like-minded health professionals who can support your Lifestyle Medicine efforts. Together, you may choose to be involved with health promotion or advocacy activities focusing on one or more of the domains of Lifestyle Medicine.
6. Make your pharmacy environment a health-promoting space
Phasing out unhealthy products that are available for sale is a great place to start. For example, chocolates and sugar-sweetened beverages can be replaced with healthy snacks and bottled water, or a filtered water bubbler on site.
The window and wall spaces that many pharmacies have are prime prospects for health promotion. Posters and displays can be used to promote healthy lifestyles and send a clear message to patients that the pharmacy can help with lifestyle change, as well as medication management. Doctors For Nutrition’s ‘Let’s Talk About Food’ poster is one great example to put up in pharmacies, GP clinics or other health settings, inviting conversations about nutrition.
7. Consider setting an action plan for personal lifestyle change
It has been shown that poor health habits among doctors impact the counselling that they provide to patients. For example, non-smoking doctors are more likely to discuss smoking risks, and doctors who exercise are more likely to provide advice on exercise than those who don’t. This is likely to hold true for pharmacists and other health professionals alike.
Making a personal commitment towards healthier living may improve the frequency and quality of lifestyle support we offered to patients. Dr Jenny Brockis has some great tips for those who want to make improvements in an area of their lifestyle and make the habit stick. If you are on track with healthy lifestyle habits, why not offer to support colleagues with theirs, starting with an education session?
Why system change is needed to promote Lifestyle Medicine
Health systems in most countries are centered around ‘sick care’ rather than ‘health care’. In general, people must wait until they become unwell to receive care and then the major focus is on treating the disease with pills and procedures rather than returning the patient to wellness. In 2020 3.8 million New Zealanders received funded medicines – that’s approximately 75% of the population. Yet despite huge advances in modern pharmaceuticals, surgeries and sophisticated models of healthcare, the burden of ‘chronic diseases’ on health systems globally is growing.
By embedding Lifestyle Medicine in every healthcare setting, including community pharmacy, we might begin to see improved outcomes for not just diabetes, but many other conditions such as cardiovascular disease, obesity, poor mental health and some cancers. While Lifestyle Medicine is not the sole solution, it is an essential part of the solution.
The full depth and breadth of benefits of Lifestyle Medicine will not be realised until appropriate funding is available to make it accessible and affordable to all. This is especially true where health equity is concerned, as many people with poorer health outcomes are not able to pay for unfunded services.
A path forward
Individual pharmacists can access education and start evolving their practice as detailed above. However to accelerate the adoption of Lifestyle Medicine by pharmacists and make it accessible everywhere to everyone who needs it, systemic change is needed. Key steps would include:
- Universities that provide pharmacy education incorporating Lifestyle Medicine into the student curriculum. Include comprehensive learning objectives on supporting patients with evidence-based nutrition, exercise, stress management, sleep, avoiding risky substances and positive social connections.
- Pharmacy owners supporting staff to access education on Lifestyle Medicine
- Regulators of pharmacists introducing competency standards relating to provision of Lifestyle Medicine
- Researchers investigating further viable ways for application of Lifestyle Medicine within community pharmacy services
- Governments and commissioners of health services providing ringfenced funding of Lifestyle Medicine services led by pharmacies
This sounds like a daunting challenge and it will take coordinated effort to scale beyond ‘bright spots’ of isolated excellence. But change is already underway. For example, Lifestyle Medicine special interest groups are being established at Universities in Australasia and the numbers of professionals sitting the Lifestyle Medicine Certification exam are growing every year.
Pharmacy has an opportunity to become a shining light in the application of Lifestyle Medicine. The question remains, will we grasp this opportunity and place this piece of the puzzle in its rightful spot, at the heart of every community?
- Knowler et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002 Feb 7; 346(6):393-403.
- Ornish et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998:280(23):2001-7.
- Stausberg J. International prevalence of adverse drug events in hospitals: an analysis of routine data from England, Germany and the USA. BMC Health Services Research. 2014; 14:125.
- Bouvy JC, De Bruin ML, Koopmanschap MA. Epidemiology of adverse drug reactions in Europe: a review of recent observational studies Drug Safety. 2015; 38:437–453
- HQSC. Polypharmacy in people aged 65 and older. Accessed 06/04/21 via https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/polypharmacy/
- PricewaterhouseCoopers. The economic and social cost of type 2 diabetes. 2020. Accessed 06/04/21 via https://www.diabetes.org.nz/news-and-update/new-report-cost-of-diabetes-staggering-but-fixable
- Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43: 173-184. 2. White ND, Lenz TL, Skrabal MZ, Skradski JL, Lipari
- White ND, Lenz TL, Skrabal MZ, Skradski JJ, Lipari L. Long-Term Outcomes of a Cardiovascular and Diabetes Risk-Reduction Program Initiated by a Self-Insured Employer. Am Health Drug Benefits. 2018;11(4):177-183. https://www.ncbi.nlm.nih.gov/pubmed/30464786
This article has been written for the Australasian Society of Lifestyle Medicine (ASLM) by the documented original author. The views and opinions expressed in this article are solely those of the original author and do not necessarily represent the views and opinions of the ASLM or its Board.
