A new way to think about environmental factors in health outcomes
It’s the age-old debate of nature vs. nurture, or genetics vs. environment.
And while it used to be acknowledged that genetics and environmental factors both play a role in health outcomes, lately it seems like many in our healthcare establishment and in discussions about public health want to declare a winner: the environment. This is especially evident in discussions about the social determinants of health, or SDOH, and in the many studies tying health outcomes to socioeconomic status.
There are many studies that look at this. The Department of Health and Human Services groups social determinants into five categories:
Education access & quality
Healthcare access & quality
Neighborhood and environment
Social & community context.
All of those are very legitimate and need to be incorporated into any overall model to improve health on a population level.
However, one thing that has fallen almost completely out of the discussion? Talk of personal responsibility. And that’s too bad because, depending on the context, understanding the extent of one’s own autonomy in decision-making can have a hugely positive effect on their health.
We just need a new way of talking about it. A new framework.
Who controls our environment?
All of this was especially evident, for example, in the public discussion just after the American Academy of Pediatrics recommended far more aggressive medical interventions for treating childhood obesity, even bariatric surgery.
As the NY Times wrote, the AAP’s new guidelines argued that “obesity should no longer be stigmatized as simply the result of personal choices, but understood as a complex disease with short- and long-term health implications.”
We’ve also seen this in other areas, with many doctors, advocacy organizations, and researchers arguing that any number of health outcomes are not really in our control, since we can’t control our environment (and we definitely can’t control our genes… at least not yet).
But there are two kinds of environments. Think of them as two categories: microenvironments, which are in our control, and macro environments, which are not.
Microenvironments are places like our bedroom or our kitchen. For example, I’ve written before about strategies for getting better sleep, such as keeping screens out of the bedroom or lowering the temperature by opening a window, or turning down the heat at night. These are decisions about your microenvironment, and they are in your control. I would argue they are essentially your personal responsibility.
However, another strategy for better sleep is to reduce or eliminate alcohol consumption before bedtime, and in this instance, there is a more complicated combination of factors that may make it easier or harder for you to do that, depending on your genetics, and your macro social environment.
How to change behavior
Another problem with dismissing personal responsibility is that you then fail to educate people about how and why personal responsibility can either fail or succeed as a tool for changing behavior.
Atomic Habits, by James Clear, is essentially all about this. It’s about how our immediate microenvironments (not his word, but still) can shape our behaviors and reinforce habits. It’s also about how little or sometimes big changes to our immediate environment can help us break old habits and form new ones.
For anyone interested in concrete strategies to do that, I definitely recommend reading the book. But the point is, we definitely can change our own behaviors. It is not ALL socially or genetically determined.
It’s crucially important that we acknowledge this, especially when it comes to chronic disease. In the debate over obesity, we have to think of our environment as divided into things in our control and things outside of it. And a lot of things are in our control!
The obesity debate
There is also something that nags at me when I hear, for example, the American Academy of Pediatrics aiming to downplay the role of personal choices. And that is the fact that the dramatic rise in chronic disease over the past 30 years, including obesity and specifically diabetes, has come regardless of socioeconomic status.
Yes, the data show, for example, that those with lower educational attainment tend to be more obese than those with college degrees. But also, the facts show that everyone at every level has become more obese over the past 30 years:
In fact, as Matthew Yglesias wisely points out, Americans have all, collectively, been gaining weight for as long as records exist—but the major studies and more thorough record-keeping on obesity rates only started being kept around 1980.
Meanwhile, the last 40 years have seen an acceleration of that trend, going from roughly 10% of the adult population categorized as obese to now nearly 50%. Certainly, environmental factors like the rise in ultra-processed foods, confusing public health advice about low-fat diets, and an influx of environmental toxins bear a large share of the blame.
To be clear: you should not be eating ultra-processed foods, and you should aim to minimize your exposure to environmental toxins. Both of these can cause a whole range of long- and short-term health problems.
But as for obesity, what records we have show that all Americans of every socioeconomic status have been steadily gaining weight since at least the 1880s. A paper about BMI values in the U.S. since 1882 found that “people born in 1900 were heavier than people born in 1880 and that people born in 1920 were heavier than people born in 1900,” and so on, rising steadily to the present day.
The explanation for that appears to simply be that over the last 140 years, we have become a much richer, more prosperous nation where there is massive food abundance and we can find pretty much any food we want, in any cuisine, at almost any grocery store in the country. As Yglesias writes:
…There probably isn’t some unitary big bad we can blame so much as a broad tendency for food to be cheaper, more widely available, and tastier, which is a situation with a lot of virtues but also some downsides
So, what are we to do about this?
I would argue we need to stop running away from messages about personal choice and responsibility. Especially we in the medical community need to stop treating that discussion as a third rail we are afraid to touch.
Instead, we need to educate and give people better strategies about how our capacity for personal autonomy can be subverted. Sometimes this is on purpose, for example, a food company trying to deliver the exact right combination of salt, fat, and sweet to keep us gorging and coming back for more. But in other cases, it’s due to neglect, carelessness, or lack of understanding.
What we in the medical community can do is actively work to repair that neglect and carelessness, and educate our patients and the general public about how to maintain the greatest possible control over their personal choices, their (I would say God-given) autonomy, and ultimately their health and wellness.