On ‘Lifestyle’.

A casual read of both the public discussion about health and the peer-reviewed literature might suggest that lifestyle is the central determinant of population health. The word “lifestyle” as a medical subject heading search term in PubMed produces more than 67,000 results, while a “lifestyle and health” Google search yields a suitably mind-boggling half-billion results.

The notion of lifestyle as central to health production goes back more than 50 years, as studies such as Framingham and Alameda County in the US and the MONICA project led by the World Health Organization (WHO) in Europe focused mainly on identifying particular behavioral risk factors (e.g. smoking and physical inactivity) that have a significant effect on mortality and morbidity.

The centrality of lifestyle to our thinking about health was solidified in the 1970s, partly as our focus of attention shifted from infectious to chronic disease in the US, with an attendant focus on which risk factors predict chronic conditions. The Nurses Health Study, which began in 1976, is one of the longest-running and most influential studies of health determination and has since published voluminous findings that center around the role that lifestyle and behaviors play in promoting good health. The centrality of lifestyle was similarly emergent in other countries. A report published by the Public Health Agency of Canada in 1974 introduced a four-field framework (lifestyle, environment, human biology, and health care environment) proposing to shift the focus of health policy to include these four areas. One of the main positions in the report, echoed in the UK in 1976 in “Prevention and Health, Everybody’s Business,” suggests that individuals are responsible for their health through their choice of lifestyles.

In 1985, the hallmark Report of the Secretary’s Task Force on Black and Minority Health, also known as the Heckler Report, discussed lifestyle in the context of minority health disparities. Although comprehensive in its focus on cultural and other macro determinants, it also suggested that lifestyle influences homicide (“the high homicide rate can be related to … lifestyle, or individual and group ways of life”), differences among groups (“differences in socioeconomic status, culture, and lifestyle are hypothesized to explain the lower relative mortality of Asian/Pacific Islanders in the United States”), and recommendations for improved health in general (“health education activities should foster the development of lifestyles that maintain and enhance the state of health and well-being”).

The United Nations recently referred to chronic conditions as “lifestyle diseases,” focusing on the modifiable risk factors of smoking, unhealthy diet, and physical inactivity; WHO produced a podcast titled “Do Lifestyle Changes Improve Health?”

There is ample evidence that adverse population health behavior influence the health of those populations. However, I would argue that our indiscriminate use of the world “lifestyle” is perilous and might set our cause—improving the health of populations—further back than we might think.

Why? I offer four reasons.

First, it has long been argued that the term “lifestyle” is often used vaguely, without reflection on its meaning and without grounding in the “social and cultural location of health behaviors.” This point is well-taken and indubitable. Sophisticated writers who use the term “lifestyle” situate it within its relevant cultural context. For example, the Heckler Report, mentioned above, also notes that homicide “can be related to … external environment including physical, historical-cultural, social, educational, and economic environments.” The tension, however, is one of emphasis. The compelling and mass appeal of lifestyle makes for its ready as a central determinant of disease over and above other drivers, casting aside the differences in life opportunities that may matter more than behavioral factors. There is ample historical precedent that such misemphases are quite likely to result in attendant shifts in resources dedicated to a particular problem and attempts at its solution, at the expense of other areas of intervention that may be more likely to find success.

Second, and relatedly, there is little question that our behaviors are inextricably linked to our broader context, and that the emphasis on lifestyle at the exclusion of other factors incorrectly elevates the role of personal agency in health determination. Perhaps this is most simply illustrated by asking the question: Do changes in lifestyle produce changes in health? Perhaps this is most simply answered through illustration. While the American College of Gastroenterology suggests that lifestyle modifications (diet, body position, tobacco, alcohol, and obesity) are the first-line therapy for gastroesophageal reflux disease (GERD), a systematic review of relevant literature published between 1975 and 2004 concluded that evidence to support lifestyle modification recommendations has not been well established. Although weight loss and head position improved the pH profile and symptoms, other lifestyle changes had no evident effect on substantiated GRED. Another study analyzed two Cochrane systematic reviews to assess the efficacy and safety of lifestyle interventions for the treatment of acute and chronic gout. The analysis concluded that while there is observational evidence linking lifestyle risk factors to the development, there are no high-quality trials to either support or refute the effectiveness of lifestyle interventions in the treatment of acute or chronic gout. And an NIH trial initiated in 2001 called Look Action for Health in Diabetes followed more than 5,000 diabetic adults for 11 years and randomly assigned them to an “intensive lifestyle intervention.” The trial ended earlier than expected when, despite reductions in body weight and other risk factors, there were no significant differences in cardiovascular disease rates between the different groups. I have written about this conundrum before, noting it to be a product of the ineluctable role of context that, if neglected, can obviate our efforts, however well-intentioned, to improve health through improving individuals behavior.

Third, lifestyle suggests not only that by changing lifestyle we can make individuals better, but also that we can predict we will do so, if only we can change lifestyles now. Unfortunately, it is well-established that action on individual behavior alone, absent environmental modification, will yield little action against intractable problems such as obesity. We also know that our capacity to predict health in individuals, characterized by any single risk factor, is extraordinarily limited. The “lifestyle” bandwagon suggests the production of complex diseases rests within individuals when in fact it does not, and implies that once we identify the culprit lifestyle we can improve an individual’s health, which we have little confidence we can.

Fourth, the word “lifestyle” is a victim of its own seductiveness, providing a media-friendly hook for popularizing health risks at the expense of harder to synthesize, but more accurate, pictures of disease causation. In a telling illustration, the Centers for Disease Control and Prevention (CDC) published a report called “Potentially Preventable Deaths from the Five Leading Causes of Death—United States, 2008–2010” that did not mention the word “lifestyle,” yet several articles referring to the report called out “lifestyles” in the headline, including those in Time magazine and the American Cancer Society. It is perhaps then a small step away to longevity coach Dan Buettner opening his TED talk, “How to Live to Be 100+,” with a reference to the Danish Twin Study and a statement that 90 percent of a person’s life expectancy is affected by lifestyle. This talk has been viewed 2.5 million times.

In sum, our lifestyle framing stands to be faulty framing with limited utility. An overreliance on the word tips our lens of focus to an individual locus of control—a set of psychological, internal stimuli that lead to the way in which the individual lives. This almost inevitably leads to the stigmatizing of the individual with the poor lifestyle, exonerating us from action on the causes of that same lifestyle that might indeed bring about a longer-term and sustainable population health change. It is probably time we stop talking about “lifestyle.”

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful for the contributions of Laura Sampson and Salma MH Abdalla MBBS, to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/