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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

Healthy Behaviour is Not Normal

Exploring the mind-body connection for better health

Wolfgang Linden, PhD

Reprinted from the "Mind-Body Connection" issue of Visions Journal, 2014, 10 (2), p. 5

Hmm, odd title?* As much as this title is meant to provoke, the real question is why Visions considered the mind-body theme. Why this topic now? What has changed?

In some ways, the answer is: “not much.” Even the ancient Greeks knew that body and mind were interlinked, that one influenced the other. On the other hand, the contemporary practice of medicine has seen a major shift toward specialty care, focusing more on individual organs than on the whole patient.

Today’s family physicians, however, tell us that over half their patients who present with physical symptoms have underlying stress and emotional problems that need treating more than these physical symptoms do. Even common sense tells you that a patient with insomnia who also reports marital problems and a fear of losing his job shouldn’t receive just medication for his sleep problems as a primary treatment.

Because the mind-body linkages flow both ways, asking questions about causality is tricky. On the one hand, for example, depression has a role in the causes of heart disease. In diagnosed cardiac patients, depression is known to increase mortality. This is at least partly explained by the fact that depressed patients are less likely to follow a diet or exercise or take their medications.1 On the other hand, systematic exercise is shown to be an effective treatment for depression and anxiety,2 and can be of benefit to post–heart attack patients.3

Your health: Whose responsibility is it?

Now, one might ask, shouldn’t patients leave it up to the professionals to tackle these health issues? I, for one, posit that health professionals and politicians actually do worry about these issues and do invest in prevention and patient-oriented treatments—but this is not enough.

The typical attitude still is that patients—and we are all patients—go for medical help so their physician can ‘cure’ them. But much of primary care, and family medicine in particular, has become the practice of chronic disease management. Because of this, we need to accept that health care needs to be a team effort.

What we need is a shift in attitudes. Patients and health care providers all need to work together, engage in prevention and consider root causes.

In spite of knowing risks, we resist...

Do people know how one behaves preventatively and do they follow physician advice? Do they know what the major health risk factors are and what they can do about them? The short answer is “yes.” We know we need to exercise, eat well, not smoke, take our medications, go for medical check-ups, engage in meaningful activities and spend time with family and friends.

But—and this is a big but—do we actually act in accordance with our knowledge? And here the answer is: “no, we don’t.” For example, among North American adults, the rate of obesity has more than doubled in the last 30 years, and that is equally true for Canada, the US and Mexico. In the US, in adults ages 20 to 74 years old, the prevalence of obesity increased from 15% (in a 1976–1980 survey) to 34% (in a 2005–2006 survey). Canada and Mexico lag a little behind, but certainly not enough to have earned bragging rights.4-5

The problem isn’t lack of knowledge, but lack of adoption and translation into action. An obvious follow-up question would be: are we actually able to engage in preventative behaviours? Again, the answer is “yes.” Everybody knows how to stop smoking (although it is admittedly very, very hard) and how to exercise (you don’t need a gym membership to go for a long walk!).

Not surprisingly, when you ask people how much they exercise, they tend to overestimate how much they do. But ultimately, the accurate answer for most people is “not enough.” When we put this into hard numbers that actually predict health outcomes, here are some 2012 statistics for percentage of adults 18 years of age and over who met US physical activity guidelines: for aerobic physical activity, 49.6%; for muscle-strengthening activity, 23.6%; and for both aerobic physical and muscle-strengthening activity, 20.3%.6

I’m sure all readers appreciate that healthy eating and regular exercise require steady effort. So why are healthy behaviours nowhere near as prevalent as they need to be? Well, for one thing, we are faced with a huge number of exciting and available food options. We also deal with competing activities like work, home responsibilities and a sense of having earned the right to some leisure. Furthermore, the consequences of poor eating and no exercise take decades to show their ugly face, and that in turn prevents us from taking the need too seriously today.

Does it look any different when the needs for healthy behaviour are much more urgent? Think about this fact: people with insulin-dependent diabetes are at very high risk for prompt coma and death if they don’t inject their insulin on a daily basis. And yet, consistent adherence to this absolutely necessary life-sustaining behaviour is only 48%.7

Consider this good news: most risk factors for disease are modifiable.8 If you bring nine of the major risk factors under control, you are 129 times less likely to develop heart disease.8 Why is this number so large? Individually, people with high cholesterol are four times more likely to develop heart disease than those with low cholesterol. Those with a stress-prone personality have a 2.5 times greater risk of heart disease. But just adding these risk numbers together misses the point because behavioural risk factors come in clusters and the inherent risk is exponential. The most frequently seen cluster packages high cholesterol, diabetes and obesity together. For another example, people who smoke are also more likely to experience depression, and depressed individuals are less physically active and have less social support.

Small steps to sustainable self and health care

In summary, the objective of this mind-body issue is to explore ways that healthy behaviours can be encouraged and ways they can be made sustainable. We look at connecting healthy behaviours to emotional health and to individual social contexts like social isolation or poverty or crime-ridden neighbourhood. Part of this effort will be geared to understanding what motivates patients and to accepting that different people can be motivated in different ways and by different arguments.

This issue isn’t about grandiose plans, which typically don’t go anywhere. This issue is about implementing small steps that make a difference and that we can actually maintain. For example, in a self-controlled walking exercise program for obese individuals, three-quarters of all participants had dropped out by three months. But in a control group where they had set up a buddy system, namely doing it together, almost half of all participants were still active at three months.9 That is a big difference, and it didn’t cost anything, nor did it require more exercise effort.

This issue is meant to highlight existing opportunities for increasing healthy behaviours. When taken in isolation, some of the suggestions may seem trivial. But when multiplied, they can lead to a major shift in attitudes. This, in turn, can drive healthy behaviour and make it last.

Enjoy reading.

*The word “normal” can be a loaded term because it has a habit of dividing the world into two camps and has, unfortunately, contributed to ongoing stigma in the world of mental health. For our purposes here, “normal” is used the same way as “frequent,” to acknowledge what most people do. It is not a value judgment.

About the author
Wolfgang is a Professor of clinical and health psychology at the University of British Columbia, where he introduced the first health psychology course in 1983. He has worked with cardiac and cancer patients for over 30 years, trying to translate research findings into better patient care models. He has also been a lifelong volunteer with the Canadian Mental Health Association and other organizations striving for improvements in mental health and substance abuse care in BC
  1. Ziegelstein, R.C., Fauerbach, J.A., Stevens S.S. et al. (2000). Patients with depression are less likely to follow recommendations to reduce risk cardiac risk during recovery from myocardial infarction. Archives of Internal Medicine, 160(12), 1818-1823.

  2. Carek, P.J., Laibstain, S.E. & Carek, S.M. (2011). Exercise for the treatment of depression and anxiety. International Journal of Psychiatry in Medicine, 41(1), 15-28.

  3. Linden, W., Phillips, M.J. & Leclerc, J. (2007). Psychological treatment of cardiac patients: A meta-analysis. European Heart Journal, 28(24), 2972-2984.

  4. Finucane, M.M., Stevens, G.A., Cowan, M.J. et al. (2011). National, regional, and global trends in body-mass index since 1980: Systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. The Lancet, 377(9765), 557-567.

  5. Public Health Agency of Canada. (2011). Obesity in Canada: A joint report from the Public Health Agency of Canada and the Canadian Institute for Health Information

  6. Centers for Disease Control. (2013). FastStats: Exercise or physical activity. Atlanta: Author.

  7. Burrell, C.D. & Levy, R.A. (1985). Therapeutic consequences of noncompliance. In National Pharmaceutical Council, Improving Medication Compliance: Proceedings of a Symposium. Reston, VA: National Pharmaceutical Council.

  8. Yusuf, S., Hawken, S., Ounpuu, S. et al. (2004). Effect of modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case control study. The Lancet, 364(9438), 937-952.

  9. McAuley, E., Courneya, K.S., Rudolph, D.L. et al. (1994). Enhancing exercise adherence in middle-aged males and females, Preventive Medicine, 23(4), 498-506.

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