Are lifestyle diseases in our control?
Health is not just about individual choices.
Are heart disease, Type 2 diabetes, and other “lifestyle diseases” in our control?
The simplistic answer is yes. There is no doubt that we would have a lot less heart disease, type 2 diabetes, cancer, and more, if everyone followed an ideal lifestyle, with excellent nutrition, regular exercise, no smoking, no alcohol, etc. Indeed, by definition, “lifestyle diseases” are shaped by our lifestyle. It’s easy to jump from here to the conclusion that your fate is in your hands (with the exception of genetically-driven risks).
The individualistic narrative - that we are fully in control - is everywhere. It’s a view that I bought into, until recently. Things began to shift for me during the pandemic, when I immersed myself in the public health world (shout out to my stellar colleagues at
!)Today, I want to help you join me in seeing diseases through the public health lens. Through this lens, diseases are not just the result of poor choices. They are also a result of broader social forces that impact our biology, our options, and our behaviours.
The term “social determinants of health” (SDOH) is widely used to describe the external factors that influence our health and disease status. Factors like education, food security, job security, physical environment, social connections, and gender. The impact of these factors is not trivial. A Canadian report on social determinants of health asserts that: “The primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living and working conditions they experience.”
To bring this idea to life, let’s look at some data on diabetes from the US CDC. As shown in the chart below, the risk of diabetes (primarily type 2) is tightly linked to income. In the highest income bracket (family income 5x higher than the federal poverty line or greater), nearly 6% of adults are diagnosed with diabetes. This percentage steadily climbs by income until it reaches 14% of adults among those with an income below the federal poverty line.
It’s a similar story with education. Among adults with more than a high school education, roughly 7% of adults are diagnosed with diabetes. Among those who did not graduate high school, the rate is nearly 14%.
Diabetes rates also vary dramatically by race. Among White adults, 7% have been diagnosed with diabetes (and many more undiagnosed!). Among other races, rates of diabetes range from 9% (Asian) to 12% (Hispanic and Black) to 14% (American Indian or Alaska Native) - double the rate in white adults.
If you’re like me, you’re probably wondering about the mechanisms underlying these factors. How exactly do income, education, and race influence health and disease? It turns out that the answers are not as simple as we may think.
With income, it’s natural to assume that access to treatments is the main driver. This is clearly a contributing factor, but it’s not the only factor. For example, lack of job security can cause stress, which can have real physiological consequences. Likewise, you may think that education only matters because it predicts income. Again, this is part of the answer, but not the full story. Education impacts many aspects of our health, from how we approach choices (like vaccines), to how we navigate the healthcare system. Similarly, the associations between race and health outcomes partially reflect income trends, but there is much more going on, such as food deserts and healthcare quality. The more I dig into the field of social determinants of health, the more I appreciate the complex landscape of forces that impact our health.
The story of diabetes in the US is just one of many examples of how social factors impact our health. It’s a similar situation for other “lifestyle diseases” like heart disease, and in other parts of the world, even in Canada, with its (supposedly) universal health care system.
In a recent podcast with Dr. Annalijn Conklin, a social epidemiologist, we spent a good chunk of our chat talking about how social factors influence health and disease. One insight that stood out to me was her comment that many behaviours that we think of as conscious choices are actually unconscious reactions to our situation.
To be clear, I’m not saying that individual actions don’t matter. They absolutely do. Anyone who consciously invests in their health deserves credit for doing so. I’m still proud of my commitment to exercise, nutrition, and mental health. My point is that this individualist mindset overlooks many other important forces at play.
With this expanded lens, let’s revisit our our original question: Are lifestyle diseases in our control? A more complete answer is: yes and no. The burden of diseases like diabetes and heart disease can absolutely be reduced through our choices, and our efforts. But, these “choices” are not realistic unless we have the vital resources and supports we need.
Opening my eyes to the role of social factors has been profoundly educational and humbling. I owe an apology to anyone that I silently judged for “not taking care of themselves”. I’m also ashamed that it took me so long to recognize that much of the credit for my health goes to the privileged bubble I inhabit.
In my bubble, we can easily access fresh, healthy, delicious foods. We have free time to cook, be active and unwind - we don't have to work two jobs to pay the bills. We have extended health insurance, and can afford professional help for mental health issues. In high school, we talk about which university we will attend - not if we will attend. The list goes on and on. These advantages make it a whole lot easier to make healthy "choices".
I hope this brief peek through the public health lens helped you understand what it takes to combat diseases at a population level. If this resonates with you, please share this post. Check out the resources and podcast below to learn more.
Best,
Related Podcast Episodes
How Social Factors Impact Your Health with Dr. Annalijn Conklin. Check out Get Real Health with Dr. Chana Davis (Ep 59) on my website, Apple Podcasts or Spotify.
Dr. Annalijn Conklin is a social epidemiologist who studies how diseases are shaped by social factors, and how these intersect with gender. She is currently an Assistant Professor at the University of British Columbia where she leads a research program to support healthy aging and reduce heart health inequities.
Recommend Resources
Social Determinants of Health (SDOH): The Canadian Facts: Why SDOH are important; how Canada is doing in addressing them; and what can be done.
Social Determinants of Health: Overview & Examples (US CDC)
Social Determinants of Risk and Outcomes for Cardiovascular Disease (American Heart Association Statement, 2015)