Exemplary medical care or Trojan horse? An analysis of the ‘lifestyle medicine’ movement

Nunan et al draw our attention to the emphasis of so-called ‘lifestyle medicine’ on behavioural determinants of health and the responsibility of individuals for behaviour modification.¹ Whilst it is important to address the leading behavioural determinants of premature mortality in England, namely tobacco use/unhealthy diet/alcohol and drug use/physical inactivity,² the authors rightly highlight the importance of considering the wider determinants of health.

An important point being made here is that overemphasis on health behaviours and individual-focussed interventions (intentional or unintentional) may actually increase health inequalities and draw attention away from the main drivers of poor health, namely the wider socioeconomic and environmental determinants of health. As the Marmot reviews have shown us, differences in socioeconomic status are associated with dramatic differences in rates of premature mortality and disability; the 2020 review reported a 12 year difference in healthy life expectancy at birth between the most and least deprived regions of England.³ Moreover, a recent cross-sectional study of 2.5 million premature deaths in England found that 1/3 of these deaths were attributable to socioeconomic inequality.⁴

Clearly, a balance must be struck between individual responsibility and wider societal/governmental responsibility. It is important not to minimise individual responsibility for one’s own health or create a false dichotomy between individual responsibility and societal responsibility; both are important and should be advocated for simultaneously. Nunan et al provide a useful framework regarding ways to integrate ‘Individual-level interventions’ with ‘Public health interventions’ to address key modifiable risk factors. In doing so, the authors remind us of the importance of national policy in improving the nation’s health and reducing health inequalities, by placing some of the responsibility at the feet of governments and national public health organisations.

References
1. Nunan D, Blane DN, McCartney M. Exemplary medical care or Trojan horse? An analysis of the ‘lifestyle medicine’ movement. Br J Gen Pract 2021; 71 (706): 229-232. https://doi.org/10.3399/bjgp21X715721.
2. Steel N, Ford JA, Newton JN, et al. Changes in health in the countries of the UK and 150 English local authority areas 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2018; 392:1647-61. https://doi.org/10.1016/s0140-6736(18)32207-4.
3. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J (2020) Health Equity in England: The Marmot Review ten years on. London: Institute of Health Equity. www.health.org.uk/publications/reports/the-marmot-review-10-years-on. 
4. Lewer D, Jayatunga W, Aldridge RW, et al. Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study. Lancet Public Health 2020; 5(1):e33-e41. https://doi.org/10.1016/S2468-2667(19)30219-1.

Nunan and colleagues caution against uncritical adoption of so-called ‘lifestyle medicine’.¹ We agree that as healthcare professionals we need to be careful to avoid unwittingly implementing or condoning non-evidence-based practices. The authors raise an important point regarding a central tenet of ‘integrative medicine’, in that it seeks to integrate so-called complementary and alternative medicine (CAM) with ‘conventional medicine’. Credulously welcoming CAM with open arms as part of integrative medicine may give undeserved credibility and legitimise practices with weak/no evidence of efficacy or worse, evidence of harm. We previously argued the case for abandoning the umbrella term CAM,² due to its ambiguous definition which groups a “highly heterogeneous group of health-related practices with significantly different evidence bases” and therefore risks conflating evidence-based treatments with pseudoscientific practices. Put simply, any healthcare intervention championed as part of lifestyle medicine should be evaluated and subjected to the same level of scientific rigor as all other healthcare practices.

We suspect that we may inadvertently enable non-evidence-based practices to pervade healthcare as a result of a fundamental desire to practice holistic medicine and support patients’ self-management, combined with a perception that many ‘alternative’ interventions are low risk. However, the hidden hand of vested interests pervades the wellness ecosystem and one of the major risks to patients is that of financial forfeiture.³ Other potential risks include adverse events resulting in emergency department visits and hospitalisations,⁴ drug interactions⁵ ⁶ and opportunity costs where patients suffer because of a delay in seeking evidence-based treatment.⁷

Sadly, it is unsurprising that the lifestyle medicine movement might be hijacked in some cases by individuals predominantly motivated by financial conflicts of interest. Whilst encouraging patients to practice self-help and seek additional lifestyle-focussed support in the community may be empowering, it is also important to caution patients against the deluge of pseudoscientific practices espoused by charlatans and ‘snake oil salesmen’. By encouraging scepticism and signposting to evidence-based information, we may help to prevent patients from being taken advantage of by the private sector. We must not permit pseudoscience to infiltrate our practice in the name of holistic medicine.

References
1. Nunan D, Blane DN, McCartney M. Exemplary medical care or Trojan horse? An analysis of the ‘lifestyle medicine’ movement. Br J Gen Pract 2021; 71(706): 229- 232. https://doi.org/10.3399/bjgp21X715721.
2. Trethewey SP, Morlet J, Trethewey CS, Reynolds EKM. Defining ‘complementary and alternative medicine’. The British Student Doctor Journal 2019; 3(1): 42–7. http://doi.org/10.18573/bsdj.74.
3. MacFarlane D, Hurlstone MJ, Ecker UKH. Protecting consumers from fraudulent health claims: A taxonomy of psychological drivers, interventions, barriers, and treatments. Soc Sci Med 2020; 259:112790. https://doi.org/10.1016/j.socscimed.2020.112790.
4. Geller AI, Shehab N, Weidle NJ, et al. Emergency Department Visits for Adverse Events Related to Dietary Supplements. N Engl J Med 2015; 15;373(16):1531-40. https://doi.org/10.1056/nejmsa1504267.
5. Werneke U, Earl J, Seydel C, Horn O, Crichton P, Fannon D. Potential health risks of complementary alternative medicines in cancer patients. Br J Cancer 2004; 90(2):408-13. https://doi.org/10.1038/sj.bjc.6601560.
6. Tucker J, Fischer T, Upjohn L, et al. Unapproved Pharmaceutical Ingredients Included in Dietary Supplements Associated With US Food and Drug Administration Warnings. JAMA Netw Open 2018; 1(6):e183337. https://doi.org/10.1001/jamanetworkopen.2018.3337.
7. Johnson SB, Park HS, Gross CP, Yu JB. Use of Alternative Medicine for Cancer and Its Impact on Survival. J Natl Cancer Inst 2018; 110(1). https://doi.org/10.1093/jnci/djx145.

We welcome positive aspects of Nunan et al’s article and the opportunity to briefly discuss their analysis. However, likening lifestyle medicine to a Trojan Horse implies deception and malice; and is both unworthy and unjustified.

There are important positive messages conveyed: for example, articulating many of lifestyle medicine’s key drivers (Box 1), plus individual and public health level interventions (Box 2).

However, there are important fallacies too and we seek to correct these:

1. Misrepresenting BLSM only as accrediting GPs. Although 885(~50%) members are GPs/GPSTs, membership includes all medicine disciplines, including internal medicine/surgery/nurses/allied health professionals/trainees. We also have patient members, encouraged to attend meetings through invitations via their clinicians (https://bslm.org.uk/events/bslm-2021-conference/) and read our open access journal, lifestyle medicine (https://onlinelibrary.wiley.com/journal/26883740).
2. Inaccurately linking alternative medicine practices/practitioners to lifestyle medicine; including bracketing BSLM with organisations like the (recently-rebranded) British Association for Nutrition and Lifestyle Medicine and (functional medicine-oriented) Prescribing Lifestyle Medicine
3. Concern ‘lifestyle medicine practitioners’ may exploit commercial opportunities.
The common fallacy here is blaming GMC/NMC/HCPC-registered practitioners for unregulated/commercial activities. This criticism (‘smearing by association’) is especially unworthy, especially as BSLM is standard-setting to mitigate these risks.
4. The ‘Health Inequalities’ section is probably the most contentious.
In brief, we recognise that environment and public health have key roles (see https://bslm.org.uk/lifestyle-medicine/what-is-lifestyle-medicine/). However, we refuse to accept that: we are likely to widen inequalities; medical practice cannot evolve; and personal/public health interventions don’t synergise. For a more detailed exposition, see
https://bslm.org.uk/critical-and-evidence-based-adoption-of-lifestyle-me....Criticising BSLM for not addressing upstream health determinants is simply incorrect: we do exactly that.

Lifestyle medicine is inclusive, evidence-based, patient-focused and is not a movement needing to attack other health delivery approaches. We hope that scientific debate can be more dignified and constructive going forwards. We absolutely agree primary care and public health colleagues should work together and practise what we preach.

Given rapid BSLM growth, plus the success and popularity of progressive curricula like Imperial College’s ‘Lifestyle medicine and prevention’ undergraduate medicine modules, that are evidence-based and rooted in population health and inequalities, lifestyle medicine is becoming mainstream. We suspect future generations will term lifestyle medicine, as simply ‘medicine’.