Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: Is lifestyle a choice?

BMJ 2020; 370 doi: (Published 07 July 2020) Cite this as: BMJ 2020;370:m2701

Read our latest coverage of the coronavirus pandemic

  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

Doctors’ attention is currently focused on coronavirus, but previous agendas haven’t gone away, including the high prevalence of non-communicable diseases in wealthier parts of the world. A key driver of this burden—contributing to diabetes, cardiovascular pathology, arthritis, and cancer—is that so many people live unhealthy lives. All of us (excepting perhaps those with medicines to sell) would agree that avoiding, and sometimes even reversing, these illnesses through exercise, weight control, or avoidance of alcohol and tobacco would be better than treating the end results with drugs.

Given that this is so uncontroversial, I’m interested in the negative reactions the word “lifestyle” engenders in many doctors, me included. Before coming across it in medicine I thought of lifestyle as something to do with glossy magazines, interior décor, and exotic holidays. As well as having connotations of wealth, it’s coupled with the concept of choice—the idea that people are free to make “lifestyle choices.”

People who suffer the most from living unhealthy lives often find that their choices are limited, at the sharp end of the social and commercial determinants of health. Whether we’re discussing insecure and low wage work that deprives people of time, the stress of poverty, the ubiquity of sugar, or the risks of overcrowded housing, these pressures make it hard for people to change their lives to improve their health. Talking about “lifestyle choices” in this context can sound like victim blaming, focusing on individuals with limited options and suggesting that they could be healthy if only they made more sensible choices, rather than attending to the structures and policies that deliver the toxic environment they live in. The appeal to individual responsibility is often a right wing response and is a distraction from the necessity of societal change.

However, in my consulting room I’ve chosen to work with individual patients. My ability to solve their housing or employment problems is minimal, still less to counter the availability of cheap sugar or alcohol, but I do have a choice about what suggestions I make to improve their health. The dice may indeed be loaded against them, but I wonder if I’m trying hard enough and whether I’m hampered by my own lack of belief in their ability to change. Do I reach too readily for the next medication before exploring with them the tougher, but potentially more effective, changes they might choose?

I need more evidence at my fingertips and more skills to work through the options with patients. Recognising that my own resources are limited, I need to be able to refer them to really good support services if they’re ready and willing to make changes. This won’t be enough to eradicate the shameful 15 year gap in healthy life expectancy between the poorest and richest areas of my city, so I’ll also continue to campaign for a fairer society.12