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  • It is one of the most serious global health challenges of the 21st century
  • It causes high incidence of morbidity, disability and premature mortality
  • It affects 30% of children and 62% of adults in the UK
  • It costs the UK £47bn a year
  • For 40 years official statistics have under-reported its main cause
  • Doctors have neither been able to reduce nor prevent it
  • Behavioural scientists are well positioned to reduce it
  
A major 21st century health challenge is under-reported for 40 years
 
A 2016 study by the UK’s Behavioural Insight Team (BIT) found that, for the past 40 years, official UK statistics have under-reported the main cause of it. The Office for National Statistics failed to pick up the fact that people consistently under-report the principal cause of it. “Such a large underestimate has misinformed policy debates, and led to less effective strategies to combat it,” says Michael Hallsworth, co-author of the study. Jamie Jenkins, head of health analysis at the Office for National Statistics, replied, “We are actively investigating a range of alternative data sources to improve our understanding of the causes of obesity”.
  
Obesity should be treated like terrorism

Although we know how to prevent obesity, it devastates the lives of millions and costs billions. In the UK obesity affects 33% of primary school children, and 62% of adults. Its prevalence among adults rose from 15% to 26% between 1993 and 2014. In 20 years, obese adults are expected to increase to 73%.
 
The UK spends £640m on programs to prevent obesity. Each year, the NHS spends £8bn treating it, and obesity has the second-largest overall economic impact on the UK; generating an annual loss equivalent to 3% of GDP. 
 
The World Health Organization warns that obesity is, “one of the most serious global public health challenges of the 21st century”. The UK’s Health Secretary says obesity is a “national emergency”, and the UK’s Chief Medical Officer argues that obesity should be treated similarly to “terrorism”.
 
Here we suggest how behavioural science rather than doctors can help to reduce and prevent obesity.
 

Vast, persistent and growing

Although we know how to address obesity, there are few effective interventions in place to reduce it. According to a 2014 McKinsey Global Institute study, the UK Government’s efforts to tackle obesity are, ''too fragmented to be effective'', while investment in its prevention is, ''low given the scale of obesity''. Being obese in childhood has both short and long-term consequences. Once established, obesity is notoriously difficult to treat. This raises the importance of prevention. Obese children are more likely to become obese adults, and thereby have a significantly higher risk of morbidity, disability and premature mortality. The global rise in obesity has led to an urgent call for action, but still its prevalence, which is significant, is rapidly increasing.
 

The incidence of certain cancers is significantly higher in obese people, and is expected to increase 45% in the next two decades. Professor Karol Sikora, a leading cancer expert, describes the association, but says we do not know the reasons why, and Dr Seth Rankin, Founder and CEO of the London Doctors Clinicsuggests that virtually every health problem known to mankind is made worse by obesity:

 

Prof. Karol Sikora - Cancer linked to obesity


Dr Seth Rankin - Can being overweight lead to health problems?
 
 The success and growth of Nudge Units

A previous Commentary drew attention to the fact that obesity is connected with a relationship between the gut and brain. Gut microbiota are important in the development of the brain, and research suggests that an increasing number of different gut microbial species regulate brain functions to cause obesity. Notwithstanding, the UK’s Behavioural Insight Team (BIT), which started life in 2010 as a government policy group known as the "Nudge Unit", revolutionized the way we get people to change their entrenched behaviours, and this has important implications for public policy strategies to reduce and prevent obesity.
 
Under the leadership of David Halpern, the BIT has been very successful and has quadrupled in size since it was spun out of government in 2014. Now a private company with some 60 people, the Nudge Unit permeates almost every area of government policy, and also is working with Bloomberg Philanthropies on a US$42m project to help solve some of the biggest problems facing US cities. The UK’s Revenue and Customs (HMRC) has set up its own nudge unit, and nudge teams are being established throughout the world.
 
The genesis of Nudge Units

It all started in 2008 with the ground-breaking publication on behavioral economics, Nudge: Improving Decisions About Health, Wealth and Happiness, written by US academics Cass Sunstein and Richard Thaler. Their thesis suggests that simply making small changes to the way options are framed and presented to people “nudges” them to change their lifestyles without actually restricting their personal freedoms. Politicians loved the thesis, not least because it was cheap and easy to implement, and ‘Nudge’ became compulsory reading among politicians and civil servants. “Nudge Units” were set up in the White House and in 10 Downing Street to improve public services and save money by tackling previously intractable policy issues.
 
Nudging people to change

The UK’s Nudge Unit has, among other things, signed up an extra 100,000 organ donors a year, persuaded 20% more people to consider switching energy provider, and doubled the number of army applicants. Now it is turning its attention to health and healthcare, and already has implemented behavior change strategies that motivate individuals to initiate and maintain healthier lifestyles. The Unit’s strategies that have demonstrated self-efficacy and self management are examples that can be further incorporated into lifestyle change programs, which help people maintain healthy habits even after a program ends and thereby be a significant factor in reducing and preventing obesity.
 
Takeaway
 
Doctors understand the physiology of obesity, but they do not understand the psychology of people living with it. Doctors are equipped to treat the morbidities and disabilities associated with obesity, but ill-equipped to reduce and prevent it. The sooner the Nudge Unit is tasked with reducing and preventing obesity the better.
 
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  • 90% of the 17m heart related deaths each year are preventable
  • Not preventing heart disease will cost US$47 trillion over the next 20 years
  • UK and US cardiovascular disease (CVD) risk calculators found to be faulty
  • Doctors play a leading role in CVD prevention
  • Doctors well equipped to diagnose and treat CVD, but ill equipped to prevent it
  • Behavioral scientists not doctors should spearhead CVD prevention strategies

Behavioral scientists not doctors will prevent CVD
 
Should we trust clinicians to devise and implement preventative healthcare strategies?
No!
Behavioral experts with knowhow and experience in techniques that successfully nudge people to initiate and maintain healthy lifestyles, rather than doctors should lead chronic disease prevention strategies. Clinicians are programed to diagnose and treat according to strict guidelines, and preventing disease is not in their DNA.
 
What is in this commentary?
 
This Commentary focuses on CVD, but its message applies to any disease prevention strategy. It reviews a number of high profile CVD tools from the UK, USA and India, and found that a CVD risk calculator developed by world-renowned UK cardiologists is over engineered, and its inventors show little appreciation of the significant practical challenges associated with its implementation via UK GPs, who are in crisis. Another CVD risk calculator, which has been used extensively by British GPs since 2009 has been found to have a software glitch, which may have led to thousands of patients being misdiagnosed and wrongly treated. A similar software problem was found in a US CVD risk calculator popular among primary care doctors, which overestimated the risk of a CVD event, and led doctors to unnecessarily prescribe cholesterol-lowering drugs called statins. A more successful CVD prevention calculator has been introduced in India by a former cardiologist and healthcare entrepreneur. The calculator’s success is associated with its simplicity, accessibility, and the fact that it effectively engages and influences people’s behavior. The Commentary describes behavioral techniques, which are necessary to engage at risk people, and nudge them towards permanently adopting healthier lifestyles.
 
Overall our review suggests that doctors are well equipped to diagnose and treat CVD, but ill-equipped to prevent it.

 
An English academic approach to preventing CVD
 
The Joint British Societies Risk Calculator, the JBS3, was launched in 2014 as a tool for the prevention of CVD. It was the result of a collaborative effort of 11 British cardiovascular societies chaired by Professor John Deanfield, the British Heart Foundation Vandervell Professor of Cardiology at the University of London. The calculator embodies the UK’s national guidelines for the prevention of CVD, and is managed by the British Cardiovascular Society, and supported by the British Heart Foundation. Although available as an app, the calculator is designed for use by doctors and practitioners with their patients.
 
Unlike conventional risk assessment devices, which focus on high-risk patients, the JBS3 emphasises lifetime risk of CVD events, such as a heart attack, ischemic stroke or dying from coronary artery disease. To achieve this, the calculator’s algorithms are predicated upon a large data pool of people who have a relatively low 10-year risk of a CVD event, but who nevertheless have a high lifetime event risk.
 
The JBS3 allows doctors to assess a person's heart age compared with a person of the same age, gender and ethnicity with optimal risk factors. It also generates estimates of 10-year CVD risk, and average CVD event-free survival.  Results are intended to facilitate an informed discussion with patients in which doctors can show, in different graphical formats, how lifestyle modifications and other interventions, such as drug treatment, can increase a patient’s years of healthier life. Such discussions are expected to motivate patients to make lifestyle choices, which help them prevent future CVD events.
 
A cautionary note
 
Developing a risk calculator mediated by GPs is no guarantee of producing a significant reduction in the vast burden of CVD. It is too early to assess the effectiveness of the JBS3 Risk Calculator, but it appears to have underestimated the challenge associated with getting overstretched and demoralized UK primary healthcare professionals to use a new tool to engage large numbers of people at risk of CVD.
 
Previous Commentaries have described the UK’s primary care crisis. Over the past decade GPs’ workloads have increased significantly, as a result of the government’s decreasing investment in primary care, and the increasing prevalence of chronic multi-morbidity lifetime conditions, such as CVD. Trainee GPs are dwindling, newly trained GPs are seeking employment abroad, and increasing numbers of experienced GPs are taking early retirement. “GPs in the UK are so fatigued and overworked that they are at risk of harming patients by misdiagnosis”, says Dr. Maurine Baker, chair of the Royal College of General Practitioners.

 
A software glitch in a popular British CVD calculator
 
In May 2016 about 33% of UK doctors were instructed by the government’s Medicines & Healthcare Products Regulatory Agency (MHRA) to warn thousands of patients that their treatment plans, developed from the results of a computer algorithm embedded in a CVD risk calculator could be wrong, and people at risk of a CVD event may have been mistakenly prescribed or denied statins.
 
The risk calculator, called the QRISK2, was introduced in 2009 by the IT company TPP to calculate the risk of CVD, and currently is used in some 2,500 primary care surgeries throughout the UK to help GPs to determine which patients are at risk of CVD. The calculator is embedded in another TPP product; SystmOne, which is a software system extensively used by GPs to access a single source of information, detailing a patient’s contact with the health service across a lifetime.
 
A faulty American CVD risk calculator
 
Recently, a widely recommended American risk calculator for predicting a person's chance of experiencing a CVD event was found to overestimate the actual five-year risk in adults overall, and across all socio-demographic subgroups, leading doctors to unnecessarily prescribe statins. The study, by Kaiser Permanente, was published in the Journal of the American College of Cardiology in May 2016.  It suggests that the incidence of heart disease over the period between 2008 and 2013 “was substantially lower than the predicted risk in each category". According to Dr Alan Go, a lead author, "Our study provides critical evidence to support recalibration of the risk equation in 'real world' populations, especially given the individual and public health implications of the widespread application of this risk calculator.”
 
An Indian entrepreneur’s approach to preventing CVD
 
Billion Hearts Beating  is an open, and easy-to-use website launched in 2010 by Dr. Prathap Reddy, an Indian cardiologist turned entrepreneur who founded the Apollo Group of hospitals, with the mission of bringing world-class affordable healthcare to India. Reddy is mindful that there are some 65m people in India with CVD, but each year only about 100,000 of these receive specialist treatment. Unsurprisingly, about 2.4 million people die each year in India from CVD related events. The Billion Hearts Beating website identifies five simple solutions for lowering the risk of CVD: (i) cessation of smoking, (ii) a healthy diet, (iii) increased physical activity, (iv) a reduction in stress, and (v) regular heart checks.
 
The Billion Hearts Beating campaign fares better than the British JBS3, not least because it employs a simpler way to engage at risk people directly and encourages them to follow recommended solutions to reduce their overall CVD risk. To date, over 505,000 visitors to the Indian website have used its embedded risk calculator and importantly, pledged to improve their diets and lifestyles in order to reduce their risk of CVD.  
 

 
CVD a leading silent killer
 
CVD is often asymptomatic, caused by atherosclerosis, and represents a family of conditions linked by common risk factors, and includes coronary heart disease, stroke, hypertension, hypercholesterolemia, diabetes, chronic kidney disease, peripheral arterial disease and vascular dementia. Many people who have one CVD condition commonly suffer from other related conditions.
 
According to the World Health Organization (WHO), each year CVD accounts for more than 17.5m deaths worldwide, despite the fact that 90% are preventable. Deaths from CVD are projected to grow to some 24m by 2030. Direct and indirect costs of CVD total more than US$316.6bn. The economic costs of not preventing CVD are estimated to be US$47 trillion over the next 20 years.
 
CVD is the UK’s single biggest killer. There are seven million people living with CVD in the UK. Annual healthcare costs associated with CVD amount to some US$14bn, while the UK’s annual economic burden of CVD, including indirect costs from premature death and disability, is over US$20bn. About 85.6m Americans are living with CVD, which is responsible for killing over 370,000 Americans a year. By 2030, 40.5% of the US population are projected to have CVD. Between 2010 and 2030, total direct US medical costs of CVD (2008 US$) are projected to triple, from US$273bn to US$818bn. CVD is the leading cause of morbidity and mortality in India, where an estimated 65m people suffer from the condition.
 
Despite the improvements in outcomes for CVD in the UK and US over the last 20years, it remains the major cause of morbidity and mortality in population throughout the world. More patients are surviving their first CVD event, and they remain at high risk. Further, levels of certain risk factors such as obesity, and diabetes are increasing. More focus on effective prevention is therefore required.

 

 
How “nudge” can prevent CVD
 
CVD prevention strategies are too important to be left to clinicians. To be successful prevention strategies have to nudge people to change their lifestyles, and this requires experts in behavioral techniques. Over the past decade behavioral scientists have revolutionized the way we encourage people to change entrenched behaviors, which are not in their interest.
 
It all started in 2008 with the ground-breaking publication on behavioral economics, Nudge: Improving Decisions About Health, Wealth and Happiness, written by US academics Cass Sunstein and Richard Thaler. The authors argue that by simply making small changes to the way options are framed and presented to people - “choice architecture” - provides a cheap and easy way to “nudge” people to change their lifestyles without actually restricting their personal freedoms. Politicians loved the thesis, and ‘Nudge’ became compulsory reading among policy makers. President Obama and Prime Minister Cameron set up “nudge units” in the White House and 10 Downing Street to improve public services and save money by tackling previously intractable policy issues.

 
Small personal touches make a big difference
 
One of the first tasks Cameron gave the Downing Street nudge unit was to encourage more unemployed people to turn up for job interviews. The unit found that the standard impersonal written request to attend a job interview only yielded an 11% response rate.  Adding the person’s name, for example, “Hi John”, increased the response rate to 15%. But when the request was ended with a personal phrase and signed off such as, “I’ve booked you a place, Good luck, (signed) Margaret”, the response rate jumped to 27%. These small personal touches were so successful that now they are used in every job center in the UK.
 
Understanding human behavior is key
 
Under the leadership of David Halpern, the UK’s nudge unit has quadrupled in size since it was spun out of government in February 2014. Now a private company of 60 people jointly owned by its employees, the Cabinet Office, and Nesta, the nudge unit permeates almost every area of government policy, and also is working with Bloomberg Philanthropies on a US$42m project to help solve some of the biggest problems facing US cities. The UK’s Revenue and Customs (HMRC) has set up its own behavioral insights unit, and nudge teams are being established throughout the world in Australia, Singapore, Germany and the US.
 
Halpern’s unit has, among other things, signed up an extra 100,000 organ donors a year, persuaded 20% more people to consider switching energy provider, and doubled the number of army applicants. Also, it has implemented behavior change strategies that motivate individuals to initiate and maintain healthy behaviors that fit their lifestyle in approachable and convenient ways. The unit’s behavior change strategies that have demonstrated self-efficacy and self management are examples that can be incorporated into lifestyle change programs, which could help people maintain healthy habits even after a program ends, and thereby be a significant element in CVD prevention strategies.

 
Takeaways
 
If the UK’s nudge unit has discovered anything, it is that an understanding of human behavior is vital for almost all public policy, and this includes healthcare and CVD prevention strategies. Clinicians leading CVD prevention programs understand the disease, but they do not understand the psychology of the people with the disease. Clinicians are well equipped to diagnose and treat CVD, but ill equipped to prevent it. The sooner David Halpern is tasked with preventing CVD, the sooner the devastating personal and economic burden of CVD in the UK will be reduced.
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Behavioural Science provides the key to reducing diabetes

  • Behavioural techniques can help reduce the burden of all chronic non-commuicable diseases

  • Each year hundreds of millions are spent on diabetes education that fails

  • Each year Diabetes UK (DUK) calls on the government to “do more”

  • Each year the personal, social and fiscal burden of diabetes increases

  • Wandsworth CCG is implementing a new pathway of care for diabetes

  • The new pathway of care benefits from behavioural science

  • DUK should advocate behavioural techniques that change behaviour


To reverse the diabetes epidemic, and slow the vast and escalating cost of the condition, Diabetes UK (DUK) should promote behavioural science techniques for diabetes education such as those, which are now being implemented by Wandsworth CCG.
 

Current strategies are failing

According to DUK diabetes is the fastest growing health threat of our times, current care models are not working, and the condition is currently estimated to cost the UK £23.7bn annually. This figure is set to rise to £40bn by 2035 if nothing changes.
In August 2015 Barbara Young, CEO of DUK, warned that diabetes is being allowed to spiral out of control. “With a record number of people now living with diabetes in the UK, there is no time to waste: the government must act now,” she said.

The poor state of diabetes education and care in England is leading to avoidable deaths, record rates of complications, and huge costs to the NHS: 1.2 million more people have diabetes now than a decade ago (a 60% increase), and DUK has warned that its cost could, “bankrupt the NHS”. 

DUK, NHS England, and Public Health England (PHE) spend millions on diabetes education, prevention and screening programs, which have failed to dent the burden of the condition.
 


Diabetes

 

Diabetes is a chronic condition and, if poorly managed, can lead to devastating complications, including blindness, amputations, kidney failure, stroke and early death. To prevent, detect, and slow the progression of complications, best-practice guidelines say that people living with the condition should regularly receive nine checks, which include: weight, blood pressure, eyes, HbA1c, urinary albumin (indicates kidney function), feet, serum cholesterol (level of cholesterol in the blood), smoking, and serum creatinine (indicates kidney function). Official audits of NHS care in England and Wales show that some 33% of people with diabetes do not receive these checks.

 

Effective education and care save money

Earlier in 2015 Barbara Young said, “Better on-going standards of care will save money, and reduce pressure on NHS resources. It’s about people getting the checks they need at their GP surgery, and giving people the support and education they need to be able to manage their own condition”.


A better approach

DUK needs to adopt and advocate tried and tested behavioural principles that will lower the risk of T2DM, propel those living with T2DM into self-management, and slow the onset of devastating and costly complications.

Behavioural scientists have generated a set of principles about how people engage in judgments and decision-making, and these have been successfully used by policy makers to explore, understand, and explain existing influences on how people behave, especially influences, which are unhelpful, with a view to removing or altering them. 
 

Tried and tested by governments

The Obama Administration in the US uses behavioural techniques to ‘nudge’ people to make better choices for themselves and enhance public policy. Soon after Prime Minister Cameron took office in 2010, he established the “Behavioural Insight Team” to ‘nudge’ the long-term unemployed into work. If it is good for the White House and 10 Downing Street, it should be good enough for DUK.

Cameron’s Nudge team, which is now well established, found that if staff at job centres texted details of vacancies to the unemployed, they achieved little. But, if they added a greeting such as “Hi Pat”, they produced a better response; and if they signed their name, “Best of luck, John”, the unemployed felt they were dealing with a local friend who wanted the best for them, and they would be more inclined to respond positively. Behavioural techniques such as these have been shown to successfully nudge people to take the right decisions about their health.

The NHS should consider adding such techniques to its armoury of strategies to reduce the burden of diabetes”, says Dr Ana Pokrajac, Diabetes Consultant at West Herts Hospitals NHS Trust, and DUK Clinical Champion for Diabetes.
 

An important precedent - Wandsworth CCG’s new pathway of diabetes care

Wandsworth Clinical Commissioning Group (CCG) has recently adopted personalized behavioural techniques, following similar principles used in the US and UK, to help make dietary and lifestyle changes in their patients living with T2DM. Wandsworth health professionals are developing and implementing a fully automated new pathway of care for diabetes based on behavioural techniques, which they piloted in 2014, to help reduce the burden of the condition. The pathway is expected to go live in November 2015.

Dr Seth Rankin, the co-chair of Wandsworth CCG’s Diabetes Group says, “We are implementing the first phase of a new and innovative pathway of care for people living with T2DM, which we piloted last year. See; "How GPs can improve diabetes outcomes and reduce costs" The new pathway is aimed to change peoples’ behaviours, and to encourage people to eat healthier diets, lose weight, exercise, stop smoking, educate themselves about the condition, regularly monitor their blood and glucose levels, get their kidneys and feet checked regularly, and attend screening sessions. Behaviours that, in time, we expect will lower the risk of T2DM, propel those living with the condition into self-management, and slow the onset of devastating and costly complications”.

The fully automated pathway, borrows from behavioural science and is predicated on a rich content library of short 60 second videos, which are clustered and sent by GPs directly to peoples’ smart phones. All the videos have been contributed by local Wandsworth CCG health professionals, and most are accompanied by personalized texts”, says Rankin. 

Figure 1 describes Wandsworth CCG’s fully automated new pathway of care for people with T2DM.
 

Figure 1: Wandsworth CCG’s new pathway of care for T2DM



 

Diabetes education in need of a new pathway of care

In 2015, the DUK’s State of the Nation Report called on CCGs to set themselves performance improvement targets and implement diabetes action plans. The charity also urged CCGs to ensure that all people with diabetes have access to the support they need to manage their condition effectively, and that the local health system is designed to deliver this. 

The medical community, including commissioning organisations, need more specific guidance about using technology and behavioural techniques if they are to prevent those at risk from getting T2DM, and reduce the burden of diabetes. Examples like the Wandsworth CCG’s initiative illustrates the strong potential of applying these techniques,” says Dr Sufyan Hassain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism, Imperial College Healthcare NHS Trust, and Imperial College London.

Below, as part of Wandsworth CCG’s new pathway of care, Roni Shavanu Saha, Consultant in Acute Medicine, Diabetes and Endocrinology at St George’s University Hospital, London provides some dietary tips for people with T2DM:

     
          (click on the image to play the video) 

 

Excursus: behavioural techniques 

Behavioural scientists have generated a set of principles about how people engage in judgments and decision-making. DUK can learn from this. For example, we are strongly influenced by who communicates information (see the illustration above about the long- term unemployed); we are motivated by incentives; we are also influenced by comparisons, and by what others do; we go along with pre-set options, for example defaults; our acts are influenced by subconscious cues, and our emotional associations can shape our actions, we seek to live up to our public commitments; and we act in ways that make us feel better about ourselves. Here are some examples, but first we describe nudge theory.
 

Nudge theory

'Nudge' theory was proposed originally in US 'behavioural economics', and was introduced to policy makers in 2008 by Richard Thaler and Cass Sunstein in their book, ‘Nudge: Improving Decisions About Health, Wealth, and Happiness’. The behavioural principles the authors describe have been adapted and applied widely to enable and encourage change in people, and groups, and have been successfully used to motivate people to lose weight, take medications, exercise, and stop smoking. Let us explain.
 

The influence of others

People are influenced by what others do, and by who it is who communicates information. This knowledge is being used in the US to change the health behaviours and decisions people make. Thus, Wandsworth CCG’s new pathway of care for diabetes uses videos of local health professionals to speak directly to people living with T2DM via their smartphones to nudge them into changing their behaviours. The time individuals spend watching the videos, the frequency viewed, and whether they share the videos, can easily be compared with data across the same indices for their peer group, and the comparisons fed back to individuals. By giving people information about their exercise and lifestyle choices relative to others in their peer group nudges them to change their behaviour and become healthier. 
 

Defaults

Nudge strategies have been used successfully to change health behaviours and decisions through the use of defaults. This exploits the insight that people tend to go with the flow of current options (i.e. defaults). Health providers can pre-set options that promote health and wellbeing and reduce costs, requiring those who want to go against the grain to “opt out”. This has been used successfully in the US by the Center for Disease Control and Prevention, which developed guidelines recommending that opt-out HIV screening with no separate written consent be routine in all healthcare settings. 

Defaults have also been successful in presumed consent for organ donation unless someone has opted out. Austria, France, Poland and Portugal have such systems, and 90 to 100% of their citizens are thus donors, compared to only 5 to 30% in countries that do not use the donor default strategy. Also, defaults have been successfully used in preventative care. In the US, doctors nudge their patients toward regular screenings by giving them a default appointment date and time. Patients must opt out of the appointment. 
 

Memories and subconscious cues

Behavioural science tells us that people are influenced by novel, personally relevant examples and explanations, and such knowledge is being successfully used to change people’s health behaviours and decisions. Emotional associations are embedded in peoples’ memories, and invoking these in images and videos shapes peoples’ decisions and behaviours. Cues can be used to encourage people to make healthier choices through reminders. Nudgesize, a smartphone application, reminds its users to get their daily exercise. Reminders have also been used to nudge people to schedule their screening appointments. 
 

Commitment and ego

Another thing we learn from behavioural science is that we seek to be consistent with our public promises and commitments, and we behave in ways that makes us feel better about ourselves. Several websites take advantage of the fact that people want to honour their public commitments. These allow users to commit themselves to achieve certain goals, such as losing weight, exercising, stop smoking, or eating a healthier diet. One example is Stickk.com, a website where users enter into binding commitment contracts by choosing a goal, such as losing weight in a given time, and appointing a referee to confirm the truth or falsity of their reports. Stickk users, who attach stakes to their goals, enter their credit card information, and if a person fails to achieve his goal, then the card is charged for the agreed amount pledged. According to Stickk it has over 56,000 contracts valued at some US$5.5m; 141,003 workouts occurred that might not have otherwise happened, and 1.1m cigarettes were not smoked that otherwise would have been.

According to a 2005 study reported in the Journal of Geriatric Physical Therapy, commitment strategies have significant influence over peoples’ behaviours even without any financial stakes attached. The study described how 84% of exercisers who signed a contract met their goal, compared to only 31% in the control group who did not sign a commitment pledge. This and similar examples suggest that part of the effectiveness of commitment strategies comes from ego, and our desire to be perceived by others as strong willed and consistent. Ego plays a role in the effectiveness of many nudges. 
 

Conclusion: the way forward

The best chance of impacting on the vast and rising incidence and cost of diabetes in the UK lies in the promotion by DUK of behavioural techniques of diabetes education such as those, which are now being implemented by Wandsworth CCG. 

 
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