North Lewisham PCN

Lifestyle Medicine Diabetes Service

A targeted lifestyle medicine service for people living with pre-diabetes and diabetes, delivering significant improvements in HbA1c and metabolic health.

Context

Building on the success of the North Lewisham Lifestyle Medicine Service, this programme was developed to provide more focused support for patients living with pre-diabetes and diabetes within the PCN population.

The Challenge

Patients living with diabetes often require more tailored, sustained support to achieve meaningful improvements in glycaemic control. Traditional approaches can lack the personalised, behavioural focus needed to support long-term change.

The Approach

  • Delivered by Health and Wellbeing Coaches and Nutritionists funded through ARRS

  • Combination of one-to-one and group coaching sessions

  • Structured around the six pillars of lifestyle medicine, with a focus on diabetes management

  • Additional emphasis on nutrition, glucose regulation and metabolic health

  • Open to adults within the PCN living with pre-diabetes or diabetes

Results and Outcomes

Patients living with diabetes

  • 100% of patients reduced their HbA1c

  • Average reduction of 24 mmol/mol at 3 months (n=26)

  • Average reduction of 32 mmol/mol at 6 months (n=9)

  • 26% of patients (8 out of 31) were no longer living with diabetes

  • 6 patients achieved HbA1c <42 mmol/mol

Patients living with pre-diabetes

  • 100% of patients reduced their HbA1c

  • Average reduction of 5 mmol/mol at 3 months (n=13)

  • 77% of patients achieved HbA1c <42 mmol/mol

  • Sustained reduction at 6 months (n=8)

Patients were assessed using a combination of biometric measures (including HbA1c, weight and blood pressure) alongside validated wellbeing scores.

Key Takeaways

  • Targeted lifestyle medicine interventions can deliver significant improvements in glycaemic control

  • Combining group and one-to-one support enables both education and personalised change

  • Integrating lifestyle medicine into existing NHS structures is both feasible and effective

  • Sustained engagement is key to achieving long-term metabolic improvements

Delivery Team

Delivered in partnership with:

  • North Lewisham PCN

  • Service Creator & Lead: Dr Camille Hirons

  • Team: Charlie Tunmore, Lily Lang, Nana Ocran, Awetchy Likofo, Dr. Barnaby Hirons

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Co-designed service delivering measurable outcomes across a diverse population

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Scaling Lifestyle Medicine services through Integrated Neighbourhood Teams in Lewisham