Now that I am entering the final years of my paediatric training (ST6), people keep asking me what I want to specialise in. At the moment I am training in “general” paediatrics, which is a kind of specialty in and of itself, although many general paediatricians also have special interests in one thing or another.
Rather awkwardly, I find myself interested mainly in a specialty that doesn’t exist (although it overlaps with many that do): paediatric lifestyle medicine. Well, it doesn’t exist yet anyway, but perhaps it should?
In 2012, Joan Younger Meek MD, Associate Dean for Graduate Medical Education at Florida State University College of Medicine, wrote an article in the American Journal of Lifestyle Medicine entitled “Pediatric Lifestyle Medicine”(1). Dr Meek is a busy woman: as well as being medically trained she is also a Registered Dietician and a Board Certified Lactation Consultant with interests in breastfeeding and infant and child nutrition.
In her article she defines paediatric lifestyle medicine as essentially preventive, encompassing “optimal nutrition, maintaining an appropriate weight, developing an active lifestyle, and avoidance of tobacco, alcohol and other substances of abuse“. She also discusses breastfeeding promotion, prevention of sexual risk behaviours (for STI’s and teenage pregnancy), wearing seatbelts and reducing screen time. Sadly, all of the above issues relate substantially to the paediatric population (under 16’s) in the UK.
Various professional groups are interested in one or all of the above issues: midwives, lactation consultants, dieticians, community paediatricians and child protection nurses and doctors, genitourinary specialists, gynaecologists, smoking cessation advisors, mental health professionals, general practitioners, bariatric surgeons and public health professionals to name but a few. In some places specialist services exist for children and young people affected by these issues, but provision is patchy and adult services are not always best placed to provide care to this age group.
So what might be the role of a paediatric lifestyle specialist within the NHS? To some extent this would be dictated by existing local services and need. But here are a few specific thoughts…
Firstly, unlike public health professionals who are concerned more with population-wide initiatives (service developments, legislation and manipulating the built/food environment to better serve the aim of good health), paediatric lifestyle specialists would be practicing clinicians seeing patients in outpatient clinics and on the wards. They would use lifestyle interventions to treat as well as prevent disease. They would see both simple and complex cases and liase with many other professionals to make appropriate referrals, for example where an overweight child was felt to have an underlying hormonal problem, or where a significant mental health issue was identified. They would be experts in evidence-based lifestyle interventions for a range of common problems, and they would be engaged in an active programme of clinical research (including the systematic review of existing studies) to assess the effectiveness of such interventions and develop new and innovative approaches to the non-pharmacological treatment of lifestyle-related physical disease.
Just to be clear, this does not mean they would not prescribe appropriate medications if and when necessary – they would. But the literature relating to nutritional interventions alone is huge and growing all the time, such that it is hard for anyone to keep up with it. It is reasonable that within a system as large and complex as the NHS, at least a few individuals are charged with this task, and with providing education and advice to everyone else who hasn’t got time. Prescribing medications safely also requires specialist knowledge, and therefore a somewhat different focus. Ideally, for conditions responsive to lifestyle interventions, medications could be reduced and even stopped under careful medical supervision following successful treatment, thus reducing the NHS pharmaceutical bill.
In the US at least, lifestyle medicine is a burgeoning specialty for adults, and the European Society of Lifestyle Medicine gives a definition, here. Dr Michael Greger of NutritionFacts.org is one leading thinker in this field. But what sort of paediatric conditions might be amenable to treatment? Obesity is an obvious contender, but otherwise this is a controversial question, as many common conditions are not recognised as lifestyle-related in medical circles, despite the existence of evidence suggesting the contrary. Strong, conclusive evidence is generally lacking in the paediatric age group, due to a general reluctance to conduct studies in children and young people, so there is a lot of work to be done.
I appreciate that this is a controversial list, worthy of a great deal of debate, not to mention a much greater level of clinical experience than we have now and many many more well designed and executed studies and reviews, but here is my list anyway of conditions occurring in the paediatric population that may, in some or all cases, be improved or even cured by lifestyle interventions: overweight and obesity, type 1 and type 2 diabetes, asthma and allergy, eczema, acne and psoriasis, dysmenorrhoea (painful periods) and polycystic ovarian syndrome (PCOS), chronic fatigue syndrome (CFS), chronic/functional constipation, non-specific abdominal pain, nutritional deficiencies such as rickets or iron deficiency anaemia, recurrent ear infections, autoimmune conditions such as arthritis, depression, attention deficit/hyperactivity disorder (ADD/ADHD), and perhaps likely to be the most contested of all – cancer.
What else? Paediatric lifestyle specialists would need to conduct a full initial assessment of patients, remaining alert to the possibility of underlying/unrecognised organic disease. They would follow the usual clinical pathways to achieving a diagnosis or at least developing a list of active problems, and they would formulate a plan of action appropriate to each patient. They would order relevant investigations such as imaging or blood tests, and they would be specialists at assessing the complex social and psychological conditions that often underlie lifestyle-related conditions. They would retain a family-focused approach to treatment, and would be experts in the science and art of motivation, combining excellent communication with coaching, counselling and psychotherapeutic skills. They may administer treatment in both individual and group settings, utilising the benefits of peer support and the multidisciplinary team (dieticians, clinical psychologists, physiotherapists etc.). They may also liase with local public health teams and hospitals regarding preventative service provisions, and sit on relevant committees.
My disappointment in reading Dr Meek’s article was that it did not spend more time considering the evidence relating to behaviour change, and specifically what works and what does not. From one perspective, lifestyle medicine may be conceptualised as the science and practice of behaviour change to achieve health benefit. Most professionals agree at least broadly that breastfeeding, healthy eating, exercise and not smoking are desirable, but most raise their hands in despair when considering how to actually effect such change in their patients. Evidence exists however, and behavioural change is possible. We need to leverage that knowledge for the benefit of all. The need is great.
1. Pediatric Lifestyle Medicine. Joan Younger Meek. American Journal of Lifestyle Medicine 2012; Vol.6, No.6:440-447