SOCIAL DETERMINANTS AND LIFESTYLES: INTEGRATING

ENVIRONMENTAL AND PUBLIC HEALTH PERSPECTIVES

ABSTRACT ObjectiveIndustrialization and urbanization have been associated with an epidemiological transition, from communicable to non-communicable disease, and a geological transition that is moving the planet beyond the stable Holocene epoch in which human societies have prospered. The lifestyles of high-income countries are major drivers of these twin processes. Our objective is to highlight the common causes of chronic disease and environmental change and, thereby, contribute to shared perspectives across public health and the environment.

Study designIntegrative reviews focused on social determinants and lifestyles as two ‘bridging’ concepts between the fields of public health and environmental sustainability.

MethodsWe drew on established frameworks to consider the position of the natural environment within social determinants of health (SDH) frameworks and the position of social determinants within environmental frameworks. We drew on evidence on lifestyle factors central to both public health and environmental change (mobility- and diet-related factors). We investigated how public health’s focus on individual behaviour can be enriched by environmental perspectives that give attention to household consumption practices.

ResultsWhile SDH frameworks can incorporate the biophysical environment, their causal structure positions it as a determinant and one largely separate from the social factors that shape it. Environmental frameworks are more likely to represent the environment and its ecosystems as socially-determined. A few frameworks also include human health as an outcome, providing the basis for a combined public health/environmental sustainability framework. Environmental analyses of household impacts broaden public health’s concern with individual risk behaviours, pointing to the more damaging lifestyles of higher-income households.

ConclusionThe conditions for health are being undermined by rapid environmental change. There is scope for frameworks reaching across public health and environmental sustainability and a shared evidence base that captures the health- and environmentally-damaging impacts of high-consumption lifestyles.

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Introduction

Over the last century, the twin processes of industrialization and urbanization have delivered improvements in living standards and life expectancy 1, 2. Since the 1950s, these improvements have been associated with rapid changes in people’s lifestyles, including changes in physical activity and diet. Thus, paid work, unpaid work and travel modes have become less labour-intensive, and staple plant-based diets have given way to animal-sourced foods, including dairy products, meat and processed meat 3-6.

These economic and social changes have, in turn, resulted in an epidemiological transition. First evident in the early-industrializing countries of North America and Europe, non-communicable disease has replaced communicable disease as the major cause of ill-health and premature mortality, both within high-income countries and globally 7, 8. Lifestyle-related factors, including physical inactivity and unhealthy diets, are its proximal cause 3, 7, 9.

Industrialization and urbanization have also produced changes in the Earth’s biophysical systems: in its land surface, oceans, atmosphere and cryosphere. Central to these systems are ecosystems: the inter-connected plant, animal, and microorganism communities and the non-living environments with which they interact 10. Ecosystems function at multiple spatial scales (for example, a field within a farm within a rural community within a region) and furnish the resources on which human life depends. Ecosystems provide food and water as well as a wider range of essential services, including soil formation, climate regulation and the production of oxygen 11, 12. Many of the human consequences of environmental and climate change are being mediated through ecosystems which are, in turn, in a state of rapid decline 11, 13.

Human-induced changes in the Earth’s systems, including its ecosystems, have been evident since the 19th century 14. However, the pace and magnitude of anthropogenic change has increased sharply since 1950, with the decade marking the beginning of ‘the Great Acceleration’ in the human transformation of the global environment 15. Among the many global indicators are increases in atmospheric CO2 and surface temperature, ocean acidification, deforestation and agricultural intensification, loss of biodiversity and oceanic ecosystems 16, 17, increases which in turn are triggering ecosystem changes that are happening too quickly for many species to adapt 18. Together, these markers of environmental stress are taken as evidence that the human modification of planetary conditions is driving a geological transition: humanity has become a global geophysical force. It is moving the Earth beyond the stable environmental boundaries of the Holocene epoch in which human societies have been able to grow and prosper to a new ‘human-dominated geological epoch’ 19. Many Earth’s systems have entered a no-analogue state, posing new and unparalleled threats to human health, and ones with disproportionate impacts on poorer communities who have contributed least to environmental and climate change 17, 20-22.

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Among the complex of factors underlying environmental change and geological transition are the consumption-based lifestyles that have underpinned economic growth and, in particular, the high-consumption lifestyles of affluent societies 23. While population growth has added to the environmental pressures, the Great Acceleration has been driven by the rapid increase in per capita consumption of the Earth’s finite resources by ‘a small fraction of the human population’, namely those living in high-income societies 24. The environmental pressures are being intensified by ‘a cultural globalization’ 25 of the consumption patterns of affluent societies as a global aspiration and, increasingly, a global norm 26. It is ‘the convergence of aspirations on high consumption patterns’ 27 in emerging economies and other middle-income countries that is increasingly driving environmental and climate change 28.

While both chronic disease and environmental change are outcomes of the lifestyles characteristic of modern societies, they have formed separate fields of research and policy. However, with both public and planetary health under increasing pressure from environmental and climate change, there are increasing calls to bring health and environmental perspectives closer together 22, 29-33. Our paper is a contribution to this urgent task.

We approach the task mindful of the barriers that can block cross-disciplinary and cross-sector understandings 34, 35. Among these barriers are the difficulties of ‘thinking outside the box’: of taking on ideas and perspectives from fields beyond those in which we practice. Studies suggest that concepts can aid this process. They can mediate understandings and facilitate dialogue, moving across disciplinary and policy boundaries in ways that evidence may not 36. In the language of science studies, concepts can serve as ‘boundary objects’ 37, 38, opening up and working across the interface between research and policy communities. We focus on two concepts already integral to public health perspectives: social determinants and lifestyles. We explore their potential intersections with environmental perspectives, and the different and complementary insights these perspectives provide.

The section below considers the concept of social determinants, looking in particular at frameworks used to capture the pathways through which these determinants have their effects. Frameworks are widely used in policy-facing research to provide simple visual representations of complex processes; like the concepts they embody, they are used to aid communication across disciplinary and policy boundaries 39, 40. We consider where the natural environment sits within a social determinants of health (SDH) perspective, arguing that widely-used frameworks obscure its position as an outcome shaped by the same social factors that determine health. We consider, too, the position of social determinants within frameworks focused on environmental change and ecosystem functioning, noting that widely-used frameworks accord causal primacy to these determinants; some, in addition,

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include a focus on human health. Recognising the synergies between the different sets of frameworks, we provide a simple illustrative example of an integrated framework.

The subsequent section identifies modern lifestyles as another focal point for linking public health and environmental perspectives. The section discusses how public health’s orientation to the individual and their behavioural risk factors can be enriched by environmental perspectives that give attention to the consumption practices of households. Terms used in the paper that may be unfamiliar to Public Health readers are defined in an online glossary 41.

Social determinants: public health and environmental perspectives

Public health frameworks are often anchored in the concept of the SDH 40, 42. The concept gained currency in the 1970s, a time when governments in high-income countries were becoming increasingly alarmed by the economic and health burden of chronic disease. The concept emerged out of a series of critiques of what was seen as an overly-narrow focus on lifestyles as the cause of chronic disease 43. Arguing that such a focus served to ‘divert attention from the social causation of disease’ 44, critics advocated ‘refocussing upstream…toward a range of upstream political and economic forces’ 45. These upstream forces were underlined in the WHO’s Health for All agenda, an agenda that explicitly recognised that health ‘is influenced by a complex of environmental, social and economic factors ultimately related to each other’ 46.

In the early 1990s, Dahlgren and Whitehead provided a visual representation of this complex process. In their ‘rainbow’ model of the main determinants of health, health was the outcome of a set of interlocking causes, running from broad societal-level factors (described as ‘general socioeconomic, cultural and environmental conditions’) through both distal (‘living and working conditions’) and proximal (‘individual lifestyle factors’) determinants 47. The concept underpinned the WHO’s Commission on the Social Determinants of Health 48 and its follow-up reviews 49. As the reports made clear, both lifestyle risk factors and their wider determinants (‘the causes of the causes’) are social in origin: produced by the societies in which people live. SDH approaches have helped shape public health policies at global and national level 42, 50, playing a particularly pivotal role in promoting policies to level up access to determinants of good health 51, 52.

However, SDH approaches have been less successful in articulating where and how the natural environment contributes to individual and population health 30, 42, 50, 53. For example, in line with the WHO Commission’s focus on ‘the fundamental global and national structures of social hierarchy and the socially determined conditions these create’ 48, its conceptual model gives emphasis to the ‘socioeconomic and political context’, to people’s social position (social class, gender, ethnicity) and to their material and psychosocial

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circumstances. The environment as a term does not feature. It does appear in other models, including the influential Lalonde report which identified both ‘environment’ and ‘lifestyles’ among the key determinants (called ‘fields’) of health 54. The environment is also included in Dahlgren and Whitehead’s ‘rainbow’ framework, both as part of the overarching arc of the model (‘general socioeconomic, cultural and environmental conditions’) and as a ‘water and sanitation’ segment within ‘living and working conditions’ 47. But, as frequently noted, the primary focus of public research and policy has been on the social environment – including housing, workplaces, and social relationships - and not on the biophysical environment in which it is embedded 31, 42, 55. This absence matters: as Rapport et al observe, the biophysical environment is ‘the human habitat’ 56 and one that is being rapidly degraded by human activity.

However, there are health frameworks that give greater prominence to ‘the human habitat’. An early example is Blum’s 1974 inputs-to-health model 57 which identified the environment as a ‘huge input-to-health’. His environmental input includes the ‘natural environment’ along with ‘natural resources’ and ‘ecological balance’ 58. A more recent example is a framework that builds on Dahlgren and Whitehead’s framework 59. As Figure 1 indicates, it expands the outer arcs of their model to give greater weight to environmental conditions as determinants of health. The environment is broken down into three concentric arcs: ‘built environment’ ‘natural environment’ (which includes ‘natural habitats’ and ‘air, water, land’) and ‘global ecosystem’ (‘climate change’ and ‘biodiversity’).

Figure 1 about here

While these models explicitly include the biophysical environment, their causal structure means it features as a determinant, and one separated from the social factors that influence health. Yet, these determinants – lifestyles, living and working conditions and wider economic systems of which they are part - are also determinants of the biophysical environment; they are the key anthropogenic drivers of the Great Acceleration. As this suggests, the transition from the Holocene into a ‘human-dominated geological epoch’ is being propelled by factors encompassed within the concept of the SDH. Frameworks therefore need to position both human health and the health of the Earth’s life-supporting systems as outcomes of a common set of social determinants.

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Figure 1: The health map 60

Source: Barton, H., & Grant, M. (2006). A health map for the local human habitat. The Journal of the Royal Society for the Promotion of Health, 126(6), 252-253. Figure 1, page 253. PMID: 17152313.

Frameworks developed within environmental science and policy provide a foundation on which to build. Here we consider general frameworks for representing the anthropogenic causes of environmental change and their consequences as well as frameworks focused more specifically on changes in the essential services that ecosystems provide.

The first set of frameworks has its origins in the OECD’s Pressures-State-Response (PSR) framework 61. It is built around a causal chain running from the ‘pressures of human activities’ through the ‘state of the environment and natural resources’ to ‘responses of economic and environmental agents’. This influential model has been progressively refined for policy use, particularly as a tool for environmental analysis.

In the 1990s, the European Environment Agency developed the Drivers-Pressures-State-Impact-Responses (DPSIR) framework 62. In this extended PSR framework, underlying human drivers (e.g. transport) were distinguished from environmental pressures (e.g. CO2 emissions), and the state of the environment (e.g. air, soil and water quality) was separated from impacts (e.g. on human health and biodiversity). The model was further refined to inform the WHO’s work on environmental health indicators. ‘Exposure’ was added between ‘state’ and ‘impacts’ (with the latter renamed ‘effects’). The resulting Drivers-Pressures-State-Exposure-Effects-Action (DPSEEA) model 63, 64 has been subsequently modified by

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Morris et al to provide a framework that that identifies potentially-modifiable factors in the relationship between the physical environment and human health 65. The revised framework adds a ‘contextual “bubble” surrounding exposure and effect’; these contextual influences include ‘social, economic, demographic, behavioural factors’ 66.

The same underlying causal structure is evident in frameworks focused on ecosystems and their essential role in sustaining planetary and human health 67. This role was documented in the Millennium Ecosystem Assessment (MEA), a global scientific assessment launched in 2001 under the aegis of the United Nations. Its overarching Conceptual Framework 11 is built around four inter-connected components: ‘indirect drivers of change’, ‘direct drivers of change’, ‘ecosystem services’ and ‘human wellbeing and poverty reduction’. Indirect drivers, which include demographic, economic and socio-political factors, are broadly equivalent to what, in SDH perspectives, are referred to ‘upstream forces’ and ‘the causes of the causes’. In the MEA framework, these factors shape direct drivers, which include changes in land use, species introduction or removal, harvest and resource consumption, and climate change. Human wellbeing is affected by both sets of drivers and by related changes in ecosystem functioning (for example, climate regulation and the capacity to provide food and water). However, the wellbeing domain is represented in broad terms only: this component of the framework refers to ‘basic material for a good life’ ‘health’ ‘good social relations’ ‘security’ and ‘freedom of choice and action’.

The connections between human activities, ecosystem impairment and human health are spelled out in more detail in the framework in the associated MEA Health Synthesis report 17. While the overarching MEA framework is more widely known, it is the Health Synthesis framework that details the health impacts in ways that connect more directly with the SDH perspectives familiar within public health (Figure 2). Three sets of health outcomes are identified: direct impacts, ecosystem-mediated impacts and indirect impacts. As in the PSR model and its derivatives, and in the overarching MEA framework, the fundamental causes are societal: the causal chain begins with ‘escalating human pressure on the global environment’. As this suggests, the models share a causal structure which accords primacy to what the public health community would recognise as social determinants 68. They are the external drivers that take their toll on biophysical conditions and ecosystem functioning and, thereby, its human impacts.

Figure 2 about here

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Figure 2: Harmful effects of ecosystem change on human health 69

Source: Ecosystems and Human Well-Being: Health Synthesis. A Report of the Millennium Ecosystem Assessment. ISBN 92 4 156309 5 – Figure SDM1."Harmful effects of ecosystem change on human health", page 1. http://apps.who.int/iris/bitstream/10665/43354/1/9241563095.pdf

Millennium Ecosystem Assessment (2005) Ecosystems and Human Well-being: Health Synthesis. Island Press: Washington DC. Figure SDM1, page 1

Their common causal structure points to the scope for integrated frameworks that reach across the fields of public health and environmental sustainability. We see the MEA Health Synthesis framework (Figure 2) as offering particular potential: it is simple but covers key processes and links. We therefore use it to inform the schematic framework below (Figure 3) in which social determinants have both direct health effects and ones mediated through environmental impacts. The framework intentionally derives its structure from other frameworks that are already well known within policy communities: from SDH frameworks and those linked to DPSIR and MEA approaches. Like these frameworks, it enables constituents of the framework (for example, interactions between social determinants and environmental changes) to be represented in separate and more complex models.

Integral to the social determination of health and environmental conditions are the lifestyles characteristic of high-income societies. We consider public health and environmental perspectives on modern lifestyles in more detail in the section below.

Figure 3 about here

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Figure 3: Social determinants: environmental and health outcomes

Lifestyles: public health and environmental perspectives

Lifestyles provide a second bridge between public health and environmental sustainability. The public health focus is on the individual and their behaviour; within the field of environmental sustainability, the perspective broadens to consider the household and its patterns of consumption. We consider these different perspectives in turn.

A set of lifestyle factors have been identified as underlying the chronic diseases responsible for the majority of premature deaths in high-income countries: physical inactivity, unhealthy diets, cigarette smoking and harmful alcohol intake 9, 70. Behavioural measures and risk thresholds vary across studies, limiting comparability of findings 71. Nonetheless, some broad patterns stand out.

Evidence for two of these behaviours - physical activity and diet - indicate that a large proportion of those living in high-income societies fail to meet minimum thresholds 3 72. Taking England as an example, 5% of adults meet the government’s recommended physical activity level 73, 1 in 4 consume the recommended minimum of 5 portions of fruit and vegetables a day 73 and, among men, mean red and processed red meat intake exceeds the recommended maximum of 70g per day 74. By comparison, over 80% of adults are non-smokers 75 and a similar proportion do not consume alcohol or drink at levels associated with low risk of alcohol-related harm 73.

Diet quality and physical activity are also socially patterned. Social disadvantage is associated with lower fruit and vegetable consumption, higher consumption of red and processed meat 76, 77 and lower levels of leisure-time physical activity 78. Like other health-related behaviours, activity and dietary patterns are habitual, woven into ‘the practices of daily life’ 79. As daily lives change, so do everyday practices. Set in a historical context, declining levels of physical activity are linked to technological changes in the home and

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workplace and a shift from active to motorised travel 72, 80-82. Across high-income countries, cars are the most common travel mode, whether measured by share of journeys or distance travelled 72, 83, 84. Changes in diet have been driven by the shift from carbohydrate-rich plant-based diets to energy-dense and animal-sourced diets, particularly meat 4, 5.

These changes in activity and dietary patterns have, in turn, had major environmental impacts. For example, increasing car use continues to drive land conversion to make way for transport infrastructure, resulting in habitat loss and fragmentation and decreased ecosystem resilience 85. The global extent of urban areas to accommodate growing populations and provide associated transport infrastructure is predicted to triple by 2030 over 2000 levels, with direct impacts on biodiversity hotspots around the world 86. There are also significant greenhouse gas emissions associated with producing and running private vehicles 87, 88. Diets high in meat and dairy products are less land- and energy-efficient than non-meat diets and contribute far more to greenhouse gas emissions 89. They are also more water-intensive during the production process and contaminate watercourses with nitrogen, phosphorus, animal waste, and pathogenic protozoa and bacteria 90. In addition, greenhouse gases (methane, nitrous oxide and carbon dioxide) are released along the food chain: during production, distribution, storage, marketing, purchasing and consumption 91. In high-income countries, a large proportion of the environmental impacts fall outside the country’s borders, and on low and middle-income countries in particular 92, 93.

Identifying and measuring these wide-ranging environmental impacts is challenging. However, methodologies are advancing and increasingly taking a consumption-based perspective. In this perspective, impacts - from the sourcing of raw materials through production, distribution and storage to consumption - are allocated to end-users.As the primary end-users are individuals and the households of which they are part, they are identified as the major cause of greenhouse gas emissions and environmental resource depletion 94, 95. The analyses point, in particular, to the contribution that mobility- and diet-related consumption in high-income societies makes to the global environmental footprint. Thus, along with domestic energy use, transport and food make up a large proportion of the greenhouse gas (GHG) emissions of households in affluent societies 87, 95. It is a finding confirmed in analyses that take account of wider environmental impacts 96. One such study of 25 European countries included a range of environmental measures, including environmental resource use, pollution and GHG emissions 97. It concluded that the total environmental impacts of household consumption derived from three major areas: food and drink, transport and housing. Of the three, food and drink (20-30% of household environmental impacts) made the largest contribution; within this area, the largest impact was from the consumption of meat and meat products, followed by dairy products. Within the transport area (15-35%), private cars made the major contribution. Housing (20-35%) included both buildings and domestic management practices, including consumption of energy and water as well as waste management practices.

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Like health-oriented studies of individual behaviour, environmental analyses of household consumption point to marked social gradients. However, the gradients are reversed: environmental footprints increase in line with household income and expenditure 92, 94-96, 98,

99. This environmental perspective is also helpful in contextualising evidence on what is variously called ‘pro-environmental behaviour’, ‘green consumption’ and ‘environmentally friendly behaviour’. Studies suggest that those living in better-off households are not only more likely to have behaviours protective of health, they are also more likely to report a range of consumption practices seen to be protective of the environment, for example buying recycled paper products, separating household rubbish for recycling, and using recycling points and bottle banks 100, 101. As Peattie notes, these domestic management practices are supported by high-impact living conditions and lifestyles, including larger and multi-appliance homes and car ownership, which remain largely unchanged 96. In consequence, the greater overall environmental impacts of high-income households more than outweigh the marginal environmental benefits of ‘green’ consumption 98. As this suggests, the connections between environmental and health behaviours require careful investigation. To facilitate this analysis and help address gaps in the evidence-base, a searchable compendium of UK studies has been compiled. It details more than 30 UK studies containing measures of health and environmental behaviours 102.

Conclusions

Environmental conditions and human health have always been tightly coupled. Up to the mid-20th century, the relative stability of these conditions provided the platform on which societies could develop and health could improve. However, the free-market approach to economic and social development has drawn heavily on the Earth’s resources, moving it beyond its stable boundaries and seriously compromising sustainable development for future generations. As the driver of economic growth and prosperity, consumption-based lifestyles have been central this process. They have also been central to the changing patterns of disease.

There is increasing recognition that the challenges to public health and environmental sustainability are inter-connected. They therefore need to be understood and addressed together. We have contributed to the development of a shared perspective by focusing on concepts that help to illuminate their common causes. The concepts of social determinants and lifestyles are widely known and used within the public health community; they also have their parallel within the environmental community.

The concept of social determinants is anchored in frameworks that have played a central role in aiding communication across public health research and policy. However, the frameworks have tended to obscure the impacts of social determinants on wider environmental conditions. Further, lifestyles tend to be seen through the lens of an

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individualistic and risk-focused approach to disease causation. Environmental frameworks can help to broaden these perspectives. They make clear that adverse changes in planetary systems and ecosystems are socially determined: they are driven by the economic systems, built environments and lifestyles developed in high-income countries. We also noted how environmental perspectives that foreground the household as a unit of consumption can broaden and complement public health’s concern with individual behaviours. We noted the different social gradients that emerge when environmental and health impacts are the outcomes of interest. In the light of these synergies, we pointed to the potential for a combined framework. We presented an illustrative example in which both human health and the planetary environment are represented as socially determined: as outcomes of dominant forms of economic and social development.

The public health community is tasked with responsibility ‘to assure the conditions in which people can be healthy’ 103. It is a task that requires the integration of public health and environmental sustainability into a common agenda, with alliances and partnerships that link across societies, disciplines and policy sectors. Our paper is a small contribution to this urgent global endeavour.

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