It’s not your fault, but it is your problem

We need to give people better incentives to make good lifestyle choices.

I recently returned to the US after five years. Thirty-six hours into my trip, I had not encountered anything I could honestly call ‘food’. There were lots of options for what I would call ‘food substitutes’, but nothing resembling the real thing. 

I had lots of options, but none of them were good options. To paraphrase the childhood obesity expert Dr Robert Lustig – when all your options are bad options, you don’t have a choice. 

I didn’t have a choice. 

As clinicians, we counsel patients on lifestyle choices to reduce their future risk of major chronic illness. The emphasis here is on ‘choice’ – volitional, self-made decisions to achieve specific goals. 

But what if, for many of our patients, most of their options are bad options, and the idea of ‘making a good choice’ from a lifestyle perspective is practically impossible? Is it really their ‘fault’ they make bad choices? 

We all have a sense of free will. So why don’t our patients exercise that free will and choose the ‘good’ option? 

Get eight hours of sleep. Avoid stress. Eat real foods. Exercise 30-to-40 minutes per day. Don’t smoke. Meditate. Avoid noise, air, and light pollution. 

As a middle-aged doctor, these are attainable goals. For a single mother with two children living in substandard, overpriced rental accommodation in a city centre food desert, working two jobs, the probability of being able to do any of these is low. 

When making good lifestyle choices, we must always be mindful of the environment in which decisions are made. A low socioeconomic grouping puts you at a much higher risk of chronic medical conditions. Those in the lowest socioeconomic groups have a life expectancy 10 years shorter than those in the highest socioeconomic group. 

Buying and preparing nutritious food takes twice as long and costs twice as much. And that was before we had a global food inflation crisis. 

Smoking rates are 14 per cent in affluent areas, but 40 per cent if you are unemployed. 

Risk is not evenly distributed and the environment drives the delta. 

Asking people in these groups to ‘make better choices’ is not a good strategy. 

Take my situation in the US; after 36 hours, I eventually had to make a food choice; believe me; it wasn’t a good one. I had a choice. I had all the best health literacy information to hand and still made a terrible decision. In my defence, the jet lag and the fact that most of that time was spent in an airport, on a flight or in the city of Las Vegas certainly didn’t help. 

Humans are incentive-based creatures. As Charlie Munger says, “show me the incentive, and I will show you the outcome.” 

Primordial prevention is the domain of policy, and policy can take years. But what about right now? 

We need to give people better incentives to make good lifestyle choices or at least create an environment where making good choices is easier. 

This is the realm of policy. This is the realm of sugar taxes, bike lanes, green spaces, and better housing. This is not about ‘healthy food pyramid’ posters; this is about advocating for a society that takes health seriously. This is not about willpower. This is about incentives. 

This is called primordial prevention, an environment that facilitates better health outcomes by its very design and ensures risk factors for chronic diseases appear later in life and less often. Primary prevention, by contrast, is managing those risk factors when they arise. 

Primordial prevention is the domain of policy and policy can take years. But what about right now? What will you say to the person across from you at your next consultation? Some patients will take your advice on board and act, but unfortunately, they are the exception. 

Most factors that increase a person’s risk of a major chronic disease are things that can be controlled. Although our patients will continue to make poor lifestyle choices, we must recognise the environmental context in which they are made and help guide them as best as we can. As I have learned to say, “It’s not your fault, but it is your problem.” We must help them tackle that problem. No matter what the odds.