I got a new watch for Christmas. It tells me how far I walk each day, how many calories I burn off through movement and it reminds me to stand up and move around every hour. It rewards me when I meet the targets set for me each day and quietly ignores me if I don’t. This is one of the many hundreds of apps available to us on phones, tablets and, increasingly, on body worn devices. We can measure our BMI, count calories, track the speed and distance we run, walk or cycle, monitor our blood pressure, play tunes to let us know how long to clean our teeth for and perform countless other acts of self-surveillance. We are also being encouraged to share the data we create with friends, posting maps of our runs or step counts on social media. Does the rise of the app represent a triumph of libertarian paternalism in the form of nudge-based public health interventions?
On the 4th January Public Health England launched their new sugar smart app. It was widely publicised in the press and on the television and made it onto the hourly bulletins throughout the day on the BBC. The app is part of a new development in the long running Change4Life campaign called under a strap line of Eat well, Move more, Live longer, providing advice about food choices, sugar and fat as well as about exercise. The app appears to draw on Richard Thaler and Cass Sunstein’s ‘nudge’ theory, which states that people will change behaviour and make ‘good’ choices if these choices are made easier. Thus a simple app which uses the phone’s camera to read barcodes provides instant information on sugar content on which we can make choices, and highlights hidden sugars we may not have been aware of. The packet of crisps I was planning to eat with my lunch contains 0.9 sugar cubes.
The link between sugar consumption and oral health is well known and documented. In 2013 a survey commissioned by Public Health England found that 12% of 3 year olds and over a quarter of 5 year olds in England had tooth decay. NHS data suggests that this leads to thousands of children having teeth removed by general anaesthetic every year, leading to renewed calls for a reduction in consumption of sugary foods and drinks, and starting tooth brushing at an earlier age. The link between sugar consumption and other non-communicable diseases has also been widely made.
In 2011 the United Nations declared that non-communicable diseases now pose the greatest risk to health globally, with cardiovascular disease, cancer, chronic lung diseases and diabetes accounting for 60% of deaths across the world. A 2012 study published in nature by Robert Lustig and colleagues suggested that sugar poses a risk as great as alcohol to population health, in terms of its link to rising rates of non-communicable diseases, and should be tackled through implementing age limits, raising prices and limiting sales of high sugar foods and drinks. In the same year an OECD report stating that English children are amongst the most obese in Europe led the then shadow health secretary Andy Burnham to call for a ban on high-sugar cereals.
That there is evidence of a link between sugar consumption and health seems relatively uncontroversial. How to tackle the problem remains more challenging. The form of libertarian paternalism advocated by the ‘nudge’ theory can be seen in many of the health-related apps that we are increasingly adopting, making it ‘easier’ for us to take responsibility for our own health. And these apps are getting ever more sophisticated, collecting large amounts of personal data which may or may not be accurate and can be shared, with family, friends and potentially by big data healthcare companies. Whilst heralded by some as a step towards more effective personalised medicine, some concern has been raised about the potentially damaging affects of constant self-monitoring.
A recent paper presented at the British Sociological Association Medical Sociology Conference by Aksel Tjora (Sept 2015) suggested not only that the proliferation of wearable health technology and apps would increase the number of worried-well citizens, but that it would also lead to larger health inequalities. Large companies are looking to develop apps which monitor our health. If these become mainstream and are adopted by health professionals then those who cannot afford the devices on which the apps run will be excluded, thus further compounding the exclusion of those living in poverty, people who are already amongst the most vulnerable to poor health.
Therein lies the crux of the problem – most, if not all, of these health issues that we seek to address by counting and measuring with our health related apps cannot be reduced solely or even mostly to individual behaviour alone. Social determinants, inequality, poverty and so forth all play a significant role in shaping the ways that we behave. These apps, the product of a marketised society with inequality at its heart, could compound the problems we face as a society rather than alleviating them if not used with care.
And what about the worried well? Big brother doesn’t really watch us anymore, he reminds us to watch ourselves. We count, compare and judge ourselves and often we find ourselves wanting. My new year’s resolution is to be a bit kinder to myself. Yes, I will try to get a bit more exercise, eat less processed food, get things ready for school and work before I go to bed so that mornings are less hectic and so forth. But I’ll also try to worry less, prioritise the important things and stop comparing myself unfavourably to other people. I’ll stick with my new activity app for a couple of weeks, if I keep meeting my targets (targets I set myself) I may continue, if not I’ll turn it off. How about that for taking control of my health?!