Guidelines Recommending That Clinicians Advise Patients on Lifestyle Changes, 2024, Johansson et al

mango · Sep 24, 2024

Guidelines Recommending That Clinicians Advise Patients on Lifestyle Changes: A Popular but Questionable Approach to Improve Public Health

Minna Johansson, Amanda Niklasson, Loai Albarqouni, Karsten Juhl Jørgensen, Gordon Guyatt, Victor M. Montori

https://www.acpjournals.org/doi/10.7326/ANNALS-24-00283

mango · Sep 24, 2024

This opinon piece is not about ME, but still relevant I think.

Tvinga inte läkare att ge hälsoråd – de hjälper ändå inte
https://www.gp.se/debatt/tvinga-int...nda-inte.ff8e999c-b838-4871-b10d-b506c8fae9c6

Auto-translate said:

Don't force doctors to give health advice - it won't help anyway

Healthcare professionals are increasingly being asked to try to improve our patients' lifestyles by giving advice on topics such as diet, exercise, weight loss and smoking. But our advice rarely helps people change their habits, and can contribute to stigmatisation and crowd out more important and valuable care, write Amanda Niklasson and Minna Johansson.

[...] With the goal of reducing the risk of disease and premature death in the population, an increasing share of health care resources is spent on health professionals trying to change their patients' lifestyles through advice on, for example, diet, exercise, weight loss and smoking. Often, this advice is linked to quality measures and financial rewards for healthcare units, as incentives to make us prioritise the task more.

But just because we know the benefits of being physically active, for example, it is not certain that counselling will help people achieve the health benefits. While the content of the advice may be spot on, there is much more to healthy lifestyles than counselling - and most of it is beyond the control of health professionals.

Societal factors

Social and community factors such as living environment, socio-economics and social networks are strong drivers of lifestyle behaviours. In fact, it seems unlikely that advice from health professionals during brief consultations would help people to change their habits, while they live every day in the social conditions that shaped those habits. In fact, there is often a lack of scientific support that lifestyle advice from health professionals actually helps people change their lifestyle.

Together with research colleagues from the United States, Canada, Denmark and Australia, we reviewed the scientific basis for medical recommendations on lifestyle advice and developed a guide to help policy makers consider the pros and cons of recommending lifestyle advice, which was recently published in the prestigious medical journal Annals of Internal Medicine.

In the UK, for example, 379 different recommendations are made to health professionals to try to change their patients' lifestyles, and nearly 100 of these recommendations should be given to more than 25% of the population. In our review, we found that only 3% of recommendations have reliable scientific evidence that lifestyle advice has a positive effect. A further 13% have some, but uncertain, scientific support. This means that for the vast majority of lifestyle recommendations, there are either studies that show that they do not have a meaningful positive effect, or there are no reliable studies to evaluate the effect [...].

Many people may think that there is no need for scientific support to recommend health professionals to give lifestyle advice and that the risks are low. But we believe that lifestyle advice can cause harm. In the patient encounter, forced prioritisation of unsolicited lifestyle advice risks stealing time and focus from other things that the patient might have wanted or benefited more from help with. There is also a risk of stigmatisation and blame when lifestyle habits are repeatedly to permeate the meeting between patient and healthcare professional. Patients need to feel that they can go to the doctor without necessarily being told every time how wrong their lifestyle is.
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Google Translate, English.

One of the authors was tweeting about it yesterday as well.

mango · Sep 24, 2024

Article published on Gothenburg University's website:

Oklart om livsstilsråd faktiskt fungerar
https://www.gu.se/nyheter/oklart-om-livsstilsrad-faktiskt-fungerar

Auto-translate said:

Unclear whether lifestyle advice actually works

Healthcare providers are increasingly giving patients advice on how to improve their health, but there is often no scientific evidence that this advice actually works. This is shown by a study from the University of Gothenburg, which also guides towards more effective recommendations.

The researchers do not criticise the content of the advice - it is good if people lose weight, stop smoking, eat a better diet or exercise more. However, there is no evidence that patients actually change their lifestyle after receiving this advice.

- There is often a lack of research showing that counselling patients has an effect. It is probably rare that the advice actually helps people,’ says Minna Johansson, associate professor at Sahlgrenska Academy at the University of Gothenburg and general practitioner at Herrestad's health centre in Uddevalla, who is the study's lead author.

Little advice is well-founded

The study, published in the journal Annals of Internal Medicine, was conducted by an international research team. They have previously analysed medical recommendations from the National Institute for Health and Care Excellence (NICE) in the UK. This organisation is responsible for 379 recommendations for healthcare professionals to give to patients to change their lifestyle.

In only 3% of cases were there scientific studies showing that the advice has positive effects in practice. A further 13% of these recommendations had some evidence, but with low certainty. The researchers also reviewed additional guidelines from other influential institutions around the world and found that these often overestimate the positive impact of the advice and rarely take into account the drawbacks.

- Trying to improve public health by giving lifestyle advice to one person at a time is both expensive and ineffective. Resources would probably be better spent on community-based interventions that make it easier for all of us to lead healthy lives,’ says Minna Johansson, who also believes that the advice can increase stigmatisation for people with obesity, for example.

Showing the way forward

It would be impossible for today's healthcare professionals to give all the advice recommended and at the same time manage to maintain other care. The researchers' calculations show that in the UK, for example, five times as many nurses would need to be employed compared to current levels to fulfil the task.

The study also presents a new guide to help policy makers and guideline writers consider the pros and cons of the intervention in a structured way before deciding whether or not to recommend it.

Victor Montori, Professor of Medicine at the Mayo Clinic in the US, co-authored the study:

- ‘The guide consists of a number of key questions, which point the way to adequately evaluate the likelihood that the lifestyle intervention will lead to positive effects or not,’ says Victor Montori.
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Hutan · Sep 24, 2024

A great find @mango.

Interesting to see Gordon Guyatt of McMaster University as a co-author.

Relevant to the Cochrane Exercise Therapy review @Medfeb

rvallee · Sep 24, 2024

Oh, so just like they've done for decades. But more? Or with a different tone? I guess?

But yeah we know this is ineffective and mostly useless, even counterproductive at times.

Creekside · Sep 25, 2024

I think lifestyle change is unlikely to succeed without some sort of immediate reward. Punishments for being overweight, underexercised or having a less than ideal diet would result in major social unrest. I think there are plenty of science fiction stories about that sort of thing.

Magic wand: that's what we need!

Nightsong · Sep 25, 2024

I was surprised to read in the Annals paper just how little consideration is given by NICE guideline panels to the potential harms of such interventions:

Finally, guideline panels should consider potential harms and opportunity costs of lifestyle interventions. Of all lifestyle interventions recommended by NICE, only 5% considered psychosocial harms and none considered practical burdens [1]. This is concerning considering the evidence around weight stigma in health care, and a plethora of testimonies in social media from people with overweight who report receiving unrequested lifestyle advice that they found humiliating [9].
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Reference [1] is to this 2022 paper (BMJ Med, open access):

Within 57 guidelines, 379 NICE recommendations were found for IOLIs; almost all (n=374; 99%) recommended the lifestyle intervention and five (1%) recommended against the intervention. Of the 379 recommendations, 13 (3%) were supported by moderate or high certainty evidence of a beneficial effect on patient relevant outcomes (n=7; 2%) or surrogate outcomes (n=13; 3%). 19 (5%) interventions considered psychosocial harms, 32 (8%) considered physical harms, and one (<1%) considered the opportunity costs of implementation. No intervention considered the burden placed on individuals by these recommendations.
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mango · Jan 9, 2025

There was an opinion piece on this by BPS proponents David Gyll and Minna Johansson (of Cochrane Sweden, she has been suffering from long covid, I don't know if she has recovered or not) and others, in one on Sweden's largest newspaper a week ago:

DN Debatt. ”Nya levnadsråden gör friska till patienter i onödan”
https://www.dn.se/debatt/nya-levnadsraden-gor-friska-till-patienter-i-onodan/

Auto-translate said:

‘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.
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mango · Jan 9, 2025

Socialstyrelsen/The National Board of Health and Welfare replies today:

DN Debatt Repliker. ”Osaklig kritik mot Socialstyrelsens nya levnadsråd”
https://www.dn.se/debatt/osaklig-kritik-mot-socialstyrelsens-nya-levnadsrad/

Auto-transatlate said:

‘Unfair criticism of the National Board of Health and Welfare's new lifestyle advice’

Thomas Linden, Director General of the National Board of Health and Welfare: Our recommendations are based on the best available knowledge - and lifestyle advice does have a some effect.

The National Board of Health and Welfare recently published updated national guidelines for the treatment of unhealthy lifestyles. They emphasise that unhealthy lifestyles increase the risk of our most common chronic diseases such as cardiovascular disease, various types of cancer and type 2 diabetes. These diseases contribute to great suffering for the individual, and high costs for society. Today, too few patients are offered support from the health and dental services.

A debate article written by ten general practitioners (DN Debatt 1/1) criticises the guidelines. The debaters claim that the recommendations lack scientific basis and that ‘the National Board of Health and Welfare wants doctors to spend their days giving lifestyle recommendations to every other Swede’. This is a misconception.

It is not about ‘every other Swede’ and it is not only doctors who have these conversations

The National Board of Health and Welfare's national guidelines support healthcare decision-makers in prioritising those with the greatest needs. This may include patients who have a lifestyle that can lead to serious illness or make an existing illness worse, such as people with cardiovascular disease who need support to quit tobacco and nicotine.

It is not just about ‘every other Swede’ and it is not only doctors who conduct these conversations. Many other professions such as nurses, dieticians, physiotherapists and others are involved in work on lifestyle habits. In addition, lifestyle counselling is usually on the patient's own agenda when a patient seeks care for a problem affected by unhealthy lifestyle habits.

There is scientific evidence that counselling can lead to behaviour change

The commentators also claim that lifestyle counselling has no effect. This is not true. The recommendations made by the National Board of Health and Welfare are based on the best available knowledge, based on the scientific basis and the experts we have engaged. The National Board of Health and Welfare has based its recommendations on studies that examine behavioural changes, not disease and death. This is so that the recommendations can be used for a wide range of diagnoses.

There is scientific evidence that the talks can lead to behavioural change. Furthermore, the authors refer to a study on ‘379 lifestyle advice’ recommended in the UK. However, these have no bearing on Swedish conditions.

‘It's positive that lifestyle issues are being raised - but it must be done on a factual basis and in a constructive spirit. The most important thing is not how many steps a person walks or how many glasses of alcohol are harmful, but that the healthcare system does not miss patients who want to improve their health by changing their lifestyle. Lack of support leads to poorer health and increased social costs.
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Sean · Jan 9, 2025

Lack of support leads to poorer health and increased social costs.

So start offering meaningful support (including long-term research funding), not this infantilising psycho-behavioural fluff that could be written on a single page in large font and posted to every citizen for virtually no cost.

rvallee · Jan 9, 2025

Seeing this thread again reminded me of that time years ago when I went to see my local health services to ask for exactly that, and they were completely lost about what to say since it's completely generic stuff that can fit on a fortune cookie.

It was after I mostly recovered from my first bout of unexplained illness. I wasn't back to full function but I wanted to see what kind of professional help and assessments they could help me with. And it turned out that after 2 minutes of going through the basic stuff (didn't smoke, didn't drink much, ate well, exercised), they got nothing. Nothing at all. All they have is generic prepared stuff for the obvious (don't smoke, don't drink much, eat well, exercise).

And of course they still got nothing more today. No different than 50 years. And likely not different from 50 years from now, because this is obviously not something for health care services. Because they're not health care services, they're disease care services. They don't do health, only disease.

And of course the 'research' supporting this is such dog shit quality that it's worse than nothing, and in the process actually diminishes the credibility of medicine.

mango said: ↑

There was an opinion piece on this by BPS proponents David Gyll and Minna Johansson (of Cochrane Sweden, she has been suffering from long covid, I don't know if she has recovered or not) and others, in one on Sweden's largest newspaper a week ago
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That's a good letter. I wonder if they get that it applies to literally all 'biopsychosocial' nonsense. Literally all of it is strictly made out of even worse stuff than this. But the response is entirely predictable from brain-dead institutions that have long ago lost the plot, or probably never really had it.

NelliePledge · Jan 9, 2025

What do CBT approaches do if not tell people how to live their lives

Arnie Pye · Jan 9, 2025

I remember, several years ago, that I was advised by a doctor to lose weight. I already knew I was overweight, I didn't need to be told.

I was referred to a dietician to help me to eat more healthily. I only saw her once - and it turned out she was substantially fatter than me. I don't know what benefit I was supposed to get from the appointment, particularly since the dietary advice I got was based on the diet for diabetics at the time i.e. to eat 70% (?) of my calories from grains, cut down on protein, and eat very little fat, particularly saturated fat.

I didn't follow the advice then, and I still wouldn't now - it is terrible advice.

Creekside · Jan 9, 2025

I think their argument that "It is not about ‘every other Swede’" translates to "I know of at least 3 people in Sweden who already follow a healthy lifestyle and thus don't need more advice", as though that totally counters the criticism. Another case of the main beneficiaries being the ones proposing this nonsense (prestige, promotion, etc).

I asked one GP whether a dietitian would provide me with useful advice for dealing with my food intolerances, or if they'd just hand me a pamphlet for some well-known disease's recommended diet. He agreed that it was pointless to try.

mango · Jan 9, 2025

rvallee said: ↑

I wonder if they get that it applies to literally all 'biopsychosocial' nonsense.
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No, they don't. They have previously written opinion pieces together with Vogt, for example, about how to manage long covid. (There are links if you search my older posts.)

ETA: Or were they just referencing Vogt and Vogt referencing them, maybe I'm misremembering? PEM right now, unable to look it up properly, sorry.

Hutan · Jan 9, 2025

mango said: ↑

Minna Johansson (of Cochrane Sweden, she has been suffering from long covid, I don't know if she has recovered or not)
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That's interesting. It would be good to know if she has been public about still having Long covid. So she wrote opinion pieces with Vogt?

mango · Jan 9, 2025

Hutan said: ↑

That's interesting. It would be good to know if she has been public about still having Long covid. So she wrote opinion pieces with Vogt?
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If I'm not misremembering, maybe I misread my own old posts? PEM right now, will have a better look later.

Here's one where Johansson references Vogt and Gyll:

https://www.s4me.info/threads/news-...e-cfs-2020-to-2021.14074/page-215#post-347490

mango · Jan 9, 2025

Hutan said: ↑

That's interesting. It would be good to know if she has been public about still having Long covid. So she wrote opinion pieces with Vogt?
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I had a quick look through her X/Twitter posts just now, and I did a Google search too. I didn't find any recent mentions of long covid.

obeat · Jan 10, 2025

I think Minna was only ill for a matter of months and thought that positive thinking and lots of TLC had helped her recovery.

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