You’re sick and it’s all your fault

When it comes to attitudes about disease, there seem to be two schools of thought:

1. You get sick because of bad lifestyle choices and a failure to take care of yourself.

2. You get sick because bad things sometimes just happen and can’t always be prevented.

It’s a pretty fierce debate, and not one that’s going to be settled any time soon. But who, if anyone, has the better argument?

An online discussion this week at Kevin MD suggests how hard it is to sort out all of this in a way that’s thoughtful rather than judgmental. A guest entry cross-posted from the excellent Heart Sisters blog, which is hosted and written by heart attack survivor Carolyn Thomas, explores what people from heart disease can learn from people with cancer.

Individuals undergoing treatment for cancer, she writes, usually focus all their energy on getting well again in ways that heart patients do not.

Yes, many people recovering from a heart attack do successfully change their lives to reduce the chances of a second heart attack, she writes.

Yet alas I’ve seen far more of those who seem to utterly lack that “change it all now” attitude. These are the heart patients who don’t exercise as instructed, or don’t change the way they eat, or stop taking their medications, or don’t bother showing up at their Cardiac Rehabilitation programs, or keep smoking – and even start smoking again after being terrified into quitting by their initial heart attack.

The harsh view would be that these people deserve the consequences for failing to do enough to modify their risks. Heck, their bad habits probably caused their heart attack in the first place.

There may be some truth to this but it’s not the whole picture. Thomas herself was a runner before having a heart attack, she explains. She said she knows many other people with heart disease who led active lives, didn’t smoke, had no obvious risk factors – but had a heart attack anyway.

Researchers have tried mightily to link cancer with health-related behaviors – for example, a recent study that linked alcohol consumption with increased risk of breast cancer. Yet most of these associations are tenuous and don’t fully explain why some people get cancer and others don’t. The link between tobacco use and lung cancer is probably one of the strongest and most convincingly demonstrated – but many of us know individuals who smoked for years, never got cancer and died of something else. Were they just lucky, or was there something else going on?

There’s been a lot of study about the many factors wrapped up in good health vs. bad health. The best estimates break it down this way: Health-related behavior, such as being physically active and avoiding tobacco and excess alcohol use, accounts for 30 to 40 percent of overall health. Genetic factors – a family history of heart disease, for instance – accounts for about 30 percent. Socioeconomics, including income and education, make up about 30 percent. The rest is divided between environmental factors and the clinical care we receive.

(Various estimates assign slightly different percentages to each category but the proportions are generally similar. Here’s a breakdown from the annual County Health Rankings project that provides a helpful visual perspective; note that it’s primarily focused on health outcomes and does not include genetics as a factor.)

There are several messages here. First, socioeconomics matter much more than many of us realize, and this particular collection of risk factors is not easy to change. Second, it’s hard to escape the forces of DNA. If your parents have high blood pressure and your siblings have high blood pressure, the odds are pretty strong that you’ll develop it too, and lifestyle changes may not be enough to prevent it.

None of this means health-related behaviors don’t make a difference. Even when we’re battling a genetic predisposition toward type 2 diabetes or live in a neighborhood without sidewalks or a nearby grocery store that sells fresh produce, there are things we can do to help modify our existing risks. We might have to work harder at it than someone who doesn’t have the same social barriers or family health history, but it’s not impossible.

Whether we can achieve total, 100 percent prevention simply by taking good care of ourselves is questionable, though. There are too many unknowns and outside factors that can neither be predicted nor controlled.

In any case, it seems counterproductive to blame people for their own illnesses. An interesting new study carried out at Ithaca College in upstate New York examined the attitudes of people who had diabetes and how responsible they felt for their disease. Those who blamed themselves had higher levels of anger and also reported more difficulty in managing their diabetes. (The study apparently didn’t break down whether there was a difference between participants with type 1 diabetes and those with type 2 diabetes.)

Perhaps it’s just easier for people to accept a new diagnosis when they aren’t second-guessing themselves or beating themselves up over habits and health decisions of the past. By all means, we should try to control what we can – but recognize we cannot control everything.

Photo: WIkimedia Commons

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