Consultant Cardiologist Dr Robert Kelly speaks to Dawn O’Shea about the emerging specialty of lifestyle medicine and empowering patients to improve their health
In recent weeks, millions of people have made a commitment to live healthier lives, be that by eating better, exercising more, or quitting smoking or alcohol. Unfortunately, many subsequently slip back into unhealthy habits. Even for people with chronic diseases, for whom healthy lifestyle choices are critical, the challenge will prove too great.
There is one simple reason why most New Year’s resolutions don’t stick, according to Dr Robert Kelly, Consultant Cardiologist and Lifestyle Medicine Physician at the Beacon Hospital, Dublin. It’s because motivation alone does not work.
“Everybody wakes up very motivated on the 1st of January. Unfortunately, by the 21st of January, at least 90 per cent of people will be back [to their old behaviours], despite their best efforts,” Dr Kelly told the Medical Independent.
“The real factor behind this is that if you try to use motivation alone, it doesn’t work, because willpower fluctuates. Willpower may be affected by the weather outside. It may be affected by how you feel. It may be affected by what you’re doing. It may be affected by stress or other things in your life that disrupt motivation.”
Throughout his career, Dr Kelly has seen hundreds of people who know they need to make lifestyle changes, who want to do so, but who struggle to maintain these changes in the long-term. It was this conundrum that drew him to the emerging specialty of lifestyle medicine.
Evidence-based
It has long been recognised that lifestyle plays a significant role in overall health. In recent years, there has been a move towards using lifestyle modifications as a form of medicine. Lifestyle medicine is an evidence-based discipline which aims to support patients to prevent, manage, and potentially reverse certain chronic conditions, using supported behaviour change skills and techniques to create and sustain lifestyle changes.
Since 2004, lifestyle medicine has been recognised as a medical specialty in the United States, where it now boasts more than 9,000 active members. In 2016, the British Society of Lifestyle Medicine was founded by two GPs and a surgeon and now has more than 2,500 members. Ireland has its own Irish Society of Lifestyle Medicine, of which Dr Kelly is a founding member.
Dr Kelly said chronic diseases account for most hospital admissions and that much of this illness is driven by lifestyle factors.
He described the familiar situation where a patient with a chronic disease, such as heart failure, is on optimal medical treatment, but has returned to the clinic with more symptoms.
“The reality is that people don’t change the reasons why they get the heart problem in the first place,” he said.
“They don’t stop smoking. They still have some bad eating habits. They are inactive. A lot of them are very stressed out. A lot of them have very significant sleep issues. As I explain to patients, there aren’t any medications for stress and social disconnection.
“All of those things are independently verified as risk factors for premature deaths, for heart attacks, for stroke, in many cases for other chronic diseases like cancer, lung disease, etc, by a significant degree.”
Lifestyle medicine employs evidence-based techniques to support patients in making positive behavioural changes around six key pillars – nutrition, sleep, physical activity, social connection, stress management, and risk reduction by avoiding harmful substances.
It uses knowledge of behavioural science and proven techniques to support patients to transition to a healthier lifestyle. Some of these techniques have been shown to be at least 80 per cent more effective in supporting behaviour change than traditional advice-giving. The methods employed include motivational interviewing, cognitive behavioural therapy, and the use of patient activation measures.
You have to learn that as a skill, because you don’t learn that in medicine
“We’re all trained in medical school to tell patients what to do. You learn off vast amounts of information, you go off and tell the patients what to do, you may give the patient a leaflet you pulled off the shelf from the Irish Heart Foundation, and you see the patient again in a couple of months,” Dr Kelly commented.
“Lifestyle medicine is a different approach. It requires you to be able to spend time with the patient, to engage with them, and ultimately you have to try to create a relationship to try to help them make changes in their behaviour, which falls back to something like coaching patients. You have to learn that as a skill, because you don’t learn that in medicine. Very few doctors do that. Many ‘outsource’ their patients to other services. The problem with that is when you outsource the patients, you don’t have ownership [of the situation]…. So I say, ‘Okay, you’re coming back to me in three months’ time or six months’ time. Let’s sit down and reassess the situation’.”
Dr Kelly acknowledged that most doctors already face time pressures in their interactions with patients and may not be in a position to spend time coaching patients. However, he clarified: “You don’t have to be with [the patient] for an hour. You can give them advice in a short consultation; you might just have to do it more often. It’s an approach that’s a little bit different to how you might normally do your medicine, but a doctor who believes in you, a doctor who wants to help you, is huge in getting people to make changes,” he said.
‘Small steps’ approach
For three years, Dr Kelly has been operating a lifestyle medicine programme for his cardiology patients, employing the ‘small steps’ approach to behavioural change.
“When you’re trying to get people to change their behaviour, you have to do it very much on an individual basis. In other words, try to meet the patients where they are at. Some people are athletes, but the vast majority of people aren’t. Some might go for the odd walk and you have to set those patients up with much more realistic goals,” he explained.
“The small step principle is based on the fact that if you do one small step today and two tomorrow and three the next day, etc, you can potentially get up to a 200-fold impact by the end of the calendar year.”
The key isn’t about how big or small the step is; the critical part is that it’s done every day, Dr Kelly outlined.
“It’s not about leading by example. It’s not about carrots. It’s not about sticks. It’s more about empathetically and compassionately listening to people, and it does work,” he said.
Dr Kelly has developed his own programme based on the small steps principles. It involves patients deciding on a change that is easy and enjoyable, and setting a goal that is personal to them. The programme also calls for patients to identify triggers to remind them about their commitment every day, such as leaving their walking shoes by the breakfast table in the morning. A critical part of the programme is that every time the person completes the task, they must celebrate it, be that with a fist pump or a smile.
Since he started the programme, Dr Kelly has been approached by GPs and hospital colleagues who have asked him to coach their patients or even themselves.

He is now on a mission to spread the message about lifestyle medicine, educating both individuals and healthcare professionals on the techniques used. To that end, he has written The Heart Book, published by Orpen Press. In the book, Dr Kelly uses a range of techniques to give people the tools to change unhealthy habits and improve heart health. Each chapter includes patient stories and tools for readers to use.
The Heart Book is available from all good bookshops and at www.orpenpress.com
A recent presentation by Dr Kelly at TEDxTralee is available at www.youtube.com/watch?v=zi2-m62oWYQ
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