Health Lifestyle Theory in a Changing Society: The Rise of Infectious Diseases and Digitalization

Disease Patterns

The first and foremost change signaling the importance of lifestyles for health was the long-term epidemiological transition from infectious to chronic diseases as the leading cause of mortality globally. The timeline of this transition through its different stages is from prehistory to around 1960 (Omran 1971). In each period, lifestyles increased in significance as a health determinant (Cockerham 2021). Such lifestyles were linked over time to cardiovascular dysfunctions, pulmonary disease, some cancers, Type 2 diabetes, kidney disease, obesity, and various other chronic afflictions (e.g., Behrens et al. 2013; Christensen and Carpiano 2014; Cockerham et al. 2017; Cockerham, Bauldry, and Sims 2022; Lawrence, Mollborn, and Hummer 2017; Loef and Walach 2012; Murimi et al. 2015). Moreover, in a proposed new transitional stage for the present era—the “Hybristic” or mixed stage—risky behaviors (unhealthy lifestyles) are viewed as a major cause of death from both chronic and infectious diseases (Rogers and Hackenberg 1987).

The link to infectious diseases is especially noteworthy. The resurgence of infectious diseases in the late twentieth and early twenty-first centuries flips Omran’s (1971) epidemiologic transition theory back to its beginning in a return to many of the features of its initial “Age of Pestilence.” Infectious diseases have returned with a ferocity as urbanization, globalization, climate change, and human penetration into formerly remote areas uncovered new viruses and put them at large in society (Barrett 2021). While coping with infectious diseases has been an ongoing problem for developing countries historically, COVID-19, in particular, illustrates the power of pestilence to disrupt social life today on a global scale. The study of social behavior in relation to infectious diseases will undoubtedly command much greater attention going forward. Exposure to infection and coping with epidemics and pandemics involve health lifestyle practices that need to be researched more fully. These practices are relevant not only because of their centrality in responding to changing disease patterns but also because of how they are differentially interpreted and integrated into public policies.

Modernity

As the industrial and postindustrial ages faded into history, the current late modern era emerged in which many traditional centers of power and authority were weaker (Bauman 1992, 2000; Beck 1992; Giddens 1991). For medicine, this meant somewhat lessened professional power compared to the mid-twentieth century (Ritzer and Walczak 1988). Decision-making authority and direct control of the marketplace by the medical profession was reduced by government cost controls and insurance programs, private health insurance company mandates, managed care systems, large corporate health care conglomerates, and a modification in the traditional patient–physician relationship featuring the direct participation of patients in decisions about their health care (Pescosolido and Boyer 2021). The latter development was boosted by the public diffusion of medical information and advice on the Internet and the widespread distribution of digital devices to access this knowledge (Henwood and Marent 2019; Lupton 2013, 2018).

Nevertheless, the medical profession remains the ultimate authority on “health” and gatekeepers to medical care. They maintain their powerful role in wellness advocacy (preventive checkups, evidence-based best practice standards, value-based care, etc.) and promoting healthy lifestyle behaviors. Adopting a healthy lifestyle in partnership with health care providers or independently gives people more control over maintaining or enhancing their health and living longer. As a result, health in today’s modernity is normatively viewed as an achievement (“a goal to work toward”) rather than a taken-for-granted physical condition passively accepted as is by the individual (Cockerham 2005, 2021). The pursuit of health by way of a healthy lifestyle has become not only a societal norm in economically advanced countries (VanHeuvelen and VanHeuvelen 2021) but also a duty (Lupton 2013).

Two major features of modern life affecting health lifestyles are COVID-19 and digitalization. COVID-19 exemplifies the pervasive rise of newly emerging infectious diseases in contemporary society (Barrett 2021), while the ascendancy of digitalization as a global mode of communication and information-sharing now extends electronically into the pursuit of healthiness (Henwood and Marent 2019; Lupton 2018). Responses to COVID-19 do not require a reformulation of health lifestyle theory, but the pandemic illustrates that lifestyle choices will change depending on the circumstances. Digitalization, for its part, provides an extensive range of information, data-driven measures, and assessments of health practices and lifestyles that are now available literally at the fingertips of users. Wearable and other technologies utilized in the pursuit of health qualify as a lifestyle practice.

Social Identities

Lifestyle consumer habits surfaced in the late twentieth century as a leading indicator of individual and group social identities (Bauman 1992; Chaney 1994; Giddens 1991). Pierre Bourdieu (1984), for example, in his seminal study Distinction, noted the relevance of a person’s “ distance from necessity,” in which the further away a person was from having to concentrate on acquiring his or her basic needs for survival, the more freedom, time, and resources that person had to develop and refine his or her personal tastes in line with a more privileged class status. Lower social strata, having to focus more on obtaining life’s necessities, did not have the range of options and resources to pursue such refinements. Instead, they had tastes more applicable to their particular situation in life. Thus, one’s tastes or choices, exhibited in a lifestyle, serve as evidence of class position and social identity. As Anthony Giddens (1991:81) once explained, lifestyles fulfill utilitarian needs and give a material form to particular narratives of social identity. Narratives about social identities (who one is) are articulated via lifestyles.

For example, identity theory, with its roots in symbolic interaction, helps us understand a person’s social identity is composed of self-views (self-categorizations) that evolve through occupying various roles in society and memberships in particular groups and social classes (Burke and Stets 2009; Stryker 1987). Narratives communicating social identities include styles of living and are verified through recognition as such on the part of others. “If identity is like a continuous story [biographies] being told through different ways of living,” says David Chaney (1994:125), “then lifestyles can be thought of as genres—narrative modes—that collect themes and resources to ground particular stories.”

Health lifestyles likewise express a person’s narrative about who they are (Frie and Janssen 2009; Jaye et al. 2018; Mollborn and Lawrence 2018; Mollborn, Lawence, and Saint Onge 2021; Mollborn and Modile 2022; Stead et al. 2011). For instance, Bourdieu (1984) depicted how social tastes in food, drink, and sports preferences were indicative of differences in class standing. Moreover, in an era in which health is an achievement, a positive social identity and cultural capital accrue to those who strive (work) to be healthy. This is seen in a qualitative study by Stefanie Mollborn and Adenife Modile (2022) that found the family socialization of socioeconomically privileged young adults imparted standards of discipline and a sense of high moral worth concerning a healthy diet and exercise that were missing in the cultural capital of lower strata counterparts. “Our findings,” state Mollborn and Modile (2022:7), “underscore the roles of not just health behaviors, but identities, narratives, norms, and understandings of health as core aspects of health lifestyles.”

Consequently, there are normative complexities about health lifestyle behaviors that bestow not only different levels of healthiness but status and moral values signifying social boundaries between people. According to Kirstin Frie and Christian Janssen (2009:221), “Unmistakable socially distinct associations of being healthy, healthy behaviour and leading a healthy lifestyle make it possible for social groups to perceive one another according to these characteristics as well as to distinguish themselves from other social groups.”

This circumstance accords health lifestyles symbolic power (Korp 2008) and pushes the behaviors into the realm of health politics and health inequality as people on the lower end of the social gradient have fewer opportunities for healthy lifestyles (Frie and Janssen 2009; Mollborn, Lawrence, and Saint Onge 2021; Phelan and Link 2013). The symbolic power of a healthy lifestyle is based on its value as a “social good” that legitimatizes particular modes of thinking and acting about health and delegitimizes others that harm health and are at odds with the norms of the affluent (Korp 2008). Therefore, as Giddens (1991:5) concluded decades ago, the lifestyle concept has taken on a particular significance in understanding contemporary social life. It has likewise taken on special importance with respect to a person’s identity and social status in relation to their health.

Health lifestyle theory, as noted, was intended to advance understanding of how lifestyles impact the health of different social groups and serve as a theoretical framework for empirical research on the topic. It has become “a mature theory in medical sociology used to explain the combination of health behaviors and their associations with health outcomes” (VanHeuvelen and VanHeuvelen 2021: 205). However, the COVID-19 pandemic and the spread of digitalization in society provide a new social context for the theory to address. The remainder of this article will discuss what these developments mean for an expanded theoretical model.

Class Circumstances

Class is the only sociodemographic variable indicative of a person’s material well-being (Chibber 2022). As such, it has profound implications for a person’s level of health and choice of health lifestyle practices. Class circumstances or SES establish the catalog of options available for the individual to choose from and the rank order of preferences for the individual. Consequently, class circumstances are the key structural variable in determining health lifestyle patterns (Carpiano, Link, and Phelan 2008; Christensen and Carpiano 2014; Cockerham 2005, 2021; Lawrence et al. 2020; Mollborn and Modile 2022; Rees Jones et al. 2011; van den Broek 2021).

Research in Western societies has traditionally shown that the health lifestyles of the upper and upper-middle classes are the healthiest overall of any social strata and that such lifestyles progressively become less healthy the lower a person’s social status. More affluent classes as a whole have the highest participation in leisure-time sports and exercise, more nutritious diets, often moderate drinking, little or no smoking, more preventive checkups by physicians and dentists, and greater opportunities for rest, relaxation, and coping successfully with stress (Andrews, Hill, and Cockerham 2017; Antunes 2011; Burdette et al. 2017; Carpiano et al. 2008; Lawrence 2017; Margolis 2013; Narcisse et al. 2009). The upper and upper-middle classes are also the first to adopt new health strategies and practices to keep themselves healthy (Missinne, Daenekindt, and Bracke 2015; Missinne, Neels, and Bracke 2014; Phelan and Link 2013). This includes the greater likelihood of using digital devices to manage their health lifestyles (Hardey 2019; Peng et al. 2016).

This pattern is not always universal, however, as seen in countries that have experienced rapid economic development, such as China. Several Chinese studies show the most affluent groups are more likely to have diets high in fat and sugar content, be more sedentary and obese, and smoke and drink more than those in lower social strata (Chen, Yang, and Liu 2010; Miao and Wu 2016; Schafer and Kwon 2012). The affluent adopt these unhealthy behaviors because they see these choices as privileges to be enjoyed with their purchasing power and higher status (Chen et al. 2010:144). Other research utilizing health lifestyle theory finds both the most healthy and most risky health lifestyles in high-SES groups (Wang 2019). Low-SES groups showed lifestyles that were a mixture of healthy and harmful practices.

Among elderly Chinese, however, those who are the most socioeconomically advantaged are most likely to have the healthiest lifestyles (Zhang 2021). This outcome suggests that the higher SES–healthiest lifestyle link exists in China but is most fully evident later in life. Consequently, the effects of social class on health lifestyles and the lifestyles themselves can be geographically or locally distinct. This is not inconsistent with health lifestyle theory that “expects group norms and understandings of ‘healthy’ behavior to vary from one place to another” (Mollborn, Lawrence, and Saint Onge 2021:392). Local social structures influence local outcomes.

While there is considerable evidence that health lifestyles are generally healthier overall at the top of society in the West than at the bottom, this outcome does not mean they are exclusively healthy. While some individuals may have lifestyles featuring either uniformly (concordant) healthy or unhealthy behaviors, others have a health lifestyle consisting of combinations of healthy and unhealthy (discordant) practices. Some U.S. studies emphasize the discordant nature of health lifestyle practices that suggests they are the norm (Saint Onge and Krueger 2017), especially during adolescence and young adulthood, when these age groups experiment with risky health behaviors (adams et al. 2022; Daw, Margolis, and Wright 2017; Lawrence et al. 2020; Mollborn and Lawrence 2018; Mollborn, Lawrence, and Saint Onge 2021).

In addition to finding discordant practices in adolescence and young adulthood, these studies did not uncover significant social class differences. Nevertheless, inconsistent or reversed findings for the effects of higher SES (personal or parental) on the health lifestyles of adolescents and young adults (adams et al. 2022; Burdette et al. 2017; Lawrence et al. 2020) are not unrealistic, considering these are transitional stages of life that affect youth of all class circumstances. As Elizabeth Lawrence and her colleagues (2020:14) determined: “Associations with SES thus appear to be developmentally specific, and socioeconomically based identities may become more salient in adulthood than in earlier life.”

This seems to be the case given that studies in the United States, Western Europe, and China find that higher SES adults are more fully represented in the healthiest lifestyles, especially in middle and older ages, compared to lower strata individuals (Cockerham, Wolfe, and Bauldry 2020; de Vries et al. 2008; Kroesen 2019; van den Broek 2021; Zhang 2021). Lawrence et al. (2020:14) suggest that despite experimentation when younger, high SES groups “come to reject risky health lifestyles as they complete advanced education, establish long-term relationships, and enter into occupational careers.” In sum, it can be said that individual health lifestyles often include a mixture of health-promoting and health-harming behaviors that are nonetheless aligned along social gradients throughout most of the life course, with the healthiest practices usually associated with higher SES and the least healthy with lower SES.

Age

Turning to age, a current research trend is to combine health lifestyle and life course theories to account for changes and continuities in health lifestyle practices at different stages in the life cycle (Burdette et al. 2017; Cockerham et al. 2020; Keyes et al. 2015; Lawrence et al. 2017, 2020; Mize 2017; Mollborn and Lawrence 2018; Mollborn et al. 2014, Mollborn, Lawrence, and Saint Onge 2021). In a pioneering study, Mollborn and her colleagues (2014) found that even preschool children have health lifestyles, which serve as precursors to health lifestyles in middle childhood. Although young children have little agency in choosing their health lifestyle as parents generally make the decisions, they do express judgments over what health-related practices they like or dislike. Social background was found particularly significant as children in disadvantaged households were likely to have lifestyles with greater health risks (i.e., less personal safety, food insecurity, less sleep, and more exposure to secondhand smoking and violence). Consistent with health lifestyle theory, primary socialization in the home was a crucial factor in a child’s health behavior. The decisive variable was not just age but class, as this and other studies (Mollborn, Lawrence, and Krueger 2021; Mollborn and Modile 2022) find that parental SES is reflected in the health lifestyles of their young children.

Other life course studies find that childhood and adolescent health lifestyles go on to influence those in young adulthood (Burdette et al. 2017; Daw et al. 2017; Lawrence et al. 2017; Lee et al. 2018; Mize 2017; Mollborn and Lawrence 2018). However, as noted, adolescent health lifestyles are often inconsistent as family influence competes with that of schools and peers, which, in the case of peers, is likely discordant (adams et al. 2022; Mollborn and Lawrence 2018; Stead et al. 2011). Parental class standing declines in strength as a determining factor in health lifestyles during adolescence (Burdette et al. 2017; Mollborn and Lawrence 2018).

In middle and old age, the aging process influences people to recognize the need to take better care of their health (Jaye et al. 2018). While it might be surmised that there is a general tendency toward healthy lifestyle practices in older ages, this is not necessarily the case. Stability with the past tends to be more common than change in health lifestyles at this time of life (Burgard et al. 2018; Cockerham et al. 2020; Lawrence et al. 2020; Rees Jones et al. 2011), unless the person has been diagnosed with a chronic disease that needs to be managed with healthier lifestyle choices (Cockerham et al. 2020).

Rather than seeing a steady upward arc of continued improvement in health lifestyles as one ages, there is evidence that earlier practices become “locked in” at older ages along class lines (Rees Jones et al. 2011). That is, social class distinctions seem to retain their significance at older ages, with healthier lifestyles remaining typical of people higher on the social scale compared to those toward the bottom (Cockerham et al. 2020; McGovern and Nazroo 2015; Rees Jones et al. 2011; Shaw et al. 2014). As people age, they carry their health lifestyle along with them as part of an age-specific cohort into the next stage of their life course, modifying or keeping the lifestyle as is while adjusting to an older and physically different body.

Gender

Gender is another significant structural variable stratifying health lifestyles in that women generally have healthier lifestyles than men, except for exercise (Annandale 2021; Cockerham 2021; Mollborn et al. 2020). This is the case even though there is research showing more variation within genders than between them (Mollborn et al. 2020). Gender’s imprint on health lifestyle practices begins during childhood as females are socialized to take care of their bodies, visit physicians more frequently than males, and deal with being sick more often. Childbearing, childrearing, and caregiving roles are also significant. Women usually adopt and maintain positive health lifestyles during pregnancy and postnatal care and socialize their children to be healthy. All of which suggest a like-minded habitus among many women featuring durable dispositions toward good health habits (Cockerham 2018).

This is not to say that all women engage in healthy lifestyle practices, as a recent decline in life expectancy among less educated White women in various low-income rural counties in the United States has been associated with smoking, opioid drug use, and obesity (Cockerham 2014; Montez and Zajacova 2013). Nevertheless, by young adulthood, most women have mostly healthy lifestyles (Mollborn et al. 2020). Men are more likely to smoke and consume alcohol than women, eat less healthy foods, be violent, drive fast, take more health risks, have more accidents, suffer more injuries, and die younger (Dolan 2011). Men with an exaggerated (hegemonic) sense of masculinity are less likely to seek preventive care and more likely to engage in risky health behaviors (Cockerham 2018; Dolan 2011; Smith and Dumas 2019; Springer and Mouzon 2011). This outcome seems to apply particularly to working-class men and others further down the social scale who maintain a heightened sense of masculinity concurrent with a marginal social status (Smith and Dumas 2019). Whereas gender is a strong predictor of health lifestyle practices in its own right, it can also be affected by class distinctions, as people higher on the social scale, regardless of gender, usually have healthier lifestyles (Audet et al. 2017; Christensen and Carpiano 2014; Cockerham 2021; Mollborn et al. 2020; Saint Onge and Krueger 2017; Smith and Dumas 2019).

Race and Ethnicity

Race and ethnicity are seriously underresearched with respect to health lifestyles. Studies focusing on the health lifestyles of Asians and Hispanics are absent from the literature. Research on Black Americans is limited, but existing comparisons show that non-Hispanic Blacks are not as likely as non-Hispanic Whites to drink heavily but are more likely to have a less healthy diet and less leisure-time exercise (Keyes et al. 2015; Saint Onge and Krueger 2011, 2017; Zapolski et al. 2014). While proportionately more Black men smoke than either White men or White women, Black women smoke less than Black men and Whites generally (Ho and Elo 2013; Pampel 2008). Smoking for men and poor diets and lack of exercise for both men and women stand out as particularly unhealthy lifestyle practices among Black Americans (Cockerham et al. 2020; Hattery and Smith 2011).

Research on Black–White differences in health lifestyles and cardiovascular disease found both racial groups engaged in a combination of healthy and unhealthy lifestyles, with those primarily lodged in the latter category showing an elevated risk of coronary heart disease and higher mortality (Cockerham et al. 2017). A significant difference was that in each of four lifestyle configurations, Blacks showed a higher probability of excessive energy intake from dietary choices than Whites—indicative of the potential for obesity. Other research shows in an all-Black sample that higher SES Black adults in late middle age have healthier lifestyles than those in the same age group with a lower SES, consistent with health lifestyle theory (Cockerham et al. 2022).

Living Conditions

The structural attributes of collectivities (normative authorities) and connectivities (computational authorities) have been previously discussed, while the fourth structural category of importance in the health lifestyle model is living conditions. The living conditions variable pertains to the natural and built environments of neighborhoods and places people live and work. It refers to the effects on health lifestyles that result from differences in climate; housing; basic utilities like heating, sewers, and safe water; neighborhood amenities such as restaurants, grocery stores, parks, and recreational facilities; and personal safety. The environment within which a person spends their life makes it probable or improbable for achieving and maintaining a healthy lifestyle in the living conditions at hand.

Health lifestyles are obviously most effective in producing health in positive living situations and least effective in disadvantaged neighborhoods where poor health behaviors and unhealthy settings are common (Fitzpatrick and LaGory 2011; Frohlich and Abel 2014; van den Broek 2021). An innovative extension of the living conditions variable in health lifestyle theory to the level of countries shows the importance of national contexts for acquiring a healthy lifestyle (VanHeuvelen and VanHeuvelen 2021).

Completing the Model

As previously stated, life choices and life chances interact dialectically, and the outcome commissions the formation of dispositions to act in certain ways (a habitus) shown in Box 5 (Figure 1), leading to practices (action) shown in Box 6 involving alcohol use, smoking, diet, exercise, vaccinations, use of health apps, and other health-related actions represented as examples in a dotted line to Box 7. Multiple health practices combine to constitute an overall health lifestyle (Box 8) whose enactment leads to its reproduction (or modification) through feedback to the habitus.

Although the emphasis on structure may suggest that the model is one of downward conflation or structural determinism, this is not the case, given that agency is represented in the model. As Anne Hammarstörm et al. (2015:14) point out, health lifestyle theory is an “agency within structure model.” A basic premise of the theory is that people choose their lifestyle, but the range of choices is constrained or enabled by what is structurally possible and influenced by the style common to their class circumstances and other structural variables.

The dispositions toward action, as noted, constitute a habitus, which is a cognitive map or set of perceptions routinely guiding and evaluating a person’s choices and options. It is a process of thinking in which social norms and cultural conventions are internalized in the mind, along with the individual’s own inclinations, preferences, and interpretations that predispose them toward certain behaviors and not others. Although the term “habitus” may be uncommon, it is an old concept that originated with Aristotle and was refined by a host of scholars over time, including Thorstein Veblen, Edmund Husserl, Weber, Marcel Maus, Norbert Elias, and especially Bourdieu (Cockerham 2018; Wacquant 2016). For example, Weber ([1922] 1978:536) saw the habitus as a disposition to see the world in a particular way and behave accordingly.

According to Bourdieu (1998), one of the principal functions of habitus is that of providing a unity of style linking the practices of a single agent to a class of agents that brings together people who are very similar to each other but different from people elsewhere. Bourdieu finds that the habitus retranslates the relational characteristics of a social position into a lifestyle reflecting a set of chosen practices that differentiates itself from the choices of persons in other social classes. As Amy Burdette et al. (2017:522) observe, “Health lifestyle theory suggests that social statuses work to shape qualitatively different patterns of behaviors in individuals that may not be summarized in terms of simple counts of healthy or unhealthy behaviors.” This is because the health behaviors of individuals cluster in varying ways and form diverse combinations of health practices within different lifestyle configurations. The result is good health and longevity for some people and the opposite for others.