Treating people like lab rats

When it comes to UK health policy, dodgy Nudge-style psychology is just as oppressive and poorly-founded as New Labour nannying

Last week, the health secretary for England, Andrew Lansley, published a White Paper that reflects the triumph of hope over experience. That’s because its theoretical foundation is ‘nudging’, the in-vogue American social policy tool that has long infatuated prime minister David Cameron and has now captured Lansley’s policy heart, too.

In Nudge, authors Richard Thaler and Cass Sunstein candidly describe how nudging works. As most of us act irrationally (and predictably so) much of the time, it takes an elite group of rational thinkers to design choices that encourage the rest of us to choose the ‘right’ option. Hence Cameron and Lansley are determined to shepherd us towards ‘good’ decisions through nudges.

What they ignore, however, is that the behavioural economics research that nudging relies upon is closer to science fiction than first-class science. The vast majority of its conclusions come from laboratory experiments that are completely artificial in their construction, as Nobel laureate economist Gary Becker, among many others, has cautioned.

Still, the White Paper assures us that government intervention will be based ‘on a rigorous assessment of the evidence’. Yet the same document then proposes plain packaging for cigarettes - for which there is absolutely no compelling evidence - and procrastinates over whether to implement a tobacco retail display ban, despite a plethora of sound studies finding that there are no public-health benefits.

The White Paper is also full of contradictions. So while warning that lifestyle-driven health problems such as obesity are at alarming levels, it confirms that ‘people in England are healthier and are living longer than ever’, and that ‘life expectancy is expected to continue to rise for both men and women’. Furthermore, ‘although we are living longer, there is no strong evidence that the burden of health conditions has increased’. In addition, the reader is correctly informed that childhood obesity rates are leveling off, and that the majority of the population either doesn’t drink or drinks in sensible moderation.

A flimsy theoretical foundation, compounded by a series of contradictory statements, is further tarnished by a litany of nonsensical assertions that reveal either the Department of Health’s stunning ignorance of the research evidence or a political decision to present a particular side of the argument to further a preordained policy agenda. The faulty policies and misinformation contained in the White Paper include the following:

An expansion of the ludicrous Change4Life programme

This policy assumes that government-directed, population-wide behavioural change with respect to diet, weight and physical activity levels is possible. Interventions based on creating such behavioural change almost always rely on theories, such as cognitive learning and the theory of planned behaviour, that have rarely been subjected to rigorous evaluation; where they have, they have generally been found to be spectacular failures. There is considerable evidence that community-level interventions designed to modify physical activity and food consumption patterns have been unsuccessful.

Eating ‘five a day’ will keep the doctor away

According to the White Paper, only three out of every 10 adults eat the recommended ‘five a day’ servings of fruits and vegetables. The White Paper assumes that ‘eating better’ can reduce the risk of disease and death. But there is little evidence from randomised clinical trials that supports any of the claims that reductions in fat and calories and increases in fibre, fruits and vegetables can reduce the risk of certain diseases, delay death, or prevent weight gain. Indeed, some of the largest of these trials, such as the Women’s Health Initiative Dietary Modification Trial, found no statistically significant differences in the risk of breast cancer, colon cancer, coronary heart disease (CHD), stroke, or cardiovascular disease (CVD) between the intervention and control groups.

If we ‘move more’ we will lose weight and live longer

There is no compelling evidence that such exhortations have any efficacy in terms of weight loss or longevity in either adults or children. For example, Yale University professor of epidimeology, Dr Loretta DiPietro, notes that, based on the long-term evidence, ‘It is not clear that increased physical activity prevents or reverses age-related weight gain at the population level’. The evidence is even less compelling with children. Numerous studies have failed to find a link in children between physical activity levels, food intake, and obesity. In fact, there is considerable evidence that neither better sports and physical education facilities, nor improved programmes or increased hours of physical education in schools, will reduce childhood overweight and obesity.

Most serious illness is lifestyle-related

Two out of three British adults are either overweight or obese and the government assumes that the overweight and obese are at risk of premature death. The government also assumes that most serious illness is lifestyle-driven: ‘a substantial proportion of cancers and… deaths from circulatory disease could be avoided.’

Neither of these assumptions is true. A rigorous academic study by Dr Katherine Flegal and her colleagues found the weight group with the lowest death rate was overweight, while Dr Jerome Gronniger’s analysis found negligible differences in risk of death among people with body mass index (BMI) values from 20 to 35 (that is, from ‘normal’ right through to ‘mildly obese’). Flegal et al’s seminal study reported no relationship between overweight and excess mortality for cardiovascular disease (CVD) or coronary heart disease. For cancer there was no relationship between excess mortality and overweight and obesity. In the Million Women Study, for all the cancers studied overweight was not associated with a statistically significant mortality risk, while with obesity the association was a barely significant 1.1 (in other words, a 10 per cent increase in risk).

In fact, being overweight actually increased one’s chance of living longer. And for all other diseases other than CVD and cancer, obesity up to a BMI of 35 was modestly protective – that is, being plump seems likely to result in a longer life. The US data was confirmed last year by a rigorous Statistics Canada study of the Canadian population.

Huge savings would accrue to the NHS from less obesity and fewer smokers

The stubborn fact is that preventing obesity and smoking doesn’t save taxpayers’ money. It costs more to care for healthy people who live years longer, according to an economic study led by the Dutch National Institute for Public Health and the Environment. The researchers found that the health costs of thin and healthy people in adulthood are more expensive than those of either fat people or smokers.

Tougher anti-drinking measures are necessary

This is despite the fact the UK recently recorded the biggest fall in alcohol consumption in 60 years, according to the British Beer and Pub Association (BBPA). The BBPA’s new Statistical Handbook reveals that there was a six per cent decline in alcohol consumption in 2009 – the sharpest decrease since 1948. It was also the fourth annual decline in five years; British drinkers are now consuming 13 per cent less alcohol than in 2004. Alcohol consumption in the UK remains below the EU average.

There’s also one assumption that is missing, but well supported by the research evidence…

Those who don’t drink tend to die sooner than those who do

A new paper in the journal Alcoholism: Clinical and Experimental Research suggests that abstaining from alcohol tends to increase one’s risk of dying even when you exclude former drinkers. In fact, abstainers’ mortality rates are also higher than those of heavy drinkers. Moderate drinking is associated with the lowest mortality rates in alcohol studies.

The overall implications of the White Paper’s glaring deficiencies are significant. They suggest that a good deal of the government’s public-health message lacks a credible scientific basis. Consequently, Cameron and Lansley’s kinder, gentler Nudge State will not succeed where the coercive Nanny State has demonstrably failed.

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Blood test can predict heart attacks years in advance

The relationship reported does seem to be a strong one

A simple blood test can predict if someone is going to have a heart attack up to six years before it occurs, researchers have said. A team in America have adapted a test normally used to establish if someone if having a heart attack to predict one years in advance. The development could allow those at high risk to take action such as adopting a healthier lifestyle and taking drugs to lower blood pressure and cholesterol levels.

The more sensitive test identified proteins in the blood that signal heart cells have been dying in seemingly healthy people with no outward signs of heart disease.

It was found that where the protein called troponin T were present, the patient was seven times more likely to die from heart disease within the next six years.

Dr James de Lemos, associate professor of internal medicine at Southwestern Medical Centre, at University of Texas and lead author of the study said: "This test is among the most powerful predictors of death in the general population we've seen so far.

"It appears that the higher your troponin T, the more likely you are to have problems with your heart, and the worse you're going to do, regardless of your other risk factors."

The findings are published in the Journal of the American Medical Association and follow on from an earlier study which suggested the protein could also predict heart failure, a condition where the organ fails to pump strongly enough causing breathlessness and fatigue.

The latest study involved more than 3,500 healthy people and 25 per cent were found to have detectable levels of troponin T.

They provided blood samples and underwent multiple body scans to examine their hearts and internal organs.

They found older people, men and African-Americans had the highest levels of troponin T along with those showing signs of thickening or weakness of the heart muscles.

They were then tracked for an average of seven years from 2000 to 2007 to establish how many people died, of what and when.

The more sensitive test can detect circulating protein levels in almost everyone with chronic heart failure and chronic coronary artery disease, the authors said.

Dr de Lemos said: "Because this test seems to identify cardiovascular problems that were previously unrecognised, we hope in the future to be able to use it to prevent some death and disability from heart failure and other cardiac diseases."

Currently doctors use computer software calculations called the Framingham Score and Qrisk to identify people at high risk of heart disease who could benefit from preventive treatments. The calculations take into account family history, smoking history, cholesterol levels, blood pressure and age.

The earlier study, published in the same journal last month, found that troponin T levels could predict the chance of heart failure up to 15 years in advance. Until now, no blood test has been able to give an indication of a person's risk of heart failure.

The study conducted by University of Maryland involved 4,000 people whose blood was taken in 1989.

Prof Christopher deFilippi, the lead researcher, said: "We found that the higher the level of troponin T, the greater the individual was at risk for symptoms of heart failure or death from cardiovascular disease over the next 10 to 15 years."

He added that those with the highest levels of troponin T were four to five times more likely to develop heart failure than those with the lowest detectable levels. People whose levels dropped over time appeared to reduce their risk of heart failure.

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