The Psychology of Lifestyle

Promoting Healthy Behaviour

Kathryn Thirlaway, Dominic Upton

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781135267278
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Improving lifestyles is thought to be one of the most effective means of reducing mortality and morbidity in the developed world. However, despite decades of health promotion, there has been no significant difference to lifestyles and instead there are rising levels of inactivity and obesity.

The Psychology of Lifestyle addresses the role psychology can play in reversing the trend of deleterious lifestyle choices. It considers the common characteristics of lifestyle behaviours and reflects on how we can inform and improve interventions to promote healthy lifestyles. Health promotion has taught people what a healthy lifestyle is – now we need to enable people to live that life. The chapters cover key lifestyle behaviours that impact on health –smoking, eating, physical activity, drinking, sex and drug use – as well as combinations of behaviours. Each chapter contains interventions that have been developed to influence and promote lifestyle change among patients and clients.

This unique book will enable readers to develop a clear theoretical and practical grasp of the psychological principles involved in all aspects of lifestyle change. It is an invaluable resource for students and professionals committed to health promotion within all health-related disciplines.

1 Conceptualising lifestyle psychology

There are people who strictly deprive themselves of each and every eatable, drinkable, and smokable which has in any way acquired a shady reputation. They pay this price for health. And health is all they get for it.

Mark Twain

At the end of this chapter you will:

• have a working definition of lifestyle diseases and lifestyle behaviours
• understand the development of a lifestyle model of disease
• be aware of the problems with measuring lifestyle behaviours
• recognise the multiple influences on lifestyle choice.

The decision to write a text on lifestyle psychology reflects an appreciation of the importance of the government and policy makers’ use of the term lifestyle to refer to diseases where behaviour plays a part in the aetiology of the condition. In a speech in 2006, the then prime minister of Great Britain, Tony Blair, called for ‘lifestyle change’ to relieve the pressure on the National Health Service (BBC News 2006). The prime minister suggested that ‘failure to address bad lifestyles was putting an “increasing strain” on the health service’. The centrality of the message, the role of lifestyle in health, and the role of psychology in promoting and improving lifestyle will form the focus of this text.

The term ‘lifestyle diseases’ is now commonly used and implies that not only are there a number of diseases that have in common a behavioural influence in their development, but also that there are behaviours that collectively contribute to a ‘lifestyle’. Furthermore, the use of the term lifestyle implies related rather than discrete behaviours (Dean et al. 1995). One of the challenges for this text is to evaluate the nature of the relationship between lifestyle behaviours and the implications for lifestyle change. Lifestyle diseases and lifestyle behaviours are commonly referred to in the media, government documents and academic papers and are intuitively understood by this broad range of audiences although there is no consensus about which diseases and consequently which behaviours can come under the umbrella term of lifestyle. As early as the 1980s the World Health Organisation (WHO) had recognised the emergence of a concept of lifestyle and offered the following definition:

Lifestyles are patterns of (behavioural) choices from the alternatives that are available to people according to their socio-economic circumstances and the ease with which they are able to choose certain ones over others.

(WHO 1986: 118)

This early definition of ‘lifestyle’ recognises the contextual element of choice and how choice may be limited by factors out of the control of the individual but does not specify which behaviours are considered to be key in terms of maintaining health and preventing disease. Indeed the WHO states: ‘it is one of the WHO’s responsibilities to ensure that the lifestyle concept is not used as a blanket explanation in which the victim is always blamed’ (WHO 1986: 118).

Nevertheless, despite this clear message that behavioural change cannot be left to the individual to achieve but must be addressed at societal and policy level, the paper concludes by commenting that: ‘We have reached the age of responsibility’ (WHO 1986: 124). In this way the notion that chronic diseases can be avoided and that we, both at an individual and at a societal level, are responsible are clearly linked to the use of the term lifestyle.

Dean et al. (1995) describe lifestyle as a sociocultural phenomenon. They argue that patterns of behaviour interact with the situational context to create a lifestyle. Cultural values and beliefs shape behavioural practices which are either constrained or encouraged by specific socio-economic conditions. Both of these authors hold a view of lifestyle as a pattern of behaviours (WHO 1986; Dean et al. 1995).

Lifestyle diseases

Doyle (2001) suggests that the six major lifestyle diseases are coronary heart disease, stroke, lung cancer, colon cancer, diabetes and chronic obstructive pulmonary disease. The rationale for their inclusion is that they ‘trace mainly to imprudent living’ (Doyle 2001). While Lloyd and Foster (2006) and Wanless (2004) agree with Doyle (2001) in his choice of those diseases which can be given the title of lifestyle diseases, other authors would widen the group. For instance, Bugel (2003) additionally included cancers in general and osteoporosis as examples of lifestyle diseases.

One of the problems with attempting to arrive at a conclusion about what constitutes a lifestyle disease is the myriad of definitions under which diseases are categorised. For instance, the Department of Health (1999b) uses the umbrella term of cardiovascular diseases (CVD) to refer to angina, heart attack, stroke, heart murmur, irregular heart rhythm, ‘other heart trouble’, reported high blood pressure or diabetes. Other publications delineate between coronary heart disease, cerebrovascular disease (stroke) and diabetes (Welsh Assembly Government 2005). It is possible to conclude that cardiovascular diseases as defined by the Department of Health (1999b), some respiratory disorders and some cancers have a behavioural component to their aetiology and are eligible to be called lifestyle diseases.

Interestingly, few authors would include sexually transmitted diseases under the lifestyle umbrella, although they could be argued to be entirely under behavioural control, with none of the genetic component that plays a part in aetiology of the six major lifestyle diseases as identified by Doyle (2001). Sexually transmitted diseases are more usually defined as infectious diseases (e.g. ONS 2007), an important distinction for clinicians but perhaps less so for primary care and community based practitioners with a remit of disease prevention through behavioural change.

In between an ‘imprudent lifestyle’ (Doyle 2001) and the development of a chronic life-threatening or life-foreshortening condition lie a number of precursors of disease. High cholesterol, high blood pressure and obesity are risk factors for the development of a number of the aforementioned lifestyle diseases. The distinction between these precursors, the diseases they predict and the behaviours that are associated with them is often blurred. They are often presented as diseases per se and interventions prescribed by the medical profession. The Department of Health (1999a) categorises high blood pressure as a cardiovascular disease. Obesity is frequently referred to using disease parameters. The phrase ‘obesity epidemic’ (Gard and Wright 2005) is one that has been widely used and characterises obesity as a disease. Consequently, obesity can be considered a lifestyle disease by some authors whereas others categorise it as lifestyle behaviour (Doyle 2001).

Lifestyle behaviours

The behaviours that are usually cited as being involved in the aetiology of lifestyle diseases are poor diet, lack of physical activity, cigarette smoking (Blaxter 1990; Doyle 2001) and, increasingly, excess drinking (Blaxter 1990; Burke et al. 1997). The taking of illegal drugs is also lifestyle behaviour with health consequences. Reducing illegal drug taking seldom appears in general government health targets (National Assembly for Wales 2000), although many specific policy documents address this issue, and this may well be because, while often high profile, drug takers constitute a minority of the population (ONS 2007).

Sexual practices are also often described as health and/or lifestyle behaviours by public health professionals (Wardle and Steptoe 2005) and are considered a key health issue by policy makers (National Assembly for Wales 2000). Despite not being directly linked to what clinicians refer to as lifestyle diseases, sexual practices nevertheless are still considered by most public health practitioners to be an aspect of lifestyle worthy of both concern and intervention (Wardle and Steptoe 2005). Furthermore, sexual practices are a clear cause of preventable and treatable diseases.

Accidents are another key cause of preventable deaths (Department of Health 1999b) that have a behavioural component, road traffic accidents being the most common. Many individual, local community and national government interventions are set in place to avoid them (Department of Health 1999b). In contrast to interventions for healthy eating, drinking and so on, many of the interventions to prevent accidents involve legislation, perhaps because many accidents involve third parties. While people may be advised to eat more fruit and vegetables, they are required by law to wear a seatbelt in the United Kingdom. Individuals can be banned from driving if they are found to be driving dangerously and are compelled to take a driving test before getting behind a wheel. New houses and extensions to old houses are legally required to include smoke alarms. Consequently, avoidance of accidents is far less of a voluntary lifestyle choice in the United Kingdom than healthy eating, physical activity, drinking, smoking and sexual habits. Accidents often require medical treatment and can cause disability but do not usually cause the development of disease. Consequently, accidents and accident prevention fall outside of the remit of this text with its focus on chronic disease and volitional behaviours.

In consequence it is argued that health-related lifestyles can be defined as behavioural choices made by individuals about eating, physical activity, drinking alcohol, smoking tobacco, taking drugs and sexual practices. Lifestyle psychology can then be defined as the study of the antecedents, consequences and interactions of lifestyle behaviours, including eating, drinking alcohol, smoking, taking drugs, physical activity and sexual practices.

Collecting together a set of behaviours that contribute to the aetiology of lifestyle diseases does not justify a subdiscipline of lifestyle psychology. Bad weather and individual driving skills both contribute to road accidents but nobody would argue that bad weather and driving skills are related in any way other than their ability to influence accidents. However, it is possible to put together a cohesive argument that lifestyle behaviours share more than their ability to influence a range of chronic diseases. First, lifestyle behaviours have multiple functions; they are not simply or even primarily health focused. Lifestyle behaviours can be mood enhancing; they can be used as a coping strategy; they are often pleasurable; and they play an important function in the development and maintenance of social relationships. Second, lifestyle behaviours are all under some degree of volitional control, although the amount of control individuals have over their lifestyle choices is contentious and likely to vary widely from context to context. Third, lifestyle behaviours are all chronic rather than acute behaviours. Usually individuals will practise regular patterns of these behaviours and their future behaviour will be best predicted by the choices they have made in the past. Finally, lifestyle behaviours have the majority of their positive consequences in the present and the majority of their negative outcomes in the future. Any lifestyle behavioural change intervention consequently requires individuals to be future orientated. Consequently, it is possible to argue that lifestyle behaviours, although each unique, share a set of common factors that unify them and indicates that common theoretical principles may underpin the aetiology and progression of these behaviours.

The rise of lifestyle models of disease

It is commonly accepted in medical, psychological and sociological texts on Western medicine that a ‘medical or biomedical model of disease’ has been, and remains still, the underlying principle behind practice (e.g. Scambler 2003). In essence a medical model is individualist and reductionist assuming that all disease can be traced to specific causal mechanisms within the person (Turner 1987, cited in Hansen and Easthope 2007). The traditional medical model derives from germ theory which postulates that each disease has a single and specific cause. This model dominated medical research up to and including much of the twentieth century ensuring that research was focused on the laboratory rather than the community and the test-tube rather than the individual (Najman 1980). The medical model can support a perceived dichotomy between disease and illness: disease being the domain of the health professional and illness the domain of patients, families and, increasingly, social scientists (Hansen and Easthope 2007).

While it is legitimate to argue that a medical model of disease is dominant in Western medical practice, other models of disease coexist and, increasingly, challenge current orthodoxy, influencing health and health care. Environmental, genetic, psychological and lifestyle models of disease all operate within medicine (Hansen and Easthope 2007). One of the key unifying themes between these alternative models of disease is one of prevention rather than cure. This could be viewed as a threat to the medical profession and commercial companies that make a living from curing disease. Prevention can offer commercial prospects as well, although perhaps not for the same players.

Genetic models of disease are similar to germ-theory-based traditional medical models of disease in that the causation of disease is considered to be internal. Although current responses to identified genetic risk are social and essentially preventative, for instance as genetic counselling to inform family planning, research is actively pursuing curative solutions (Collins et al. 2003).

Environmental and lifestyle models of disease differ considerably from medical and genetic models because their explanations for disease are based in social rather than biological processes. Environmental theories of disease focus on factors such as poor foodstuffs, environmental hormones, solar radiation, pollution, medicines, chemicals, substandard housing, sanitation, population density and the biological environment (Chavarria 1989; Hume-Hall 1990; Foster 1995; all cited in Hansen and Easthope 2007). These factors are usually associated with the workings of governments or major corporations and outside of the control of individuals. Environmental models stress societal and political responsibility. They focus on factors that are potentially modifiable in the long term, given political will. However, an overarching political commitment to reducing socio-economic inequalities by investing in infrastructure has not been forthcoming in the years since the Black report of 1980 (Berridge 2002; Shaw et al. 2005) first offered irrefutable evidence that health is linked to socio-economic circumstances.

Lifestyle models emphasise the role of individual choice in health-related behaviour and focus on factors such as physical activity and alcohol consumption. Lifestyle models stress personal responsibility. They focus on factors considered to be modifiable in the short term that have primarily long-term consequences; in this way they are orientated towards the future, with an emphasis on maintaining health and preventing disease. As such it is the most positive disease model with potential for individuals to take control of their own health. An increasing acceptance of a lifestyle model of disease creates pressure for a change in funding emphasis away from curative practices toward health promotion and public health.

Lifestyle models of disease are not new but during the nineteenth and twentieth centuries were subsumed in the battle to control infectious diseases that dogged developing industrial societies. During the twentieth century infectious diseases declined, and a history of how this occurred can be found in the classic text of McKeown (1979), and chronic diseases with behavioural and social determinants have increased, partly as a function of our ageing population and partly as a result of our changing lifestyles. It is these changing demographic and disease parameters that have primarily instigated the rise of the lifestyle model of disease. However, epidemiology, the development of a risk society, health care economies and consumerism have also contributed to a changing emphasis in health and health care.

Epidemiology is the study of the distribution and determinants of disease occurrence and outcomes in humans (Hansen and Easthope 2007) and traditionally investigated the spread of infectious diseases. Epidemiology played a central role in the reduction of infectious diseases and consequently has moved on to consider non-infectious diseases. Epidemiologists work with a probalistic conception of causation; that is to say they deal with risk and risk factors (Rothman 1998, cited in Hansen and Easthope 2007). Epidemiologists interested in chronic disease usually adopt a web of causality approach which considers chronic disease to be the result of a complex interaction of variables. Generally, social factors such as socio-economic inequality, living conditions and employment are considered too distant and non-specific to be included in epidemiological analyses (Remennick 1998, cited in Hansen and Easthope 2007) so epidemiologists have focused on more proximate causes of disease such as lack of exercise, smoking, diet or environmental hazards (McKinlay 1993, 1994, cited in Hansen and Easthope 2007). Epidemiology has been criticised for such reductionist methodologies. These criticisms are based in a belief that lifestyle behaviours are not the fundamental cause of disease but are a mechanism through which social inequalities influence disease. However, recent research on the relationship between lifestyle behaviours and socio-economic status indicates that the relationship is far from clear and detrimental lifestyle choices do not solely arise out of disadvantage (Department of Health 2003; Welsh Assembly Government 2005; Scottish Executive 2005; Department of Health, Social Services and Public Safety 2001). Furthermore, lifestyle behaviours have clear physiologically supportable links to disease and epidemiologically identified links between behaviour and disease can direct genetic, pharmacological and physiological research down promising avenues. For instance, breast cancer has been found to be linked to diet but not to smoking behaviour.

Epidemiology deals with risk factors and in this way contributes to what Beck (1990) identifies as the ‘risk society’. Beck (1990) describes modern society as one where perceptions of risk are heightened and the identification of risk and management of risk has become a major concern at all levels of society. Lifestyle ‘risks’ are just another category of risks that we must manage.

A lifestyle approach fits well with the modern emphasis on rationality. Social actions can be rationalised in terms of a cost/benefit approach. An economic rational approach sees preventive programmes that emphasise the role of the individual rather than the state as having the potential to reduce health care costs in the future. Nevertheless, few preventive programmes provide any cost/benefit analysis in their evaluations (National Institute for Health and Clinical Excellence (NICE) 2006b). An environmental approach to health care improvement may also reduce health care costs in the future but would require more economic intervention from the state. Modern society is increasingly individualistic and so an approach that sees health as an individual’s responsibility is in line with current political thinking and ideology. Giddens (1991) argues that stemming from individual responsibility comes the idea of health as a project to be worked on. This notion of health as a project enables our consumerist society to reconceptualise health as a commodity that we can buy. While traditional medical drug companies peddling cures may view lifestyle models of disease as a threat to their income a new generation of ‘health and fitness’ companies make a good living out of selling diets, vitamins, fitness, alternative therapies, clothes to exercise in and so on.

Despite well-voiced concerns about a medical model of disease that places its primary emphasis on cure rather than prevention a changing focus to prevention through lifestyle change has not pleased all public health practitioners. The epidemiological focus on specific behavioural factors rather than underlying social causes enables governments who would prefer not to take responsibility for the health of the nation to argue that lifestyle behaviours are an individual’s responsibility. To those in favour of political action at the roots of social problems to reduce health inequalities, lifestyle explanations of disease are viewed as oppositional. Indeed, early responses to epidemiological evidence of behaviourally caused disease did focus on knowledge-based health promotion campaigns that left the individual to resolve any behavioural flaws.

In response to the arguments that a risk factor health education lifestyle approach is flawed, public health policy makers at all levels have made position statements about expanding the medical definition of lifestyle to take into account the social nature of lifestyle behaviour (Ashton and Seymour 1988; Bruce 1991; Armstong 1983, cited in Hansen and Easthope 2007). ‘New public health’, as it has been coined, purports to replace individual behavioural modification achieved throug...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgement
• Introduction
• 1 Conceptualising lifestyle psychology
• 2 Theories of change
• 3 Eating
• 4 Physical activity
• 5 Drinking
• 6 Smoking
• 7 Sex
• 8 Illicit drug misuse
• 9 Evaluating lifestyle psychology
• 10 Strategies for the twenty-first century
• References