LIFESTYLE MEDICINE – THE NEXT BIG THING?

By Prakhar Srivastava

4TH YEAR MEDICAL STUDENT, UNIVERSITY OF MANCHESTER WORD COUNT = 1500 (EXCLUDING REFERENCES)

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Lifestyle, health and the NHS

Lifestyle is defined as, “the way in which a person lives” (1). This is wonderfully ambiguous

and suggests that everyone is unique. Unfortunately, the luxuries of modern life have led to

maladaptive behaviours becoming extraordinarily commonplace such as smoking, alcohol

consumption, stress, sleep deprivation, inactivity, dietary imbalance and social isolation and it

is no secret that these factors are determinants of major chronic conditions (Table 1) (2). Many

of these behaviours are already being tackled at a public health level, from gruesome

advertising requirements for tobacco, the formation of DrinkAware and more recently, a

Cancer Research UK driven awareness campaign on the links between obesity and cancer.

However, many believe there is a deeper opportunity for using lifestyle interventions as the

primary means of treating and even reversing the chronic conditions which plague our times.

In 2014, the World Health Organisation (WHO), reported that the percentage of deaths

attributed to chronic non-communicable diseases (NCDs) in the United Kingdom (UK) was a

startling 89% (Figure 1) (3). Whilst this statistic is a testament to improvements in hygiene,

vaccination programs and acute injury management, it suggests that our National Health

Service (NHS) needs to evolve to tackle modern afflictions. Unfortunately, the NHS is

struggling in this regard. Approximately 15 million people in England have at least one chronic

disease and approximately 70% of the NHS Primary and Acute Care budget is spent treating

these conditions (4). Given that the NHS is facing an unprecedented level of financial pressure

(5), finding solutions which are affordable, efficacious and easy for individuals to access is

critical. Influencing population lifestyle choices might be the only economically sustainable

solution.

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Figure 1 – [a] Causes of mortality in the UK; [b] Stratification of NCDs in the UK.

*Cardiovascular diseases primarily refer to coronary artery disease, cerebrovascular

disease (stroke) and rheumatic heart disease (3).

[a]

[b]

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Risk Factor Heart Disease Stroke Cancer CLDs* Diabetes

Tobacco ✓ ✓ ✓ ✓ ✓

Poor Diet ✓ ✓ ✓

✓

Inactivity ✓ ✓ ✓

✓

BMI > 25 ✓ ✓ ✓

✓

Alcohol Consumption

✓ ✓

Defining Lifestyle Medicine

The connection between lifestyle and health can be traced back to the father of modern

medicine, Hippocrates, who is famously quoted as saying, “Let food be thy medicine, and

medicine be thy food,” and, “walking is man’s best medicine”. Today, the Lifestyle Medicine

organisations across the world have expanded on those ancient Greek principles and the

concept of Lifestyle Medicine (LM) can be distilled into the following:

“An evidence based approach in which comprehensive lifestyle changes (including nutrition,

physical activity, sleep, stress management, social support and tobacco/alcohol/drug

limitation) are used to prevent, treat and reverse the progression of chronic disease, by

addressing their underlying causes, whilst promoting self-management” (6, 7).

It is worth elaborating on the evidence base for LM. There is an abundance of data which

identifies lifestyle choices as a major determinant of disease and a growing collection of

evidence which demonstrates the efficacy of lifestyle interventions as a primary treatment for

disease and on occasion, a facilitator of disease reversal. Capturing the scope of evidence

relevant to LM can be difficult, but a selection of research findings can be seen in figure 2.

Table 1 –Lifestyle choices as determinants of chronic conditions (2). *CLDs = chronic lung

diseases.

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Figure 2 – A selection of findings which demonstrate the scope of lifestyle driven

consequences and the breadth of reported benefits of lifestyle interventions.

The COST of lifestyle choices

The PROMISE of lifestyle-interventions

Diabetes costs the NHS £10 billion per year, is the leading cause of blindness in those of working age and results in over 100 amputations per

week. (8)

Sleep deprivation costs up to £40 billion per year to the British Economy (11)

Sitting for >6 hours/day is associated with 94% and 48% increases in relative mortality for women and men respectively (10)

Cardiovascular diseases affects 7 million people in the UK and there are 545 heart attacks daily (9)

Lifestyle interventions can reverse coronary artery disease (12, 13), have been demonstrated to reduce stroke risk (14) and are associated with a

significantly lower incidence of cancer (15)

A low-fat vegan diet can improve glycaemic and lipid control (16) in type 2 diabetics and comprehensive lifestyle interventions can induce partial

remission of disease (17)

Lifestyle interventions can maintain or even improve cognitive function in the elderly (18, 19)

Lifestyle interventions can promote telomere lengthening – a potential anti-aging effect (21)

A crucial function of sleep is to facilitate removal of degradation products from neural activity which accumulate during waking (20)

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Do clinicians have the time and expertise to utilise such a diverse range of

interventions?

On face value, the notion that a single doctor could ever adequately assess a patient’s lifestyle,

suggest appropriate interventions and monitor their effects, whilst also managing any disease,

seems nonsensical when considering the 10-minute timeframe which General Practitioners

(GPs) are pressured to function within. In fact, no single healthcare professional can

independently practice LM but rather, a diverse team is a necessity, with doctors, nurses,

dieticians, exercise physiologists, physiotherapists and psychologists each performing their

roles with a GP pulling the strings. Furthermore, if LM delivers on its promise of large-scale

reduction in chronic disease burden, the NHS would be rewarded with time, money and

manpower to tackle the issues that remain.

Regarding the level of expertise in LM, the current circumstances are mixed. Whilst the

General Medical Council (GMC) dedicates a chapter to Health Promotion and Illness

Prevention in their 2018 Outcomes for Graduates publication, they don’t mention the use of

lifestyle interventions as a primary treatment (22). Furthermore, most senior doctors qualified

years if not decades ago, when such guidelines were not in place. However, a defining feature

of the healthcare professions is the commitment to lifelong learning and one doesn’t need to

look far to find doctors who are leading the way. From Dr Rob Lawson who heads the British

Society of Lifestyle Medicine (BSLM), BBC’s Doctor in the House, Dr Rangan Chatterjee, or

Dr Rupy Aujla who runs The Doctor’s Kitchen website and envisages a day where each GP

surgery is affiliated with a community kitchen. These healthcare innovators are inspiring a

generation of doctors to embrace the LM philosophy and for current doctors who feel ill-

equipped, reforms to education are beginning to surface. The Royal College of GPs now

approve LM courses delivered by the BSLM and Lobe Medical and work on a culinary

medicine course by The Doctor’s Kitchen is in progress too. With time, these educational

opportunities are sure to multiply and flourish.

Should NHS clinicians be looking outside the orthodox, western, biomedical model for

therapists to refer to?

On the NHS Choices website, there is a webpage dedicated to “Complementary and

Alternative Medicines” (CAMs), but in principle, these therapies are not lifestyle interventions.

On the other hand, the concept of “Social Prescribing” (SP) embodies the philosophy of LM

perfectly. SP describes the referral of patients from primary care to local, non-clinical services

such as voluntary or community sector organisations which can help GPs identify new life

opportunities which cater to the increasingly complex needs of patients (24). For example, a

GP might want to address a patient’s inactivity and their feeling of social isolation and to find

a solution, they refer to an SP scheme which can help direct the patient to suitable local

opportunities such as sports groups, walking clubs or dancing classes.

Implementation of SP schemes is limited, but reported patient benefits include reduced

anxiety, higher quality of life and fewer GP attendances, emergency department visits and

hospital admissions (25, 26). Unfortunately, most studies related to SP are small in scale,

conducted without the use of control groups and rely on self-reported outcomes. After

examining the evidence base for SP, the University of York’s Centre for Reviews and

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Dissemination concluded that there is insufficient data to suggest that SP is either efficacious

or cost-effective (27). However, others argue that such findings are unsurprising because SP

schemes aim to provide benefit over much larger time-scales and the breadth of benefits can

be difficult to measure (24). Constructing an evidence-based case will require several long-

term and comparative schemes to be implemented across the UK. Despite these challenges,

NHS England include the principles of social prescribing and the role of local non-clinical

services in both the NHS Five Year Forward View and the GP Forward View publications (28,

29).

Conclusion

To transition from a reactionary, pill-based approach, to a pro-active and lifestyle focused

philosophy, will be time-consuming, challenging and subject to intense scrutiny. Nonetheless,

convention has led to our population living longer but not necessarily better, with the time

spent with injury or illness rising alongside life expectancy (30). We can continue to medicalise

all health conditions or recognise that many ailments can be resolved, with the use of social

capital and lifestyle modifications alone. The case for the adoption of lifestyle medicine has

never been stronger and the future of the NHS might depend on its implementation.

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References

1. Lifestyle | Definition of lifestyle in English by Oxford Dictionaries [Internet]. Oxford

Dictionaries | English. 2018 [cited 30 June 2018]. Available from:

https://en.oxforddictionaries.com/definition/lifestyle

2. Kushner R, Mechanick J. Lifestyle Medicine—An Emerging New Discipline. US

Endocrinology. 2015;11(01):36.

3. World Health Organisation. Noncommunicable Diseases (NCD) Country Profiles

[Internet]. 2014. Available from: http://www.who.int/nmh/countries/gbr_en.pdf

4. Department of Health. Long Term Conditions Compendium of Information: 3rd

Edition [Internet]. 2012. Available from:

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ent_data/file/216528/dh_134486.pdf

5. The King's Fund. Understanding NHS Financial Pressures: how are they affecting

patient care? [Internet]. 2015. Available from:

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ng%20NHS%20financial%20pressures%20-%20full%20report.pdf

6. Sagner M, Katz D, Egger G, Lianov L, Schulz K, Braman M et al. Lifestyle medicine

potential for reversing a world of chronic disease epidemics: from cell to community.

International Journal of Clinical Practice. 2014;68(11):1289-1292.

7. Egger G, Binns A, Rossner S. The emergence of "lifstyle medicine" as a structured

approach for management of chronic disease. 2009.

8. Diabetes UK. The Cost of Diabetes: Report [Internet]. 2014. Available from:

https://www.diabetes.org.uk/resources-s3/2017-

11/diabetes%20uk%20cost%20of%20diabetes%20report.pdf

9. British Heart Foundation. BHF CVD Statistics Factsheet: UK [Internet]. 2018.

Available from: https://www.bhf.org.uk/research/heart-statistics

10. Patel A, Bernstein L, Deka A, Feigelson H, Campbell P, Gapstur S et al. Leisure

Time Spent Sitting in Relation to Total Mortality in a Prospective Cohort of US Adults.

American Journal of Epidemiology. 2010;172(4):419-429.

11. Hafner M, Troxel W, Stepanek M, Taylor J, Van Stolk C. WHY SLEEP MATTERS:

THE MACROECONOMIC COSTS OF INSUFFICIENT SLEEP. Sleep.

2017;40(suppl_1):A297-A297.

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12. Ornish D, Brown S, Billings J, Scherwitz L, Armstrong W, Ports T et al. Can lifestyle

changes reverse coronary heart disease?. The Lancet. 1990;336(8708):129-133.

13. Ornish D. Intensive Lifestyle Changes for Reversal of Coronary Heart Disease.

JAMA. 1998;280(23):2001.

14. Galimanis A, Mono M, Arnold M, Nedeltchev K, Mattle H. Lifestyle and stroke risk: a

review. Current Opinion in Neurology. 2009;22(1):60-68.

15. Ford E, Bergmann M, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy Living

Is the Best Revenge: findings from the European Prospective Investigation into

Cancer and Nutrition-Potsdam study. Archives of Internal Medicine.

2009;169(15):1355.

16. Barnard N, Cohen J, Jenkins D, Turner-McGrievy G, Gloede L, Jaster B et al. A Low-

Fat Vegan Diet Improves Glycemic Control and Cardiovascular Risk Factors in a

Randomized Clinical Trial in Individuals With Type 2 Diabetes. Diabetes Care.

2006;29(8):1777-1783.

17. Gregg E, Chen H, Wagenknecht L, Clark J, Delahanty L, Bantle J et al. Association

of an Intensive Lifestyle Intervention With Remission of Type 2 Diabetes. JAMA.

2012;308(23):2489.

18. Ngandu T, Lehtisalo J, Solomon A, Levälahti E, Ahtiluoto S, Antikainen R et al. A 2

year multidomain intervention of diet, exercise, cognitive training, and vascular risk

monitoring versus control to prevent cognitive decline in at-risk elderly people

(FINGER): a randomised controlled trial. The Lancet. 2015;385(9984):2255-2263.

19. Small B, Dixon R, McArdle J, Grimm K. Do changes in lifestyle engagement

moderate cognitive decline in normal aging? Evidence from the Victoria Longitudinal

Study. Neuropsychology. 2012;26(2):144-155.

20. Xie L, Kang H, Xu Q, Chen M, Liao Y, Thiyagarajan M et al. Sleep Drives Metabolite

Clearance from the Adult Brain. Science. 2013;342(6156):373-377.

21. Ornish D, Lin J, Chan J, Epel E, Kemp C, Weidner G et al. Effect of comprehensive

lifestyle changes on telomerase activity and telomere length in men with biopsy-

proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study. The

Lancet Oncology. 2013;14(11):1112-1120.

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22. General Medical Council. Outcomes for Graduates [Internet]. 2018. Available from:

https://www.gmc-uk.org/-/media/documents/dc11326-outcomes-for-graduates-

2018_pdf-75040796.pdf

23. NHS Choices. Complementary and alternative medicine [Internet]. nhs.uk. 2018

[cited 30 June 2018]. Available from: https://www.nhs.uk/conditions/complementary-

and-alternative-medicine/

24. Brandling J, House W. Social prescribing in general practice: adding meaning to

medicine. British Journal of General Practice. 2009;59(563):454-456.

25. Kimberlee R. Developing a social prescribing approach for Bristol. Project Report.

[Internet]. University of the West of England; 2013. Available from:

http://eprints.uwe.ac.uk/23221/1/Social%20Prescribing%20Report-final.pdf

26. Dayson C, Bashir N. The social and economic impact of the Rotherham Social

Prescribing Pilot [Internet]. Sheffield Hallam University, Centre for Regional

Economic and Social Research; 2014. Available from:

https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/social-economic-impact-

rotherham.pdf

27. The University of York, Centre for Reviews and Dissemination. Evidence to inform

the commissioning of social prescribing [Internet]. 2015. Available from:

https://www.york.ac.uk/media/crd/Ev%20briefing_social_prescribing.pdf

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29. NHS England. General Practice Forward View [Internet]. 2016. Available from:

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30. Lim S, Vos T, Flaxman A, Danaei G, Shibuya K, Adair-Rohani H et al. A comparative

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of Disease Study 2010. The Lancet. 2012;380(9859):2224-2260.

Felicity Allman Michael Pittilo Student Essay Prize 2018

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Can lifestyle medicine save the NHS? This essay considers the potential impact of an enhanced focus on lifestyle medicine in the National Health Service (NHS) and the UK more generally. It defines lifestyle medicine; considers the role of the expert patient and how peer support, motivational interviewing and tailored lifestyle prescriptions can support self-management; and discusses damaged patient-practitioner relationships that could be enhanced by the introduction of lifestyle medicine in the NHS. Defining lifestyle medicine There is an argument that, if 10% of disease risk is genetic, then the other 90% is the result of lifestyle choices (Panja & Chatterjee, 2017), indicating that lifestyle medicine could significantly reduce the national burden of disease. The negative consequences of poor lifestyle choices are the leading cause of mortality (Sagner et al., 2014) and account for the vast majority of primary care appointments in the developed world (Egger et al., 2009). Prevention of these issues is cheaper than cure (Chatterjee, 2017), and fits into four categories: food, movement, sleep, rest (Panja & Chatterjee, 2017), with reduced alcohol and tobacco consumption (Lianov & Johnson, 2010) as well as social interaction (Sarris et al., 2014) sometimes included. These interventions are effective for preventing, treating and reversing many of the highly prevalent and rapidly increasing chronic conditions (Hyman et al., 2009; Sagner et al., 2014). Overweight, inactivity, insomnia, stress and substance misuse contribute to low-level bodily inflammation (Sagner et al., 2014) and affect gene expression (Hyman et al., 2009), both of which lead to chronic conditions. In addressing these conditions, lifestyle medicine promotes healthy longevity and therefore dignity in death, addressing not only our health, but our humanity (British Society of Lifestyle Medicine, 2018). Expert patients Debate exists over whether placing these preventative powers into the hands of patients is truly an empowerment of the individual (Wilson, 2001). The expert patient came into official use in the UK with the publication of Saving lives: Our healthier nation (Department of Health, 1999). This policy document supported individual responsibility for improving and maintaining health, via public health initiatives and primary care trusts. These are the domains of nurses and general practitioners, now arguably the most overstretched members of the NHS workforce (House of Commons Health Committee, 2018; Iacobucci, 2018), and those who stand to benefit most from enhanced lifestyle medicine. Indeed, it was a nurse – Prof Kate Lorig – who drove the evidence base for patient engagement in chronic disease management (Greenhalgh, 2009; Lorig et al., 1999; etc.), from which the expert patient was born. However, Saving lives appears to be based more on an ideology of inclusivity than an evidence base (Griffiths et al., 2007). Self-management in lifestyle medicine is perceived by some as traditional biomedicine masquerading as holism (Greenhalgh, 2009): complete the tasks, feel the results. A model that views humans as econs (Kahneman, 2011; Thaler & Sunstein, 2008), rational being who will only ever act in a goal-oriented way for their best interests and will not struggle with motivation (Kralik et al., 2004; Tattersall, 2002) will never be practicable or sustainable. Furthermore, a model that suggests that these rational beings are able to intellectually cut through swathes of misinformation (Glass & McAtee, 2006), running counter to commercial interests (Sagner et al., 2014) is simply irrelevant.

Felicity Allman Michael Pittilo Student Essay Prize 2018

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There are three key ways to translate the theory of self-management into practice. Firstly, given that lifestyle medicine struggles to offer a means of coping with life with a chronic disease (Mol, 2008), this gap is often plugged by peer support (Greenhalgh, 2009), making use of the NHS’s most valuable and underused resource (Basset et al., 2010). This was recognised in The expert patient’s (Department of Health, 2001) conception of a user-led NHS, where these human issues would be considered at service development level (Tattersall, 2002), a sort of preventative peer support. Secondly, as financial support for this type of systemic change has not been made available (Glass & McAtee, 2006; Tattersall, 2002), motivational interviewing must be introduced into undergraduate medical education (Egger et al., 2009; Sagner et al., 2014; Phillips et al., 2015) to reduce the financial strain on the NHS while still providing methods of promoting behaviour change. Finally, lifestyle prescriptions must be tailored, as with any other prescription (Hyman et al., 2009), to ensure that people are not led astray in their efforts by poorly researched websites and magazines. Repairing damaged relationships Beyond financial resources – and for the benefit of peer support, motivational interviewing, or tailored prescriptions –a ‘sea change in attitudes’ of patients and professionals is required (Tattersall, 2002, 229; Coulter, 1999). There is a patriarchal hangover in the NHS that extends beyond patient-practitioner relationships and into multidisciplinary hierarchies (McKay & Narasimhan, 2012; Sweet, 1995; Carter, 1994), and doctors’ mistrust those with chronic conditions to self-manage effectively (Griffiths et al., 2001; Coulter et al., 1994). The expertise of lived experience barely overlapping with the expertise of professional experience (Coulter, 1999; Tang & Anderson, 1999), but as longer lives increase the prevalence of chronic illness (DH, 1999), professional experts are recognising the need for expert patients to bear part of the burden. Definitions of chronic illness and disability generally imply medical dependence (Hughes, 1998; Bury, 1997), feeding a patronising conception of the expert patient (Coulter, 1999). This also contributes to individual adoption of a sick role identity, which further increases dependence and reduces self-efficacy (Baker & Stern, 1993). To be an authentic expert patient is to extricate oneself from this dependence and empower oneself to take responsibility for personal health and lifestyle needs (Rapley & Fruin, 1999). People with chronic conditions are not sick, but survivors (Kralik et al., 2010; Baker & Stern, 1993). In this way, lifestyle medicine is the meeting point of traditional biomedical expertise and experiential expertise. Lifestyle medicine and patient expertise is also a way of redressing the power imbalance within the NHS (Coulter, 1999), although arguably only at a superficial level. For instance, a person with a chronic condition who adheres to a self-management programme is still complying with a prescribed regimen (Thorne et al., 2000), and the power lies with the doctor to label the person noncompliant with no reciprocal power on the part of the patient (Porter, 1998), even when medical support is insufficient (Lianov & Johnson, 2010). If the prescriber is motivated by reducing financial and time pressures on the NHS, the Expert Patient programme becomes less about a transfer of power and more about a simple ‘discharge with advice’ for professionals (Wilson, 2001). Furthermore, this imperative on individual responsibility smacks of the ‘victim blaming’ culture of years past (Watt, 2007; Crawford, 1977). This reduces lifestyle medicine to an ultimatum: follow the rules and be well or ignore them and suffer. The NHS has adopted a focus on patient education, although education is inadequate by itself (Kralik et al., 2010; Thorne et al., 2000; Lorig et al., 1993). The fact that healthcare and medicine may be demystified by these education efforts goes at least some way towards dethroning the doctor-god (Osmond,

Felicity Allman Michael Pittilo Student Essay Prize 2018

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1980), who frequently withholds crucial illness information and treatment options, thus blocking patient autonomy through medical mistrust (Thorne et al., 2000).

There is a perception that doctors don’t ‘do’ lifestyle medicine even though health behaviour changes (like wearing seatbelts and applying sunscreen) have improved or saved countless lives (Hyman et al., 2009). As a form of medicine, the evidence base exists for lifestyle modifications in reducing blood pressure (Appel et al., 2003), preventing type 2 diabetes (Lindström et al., 2003), improving outcomes in metabolic syndrome (Bo et al., 2007) and more. The evidence base for lifestyle medicine in mental health is also evolving (Sarris et al., 2014). Chronic care and public health are still largely the domain of nurses (Carter, 1994), who are increasingly trained in promoting individual choice and autonomy (NMC, 2015). However, nurses themselves lack power within the greater NHS hierarchy, even as they are recognised as authorities by patients (Hewison, 1995; Davies, 1995) and acknowledge limiting options for patients (Wilkinson, 1999; Wilson, 2002). There is a huge benefit in community nursing those with chronic conditions, where the power is undeniably shifted back to the patient (Millard et al., 2006). A person’s home is a space in which people may interact further outside the medical sphere than in a hospital setting, and a shared humanity can be recognised. This is the magic ingredient in curing the NHS, because it is within this reciprocal humanity that compassion and communication lie (Bailey, 2009; NHS England, 2012). Even though some feel uncomfortable with the clinical gaze extending into the person’s home (Wilkinson, 1999), without compassion and communication – between nurses and doctors or patients – incidents like those at Mid Staffs occur (Healthcare Commission, 2009). Therefore, any method of enhancing communication and compassion benefits patients and practitioners, and fixes these crucial relationships that have been damaged by the remnants of a former patriarchy (Carter, 1994), thus saving the NHS. Lifestyle medicine holds the key to a collaborative and equal National Health Service. This essay defined lifestyle medicine; discussed perceptions of the expert patient and self-management of chronic conditions (enhanced by peer support, motivational interviewing, and tailored lifestyle prescriptions); and considered power imbalances within and between patients and healthcare professionals. Lifestyle medicine has the potential to move the NHS further from its patriarchal and paternalistic roots to promote quality of life, healthy longevity, and individual empowerment.

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References Appel, L.J., Champagne, C.M., Harsha, D.W., et al. (2003) ‘Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial’, Journal of the American Medical Association, 289(16), 2083-93. Bailey, J. (2009) Cure the NHS’s blueprint for a new NHS. Available at: http://www.curethenhs.co.uk/wp-content/uploads/2012/10/Blueprint-for-the-NHS.pdf (Accessed: 25 June 2018). Baker, C. & Stern, P.N. (1993) ‘Finding meaning in chronic illness as the key to self care’, Canadian Journal of Nursing Research, 25(2), 23-26. Basset, T., Faulkner, A., Repper, J., & Stamou, E. (2010) Lived experience leading the way: peer support in mental health. Available at: http://www.together-uk.org/wp-content/uploads/downloads/2011/11/livedexperiencereport.pdf (Accessed: 10 May 2018). Bo, S., Ciccone, G., Baldi, C., et al. (2007) ‘Effectiveness of a lifestyle intervention on metabolic syndrome: a randomised controlled trial’, Journal of General Internal Medicine, 22(12), 1695-1703. British Society of Lifestyle Medicine (2018) About BSLM: Energising, reframing healthcare and bringing optimism. Available at: https://bslm.org.uk/about/ (Accessed: 24 June 2018). Bury, M. (1997) Health and illness in a changing society. Routledge: London. Carter, H. (1994) ‘Confronting patriarchal attitudes in the fight for professionals recognition’, Journal of Advanced Nursing, 19(2), 367-372. Chatterjee, R. (2017) Is lifestyle medicine the only way to save the NHS? Available at: https://drchatterjee.com/video-is-lifestyle-medicine-the-only-way-to-save-the-nhs/ (Accessed: 24 June 2018). Coulter, A. (1999) ‘Paternalism or partnership? Patients have grown up – and there’s no going back’, British Medical Journal, 319(7212), 719-720. Coulter, A., Peto, V., & Doll, H. (1994) ‘Patients’ preferences and general practitioners’ decisions in treatment of menstrual disorders’, Family Practice, 11, 67-74. Crawford, R. (1977) ‘You are dangerous to your health: the ideology and politics of victim blaming’, International Journal of Health Services, 7(4), 663-680. Davies, C. (1995) Gender and the professional predicament in nursing. Open University Press: Buckingham. Department of Health (1999) Saving lives: Our healthier nation. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/265576/4386.pdf (Accessed: 24 June 2018).

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Department of Health (2001) The expert patient: a new approach to chronic disease management for the twenty-first century. Available at: http://webarchive.nationalarchives.gov.uk/20120511062115/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4018578.pdf (Accessed: 25 June 2018). Egger, G.J., Binns, A.F., & Rossner, S.R. (2009) ‘The emergence of “lifestyle medicine” as a structured approach for management of chronic disease’, Medical Journal of Australia, 190, 143-145. Glass, T.A. & McAtee, M.J. (2006) ‘Behavioural science at the crossroads in public health: extending horizons, envisioning the future’, Social Science & Medicine, 62(7), 1650-71. Greenhalgh, T. (2009) ‘Chronic illness: Beyond the expert patient’, British Medical Journal, 338, 629-631. Griffiths, C., Foster, G., Ramsay, J., Eldridge, T. & Taylor, S. (2007) ‘How effective are expert patient (aly ed) education programmes for chronic disease? British Medical Journal, 334(7606), 1254-6. Griffiths, C., Kaur, G., Gantley, M., et al. (2001) ‘Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study’, British Medical Journal, 323(7319), 962-6. Healthcare Commission (2009) Investigation into Mid Staffordshire NHS Foundation Trust: Summary report. Available at: http://image.guardian.co.uk/sys-files/Guardian/documents/2009/03/17/Investigation_into_Mid_Staffordshire_NHS_Foundation_Trust_Summary.pdf (Accessed: 25 June 2018). Hewison, A. (1995) ‘Nurses’ power in interactions with patients’, Journal of Advanced Nursing, 21(1), 75-82. House of Commons Health Committee (2018) The nursing workforce: Second report of session 2017-19. Available at: https://publications.parliament.uk/pa/cm201719/ cmselect/cmhealth/353/353.pdf (Accessed: 26 June 2018). Hughes, G. (1998) ‘A suitable case for treatment? Constructions of disability’. In Saraga, E. (ed.), Embodying the Social: Constructions of Difference, 53-90. Routledge: London. Hyman, M.A., Ornish, D. & Roizen, M. (2009) ‘Lifestyle medicine: Treating the causes of disease’, Alternative Therapy Health Med, 15(6), 12-14. Iacobucci, G. (2018) ‘“Exploited” doctors are keeping overstretched NHS going, says GP leader’, British Medical Journal, 360, k1136. Kahneman, D. (2011) Thinking, Fast and Slow. Allen Lane: London. Kralik, D., Koch, T., Price, K. & Howard, N. (2004) ‘Chronic illness self-management: taking action to create order’, Journal of Clinical Nursing, 13(2), 259-67.

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Kralik, D., Price, K. & Telford, K. (2010) ‘The meaning of self-care for people with chronic illness’, Journal of Nursing and Healthcare of Chronic Illness, 2, 197-204. Lianov, L. & Johnson, M. (2010) ‘Physician competencies for prescribing lifestyle medicine’, Journal of the American Medical Association, 304(2), 202-3. Lindström, J., Louheranta, A., Mannelin, M., et al. (2003) ‘The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity’, Diabetes Care, 26(12), 3230-6. Lorig, K.R., Sobel, D.S., Stewart, A.L. et al. (1999) ‘Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalisation: a randomised trial’, Medical Care, 37(1), 5-14. Lorig, K.R, Mazonson, P.D., & Holman, H.R. (1993) ‘Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs’, Arthritis & Rheumatology, 36(4), 439-46. McKay, K.A. & Narasimhan, S. (2012) ‘Bridging the gap between doctors and nurses’, Journal of Nursing Education and Practice, 2(4), 52-55. Millard, L., Hallett, C. & Luker, K. (2006) ‘Nurse-patient interaction and decision-making in care: patient involvement in community nursing’, Journal of Advanced Nursing, 55(2), 142-150. Mol, A. (2008) The logic of care: health and the problem of patient choice. London: Routledge. NHS England (2012) Compassion in practice: Nursing, midwifery and care staff – Our vision and strategy. Available at: https://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf (Accessed: 25 June 2018). Nursing and Midwifery Council (2015) The code: Professional standards of practice and behaviour for nurses and midwives. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf (Accessed: 25 June 2018). Osmond, H. (1980) ‘God and the doctor’, New England Journal of Medicine, 6(10), 555-8. Panja, A. & Chatterjee, R. (2017) ‘Lifestyle medicine’ could revolutionise patient care. Available at: http://www.pulsetoday.co.uk/clinical/diabetes/lifestyle-medicine-could-revolutionise-patient-care/20035520.article (Accessed: 24 June 2018). Phillips, E., Pojednic, R., Polak, R., Bush, J. & Trilk, J. (2015) ‘Including lifestyle medicine in undergraduate medical curricula’, Medical Education Online, 20(1), 1-4. Porter, S. (1998) Social theory and nursing practice. Macmillan: Basingstoke.

Felicity Allman Michael Pittilo Student Essay Prize 2018

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Rapley, P. & Fruin, D.J. (1999) ‘Self-efficacy in chronic illness: The juxtaposition of general and regimen-specific efficacy’, International Journal of Nursing Practice, 5(4), 209-215. Sagner, M., Katz, D., Egger, G., et al. (2014) ‘Lifestyle medicine potential for reversing a world of chronic disease epidemics: from cell to community’, International Journal of Clinical Practice, 68(11), 1289-1292. Sarris, J., O’Neill, A., Coulson, C.E., Schweitzer, I. & Berk, M. (2014) ‘Lifestyle medicine for depression’, BMC Psychiatry, 14, 107-120. Sweet, S.J. (1995) ‘The nurse-doctor relationship: a selective literature review’, Journal of Advanced Nursing, 22(1), 165-170. Tang, S.Y.S. & Anderson, J.M. (1999) ‘Human agency and the process of healing: lessons learned from women living with chronic illness – ‘re-writing the expert’, Nursing Inquiry, 6, 83-93. Tattersall, R. (2002) ‘The expert patient: a new approach to chronic disease management for the twenty-first century’, Clinical Medicine, 2(3), 227-229. Thaler, R.H. & Sunstein, C.R. (2008) Nudge: Improving decisions about health, wealth and happiness. Yale University Press: New Haven, Ct. Thorne, S.E., Ternulf Nyhlin, K., & Paterson, B.L. (2000) ‘Attitudes toward patient expertise in chronic illness’, International Journal of Nursing Studies, 37(4), 303-311. Watt, R.G. (2007) ‘From victim blaming to upstream action: tackling the social determinants of oral health inequalities’, Community Dentistry and Oral Epidemiology, 35(1), 1-11. Wilkinson, G. (1999) ‘Theories of power’, in Wilkinson, G. & Miers, M. (eds.), Power and Nursing Practice, 7-23. Macmillian: Basingstoke. Wilson, P.M. (2001) ‘A policy analysis of the Expert Patient in the United Kingdom: self-care as an expression of pastoral power?’, Health and social care in the community, 9(3), 134-142.