Can We Nudge the Diabetes Crisis Away? A UK Perspective
Behavioral economics has become somewhat of a buzzword, much like globalization and digitalization. It makes an alluring promise to change human behavior enough for governments to ditch old-fashioned regulation. According to former British Prime Minister David Cameron, “Behavioral economics can transform people’s behavior in a way that all the bullying and all the badgering from a government cannot possibly achieve.”[i]
Given health trajectories, there is arguably no policy area in more desperate need of mass-consumer behavior transformation than public health. Current forecasts predict that one in three British adults will be obese by 2034,[ii] and at £27 billion per year, [iii] obesity is quickly becoming one of society’s most expensive trends. In fact, more is spent annually on obesity and diabetes treatment in the UK than on the police, fire service and judicial system combined.[iv] But we cannot solely rely on the transformative power of behavioral interventions to counter these forecasts. The wider structural issues surrounding the diabetes crisis should also be addressed and tackled with our old friends: taxation and legislation.
Diabetes and demand-side policies
The rise of type-2-diabetes has come hand-in-hand with our ever-expanding waistlines; diabetes treatment now accounts for 9% of the National Health Service’s (NHS) annual budget at £8.8 billion.[v] Given the scale of the crisis, the government is increasingly turning to behavioral-intervention programs. Behavioral economics broadly rejects the rational decision-making model of standard economic theory. Instead, it describes an unrealistically optimistic, loss-averse and irrational human agent prone to inertia and a number of cognitive biases.[vi] Attracted by low-cost, big-impact policies, government ‘nudge units’ are rapidly expanding. The well-documented ‘nudge’ refers to non-regulatory and non-monetary interventions that preserve freedom of choice while influencing peoples’ behavior.[vii] For instance, simply changing the wording from ‘opt-in’ to ‘opt-out’ on the government’s auto-enrolment pension scheme has seen an extra nine million people join workplace pension schemes since 2012.[viii]
The UK government’s Behavioural Insights Team supports multiple policy areas with evidence-based behavioral interventions. In 2016, it rolled out the first nationwide Diabetes Prevention Programme with the NHS, targeting high-risk individuals. Over a minimum of nine months, nutrition and exercise group classes are offered to individuals identified by the NHS with the aim of changing dietary behavioral patterns. Similar policy approaches have also focused on influencing behavior linked to obesity. For instance, the 2016 Childhood Obesity Strategy encouraged an extra 30 minutes of physical activity per day.[ix] Several economic evaluations predict that the Diabetes Prevention Programme will be extremely cost-effective; [x] the overall undiscounted net benefit is forecasted at a whopping £1.2 billion for a 5-year cohort, a clear justification for the government’s support.[xi]
The cost-effectiveness of these lifestyle-intervention programs rests on an important premise, namely that they change people’s long-termbehavior. Consider this important aspect of the debate: why has obesity substantially increased to start with? Have people just ‘suddenly’ lost all self-control when it comes to their appetites?[xii] Or, are there wider structural changes that also need to be accounted for? Arguably the latter. What’s changed isn’t the way the human brain functions, rather the increased accessibility of cheap fast food, cleverly advertised by corporations who have been harnessing our behavioral biases long before government nudge units.[xiii] Government lifestyle-intervention programs are entering a behavioral-bias battleground where consumer biases are constantly targeted, whether it be by a NHS nutrition class or the burger advert outside. While behavioral interventions alone may suffice for pension-enrolment schemes, the battle for our waistlines takes place on two fronts: supply and demand.
Combining supply and demand
In this sense, a hybrid approach that uses behavioral insights to strengthen conventional policy measures is essential. Simply providing what scholars have labelled as mere light touch alternatives is not enough.[xiv] The UK government implemented a sugary drink tax in April 2018 following the success of a similar law in Mexico in 2017. The government should extend the sugar tax to food products and use the extra funds raised to subsidize healthier options. Revenues from the sugary drink tax have been used to support the Childhood Obesity strategy’s breakfast clubs, and further funds could be used to lengthen current lifestyle intervention programs, such as factoring follow-up meetings into the Diabetes Prevention Programme.
The government must also enforce tougher advertising rules. A ban on the advertising of foods high in fat, salt, and sugar during children’s airtime and during programs with a high child audience was introduced in 2007, with stricter rules enforced in 2017. This must be extended further, banning this type of advertising before the 9pm watershed. This would involve the government taking a stronger stance against the food industry. Curtailing the marketing activities of the food and drinks industry has been met with fierce resistance in the UK.[xv] In 2011, for instance, the food industry successfully lobbied against the introduction of a proven as effective traffic light system to signal high-fat foods. The government opted instead for a system of labelling based on percentage of the Guideline Daily Amount (GDA) as “traffic lights would not have been consistently adopted by the food industry”.[xvi]
It’s crucial to also consider the link between deprivation and obesity. Children living in the most deprived areas in the UK are twice as likely to be obese than those living in the least deprived areas.[xvii] The density of fast food outlets is also strongly linked with area deprivation.[xviii] If behavioral insights tell us anything,it is that our ecologies exert a strong influence over our behavior, and that changing human behavior starts with changing their environment. In this sense, actually reducing the number of fast food outlets is likely to be far more influential than what behavioral scientists have termed as superficial awareness-raising schemes and education.[xix] The introduction of ‘zoning laws’, which restrict fast food outlets opening within certain distances of schools, was endorsed by London Mayor Sadiq Khan in 2017, and would be a step in the right direction. Extending these ‘zoning laws’ to more deprived areas could also be considered, naturally with a view to subsidize healthier alternatives.
While nudges and behavioral insights offer promising policy ideas for some societal problems, these approaches alone are insufficient in the battle against diabetes and obesity. The government needs to address the structural issues surrounding the diabetes crisis using traditional economic policies: extending the sugar tax, enacting stricter advertising regulations and introducing zoning laws. The ‘magic power’ of behavioral insights must be seen within a broader policy approach, as they cannot nudge the diabetes crisis away alone.
Picture by Kim Davies.
[i]David Cameron, “The Next Age of Government”, TED, 2018, Last accessed December 12, 2018,
[ii]NHS, “NHS Diabetes Prevention Programme (NHS DPP)” National Health Service, 2016, p. 1. Last accessed December 12, 2018, https://www.england.nhs.uk/diabetes/diabetes-prevention/
[iii]UK Government, “Health matters: getting every adult active every day”, UK Government, 2016, Accessed December 11, 2018, https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day/health-matters-getting-every-adult-active-every-day
[iv]UK Government, “Health matters: getting every adult active every day”, UK Government, 2016, Accessed December 11, 2018, https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day/health-matters-getting-every-adult-active-every-day
[vi]Daniel Ariely, Predictably Irrational, Revised and Expanded Edition: The Hidden Forces That Shape Our Decisions(New York: Harper Perennial, 2010)
David Halpern, Inside the Nudge Unit: How small changes can make a big difference, (London: W. H. Allen, 2016)
[vii]Cass Sunstein, “Default Rules Are Better Than Active Choosing (Often)”, CellPress.2017, 21(8), 600-606.
[viii]UK Government, “Workplace pensions”, UK government, Available online: https://www.gov.uk/workplace-pensions/if-you-want-to-leave-your-workplace-pension-scheme[Last accessed: February 19, 2019]
[ix]Guardian, “Schools are not the answer to childhood obesity epidemic study shows”, Guardian, 2018, Accessed December 10, 2018, https://www.theguardian.com/society/2018/feb/08/schools-are-not-the-answer-to-childhood-obesity-epidemic-study-shows
[x]Penn, L.; Rodrigues, A.; Haste, A.; et al. (2018) ‘NHS Diabetes Prevention Programme in England: formative evaluation of the programme in early phase implementation’, in: BMJ Open 8 (2), published online 21.02.2018, available at: https://www.ncbi.nlm.nih.gov/pubmed/29467134 [Last accessed: 15.11.2018].
[xi]NHS, 2016, p 28
[xii]George Loewenstein and Nick Chater, “Putting nudges in Perspective”, Behavioural Public Policy, 2017, 1:1, 26-53.
[xiii]For an extension of this argument see: Oliver, A., Ubel, P, “Nudging the Obese: a UK-US consideration, Health Economics, Policy and Law”, 2014, (9) 239-342.
[xiv]Adam Oliver and Peter Ubel, “Nudging the Obese: A UK-US consideration”, Health Economics, Policy and Law, 2014, (9) 239-342.
[xvi]House of Lords, Behaviour Change: 2ndreport of Session 2010-2012, Science and Technology Select Committee, House of Lords, 2011, p.289.
[xvii]NHS, National Child Measurement Programme, National Health Service: Data and Statistics 2017, accessed on December 12, 2018 https://digital.nhs.uk/data-and-information/publications/statistical/national-child-measurement-programme/2016-17-school-year,
[xviii]Public Health England, Obesity and the environment, Public Health England, 2017, accessed on December 10, 2018 https://www.gov.uk/government/publications/fast-food-outlets-density-by-local-authority-in-england
[xix]Daniel Nettle, “Social Class through the evolutionary lens”, The Psychologist, 2009, 22(11).
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