A 43-year-old woman presents asking about strategies to reduce her breast cancer risk. Her mother was diagnosed with breast cancer at age 48 and her maternal aunt at age 52. She has no personal history of breast disease. Clinical examination is normal. She takes the combined oral contraceptive pill and drinks 10 units of alcohol weekly. Her BMI is 26 kg/m². After appropriate genetic assessment, she is found not to carry BRCA mutations. Which lifestyle modification would provide the greatest reduction in her breast cancer risk?

Reducing alcohol intake to below 5 units per week

Stopping the combined oral contraceptive pill

Achieving and maintaining BMI <25 kg/m² through weight loss

Undertaking regular vigorous physical activity 150 minutes weekly

Adopting a plant-based Mediterranean diet low in processed foods

A 66-year-old man attends after receiving an NHS AAA screening result showing an infrarenal aortic diameter of 4.8 cm. He is asymptomatic. He smokes 15 cigarettes daily, has hypertension treated with ramipril, and his BP is 138/82 mmHg. What is the most appropriate surveillance and management plan?

Repeat ultrasound in 3 months and refer to vascular surgery

Repeat ultrasound in 12 months and reinforce smoking cessation

Immediate referral to vascular surgery for consideration of intervention

Repeat ultrasound in 6 months and optimize cardiovascular risk factors

CT angiography for surgical planning and urgent vascular referral

A 55-year-old woman with a BMI of 32 kg/m² attends for weight management support. She has tried multiple diets without sustained success. She has no other medical conditions. She asks about pharmacological options for weight loss. According to NICE guidance, what is the threshold for considering orlistat in this patient?

BMI ≥30 kg/m² with commitment to dietary and lifestyle changes

BMI ≥25 kg/m² with commitment to dietary changes

BMI ≥28 kg/m² with obesity-related comorbidities

BMI ≥32 kg/m² after failed conservative management

BMI ≥35 kg/m² or BMI ≥30 kg/m² with comorbidities

A 71-year-old woman with type 2 diabetes for 18 years attends for review. Her diabetic eye screening report from 2 weeks ago shows 'proliferative diabetic retinopathy with new vessels at disc in left eye'. She reports no visual symptoms. Her HbA1c is 72 mmol/mol, BP 156/88 mmHg. She has not yet received any ophthalmology appointment. What is the most appropriate action?

Contact ophthalmology to confirm urgent referral has been received and processed

Reassure that ophthalmology will contact her within 2 weeks of screening report

Arrange repeat diabetic eye screening in 3 months to monitor progression

Refer urgently to ophthalmology via GP pathway in case screening referral was missed

Optimize glycaemic and blood pressure control and wait for screening programme referral

A 29-year-old woman attends for preconception counselling. She is planning pregnancy with her partner. She had one previous pregnancy 3 years ago with uncomplicated vaginal delivery. She takes no regular medications and has no chronic conditions. Which of the following screening tests should be offered before conception?

Rubella immunity only, as other infections are tested in pregnancy

No infectious disease screening needed as she had testing in previous pregnancy

Rubella immunity, HIV, hepatitis B, and syphilis serology

Full sexually transmitted infection screen including chlamydia and gonorrhoea

HIV and syphilis testing only if high-risk factors identified

A 31-year-old woman attends with her cervical screening result showing hrHPV positive with low-grade dyskaryosis. She is 8 weeks pregnant with her second child. She had a normal screening result 3 years ago. What is the most appropriate management?

Refer for colposcopy after delivery and postnatal period

Refer for colposcopy within 6 weeks

Refer for immediate colposcopy before 12 weeks gestation

Repeat cervical screening at 28 weeks gestation

Defer all cervical screening until 12 weeks postpartum

A 64-year-old man returns for discussion of his NHS bowel cancer screening result. His FIT result is 78 µg Hb/g faeces. He has no symptoms, no family history of colorectal cancer, and examination is unremarkable. He takes aspirin 75 mg daily for previous myocardial infarction. What is the most appropriate management?

Refer for colonoscopy via the screening programme

Reassure and repeat FIT in 2 years as part of routine screening

Stop aspirin for 2 weeks and repeat FIT test

Arrange urgent suspected cancer (2-week wait) referral to gastroenterology

Arrange faecal calprotectin test to exclude inflammatory bowel disease

A 58-year-old woman attends for NHS Health Check. She has a BMI of 28 kg/m², BP 128/82 mmHg, and smokes 10 cigarettes daily. Bloods show total cholesterol 5.2 mmol/L, HDL 1.4 mmol/L, HbA1c 39 mmol/mol. Her QRISK3 score is 8.5%. She is motivated to improve her health. What is the most evidence-based lifestyle intervention to offer?

Smoking cessation support with varenicline or combination NRT

Exercise programme targeting 150 minutes moderate activity per week

Weight loss programme targeting 5-10% body weight reduction

Mediterranean diet advice with emphasis on reducing saturated fat

Combined lifestyle intervention addressing all modifiable risk factors

A 67-year-old man with type 2 diabetes for 15 years attends for review. His diabetic retinopathy screening report shows 'moderate non-proliferative diabetic retinopathy with diabetic maculopathy' in both eyes. His HbA1c is 68 mmol/mol and BP 142/86 mmHg. What is the most appropriate action regarding his eye care?

Refer to ophthalmology for assessment within 6 weeks

Increase screening frequency to 6 months

Continue annual diabetic eye screening

Arrange urgent ophthalmology referral within 2 weeks

Refer to optometry for visual acuity assessment

Lifestyle interventions - Free UK Medical PG Review

Quick Overview

Lifestyle interventions are evidence-based brief interventions targeting smoking, alcohol, diet, and physical activity-the four major modifiable risk factors in primary care. NICE NG209 emphasizes structured approaches using validated tools and motivational interviewing techniques to support behaviour change, with clear referral pathways to specialist services when needed.

Core Facts & Concepts

🚬 Smoking Cessation

Very Brief Advice (VBA): ASK-ADVISE-ACT framework (30 seconds)
Pharmacotherapy: Varenicline (first-line), NRT, or bupropion for ≥12 weeks
Success rates: Combination NRT + behavioural support = 15-20% quit rate at 1 year
Referral: Stop Smoking Services for intensive support (4+ sessions)

🍺 Alcohol Interventions

AUDIT-C screening: Score ≥5 (men) or ≥4 (women) = harmful drinking
Brief intervention: FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy)
Units: 1 unit = 10mL pure alcohol; max 14 units/week spread over ≥3 days
Referral threshold: AUDIT score >20, or dependence features

Figure 1: AUDIT-C questionnaire showing three-question screening tool with scoring system

🥗 Diet & Nutrition

5-a-day: ≥400g fruit/vegetables daily (80g portions)
Eatwell Guide: Visual plate model (⅓ fruit/veg, ⅓ starchy carbs, protein, dairy, minimal fats/sugars)
BMI thresholds: Overweight ≥25, Obese ≥30, refer at ≥40 or ≥35 with comorbidities
Referral: Tier 3 weight management services (specialist MDT)

🏃 Physical Activity

Adults: 150 minutes moderate (or 75 vigorous) weekly + 2 strength sessions
Older adults: Include balance/coordination activities 2×/week
Prescription: Exercise referral schemes for inactive adults with long-term conditions

Problem-Solving Approach

1. Assess readiness to change (Stages of Change model)

Pre-contemplation → Raise awareness, avoid confrontation
Contemplation → Explore ambivalence, provide information
Preparation → Set specific goals, action planning
Action/Maintenance → Support, relapse prevention

2. Use motivational interviewing techniques

OARS: Open questions, Affirmations, Reflective listening, Summarizing
Elicit change talk ("What concerns you about...?")
Avoid the "righting reflex" (telling people what to do)

3. Apply validated screening tools

PHQ-9: Depression screening (score ≥10 = moderate-severe)
GAD-7: Anxiety screening (consider psychological barriers)
Fagerström: Nicotine dependence (score ≥6 = high dependence)

4. Set SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound)

5. Arrange follow-up

Week 1-2: Critical period for relapse prevention
3-6 months: Long-term behaviour maintenance

🚩 Red Flags for Immediate Referral: Alcohol withdrawal risk, severe depression (PHQ-9 ≥20), eating disorder features, unstable angina with exercise

Analysis Framework

Intervention	Tool	Brief Intervention Duration	Specialist Referral Criteria
Smoking	Fagerström Test	5-10 minutes	Failed 2+ quit attempts, complex needs
Alcohol	AUDIT-C/AUDIT	5-20 minutes	AUDIT >20, dependence, safeguarding
Diet	BMI, waist circumference	10-15 minutes	BMI ≥40, ≥35 + comorbidity, eating disorder
Physical Activity	GPPAQ	5-10 minutes	Cardiovascular risk, specialist conditions

Key Discriminators for Intensity

Low intensity: VBA, written materials, signposting
Medium intensity: Brief intervention (5-20 min), self-help resources, apps
High intensity: Extended support (4-12 weeks), group programs, pharmacotherapy
Specialist: Complex comorbidities, previous failures, safeguarding concerns

Visual Aid

Key Points Summary

✓ VBA framework: ASK-ADVISE-ACT takes 30 seconds and increases quit rates by 30%

✓ AUDIT-C cutoffs: ≥5 (men), ≥4 (women) triggers brief alcohol intervention

✓ Motivational interviewing: OARS technique (Open questions, Affirmations, Reflections, Summaries) enhances engagement

✓ Physical activity target: 150 min moderate weekly-even 10-minute bouts count

✓ Referral thresholds: BMI ≥40, AUDIT >20, Fagerström ≥6, or 2+ failed quit attempts

✓ Follow-up timing: Week 1-2 critical for relapse prevention; reassess at 3-6 months

✓ Combination approach: Pharmacotherapy + behavioural support doubles success rates for smoking/alcohol