Lifestyle Approaches to Heart Health Threaten the Health of Canadians

Health care and public health workers tell Canadians that illness and disease
results for the most part from their lifestyle choices. Such exhortations
neglects the strong impacts upon health of factors such as low income, poverty,
lack of food, poor or insecure housing, discrimination and isolation, and other
societal determinants of health. To illustrate, low income is one of the
strongest predictors of the incidence of heart disease and cancers, having a
much stronger effect than any lifestyle factors such as diet, exercise, weight,
or tobacco use.

This emphasis is even more surprising given that there is little evidence of the
long-term effectiveness of lifestyle efforts towards improving health and these
approaches have side-effects that can work against health. One side-effect of
the lifestyle emphasis has been to completely remove any public awareness that
societal factors such as those listed above play important roles in the
development of disease. The pervasiveness of this public blind spot concerning
the societal determinants of heart disease was seen in a recent survey of
Hamilton, Ontario residents that was published in the Canadian Journal of Public
Health. When asked an open-ended question about the causes of heart disease and
provided with the opportunity to give up to seven responses, only one respondent
of 601 identified poverty as a cause of heart disease -- a fact that has been
repeatedly demonstrated in careful studies of the incidence of heart disease in
Canada and elsewhere.

What are low income residents of Hamilton, Ontario -- and elsewhere -- to make
of the greater incidence of heart and others diseases among their low income
neighbours, friends, and relatives than that seen among their more well-off
neighbours? Research evidence indicates that the greater incidence of disease
should be attributed to their lower income status which in most cases results
from factors outside their personal control.  But the ideology of lifestyle
choices being responsible for heart disease promulgated by health care and
public health workers -- and clearly  internalized by most Canadians -- lead
them to blame themselves for their higher incidence of disease and illness,
subsequently relieving government policy makers from taking responsibility for
their health threatening policies.

In Ontario, for example, government policies that have reduced social assistance
benefits, eliminated new social housing, and transferred wealth from the poor to
the wealthy through income tax reduction for the well-off are likely to increase
the incidence of heart and other diseases.  Yet the government can point to its
lifestyle-oriented heart health program as evidence of its commitment to health.

This process is especially insidious in light of the limited evidence that
lifestyle choices -- especially physical inactivity, weight, and diet -- are
major causes of heart and other diseases.  Essentially, individuals and
communities encountering heart and other health difficulties as a result of
governmental policies are doubly damaged.  First, they experience health
threatening life situations, and second, they fall under the accusatory and
blaming gazes of health care, public health and other governmental authorities.
Sadly, health workers espousing lifestyle messages can become complicit in the
process of



"poor bashing," a process of Ignoring facts and repeating stereotypes
about people who are poor.

In the end, lifestyle approaches remove the societal determinants of disease
right off the public debate agenda. The lack of pressure for governments to
address these fundamental determinants of health allows these health threatening
conditions to remain or even worsen. Second, low income people are made to feel
that they are responsible for their own poor health.  The impact of this
perception -- also known as "victim-blaming" -- adds to the psycho-social
difficulties these people are experiencing. By masking the true source of
people's health problems, these approaches do nothing to enable people to gain
control over the determinants of their health -- the key component of health
promotion contained in Health Canada and provincial health documents. Health
care and public health workers must begin to seriously address the societal
determinants of Canadians' health.  The alternative is to continue to invest in
activities that may not only be ineffective in promoting the health of citizens
but may actually be serving to harm it.

Dennis Raphael is an associate professor in the School of Health Policy and
Management at York University, and the author of Social Justice is Good for Our
Hearts:  Why Societal Factors -- Not Lifestyles -- are Major Causes of Heart
Disease in Canada and Elsewhere which is being published by the CSJ Foundation
for Research and Education.