Engaging with the discourse on lifestyle modifications

Engaging with the discourse on lifestyle modifications
Evidence from India
Arima Mishra

Volume 1, No. 1 (2011)

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ISSN 2161-6590(online)

DOI 10.5195/hcs.2011.28| http://hcs.pitt.edu

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Abstract Lifestyle modifications through a range of health care practices are considered central to the management, control and prevention of chronic non-communicable diseases. While there is a critical perspective on the epistemologies of such global health discourses in existing literature, empirical evidence on how people engage with such prescriptive lifestyle modifications in different cultural contexts is very limited. The paper in this context draws on illness narratives of heart patients to discuss about the anxiety and uncertainty expressed by patients and others about notions of what constitutes ‘healthy’ and ‘risky’. It specifically unpacks the global-local dynamics in the construction of risk and healthy lifestyle and examines the contexts in which such global discourses are embodied, resisted or negotiated in different cultural contexts. The paper also examines how global health discourses travel to local sites through popular press. The paper draws on evidence collected through analyzing two Indian national English dailies and in-depth interviews with heart patients and their family members in Delhi, India in 2007-2008. Keywords: lifestyle; discourse; risk; patients; India
Health, Culture and Society Volume 1, No. 1 (2011) | ISSN2161-6590 (online) | DOI 10.5195/hcs.2011.28| http://hcs.pitt.edu

Engaging with the discourse on lifestyle modifications
Evidence from India
Arima Mishra1

I. Introduction
Lifestyle modifications through a range of health care practices are considered central to the management, control and prevention of chronic diseases such as diabetes, cancer and cardiovascular disorders which are often termed as ‘lifestyle diseases’. Lifestyle modifications in dominant public health discourse imply that individuals are largely responsible for their own health, being able to lead healthy lives by engaging with a range of health care practices including healthy diet; being physically active; managing stress; controlling obesity; undertaking regular screening check-ups, etc., The rationale for a healthy lifestyle lies in the epidemiological evidence on the nature of risk factors for most of the chronic non-communicable diseases. Sociologists however have gone beyond these limits to locate such rationale in the larger context of changes originating from a) disease patterns; b) modernity and, c) social identity.2
Epidemiological transition suggests that chronic non-communicable diseases are the major sources of morbidity and mortality across the world. A wealth of epidemiological evidence additionally demonstrates that these diseases can indeed be controlled and prevented through changes in personal lifestyle patterns that constitute major behavioral risk factors. Some of the commonly known behavioral risk factors are sedentary lifestyle; unhealthy diet; smoking; obesity and stress. The epidemiological transition and evidence on prevention of chronic diseases imply that individuals are largely responsible for leading a healthy lifestyle to avert risks of these diseases.3 Cockerham thus argues: “Greater personal responsibility means that achieving a healthy lifestyle is more of a life or (time of) death question. 4”
1 Faculty, Institute of Public Health, Bangalore 2 See Cockerham, William. “Health lifestyle theory and the convergence of agency and structure”. Journal of Health and Social Behaviour, 46 (2005): 51-67, Giddens, Anthony Modernity and Self-identity: Self and society in late modern age, Stanford: Stanford University press 1991, Turner, Bryan Regulating Bodies : Essays in medical sociology. London: Routledge 1992 3 See Mishra, A. Deconstructing self-care in biomedical and public health discourses In Health, Illness and Medicine: Ethnographic Readings London: Routledge 2010, for a genealogical analysis of debates around self-care in management of chronic illness and its risk factors. Also see Lalonde, M. A new perspective on the health of the Canadians, Ottawa, Government of Canada 1974, Crawford, Robert. On a cultural account of health: Control, release and the social body, in, Issues in the political economy of health care ed John McKinley , pp: 60-103, New York, Tavistock 1984 4Cockerham, P. 52 Health Education and Social Behaviour, 2005

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Along with changing disease burden, sociologists have shown that changes arising from a new form of modernity5 pervaded all aspects of life including family; kinship; patterns of stratification and health. More specifically, in the field of health, such changes are marked by the use of rhetoric where we hear, and very much read, of patients as partners who are expected to participate actively in the process of treatment decisions; be well informed about symptoms, risk factors of diseases and possible courses of treatment. The changes following late modernity also include a shift from a cure to care model due to the nature of chronic diseases that cannot be cured but controlled and managed. Many of these diseases need long term care rather than mere cure from specific episodes of illness. The notion of individual responsibility in health is also supported by the neo-liberal ideology promoting the idea of a rational individual/consumer asserting choices and taking responsibility for these choices6
Accompanying such large scale changes patterning late modernity is also the argument that lifestyle consumption habits have become an important marker of social identity rather than mere work or occupation7. Following Giddens, Cockerham argues that lifestyles “not merely fulfill utilitarian needs but also give particular material forms to a narrative of self-identity.8” Concerns for leading and building healthy lifestyles have been articulated as important values that need to be sought after and developed. Consequently, leading a healthy lifestyle becomes a marker of positive self-identity and classifies groups into ‘healthy’ and ‘unhealthy’. These concerns for ‘health’ are distinctly visible in scientific, popular and political discourses, though the language and rhetoric used to articulate these concerns can differ to varying degrees and impact. In popular discourse, there are a number of magazines that bear terms such as Men’s Health, Women’s Health, and Prevention. There are specific columns in newspapers on ‘lifestyle facts’, ‘health, body and mind’, ‘Mind, Universe and Everything.’ If leading a healthy lifestyle through averting risk is the established norm and ideal, it also implies that normality is constituted not as a state of the body or mind (the normal and pathological were once drawn at the boundary of a diagnosed disease) but normality as constituted through doing health – engaging with a range of health care practices to control risk, in order to achieve and maintain health.
A critical perspective on the epistemologies of such discourses is extensively discussed in contemporary literature9. However, empirical evidence as to how such discourses travel to local sites and how different communities engage with such discourse on healthy lifestyle is relatively sparse, more so in developing countries. This study seeks to thus fill this gap and analyze the contexts through which such global discourses are embodied and at times reconstructed in different cultural contexts.10 Following this objective, three sections mark the present
5 Beck Ulrich, Risk society: Towards a new modernity, London: Sage 1992, Giddens, Anthony, Modernity and Self-identity: Self and society in late modern age, Stanford: Stanford Univ Press 1991 6 Petersen, A Risk Governance and the new public health In Foucault, health and medicine eds Alan Petersen and Robin Bunton 189-206, London: Routledge, 1997, Galvin, Rose “Disturbing Notions of chronic illness and individual responsibility : Towards a genealogy of morals”, Health 6.2 (2002): 107-137 7 Annandale, Ellen The sociology of health and medicine: A critical introduction. Cambridge, United Kingdom: Polity Press 1998, Cockerham, Cockerham, William. “Health lifestyle theory and the convergence of agency and structure”. Journal of Health and Social Behavior, 46 (2005): 51-67, 2005, Giddens, Anthony, Modernity and Self-identity: Self and society in late modern age, Stanford: Stanford Univ Press 1991 8Cockerham P. 52 Health Education and Social Behavior, 2005 9Galvin , Rose “Disturbing Notions of chronic illness and individual responsibility : Towards a genealogy of morals”, Health 6.2 (2002): 107-137, Lupton, Deborah The Imperative of Health: Public Health and the regulated body , London: Sage 1995; Petersen, A and Bunton, Robin eds. Foucault, health and Medicine, London: Routledge1997; Rose, Nikolas, The Politics of life itself: Biomedicine, Power and Subjectivity in twenty first century. Princeton: Princeton University Press 2006 10 This study is part of a larger research on ‘Social Construction of Heart Diseases in India’ which the author was engaged in as a faculty member in the Department of Sociology, Delhi School of Economics, University of Delhi between 2004-2009. The study examines the discourse on heart diseases through a number of sites and methods that include life histories of patients, lay

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Volume 1, No. 1 (2011) | ISSN 2161-6590 (online) | DOI 10.5195/hcs.2011.28 | http://hcs.pitt.edu

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investigation: the first shows how global discourse of risk and healthy lifestyle travels to local sites through the popular press in India, circulating certain ideas and words which may constitute a “common knowledge” or “public awareness.” The second, discusses the experiences of patients and family members with the everyday demands of maintaining and achieving health. The third section to the study, will draw upon key discussion points.
II. The case of India
India like many other developing countries witnesses a double burden of diseases. Epidemiological data show that the incidence of non-communicable diseases, particularly that of cardiovascular diseases (CVD), cancer and diabetes is on the rise in India11. India supposedly earns the distinction of the ‘diabetes capital of the world.’12 . Reinforcing Bulato and Stephen’s study (1992) on the global estimates of mortality, Reddy and Yusuf argue that mortality attributed to circulatory system diseases would rise by 103 per cent in men and 90 per cent in women during the period 1985-2015. By 2015, these diseases are expected to account for 34 per cent of all male deaths and 32 per cent of all female deaths.13 Specific community based studies further reveal that there is a high prevalence of Coronary Heart Disease (CHD) in Indian urban areas14. Moreover, a recent study reports that 60 per cent of the worlds’ heart diseases are detected in India.15 While most of these studies do point towards the higher incidence of CHD and diabetes among the urban higher and middle socio-economic sections, recent studies do argue that individuals with a low level of income and education (in both rural and urban areas) are also affected by CHD confirming the global evidence that as CVD and its risk factors mature, all sections of society are affected.16Even while epidemiological evidence suggests the rising incidence of cardiovascular diseases, diabetes and cancer in India, there is no concerted Government policy and program on the prevention and control of such diseases. However, the market, including an increased number of private, specialized hospitals, mass media, and other public spaces in large Indian cities, are invariably inundated with information on the burden, management, control and prevention of these lifestyle diseases.
epidemiology that follows discussion/social analysis of a particular episode of illness, media coverage on the issue, research dialogue within the medical community through relevant articles in medical journals. Ethnographic field work for the research was undertaken in Delhi and supported by the Department of Sociology, University of Delhi under the CAS-ASSISH program. The paper was presented in the BASAS conference at the University of Edinburgh, UK. I am grateful to the participants for their valuable feedback on the paper. Some parts of the research on media narratives were published earlier as an occasional paper, Department of Sociology, Delhi School of Economics, University of Delhi. 11 Reddy, K.S. and S. Yusuf “Emerging epidemic of cardiovascular diseases in developing countries” Circulation. 97 (1998): 597601; Reddy, K.S. et al “Responding to the threat of chronic diseases in India, Lancet 12 (2005): 1744-1749; Sethi, P.K. et al “Stroke: The neglected epidemic, an Indian perspective” The Internet Journal of Neurology, .8.1 2007 12 Mohan, V et al, “Epidemiology of type 2 diabetes: Indian scenario”, Indian Journal of Medical Research 125 (2007): 217-230 13 Reddy and Yusuf, p. 598, Circulation Vol. 97, 1998 14 Reddy and Yusuf, “Emerging epidemic of cardiovascular diseases in developing countries” Circulation, 97 (1998): 597-601, ChadhaS..L et al “A 3 year follow up study of coronary heart diseases in Delhi” Bulletin of the World Health Organization 71.1 (1993): 67-72 15 Xavier, D et al ‘Coronary artery diseases in India’ The Lancet 371.9622 (2008) : 1435-42 16 Gupta, R and Gupta, V.P ‘Meta analysis of coronary heart disease prevalence in India’, Indian heart journal, 48 (1996) : 241245 Ramchandran, A et al, ‘High prevalence of diabetes and impaired glucose tolerance in India : National Diabetes survey’, Diabetologia 44.9 (2001) : 1094-1101
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‘Take charge of your health’: The media representation of risk and healthy lifestyle In order to examine the representation of the aspects of health and lifestyle in the print media, data was collected from relevant sections in two of the most widely read Indian national dailies (Delhi editions)—Hindustan Times and The Times of India—over January 2007–December 2008. Focused was given to specific sections in the newspapers reporting medical research findings on health issues and considered to be the legitimate space for ‘expert knowledge’. Thus one comes across validating references of knowledge through headlined phrases such as ‘Experts speak’, ‘says Study’, ‘Research shows’ ‘This is not pop science but published in the journal […]’etc., With this, is coupled the citation of statistical figures for added scientific clarity, reinforcement and psychological impact value within public consciousness. The narrative techniques and strategies through which scientific information about ‘healthy life’ is presented in the media vary from (1) the use of oppositional categories; (2) the emphasis of individual responsibility and implicit blame of the victim; (3) the prediction of morbidity patterns and status of control/prevention of diseases and, (4) the generalization of risk to cover increasing aspects of life.
Use of oppositional categories and assigning individual responsibility Media narratives, as with all narrative forms, are created through the employment of oppositions. These oppositions in the popular press are expressed through series of social distinctions such as you/us, danger/safety, victims/heroes, laypersons/experts, active/sedentary, fit/unfit, life/death and damage/repair (protection). For example, some of the news items (compiled from both the newspapers consulted) read:
Eating breakfast daily helps to keep [us] slim and healthy
Eat Breakfast and avoid obesity
How to live 14 years longer
Obesity knocks 13 years off your life
Such news items (emphases added) oppose slim and obese, as healthy and unhealthy social categories, thereby reinforcing the social norm of slim=healthy. Similarly, damage is contrasted with how to stop and protect against potential health adversities where even choosing to live longer is contrasted with living 13 years less. One could go on with citing more examples of such oppositional interplay that form the rationale of health news articles and the eventual healthy “choice” of the public readership. These oppositions, moreover, help to depict a common plot – why and how, individuals should lead a ‘healthy lifestyle’, which is the ‘norm’.17
17 The use of similar oppositional categories and the strategic use of adjectives to alert popular consciousness in the media has been discussed in other studies by Lupton, Deborah ‘Analysing the media coverage’ In The Fight for public health: Principles and practice of media advocacy eds Simone Chapman and Deborah Lupton London: BMJ Publishing Group 1994 and Seale, Clive ‘Health and media: An overview’, Sociology of Health and Illness 25.6 (2003): 513-531

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The information to hand clearly spells out individual responsibility and choice through a psychological strategy composed of implicit notions of blame, furnishing guilt on the part of individuals who do not engage in such healthy behaviours or do not care for the risk that might be involved in unhealthy behaviour. Thus some of the headlines in the newspapers read:
‘To be healthy, you have got to work up a sweat’ ‘Strokes among middle-aged women triple: Belly fat to blame’
‘Mums, kids binging on junk food and loving it (this is along with a heading in the text box on ‘Fast track to obesity’18
Along with individual responsibility, health is displayed as achievable and diseases preventable largely through modifying individual lifestyle. Health information in the newspapers implies that people’s beliefs and knowledge directly impact upon their behaviour and hence health intervention and promotion programs should be oriented towards furnishing people with the correct health knowledge and consciousness of disease management. There is a great deal of public health literature, however, demonstrating the relationship between educational campaigns and the modification of people’s behaviour is much more complex than what it is commonly assumed to be19. Health information in the Popular Press (which is indeed an institution) uses a language that does not merely state that individuals are responsible, but that they can in fact (and hence must) do and perform health. Thus we read:
‘Five easy steps to live longer and well’ 20 (should be superscript?)
‘Being diagnosed with heart disease need not always mean a lifetime of angioplasty, angiographies and bypass surgery. A daily dose of yoga, along with a low cholesterol diet and an active lifestyle can be a recipe for further progression- and in some cases- the reversal of heart disease’21
The implication here is that since these practices are easy, individuals should choose to indulge in selfdiscipline and self-regulation. Capitalizing on an individual’s responsibility and choice, the pharmaceutical companies, the fitness industry and the food industry likewise offer a range of readymade packages facilitating a healthy life in a timeframe suited to the demands of modern lifestyles.
18 The Times of India, January 19, 2008, The Times of India February 22, 2008, Hindustan Times, October 27, 2007 19Williams,Simon J ‘Theorising class, health and lifestyle: Can Bourdieu help us?’ Sociology of health and illness 17 (1995): 577604, Blaxter, Mildred Health and lifestyle. London: Routledge 1990, Lawton, Julia ‘Colonizing the future: Temporal perceptions and health relevant behavior across adult life course’, Sociology of Health and Illness 24.6 (2002): 714-733, Dean, K. ‘Self-care components of lifestyle: the importance of gender, attitudes and social situations’ Social Science and Medicine 29.2 (1989): 137152 to cite a few 20 Hindustan Times August 16, 2007 21Hindustan Times, September. 30, 2007 p. 20
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The Language of Crisis The language of crisis and emergency (with carefully chosen adjectives, superlatives and nouns) is the vehicle carrying data on prevalence, incidence and predictions of the burden of diseases. For instance, the prevalence of heart diseases in India is reported as “3 million people die of cardiovascular disease (CVD) every year, 30% of all deaths are caused by CVD, 5 million will die of CVD by 2020.22”
Here is how sleeplessness plays havoc with your health
More than genes, it is the way we live that determines our risk of heart disease, India’s number one killer
You think more and more people around you are being diagnosed with the dreaded C-word? Lifestyle changes, increased longevity and higher detection rates have made cancer the fourth largest killer disease in India: The Mysterious Trigger (emphases added)23
The use of quantitative data to express the burdens of disease acts as one of the ‘technologies of trust. 24’(this footnote no. should be superscript?) It successfully evokes a sense of threat for the future and creates a situation of crisis, disequilibrium and emergency. It calls for everybody’s attention to the social problems i.e. the threat of disease. And as demonstrated in other studies, the metaphors of war, battle and crisis are frequent with reference to the need for management of health in the media.25
What is risky? Etiologies of diseases Two points are worth analyzing here to understand what constitutes risky and healthy. The first is identification of risky behaviors that need to be averted. Here one witnesses the reporting of increasing expansion of areas of life that are potentially risky. The risk checklist that is provided in the media includes a wide array of social spaces of the individual. For heart disease, for instance, it includes physical factors such as smoking, high blood pressure, low HDL, family history, diabetes, abdominal obesity and psychosocial factors that include anger/hostility, anxiety, social support and chronic stress26. Hence one must be screened possibly for a range of risk factors to ensure an existence free of heart risk. While men above 45 are considered risky, children are also covered under this risk analysis. Childhood obesity, moreover, and its potential for many of these lifestyle diseases is a much stronger concern reported in the Indian media, reflecting the larger, global trend medicalizing childhood obesity.

22 Hindustan Times September 30, 2007 23 Hindustan Times, April 15, September 30, 2007 24Shapin, Steven and Scaffer, Simon Leviathan and the air pump: Hobbes, Boyle and the Experimental life. Princeton NJ: Princeton University Press 1985 use this phrase to refer to numbers and other quantitative techniques that help to separate facts from opinion, research evidence from anecdotes and render facts a kind of mechanical objectivity. 25 Martin, Emile “Towards an anthropology of immunology” : The Body as nation state” Medical Anthropology Quarterly, 4.4: (1990); 410-426 Saguy, Abigal C and Almeling Rene ‘Fat in the fire? Science, the News media and the ‘Obesity epidemic” Sociological Forum 23.1 (2008): 53-83; Halpin, Michael et al “Prostate cancer stories in the Canadian print media: Representation of illness, disease and masculinities” Sociology of Health and Illness, 31.2 (2009): 155-169 26 Hindustan Times, September 30, 2007, January 13, 2008

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Secondly, despite ever growing risk factors, one also witnesses contradictory and conflicting information on what constitutes “risky behavior”. Some examples are: Obesity on the one hand is projected as a major disease of the 21st century, and is linked to risking several illnesses, more directly high blood pressure, diabetes, heart disease, stroke and cancer. Substantial sections of the information coverage in newspapers are indeed devoted to ways of controlling obesity, assuming that this is a preventable entity. On the other hand, there are media reports to the contrary, namely that obesity can be hereditary. As we read: British and French scientists have identified the gene that causes obesity. “Obesity can be inherited”27 and further, ‘‘Indian-origin researcher finds gene behind heart attack”, where, “Now Svati Shah, co-author of the study along with colleagues believe they have pinpointed a gene or marker that can help predict in advance whether someone is at increased risk.28” Increasingly, research is oriented towards why people overeat, seeking to single out genetic and hereditary tendencies rather than unhealthy behavior. And while obesity is identified as a major risk factor, non-obesity is not necessarily less risky. As one headline reads:
‘Fat chance of an attack? Wrong! The lean and slim also need to eat healthy food and exercise to lower their risk of heart disease’29
‘[The] Non-obese should not consider themselves fortunate/healthy—lean and slim are also prone to risk factors,Your slim kid can have high cholesterol too(Experts at the Children’s Hospital of Philadelphia have recommended that kids should
have a complete cholesterol check up if they have a family history’30.
In the process of claiming to tame the uncertainty that might be associated with the future, the discourse on risk reported in the media creates further uncertainty. Where does one locate the nature and source of such uncertainty? While further research is needed to analyze the reporting of study findings in medical journals and their import to local media, one hastens to cite Saguy and Almleling’s31 findings on a comparative framing of social problems in medical science and news reporting. They jointly argue that the media has a tendency not to cite debates surrounding contradictory medical research findings. The analysis on newspaper coverage also shows the process of the globalization of the media as well as the universalization of strategic language. It often reports scientific findings derived from countries with different demographics, sets of risk factors and leisure activities and hence such findings may not necessarily hold true in terms of cultural variance for a specific context like India.
Though the media has its own rhetoric and narrative techniques, it nevertheless reinforces the larger thrust of global risk discourse to which risk management and the modification of one’s lifestyle is central. While such discourse articulates risk and its management with certainty, evidence on everyday contexts highlights a contrasting picture as to what actually constitutes the risky and the healthy. The following section discusses the experiences of patients and their family members with this everyday demand of lifestyle modification.
27 Hindustan Times, August 16, 2007 28 Times of India, January 4, 2009 29 Hindustan Times, January 13, 2008 30 Hindustan Times, February 7, 2008 31Saguy, Abigal C and Almleling Rene “Fat in the fire? Science, the News Media and the ‘Obesity epidemic” Sociological Forum 23.1 (2008): 53-83
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III. The Data
Illness narratives were elicited through in depth interviews with patients diagnosed with heart disease in 20072008 (N=50, M= 27 and F= 23). Patients were recruited from both hospital (one private tertiary hospital specialized in research and clinical care of CVD) and community settings in Delhi, India. For the former, patients who were admitted in the general wards (and were recovering) and those in the Out Patient Department (who had come for follow up) were interviewed. Permission to obtain oral testimony was granted through the hospital authorities. Patients in community settings were identified through snowball sampling. The patients interviewed belonged to the middle class who had access to private health care. They were in different stages of their illness trajectory spanning from the recently diagnosed; those recovering in the hospital following surgery; those attending for follow up, and in some cases those patients claiming to have been completely ‘cured’ and thereby agreeing to narrate their illness experience in terms of past episodes. The age group of patients ranged from 30-62.
The analysis additionally draws upon the author’s observations on ‘everyday speech’ (that took place in the author’s networks of families, neighborhoods and offices) with regard to specific episodes of heart diseases which people may have either heard or witnessed.32
Choosing a healthy lifestyle Lifestyle discourse is premised upon the notion of individual agency and choice in leading a healthy life by controlling multiple risk factors. Such a choice framework explains failure to engage with this discourse either in terms of lack of knowledge or lack of self-control. Lay illness narratives though emphasizing individual agency highlight a series of constraints in exercising such choice. Such constraints range from the lack of feasibility (lifestyle prescriptions are often considered inconsistent with people’s lived realities); lack of precision (risk factors of specific diseases, information on specific components of lifestyle that need to be modified etc); lack of trust in expert knowledge (as consequence of the first two constraints along with the risk explanations often failing to account for incidence of specific diseases in real life situations), and lack of access to resources (time and money).
I wish I had the magical bracelet to cure my disease! Many patients shared their experiences of how many of these healthy prescriptions are inconsistent with their daily lived realities even when exerting compliance. A 60 year old woman belonging to a lower middle class family had a history of diabetes and high blood pressure and had been recently diagnosed with acute MI at the time of interview in 2007. The following excerpt highlights the anxiety in her attempts to modify her lifestyle patterns based on her understanding of the doctor’s prescription.
There are elaborate restrictions on food. The doctor says I should have only two whole grain chapatis (Indian bread) per meal. You know, I have been eating four chapatis all these years! I know I need that much to eat to feel energetic and active. The doctor had strictly advised me to avoid all fried and spicy stuff and suggested that
32 See Chaudhary, Nandita Listening to culture: Constructing reality from everyday talk. Delhi: SAGE 2004 for insights into the methodological use of everyday talk to understand culture.

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