Bad lifestyle isn’t a medical issue, it’s a social one

Almost every Sunday night, I walk to this one restaurant in my neighborhood for some comfort food (we’re creatures of habit aren’t we?).

I pass a church on my way where an Alcoholics Anonymous meeting is held almost every night. As I walk through the crowd of smokers, I look at them and they look at me. They don’t know that I know they’re recovering addicts. And they put a smile on my face. They’ve taken the initiative to change their lives, restructure their lifestyle, and improve their health. They’ve realized that overcoming bad lifestyle takes friends, family, and professionals. What does the social science community know about AA?

Not much:

Alcoholics Anonymous and its steps have become ubiquitous despite the fact that no one is quite sure how—or, for that matter, how well—they work. The organization is notoriously difficult to study, thanks to its insistence on anonymity and its fluid membership. And AA’s method, which requires “surrender” to a vaguely defined “higher power,” involves the kind of spiritual revelations that neuroscientists have only begun to explore.

What we do know, however, is that despite all we’ve learned over the past few decades about psychology, neurology, and human behavior, contemporary medicine has yet to devise anything that works markedly better. “In my 20 years of treating addicts, I’ve never seen anything else that comes close to the 12 steps,” says Drew Pinsky, the addiction-medicine specialist who hosts VH1’s Celebrity Rehab. “In my world, if someone says they don’t want to do the 12 steps, I know they aren’t going to get better.”

Overcoming addiction doesn’t happen in silos. Health is social. Lifestyle change is social change.

Positive change is about you, your friends, your family, and the physical environment of your home and neighborhood — that is where health happens. That is not where medical care happens. Bad lifestyle isn’t a medical issue, it’s a social one, hence the reason why “contemporary medicine has yet to devise anything that works markedly better.” Doctors are just so bad at lifestyle and behavior modification. Or maybe they’re just uninterested, or ill-prepared, or not reimbursed for social change? Maybe individual physicians think fixing these big hairy problems is too big of an issue for them to exert any effort? Medical care has pills and scalpels– not urban design, portion size, influential friends, walkability, and the complexities of the modern family structure. I should know. I got about 4 lectures in medical school on topics other than sickness. I had to seek out, on my own, solutions for the real problems our modern culture face– hyperlocal relationships with other people and with our environment that make choosing health difficult.

AA is one of those hyperlocal solutions because it fundamentally understands that alcoholism doesn’t happen in silos, nor does it happen in institutions– it takes a restructuring of your lifestyle in your own neighborhood to kick the habit. How do we change our lifestyle? Good question. There’s not as much research happening on this topic compared to medical interventions. You can’t bottle up and sell “lifestyle change” and turn it into a multi-billion dollar market, so who’s going to do it? And how does patient privacy fit with solutions that require your friends, family, and acquaintances? Can you do meaningful outcomes research on these kinds of social solutions? Are there technology solutions to lifestyle change? Or can we simply design things that people use and want? Is it good enough to just have a 1.2 million person following like AA? Or must we have to put numbers on its effectiveness? Social solutions are notoriously difficult to measure. AA has been going strong for 75 years and it’s still an enigma, but it’s the kind of solution that will save us from the deadliest disease we know– unhealthy lifestyle.

Do we need more AA-like solutions? We’d say yes. We can chase our tails for 75 years looking for a +/- 5% difference or we can design engaging solutions that people enjoy. Should we care about measurability? Good question.

Jay Parkinson is a pediatrician and preventive medicine specialist and founder of The Future Well. He blogs at his self-titled site, Jay Parkinson + MD + MPH.

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  • everyman

    MD’s shouldn’t be criticized for this, we can’t possibly be asked to change social behaviours for an entire community as well as treating disease, and I try more than most as a PMD, i’ve given advice on financial management and as well encouraging positive social activity in an effort to help the patient’s overall well being, it’s definitely not in my realm but I do it anyway. That being said i don’t think we should obligated to do so.

  • http://www.drveronica.com Dr. Veronica

    It is the responsibility of MD’s to give out excellent care along with accurate information about the disease state and options for treatment. It is the responsibility of the individual to decide what he wants to do with that information and whether or not to do what it takes to be well.

    Physicians also need to lead by example and I am sorry to have noticed that many of my colleagues eat too much, drink too much, smoke and drug, or are workaholics. No wonder the citizens are in trouble. They see the ones in an esteemed profession not doing many of the things they tell their patients/clients to do. It is similar to children ignoring what their parents say and doing what they see the parents do.

    But I also know that medical school and training gives MD few skills on ow truly to teach people to change their lives.

    Physicians need to lead by example. Patients need to take individual responsibility.

  • Jake

    Dr. Parkinson’s final points are:

    1. “AA has been going strong for 75 years and it’s still an enigma, but it’s the kind of solution that will save us from the deadliest disease we know– unhealthy lifestyle.

    2. Should we care about measurability? Good question.”

    Concerning Item 1: What is Dr. Parkinson’s basis for suggesting that AA will save us from an unhealthy lifestyle (such as uncontrolled use of alcohol)? AA is a religious program, famous for 12 steps that have nothing to do with its purpose of treating alcoholism, but a lot to do with promoting religion. If religion is a treatment for alcoholism, perhaps we should use the judicial system to force people to attend the Christian Science Church (as it often forces people to AA). Maybe “Bill” (of AA fame) could have learned a lot for developing his treatment program from Mary Baker Eddy, rather than from the Oxford Movement.

    Concerning Item 2: Measurability would be great when talking about alcoholism treatment, so he should apply the need for it to AA. We have very little of it concerning AA, but most of what we do have shows a dismal success rate for AA.

    I certainly do not know the solutions to the myriad social problems we have, but I do think that Medical School rarely teaches such solutions to physicians-to-be. Dr. Parkinson should take a hard look at his qualification for making his statements about the need for “more AA-like solutions.”

    • Bill Bessonette

      Correction: AA is NOT a religious program, it is a spiritual program which works well even for agnostics and atheists. I would suggest that you do additional research before offering an expert opinion.

      • JRB

        I agree. Jake mentions religion fourteen times in his posts. Where do you come up with that Jake? AA is not allied with any sect, denomination or politics. And the way you modified “God of our understanding”. Even athiests use words like ‘soul’ and ‘spiritual’, but that is for lack of a better metaphor, not for anything to do with religion. I don’t know where you get that inference or what your motivation is for stressing AA is a religion when it’t not. Alas that is your opinion, mistaken though it is.

  • Jake

    Terminology mistake:

    In my above comment I used the term “Oxford Movement.” That was a mistake. I should have said “Oxford Group.”

    I regret the error.

  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    Jake, Jesus forgives you

  • Jake

    Happy

    I hope those high church Episcopalians who may have thought that I was accusing them of being associated with Buchmanism will be equally forgiving.

  • http://minochahealth.typepad.com doc

    There appears to be abdication of responsibility at various levels, society, educational system, regulatory agencies and health care providers for a whole host of reasons. Let us not forget the individual responsibility which should be at the top the the list.
    .

  • Healthcare Observer

    Public health and health promotion should be seen as part of the overall healthcare system. There are many well-evaluated interventions for ‘lifestyle’ health issues such as smoking.

  • http://www.thekarisgroup.com Tony Dale

    I have read Jay’s blog about bad lifestyle choices, and how to modify those choices with considerable interest. In both of the family practice partnerships that I was a part of we had to deal with a physician who had become addicted to drugs. More recently I have watched the incredible destruction that is brought to a family, in this case one of my own children’s family, by the ravages of addictions. So what changes people and lifestyles.

    Clearly there is no one size fits all answer to this basic question. But that many of those who end up “cured” have found considerable help from spiritual type interventions can hardly be denied. Why do so many with scientific backgrounds struggle with the available evidence of the power of prayer. Even if the effect of prayer is similar to the effect of placebo, we should still welcome the results!

    The antagonism to the presence of God within public discourse, whether political or scientific, is both irrational and unhelpful. In my own current involvement in the health care debate as a businessman who provides a widely used patient advocacy service to help those who have more medical bills than the ability or benefit necessary to pay those bills, I find that it is the moral/spiritual underpinning of our society that is most likely to bring us to a place of significant change for the better.

    For any interested to explore these ideas further do a Google seach on “Musings of an Old World doctor about the New World healthcare marketplace.”

    • MD in recovery

      I am a physician in recovery and I am an atheist. I go to AA meetings in spite of the spiritual component because the primary purpose is to help each other stop drinking. I have worked the steps, I have a sponsor and a sponsee, and my family goes to alanon. I used to be a devout Christian. I am clearly an anomaly because I shed religion in recovery.

      I used to pray and read the bible everyday. I have not prayed one time to God since I started recovery. I say the Serenety Prayer and the Lord’s Prayer with the group for the introspection of acceptance, change, and forgiveness, not for any God.

      You say “The antagonism to the presence of God within public discourse, whether political or scientific, is both irrational and unhelpful.” I emphatically disagree. God and religion are not good for humanity. Belief in God is not rational and I challenge you to validate that it is. There is no evidence for God, but the evidence discounting the existence of God is growing exponentially in today’s scientific world. People who make statements of authority about topics that they can no way be certain about should be challenged, whether they are talking about religion, God, or any other topic. If they cannot support their claims with evidence and reason, they should be marginalized.

      I refer you to ‘The End of Faith’ by Sam Harris, a book about the threat religion (extremist and moderates alike) poses to the future of humanity. Also, anything by Hitchens or Dawkins. I have read your book, the bible. It’s fair to encourage you to read some of these books. Then tell me that you still believe antagonism to God has no place in public discourse. That is a ridiculous position when you actually think about it.

      Now, I will say that religious antagonism, from atheists or christians, does not belong in AA, because AA is not public discourse, it is private, and the purpose is not to discuss religion, but to help each other stop drinking.

  • http://www.thekarisgroup.com Tony Dale

    Actually, I have read both The End of Faith by Harris and books by Hitchens and Dawkins, because the very son who has such a troubled life as alluded to in my comments above, has pointed me to those authors! I can’t prove the existence of God any more than anyone else can disprove the existence of God. As CS Lewis said, “I believe in Christianity as I believe that the sun has risen: not only because I see it, but because by it I see everything else.” Whether it was Bill Wilson founding AA or myself trying to understand my life, my family, my patients, and now the business world that I work in, my experience pushes me back to the essential role of that “higher power.” As Benjamin Franklin noted as the Continental Congress was stymied in its efforts to build consensus, “I have lived, Sir, a long time, and the longer I live, the more convincing proofs I see of this truth – that God governs in the affairs of men.” I, for one, welcome God’s help in any way that He choses to show it!

    • MD in recovery

      “Theocracy is the worst of all governments. If we must have a tyrant, a robber baron is far better than an inquisitor. The baron’s cruelty may sometimes sleep, his cupidity at some point be sated; and since he dimly knows he is doing wrong he may possibly repent. But the inquisitor who mistakes his own cruelty and lust of power and fear for the voice of Heaven will torment us infinitely because he torments us with the approval of his own conscience and his better impulses appear to him as temptations.”

      To badly paraphrase, religion has no business telling people how to live.

      I respect your right to your own opinion. I first replied to call out the claim that religion is rational in an effort to stop someone from representing their beliefs as something they are not. Your reply acknowledged the subjective nature of ‘Higher Power’ and fails to validate the claim that religion is rational. Your’s is the Christian God, but you may as well be praying five times a day to the real God of Islam. No religion has a monopoly on enlightenment or morality. Atheists have ‘spiritual’ experiences when we see a sunrise too, but we don’t feel compelled to attribute our emotion to a God and then impose our belief on others without a shred of evidence. Define rational and get back with me. Do you really think religion is rational?

      You mentioned evidence of the power of prayer. You will recall Dawkins pointed out in ‘The God Delusion’, the power of prayer was put to the test, paid for by the Templeton Foundation and published in ‘American Heart Journal’, 2006, which proved no benefit for patients who were prayed for over those who were not. What’s more, those who knew they were being prayed for suffered far greater complications and negative outcomes. Evidence is against “the power of prayer”, and the claim to the contrary is mistaken.

      I just came from an AA meeting and feel good about my recovery. God does not deserve the blame for my problems any more than he deserves the credit for my happiness. I love AA, but God is not great. Pleasant discussions with intelligent Christians like you only further solidify my perspective on the absence of God and that religion, in terms of risk/benefit to humanity, is bad.

      The first quote above is C.S Lewis. The following is Benjamin Franklin:

      “Lighthouses are more helpful than churches.”

  • Nick Sidorovich, MSEd

    I’ve enjoyed reading all the posts related to this article. I’ve struggled with the issue of effecting lifestyle change in a professional setting as a former manager of employee health and fitness programs and I’d like to offer the following anecdotal evidence.

    The employee populations that I’ve worked with seemed to be a microcosm of the American population as a whole and could be broken down into three categories.

    About one third of the population would exercise and eat right completely of their own volition and did not seem to need health promotion programs to motivate them – we simply made exercising more convenient for them by offering an on-site exercise facility. Prior to joining the employee fitness center, these people worked out at home or at a gym, or jogged or biked outdoors. Of this one third, about half were sporadic exercisers and the other were regular exercisers.

    Another one third of the employee population never used the fitness center. Of this one third, about half preferred to exercise outside of work (either sporadically or regularly) and the other half seemed to have no interest in exercising or eating right (one could surmise that, of the employee population suffering from cardiometabolic disease, a high percentage came from this latter half).

    And finally, there was one third of the population that seemed to be sitting on the fence. These were the people most likely to be influenced by the health promotion efforts of others. And of this one third, only about a third (roughly 10% of the entire employee population) would be sufficiently motivated by the aforementioned health promotion efforts to change their lives for the better. These people were our success stories. The remainder of the fence sitters seemed to be in a state of flux, approaching lifestyle change in fits and starts, gaining and losing the same 10 or 15 pounds in an almost seasonal pattern.

    Lifestyle change does seem to be social, even if that change seems to occur within a society of one – that is, lifestyle change seems to rest primarily with the individual. We in the health care community can be influencers for certain, but as the saying goes “you can lead a horse to water but you can’t make him drink”.

    I’ve spoken with Dwayne Proctor, PhD, of the Robert Wood Johnson Foundation about the Foundation’s interest in funding childhood obesity initiatives that are primarily environmental in nature, e.g., increasing access to supermarkets that provide fresh, healthful foods, and providing safe places to play and exercise in neighborhoods that are often dangerous to walk through or have no playgrounds at all.

    Yet, as a resident of Chatham, New Jersey, voted by Money magazine (twice) as one of the 10 best places to live in America, I see that my town offers plenty of access to good food and safe environments to play and exercise in, yet my town also has plenty of overweight, sick people.

    Environment plays an essential part in effecting lifestyle change, but it only goes so far. Lifestyle change is a multi-factorial process, it seems, and I do agree that a person’s will, religious faith, and mind-set play a big part in that change. Self-help guru Anthony Robbins said that lifestyle change will not occur until the pain resulting from a poor lifestyle is greater than the pain of adopting a healthier lifestyle (i.e., it hurts more physically and psychically to be sick and fat than it hurts to exercise and say no to ice cream).

    I currently work as a medical writer and do believe in the value of health education. There is much that we can teach people. But knowledge isn’t usually what changes people – it is the will to put that knowledge into practice. In helping people engage their will it does help to offer encouragement on a regular basis. G.K Chesterton, the British theologian, said that “People need to be reminded much more than they need to be instructed”.

    I’m not sure if that means that we health educators are primarily cheerleaders, but I do know that stirring people’s emotions gets them to make decisions better than a lecture any day of the week. Now, if you combine the two – a substantive lecture backed by an impassioned call to action – then you have a chance to impact people’s lives in a significant way.

  • gzuckier

    The question of whether or not the proper function of the medical profession is to advocate for social change to improve general health status, or whether it is merely to provide pharmaceutical or surgical care for the individual patient’s physical problems is closely related to the current debate over healthcare costs, and the longstanding dilemma of incentivizing wellness, rather than care for illness, at least for somebody in the healthcare system.

    We know that lifestyle change is socially malleable; witness the recent “The Spread of Obesity in a Large Social Network over 32 Years” http://www.nejm.org/doi/full/10.1056/NEJMsa066082 . And there is plenty of experience demonstrating that attempting to motivate individual behavioral change is virtually hopeless with such negligible rewards as the promise of avoiding debilitating illness and/or premature death. So there is a good argument that physicians who do not engage in some sort of health-related “social change” are not doing their job; on the other hand, there are many physicians, among others, who feel very strongly that such efforts represent some sort of attack upon individuality http://www.google.com/search?hl=en&source=hp&q=%22there+is+no+such+thing+as++public+health%22&aq=f&aqi=&aql=&oq=&gs_rfai=CvAkYjsKkTMHFE4zmNL-RiTYAAACqBAVP0G2_Tg, their poster child being the successful smothering of efforts to treat firearm injuries as a public health problem. Unfortunately, this is a difference in basic philosophy rather than something amenable to factual analysis or a matter of “Good vs. Evil”, no matter how much proponents of either side may view it as such, so there is no forseeable conclusion. The biggest influence would seem to be what is fashionable in medical schools at a given point in time.

  • Jake

    MD In Recovery said:

    “Now, I will say that religious antagonism, from atheists or christians, does not belong in AA, because AA is not public discourse, it is private, and the purpose is not to discuss religion, but to help each other stop drinking.”

    When the judicial power of the state is used, either explicitly or implicitly, as it so often is, to compel attendance at AA, then AA is no longer private, it is public discourse.

    MD in Recovery may be successful in using AA to handle alcohol problems while not accepting the pervasive religious aspects of the program, but I really wonder how someone can, in good conscience, sponsor others into the AA program while rejecting the fundamentals of the program.

    • MD in recovery

      Jake you misinterpret the ‘fundamentals of the program’. I encourage you to attend several Open AA meetings and gain a perspective of AA from the inside looking out, because it appears your view of AA is from the outside looking in.

  • Jake

    MD In Recovery

    I have attended a number of AA meetings, in different parts of the country, and therefore believe I have a very good perspective of being on the inside, looking out.

    I have never met any regular attendee of AA meetings who would not agree that the 12 Steps (perhaps in combination with the 12 Traditions) represent the fundamentals of the AA program. (Note: for those who are not familiar with AA, here are a few of those 12 Steps with religious references: (Make) a decision to turn our will and our lives over to the care of God…, (Seek) through prayer and meditation to improve our conscious contact with God…)

    Anyone who attends AA meetings will learn that prayer is an essential part of each meeting (the beginning prayer, the ending prayer, and often religious testimonials and other religious activities during meetings), and also that other religious activities (outside of the meetings) are considered essential by most AA stalwarts. Again for those not familiar with AA, I should mention that the AA position is that all these religious activities are “spiritual, but not religious.” That is a distinction without a difference.

    Does this mean that we should not have AA? Of course not. But it does mean that it is disingenuous to pretend that it is not a religious program and it is certainly wrong for our judicial system to force people into such a religious program.

    I hope it continues to be a success for MD in Recovery and for his/her family as they learn about and practice the AA religion while doing the 12 Steps at the Alanon meetings. (Also, for those not familiar with AA, Alanon is an offshoot of AA, in which friends and relatives of those with alcohol problems have meetings using the same 12 steps as at AA meetings)

    Available information unfortunately shows a very low success rate for the AA program; I hope that MD in Recovery can be one of the success stories.

    I, of course, leave it to MD in Recovery to rationalize his atheism with his strong support of AA, not only by his attendance, but by his active encouragement of others to participate in religious activities (by his service as a sponsor to other AA members).

  • MD in recovery

    Jake, with all due respect, please don’t represent an expert opinion on AA after a few meetings and cursory reads of the Big Book of AA. Likewise, I don’t represent to be an expert. AA is about attraction rather than promotion, and we try to stay out of public discussion. The wording of the 12-steps and the 12-traditions are very specific and like this post and links said, have been thoroughly vetted. You conspicuously left out an important part after God, ‘as we understood him;’

    Please stop insisting that for one to seek help in AA one must “practice the AA religion.” Statements like this can very well be the deterrent that prevents desperate alcoholics from getting help and finding recovery.

    You must assume that my sponsee is not a non-believer? One of the most read chapters in the Big Book is specifically for non-believers like me.

    I, too, have been to groups all over the country. Sometimes the people share about how their faith or belief in God has affected their experience, good or bad. It is true, sometimes I personally find this annoying, but I don’t interfere with their sharing or offer rebuttal in meetings and neither do they to me. In my experience, taking the discussion of the group into religious territory is a no-no. And prayer is entirely optional.

    Thank you for your support in your hope for my continued sobriety. There is no guarantee. I am trying to do my best; and for alcoholics, helping others helps keep ourselves sober.

    I agree with you about people being forced to go to meetings by courts, etc. That is why I prefer closed meetings. The only requirement for AA membership is a desire to stop drinking. Please don’t eliminate an opportunity for someone to find recovery from alcoholism by discouraging AA based on the fact that someone has a probation paper they need signed.

    In light of the 11th Tradition, I am going to stop commenting on this blog. Thanks for the feedback and well wishes.

  • Jake

    I agree with MD in Recovery that enough is enough for now on this issue.

  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Dr. Parkinson is correct. Bad lifestyle isn’t purely an individual problem or a medical one, but also a social / environmental one much the same way a medical error isn’t simply a bad doctor but often a system that increased his likelihood for failure.
    When McDonalds can offer a bottled water for $1.50, which has no added ingredients and yet can offer a soda for less at $1, how can individuals make the right choice? Doctors alone can’t solve this problem. Everyone, not just the individual patient, must solve this problem.
    http://davisliumd.blogspot.com/2010/09/empowered-patient-is-this-what.html
    http://davisliumd.blogspot.com/2010/05/our-big-problem-obesity-who-will-solve.html

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