Commentary

Behavioral economics finds the right triggers for diabetes prevention

If an ounce of prevention is worth a pound of cure, it is natural to wonder what drives people’s decisions about their health in the first place. Increasingly, the field of behavioral economics is providing insights into the triggers for lifestyle choices that can lead to healthier behaviors.

Behavioral economics combines concepts from psychology and economics to investigate how people actually behave — influenced by emotions, identity, environment and the framing of information presented to them — as opposed to how they would behave if they were being perfectly rational, with unlimited willpower and solely acting out of self-interest. Although many lessons of behavioral economics apply to public health challenges, five can be harnessed to support lifestyle change in the prevention and management of diabetes.

Frame the message

Tryggvi Thorgeirsson

“Fast thinking” controls most lifestyle choices.

Behavioral research suggests that two separate cognitive systems control our judgment and choices. Daniel Kahneman, PhD, psychologist and winner of the Nobel Memorial Prize in Economic Sciences, describes these systems as fast thinking (intuition) and slow thinking (reasoning). Thought processes in the former system tend to be automatic, intuitive and emotionally charged. By contrast, thought processes in the latter system tend to be deliberate, reflective and effortful.

Most of our actions, including our lifestyle choices, are governed by fast thinking, albeit under some degree of monitoring by slow thinking. The advertising industry adeptly targets fast thinking with emotional appeals and colorful campaigns to sell products like soda and junk food. Conversely, public health authorities tend to target slow thinking with information-laden, monochromatic nutrition and warning labels.

The framing of health messages can have a significant impact on people’s lifestyle choices. Behavioral economist Frederick J. Zimmerman, PhD, analyzed how for-profit fitness companies promote healthy behavior through a frame of personal achievement, social interaction and fun (“Get Game! Have Fun”), whereas public health authorities tend to employ a frame of duty and obligation (“Regular physical activity is important for good health”). According to Zimmerman, shifts in message framing may fundamentally alter our understanding of an activity from a burdensome duty to a rewarding experience.

With this in mind, health messages in diabetes prevention and management should be framed in a positive manner when possible — emphasizing factors such as personal achievement, social interaction and fun. Furthermore, fast thinking should be targeted with methods similar to those employed by the advertising industry, such as colorful graphics, humor, stories, games and instant gratification through virtual and real rewards.

Manage stress

Stress, multitasking and other cognitive demands may increase the use of fast thinking and adversely affect lifestyle choices.

According to Kahneman, our cognitive capacity is limited. Slow-thinking processes require substantial cognitive effort and tend to disrupt each other, whereas automatic fast thinking processes do not. As a result, when we are tired, under stress or multitasking, we tend to “outsource” decision-making to fast-thinking processes, leading to more impulsive and emotional behavior.

This applies to food choices. In one study, participants were asked to choose between cake and fruit salad. Participants who were given a challenging mental task to perform while making their selection were 50% more likely to choose cake than participants in the control group.

Managing strain on cognitive resources can be an important aspect of improving health behavior. In light of this, the CDC’s emphasis on stress management in the National Diabetes Prevention Program is commendable, and it is encouraging to see many organizations incorporating stress management efforts into their lifestyle change programs.

Reduce mindless eating

People use mental shortcuts to aid decision-making, which can lead to biases that cause unhealthy behaviors.

People’s lifestyle choices, such as how much to eat, are frequently biased toward some initial “anchor” value. The quantities of food and drink consumed at a meal, for example, are subconsciously anchored by external cues like the sizes of dishes and glasses. Experiments show that large packages, plates and bowls can increase how much people serve and consume by 15% to 45%. This subconscious anchoring of consumption has been referred to as “mindless eating.”

The concept of anchoring has been applied successfully in a weight reduction trial among obese patients with type 2 diabetes during a 6-month period. The intervention group received smaller “portion control plates” and a 15-minute session outlining the use of the plates. The control group received usual care through dietary assessment and teaching by dietitians. Compared with controls, a higher proportion of the intervention group achieved at least 5% weight loss (17% vs. 5%), and more patients in the intervention group required a decrease in diabetes medications (26% vs. 11%).

Diabetes program educators can help offset the impact of mindless eating by encouraging participants to consider their containers. Recommending that program participants drink high-calorie drinks, such as fruit juice, from tall, narrow glasses may nudge them to consume fewer calories without any effort.

Promote short-term benefits

People tend to discount future costs and benefits, thus placing a higher value on the present.

When costs and benefits of a behavior are separated by time, lifestyle change becomes difficult. This challenge characterizes most preventive behaviors: Floss now to avoid a dentist visit later. Conversely, for so-called sinful goods, the fun of enjoying a doughnut is now, and the costs come later. Attributing a higher value to the present, or “future discounting,” can work against healthy lifestyle choices.

In one study of studied the effects of financial incentives on weight loss, participants who met their goals became eligible for daily lottery prizes, with frequent small prizes and occasional large rewards. After 4 months, the incentive group had lost more than three times more weight than the control group (14 lb vs. 4 lb).

To mitigate future discounting, lifestyle change programs should aim to bring the costs and benefits of lifestyle change closer together. Providing instant rewards, prizes and positive feedback can all be helpful. A similar strategy would highlight the short-term benefits of healthy behaviors, such as improved energy levels and positive social interactions, as opposed to longer-term benefits, such as reduced risk for diabetes or myocardial infarction.

Engage with altruism

Behavioral economics models assume people are motivated by more than pure self-interest.

Altruism is an important motivator for health-related behaviors, such as blood and organ donation, as well as many group- and peer-based interventions. Furthermore, incentives benefiting our friends can be several times more effective than standard, individually targeted incentives.

Lifestyle change programs can harness these concepts by facilitating interaction and peer support among members in groups. In addition, social network incentives, in which group members or the group benefits from individual participants’ good work, as well as altruistic rewards, such as rewarding participants’ efforts with gifts that benefit food banks or children in need, can motivate participants to continue their engagement in a program.

Diabetes prevention programs must continuously seek improved methods to promote healthy behaviors, and the field of behavioral economics provides valuable insights into the triggers behind lifestyle choices. Applying lessons about the way people think to the actions that they take may be the best opportunity to drive the prevention and management of chronic disease.

If an ounce of prevention is worth a pound of cure, it is natural to wonder what drives people’s decisions about their health in the first place. Increasingly, the field of behavioral economics is providing insights into the triggers for lifestyle choices that can lead to healthier behaviors.

Behavioral economics combines concepts from psychology and economics to investigate how people actually behave — influenced by emotions, identity, environment and the framing of information presented to them — as opposed to how they would behave if they were being perfectly rational, with unlimited willpower and solely acting out of self-interest. Although many lessons of behavioral economics apply to public health challenges, five can be harnessed to support lifestyle change in the prevention and management of diabetes.

Frame the message

Tryggvi Thorgeirsson

“Fast thinking” controls most lifestyle choices.

Behavioral research suggests that two separate cognitive systems control our judgment and choices. Daniel Kahneman, PhD, psychologist and winner of the Nobel Memorial Prize in Economic Sciences, describes these systems as fast thinking (intuition) and slow thinking (reasoning). Thought processes in the former system tend to be automatic, intuitive and emotionally charged. By contrast, thought processes in the latter system tend to be deliberate, reflective and effortful.

Most of our actions, including our lifestyle choices, are governed by fast thinking, albeit under some degree of monitoring by slow thinking. The advertising industry adeptly targets fast thinking with emotional appeals and colorful campaigns to sell products like soda and junk food. Conversely, public health authorities tend to target slow thinking with information-laden, monochromatic nutrition and warning labels.

The framing of health messages can have a significant impact on people’s lifestyle choices. Behavioral economist Frederick J. Zimmerman, PhD, analyzed how for-profit fitness companies promote healthy behavior through a frame of personal achievement, social interaction and fun (“Get Game! Have Fun”), whereas public health authorities tend to employ a frame of duty and obligation (“Regular physical activity is important for good health”). According to Zimmerman, shifts in message framing may fundamentally alter our understanding of an activity from a burdensome duty to a rewarding experience.

With this in mind, health messages in diabetes prevention and management should be framed in a positive manner when possible — emphasizing factors such as personal achievement, social interaction and fun. Furthermore, fast thinking should be targeted with methods similar to those employed by the advertising industry, such as colorful graphics, humor, stories, games and instant gratification through virtual and real rewards.

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Manage stress

Stress, multitasking and other cognitive demands may increase the use of fast thinking and adversely affect lifestyle choices.

According to Kahneman, our cognitive capacity is limited. Slow-thinking processes require substantial cognitive effort and tend to disrupt each other, whereas automatic fast thinking processes do not. As a result, when we are tired, under stress or multitasking, we tend to “outsource” decision-making to fast-thinking processes, leading to more impulsive and emotional behavior.

This applies to food choices. In one study, participants were asked to choose between cake and fruit salad. Participants who were given a challenging mental task to perform while making their selection were 50% more likely to choose cake than participants in the control group.

Managing strain on cognitive resources can be an important aspect of improving health behavior. In light of this, the CDC’s emphasis on stress management in the National Diabetes Prevention Program is commendable, and it is encouraging to see many organizations incorporating stress management efforts into their lifestyle change programs.

Reduce mindless eating

People use mental shortcuts to aid decision-making, which can lead to biases that cause unhealthy behaviors.

People’s lifestyle choices, such as how much to eat, are frequently biased toward some initial “anchor” value. The quantities of food and drink consumed at a meal, for example, are subconsciously anchored by external cues like the sizes of dishes and glasses. Experiments show that large packages, plates and bowls can increase how much people serve and consume by 15% to 45%. This subconscious anchoring of consumption has been referred to as “mindless eating.”

The concept of anchoring has been applied successfully in a weight reduction trial among obese patients with type 2 diabetes during a 6-month period. The intervention group received smaller “portion control plates” and a 15-minute session outlining the use of the plates. The control group received usual care through dietary assessment and teaching by dietitians. Compared with controls, a higher proportion of the intervention group achieved at least 5% weight loss (17% vs. 5%), and more patients in the intervention group required a decrease in diabetes medications (26% vs. 11%).

Diabetes program educators can help offset the impact of mindless eating by encouraging participants to consider their containers. Recommending that program participants drink high-calorie drinks, such as fruit juice, from tall, narrow glasses may nudge them to consume fewer calories without any effort.

Promote short-term benefits

People tend to discount future costs and benefits, thus placing a higher value on the present.

PAGE BREAK

When costs and benefits of a behavior are separated by time, lifestyle change becomes difficult. This challenge characterizes most preventive behaviors: Floss now to avoid a dentist visit later. Conversely, for so-called sinful goods, the fun of enjoying a doughnut is now, and the costs come later. Attributing a higher value to the present, or “future discounting,” can work against healthy lifestyle choices.

In one study of studied the effects of financial incentives on weight loss, participants who met their goals became eligible for daily lottery prizes, with frequent small prizes and occasional large rewards. After 4 months, the incentive group had lost more than three times more weight than the control group (14 lb vs. 4 lb).

To mitigate future discounting, lifestyle change programs should aim to bring the costs and benefits of lifestyle change closer together. Providing instant rewards, prizes and positive feedback can all be helpful. A similar strategy would highlight the short-term benefits of healthy behaviors, such as improved energy levels and positive social interactions, as opposed to longer-term benefits, such as reduced risk for diabetes or myocardial infarction.

Engage with altruism

Behavioral economics models assume people are motivated by more than pure self-interest.

Altruism is an important motivator for health-related behaviors, such as blood and organ donation, as well as many group- and peer-based interventions. Furthermore, incentives benefiting our friends can be several times more effective than standard, individually targeted incentives.

Lifestyle change programs can harness these concepts by facilitating interaction and peer support among members in groups. In addition, social network incentives, in which group members or the group benefits from individual participants’ good work, as well as altruistic rewards, such as rewarding participants’ efforts with gifts that benefit food banks or children in need, can motivate participants to continue their engagement in a program.

Diabetes prevention programs must continuously seek improved methods to promote healthy behaviors, and the field of behavioral economics provides valuable insights into the triggers behind lifestyle choices. Applying lessons about the way people think to the actions that they take may be the best opportunity to drive the prevention and management of chronic disease.