A case in Lifestyle Medicine and why your membership matters
I would like to share a case that highlights the difference between a Lifestyle Medicine approach and the current, often pharmaceutically-dominant medicine approach I was taught in my medical and GP training. I want to make clear this is not a criticism of any individual past or present, or of pharmaceuticals which can be life-improving and lifesaving in the right setting.
The key word here is ‘dominant’. It is not that modern medicine is solely this, as clearly health professionals demonstrate profound skill, care, and dedication across many areas. However, we also need to recognise that modern medicine and education are dominated by pharmaceuticals and procedures, whilst meaningfully addressing lifestyle and social determinants is often neglected because of our inadequate education and models of care despite them being safe, desired by patients and bio-psycho-socially impactful.
In the paraphrased words of Sir Michael Marmot, “Medicine is not wrong, just incomplete.” The research, the many commissions and reviews, our colleagues and most importantly our patients are all demanding change.
This is a case that all health professionals are likely to come across, and my hope is it highlights the fundamental evolution and vision of healthcare that ASLM, its partner organisations and universities, and its members are working towards. Together, we can transform this movement from a vision to a reality.
The case study
Starting point
About 9 months ago, I saw a professional man in his late 30s in my rural/regional GP practice for a second opinion. We shall call him by the pseudonym “John” for confidentiality. John is a fairly standard case in modern medicine; he works full time, has two children, and is busy overall. On a work health screen his blood sugar was found to be significantly elevated. Looking at his history, he had no significant symptoms of diabetes except fatigue. However, upon clarifying his past medical history, the data revealed a diagnosis of high blood pressure 3 years prior, obstructive sleep apnoea treated with CPAP 1 year prior, along with a slowly creeping up weight with a BMI, now 30. By the time I saw him he was on two oral diabetic medications with recommendation for a third due to poor HbA1c control. He was also taking blood pressure and cholesterol medication. He reported, “one doctor mentioned lose some weight. I suppose it’s just I need to eat less”.
And that was it, that was his future. A continual decline in physical, mental, and social health with a pharmaceutical response to his chronic disease, and a very limited approach to addressing the determinants and risk factors.
Between 75.6 and 98% of people with type 2 diabetes mellitus are on medication1. The frightening aspect of such cardiometabolic diseases is the increasing prevalence. As it stands, 15% of Australians have pre-diabetes, and 5% have diabetes with the rates increasing globally. This is increasing at a faster rate than any other chronic disease. In 2019, the American College of Cardiology reported that “from 2000 to 2016, young people <40 years having a heart attack is rising by 2%/year2.”
This is extremely serious. Pharmaceuticals alone were never the answer. We must address and improve the lifestyle and social determinants.
Now this is where a Lifestyle Medicine approach starts to differ from current standard medical practices. Whilst Lifestyle Medicine professionals welcome the appropriate and safe use of pharmaceutical medicine, we go deeply into the lifestyle and social determinants of disease and health and when appropriate and safe, consider deprescribing. When I saw John, I thoroughly assessed his dietary intake, including quantity, quality, order, timing and associated behaviours, his sedentary and movement behaviours, sleep routine and patterns, stress levels, how he managed his stress (food and screens – the modern human’s legal drugs), social support, substance and screen use, social needs, time in nature, motivation, knowledge, his self-efficacy, his values and his past experiences with changing behaviour and much more. This revealed many things, but, in particular, it demonstrated a person whose health had been spiralling for years in a predictable fashion – high blood pressure, fatty liver, sleep apnoea, then diabetes. A “healthcare” system should not have allowed this to happen. We need to address the determinants!
Patient management
Then came management. I asked John to buy a finger prick or continuous blood glucose monitor to check his sugars before and after meals. Continuous blood glucose monitoring (CGM) for short periods is cost accessible for most people (especially during Christmas specials) and is an instantly informative biofeedback tool. Immediately he noted the effect of refined carbohydrates spiking his BSLs, so he reduced these. Interestingly, some other less-obvious foods also affected his BSLs as well. The importance of personalisation!
With thorough education on the physiology of our metabolism and lifestyle behaviours along with health coaching, we helped him shape a personalised, lower-carb diet rich in healthy plants, fats, and protein sources. I note there are many acceptable, evidence-based dietary approaches to metabolic health, and this specific approach was based on informed and shared decision making and health coaching principles. We reduced his sedentary time using various tips, increased his movement for play and pleasure (games and dance with the kids!), explored the management of urges and cravings, coached around sleep and screen use, reconnected him with old mates and socially prescribed him to a local men’s group. The importance of peer support in lifestyle changes (aka shared medical appointments)!
Results
Upon implementing the above interventions, John’s BSL was in the normal range within weeks, after 3 months his HbA1c was to target, and at each 3-month HbA1c check he was deprescribed all but the lowest dose of metformin with his HbA1c to target. Additionally:
- His weight had decreased by 5kg (which was the max of the goal for that time period (see below).
- His sleep had improved.
- His blood pressure had reduced.
- He was feeling socially reconnected.
- Cognition and mental health improved (one of the benefits he prized the most as the impact on his work and family life were significant)
- He was inspired to continue with these behaviours.
Despite the encouraging outcomes, I made it clear that diabetes is not put into remission by simply reducing refined carbohydrates as that only manages the hyperglycaemia (which is still very important). The reality was the underlying metabolic pathology (e.g., insulin resistance, metabolic inflammation, etc.) needed to be addressed.
Moving forward
We continued to refine his lifestyle and social factors including his BMI using the interval weight loss method from Dr. Nick Fuller at the University of Sydney. This is a slower stepwise weight loss approach that helps reset the brain’s weight set point, so the body doesn’t try to fight weight loss, and hence much less likely to lead to weight regain. Over time we have been able to further develop his lifestyle practices. For example, we’re now using higher intensity movement especially around eating carbohydrates to support insulin sensitivity. We’re paying attention to the order, timing, and intervals of food intake. We’re working on relearning bodily cues to stress, food, and sleep using mindfulness and other approaches so he can respond to these cues in ways that genuinely address them.
After 6 months we repeated his CGM and found he could tolerate many more foods again. Hence, he has been able to transition to a personalised variant of the Mediterranean diet.
Outcome to date
So, the outcome to date? Diabetes near remission, blood pressure reduced, medication deprescribed, sleep apnoea improved, mental health improved, and BMI down to 26 (so far). But it goes much further because, since we addressed the determinants of health, his risk of several other diseases is now also reduced, and his resilience and wellbeing are increased. His complex physiology has changed for the better. Plus, this approach is far cheaper than medication in health expenditure without the side effects.
Whilst the specific management is always personalised, the pillars of Lifestyle Medicine are effective to varying degrees in so many chronic diseases: cardiovascular, diabetes, cognitive impairment, depression, anxiety, cancer, autoimmune disease, chronic pain and so on. Our healthcare system approach needs to be far more than a tokenistic and superficial “eat less, move more”.
Additional thoughts
The truth is I have many stories like this in multiple different conditions, and yet we have barely scratched the surface of the field of Lifestyle Medicine and the models of care to support it. The future of healthcare is inspiring when we realise the potential of this field. But I won’t pretend for a second that all cases are like this one or that lifestyle medicine is a panacea! I use an analogy similar to smoking cessation: with no support, the quit rate at 12 months is around 3-5%, but with the best care available, rates sit around 25%. Whilst the exact percentages vary, this too is my experience with Lifestyle Medicine. Not practicing it basically guarantees our patients will never get better for the long-run, and doing it means many more will (especially if we improve our models of care). Therein lies the work of addressing the macro socio-industrial determinants, a crucially important aspect of lifestyle medicine and public health.
As Dr Dean Ornish said, “I don’t understand why asking people to eat a well-balanced diet is considered drastic, while it is medically conservative to cut people open and put them on cholesterol lowering drugs for the rest of their lives”.
How did we get to a place where over 85% of consults end with a script, yet <10% end with a lifestyle intervention1? Is this the healthcare we want to deliver? Is this the healthcare we would want ourselves or our loved ones to receive? Will this approach lead to genuine whole-of-person wellbeing, betterment, and engagement with society more broadly?
Where ASLM comes in
This is where the three goals of ASLM come in. These goals are as follows:
- Deliver training to health professionals and support the interdisciplinary workforce in lifestyle and social based assessment and interventions.
- Disrupt healthcare by collaborating to create new models of care in health service provision and community settings.
- Drive initiatives that advocate for governments and businesses to genuinely address the lifestyle, social, and environmental determinants of health.
These three goals are critical if we are going to successfully navigate the existing social and health crisis.
I have met with so many health professionals over the years who have told me how practicing lifestyle and social medicine has changed their personal and professional lives, how their own health has improved, how they feel “this is why I got into medicine/health”, and how they are more connected to their practice and patients at a deeper level. They have “found their tribe” and feel hope again for the future. This is what inspires me to keep going, and I hope it inspires you, too.
We invite you to join the Lifestyle Medicine movement.
Join a community of passionate healthcare professionals, Board members, students, and staff who are ready to make the changes required to have a healthier, happier Australia and New Zealand.
ASLM is committed to understanding and explaining the underlying issues our population and our systems are facing to drive change. Our impact is on the rise. NOW is the time to join this movement. Only together we can make the change.
Join as a member today!
Sincerely,
Dr Sam Manger.
Sam Manger
Education pathways in Lifestyle Medicine
In addition to membership, ASLM offers several educational pathways, including the ASLM Accreditation in Lifestyle Medicine and the ASLM Fellowship. We also proudly partner with universities offering a suite of postgraduate courses in Lifestyle Medicine.
Dr Sam Manger is the Academic Lead of the Postgraduate Degrees in Lifestyle Medicine at James Cook University’s College of Medicine and Dentistry. Their Graduate Certificate, Graduate Diploma and Master of Lifestyle Medicine are recognised pathways towards the ASLM Fellowship, accredited health coaching with Health Coaching Australia and New Zealand, higher research degrees and exciting career opportunities. The ASLM Accreditation in Lifestyle Medicine may also help you gain recognition of prior learning in these courses.
- Britt et al, General practice activity in Australia 2015–16, Bettering the Evaluation and Care of Health (BEACH)
- American College of Cardiology, Heart Attacks Increasingly Common in Young Adults, 2019
