"Unhealthy Lifestyle Main Cause of Heart Disease."
"Reduce Cancer Chances by Making Lifestyle Choices."
"Unhealthy Lifestyle Can Knock 23 Years off Lifespan."
These are just a few recent headlines in our daily diet of health news, which makes liberal use of the word "lifestyle," a media-friendly hook for popularizing health risks that tips our lens of focus to the individual.
A casual read of both the public discussion about health and scholarly literature might suggest that lifestyle is the central determinant of population health. The word "lifestyle" as a medical subject search term in PubMed produces more than 67,000 results, while a "lifestyle and health" Google search yields a mind-boggling half-billion results.
The notion of lifestyle as central to health goes back more than 50 years, as studies such as the Framingham Heart Study in the U.S. and the
World Health Organization's MONICA project in Europe sought to identify particular behavioral risk factors, such as smoking or physical inactivity, that influence mortality and illness. That concept expanded in the 1970s, as our attention in the U.S. shifted from infectious to chronic diseases, with a focus on which risk factors predict chronic conditions. The long-running and influential Nurses Health Study, which began in 1976, has published voluminous findings that center around the role that lifestyle and behaviors play in promoting good health. In 1985, the hallmark Report of the Secretary's Task Force on Black and Minority Health, discussed lifestyle in the context of minority health disparities, including a suggestion that lifestyle influences the homicide rate. More recently, the United Nations referred to chronic conditions as "lifestyle diseases," focusing on the risk factors of smoking, unhealthy diet, and physical inactivity.
There is, without question, ample evidence that adverse behaviors influence health. But I would argue that our indiscriminate use of the world "lifestyle" is dangerous and could set back the goal of public health: improving the health of populations.
Framing health this way is convenient, but not accurate.
What the overreliance on "lifestyle" leaves out is the fact that our behaviors are inextricably linked to a broader environmental context.
Excluding those external 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? Not always.
While the American College of Gastroenterology suggests that lifestyle changes (diet and tobacco and alcohol cessation among them) are first-line therapy for gastroesophageal reflux disease, a systematic review of research published between 1975 and 2004 concluded there was not enough evidence to support all lifestyle modification recommendations. Similarly, an NIH trial started in 2001 that followed more than 5,000 diabetic adults for 11 years and randomly assigned them to an "intensive lifestyle intervention" 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.
The focus on lifestyles suggests that we can make people better, if only they would change their ways. But it is well-established that action on individual behavior alone, absent environmental modification, will yield little progress against intractable problems such as obesity. We also know that our ability to predict health in individuals, characterized by any single risk factor, is extraordinarily limited. The "lifestyle" bandwagon suggests that the production of complex diseases like cancer and diabetes rests within individuals, when in fact it does not.
The word "lifestyle" now pops up with regularity in discussions of risk factors and disease causation. In a telling example, 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 on the report, including those in Time magazine and on the American Cancer Society website, warned of unhealthy "lifestyles" in their headlines. So it is perhaps not a huge step from there to longevity coach Dan Buettner's assertion in the opening of his TED talk, "How to Live to Be 100+," that 90 percent of a person's life expectancy is affected by lifestyle. The talk has been viewed 2.5 million times.
Our lifestyle framing is faulty, with limited utility. The idea that an individual locus of control -- a set of psychological, internal stimuli -- drives health outcomes sends the wrong message. This almost inevitably leads to the stigmatizing of the individual with the poor lifestyle, while excusing us from acting on causes that might actually bring about a broader, sustainable population health change.
It is time we stop talking about "lifestyle" as the key to good health -- and start talking about the conditions in which we style our lives.