Nudging, not judging - Health Policy Today, 24th July 2008

Tom Smith contrasts emerging approaches to tackling obesity in Japan and England.  

Japan has just set a legal limit to the size of waists – and is enforcing it – while England, according to a speech from Alan Johnson to the Fabian Society tonight, will attempt to build a social ‘movement’ to combat the problem.  Interestingly, both approaches seek to make obesity psychologically and socially undesirable.  

Obesity is a problem all over the world.  It has a great impact on all societies, contributing, for example, to rising costs in healthcare because of an association between obesity and diabetes, coronary heart disease and others health problems.  

These are problems are taken so seriously by the Japanese government that it has adopted strict targets and what seems to be a heavily paternalistic approach - http://www.nytimes.com/2008/06/13/world/asia/13fat.html?_r=2&oref=slogin&oref=slogin. In April a new law set national limits for waist sizes (33.5 inches for men and 34.5 for women).  

Local authorities (who look after public health plans) and companies (who fund private plans) are now required to measure waists and they will face fines if the target of reducing obesity by 10% within four years and 25% in seven years is not met.  
Those who are covered by public health plans will be checked by local authorities. It is interesting to compare the public and private approaches, local authority checks with employers’ more psychological approaches.

In Amagasaki, a city in western Japan, officials have moved aggressively to measure waistlines in what the government calls special checkups. The city had to measure at least 65 percent of the 40- to 74-year-olds covered by public health insurance.
The NY Times tells a story about a flower shop owner, Mr Nogiri.  ‘He bared his midriff, exposing a flat stomach with barely discernible love handles. A nurse wrapped a tape measure around his waist across his belly button: 33.6 inches, or 0.1 inch over the limit.’

There are a number who criticise the plan.  Some believe the limit has been set too low, others worry that fitness will become medicalised and ultimately end up costing more money.

While the government has imposed a hard target, some of the companies are employing more psychological techniques to change behaviours.  They are trying to change the language away from ‘obesity’ (which is negative) towards ‘metabo’.  One firm has started giving its employees ‘metabo check’ towels that double as tape measures.

The NY Times quotes company nurse, Kimiko Shigeno.  “Nobody will want to be singled out as metabo”. “It’ll have the same effect as non-smoking campaigns where smokers are now looked at disapprovingly.”

It may be that this social marketing or psychological approach, being adopted in the private
sector, may be more effective that the public sector approach.  Employers perhaps have greater influence on individual behaviour.

Alan Johnson gave a speech to the Fabian Society last night in which he too majored on obesity.  Like the Japanese, he sees it as a huge social problem, though he is not advocating rounding people up and measuring their waists.  He is calling for ‘a national movement’, no less, in order to tackle the problem.  

"Obesity is the biggest health challenge we face. Over the last 60 years, the number of people who are severely overweight has risen steadily. There is a very real danger that today's children will be the first to live shorter lives than their parents and spend more of their years in poor health.

All of this is true, but in political terms, fairly predictable.  The interesting part of the speech was when he talked about the responsibilities that people and families have, as well as the responsibilities of the government, industry and local government.

"Just as the government has a moral duty to tackle poverty and exclusion, so it also has a duty to address obesity. But this is not a licence to hector and lecture people on how they should spend their lives - not least because this simply won't work. Tackling obesity requires a much broader partnership, not only with families, but with employers, retailers, the leisure industry, the media, local government and the voluntary sector. We need a national movement that will bring about a fundamental change in the way we live our lives.”

His words seem to recognise that public health messages have to change.  
"Research shows us that vilifying the extremely fat doesn't make people change their behaviour. Commentators who point and shout at pictures of the morbidly obese simply fuel the problem. Those whose seriously unhealthy lifestyles are not advertised by their waist lines will simply say: "Well that's not me. I don't need to change what I do."

But if you present the message more intelligently - if you explain to parents that many children, regardless of their size, have dangerous levels of fat in their arteries or around their organs, and this may reduce their life expectancy by up to 11 years - then people respond.

There was a strong political element to Johnson’s speech.  Johnson was trying to link the recent comments by David Cameron, talking about people who eat too much, as being akin to a Victorian morality, judging people and not helping them.

"Not every child is lucky enough to live in an environment that promotes good health ... not every family can afford to buy fresh organic produce from the farmers' market. In approaching this problem, we reject both the nanny state, which polices shopping trolleys and institutes exercise regimes, and the neglectful state, which wipes its hands of the problem and wags the finger in the direction of the most vulnerable families in the vague hope they will do as they are told."

But if Johnson is looking for a third way on delivering public health messages, the details of how he will do this seem patchy.  The core of his announcement is that there will be a new fund – with contributions from firms like Cadbury – but how will the money be spent?

It is interesting, in this context, to consider the much talked about new book, ‘Nudge’ - http://www.nudges.org/.   It too claims to be a third way – describing its position as ‘libertarian paternalist’.  This does not seek to tell people what to do and encourages choices, but neither is it neutral, believing obesity, for example, to be a big risk for society.  It believes in ‘nudges’ – using psychological insights and behavioural economics to prod people to change their behaviour.

Interested in how this approach would work in relation to obesity, I looked at the Nudge website.  It links to a paper published last year in the New England Journal of Medicine - http://content.nejm.org/cgi/content/full/357/4/370

The paper has some interesting things to say about social connections and the role this plays in obese.  For example, ‘a person's chances of becoming obese increased by 57% (95% confidence interval [CI], 6 to 123) if he or she had a friend who became obese in a given interval’.  Furthermore, ‘among pairs of adult siblings, if one sibling became obese, the chance that the other would become obese increased by 40%.’  And, ‘if one spouse became obese, the likelihood that the other spouse would become obese increased by 37%.’
The conclusions of the paper are that ‘obesity appears to spread through social ties’. As the authors suggest, these findings have implications for clinical and public health interventions.  It means that the government should perhaps tailor their messages for friends and family.

While some may find the Japanese approach too intrusive, it will be interesting to judge whether it is successful in the next few years.  It will also be interesting to see whether we English can adopt an alternative approach to tackling obesity.