by Marion Nestle
Mar 9 2012

The Lancet on nudging and nagging vs. environmental change

I’m getting caught up on my journal reading and just ran across an editorial from The Lancet, January 21It takes on the UK government’s “personal responsibility” approach to health promotion based on the idea that

gently ‘nudging’ people to change their unhealthy behaviours was the key to public health.

Even the UK government has to admit that the nudge approach isn’t working.  Now it is telling physicians in the National Health Service (NHS) to nag:

use every contact with patients and the public to help them maintain and improve their physical and mental health and wellbeing.

The Lancet asks:

Is this a realistic, sensible, and effective recommendation? We would say not.

Effective, evidenced-based public health measures do not include nudging people into healthy behaviours or getting NHS staff to lecture patients on healthy lifestyles.
They include measures such as raising taxes on cigarettes, alcohol, fatty foods, and sugary drinks, reducing junk food and drink advertising to children, and restricting hours on sale of alcoholic drinks….Focusing on other approaches is foolish.
The nudge and nag approaches need one thing: the firm elbow.
I do enjoy reading The Lancet.  Its editors are so clear about the need for environmental changes to make it easier for people eat better diets and be more active.
  • Beenie

    Well, the UK is the poster child for the nanny state, so this claptrap from the Lancet is no surprise. Look, people have the right to prioritize their health and eating habits in whatever manner they want. Government has only one role in this situation: provide fair access to the foods people want to eat (whatever they may be), and provide access to safe movement options that they enjoy (whatever those may or may not be), then it needs to get the hell out of the way and let people make their own decisions.

    Government has no business telling me what a healthy food is and what I can and cannot eat. I’m an adult; I’m perfectly capable of making those decisions my self. I’d prefer it if people didn’t eat fast food, but I can’t make them. Nobody can. A tax on fatty foods? Are you seriously suggesting that it’s ok for a government entity to tell me that I can’t use butter? That’s just nonsense. GET OUT OF MY KITCHEN!!!

  • If you look at some of the UK governments untenable positions on, for instance diabetes, it is no wonder people ignore/mistrust them. And they are not the only ones promoting ‘health’ in an unscientific way. A good article on the UKs misguided diabetes recommendations here –

  • Anthro

    Dr. Briffa’s status: (from his website)

    Practitioner of Integrated Medicine – Hospital of St John and St Elizabeth, London, UK

    Practitioner of Integrated Medicine – Highgate Hospital, London, UK

    Quack! Quack! What is it that needs “integrating” in medicine anyway?


    As to Beenie, I can only suggest reading the post before commenting. How does “…environmental changes to make it easier for people eat better diets and be more active” come across as the government telling you what you can or cannot eat? I’m just fine with you eating what you please, weighing what you please, dropping dead from a heart attack when you please, just please allow the rest of us to avail ourselves of good science and good policy so that we may do otherwise.

  • Beenie

    Anthro: Your quote is NOWHERE in that statement from the Lancet. Did *you* read it? Also, I just said that the government’s only roles are to:

    1) Provide fair and affordable access to food that people want to eat by:
    –Eliminating food deserts
    –Reassigning subsidies so that all foods are given a fair shot in the market place.
    –Re-evaluating the SNAP and WIC programs so that they are fair for all needy families and provide for a wide range of foods.
    — Providing even-handed nutritional education in schools alongside cooking education as a lifeskill.
    — Not taxing or forcing price inflation on ANY food,

    and; 2) Provide safe movement options and environments that encourage physical activity in a safe manner, and encouraging people to find physical activity they enjoy. Local governments should provide reduced or free public recreation center memberships to people who cannot afford the full cost. Federal funding can be used to bring rec centers, safe parks, and safe playgounds to places that don’t have them.

    This is what governments should be doing. Not legislating behavior and moralizing health and food choices. When governments start doing that, they cross a very defined line.

    Legislating diets and eating behaviors by taxing and shaming certain foods is clearly a message of “these foods are bad, and you shouldn’t eat them.” That’s not the government’s job. It’s my job to decide what *I* want to eat, not anyone else’s. These types of government controls also end up shaming people and forcing a certain type of moral health code on the public, and that is also nowhere in the domain of government. Those are personal choices that people make, and their’s alone.

  • Beenie

    Also, Integrative Medicine is not quackery. I suggest you look it up and do some research. Integrative medicine serves to bring a wide range of health practices to general medicine in a central location for patients using a team approach: physical therapy, massage therapy, pain management, acupuncture, herbal medicine, nutritional counseling and therapies, specialized areas of conventional medicine (cardiology, gynecology, etc), and conventional family medicine. Are you so stuck in your conventional thinking that you can’t possibly even consider the very real benefits to this approach to health care? I live in the Denver Metro Area, and we have one of the largest integrative medicine centers in the country, at University of Colorado Hospital!

  • David Driscoll

    Beenie, if the government are expected to ‘pick up the tab’ on most of the health care costs (as they do in many civilised countries), then why not try to minimise the people using it.

    Re Alternative medicine ‘intergration’, when it has adequate evidence, it is no longer considered alternative, right? I haven’t seen cardiology (in it’s own right) ever described as part of intergrative medicine, so maybe part of the issue here is defining it?0

  • Beenie

    David: I don’t know what you mean by “minimize the people using it.” ??

    Integrative medicine has evolved considerably since it first appeared on the health care scene. It now means a centralized team approach to solving health problems and providing health care using a variety of modalities. The theory is that a whole health/whole body approach is critical to resolving a health care crisis, such as heart disease being treated not just by a cardiologist but also by health practitioners that specialize in nutritional therapies and minimizing pain and stress that can severely impede a patient’s wellness and recovery. A patient’s health care team consists of all these people that have a hands on approach to treating the condition. Patients are diagnosed and treated by the whole team and not just by one person. It’s really changing the face of healthcare. The Center for Integrative Medicine at University of Colorado Hospital is the industry leader and innovator for this type of approach.

  • Public health guru

    Public health IS the government’s responsibility, a genuine fact despite the radical right’s PR-industry-funded aversion to government regulation.

  • Cathy Richards

    You can nudge people to take personal responsibility — and we all can endeavor to be responsible for ouselves. However if you have no sidewalks, no bike paths, no leisure time away from a work desk, financial/social stress, then it’s not that easy to eat more veggies or join a gym or walk safely.

    Did we tell people to stop throwing their chamber pots’s contents onto the streets? Yes, and it was ineffective at preventing cholera, etc. What worked was creating a built environment — street drains and sewers systems, separating fresh water from grey water.

    We require drivers to be licensed, but we don’t just tell them okay, now you can drive anywhere but just be careful. We create a built environment that helps them drive more carefully — we paint lines and crosswalks on the road, we post stop signs and traffic lights, we monitor speed.

    How many people quit smoking because we told them it was bad for them? Then how many quit because we taxed tobacco, created non-smoking environments? A heck of a lot more.

    The environment must support personal responsibility.

  • Joe

    Beenie your post that says:

    “Government has no business telling me what a healthy food is and what I can and cannot eat. I’m an adult; I’m perfectly capable of making those decisions my self” is terrific and I agree with it however it is made void by your next post which outlines all that government should do i.e eliminating food deserts, providing parks for recreation etc…

    It is the government here and in Great Britain that make things worse. For example the idea of food deserts that is the current rage among food activists is a pointless exercise. Why because the USDA itself in the report on food deserts concludes that true food deserts exist in only about 2% of the populations. This conclusion was reached only after the data was chopped and reformed to try and show a problem that doesn’t really exist.

    Yet we are led to believe that access to fresh fruits and vegetables is limited because someone might have to get on a bus and travel over 2 miles to shop at the nearest grocery store? The problems with food and nutrition here or anywhere start with “Hello I am from the government and I am here to help”.

  • Just read the book “Mindless Eating” by Brian Wansink and you will realize just how much the environment influences what you “choose” to eat. It is simplistic and wrong to think that self-control is easy, unless you have an environment set up to “push” good choices. The “nanny state” argument is not based on evidence, but political belief. Also, consider the USDA subsidies for corn-based foods (think HFCS), making those foods that contain them artificially cheap, and not subsidizing vegetables, fruits and other non-processed foods.

  • BKcynic

    Will those who doubt the efficacy of education come out and candidly tell Americans that the “toxic environment” has left them so hopelessly brainwashed and unable to care for themselves that bad choices have to be taken away or disincentivized?

    My background is in nutrition education, but I tend to side more with the personal responsibility case, usually decried as evil big food’s way of absolving itself.

    I’d rather live in a country where we make a meaningful attempt to teach people how to take care of themselves. The status-quo certainly demands some government intervention, but not solely industry regulation.

    Take a trip to a few Food Stamp offices and talk to some teenagers outside of Pleasantville. If you find evidence that great strides are being made to teach young people to care for themselves, and that SNAP is designed to do more than to pacify the poor, let me know.

  • RoastedLocust

    Everybody has the freedom to choose, but choices come with consequences. That’s why if you want to be a fat slob, the government should let you die when you have a heart attack. If you’re a smoker, don’t expect the government to find a fresh set of lungs for you (unless you’re a government official or another wealthy person).

    And remember that when you make it the government’s business to take care of your health, they have to encourage healthier living habits or they go bankrupt. You’d think Europeans would understand this by now. And Nanny states only get worse as populations grow and resources shrink.

  • Monica

    I work in a true food desert that is recognized by the USDA. I teach kids about cooking and eating fresh vegetables. They love good food, they love kale, arugula, and cabbage. Parents want to feed the good stuff too. But can you get it in the neighborhood stores?–no. Taking a bus in this neighborhood to a grocery store is a nightmare.
    Can it compete with the toxic junk that big food has been aggressively marketing to the poor.?–No. Compare eating a bunch of greens to the cheap, subsidized garbage. The former requires access and knowledge to cook it. The latter is cheap and easy to get. Plus it is wantonly processed to make it addictive and make us crave it. It is no contest in the mind of a undereducated, uninformed, low income person. This community has been made addicted to the junk, lost its cultural knowledge of how to cook, and even if you are motivated to eat well, the good stuff is not available.
    Big food has been allowed to create a toxic food environment in this country and convince us all that we have free choice to like and want it. But it is not free choice if the deck is stacked.

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  • Margeretrc

    Dr. Briffa: “The UK’s largest diabetes charity – Diabetes UK – advises diabetics to include starchy foods with every meal. I strongly object to this on the grounds that this approach is unscientific, counter-intuitive, and likely to worse[n] blo[o]d sugar control and increase the risk of complications.” Sounds pretty logical to me. Unlike you, @Anthro, I’m unimpressed by a person’s qualifications or lack of them, only by their knowledge. Dr. Briffa clearly knows that encouraging diabetics to eat food that is poison to them is wrong, and unlike many “experts” who are not “quacks” by your definition.

  • Margeretrc

    @ “if the government are expected to ‘pick up the tab’ on most of the health care costs (as they do in many civilised countries), then why not try to minimise the people using it.” That presupposes that the government knows how to minimize the people using it. Taxing fatty foods, thus encouraging people to eat ever more carbohydrates, is not going to do it–it is going to make the problem worse, mark my words, as I’m sure we’ll eventually see in Denmark. I’m with @BKcynic. Education based on good science (not bad science as is most of the information in nutrition today) is the only answer that doesn’t involve taking away freedom of personal choice. Generally, people don’t and won’t choose to (regularly) eat food they know is unhealthy–unless they can’t afford anything else. Problem is, we’ve been misled for decades about what is and isn’t healthy. Food isn’t like alcohol and cigarettes, @Cathy. We do need a certain amount of it and, unlike alcohol and cigarettes, we don’t have enough solid evidence against anything except added sugar and trans fats to create the environment which “supports personal choice.” Let’s first rectify the mistakes of the past before we try to strong arm people into making the right choices and who knows, perhaps we won’t need to strong arm them!