Prevention is always better than cure

One New Year’s Eve, frustrated by that year’s lack of willpower, I signed up to donate money to a cause I loathed if I failed to stick to my goal of doing five hours exercise a week. The cause was an anti-abortion charity, and my reluctance to let them get their hands on my cash proved to be galvanising for quite a while, until an injury intervened.

As 2019 races to a close and we feel our self-restraint ebbing over the mince pies, commitment contracts like this are worth a thought. They are based on the insight of behavioural economists Daniel Kahneman and Amos Tversky that human beings dislike losses more than we relish gains. When it came to skipping gym sessions, the knowledge that I would look and feel better had far less impact on my psyche than imagining the pain I would incur if I had to stump up the cash.

Exercise is a “miracle cure”, according to the Academy of Medical Royal Colleges, which reduces the risk of developing heart disease, stroke, type 2 diabetes, some cancers and even dementia. It can lower blood pressure and boost mental health. Yet only a third of us in high-income countries are even doing the recommended 150 minutes of moderately intense exercise a week.

We humans are terrible at motivating ourselves to stay healthy, something that is posing a profound challenge to healthcare systems. A majority of UK and US citizens are now overweight, and over a quarter are obese. Even in Italy, the slimmest country in Europe, a third of adults are overweight. Obesity makes people old before their time and significantly increases the risk of chronic diseases.

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This could be the first time in our history when those of us living in peaceful nations are threatened almost as much by our own behaviours as by outside forces.

Vaccination, sanitation, safer roads and medical advances have rescued us from many of the tragedies that used to kill us. Our daily decisions about what to eat and drink, and how active to be, are blighting our futures. This is true across all classes, although the poor notably fare worst.

This is not merely about a lack of education. We are larded with information about how to be healthy. The mantra of “five a day” is pretty much inescapable. And “traffic-light” labels show us the amount of fat, salt or sugar in each supermarket product.

The problem comes in how we process that information, when we are in the grip of a primitive brain which is more interested in gorging on processed food. We judge what is normal by looking at our peer group. And our subconscious assumes a world of scarcity, which will always push us to grab an immediate reward — lounging on the sofa — over a long-term benefit — getting fitter.

Some projects try to change habits by offering bonuses or social approval. But in his book Drive: The Surprising Truth About What Motivates Us, the author Daniel Pink argues that such external rewards can undermine our intrinsic motivation to seek autonomy and purpose. In one study, people who were paid to lose weight put it all back on again.

We are up against ourselves, but also a world of pervasive marketing. Our primitive brains respond to environmental cues: supermarket aisles full of fizzy drinks, sports games sponsored by sweet makers; junk food shops by the school gates.

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We can help ourselves by altering some of the triggers that make mindless choices our defaults: substituting fruit for biscuits at the board table or cycling to work, but we also need leading advertising agencies to devise health campaigns.

The battle is hardest if you’re poor, anxious, working shifts and un­able to access good food. In one part of Pennsylvania, doctors working for the Geisinger organisation are now prescribing fresh food to obese people whose diabetes is so severe that it is life-threatening.

As chronic diseases rise and healthcare budgets balloon, our postwar healthcare systems need to mount an all-out assault on helping us to stay well, not just treating us when we are sick. “Public health” has long been a Cinderella service, regarded as an add-on to healthcare, but it needs to be central to it.

In the US and UK, only two in 10 doctors talk to patients about their weight: it’s easier to hand out a pill for backache, apparently, than to raise such a sensitive subject. I’ve spoken to some doctors who are embarrassed about their own weight, and others who don’t believe it’s possible to shake people out of their lifestyles and don’t want precious clinic time to be swallowed up by lengthy personal conversations.

But experiments have shown that doctors can have a big impact in persuading people to attend weight loss programmes, and to become more physically active.

We don’t know enough yet about what works to motivate people. Information alone clearly isn’t enough. We can learn from models like Alcoholics Anonymous which creates peer support and accountability.

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But some of the smart money, I think, will also mine what we know about loss aversion. The insurer Vitality Health has had success giving some of its clients Apple Watches, then waiving the instalments if they meet their activity goals.

I’d love to persuade my gym to waive the membership fee if I attend, say, four times a week. But it’s more likely that this New Year I’ll be looking for a new anti-cause to support — in a spirit of optimism.

The writer, a former head of the Downing Street policy unit, is a Harvard senior fellow


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