Robert Thomas: Lithuania has a vision for exercise and lifestyle medicine

The Lithuanian Cancer Patient Coalition recently organised a series of lectures in the two largest University Hospitals located at Vilnius and Kaunas. Enthusiastic patients and medical staff were eager to hear about the latest research highlighting the links between a healthy lifestyle and a reduced incidence, progression and relapse of cancer and other chronic diseases. 1, 2,3, 4

Although understanding of these data is improving, the challenge remains the implementation of effective behavioral change strategies within routine clinical practice. Certainly, schemes which simply provide written or verbal information for patients don’t seem to change lifestyle habits, as highlighted by a UK study which showed no change in physical activity levels over 5 years, with only 4% of a post cancer population reporting >3 hours of moderate exercise a week. 5

Lithuania, however, already has a national strategy driven by a vision from the minister of health, Aurelijus Veryga. It involves the creation of the building blocks for a new lifestyle medical specialization, which could potentially save billions of Euros for the government and improve the health and the quality of life of an entire population. They have funded a postgraduate degree which pulls together doctors, exercise professionals, nutritionists, dieticians, and psychologists with behavioral change skills. The aim is to create an army of lifestyle specialists who will be posted to community medical practices across the country that are kitted out with exercise and counselling facilities. Patients with lifestyle related diseases such as obesity, borderline hypertension, early diabetes type II, high cholesterol, simple constipation, or those who partake in unhealthy habits such as smoking or high alcohol intake, will attend the lifestyle clinic rather than costly medical clinics which have a poor record of changing behaviour. 6 Attendees will undergo a series of behavioural change interviews and supervised exercise programmes and be monitored regularly for uptake and effectiveness.

Instigating change in a country with a population of 3 million with an effective infrastructure and a history of central control is more likely to be achievable than in the sprawling goliath of the UK’s health system. But even in the UK the benefits would be considerable. In the UK, each year, we spend £1 billion on statins, £774 million on anti-hypertensives, £800 million on type 2 diabetic drugs, £78 million on laxatives, and £660 million on anti-indigestion medication. 7 There is strong evidence that lifestyle changes reduce the need for these treatments 8 so even a moderate reduction in use would save billions of pounds a year in drugs alone, not to mention the improvement in patients’ wellbeing. In terms of cancer, the World Cancer Research Fund recently estimated that 50% of cancers could be prevented by a healthy lifestyle, and 30% with just dietary and physical active changes. 9 What’s more, the benefits of lifestyle do not stop after diagnosis. Formal exercise programmes have been shown to help mitigate fatigue and improve quality of life after cancer treatments. 10 Several large cohort studies have also linked >3 hours of physical activity a week with a 20-30% reduced risk of breast, prostate, and bowel cancer relapse via a number of biochemical pathways1. The treatment of relapse cancer is particularly expensive as patients with metastatic disease are now often maintained on treatment for an increasing number of years thanks to advances in effective, albeit costly, biological therapies. 11

The Lithuania lifestyle clinics would create opportunities for research links in nutritional and natural therapies providing much needed evidence for the benefits of commonly taken over the counter therapies. In particular, the two recent RCT from our institution (UK polybalm study 12  and Pomi-t study 13 ) which are now being further investigated in partnership with USA hospitals can be expanded to Lithuania, increasing recruitment and providing data on cultural diversity.

Critics would argue that we should wait for more randomised controlled trials before diverting tax payers money, but designs addressing lifestyle, including hard endpoints such as overall mortality and relapse free survival are notoriously difficult to organise and will be several years coming. In the mean time, even just considering toxicities alone, the benefits would be enormous. With the evidence available to date, Lithuania are taking a highly commendable lead in the right direction. Routinely referring patients with early medical conditions or after cancer into interventions supervised by the lifestyle consultants is likely to unclog busy GP and hospital clinics, and provide much needed effective support for patients and their families. As they also have reliable and practical computer records in Lithuania, the rest of us bystanders will have real world data to refer to and hopefully applaud.

Robert Thomas, Consultant Oncologist Bedford and Addenbrooke’s Cambridge University NHS Trusts. Professor of Biological and Exercise Science Coventry University.

Šarūnas Narbutas, President of the Lithuanian Cancer Patient Coalition (POLA)

Competing interests: RT: I have no financial connection with Lithuania or any commercial or academic bodies in Lithuania. My travel accommodation and a speaker fee was paid for by Helsinn integrative and I have recently received travel grants from Bayer Healthcare and speakers fees from Astra Zenica.