Preventive medicine: Helping patients alter their lifestyle

Is it the practice nurse's role to help patients their modify lifestyle choices and if so, to what extent and does it work anyway?

A study was reported in the BMJ in 2008 of a 24-year follow-up of nearly 78,000 nurses in the US, aged 24 to 59 at the start of the study.¹ Five aspects of lifestyle were measured and related to the chance of dying during the study period. The aspects were: cigarette smoking; being overweight; taking little moderate to vigorous physical activity; drinking too little alcohol; and eating a poor diet.

Those interested can check the reference in detail, and will probably quibble with the methods - for example the idea that it is possible to drink too little alcohol was popular a few years ago (remember the 'U' shaped curve?), but has rather fallen from favour as the problem of consuming too much alcohol is evidently more important - but otherwise the results are compelling. Subjects with all five adverse lifestyle factors were 4.³¹ times more likely to die than subjects with none of the factors. Nearly 9000 deaths were recorded during the study, and 55% of the deaths were estimated to be attributable to adverse lifestyle choices (of which cigarette smoking contributed half, and too little alcohol contributed nothing). So in middle aged professional American women at least, lifestyle has an enormous impact on the likelihood of staying alive. I suspect that UK practice nurses are similarly vulnerable.

PERSONAL CHOICE

When considering what responsibility UK healthcare professionals have towards patients who are damaged or likely to be damaged by their lifestyle choices, the ethics become muddy. On one hand lifestyle choices are just that - personal choices - and any damage that accrues is surely the responsibility of the person making those choices. The taxpayer and the healthcare professional are not to blame for these choices and should not be required to pick up the resulting debris. Adverse lifestyle choices are clearly linked to social deprivation,² which implies that government policies can have an effect. Taxation and duty paid leading to higher prices are known to have a direct impact in reducing the consumption of cigarettes³ and alcohol.⁴ The duty paid by consumers on alcohol and cigarettes is considerable: for example in 2009-10 the revenue from tobacco taxes was £10.5bn,⁵ money which is used (among other things) to pay for the NHS. You will have heard some smokers complain that they deserve healthcare treatments because of the money they contribute. These are things clearly outside the control of healthcare professionals.

INTERVENTIONS

On the other hand interventions can to a limited extent help patients to stop their unhealthy habits,⁶ and this sometimes requires the use of medications which are only available from healthcare professionals. Users of tobacco and alcohol are sometimes described as 'addicted' to their drug and so presumably not personally responsible for their plight, and needing psychiatric care. Reflection in these areas often leaves healthcare professionals with steam coming out of their ears.

Trying to help patients give up their bad habits is frustrating and often soul-destroying. At best interventions are only partially effective,⁶ and work with individual patients is often associated with frequent relapses so that after years of struggle the same patients are again returning for help. To a professional not convinced that lifestyle alteration is the proper function of healthcare, this can take considerable effort.

CASE STUDY

So it's time to introduce you to David. He is 65 years old and has a history of treated hypertension. He smokes 30 cigarettes a day and has done so for years. For most of the past 10 years he has been caring heroically for his wife who was increasingly disabled with multiple sclerosis. Bedridden for the last three years of her life, David kept her at home until she died peacefully. Because he was crucial to her care, David was adopted into the care team for his wife. Out of professional courtesy his smoking has been mentioned over the years, but no serious attempt has been made to help him stop. David was investigated some years ago for intermittent claudication, but now the leg pain is stopping him walking his dogs, so he has consulted a vascular surgeon again. The surgeon told him that unless he stops smoking then surgical intervention will not do him any good. David is incensed at this response, and is planning to consult another surgeon privately with a view to having surgery in Spain 'where everybody smokes'. Paradoxically he has also booked on a non-smoking programme at a local chemist. How can we help David?

STAGES OF CHANGE

Two ideas will help to structure an appropriate response to David's care, and offer insight into why people in need of lifestyle changes behave as they do. They are presented below in relation to David and his smoking, but have general applicability across a range of lifestyle changes. The first derives from the literature of psychology and is usually called the Stages of Change model.⁷ This postulates a series of different mindsets that patients may display. For example:

Pre-contemplation

There is no intention to make any lifestyle change. This is a curious state given that (for instance) most smokers are aware that smoking is bad for them - they could hardly avoid all the publicity on this topic, not to mention the increasingly lurid warnings that appear on the cigarette packs themselves. Some (especially the young) may take the view that because of their youth they are unlikely to be damaged already, and there is plenty of time in the future to get around to stopping. Others may feel that they deserve the treat of a cigarette to compensate for life's adversities, and as mortality is anyway inevitable they will make the most of their pleasures while they can.

Contemplation

The need to stop smoking is accepted, but the way of stopping and particularly the time to stop has not been confirmed. Many smokers oscillate between pre-contemplation and contemplation as the mood takes them.

Preparation

This is the stuff of the New Year's Resolution, a taking stock of life and putting into place remedial strategies. January is a key month for trying to stop smoking, eating less and joining a gym. Once active plans are being made then it is worth healthcare professionals getting involved - there is really little point in trying to change lifestyle unless your patient is committed towards the change: the professional is mainly a facilitator. Such facilitation may include arranging access to NHS Stop Smoking services and/or the use of medication - bupropion, varenicline and varieties of nicotine replacement are available on prescription.

Action

Your patient is actively engaged on a change programme. Support will still be needed as lapses are common and it is not unusual for people to try and stop smoking repeatedly. Though this may bring frustrations and the sense of failure, at least the total life consumption of cigarettes is likely to be less. As Mark Twain is alleged to have said:

'To cease smoking is the easiest thing I ever did. I ought to know because I've done it a thousand times'.

MOTIVATIONAL INTERVIEWING

The second idea was originally intended to help excessive users of alcohol to reduce their consumption. The Stages of Change model is a little passive in that it is an attempt to understand behavioural changes but does not seek to move patients from one stage to another. Motivational Interviewing is a way of actively encouraging a move from pre-contemplation to contemplation and so on towards change.⁸

Motivational Interviewing is based on two observations:

• If you express a viewpoint, then your patient will tend to take the opposite view,

and

• If a person says something often enough, they will come to believe it.

It follows that nagging at a patient to reduce their smoking is likely to be counter-productive. In his expressed views, David has apparently seen the comments of his vascular surgeon as an attack - either on his moral fibre or intelligence. He has had a strong reaction to a perceived challenge, and hence his comment that if he went for his treatment in Spain he would be less likely to be criticised. While such an attitude persists David is unlikely to make any progress.

Patient beliefs

Work within your patient's own framework. David is fully aware of the risks he is running by continuing his cigarette habit, and now he also has evidence of actual damage. It is now interfering with the care of his beloved dogs, so things are getting serious. At this stage it is not clear if he has concerns about the other risks of smoking - heart attack, stroke. Many of you will have come across patients who try and bargain with the statistics, arguing that if they stopped smoking they would gain weight and that would confer an extra coronary risk. Other reasons to stop smoking might be the expense, the effect on taste, the adverse effects of smelling like an ashtray. The best way to find out your patient's beliefs is to ask.⁹

Pros and cons

Discuss the advantages and disadvantages of smoking and not smoking. Such a 'profit and loss balance' should include mainly the reasons the patient gives, but the professional may offer suggestions. It is also an acknowledgement that smoking is not all negative - it relaxes, aids concentration, encourages defecation, controls the appetite and gives pleasure. The delivery system is highly effective and much quicker than taking a tablet. Were it not so dangerous tobacco would probably be available on prescription

In discussion, pick out statements which demonstrate your patient's own reasons for cutting down or stopping. This also recognises that stopping totally, while remaining the best outcome, is not the only desirable outcome. If David can get down from 30 to 20 a day, it is not a complete result, but it is certainly a step in the right direction

Encourage your patient to emphasise their own role in the smoking behaviour. They can always choose to smoke less, and it's no good constantly blaming external factors. Some smokers are tobacco addicts, but many are not, and so fear that the effects of stopping will be greater than is actually the case. My father used to smoke after tea. One day he was involved in something with my elder brother, and realised some time later that he had missed his habitual cigarette. He reasoned if he could miss one he could do without them all together and never smoked again. He was not addicted to tobacco - he smoked because it was time to smoke. My mother, imbued with the post-war waste-not-want-not mentality, felt honour bound to smoke the remaining family supply of cigarettes before she too stopped for good.

Sympathise with the wish to alter smoking habits, and also with the difficulty of doing so.

Fact not opinion

Use facts rather than opinions. Smoking is now very much a minority pastime, and smokers need considerable resolve to pursue their habit now that public smoking is largely outlawed. Do you never feel a vicarious sympathy for the poor souls huddled outside work in the wind and rain miserably experiencing a quick fag? A blood count in smokers will often reveal a raised haemoglobin level, evidence of a physiological reaction to the toxins. Stop-smoking clinics often use carbon monoxide breath meters to monitor progress.

Cognitive dissonance

The term cognitive dissonance is used to describe the feeling of discomfort that results from holding two conflicting beliefs. When there is a discrepancy between beliefs and behaviors, something must change in order to eliminate or reduce the dissonance.

• 'You say that you smoke because you are fed up with being in debt. But your smoking is costing you £40 a week.'
• 'You say you smoke because your wife won't have sex with you. But she says she won't have sex with you because your breath smells so bad because of the smoking. I don't understand.'

In order to reduce the dissonance between belief and behaviour, something must change - in this case, we hope it will be the behaviour.

CONCLUSION

Lifestyle choices have a demonstrable and marked effect on mortality. Whether or not a professional believes it is the proper function of healthcare to rescue patients from their bad habits, nevertheless people bearing the scars of their life and behaviour will be common users of the service.

Methods of persuading people to change their lifestyle are published and verified. However, the impact of these interventions is limited and it would be easy for a professional to become as despondent as her patient with repeated failures. But even a temporary improvement in lifestyle is better than no improvement at all as it appears that the total load of life toxins is often more important than current behaviour. An attitude of cheerful realism is appropriate.

REFERENCES

1. Rob M van Dam RM, Li T, Spiegelman D, Franko OH and Hu FB. Combined impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ 2008; 337:a1440

2. C Kelleher C, Timoney A, Friel S and McKeown D. Indicators of deprivation, voting patterns, and health status at area level in the Republic of Ireland. J Epidemiol Community Health 2002;56:36-44 doi:10.1136/jech.56.1.³⁶

3. Townsend J, Roderick P and Cooper J. Cigarette smoking by socioeconomic group, sex, and age: Effects of price, income, and health publicity. BMJ 1994;309:923-7.

4. Gilmore I and Sheron N. Reducing the harms of alcohol in the UK. BMJ 2008;335:1271-2.

5. Tobacco Manufacturers' Association. Tax revenue from tobacco. http://www.the-tma.org.uk/tma-publications-research/facts-figures/tax-revenue-from-tobacco/ [Accessed 01.10.2011]

6. Effective Health Care. Brief interventions and alcohol use. Nuffield Institute for Health, University of Leeds; Centre for Health Economics, University of York; Research Unit, Royal College of Physicians, 1993.

7. Prochaska, JO, DiClemente, CC. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, Vol 19(3), Fal 1982, 276-288

8. Miller W R. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy 1983;11:147-72.

9. Warren E. BARD in the practice. Oxford:Radcliffe Medical, 2006