By Lizzy Mayes (BSc Economics)
A Big Fat Problem
Obesity is rampant in England right now and it’s causing terrible damage. In 2019, 28% of adults in England were classified as obese while 64% of adults were in the overweight or obese category (Baker, 2022). These numbers keep rising, with the percentage of obese adults in England nearly doubling in the past 30 years. The damage being overweight or obese can cause is well documented, it can lead to many health problems; diabetes, heart issues, and an increased chance of cancer to name a few (NHS, 2019). Not only is this obesity epidemic causing damage to us as individuals, but the impact on the NHS is massive. Obesity related diseases cost the NHS in excess of £6bn per year and if urgent action isn’t taken by 2050, that cost is estimated to increase by a staggering £3.7bn (PHE, 2017). While this is a lot to take in, it is the stark reality of obesity in England today and the backdrop to the release of England’s 2022 “Tackling Obesity” policy paper.
We see clearly that obesity is out of control, causing serious harm to the public and the health service, and in desperate need of effective policy intervention. Yet the policies we see in the new obesity strategy seem to suggest very small changes such as putting calorie labels on menus and stopping unhealthy food and drink ads being shown before a certain time (DHSC, 2020). An understandable initial reaction is that these policies seem underwhelming in response to the enormous problem of obesity, but is there more than meets the eye to these policies? These “small changes” types of policy are rooted in the principles of nudge theory, but what is nudge theory and how effective can we expect these nudge-based policies to be in our fight against obesity?
Nudge, Nudge, Hint, Hint
To best explain nudge theory, let me transport you to a men’s airport bathroom in Amsterdam in the early 1990s. In an effort to cut cleaning costs, Schipol airport added pictures of flies to their urinals. it wasn’t stated to anyone using the bathroom, but the idea was that by men aiming at the flies there would be less spills and it would be easier to clean. This is an example of a wildly successful nudge that reduces spills by 80% and cut cleaning costs by around 8% (Thaler and Sunstein, 2008). At its core, a nudge is an intervention which predictably changes someone’s behaviour, however it does not ban any options or change the economic costs or benefits of the decision significantly for the person choosing. For instance Thaler and Sunstein, who not only figuratively but literally wrote the book on nudge theory, wrote that for something to be classified as a nudge, “the intervention must be easy and cheap to avoid” (Thaler and Sunstein, 2008). Often nudges are covert and individuals do not realise their behaviour is being effected by the nudge, just like our airport example.
The way nudges change people’s behaviour is through considering something called the choice architecture, which is how choices are designed and presented and what outside influences may affect people’s decisions. By altering the environment (i.e. by adding a picture of a fly), the airport was able to alter people’s behaviour and what choices they made, while not removing any of the previous choices available to the public. We can predictably change behaviours like this because, while people may not be acting rationally, there are still patterns in their behaviour. Behavioural economics gives us insight into these patterns such as the fact that people tend to feel losses larger than they feel gains or that people tend to live for today at the cost of tomorrow (Dolan et al., 2010).
Nudge theory has already been successfully used by the British government in previous policies, such as changing pensions from opt in to opt out. Now with employees auto enrolled into a pension, 10.3 million more people are saving for later life with their pension (Collinson, 2019). However, success in changing actions in one area of our lives does not mean this will translate to all aspects of life, so how effective can we expect nudge policies to be when we are dealing with obesity?
Will Nudge Make the Fat Budge
Nudge polices are attractive prospects to policy makers as, by nature, they need little regulation and often don’t appear to intrude on people’s lives and choices (Dolan et al., 2010). This makes these policies easier for members of the public across the political spectrum to get on board with compared to harsher seeming polices such as bans. This is a strength of the policy type as other polices that could be argued would be more effective in theory in the fight against obesity, may be unlikely to ever be implemented due to people’s concerns with the high costs of regulation and taking away of liberties. This has led to a quick adoption of nudge polices around the globe.
While nudge theory is a relatively new concept, enough time has passed that we can now assess how successful some of the previous nudge based polices to tackle obesity have been. New York has been an experimentation ground for many kinds of obesity policies in recent years, one being the introduction of a nudge-based policy of calorie labelling on menus of chain restaurants in 2008. This is very similar to the calorie labelling on menus policy included in the latest “Tackling Obesity” paper in England. However, when considering New York’s calorie labelling policy’s effect, initial studies found no visible change in calories bought (Elbel et al., 2009). This does not support nudge-based policies being an effective tool in tackling obesity; however, this is just one nudge policy.
A more complete view of the success of previous nudge-based policies in tackling obesity may be found in Arno & Thomas’ review of 42 studies relating to nudge policies effect on influencing adult dietary habits. Gathering and averaging the results of all 42 studies, it was found these varying nudge policies resulted in an average 15.3% increase in healthier dietary or nutritional choices, which we would deem a success (Arno & Thomas, 2016). While individual policies such as calorie labelling in restaurants may not be fruitful, others considered within that review such as nutritional labelling have been a success, and the overall impression from previous nudge policies is that they have the potential to cause a positive change to people’s unhealthy behaviour.
A harmful drawback however is that by the nature of a nudge it tends to be undiscerning in who it nudges, which is great if we want to nudge the whole population a particular way but potentially harmful for those who are nudged to behave in a way which is harmful to them. We can see this in the backlash to the calorie labelling on menus policy, where we are already seeing academics and citizens alike speaking out about the dangers the nudge of calorie labelling will have on those suffering from eating disorders (Rackham, 2022).
It’s clear nudges can be effective at changing peoples behaviour with regards to exercising and dietary choices, whether positively or negatively for that individual. However, this obesity problem did not appear and maintain itself the way it has without other things pulling our strings the opposite way. Are nudge-based policies a fair match for these other external influences on our behaviour?
Not My Fault, England Made Me Do It
More and more research is pointing to our social, economic and political environment having a heavy influence on our diet and exercise choices (Smith & Toprakkiran, 2019). The modern society has become such that a heavier population is hard to avoid and unless the influences of the environment we are in is considered in policy design, the effectiveness of nudge polices is very limited. As Public Health England stated in a report when considering the need to lower sugar intake: “This is too serious a problem to be solved by approaches that rely only on individuals changing their behaviour in response to health education and marketing, or the better provision of information on our food. The environmental drivers of poor diets we face are just too big.” (PHE, 2015). For example, a factor from our environment that has been linked with obesity is deprivation, with communities from more deprived areas having higher rates of obesity (Smith & Toprakkiran, 2019).
While nudges which address individual behaviour such as the “five a day” fruit and veg campaign are not ineffective in theory, they ignore the fact that our environment pushes us towards unhealthy choices. Simply put, you can nudge people closer to fruit and veg but if they are surrounded by takeaways and the nearest supermarket is an hour’s walk, the effect is going to be limited.
Nudging England to a Healthier Weight
It appears the key to successful nudge-based policies is them being centred around changing the environment someone is in, rather than the individual’s choice. Instead of information-based nudge policies such as the change 4 life campaign, limiting promotions of unhealthy foods and stopping unhealthy foods being placed near the checkouts are looking much more promising in tackling obesity. Thankfully the latter two are some of the current nudge policies proposed for England, which help change the food environment we are in.
However even with targeting the food environment when designing nudge-based policies, behavioural economists aren’t of the opinion that nudges should entirely replace stricter forms of food legislation (Smith & Toprakkiran, 2019). Rather, nudges should be seen as an additional tool to accompany regulation. With the relative success of nudge-based policies in general and in fighting obesity, and a new focus in using nudge-based policies to address more food environment-based issues, things look promising. I believe there is reason to be cautiously optimistic about the good these nudge policies, in partnership with more traditional forms of legislation, can do in in tackling obesity, saving the NHS money, and saving lives.
Bibliography
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