‘New lifestyle advice turns healthy people into patients unnecessarily’
The National Board of Health and Welfare wants doctors to spend their days giving lifestyle recommendations to every other Swede. This is as pointless as New Year's resolutions - which in any case do not cost taxpayers hundreds of millions of kronor. How will healthcare now have time to care for the elderly and the truly sick? write ten specialists in general medicine.
The traditional New Year's resolutions - to drink less, quit smoking, eat better and exercise more - are being challenged this year by the National Board of Health and Welfare's recently published, updated advice on ‘Care for unhealthy lifestyles’.
The advice proposes a range of interventions aimed at making the Swedish people healthier and better. We believe that this advice, like New Year's resolutions, is based on weak scientific evidence and has little potential to make a real difference.
Doctors have always talked to their patients about lifestyle habits, because we know that they have a major impact on health. This is best done with respect for each patient's unique situation in a functioning primary care setting, based on long-term relationships and realistic priorities.
Instead, the National Board of Health and Welfare advocates that health professionals provide patients with tailored advice on alcohol, tobacco, diet and exercise, either as ‘counselling sessions’ lasting 5-15 minutes, or as ‘advanced counselling sessions’ taking longer. The interventions should target the patients with the highest needs, which sounds reasonable until you realise that they represent a majority of the population.
For health care, the task is more likely to be to separate out the few physically active, diet-conscious and nicotine-abstaining sober people who do not need advice.
Priority groups are young people, pregnant women, those waiting for surgery and adults at particular risk. ‘Special risk’ is anyone with at least one chronic diagnosis or risk factor, low socio-economic status or more than one unhealthy lifestyle habit, i.e. more than half of all adults. For health care, the task is rather to separate out the few physically active, diet-conscious and nicotine-abstaining sober people who do not need advice.
An average patient meeting in primary care takes about 20 minutes. The National Board of Health and Welfare therefore recommends that for many patients we spend a large proportion of that time on counselling about lifestyle habits, instead of what is the patient's agenda. The work will be recorded manually based on 28 indicators, in order to evaluate how good the care is. What does the National Board of Health and Welfare expect healthcare professionals to stop doing to make room for lifestyle counselling and its documentation?
The National Board of Health and Welfare chooses to emphasise small studies with short follow-up and self-reported outcomes instead of effects on disease and death. For example, it is claimed that ‘strong evidence’ indicates that qualified counselling sessions on diet result in an increased intake of one fruit per day. This is thought to lead to better health. However, the studies only show that participants say they eat more fruit and vegetables, which could just as easily be wishful thinking or wanting to make the investigators happy.
The National Board of Health and Welfare chooses to emphasise small studies with short follow-up and self-reported outcomes instead of effects on disease and death
Such systematic errors in self-reporting are common in lifestyle studies. The assumption that an extra self-reported fruit per day would lead to substantial reductions in stroke, heart attack and death in 25 years is undeniably shaky. Yet it concludes that counselling sessions are cost-effective.
There are large, well-designed, randomised studies with long follow-up that the National Board of Health and Welfare ignores, such as the Look Ahead study. It showed that intensive support for better habits and follow-up had no effect on morbidity or death from cardiovascular disease over ten years.
In addition to the lack of evidence and the time required, it is expensive. The National Board of Health and Welfare estimates that qualified counselling sessions on healthier eating habits with 80% of all adults at ‘special risk’ alone would cost up to SEK 837 million. Counselling where the evidence points to minimal or no effect. The cost of the displacement effect for other care is not calculated.
According to the ethical principles of healthcare, those with the greatest needs should be cared for first and interventions should be cost-effective at the societal level. The seriously ill, frail and elderly will be pushed aside if healthcare is to spend more time on the lifestyle of younger and healthier people.
Focusing on the individual's problematic behaviours overshadows the discussion on the role of society
Advocates of counselling tend to argue that it is better to prevent illness than to wait for it to happen and then treat it. We fully agree with that. The problem is that counselling on alcohol, tobacco, diet and exercise has little effect. Researchers recently showed that 97 per cent of the 379 lifestyle recommendations in the UK lack reliable evidence that they help people change their habits.
Focusing on the individual's problematic behaviours overshadows the discussion on the role of society. There is a solid body of knowledge on what influences public health. Examples include economic security, mobility-enhancing infrastructure and taxation of unhealthy products. Seeking to improve such determinants is sometimes described as political interference with individual freedom. We argue that broadly targeted counselling with intensive follow-up is at least as much of an intrusion, and unnecessarily turns healthy people into patients.
Public health is important. Therefore, interventions with evidence-based effectiveness and reasonable cost-effectiveness should be recommended. The rule-driven, comprehensive lifestyle counselling sessions recommended by the National Board of Health and Welfare do not meet these criteria. In any case, New Year's resolutions are free.
