We have now entered a world where most the obviously good ideas are already taken. Someone has already invented the chair. Someone has already invented the desk. The spaces where innovation will occur now are in the crevices of where academic disciplines come together. By using paradigms from behavioral economics, I believe physicians and public health officials can navigate this uncharted interdisciplinary terrain to solve the U.S.’s current obesity problem.
In the late 1970s, famous behavioral economist Richard Thaler was fraught by the problem of modeling intertemporal decision-making, which involves people making decisions where the consequences (good or bad) arrive sometime in the future. As the data from his experiments began to pour in, he arrived at a breakthrough. He found that the human mind is poorly equipped with the ability to make decisions on events whose ramifications extend far into the future.
Specifically, Thaler’s experiments revealed that rational individuals put great value in the present. So much so, that it takes a massive future reward in order to forgo the impulses of the present and invest in the future. This phenomenon can be observed by seeing how young adults invest in their 401K or IRAs. Although they could save a little of their income now, they value the present far greater than the future. Thus, they invest little in their retirement accounts now, only to feel great regret of their actions as they approach retirement. This phenomenon came to be called hyperbolic discounting or present bias.
Now, as we fast forward from 70s to the present and away from the field of economics to look at medicine, researchers have been able to wipe out most life-threatening communicable diseases in the U.S. Today, however, we see a health crisis unlike ever before. Obesity rates in the U.S. have reached pandemic levels. Preventable diseases linked largely to poor lifestyle choices are among the top killers in the country (i.e. heart disease, the number 1 cause of death in the U.S., claimed 597,689 lives in 2010, almost 20,000 more than cancer).
Physicians and public health officials alike have tried a variety of strategies, aimed at stopping this meteoric rise in obesity. However, to date, none have proven effective. When dealing with infectious diseases, which were the most deadly killers for most of human history (in the majority of developing country they still are), hard science and a wet lab are most often the solutions while time is the limiting-factor. However, now the tables have turned, science can only help develop treatments, but the root cause of most obesity-related disease lies in human behavior and bad habits. Specifically, individuals jeopardize their future for instant pleasure in the present, whether it be indulging in unhealthy snacks or procrastinating on exercise. While it is clear that genetics and other factors beyond our control exert a powerful influence on obesity and the diseases that come along with it, on average, the vast majority of these health problems can be curtailed with healthy lifestyle choices.
The present bias that Thaler discovered in the 70s tells us that our brains, subconsciously, don’t care enough about the future to forgo pleasure in the present, and simply being educated about the future ills of unhealthy lifestyle choices in the present are not enough to get individuals to change their behavior and invest in the future. In discussing the predicament of present bias Thaler says, “Plans made in advance are consistently broken because temptation becomes too great. What the person knows to be his best long run interests conflict with his short run desires.”
A considerable amount of research energy is being devoted to determine how to best control this internal impulse that makes costs of changing behavior today to appear very large relative to their long-term benefits.
One option is a legislative one. In a time before vaccine immunizations were compulsory, present bias made parents postpone getting their children immunized while those same parents were willing to spend massive amounts of money on dubious curative or treatment options for the same disease for their children. In the U.S. and in most developed countries today, the vast majority of children are vaccinated because they are required to do so to enroll in public schooling.
Another option is to utilize commitment devices. Our brain puts greater weight on default options, which gives rise to seemingly strange anomalous behavior. Experimental evidence shows that a phenomenon known as the endowment effect impedes individuals from switching to another option even if they find it more appealing. An example of the endowment effect can be observed when an individual purchases a mug for, say, $5, which they believe to be a fair price. However, she must be paid as much as double that buying price of the mug to sell that same mug. A rationalization for this phenomenon is that somehow after acquiring an item, the mind develops some sort of sentimental attraction to it, and thus does not want to let go of the item. This effect can be leveraged to enable healthy eating. In 2007, the Economic Research Service and the U.S. Department of Agriculture published a study, showing that “changing the default menu on school meals more healthful, such as a fruit salad instead of French fries, may increase the likelihood that they will choose more healthful foods.” Further, the endowment effect will ensure that few people will chose to opt out.
These solutions are still imperfect and much work lies ahead. Public health officials and physicians can use these more textured models of behavior developed by behavioral economists to approach the obesity pandemic from another angle. By melding the rigorous models of behavioral economists with physicians’ more nuanced expertise, maybe we can develop a creative strategy to attack obesity and encourage health maintenance.
Birju Rao is a medical student.