(In this article, part of the Communi-action Series, we examine why despite so much communication about these issues people are still laggard in changing dietary habits and physical inactivity. This article can be read in conjunction with the article “#1 Killer of women (NCDs)” and “The Gift of Goffman” article on importance of everyday life in determining our behaviors.)
Chronic diseases or non-communicable diseases have increased dramatically in the past few decades (see data in article “# 1 Killer…” in this issue). Experts find the root cause of rise in non-communicable diseases in our time to be our modern lifestyle –inappropriate diets, junk food, improper eating habits, sedentary jobs and physical inactivity.
Obesity has reached epidemic proportions globally, with at least 2.8 million people dying each year as a result of being overweight or obese. Once associated with high-income countries, obesity is now highly prevalent in low- and middle-income countries. We live in a perfectly imbalanced world with about half the world suffering from overweight or obesity while half the world remains underweight or malnourished. Physical inactivity is the fourth leading risk factor for global mortality. Increasing levels of physical inactivity are seen worldwide, in high-income countries as well as low- and middle-income countries.
Despite many attempts at communicating to and educating people about the importance of taking steps to improve diets and increase activity, most people in the world do not seem to comply. Occupation, social standing, income does not seem to matter – people across different social groups find it difficult to change behaviors. So we talked to people about why they did not exercise or change dietary habits.
Plenty of reasons were given for not taking up physical activity; but top of the list happens to be “lack of time.” Most people in cities and urban areas cited time constraints as the primary reason for not engaging in physical activity; they just could not fit physical activity into their daily timetables. Even a 20 to 30 minute walk in the morning or evening seemed difficult to fit into their schedules.
We probed further. Some of them said there were no parks or walking spaces in their neighborhood. So we said: All you need is a road (to walk on). People mentioned the congested traffic; some said dangerous traffic and blamed cars and all sorts of vehicles, with or without an engine. In developing countries, where traffic rules are seldom followed, some of these fears are real.
What about late nights? There is no traffic at that time, we persisted. And not just the women, but also men (almost all) talked about crime and safety.
What emerged as one of the reasons for not engaging in the simple act of walking was the concern about safety! Thus, physical activity or the lack of it was connected with the issue of physical safety. We seem to think: If my physical body is endangered in my attempt to be physically active, then I choose to retain my physical body with all its possible problems and not put its physical safety at risk.
Is there a primal instinct at work here? Surviving comes first; we will worry about thriving later.
Interestingly a few of the (inactive) persons we interviewed live in an area with a six-acre park right across the road from their apartment block. One person tried to brush off the subject by seeking digression through humor, “I don’t go jogging in the park because even after I stop, parts of my body still keep jogging”. It is not that these rationalizations are coming from people who feel that the need to exercise is being thrust upon them. These are coming even from people who themselves want to shed their excess weight and keep talking about it or ruminating about it.
So we kept digging.
And then the ONE answer that emerged was that lack of time arose from people’s daily timetables which were packed with only those activities that helped them earn some more money. The priority and pre-occupation for most people – rich and poor – was to earn money. In our daily lives we have prioritized all and only those actions that would lead to the generation of money. At the heart of it was the firm belief that only “money” would give them security. Money would lead to both goals: it would help them survive and it would also help them thrive.
Therefore, the 24 hours of the day had to be maximized in such a way that the maximum number of hours was spent in gathering this one “factor” this one “thing” that would address both issues – survive and thrive.
In fact even our leisure times are marked by those activities that require the spending of money and demonstrate our economic power. Thorstein Veblen and other sociologists have pointed to conspicuous consumption as a way of demonstrating economic power and social standing. Thus, socially money has become the soul of our society.
One person said that modern society (urban and rural) has been structured in such a way that each individual human has to give the most attention to his or her ability to garner this one resource that will solve all the problems of living. It may not buy love but money can pretty much buy everything else.
The only commodity that is distributed equitably across all social groups – rich or poor – is TIME. Everyone who is alive and will be alive at the end of the day has 24 hours at her or his disposal. In a strange way this one commodity had become intricately connected with MONEY. The time at one’s disposal was seen as fruitful or useful or good only if one could use this resource to make money because money has come to underlie every other aspect of life and living.
Then we asked: Do you not want to be healthy? What will you do with all the money if you become sick? We showed people the data on non-communicable diseases. We showed them the health consequences and also discussed the financial consequences of becoming sick with a disease such as diabetes. Given the high cost of health care; if we earn money only to lose it to a hospital because we become sick in the process of earning it, then what sense does it make?
The unanimous response that came forth with respect to physical activity was: “If someone comes into my house and makes me start exercising, I will probably do it.” Some people said, if you disable the elevator in my office building, probably I will start using the stairs.”
The same thing was said for consuming healthy foods: “If you put it in front of me, I will eat it.” If you ask me to take time to go to the markets and purchase the food or take time to prepare the foods and so on, I will not be able to follow your advice.”
(for more on these exercise machines of the late 1800s – see Gustav Zander in references)
JUST MAKE ME DO IT
We need a push. Not a nudge, not a poster, not a TV commercial, not a reminder, not a text message or a phone call. But literally someone to push us to exercise – someone who will come into my house and drag me out to run or walk AND later come into my house, take over my fridge, put the healthy food in front of me.
Does that mean we are essentially lazy?
Not necessarily. The same person who does not exercise may actually be one of the best workers in the office. There is a mismatch or discordance between these healthy behaviors of everyday living and our priorities in everyday life.
People also seem to have reached a point of fatigue with respect to health messages. There are simply too many messages, which may often be contradictory; they are hard to comprehend at times and difficult to remember:
‘Eat fruits, but do not drink juice.’ — ‘Don’t eat sugar’ but desserts are served in the office cafeteria. ‘Be active’ but then there is no place to walk on the streets.
The messages for health are too many – too confusing and then whatever the health messages ask us to do in terms of behaviors, appear too cumbersome to be practiced in reality.
I do not have time for healthy practices even though I know many of them – when do you think I will have time to read all the messages, understand them and put them into practice.
“Brush your teeth every day” became a simpler message to follow only when private sector companies started advertising the aesthetic, social and romantic values of clean teeth and flooded the market with their toothpastes.
“Practice yoga or exercise for at least 20 minutes any time of the day” will become an easy message to follow when the concomitant changes are made in the environment – whether by government or the private sector.
Why is self-regulation of behaviors – that are so important for our health and survival – so difficult to do? There are two aspects that we would like to discuss because what we interpreted was that essentially our participants and respondents were saying: “Just make me do it. Just force my hand. Until you can change my prioritization pattern and build my environment, just come into my home and make me do it. –
First, there is a strong environmental component in all of our behaviors, especially the behaviors of everyday living such as diet and physical activity.
Although we spoke only to individuals; and though it is important that we take responsibility for what we eat and what we do – it would also be wrong to blame only these individuals for their behaviors. Governments, markets, private companies and sector, civil society, non-governmental organizations all have vital roles to play in contributing to obesity prevention through better eating habits and more physical activity – EVERYDAY.
Our environment plays a huge role in determining our daily practices. Just think of countries that have litter-free roads versus countries where the streets are dirtier than a trashcan. The same person who lives in a dirty country starts behaving like a concerned citizen and throws trash in the proper places when he or she travels to a country where the streets are clean. The behavior of throwing litter on the streets is not coming from within the person but it is the environment of the country that determines the sanitary actions. It is the availability of trash cans in the proper place, the implementation of rules and laws and fines by the government and the culture of cleanliness that pervades a country. These are all part of the physical, social, and cultural environment of a country that has prioritized cleanliness that determines an individual’s behavior. On the other hand, the phenomenon of “broken windows” applies in the context of the dirtier country. The individual sees trash littered all around and reckons this is a license to do the same and thus the dirty environment, the lack of rules only perpetuates the wrong behaviors. The same applies to healthy foods and physical activity.
There is a growing focus within the public health sector on examining the built environment and the role the built environment plays in improving health outcomes. And therefore, the design of spaces has come to play a big role in the health sector.
It is important to remember that behavior change, especially for diet and activity has been difficult even when governments have tried to change policies. For instance, sometime in 2011, the country of Denmark imposed a tax: a tariff on saturated fats. However, it soon went on to become one of the most disliked taxes by farmers, retailers, manufacturers and interestingly consumers. The thought behind it was simple: Increase taxes on unhealthy, fatty food to increase the price at the cash register. This would mean that people would buy less unhealthy food items and this in turn would reduce obesity and the subsequent non-communicable diseases improving the health of the population. This has been tried with cigarettes. The food tax in Denmark not only hit junk foods such as potato chips but also high-end cheeses. The taxation structure was complicated. And most importantly, families just went across the border to neighboring countries to do their shopping for unhealthy, junk foods and drinks. Apparently, these shopping trips cost the Danish Government nearly 2 billion dollars in lost revenues.
The tax was repealed almost within one year.
Some complained that “money” (and its synonym – economy) was prioritized before health by the politicians.
Dubai tried giving gold to its citizens as an incentive to make them lose weight. In a country where more than 50% of citizens are said to be overweight or obese, this was part of a larger effort of the United Arab Emirates (UAE) government to help improve health and reduce the burden of non-communicable diseases. The government of Dubai launched a weight-loss challenge program in the month of Ramzan (Ramadan) in 2013 titled: “Your Weight in Gold.” For every 2 kilograms lost (about 4.4 pounds), the individual stood to win two grams of gold. The results of this experiment are not out. But it’s another case of money used as an incentive to promote health.
Environment change through policy measures for ensuring better diets and activity is still in a nascent stage and it is probably too early to say if the experiments are failing or succeeding.
The second aspect we want to discuss is the priorities of daily living. We seem to prioritize based on our immediate needs and based on what makes us feel better about ourselves. We are all addicts in that sense – we are addicted to what makes us feel better. We are addicted to what makes us feel good about ourselves. And sometimes good diet or activity may not be the factors that make us feel as good as being busy or earning more money.
“‘Busy’ used to be a negative sort of word. It meant having no time for self, no leisure. Now, though, busyness is bullish, conspicuous industriousness is the rule.” said Richard Stengel, who has been an editor of Time Magazine.
Stephen R. Covey in his book ‘First Things First’ terms it as ‘the urgency addiction’. He goes on to explain that many important things that contribute to our overall objectives and give richness and meaning to life don’t tend to act upon us or press us – because, they are not ‘Urgent’. As a result we tend to devote maximum time in dealing with matters that are ‘Urgent and Important’ and push back the actual, advisable approach of concentrating first on issues that are ‘Important but Not Urgent’.
The environment of the human being has changed drastically in the past couple of centuries. From a normally active everyday life, humans have taken to sedentary jobs and leisure time activity such as TV-viewing. Our diets and our bodies were built to survive scarcity. However, now our world has changed. If we are to live longer then we have to pay attention to our diet and activity. Thus, it would seem that survival in the contemporary world requires us to change our ways of being and behaving. However, people’s behaviors seem to be contrary to what is required for survival in this era. As one of my colleague’s daughter used to say: “There is healthy food and then there is tasty food, which includes all the junk food, burgers and pizzas. I choose tasty food.”
How does the individual choose what is important? Is communication through posters, pamphlets, television commercials and newspaper advertisements adequate or do we need to go beyond mere communication of health messages? If we believe that individuals make independent choices that help shape their history then who will help the individual choose the “important” things in life – parents, peers, schools, communities, media, other societal institutions including religion, governments, markets? After all, an individual still remains a product of his own society and time OR can an individual transcend his own time and society and do things differently? Despite all the knowledge that we have at our disposal in this Age of Instantaneous Information – the regulation of human behavior still remains a mystery.
© Nilesh Chatterjee & Dharmendra Singh.
Worldwatch Paper #150: Underfed and Overfed: The Global Epidemic of Malnutrition
Denmark’s Food Taxes (Fat Chance). From http://www.economist.com/news/europe/21566664-danish-government-rescinds-its-unwieldy-fat-tax-fat-chance
Dubai paying citizens gold to lose weight in fight against obesity
About Gustav Zander (read links below):