Weighing up carrots and sticks

Guest Blog by Matt James, Senior Researcher at 2020health

Overeating and poor diet. Lack of health literacy. Not enough time for exercise and a rise in sedentary lifestyles. These are just some of the reasons often cited for the rise in the obesity ‘epidemic’. It is clear from the statistics that England’s obesity issue shows no sign of abating.

* The National Health Service is spending £5 billion a year treating various consequences of obesity, including heart attacks, strokes, diabetes, cancer and hip and knee joint replacements. Estimates predict that it will reach £15 billion within a few decades.

* Worldwide obesity has nearly doubled since 1980 (European Association for the Study of Obesity 2014).

In our last blog post we saw that the ‘time bomb’ of obesity poses a significant threat on several different fronts: individual and community health as well as financial implications of days lost in work, mounting health costs and impact on society as a whole.

Research to date indicates levels of obesity are growing in a population who are health illiterate and unable to make healthy and nutritious choices. While messages on eating less and exercising more have been consistent, they have not been effective.

One of the main barriers to dealing with the obesity is framing the problem as relevant to the individual (Mackay 2011: 898). People are obese as a consequence of poor choices and lack of self-restraint. One approach has been to encourage the population to exercise greater personal responsibility in their food choice. Another approach has focused on giving appropriate recognition to the role of the environment in influencing and constricting individual behaviour. What often results though is a conflict between preserving individual autonomy and upholding personal responsibility on the one hand, and protecting public health through government intervention on the other. What is certain is the need for careful negotiation between personal responsibility and state intervention.

Changing people’s behaviour is a huge challenge, and realism is required rather than knee-jerk ‘banning’ responses. There is also an ongoing debate around the virtue of “pushing” rather than “nudging”. Numerous research papers have explored what constitutes a healthy diet, describing “good foods” and “bad foods” and detailing the effects they have.

Importance of norms
One way in which to try and achieve this has been to build upon the relationship between laws and norms.

What is perceived to be normal is closely associated with how people come to make decisions. There is a range of different factors which contribute to how people reach and arrive at a decision, particularly in terms of health related behaviour.

Today there is often a psychological conflict between what people want and their desire to be healthy (Government Office for Science 2007: 49). People continue to enjoy eating foods that are high in calories and find it difficult to exercise. Various factors, including habits, help to shape behaviour and decision making.

Swap it
People therefore have to be helped to train themselves to choose the more virtuous option. The ‘Swap It Don’t Stop It’ campaign (run in the UK and Australia) builds on this kind of understanding. The campaign aims to empower the individual to make small, sustainable changes to diet and lifestyle that are easily implemented and remove feelings of deprivation. This positive approach underlying the phrase, ‘you don’t have to stop it, you just have to swap it’ takes the ‘can’t’ out of the equation.

Giving a nudge
More understanding of how the relationship between laws and norms can be applied in various policy contexts has been the focus of recent work, giving rise to Thaler and Sunstein’s ‘nudge theory’. Wiser choices are made when individuals are presented with a clear set of options that respond to various human idiosyncrasies” (Bogart 2013: 24).

However the empirical evidence shows that simply “pushing” and legislating has not worked particularly effectively to date. However it is essential that further action should be mandated in conjunction with “nudging” appropriately in a variety of ways.

Giving people a nudge in the right direction is a necessary part of a multifaceted strategy designed to elicit a specific response to a particular problem. There is a need to design policy with a twofold approach:

* Understanding why people make bad choices

* Normalise healthy choices so that they are easier to make.

Rather than actually having a direct impact on personal choice, regulation frequently helps to change the culture in which decisions are made. Understanding the mechanism by which regulation works is therefore crucial in harnessing it effectively.

An example of this can be seen with smoking and the recent smoking ban in public places. Researchers estimated a 2.4 percent reduction in heart attack emergency admissions to hospital (or 1,200 fewer admissions) in the 12 months following the ban in 2007 (NHS Choices 2010). A review assessing the impact of the law five years on indicates benefits for health, along with changes in attitudes and behaviour. People are less likely to have stopped smoking for fear of prosecution than they are to have stopped because of the environmental and cultural change which the legislation introduced. Cultural attitudes shifted so that it became less publicly acceptable to smoke in public places.

Whatever interventions are introduced, there remains a responsibility on individuals for their own health. ComRes polling conducted as part of 2020health research demonstrated that parents and individuals see themselves as most responsible for ensuring that they are well informed about how to eat and drink more healthily. Engagement at personal, local and strategic levels will help to influence positively the affordability, availability and acceptability of food, which in turn will help shape healthy choices and behaviour.

At the end of the day, it is not just about loosing weight but living a healthy lifestyle. People may decide to eat more healthily and make changes for the better which can improve lifestyles. Far from being obsolete, legislation has a role to play in helping people to make those healthy choices.

References
Bogart, W.A. 2013. Regulating Obesity: Government, Society and Questions of Health. Oxford: Oxford University Press.

European Association for the Study of Obesity. 2014. Obesity Facts & Figures. http://easo.org/obesity-facts-figures

Government Office for Science. 2007. Foresight – Tackling Obesities: Future Choices – Project Report. 2nd Edition.

He, F.J. et al. 2012. Reducing salt intake to prevent hypertension and cardiovascular disease. Rev panam salud publica

32(4)

MacKay, S. 2011. Legislative solutions to unhealthy eating and obesity in Australia. Public Health 125 (2011), 896-904.

NHS Choices. 2010. Heart attacks fall after smoking ban, 9th June 2010. http://www.nhs.uk/news/2010/06June/Pages/Heart-attacks-fall-after-smoking-ban.aspx