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Helen Salisbury: Is lifestyle a choice?

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

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Re: Helen Salisbury: Is lifestyle a choice?

Dear Editor,

Helen Salisbury discusses issues to do with lifestyle choices. The idea is that lifestyle choice is OK if you have a garden and decent salary and live in a leafy suburb. The experience and implication is that if you live on a seventh floor apartment block your choice is seriously limited. This has been the case and will be the case unless a concerted effort is made to help people to change.
The evidence for the beneficial and health promoting effects of the Big Five is enormous.1-6 They are exercise; healthy diet; adequate sleep; occupation or job; friends or social contacts. The literature is awash with good evidence showing that these interventions are the way to go. The problem is that you can't get people of modest means or those living in poverty to do these things. This is a world wide phenomenon and must be addressed by policy. The Greens are lobbying for renewables and biodiversity and clean water and air, and rightly so. However the population also needs to be greened - of toxins - sugars, diesel fumes, noise pollution, cramped housing, excess alcohol and tobacco, poverty, unemployment..., and given something useful and substantive to occupy them. Education but also restriction of harmful pollutants, be they cheap alcohol, junk food, congested cities, drugs, polypharmacy...the list goes on.
The health budget for most countries in the OECD for the past decades is of the order of 10 -20% of GDP. The public deserve more value for money. High tech medicine and pharma and insurers take the lion's share of the money - and meantime there is a token public health system exposed by the pandemic, little if any prevention and education programmes to teach and educate and encourage people to live healthier lives. Policy and structures need to actually empower those in high rises to make good lifestyle choices. The health system is skewed toward end organ disease - costing percentages of national budgets- while at the other end of the spectrum the very causes of these diseases are being ignored or actually promoted.

1. Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States. July 26, 2010. Available from:

2. World Health Organization, Commission on Social Determinants of Health. Closing the Gap in a Generation: Health equity through action on the social determinants of health. Available from: Web Site Policy

3. National Partnership for Action: HHS Action Plan to Reduce Racial and Ethnic Health Disparities, 2011; and The National Stakeholder Strategy for Achieving Health Equity, 2011. Available from:

4. The National Prevention and Health Promotion Strategy. The National Prevention Strategy: America’s Plan for Better Health and Wellness, June 2011. Available from:

5. The Institute of Medicine. Disparities in Health Care: Methods for Studying the Effects of Race, Ethnicity, and SES on Access, Use, and Quality of Health Care, 2002.

6. Health Impact Assessment: A Tool to Help Policy Makers Understand Health Beyond Health Care. Annual Review of Public Health 2007;28:393-412. Retrieved October 26, 2010. Available from: Web Site Policy

Competing interests: No competing interests

07 July 2020
Eugene Breen
Psychiatrist, Associate Clinical Professor
62/63 Eccles St Dublin 7