The future of obesity care in the UK will partly be shaped by the National Institute for Health and Care Excellence (NICE) endorsement of semaglutide (Wegovy) to treat obesity in March, 2023. 1 National Institute for Health and Care ExcellenceSemaglutide for managing overweight and obesity. Technology appraisal guidance [TA875]. https://www.nice.org.uk/guidance/ta875Date: March 8, 2023 Date accessed: May 25, 2023 Google Scholar Semaglutide joins another glucagon-like peptide 1 (GLP-1) receptor agonist liraglutide as an obesity treatment, together with behavioural interventions and bariatric surgery. Although semaglutide as an obesity treatment has been hailed as a game changer, 2 Lenharo M Game-changing obesity drugs go mainstream: what scientists are learning. Nature. 2023; (published online May 23.)https://doi.org/10.1038/d41586-023-01712-8 Crossref Scopus (1) Google Scholar the implications of this pharmaceutical focus in obesity management will unfold in UK general practice over the coming months. Lessons can be learnt from the USA, where semaglutide was licensed in 2021 and demand shortly outstripped supply and led to reduced availability of GLP-1 agents licensed for type 2 diabetes. 3 Novo NordiskUpdates about Wegovy. https://www.novonordisk-us.com/products/product-supply-update.htmlDate: May 4, 2023 Date accessed: May 25, 2023 Google Scholar Wegovy also became a popular social media topic involving celebrities, leading Novo Nordisk to respond to criticism about inequitable access and unlicensed use of semaglutide. 4 Goodman B As the market for new weight loss drugs soars, people with diabetes pay the price. CNN, Dec 28, 2022https://edition.cnn.com/2022/12/28/health/weight-loss-diabetes-drug-shortages/index.htmlDate accessed: May 30, 2023 Google Scholar An investigation by The Guardian highlighted similar risky prescribing in the UK, for example, to people with a healthy weight or with previous eating disorders. 5 Davis N Online UK pharmacies prescribing weight loss jabs to people with healthy BMI. The Guardian, May 10, 2023https://www.theguardian.com/society/2023/may/10/online-uk-pharmacies-prescribing-weight-loss-jabs-to-people-with-healthy-bmi-investigationDate accessed: May 25, 2023 Google Scholar There are major challenges for the effective, equitable, safe, and sustainable use of these newer obesity medications in the UK.

Ellen Fallows vice president Mathew describes the overwhelm clinicians feel when seeing patients with many complex conditions who have brough both physical and social problems to a long awaited but short consultation.1 When medical guidelines are viewed in totality, it is clear we can’t see the wood for the trees, have forgotten the person behind the disease, and are failing to tackle the root causes of their symptoms. Basic science now describes a common underlying pathology to long term conditions: immune dysregulation resulting in chronic systemic inflammation.2 The key drivers include environmental and lifestyle factors influencing gene expression and our microbiome. Our current medical model is, however, based on a reductionist and deterministic view of health that stems from the era of gene discoveries. This has led to a belief that diseases exist in isolation and we are powerless withoutmedicine anddrugs. This is not the case. Ifwe stepback from the relentless assessment, quantification, and labelling of disease and spend more time tackling its root causes, we can support people to reverse—or at least improve or delay—these conditions. Fewer guidelines and assessments are needed—as well as more public health measures and more lifestyle medicine. Lifestyle medicine is a discipline that considers the socioeconomic drivers of behaviour, acknowledges the difficulties people face, and uses person centred techniques to support lifestyle changes to tackle nutrition, physical activity, social isolation, sleep, mental wellbeing, and consumption of harmful substances such as tobacco and alcohol.3 This approach isn’t new, nor is it controversial—it is the first step in all major long term condition guidelines. But it is neglected, with funds for creating good quality education and an evidence base sorely lacking and requiring a policy shift. The hardest behaviour to change, however, is not that of patients but that within medicine itself.

British Journal of NursingVol. 32, No. 5 RegularsLifestyle medicine: a modern medical discipline full of optimismEllen Fallows, Alex Maxwell, Rob LawsonEllen FallowsE-mail Address: [email protected]GP and Vice-President, British Society of Lifestyle MedicineSearch for more papers by this author, Alex MaxwellGP and President, British Society of Lifestyle MedicineSearch for more papers by this author, Rob LawsonChair, British Society of Lifestyle MedicineSearch for more papers by this authorEllen Fallows; Alex Maxwell; Rob LawsonPublished Online:13 Mar 2023https://doi.org/10.12968/bjon.2023.32.5.268AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Alegría-Torres JA, Baccarelli A, Bollati V. Epigenetics and lifestyle. Epigenomics. 2011;3(3):267-77. https://doi.org/10.2217/epi.11.22 Crossref, Medline, Google ScholarEgger GBinns ARössner SSagner M (eds). Lifestyle medicine: lifestyle, the environment and preventive medicine in health and disease paperback. London: Academic Press; 2017 Google ScholarFurman D, Campisi J, Verdin E et al.. Chronic inflammation in the etiology of disease across the life span. Nat Med. 2019;25(12):1822-1832. https://doi.org/10.1038/s41591-019-0675-0 Crossref, Medline, Google ScholarJacka FN, O’Neil A, Opie R et al.. A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’ trial). BMC Med. 2017;15(1):23. https://doi.org/10.1186/s12916-017-0791-y Crossref, Medline, Google ScholarJarbøl DE, Larsen PV, Gyrd-Hansen D et al.. Determinants of preferences for lifestyle changes versus medication and beliefs in ability to maintain lifestyle changes. A population-based survey. Prev Med Rep. 2017;6:66–73. https://doi.org/10.1016/j.pmedr.2017.02.010 Crossref, Medline, Google ScholarLean ME, Leslie WS, Barnes AC et al.. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018;391(10120):541-551. https://doi.org/10.1016/S0140-6736(17)33102-1 Crossref, Medline, Google ScholarOrnish D. Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. Am J Cardiol. 1998;82(10B):72T-76T. https://doi.org/10.1016/s0002-9149(98)00744-9 Crossref, Medline, Google ScholarRidge K (chair). Good for you, good for us, good for everybody. A plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions. (The report of the National Overprescrining Rreview.) 2021. https://tinyurl.com/3drvj7hu (accessed 1 March 2023) Google ScholarRodriguez-Castaño GP, Caro-Quintero A, Reyes A, Lizcano F. Advances in gut microbiome research, opening new strategies to cope with a western lifestyle. Front Genet. 2017;7:224. https://doi.org/10.3389/fgene.2016.00224 Crossref, Medline, Google ScholarSaneei P, Salehi-Abargouei A, Esmaillzadeh A, Azadbakht L. Influence of Dietary Approaches to Stop Hypertension (DASH) diet on blood pressure: a systematic review and meta-analysis on randomized controlled trials. Nutr Metab Cardiovasc Dis. 2014;24(12):1253-1261. https://doi.org/10.1016/j.numecd.2014.06.008 Crossref, Medline, Google ScholarSrour B, Kordahi MC, Bonazzi E, Deschasaux-Tanguy M, Touvier M, Chassaing B. Ultra-processed foods and human health: from epidemiological evidence to mechanistic insights. Lancet Gastroenterol Hepatol. 2022;7(12):1128-1140. https://doi.org/10.1016/S2468-1253(22)00169-8 Crossref, Medline, Google ScholarTreadwell JS, Wong G, Milburn-Curtis C, Feakins B, Greenhalgh T. GPs’ understanding of the benefits and harms of treatments for long-term conditions: an online survey. BJGP Open. 2020;4(1):bjgpopen20X101016. https://doi.org/10.3399/bjgpopen20X101016 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 9 March 2023Volume 32Issue 5ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 13 March 2023 Published in print 9 March 2023 Information© MA Healthcare LimitedPDF download

ABSTRACT Our traditional medical mindset and healthcare culture are being severely challenged. In the face of novel infectious diseases, such as Coronavirus 2019 (COVID-19), along with rising levels of chronic diseases, such as obesity, type 2 diabetes mellitus, psychiatric illness, cardiovascular disease and cancer, many argue that current healthcare practices are failing to meet our needs. Energy and vision for a new way of practicing medicine are colliding, from both top-down, driven by policy, and bottom-up, driven by clinicians and patients. Policy makers have laid out the need for integration of healthcare delivery to address the complex chronic disease burden; creating integrated care partnerships, health and wellbeing boards and primary care networks to bring together 'at the place level' primary and secondary care, mental and public health services, social care and the voluntary sector. In practice, this is starting to build lasting working relationships between previously siloed services, to address the complex environmental, social, cultural, lifestyle and biopsychosocial drivers of ill health rather than simply providing access to hospitals, doctors and medication. Similarly, out of frustration with our traditional pharmaceutically driven medical model, grass-roots clinicians have built a new vision for their role in this better integrated health system, with the discipline of lifestyle medicine.

Since early 2020, COVID-19 has dominated headlines, claimed millions of lives, crippled global economies, overwhelmed health services, attracted multi-disciplinary scientific attention and transformed our daily lives. Unsurprisingly, the Lifestyle Medicine field has not been immune to the pandemic's wide-reaching influence. Although COVID-19 highlighted the necessity of maintaining healthy behaviours, the associated lockdowns and social distancing measures challenged our ability to do so. Attempts to mitigate the spread of COVID-19 may, therefore, have exacerbated the obesity pandemic and other diseases associated with unhealthy lifestyle habits. One hopes this devastating virus provides the impetus for policymakers, clinicians and patients to collaborate in tackling the diseases of modern life. This commentary explores how lifestyle-correlated conditions (which are closely intertwined with socioeconomic factors) rendered much of the UK population vulnerable to COVID-19 infection, morbidity and mortality. Subsequently, we consider the impact of lockdown measures on the accessibility of healthy living, focussing on eating behaviours, physical activity, relationships, sleep and substance abuse, as well as the social demographics particularly affected. Approaching the aftermath of this vicious cycle with optimism, we discuss why the post-Covid era presents a unique opportunity for Lifestyle Medicine, as an evidence-based approach to supporting patients to adopt and sustain healthy behaviours.

The transfer of research evidence into practice has been historically slow, and requires an integration of many elements, including quality evidence, supportive physical and intellectual environments, and facilitation, as discussed at the NNEdPro Sixth International Summit on Nutrition and Health. Examples of applying clinical research into practice focused on the use of group consultations (also known as group clinics or shared medical appointments) to support behaviour change, the role of dietary micronutrients during the COVID-19 pandemic and the potential of Precision Nutrition. An emerging area from early implementation evidence includes group consultations, also known as shared medical appointments, as discussed by Dr Fallows. Group consultations have been shown to improve clinical outcomes for some patient groups (e.g., HbA1c, lipids, BMI), as well as improve self-care and health education, and patient and clinician satisfaction. These groups have been piloted throughout the UK both face-to-face and virtually, with initial findings suggesting they are feasible and acceptable to patients and clinicians. Further work is needed to assess whether these could be cost-effective when scaled-up in National Health Service UK primary care. During the COVID-19 pandemic, there has been increasing emphasis on the central role of nutrition in health, including the role of dietary micronutrients, as discussed by Dr Van Dael and Shane McAuliffe. Nutrition plays an important role in immunity, yet the nutritional status of the most vulnerable population groups is likely to deteriorate further due to the health and socio-economic impacts of the novel coronavirus. Thus, implementation of this evidence into health care practice is key. Precision Nutrition, defined as an ‘approach that uses information on individual characteristics to develop targeted nutrition advice, products or services’, offers an exciting opportunity to further individualise dietary advice for behaviour change, as discussed by Dr Kohlmeier and Dr Hernandez. Precision nutrition is underpinned by the recognition that individuals differ in many important ways due to identifiable molecular traits and can be utilised to determine personalised weight loss interventions based on genetic variants. Use of implementation science is in line with one of the six cross-cutting pillars of the Nutrition Decade: Aligned health systems for universal coverage of nutrition actions. Dr Bell, an Advanced Accredited Practising Dietitian in Australia, provided an overview of key implementation science models and frameworks. Implementation frameworks such as the Action Research Framework, the Knowledge to Action Cycle, and the Spread and Sustain Framework, are underpinned by knowledge creation, effective education, and culture change. Dr Bell then highlighted how theoretical frameworks have provided guidance for the implementation of real world, complex nutrition interventions, including the Systematised Interdisciplinary Program for Implementation and Evaluation (SIMPLE) in Australia, and the More-2-Eat program in Canada.

Thank you for publishing this important and heartfelt piece about how being listened to and supported by her GP helped one anonymous patient through a traumatic time.1 I’m so grateful she shared her experiences and raised important points about relationship based care and the art that is general practice. Her point about the unmeasured going unnoticed is critical to protecting what we do as GPs. It isn’t just technology that threatens …