Lifestyle Choices are Influenced by the Culture in Which We Live
by ACLM Board Member, Richard Safeer, MD
There are many forces that influence health and the recipe is well known to all of us: sleep, healthy foods (not too much), movement and the other usual ingredients. Behavior is a complicated thing of course and while many of our ACLM members are adept at motivational interviewing and coaching, we are not treating the whole patient if we are not addressing our patients’ social circles and the culture in which they live and work. It’s not as if you are going to ask your patient to bring in his or her parents, friends and friend’s friends to the next appointment. However, it is reasonable to have an understanding of these social influencers and be mindful of how you guide your patients based on the forces from which they are regularly exposed. Furthermore, having an understanding of the environment, policies and resources in their sphere will increase your effectiveness in navigating your patients toward healthier habits.
‘It runs in my family’, in reference to a chronic disease. Who hasn’t heard that from a patient? You rarely hear a patient acknowledge that behaviors run in their families too. It’s not just families though. Our food choices for example are influenced by our friends, our friend’s friends and their friends. Even the stranger eating at the table next to you! Obesity tends to run in spheres of social influence. The more friends one has who are obese, the more likely that is to be the situation for your patient. Emotions are also contagious. The moods of our patients’ roommates, family and coworkers influence their mood. It’s not just those immediately in contact with our patients, but rather their friends and their friend’s friends. In fact, a whole book, “Connected”, was written on this topic of three degrees of influence by Nicholas Christakis and James Fowler. You’re certainly not going to tell your patient to cut ties with their unhealthy friends. However, it’s worth exploring with your patient these relationships and that they are more likely to succeed in developing a healthy habit if they do this in conjunction with a friend. In fact, the more friends who participate in this journey, the more likely they are to succeed.
Our patients’ environments also greatly influence their habits. Those whose occupations require manual labor may not be short of exercise during the workday, but perhaps the company cafeteria lacks healthy choices or they aren’t as affordable as the omnipresent hotdog. On the other end of the spectrum of activity might be the ‘white collar worker’, tied to his or her desk. They could use some help integrating movement in to their daily routine. Environmental design also plays a role at home. Fruit in a bowl in the kitchen is more likely to prompt its consumption rather than it being stored in the refrigerator. What are the environmental cues that are helping or harming your patients?
Yet some of the most influential factors on one’s choices are not those they can see or touch, like a bowl of fruit or a standing desk. Taxes, for example, have played a substantial role in the downward trend of smoking prevalence and taxes on sugary sweetened beverages in various municipalities across the country are starting to take hold. If policy advocacy at the government level isn’t in your near future, perhaps playing a similar role within your house of worship or place of employment can also positively influence the circles in which your patients reside. You can be quite influential on how social gatherings are shaped through parameters around activities. Active gatherings like line dancing clearly have more health benefits than watching a movie together.
Most members of ACLM are likely to have greater resources to apply toward a healthy lifestyle than our patient population as a whole. It’s important then to help your patient leverage the resources they already currently have at their disposal. One of the challenges in this regard is that they may not even know the resources that they have in their reach. It behooves us to better understand the community resources as well as those they might gain through their health insurance and for that matter, their employer. It’s not likely you will be able to learn of the specific resources for each of your patients. However, you do need to learn how to ask these questions and prompt them to be proactive in this regard.
I encourage you to go beyond the behaviors of the individual sitting in front of you and expand your evaluation process to include the cultures within which your patient lives. The same goal setting and teach back techniques that are used for individual health behaviors can also be used for building a home environment more supportive of health, finding resources at work and in the community and shaping the behavior of family members and friends. You can exponentially improve your effectiveness as a clinician by helping your patients navigate, or even change their culture.
Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives by Nicholas A. Christakis and James H. Fowler, New York: Little Brown and Company, 2009.