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



Stating that vitamin K2 helps put calcium in bones


RCT evidence with effect sizes, mechanisms


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

Public Health Strategies Part 2: Personal Responsibility

By Steven Hamley

If you find one of the ideas in these posts on public health strategies objectionable consider waiting before jumping to conclusions because I may address your concerns in a later post

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 personal responsibility, which I thought fits nicely into the libertarian right quadrant.  This is because personal responsibility is a key value of the political right, and because personal responsibility is a strategy that maximises individual freedom and ultimately limits the influence of government and others

It’s tempting to blame what’s called the obesogenic environment (which is a decent point I’ll discuss later) and ‘evil corporations’ for the rise in obesity and other chronic diseases across the globe.  Similarly, because free will cannot exist, one could justify playing the victim, that they are not personally responsible for the bad things that happen in their life including their poor health behaviours and health status, that they are a victim of being born to the wrong parents and living in an obesogenic environment.

As discussed in the previous post, even though free will does not exist there is value to society and us as individuals to emphasise a belief in personal responsibility.  We have plenty of options to make healthy or unhealthy lifestyle choices; we all know the basics of what to do to improve our health (that whole foods are on average healthier than highly processed foods and that getting enough exercise and sleep are important); and no one has a gun to our heads forcing us to make the wrong choices.  The blaming of business is not really appropriate (except when they distort science and engage doctors/dieticians for hire) as businesses cannot force us to purchase their products (unlike government), but instead they are reacting to what consumers want when they decide to open more stores and make more products (supply and demand).  In addition, there should come a time when people realise that although playing the victim may give you an excuse and sympathy in the short-term, but in the long term others will become desensitised to the strategy such that it no longer has the same effect, and is ultimately unproductive as your problem will remain until you take active steps to fix it.  In this respect, holding yourself and others personally responsible is more empowering than wallowing in self-pity

The efficacy of personal responsibility as a public health strategy is difficult to assess.  Some people may argue that it’s the status quo and so is failing as a public health strategy.  However, I don’t think this is completely true

1) Taking personal responsibility for your health isn’t as incentivised as it could be.  Most Western countries have some degree of universal healthcare, health insurance, subsidised pharmaceutical drugs, and government funding into the basic sciences that can lead to drug development.  These policies and institutions mean that individuals and not completely financially responsible for the costs of poor health resulting from poor lifestyle choices, and the financial costs are instead shouldered by others to varying degrees in the form of more taxes, or from funding being taken away from other public services.  Under such conditions it would be expected that individuals would be less motivated to prevent and treat diet and lifestyle diseases themselves by improving their diet and lifestyle

2) Our society’s narrative on ageing and chronic disease is one that emphasises an inevitability of chronic disease and the role of bad luck, rather than personal responsibility.  I think some of this narrative is to protect against blaming and shaming when people are at their most vulnerable, but it has the unintended consequence of fostering a belief that humans are broken and creating a sense of hopelessness

So the potential of personal responsibility as a public health strategy is not likely to be realised in a society that has universal healthcare, social norms against personal responsibility and a pessimistic attitude towards ageing and chronic disease.  So the strategy of personal responsibility should be coupled with:

(1) a major change in universal healthcare, or at least the addition of a mechanism that incentivises people not getting lifestyle diseases/adopting good health choices (focus of the next post I have planned); and

(2) a change in society’s narrative of chronic disease to one that empowers people

The second point illustrates a weakness with personal responsibility as a public health strategy.  Which is that it requires that people either know or have readily available access to the knowledge that will allow them to make the healthy lifestyle choices that will dramatically reduce their risk of chronic disease or in other cases treat or reverse existing diseases.  Some of this knowledge is already widely known, but most people don’t know about even well supported interventions (such as very low calorie diets for type 2 diabetes, vitamin K2 for osteoporosis, and higher protein diets for fat loss and sarcopenia) and there will almost certainly be more options available that no one knows yet until more research is done.

Part 3 of this Public Health Strategies series coming soon.

Steven Hamley is a PhD candidate at Deakin University in Melbourne. His research project is on the prevalence of pre-diabetes and insulin resistance in healthy young adults and the relationship these have with body composition, diet, metabolites, and alterations in insulin signalling.

Steven will be speaking at the upcoming AHSNZ Symposium 20-22 October 2017. His presentation is titled Insulin Resistance: the Elephant in the Room of Chronic Disease.

Part 2: Addressing 21st Century Excesses and Deficiencies

This post follows on from Part 1 – On 21st Century Excesses & Deficiencies.

Dr Karen Faisandier gives her thoughts on how to restore yourself to your most optimal level of wellbeing after physical and mental health difficulties, using a range of nutritional and lifestyle interventions. 

Symptoms of physical and mental health difficulties often co-occur via the gut-brain-axis (because your body is not separate from your mind), and therefore integrative solutions are often required (Greenblatt & Brogan, 2015). So when the gut-brain-axis has been compromised (read Part 1 all about this if you haven’t first), and is causing ill health, it often requires a considered effort to return to a state of wellness. At the end of my talk, an audience member aptly asked me the question, “But how do I actually do this?” This question stayed with me for weeks afterwards with thoughts about how hard it can be to recover your wellness when you’re physically and mentally symptomatic, especially when you don’t have energy, don’t have sufficient time or resources, and have an absence of support. So the following is my considered response to this compelling question.

An Intricate Jigsaw Puzzle

When you encounter chronic physical or psychological difficulties, there are many multifaceted pieces to find on the road back to wellness – much like a jigsaw puzzle. Sometimes you’ll find the right pieces yourself, sometimes you’ll need a hand, and sometimes pieces don’t fit. Sometimes you may want to give up – it seems too hard or you’re too unwell. Sometimes a piece may go missing, or you need a break from looking, or bits you’ve started have to be re-done. Along the way you may feel frustrated, impatient, elated, renewed, empowered, or like you’’ll never get there. Your world view can be forever changed by the experience and new values and boundaries may develop around your health and wellness.



Anyone who has any experience with doing a jigsaw puzzle will know that in order to get anywhere (and not become extremely frustrated and give up) you need to have the picture on the box to guide your process – this is a reference point. In healthcare, this picture is analogous to an evidence base, which also requires a strong therapeutic alliance with the practitioner you work with (e.g, the degree of trust, compassion, and credibility they bring to their work). Everyday in my job, I sit with people who are working out the pieces of their own puzzle, and I am tasked with providing them a robust picture on a box and compassionate guidance. In recent years, more and more of the pieces of the picture I provide have revolved around nutrition, gut health (gut-brain-axis), and lifestyle design, alongside traditional psychological and therapeutic models.

If you have had to work out your own puzzle (or are still working on it) because of chronic illness, this process usually involves a philosophical shift and a journey – it took you time to arrive at this point and it will also take time to learn and apply what’s needed for your recovery. This journey is yours alone and won’t look exactly the same as anyone else’s. Hence, my key points in maintaining or resuming an individuals gut-brain-axis health involve a broad and individually tailored approach. This applies whether you simply want to learn how to stay well or whether you have experienced a health crisis that has required you to sit up and pay attention to your body. If this is you, and you notice a sense of overwhelm or resistance to what this journey might involve, just choose where you want to start and do what you can. It is the journey itself that matters and this requires both knowledge about, “What it takes” and an understanding of, “How to do it”.


“The known is finite, the unknown infinite.”

                                                           ~ Thomas Huxley

What it Takes

Having attempted to boil everything down simply (I am a minimalist at heart), I fitted onto one slide all the vital components of maintaining or returning to a well functioning gut-brain-axis.  In an even further reduced form, my core message is this: Find ways to dampen the stress of modern living on your body and mind, in whatever form these stressors take for you. Of course, having identified these is the easier bit – the devil is in the details.

Seven Thoughts on “How to do it”

1) Some things are in your control

The choices you make (nutrition and lifestyle) have a significant effect on the route your path will take when it comes to your physical and mental health.  In this model, you can avoid, treat or lessen symptoms through addressing the excesses and deficiencies you are bombarded with daily, to support your gut-brain-axis. And even more importantly then simply reducing symptoms; you can function optimally, as you were designed to.

2) Find your people

Find your people – a journey can be less arduous and lonely if you have other people for the ride. We need others – good attachments are so powerful that they are found in studies to offset our stress response, reduce the experience of pain, and promote wound healing (Cassidy & Shaver, 1999). There are now many local groups interested in community and wellness – the AHSNZ is one such group who provide social media connection and local events (not to mention an awesome international Symposium coming up later this year). Work with health practitioners that you feel heard by, can trust, and who have a sound philosophy and evidence base that informs their practice (Note: sound evidence is more than randomised control trials alone). Notice who uplifts you in your family and peer group and find those who are likeminded and supportive of your intentions. If you don’t have this important component, connect online and find a suitable tribe that way.

3) Just take one step

Remind yourself that you can only do what you can do – especially when you are unwell. Start small and take one step, whether that step may be deciding to work with a health professional, informing yourself by listening to an educational evidence-based podcast like Revolution Health Radio (Chris Kresser) or ancestrally oriented health podcasts such as The Primal Shift orHarder to Kill Radio. Or read some guiding “how to do it” books like The Ultramind Solution (Hyman, 2008) or A Mind of Your Own (Brogan & Loberg, 2016).

4) Address excesses

Build on each small step with one more – the benefits will accumulate. For the excesses you face, which perpetuate a stress response, it may be cutting down and stopping coffee for a month to observe positive changes to your anxiety, stress, energy and sleep. It could involve committing to a break from alcohol and noticing the effects on your physical and mental health (especially sleep and mood quality). It could be getting a relaxing, pleasurable, and screen-free evening routine to optimise your sleep (e.g., using a website blocking App like this to externally control use of social media). In my house, I often do technology-free Sunday’s. Every time, after the first couple of hours of device-checking withdrawal, I feel fundamentally changed from a state of busy ape-brain to feeling content and more present.

5) Address deficiencies

To deal with the deficiencies that we all face to some extent, start with adding in as much nourishing food and good hydration as possible. Optimal nutrition involves an individually tailored approach as everyone is different, but as a general rule, focus this around food that was recently alive (i.e., not in a packet), seasonal fruits and vegetables (organic where possible), nuts and seeds, and well treated animal products. The macronutrient balance you eat matters to your wellbeing – so having sufficient protein, good quality fats (e.g, olive oil, avocado, coconut oil, animal fats), and complex carbohydrates for you is important to maintain a stable blood sugar, make hormones and neurotransmitters, and support adequate energy production. Research evaluating nutritional interventions as a clinical psychology treatment for psychological difficulties is being produced through the Food & Mood Centre in Australia, led by Dr Felice Jacka.  This research is in its infancy; however we know enough to advise that nutritional interventions like that outlined above are low risk, accessible, affordable interventions people can investigate, and that an improved diet is associated with lowered rates of anxiety and depression, and improved brain functioning.

If you have more complex gut health issues to contend with then you will likely require working with a health practitioner (my clients often work with my naturopathic colleague alongside me – the very lovely and skilled Felicity Leahy), and having some tests to rule out commonly overlooked deficiencies like B12, Folate, Iron, and Zinc. You might consider appropriate supplementation to boost any nutrient deficiencies up to optimal levels (e.g., this is particularly the case in adrenal and other hormone dysregulation, gut health issues where absorption is impaired, or if vegan or vegetarian). Nutriceuticals (vitamins and minerals) can be important in mental health treatment, and research supports the specific application of these for different types of psychological concerns like ADHD, stress/anxiety/mood after trauma, and insomnia (check out this trailblazing research via the Mental Health and Nutrition Research Group).

Another deficiency I see regularly in our current time, where we are caught up in the constant treadmill of society, is of people not being present in their own lives. Our minds take us into our past and ahead into the future, so much so that we often struggle to sit in the experience we have now. Thus, it can be revolutionary to discover and practice your own brand of mindfulness. Note that the definition of mindfulness that I subscribe to is not about reaching a zen state, but about being able to be compassionately present with your experience, and to do what it takes in that moment to head towards what is important to you.This can involve focusing on your breathing (which itself can shift you from the stress response into the relaxation response), ‘unhooking’ from thoughts, allowing difficult emotional or physical experiences to come and go, or a formal practice that could involve physical components (e.g., kundalini or yin yoga or mindful time in nature).

6) Shape a new lifestyle philosophy

Chronic physical or mental health problems often require that certain difficult questions be confronted, and these are questions that come up all the time in my practice as people attempt to make sense of their situation and find their way to wellness. Have you ever asked yourself these questions?

  • How did I get to be unwell?
  • How do I want my relatively short time here to be spent? (e.g., Stats report we spend an average of 50 minutes face-booking per day – that’s a lot of time lost into the mindless abyss: What else could you do with that time?).
  • How do I want to treat my body and mind?
  • What health behaviours do I want my children to learn from me?
  • What really matters to me – what’s the point of all this?
  • If I did change my health behaviour – what would motivate that change – e.g., children, finances, relationship, sustainability/ethical values, confronting death or disability? Use these values to leverage your motivation.

7) Avoid perfectionism in the quest for health

Importantly, be aware that your expectations, personality traits, and the drive towards perfectionism in health may also maintain a state of unwellness. Orthorexia Nervosa is not an official diagnosis but has recently been used to describe the experience where someone has fixated on rigid eating and lifestyle rules. This is different to choosing to follow a specific food protocol for a health condition (e.g., gluten-free for coeliac disease) or having a passion for a consistent healthful routine. In the quest for optimal functioning after a period of chronic ill health, while you can continue to strive towards recovery, the mantra of “good enough” may be more health-inducing then aiming for “perfect.” “Perfect” is often obsession or anxiety driven and can perpetuate a stress response in its own right.

Thanks to all the attendees who came out in the wake of the November earthquake to gather with us and converse on all things women’s wellness.  Getting to partake in this event with my co-presenters was a huge honour and I look forward to speaking at further events with the team at the AHSNZ – especially the 2017 Symposium in Queenstown October 20-22nd.  The topic I am speaking on will be released very soon and involves a focus that I’m very excited about pulling together between now and October

Brogan, K., & Loberg, K. (2016). A Mind of Your Own: The Truth About Depression and How Women Can Heal Their Bodies to Reclaim Their Lives. New York: HarperCollins.

Cassidy, J., & Shaver, P. R. (Eds.). (2016). Handbook of attachment. Theory, research, and clinical applications (3rd Ed.). London: The Guilford Press.

Greenblatt, J. M., & Brogan, K. (Eds.). (2015). Integrative Therapies for Depression: Redefining Models for Assessment, Treatment and Prevention. CRC Press.

Hyman, M. (2008). The ultra mind solution. Fix your broken brain by healing your body first. Simon & Schuster.

The Primal Shift Interviews AHSNZ

In late January, the President and Vice-President of the Ancestral Health Society, Jamie Scott and Dr Anastasia Boulais, were fortunate to grab a few hours with Jo and Crystal – two-thirds of the Melbourne-based The Primal Shift team.  During that time, between the sharing of good food and good coffee, The Primal Shift team recorded an interview with Jamie and Anastasia, discussing, amongst many things, the upcoming Wellington and Queenstown conferences.

Listen here: TPS 40: Modern Living & Ancestral Health with Jamie Scott and Dr Anastasia Boulais