When it comes to obesity, it seems that everyone has an opinion. Some advocate that individuals should ‘take responsibility’ for their own behavioural choices, while others point to the government and policymakers to ‘change the environment’ we live in so that healthy choices are easier.
If we look at the prevalence of obesity around the world, it is apparent that no intervention, program or policy has made much of a dent. Could it be that both sides of the argument are wrong?
For many decades, researchers have been fascinated by the link between how people behave and the pressures from society.
Way back in the 1800s, Emile Durkheim, a French sociologist, investigated the rise of suicide in his community.
Until that point, suicide had been seen as an individual behaviour ‘choice’, but Durkheim showed that there were clear patterns between suicide rates and the type of financial economy and stress that communities were experiencing.
He was able to show that instead of being restricted to individual choice, suicide was often the result of a complex interaction between community pressures and policy decisions, finances and economics.
A modern-day example might be the ‘robo-debt‘ tragedy, in which there have been reported patterns associating suicidal ideation with financial stress from government notices about money owing.
We can also see patterns in communities with higher rates of obesity in women, especially those from lower socioeconomic groups.
These patterns indicate that people’s behaviour is linked to and influenced by decisions made at higher levels of government.
The emphasis on the environment affecting behaviour has meant that some researchers, clinicians and policymakers have focused solely on this factor, downplaying the relevance of choices made by individuals.
Margaret Archer is a modern philosopher who blasted into this space in 2000. She argued that focusing exclusively on ‘the environment’ was wrong.
Archer highlighted the complex interaction between the environment and individual behaviour, emphasising that thinking, reflecting and remembering are all important parts of what makes us human.
The effect of context on individual choice
We can sometimes forget this complex balance when we lament the decisions of patients we care for.
“If only they would stop smoking,” we think in dismay. “If only they would make food choices that are sensible for their health.”
I often reflect on a conversation I had with Professor Chris van Weel, a pre-eminent Dutch GP academic and former WONCA world president.
“If the patient seems to be behaving in an irrational way,” he said, “it is only because you haven’t understood the reasons they have behind their behaviour. Within their own context, no patient behaves irrationally.”
This wisdom particularly rings true when thinking about behaviours that people use for comfort and stress relief.
Professor Carl May is a social scientist from the UK who has led groundbreaking work to better understand how and why evidence works in daily healthcare settings.
He believes the biggest challenge of our time is how to bring together individual behaviour and community context to facilitate more powerful interventions.
If we can work out how to do this, we will be able to make a bigger impact on health outcomes, he said in a recent lecture in Canada.
Perhaps this is where general practice and primary care are best positioned to make a difference?
One of the key factors in high-quality general practice is its person-centred nature. When done well, this involves treating an individual while being aware of their family, community and society.
Current funding models do not encourage general practice to work well beyond the consultation room. However, does this mean we are missing the most powerful mechanism of primary care — influencing individual decision-making behaviour within the context of society’s complexity?
In Belgium, family doctors run forums with patients and community members where they ‘diagnose’ the problems that are facing their communities.
These ‘community diagnoses’ are used to establish programs within community health centres that, in effect, push the boundaries of individual consultations.
Could a similar strategy be used to reduce the prevalence of obesity, by allowing us to move beyond focusing solely on the individual on one hand, or on public health policy on the other?
We need to be innovative: it’s clear that the current siloed approach isn’t working for anyone.
First published at Medical Observer, on 14 October, 2019 (editor, Jo Hartley)