It can feel daunting to bring up complex issues with patients around carbon emissions and the climate crisis. How can this fit in with everything else during a consultation?
We have tried to influence the behaviour of our patients for many years with advice on smoking cessation or safe alcohol consumption. We look at their health goals, their barriers to change, the rewards to them as individuals, and how they measure their success, and then help them find the resources they need to achieve their aims.
With more of the population becoming aware that we need to take more positive actions to address our environmental impact and contributions to the climate crisis, now is a better time than ever to link the positive health benefits for an individual with the impact our behaviours and lifestyle have on the planet. People are more likely now than they were to change behaviour based on environmental goals or impacts. I am fortunate as I’ve been back to university and studied environmental issues, but we can all become familiar with the basics. Indeed, we all have a responsibility to do so.
There are various approaches to behaviour change we use in our daily work. I loosely follow the “5 A’s” model comprising Assess (health risks and goals), Advise (information giving), Agree (appropriate goals and methods), Assist (behaviour change strategies), and Arrange (follow up and ongoing support). I find it easier to talk with patients about behaviour change and environmental/sustainability issues when the issues are connected with their current presenting problems. For me, this is part of the treatment phase—looking for the maximum benefit for the patient and the least damage to the planet. Can I help the patient improve their health by living a more sustainable lifestyle?
There are some obvious links.
A mother is worried about her daughter’s breathing and concerned she may be developing asthma. After clinical assessment, including serial peak flow monitoring, we can begin a wider discussion about the impact of local air pollution from driving, the impact on health, and different methods of transport to school. Walking will benefit the daughter’s health and allow her to avoid the worst air quality on the main roads benefit the community by avoiding using the car for short journeys. I don’t know of a respiratory illness that isn’t benefitted by having clean air to breath and more physical activity.
A patient with hypertension and heart disease will benefit from lifestyle advice on physical activity. Suggesting ditching the car and walking or cycling for the daily commute or for leisure pursuits can help the patient physically, mentally, and financially. This is lower carbon—good for the patient and good for the planet—and can be expressly highlighted as such. For the change to be permanent, it must be relevant to their way of life. For years I used to cycle on home visits. I learned several things: firstly, it is important to live by example; secondly, I was always the surprise guest on the doorstep with my cycle helmet (‘Why are you not driving Doctor?” opens up the conversation about air quality benefits for others as well as keeping fit); and, thirdly, none of the local care homes have cycle racks for bikes (which begs the question “How would their staff ever start cycling to work?” to which the answer is “Probably never”).
For an anxious patient ecotherapy—a therapeutic treatment involving nature-based activities—can be recommended. Suggesting daily walks helps with structure and routine, provides access to green environments, can improve sleep patterns and levels of physical activity, and offers positive distraction. Reconnecting with the slower pace of nature can be framed as beneficial to the patient, but also beneficial for the planet. We saw people report gains to their mental health from access to nature and outdoor spaces over the covid lockdowns.
Overweight patients with diabetes need an alternative reason to improve their diet. Providing everyone access to healthy diets without destroying our common planetary home is one of the greatest issues facing humanity. Poor diet is a major contributor to environmental and planetary damage and impacts on human health with 11 million premature adult deaths annually. The EAT-Lancet forum advised a diet with more plant-based foods and fewer from animal sources to be healthier for humans and the planet. GPs advise patients on diets with relatively little specific training. The easiest way I have found to talk to patients who have raised weight loss, healthy eating, or diets that are good for bowels and hearts is with a picture of the Canadian Food Plate. This simple image is an updated version of the Eatwell Food Plate, but advises more fruit and vegetables, protein foods with less meat, and carbohydrates that move away from white starch foods (potatoes, pasta, rice) and promote whole grain. This helps identify barriers for patients such as access to food stuffs, personal preference, and finances and can provide an opportunity to intervene. For example, for patients who worry about the cost of a healthier approach, I recommend A Girl Called Jack by Jack Monroe as an inspiration for cooking healthily on a budget. I have lost count of how many times I have used her blog and webpage for patients.
The patient with a fear of flying provides an opportunity to address reducing air travel. Rather than prescribing diazepam for the flight to Spain (or elsewhere in Europe) an option is to discuss flight free options—the benefit to their personal health through lessening their anxiety and the benefits to the planet from less air travel. Knowing there are websites for planning journeys and the travel (and company) can be more important than the destination. Highlighting the positives of an alternative way to travel results in the same outcome (a European holiday), reduces the medicalisation (pill for every ill) and the environmental impact, and has been successful for several patients.
Contraception is controversial. I offer it but not for environmental reasons. It is often quoted that having fewer children is one of the greatest actions an individual can have. However, in the UK, the birth rate is about 1.87 babies per woman. I suspect contraception delays a wanted pregnancy, but for most women it isn’t being used to prevent pregnancy on environmental grounds, although I know there are some exceptions.
Some patients can be encouraged to make public their pledge to improve their lifestyle and health—for example, through a sponsored swim or walk for charity. However, it is the daily actions of walking to school or work that leads to the longer-term benefits.
In each case, by asking, the patient shows they are interested and ready for change. If the doctor provides information and choice and directly links their health concerns to personal and planetary improvements the patients can weight up their options and take action. However, not all patients are interested, and that’s OK. But those who are interested can be encouraged to change their behaviour for both personal health improvements and global planetary gain.
Doctors have not been fearful to tell patients that smoking is bad for them, and I don’t think we need to be fearful about linking their health with the planetary impacts. I am optimistic that patients are increasingly receptive to environmental issues, which can be translated into co-benefits for the patient and the planet.
Dr Matthew Sawyer
Matthew Sawyer has been a GP in the North East of England for about 15 years. He works as a front line GP two days a week. The rest of the week is spent running a sustainability consultancy – SEE Sustainability – working to improve planetary health and human health. He covers sustainability issues facing primary care such as helping practices understand their carbon emissions footprint from running their practice and helps produce a roadmap to work towards net zero. This blog was first published by the BMJ.