Public Health Strategies Part 3: Education

By Steven Hamley

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.   In this post I’ll discuss the strategy of education, which I thought fits nicely into the libertarian left quadrant.  This is because this strategy holds a lack of education and empowerment primarily responsible for people not adopting healthy lifestyle behaviours rather than character defects, and then ultimately leaves the adoption of healthy lifestyle behaviours up to individuals once these educational needs are met

 

Role of Education

In earlier blog posts I discussed how one of the weaknesses of relying on individual personal responsibility is that that strategy depends on individuals having reasonably easy access to reliable information that when implemented would improve their health, substantially reduce their risk of chronic diseases (which I consider as >80-90%), and better treat or even reverse the chronic diseases they currently have

The whole point of improving health is a (reasonable) belief that poor health and chronic disease substantially impairs quality of life, whereas the sacrifices to quality of life in adopting healthy lifestyle behaviours is/should be very small or improves quality of life as early as the day you make them or the following day.  Otherwise, if the costs of adopting healthy lifestyle behaviours exceed the benefits of good health and reducing the risk of chronic disease, then education as a public health strategy is simply one big con

If we assume for the moment that humans are rational creatures, we would therefore make decisions based on objective cost-benefit analyses, and so this shift in favour of healthy lifestyle behaviours in theory should be quite automatic and shouldn’t be too difficult.  However, these analyses depend on our perception on the costs and benefits of various behaviours and our perception is based on our knowledge of the world (perceived cost-benefit).  Therefore, the rationale of education is that providing information regarding the efficacy and implementation of healthy lifestyle behaviours, and the consequences of good health and chronic disease, would shift peoples’ perceived cost benefit analyses in favour of adopting behaviours that improve their health and reduce their risk of chronic disease

You could break down this information to along simple-complex lines and along theoretical-practical lines.  The dietary guidelines are actually a fairly good example of this as they include both a complex 100s of pages long report, and a summary report including how to implement these guidelines.  I’ve included another example of what I’m thinking of below, using the scenario of vitamin K2 for osteoporosis:

Simple Complex
 

Theoretical/justification

 

Stating that vitamin K2 helps put calcium in bones

 

RCT evidence with effect sizes, mechanisms

Practical/implementation  

What foods are rich in K2?

Eat X serves of Y

 

Supplementation, blood tests to measure vitamin K2 status

Health Associations

Here’s the problem, Osteoporosis Australia doesn’t have content on vitamin K2 alongside their content for calcium and vitamin D, and the information they do have only satisfactory checks the simple-theoretical box.  They don’t provide RCT evidence from the vitamin K2 supplementation trials, they say what foods are rich in vitamin K2 but don’t give an indication on how much you should aim for with prevention and treatment (like what they did with calcium and vitamin D), and they don’t inform people on possible blood tests to check for vitamin K2 status.  Osteoporosis Australia also doesn’t have a section for protein (alongside their sections on calcium and vitamin D) which I would think is important considering the popularity of the debunked hypothesis that high protein intake contributes to osteoporosis due to the acid load of protein, despite higher protein intakes actually improving bone mineral density

I’m not targeting Osteoporosis Australia specifically as you could level similar criticisms against just about every other health association.  Many of these health associations provide the earthshattering information that their disease is caused by genes and environment, spread information that is outdated or based solely on observational studies, feature a disproportionate number of recipes for deserts if they have a recipe section, don’t discuss any science beyond the most basic, don’t mention that their disease was historically near absent and near absent in various populations prior to adopting a western diet and lifestyle.  For example, on the Diabetes Australia website you will be told that type 2 diabetes is a progressive disease and see a disproportionate number of recipes for desserts, but won’t be told about superior strategies to manage type 2 diabetes such as a low carbohydrate diet or strategies that have a good chance at reversing type 2 diabetes such as the very low calorie Newcastle diet.  On the Heart Foundation website you will be told that salt is a meaningful factor in the development of hypertension and that saturated fat increases your risk of heart disease, and once again you will see a disproportionate number of recipes for desserts, but you won’t see much on the Mediterranean diet, the PREDIMED Study or the Lyon Diet Heart Study.  On the cancer council Australia website you will be advised to eat a low-fat diet and that red meat increases the risk of colorectal cancer.  You will read about the evils of sun exposure, but won’t be told that vitamin D reduces the risk of other cancers or the possibility of a ketogenic diet potentially improving cancer prognosis.  (I wouldn’t include dietetic associations on this list, as it is clear that their primary goal is to benefit dieticians as a group rather than the health of the general public (they function much like a trade union in this respect))

Suffice to say, I think information regarding health and disease can be substantially improved, and this is a reason why I’ve gone down this path.  I think health associations should:

  • Remove things that aren’t correct
  • Provide information that allows people to increase the number of methods by which they can improve their health and reduce the risk of chronic disease
  • Justify these approaches with evidence, particularly from RCTs
  • Add some clinical information in case that their doctor doesn’t know about the latest research, because otherwise this will be limited to online forums
  • Provide more information regarding the probable causes of disease.  We may not know everything, but we certainly know more than the obvious genes + environment

Education is not Always Sufficient

That being said, we don’t live in an ideal world where education/knowledge is sufficient to cause behaviour change.  I’m sure each of us could identify at least one area of our lives where this is the case.  But most importantly, it’s clear the education has worked in a sense that people know the basics of a healthy lifestyle (fruit and vegetables are healthy and that soft drink and desserts are not, walk regularly and do some moderate to vigourous physical activity each week, and get enough sleep) and have some understanding of their importance (one could hardly go through life and not be exposed to health information via school and the media at least).  However, that so many people are failing at the basics suggests that simply restating the basics won’t achieve much (the anointed strategy of ‘if it fails, just do the same, but bigger’) and also that education is not always sufficient to change behaviour

Some of the reason for this is that we are wired to be more like instant gratification monkeys rather than deeply logical and rational robots.  In fact this acknowledgement of our own irrationality and impulsivity is something I think that’s missing from health education and education in general*.  Many healthy lifestyle choices require a sacrifice of instant gratification now for a larger payoff in the future.  The way that that health information is presented doesn’t help this as the benefits of a healthy lifestyle is discussed in terms of risk while rarely providing information regarding the magnitude of risk reduction.  Our environment doesn’t help either, as maintaining good health and a healthy weight requires consistently making more effortful and less hedonistic choices such as the purchase of blander and less well marketed foods rather than hyper palatable, high reward and well marketed foods, as well as doing some exercise, meditation or going to sleep when something on the computer or TV is more engaging, etc**

* Something else I think that’s missing from health education is dispelling people’s beliefs that they are healthy when they’re not, although I appreciate that telling people that they’re fat, sick, instant gratification monkeys is a hard sell, but it’s probably necessary.  A recent report found that about 50% of Australians heave a chronic disease and 63% are overweight or obese, but 85% said they were in good or excellent health [1]

** I consider the environment to be the most important factor regarding health.  Remember, I don’t believe in free will, and consider everything to be a consequence of genes + environment, and our genetics haven’t significantly changed in the last few decades.  But I don’t think that a substantial change in the environment (like a regression back to the 1950’s or earlier) is a feasible public health strategy because we want cheap delicious food, labour saving devices and entertainment.  We can make some changes to incentivise healthy lifestyle behaviours (such as a user pays healthcare system and taxes/subsidies) and ban the worst offenders that no one really wants (industrial trans fats).  Beyond that, it’s really up to education and having people create their own micro-environment that promotes health

Targeting the Early Majority

In addition, while it’s probably politically incorrect to say so, some people just don’t care about health, and all the health education in the world isn’t going to change that.  Smoking has had many strategies used against it (education, taxation, bans, stigma, graphic images to invoke disgust, nicotine patches, support for quitting, etc) but people still smoke anyway, much like how people know various crimes are wrong but still commit crime anyway

The following graph is the prevalence of number of healthy behaviours in the US (not smoking, ≥7 hours of sleep, moderate or no alcohol, met physical activity recommendations, normal BMI) [2].  It may not seem too bad, but diet isn’t included, and “76% did not meet fruit intake recommendations, and 87% did not meet vegetable intake recommendations” [3] (similar to “…95 per cent of Australians did not eat the recommended servings of fruit and vegetables” [1]).  There is an explanation for everything, in this case, our high incidence of overweight/obesity and chronic disease.  We are only as good as our weakest link so unless you won the genetic lottery, you will need to do them all

I think you could draw a parallel between the theory of diffusion of innovations, the prevalence healthy lifestyle behaviours, and health consciousness and consequently the receptivity to health education/information

Innovators + early adopters = highly motivated by health (4/5 – 5/5).  These people will seek out health information beyond what is provided by health associations.  Public health doesn’t need to target these people, but providing more complex information will make their research more convenient

Early majority = fairly motivated by health (3/5 – 4/5).  These people are fairly receptive to health information but health education may need to be improved to sufficiently inform, motivate and empower them (such as changes suggested here, plus others I haven’t thought of).  Since the theory of diffusion of innovations suggests targeting the early majority and this group is fairly receptive to health information, I don’t think health associations/etc should be too concerned with providing more detail, depth and complexity than the bare minimum

Late majority: not very motivated by health, but not a disaster either (2/5 – 3/5).  Once the early majority has adopted more healthy behaviours and become healthier, and such things have become normalised, the late majority will see that such behaviour change is both feasible and a net benefit to their life.  We might then see a social contagious model of health rather than one of obesity [4]

Laggards = doesn’t really care about health (0/5 – 2/5).  This group can get some rare and awful health scares, but these health scares rarely change behaviour.  Other strategies are probably more productive if you want to improve the health of these people (see next post)

You can read more on Steven’s work HERE