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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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  • Obesity is common, serious and costly
  • Obese adults in the UK will soar by a staggering 73% to 26m by 2030
  • Obesity generates an annual loss equivalent to 3% of the UK’s GDP
  • Obesity cost NHS England £8bn in 2015
  • The obesity epidemic will only get worse unless we take effective action
  • Innovative research to control appetite could provide a cheap and scalable answer to the obesity epidemic
  • The UK’s obesity crisis should learn from the way AIDS was tackled 

Can the obesity epidemic learn from the way Aids was tackled?
 
Obesity is a common chronic health challenge, which is serious and costly.It is one of the biggest risk factors for type-2 diabetes (T2DM) and together - obesity and T2DM - form a rapidly growing global diabesity epidemic, which today affects some 9m people in England.
 
Experts forecast the incidence rate of obesity will rise sharply, and bankrupt the NHS. Conventional strategies to reduce obesity and prevent T2DM have failed. According to the Mayo Clinic it is common to regain weight no matter what weight loss treatment methods you try, and you might even regain weight after weight-loss surgery. This Commentary suggests that extra resources are urgently needed to accelerate and broaden innovative obesity research.
  
Efforts to tackle obesity are low priority and fragmented
 
Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. Risks of coronary heart disease, ischemic stroke, and T2DM increase steadily with raised body mass index (BMI). High BMI also increases the risk of osteoarthritis; sleep apnoea, gallbladder disease, and some cancers. Cancer Research UK predicts that obesity related cancers are expected to increase 45% in the next two decades, causing 700,000 new cases of cancer. Mortality rates will increase with increasing degrees of obesity. It is therefore important that obesity is treated aggressively. According to a 2014 McKinsey Global Institute study, the UK’s Government efforts to tackle obesity are ''too fragmented to be effective'', while investment in obesity prevention is ''relatively low given the scale of the problem''.
 
A multi-generational problem
 
The 2014 Health Survey found that 61.7% of adults in England (16 years or over) are either overweight or obese, and the prevalence of obesity among adults rose from 14.9% to 25.6% between 1993 and 2014. The number of obese adults in the UK is forecast to soar by a staggering 73% to 26m over the next 20 years.

In 2014-15, there were 440,288 hospital admissions in England due to obesity: 10 times higher than the 40,741 recorded in 2004-5. In England one in five children in their first year at school, and one in three in year 6 are obese or overweight. Also, in the past 10 years there has been a doubling of children admitted to hospital for obesity. Over the past three years 2,015 overweight youngsters needed hospital treatment, and 43 of these have had to undergo weight-loss surgery to reduce the size of their stomachs. Today, diabesity is a multi-generational problem, which suggests that far worse is still to come.
 
Costs and spends
 
The UK spends less than £638 million a year on obesity prevention programs - about 1% of the country's social cost of obesity. But the NHS spends about £8bn a year on the treatment costs of conditions related to being overweight or obese and a further £10bn on diabetes.
 
Obesity is a greater burden on the UK’s economy than armed violence, war and terrorism, costing the country nearly £47bn a year, the 2014 McKinsey study found. Obesity has the second-largest economic impact on the UK behind smoking, generating an annual loss equivalent to 3% of GDP. The current rate of obesity and overweight conditions suggest the cost to NHS England alone could increase from £8bn in 2015 to between £10bn and £12bn in 2020.

 
19th century technologies for a 21st pandemic
 
A year after the publication of the McKinsey study, the UK government launched a national Diabetes Prevention Program (DPP) led by NHS England, Public Health England (PHE), and the charity Diabetes UK (DUK). The program offers people at risk of T2DM an intensive personalised course in weight loss, physical activity and diet, comprising of 13 one-to-one, two-hour sessions, spread over nine months, and is expected to significantly reduce the estimated five million overweight and obese people in England, and thereby prevent them from developing T2DM. A previous Commentary predicted that the DPP would fail because it is using a 19th century labour intensive method to address a 21st epidemic.
 
This suggests that the diabesity epidemic will only get worse unless we take more urgent and effective action. A view supported by Majid Ezzati, Professor of Global Environmental Health at Imperial College, London, and the senior author of the most comprehensive review of obesity ever undertaken, and published in The Lancet in April 2016. According to Ezzati, “The epidemic of severe obesity is too extensive to be tackled with medications such as blood pressure lowering drugs or diabetes treatments alone, or with a few extra bike lanes”.

 
Radical action: weight loss surgery
 
The gravity of the UK’s obesity epidemic is demonstrated by the National Institute for Health and Care Excellence (Nice) 2016 suggestion to lower the threshold at which overweight people are offered weight loss surgery. The UK lags behind other European countries in this regard, and experts argue that lowering the threshold would mean the number of people who qualify for weight loss surgery would increase significantly.

According to a report prepared by English surgeons, weight-loss surgery would make people healthier and save the NHS money. The report concluded that after weight loss surgery obese people are 70% less likely to have a heart attack, those with T2DM are nine times more likely to see major improvements in their condition, and also the surgery has a positive effect on angina and sleep apnoea. If all the 1.4m most severely obese people in the UK had weight loss surgery, which costs the NHS around £6,000 per operation, the total cost would be £8.4bn.

 
Weight loss surgery and the brain
 
Initially it was thought that weight-loss surgery worked by reducing the amount of food that can be held by the stomach. However, some patients were found to have elevated levels of satiety hormones, the chemical signals released by the gut to control digestion and hunger cravings in the brain. Patients who had undergone surgery were also found to prefer less fatty foods, which supports the thesis that the hormones also change the patients’ desire to eat, and reinforce the gut brain relationship. This finding reinforces the important link between the gut and the brain on which some of the most promising obesity research is predicated.
 
Gut brain relationship
 
Dr Syed Sufyan Hussain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism at Imperial College London describes the gut-brain relationship and explains why we eat and why we stop eating:
 

 
Cheap, safe and scalable treatment for obesity
 
The person who has spent most of his professional life searching for cheap, safe and scalable alternatives to weight loss surgery and ineffective weight loss therapies is Professor Sir Steve Bloom, Head of Diabetes, Endocrinology and Metabolism at Imperial College London. Bloom believes that the answer to the UK’s obesity epidemic lies in the gut-brain relationship, and is working on two innovative methods of appetite control, which he and his colleagues believe could significantly reduce the burden of obesity.
 
Method 1: an implantable microchip
 
One method is comprised of a small implantable microchip attached to the vagus nerve to suppress appetite in a natural way. The chip reads and processes both electrical and chemical signatures of appetite within the vagus nerve, and then sends electrical signals to the brain to either reduce or stop eating. Bloom has proven the method’s concept, and in 2013 was awarded €7m from the European Research Council to continue his research. Early findings suggest that chemical rather than electrical impulses are more selective and precise, and the chip reduces both consumption and hunger pangs. All things being equal, it will take another 10 years before this treatment gets to market.
 
Method 2: naturally occurring hormones
 
Bloom is also working on another method to treat obesity, which uses naturally occurring hormones that reduce appetite. Early clinical studies suggest that people will consume 13% fewer calories when they eat a meal after taking the hormones. In 2013 Bloom received £2m from the Medical Research Council to develop this research. One of the significant challenges he faces is hormones normally last only a few minutes in the human body. To overcome this Bloom and his colleagues have had to develop versions of the hormones that can last up to a week before they start breaking down. This suggests that patients could take a single weekly injection to control their appetites. Another approach would be to develop a device, which delivers the hormones continuously. While promising, this method too will take 10 years to get to market.
 
Takeaway: treat obesity the same as Aids
 
Bloom believes that if we approached obesity as we did Aids, the time to develop a cheap, effective and scalable drug for weight control could be cut by half. "The obesity pandemic is the biggest disease that has hit mankind ever in terms  [of] numbers. It is killing more people than anything else has ever killed, . . . . . . . in terms of disease [there are] more deaths from obesity than anything we have known about. The time needed to develop an effective drug could be cut by more than half if conservative checks and balances were loosened. I think we might need to treat obesity in a hurry, and we are being held up. The Aids lobby forced Aids’ drugs on to the market before they had finished testing, but they turned out to be useful and lives were saved. Something similar should be considered for obesity,” says Bloom.
 
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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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