Undertaking an extended role in lifestyle medicine

Delivery of care is achieved through:

• Comprehensive and holistic assessments of relationships/social isolation, mental wellbeing, sleep quality, physical activity, sedentary behaviour, nutrition and harmful substances and behaviours whilst accounting for socio-economic determinants of health, through a targeted lifestyle history and a clinical assessment of lifestyle factors.
• Using a whole person (biopsychosocial) approach which offers all treatment options including support for lifestyle change alongside medications or surgery where appropriate.
• Multidisciplinary team working including person-centred assessments and shared decision-making to support behaviour change and work with patients to create their own goals. This can be done in chronic disease reviews lead by primary care nurses, with additional primary care roles such as health coaches, social prescribing link workers, first contact dieticians and physiotherapists, pharmacists and mental health workers.
• The use of group care such as group consultations, group clinics, shared medical appointments, group medical care for example where patients are brought together by a trained facilitator and/or educator to explore people’s key concerns and questions, followed by a shared consultation with a clinician and often a wrap-up with goal setting and signposting to further support (see use of group consultations, group clinics and group education by GPwERLM).
• Careful medication review including down-titration and deprescribing where lifestyle changes have treated or put into remission long-term conditions previously treated with medications.
• Managerial skills/supervision/mentoring of the MDT roles that may be needed in lifestyle medicine practice (see supervising and mentoring the MDT roles required for lifestyle medicine practice).

Delivery of lifestyle medicine does not usually involve additional risk factor testing other than that usually required in primary care nor the prescription of nutritional supplements – most micronutrients can be obtained from whole foods. Lifestyle medicine is a low-tech approach to health.

A patient’s own goals and preferences for care form the basis for consultations using lifestyle medicine. 

An assessment of the six pillars of lifestyle medicine would usually be required, and may include assessment and support around:

1. Mental wellbeing: assessment of mental wellbeing from a positive psychology approach including aspects such as meaning, engagement, achievement and purpose in life as well as the presence of mental illness. An assessment of psychological stressors and exploration of the person’s own methods to manage stress whilst exploring additional relaxation methods such as access to time in nature, breathing techniques, meditation and yoga.
2. Healthy relationships: assessment of the social structures around an individual, the depth and quality of these relationships and how to strengthen them. Purpose in life and community involvement have been shown to be potent drivers of good health.
3. Healthy eating: nutrition assessments (see tools for assessing pillars of lifestyle medicine) to assess food quality and timing and compare this to the latest nutrition evidence. Giving specific and personalised advice around healthy dietary patterns of the patient’s own choosing (for example a Mediterranean diet, a plant-based diet, a low carbohydrate diet etc.) and where appropriate and safe, a reduction in snacking and the use of therapeutic intermittent fasting. Deprescribing where required, following intensive nutritional changes for example the down-titration of insulin, hypoglycaemic and hypotensive agents that can be harmful if blood sugar and blood pressure have normalised following a lifestyle intervention such as nutritional changes.
4. Physical activity: assessment of physical activity (see tools for assessing pillars of lifestyle medicine) and sedentary time. Personalised goal setting and support to increase activity and reduce time spent sitting. Assessment of falls risks and health assessments prior to embarking on physical activity programmes. Personalised advice on specific types of activity appropriate to the life-stage e.g. balance, flexibility, high-impact cardio and strength training.
5. Minimising harmful substances: assessment of nicotine, caffeine, alcohol, recreational drug consumption. Other addictions of relevance include gambling, technology, and social media. Support offered to reduce the harms of these behaviours and avoid their use when needed.  It is also an opportunity to assess exposure to air pollution and endocrine disruptors.
6. Sleep: assessment of sleep quality and identification of common sleep disorders. Support to prioritise sleep as part of healthy living as well as increasing sleep quality. 

People with long-term conditions

Lifestyle medicine is relevant to all populations, but particularly important for those living with long-term conditions such a mental illness, Type 2 diabetes, obesity, hypertension, autoimmune conditions, dementia and cancer. 

People living in more socio-economically deprived communities 

A GPwERLM will be able to deliver personalised support tailored to the challenges in people’s lives. A GP with these additional skills may be more likely to reduce the harms of polypharmacy for this group who are more likely to experience polypharmacy. Lifestyle medicine interventions are important and effective in deprived populations (see use of group consultations, group clinics and group education by GPwERLM for examples. 

People with obesity and metabolic disease

Lifestyle medicine will be particularly important in the management of obesity as part of a holistic strategy including as a part of Tier 3 weight management services as described in NICE guidance. 

Supporting peri-operative care

Lifestyle medicine has been successfully used as part of ‘prehabilitation’ prior to surgery to reduce the risks of surgical interventions.

All life stages

Lifestyle medicine is relevant across all life-stages. Young people with obesity and mental illness particularly benefit from early intervention to address nutrition, physical inactivity, the impact of harmful technology, alcohol, smoking and social isolation. Reliance on medication only approaches are particularly risky in this age group due to the long-term need for medications such as anti-depressants whose adverse effects are of greater concern when started earlier.  Lifestyle medicine approaches are also important to support healthy ageing with nutrition, social connection and physical activity critical to reduce frailty. 

• Routine general practice: A GPwERLM can bring their skills to all parts of community care.
• Lifestyle medicine clinics and services: A GPwERLM may support practices across a network or cluster. A GPwERLM may combine routine GP work with the provision of focused lifestyle medicine clinics (either individual or group based) in primary or secondary care setting. Several other health professionals may be included in these clinics including, but not limited to, nurses, health coaches, link workers, physiotherapists, dieticians, nutritionists, exercise professionals and health psychologists (case studies of lifestyle medicine practice).
• Healthcare leadership: A GPwERLM is ideally placed to attend cluster or network meetings of GPs and other health-professionals, local councils, public health and third-sector workers to advise on health care system design that can support healthy lifestyles.
• Training and education: A GPwERLM can address the unmet need for training of future GPs and their team in lifestyle medicine, for example teaching on the GP VTS, GP fellowship schemes, to medical students, allied health and direct to patient groups and schools.
• Community and secondary care long-term condition clinics: Pain clinics, long COVID clinics, metabolic syndrome clinics, etc. A GPwERLM will have the skillset required to act as the prescribing clinician for example in NICE Tier 3 weight management clinics. They can also work with surgical teams to provide peri-operative/rehabilitation clinics.
• Corporate and Trust workplace health and wellness: A GPwERLM may work delivering employment ‘wellness’ interventions or clinics.
• Academic settings: A GPwERLM can work with academic teams to research lifestyle medicine interventions and particularly on how best to translate evidence into practice with well-evaluated pilots.
• Public communication and media settings: A GPwERLM may have the skills to effectively communicate to the public the role of self-care, healthy lifestyles and options beyond pills. This role is increasingly important given the evidence that young people in particular make lifestyle change following information found online. These roles are also needed to counterbalance the poor-quality information often shared by “lifestyle influencers”.
• Policy settings: A GPwERLM may work in an advisory capacity on guideline committees, health boards, advising policymakers, attending All Party Parliamentary Groups etc.

For further case studies describing the work of a GPwERLM, see case studies of lifestyle medicine practice.

Future possible settings

• Precision nutrition/medicine
• Health tech/AI consultant
• Healthy lifespan clinics (healthy ageing/longevity clinics)

Patients are accepted by referral from a variety of sources including GPs, practice nurses, dieticians, physiotherapists, secondary care, voluntary sector, community teams, as well as self-referral or from those caring for them. Depending on the needs of the local community, Lifestyle Medicine GPwER may also decide to accept self-referrals.

The GPwERLM works autonomously as a GP and is appraised covering the full scope of their practice as per the GP appraisal scheme. Additional best-practice governance will vary depending on the organisation delivering the service but a GPwERLM should endeavour to demonstrate that they are keeping their skills and knowledge of Lifestyle Medicine up to date for example by:

• keeping a reflective log of cases where a lifestyle medicine approach was used.
• keeping a record of significant events, complaints and compliments arising in their work as a GPwERLM.
• attending relevant conferences in lifestyle medicine for example in nutrition, physical activity, sleep.
• keeping a record of relevant accreditation and additional qualifications obtained in lifestyle medicine or related fields for example health coaching, psychology, use of group consultations, nutrition, sports and exercise medicine, etc.
• recording teaching given in lifestyle medicine.
• conflicts of interest: a GPwERLM should be mindful of conflicts of interest whilst practising and when writing on the topic of lifestyle medicine. Publicly searchable declarations of interests are advised, for example on Sunshine UK. For further guidance see conflicts of interest on the GMC.

We encourage the use of the terminology ‘GP with extended role in lifestyle medicine’ to offer clarity and standardisation.

A GPwERLM interfaces with:

• GP networks (e.g., clusters or PCNs)
• primary care
• social services
• physiotherapy
• exercise professionals
• dieticians
• nutritionists
• occupational therapy
• pharmacy
• third-party health and well-being providers
• secondary care
• community teams
• voluntary sector
• discharge teams
• nursing home staff
• supported living home staff
• public health
• research and academia
• sport bodies e.g. Swim England, Sport England
• policymakers e.g., Royal Colleges, NICE, All Party Parliamentary Groups, etc

The time commitment for a GPwERLM is flexible, ranging from short interventions to a full-time role, but should remain grounded in the role of a General Practitioner.

A GPwERLM can be employed by a Hospital Trust, Primary Care Network (or equivalent in the devolved nations), commissioners or other service providers. They might also be employed or commissioned by a GP network, hospital trust, leisure centre, corporation or similar. A GPwERLM could be a partner, a salaried GP or locum/sessional GP. Their contract could stipulate that they are a GP employed to provide lifestyle medicine services.