The Health Policy Partnership. Developing credible resources to help inform policymakers about key health issues across the globe. A range of international healthcare policy change research topics including; Person-centred care, NASH, BRCA, etc.
15 September 2022
As modern societies have experienced a transition from infections to non-communicable diseases (NCDs) being the main source of ill health, we have also changed the way we talk about health. Heart disease, obesity and diabetes in particular are often described as ‘lifestyle diseases’, caused by unhealthy choices in the way we live our daily lives. The PubMed database shows hits for ‘lifestyle’ in medical journals growing from just two counts in 1970 to 13,000 in 2021.
This framing holds back our understanding of the real causes of NCD epidemics. It makes healthcare harder to resource and deliver. And it actually prevents policy progress.
Seeing the rise of NCDs as ‘lifestyle’-driven misrepresents the evidence. One environmental cause – outdoor and indoor air pollution – leads to more deaths from NCDs globally than so-called ‘lifestyle’ causes such as high body mass index and alcohol consumption (in fact, air pollution is a risk factor for obesity). Other factors such as extreme heat and weather are growing causes of NCDs (and deaths) that are not determined by individual lifestyle choices.
The food we eat is as important to health as the air we breathe, and diet is commonly framed as a behaviour determined by bad ‘lifestyle’ choices. But unchosen social circumstances strongly shape these choices, whether through stress-eating or through income constraints. Even before we are born, our metabolism is affected by the stress our mothers experience – so if your parents had money worries or suffered a bereavement, you will be more susceptible to obesity and other health problems regardless of your lifestyle.
Heart disease, obesity and diabetes in particular are often described as ‘lifestyle diseases’. PubMed shows hits for ‘lifestyle’ in medical journals growing from just two counts in 1970 to 13,000 in 2021.
Children today are ‘drowning in a flood of unhealthy food and drink options’. The food we eat is driven by what is on sale and at what price, how it is marketed (including positioning on the shelf), what we have access to and how it is processed. Many deprived neighbourhoods are fresh food deserts or swamped by fast food outlets. Fat, salt and sugar content in convenience foods is determined by their manufacturers, not by their consumers. The shift to ultra-processed foods (now more than half of the UK’s average shopping basket) makes the same nutritional choices as a generation ago more fattening and health harming. There is even evidence these types of foods drive people to eat more and stimulate the same synapses as addiction. This sudden shift in diet has been mostly driven by industry, exacerbated by social circumstances rather than choices.
Huge progress has been made to destigmatise HIV and mental illness, so that people are more likely to seek help. Yet the continued shaming of a person with a ‘lifestyle disease’ makes them less likely to access services. More than half of people with diabetes in a US study reported perceiving stigma, reducing adherence to self-management and impacting their mental health.
That is not to say that healthcare professionals, and health policies, should not address behavioural risks such as smoking, alcohol consumption, diet and physical activity. But these should be addressed in the context of a person’s social environment rather than as issues of morality or willpower. With the label of individual choice removed, the person and their healthcare professional can work together more collaboratively to put in place the changes in the social environment – removing the stresses and triggers, providing strategies to access support – that could enable them to actually improve their health.
Governments are less likely to channel resources to people who are perceived as undeserving. Surgery is already rationed for people categorised as obese, and public health efforts are concentrated on less effective health promotion and education approaches that target conscious processes, often exacerbating inequalities. In Germany and Spain, some treatments for obesity are restricted by insurance funds because they are deemed ‘lifestyle choices’ rather than clinical needs. Clinicians may also hold biases about weight that can impact their provision of care.
Awareness of health inequalities is low in public debate, and when the topic is discussed in the media it is usually presented through the lens of lifestyle differences, playing into the already existing frames of poverty as a moral choice. Reinforcing this language in policy discussion prevents better public understanding of the wider drivers of health and the policy solutions required to address them.
Policy researchers are part of this debate, and we need to play our part in reframing NCDs as being driven by our social and commercial environment, rather than lifestyle choices.
Research commissioned by the Health Foundation in the UK, echoing similar findings in the US, found that the dominant frame of individual responsibility in public discourse is so strong that any reference can crowd out acceptance of wider social drivers. Focus groups found that the wide gaps in COVID-19 mortality were perceived as being caused by individual lifestyle failures rather than by underlying inequalities in living and working conditions.
Policy researchers are part of this debate, and we need to play our part in reframing NCDs as being driven by our social and commercial environment, rather than lifestyle choices. We have done it before – just 20 years ago smoking was framed as a lifestyle choice, to be addressed by information to allow individuals to make a decision for themselves. We have seen this frame being replaced by a consumer- and worker-protection perspective, leading to major advances against the commercial drivers of smoking. The World Health Organization has just launched an eye-catching campaign to reframe alcohol misuse as a commercially driven trend rather than a lifestyle choice, and the new EU strategy on NCDs promises to address alcohol marketing.
A recent BMJ comment called on the health research community to ‘find better ways to tell the stories that matter, and better ways to counter the pollution of discourse on health’. I believe that the ‘lifestyle’ framing is part of that pollution, and am dropping the word from my health policy language. It’s time to clean up our act.