Exercise, diet, and sleep matter for brain health. But researchers caution that too much focus on personal choices risks fueling stigma and misplaced blame.
Can dementia really be prevented with healthier habits — or does that public health message risk doing more harm than good? Mounting research shows that making certain healthy lifestyle choices — like eating a Mediterranean diet, or socializing, or sticking to a regular sleep schedule — can reduce a person’s risk of developing dementia. Encouraging these behaviors can also help reduce the prevalence of dementia among older adults, on a population-wide scale. In fact, these lifestyle factors appear to be associated with nearly half of dementia cases worldwide.
This is an empowering thought, but genetic and environmental factors beyond a person’s control play an important role, too. Experts say over-emphasizing the amount of control people have over their cognitive health can backfire.
For example, Australian researchers Joyce Siette and Gilbert Knaggs recently laid out in a commentary in The Lancet how public health messaging that focuses too narrowly on behavior “can lead to a two-tiered system, where affluent people are praised for their proactive brain health, while marginalized groups face barriers to participation and are blamed for their perceived inaction.”
Arizona State University healthcare researcher Allie Peckham has studied the impact of this messaging on public health. Her worry is that overemphasizing the importance of personal choices could turn dementia into “yet another lifestyle disease.” Peckham told Being Patient: “You may do everything right, and you may still end up with cognitive decline.”
Shifting attitudes
To investigate current perceptions around dementia, Peckham and her colleagues conducted a study, which was published last year in the journal Dementia. Peckham’s team interviewed a group of 23 cognitively healthy adults between the ages of 58 and 89, asking them questions about what they knew about dementia risk and risk reduction.
The participants had a range of attitudes towards dementia, with some viewing the disease as unavoidable, while others believing they could prevent it with active lifestyle interventions. Another group of the participants said that they did not believe they could entirely prevent dementia regardless of the choices they made, but they still strove to improve their brain health because they wanted to be confident that it wasn’t their fault if they ultimately developed the disease.
According to Peckham, this range of attitudes actually reflects a positive shift in dementia discourse: Historically, she said the disease has been perceived as “an inevitable part of aging” and a scary, uncontrollable outcome. But, her study indicates that a growing number of people feel a sense of agency, which can be incredibly empowering. At the same time, “overemphasizing individual behavior around your personal responsibility for health and your future, with or without cognitive decline, really offers an opportunity for self-blame [or] for stigma,” she said.
Peckham used a hypothetical woman named Cynthia who had recently been diagnosed with Alzheimer’s as an example. Previously, her neighbor may have said, “We found out she’s got diagnosed with Alzheimer’s disease. Oh, poor Cynthia.” But as dementia becomes more and more associated with lifestyle choices, Cynthia’s neighbors may instead start to say things like: “Oh, well, she was on the bottle, like, every weekend. So, yeah, I kind of thought this might happen to Cynthia.”
Striking the right balance
Overemphasizing the contributions of lifestyle choices to dementia risk could ultimately undermine efforts by public health advocates and other groups to reduce the prevalence of dementia by exacerbating people’s anxieties about the disease and making them closed off to other risk factors. Not only does stigmatization ignore genetic and environmental factors that drive many cases of dementia, but it also fails to account for structural inequities that can prevent disadvantaged groups from making healthier choices.
A study published in the journal Ageing & Society earlier this year suggested that public health messaging may already be driving societal discourse towards stigmatization. Kristina Chelberg, a health law researcher at the Queensland University of Technology in Australia, examined webpages created by medical providers, advocacy organizations, and other groups. These resources included items like a blog post about the connection between brain health and physical exercise published by a professional society of exercise professionals and a dementia resource page from an educational self-help organization.
According to Chelberg’s analysis, these messages collectively reinforce Australian society’s understanding of dementia as failed aging: an outcome that every individual has a civic responsibility to avoid by engaging in healthy choices like exercising and doing crosswords.
Not only does framing dementia as a failed endpoint create an impossible standard of success for many people, but it also may foster a sense that life becomes less meaningful or dignified after diagnosis. Siette and Knaggs wrote in The Conversation: “Preventing dementia is a worthy goal, but so is ensuring dignity, inclusion, and care for people who live with it. A just approach to brain health must do both.”
At the same time, Siette and Knaggs think that too much emphasis on personal empowerment can cause people to lose sight of the collective responsibility that members of society have to one another. “Brain health should be supported through public infrastructure, equitable access to care, and culturally sensitive health promotion,” they wrote.
To create more nuanced messaging around dementia, Peckham said the most important thing to do is to be very clear about what is possible when it comes to controlling a person’s likelihood of developing dementia.
Although healthier lifestyle choices can promote healthier aging, they cannot necessarily negate the impact of genetic mutations and exposures to environmental hazards, many of which disproportionately affect people who are socioeconomically disadvantaged.
“We’re not preventing,” she said. “This is simply risk reduction.”
Beyond that, she said that messaging has to meet people where they are.
“Behavior change is hard on a good day. Behavior change is hard for someone with all the resources,” she said.
Of course, she acknowledged, for people who are food insecure or housing insecure, making healthier choices can be nearly impossible. And even if change is feasible, lifestyle interventions that clash with a person’s personal or cultural values — like trying to get someone to take up exercise or to change lifelong eating habits — are easier said than done.
Public health officials will need to get out and learn about the needs and desires of the people they aim to help, and then craft messaging campaigns that meet those people where they are. This, Peckham believes, is the “baseline start.”
