A personal reflection
Suzanne Carroll MACN
When it comes to our health, where we live matters. Our family, friends, and even our neighbours may be making us unhealthy. Though we may not realise it, each of us is influenced by the attitudes and behaviours of those around us.
We are constantly surrounded by social norms, informing us as to how we should look and behave – and though many of these come from the people closest to us, they also come from our neighbours.
Social norms include two types, injunctive and descriptive norms (Cialdini, Reno & Kallgren, 1990). Injunctive norms describe what ought to be done; what is generally considered to be acceptable behaviour. On the other hand, descriptive norms describe what is typically done; what is normal. Both injunctive and descriptive norms influence our attitudes, beliefs and behaviours. Often injunctive and descriptive norms are similar, but sometimes they are not. We know we ought to eat healthy, be physically active, maintain a healthy weight, and not smoke, and most people would approve of these behaviours, yet many of us don’t meet the appropriate health recommendations.
The injunctive and descriptive norms of our friends and families influence our own attitudes, beliefs and behaviours. We are more likely to be active, eat well, maintain a healthy weight, and not smoke if our family and friends are active, eat well, maintain a healthy weight and don’t smoke (Christakis & Fowler, 2013). Recent research has found that we are also influenced by our neighbours’ behaviours, whether they are our friends or not.
A series of studies using data collected for a 10-year adult cohort in Adelaide have found that individuals living in areas with a greater number of people who were overweight or obese, physically inactive, or with poor diets, had worsening cardiometabolic risk than individuals surrounded by residents with healthier body weight and behaviours (Carroll et al., 2016, Carroll et al., 2017). This was after accounting for other important factors related to health and health behaviours, including individual age, sex and socioeconomic status, and other residential features such as walkability and availability of healthy resources relating to diet and physical activity, and neighbourhood socioeconomic status.
Behavioural theories suggest we imitate the behaviours of others (Bandura, 1971, Rivis & Sheeran, 2003), while normative theories tell us that we use the attitudes and behaviours of others to inform appropriate behaviour (Cialdini, Reno & Kallgren, 1990). In areas with a greater number of overweight or obese people, a larger body size may become accepted as normal. This new normal may then reduce motivation to follow health recommendations regarding body size, diet and physical activity. Indeed, overweight individuals may not even realise they are overweight as their body size seems “normal”. This obviously has important implications for population health, especially as more and more of the population become overweight and obese, driving the norm upwards with consequent increases in health cost to individuals and governments.
Overweight and obesity continues to rise in Australia, with almost two in three Australian adults currently overweight (AIHW, 2016). Of particular concern is that much of the rise in overweight and obesity is driven by increases in obesity rates, from 19% in 1995 to 28% in 2014-15. Overweight and obesity are major risk factors for cardiovascular disease, type 2 diabetes, musculoskeletal conditions, and some cancers. These risks increase as the excess weight increases (AIHW, 2016).
Suggestions that individuals lose their excess weight seem reasonable, yet substantial weight loss is very difficult and few individuals manage to maintain their weight-loss (Montesi et al., 2016). Moreover, fat stigmatisation and shaming is associated with adverse health effects including mental health issues, negative coping strategies (e.g. binge eating and exercise avoidance), weight gain, and cardiometabolic risk (Papadopoulos & Brennan, 2015, Pearl et al., 2017, Sutin & Terracciano, 2013).
While there is a desperate need to denormalise overweight/obesity and reawaken awareness of what healthy looks like, this needs to be achieved while avoiding fat stigmatisation. These two aims are seemingly at odds. While we should continue to acknowledge the health risks of obesity, we can focus our attention on improving health behaviours; healthy diet and physical activity provide many more health benefits than simply controlling weight (Warburton, Nicol & Bredin, 2006, AIHW, 2017).
Currently most people do not get enough exercise or eat enough fruits and vegetables while they often consume too much fat and sugar. As individuals, we can focus on our own behaviours and set good examples for others, especially our children. But we also need policies that support healthy behaviours, ensuring adequate opportunities for healthy behaviours while reducing opportunities for unhealthy behaviours. We can all advocate for such policies.
The new normal relating to body weight and associated health behaviours is being transmitted to our children, along with the consequent increased risk of ill-health. Already greater than one in four of our kids (27%) are overweight or obese. Surely we need to reassess what is being accepted as “normal” – shouldn’t this be the healthy option?
Australian Insitute of Health and Welfare (AIHW), 2016, Australia’s Health 2016, cat. no. AUS 199, Australian Institute of Health and Welfare, Canberra
AIHW, 2017, Food & Nutrition, accessed 24 September 2017, <https://www.aihw.gov.au/reports-statistics/behaviours-risk-factors/food-nutrition/overview>
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