Quality of Life: The Primary Goal of Lifestyle Intervention

Abstract

In much of lifestyle medicine, health-related quality of life (HRQoL) is a primary focus with the assumption that symptom reduction increases quality of life (QoL) in a more global sense. Lifestyle medicine research has shown that reducing symptoms increases the likelihood that QoL is improved. However, little information is available as to the impact of interventions when they are not effective in creating the desired healthy outcomes. It is possible that some lifestyle interventions have a negative impact on QoL, especially when a patient is not “successful” in reducing their symptomatology. Considering QoL from a broader perspective as an outcome in combination with traditional health outcomes may improve provider-patient rapport and empower patients to provide feedback on treatment, which, in turn, may improve overall treatment.

. . . the primary focus of most treatment and research is how to best treat a disease state.

A recognition of how physical health and quality of life (QoL) are related is at the center of much of the care that is provided in lifestyle medicine.^1-3 However, the primary focus of most treatment and research is how to best treat a disease state. For example, it is likely that many who provide care and conduct studies are primarily interested in if an intervention successfully improved a clinical outcome. This approach is meaningful as individuals are typically coming to a health care provider to address or minimize the consequences of a disease state. A shift occurs with the importance of QoL in some areas.^4-6 Specifically, QoL is given greater priority in fields that disease is advanced or terminal. In these instances, QoL is often emphasized above all other outcomes.^7,8 Although subtle, individuals working in palliative care consistently remind other providers in lifestyle medicine that their thought process is different. For example, Anandarajah et al ⁹ in this issue, state, “in settings which prolongation of life may no longer be the primary goal . . ., optimizing function as well as physical, emotional, and spiritual well-being become the driving factors in clinical decision making.” The implication in this statement is that these are not the primary driving factors in other areas of lifestyle medicine.

The issue at hand then is if QoL should be the primary driving factor for lifestyle medicine in general. Instead of simply assuming that interventions are improving QoL because they treat disease, should the impact of interventions from a QoL perspective be considered first? In order to address this question, multiple factors should be considered that are both practical and philosophical in nature. The goal of this article is to provide a background into QoL research and discuss in practical terms how a greater focus on QoL could affect treatment planning and be implemented into patient care.

Overview of Quality of Life

The concept of QoL is centuries old and was discussed frequently by ancient philosophers (eg, Aristippus of Cyrene, 435-356 bc). However, the actual use of the term QoL is fairly recent. ¹⁰ A seminal editorial published in 1966 raised the question of how to protect and improve QoL in patients. ¹¹ Soon after this, QoL was introduced as an outcome measure in health care, and in 1977, it became a keyword in the Medical Subject Headings of MEDLINE. It was defined as “a generic concept reflecting concern with the modification and enhancement of life attributes, e.g., physical, political, moral, social environment as well as health and disease.” ¹²

Most of the current definitions of QoL are based on subjective well-being, expectations and phenomenological viewpoints. ¹³ According to the World Health Organization (WHO), QoL is the perception of an individual regarding their position in life considering their goals, expectations, and concerns. ¹⁴ Some argue that in addition to subjective factors described by the WHO, objective factors should also be included. ¹⁵ In summary, the global concept of QoL is a multifaceted/multidimensional phenomenon composed of different domains including physical status and functional abilities, psychological status and well-being, social interactions, economic and/or vocational status, and religious and/or spiritual status.^16,17

In lifestyle medicine, health-related quality of life (HRQoL) is the most frequently discussed QoL construct. HRQoL encompass the aspects of overall QoL that affects physical and/or mental health. ¹⁸ Although measures of a community level HRQoL exists, ¹⁹ the most common applications focus on subjective well-being that is associated with lack of symptoms, one’s psychological state, and the activities they pursue. ²⁰ Physical well-being is typically assessed as a lack of symptomatic complaints, including pain, poor system functioning, lack of sleep, or problems with sexual functioning. Psychological well-being typically includes depression, anxiety and cognitive functioning and the activities include work, leisure, social functioning, and fulfilment of roles. The assumption is that the lack of symptoms will increase the more global concept of QoL as well.

An Issue With Research on Improvements in HRQoL

Numerous studies have shown that HRQoL improves when lifestyle disease is reduced. For example, research in cardiac rehabilitation, ²¹ diabetes management, ²² and obesity treatment ²³ have all shown that HRQoL or psychological well-being improves when symptoms are reduced. One of the main shortcomings with this type of research is that the interventions discussed did not significantly improve the HRQoL of all individuals in the study, and among some individuals, QoL actually decreased. In the case of the above example for obesity treatment, ²³ weight loss was associated with an improvement in depression; however, many individuals did not lose weight, and depressive symptomatology increased among a substantial percentage of participants. One of the issues in current lifestyle medicine research is a lack of knowledge about the impact that interventions have on those who are not “successful.”

In some cases, it is possible that lifestyle interventions significantly negatively affect QoL. Although many explanations can be offered about the causes of decreased QoL in research (eg, natural declines over time, other life circumstances), it is also possible that putting individuals on a diet and exercise regimen negatively impacts their QoL. This may be especially true when patients do not have the expected symptom reduction. Lifestyle change is difficult, and many times changes suggested by health care providers can have a negative emotional response. For example, dietary changes intended to promote health have been shown to worsen mood. ²⁴ Little research is conducted on this issue, and more information is needed to better understand when treatments have a negative impact on patients. Until this is better understood, the consideration of not only physical but psychological and social well-being outcomes is critical when providing care.

Incorporating Quality of Life Into Treatment

A focus on QoL in a broader sense could have a substantial impact on the way that health care providers interact with patients. QoL is an important outcome to patients that is not necessarily dependent on an objective measure (eg, weight, cholesterol, glucose, blood pressure). The use of QoL as an outcome can empower patients to have a say in how they feel their treatment is progressing and take ownership of their care. The combination of traditional health outcomes with QoL provides health care providers a natural way to help patients connect treatment steps with how they want to feel each day. Discussions of this sort are likely to lead to improved provider-patient relationships. ²⁵ Greater provider-patient rapport is consistently linked with improved treatment adherence, retention, and health outcomes,^25-28 including HRQoL.^29,30

While the use of QoL as a treatment outcome would likely have many benefits, incorporating QoL discussions during care involves a number of practical challenges. Addressing the full spectrum of QoL may be uncomfortable for health care providers, many of whom may not have robust training in psychological or social well-being. Additionally, as is typical with strategies that improve provider-patient relationships, QoL discussions would require additional time to each patient encounter. ³¹ It is important for research to address the impact that including QoL discussions in lifestyle medicine may have on traditional patient outcomes. This information can help providers balance the challenges of incorporating QoL discussions into care with the potential benefits in adherence, provider-patient rapport, retention, and physical outcomes.

Conclusion

Incorporating the broad concept of improving QoL is consistent with lifestyle medicine objectives. However, a tendency is seen in focusing heavily on symptom reduction as the primary outcome of treatment and research. This is not to say that a focus on HRQoL is unwise or inappropriate. It may be that lifestyle medicine has specialized to the point that the primary goal should be symptom reduction with less concern about a broader sense of QoL. Conversely, it is possible that a more widened concept of QoL in practice and research should not be solely reserved for palliative care. Ultimately, it is beyond the scope of this article to make this determination but understanding one’s position on this issue is likely to improve interactions with patients.