Monday, November 9, 2015

Apps, Attention, and Obesity

At one point in my career, since I have a strong background in nutrition (I am a Fellow of the American College of Nutrition and was board certified in clinical nutrition) I thought I would make my fortune by writing the ultimate diet book.  It was really very simple.  On each page I would print the following message:

Of course that was many years ago and now the current version of my book is achieved by creating the ultimate weight loss app.  The many apps that have appeared are as equally effective as my book concept would have been.  Or so it seems in a very nice study this month in the journal Obesity.  The Duke team, one of the best in the country in treating obesity, investigated whether apps on a cell phone helped young obese adults lose weight.  The answer was no.  In their words, “this behavioral intervention did not lead to significant weight loss relative to control at any trial time point.” 

In some ways, this is not surprising.  Shlomo Benartzi, author of the book, “The Smarter Screen” and a professor and co-chair of the Behavioral Decision-Making Group at UCLA’s Anderson School of Management, makes the point that computer screens, or cell phone screens are “changing the way we think making us more impulsive and reactive.”  For behavior change to occur especially when it comes to overeating, becoming more impulsive is not likely to drive a successful strategy.  He notes, that “people think faster on screens, and this can lead us to become more reliant on our instinctive responses and initial impressions, even when they are misleading and incorrect.”  So while the app may tell you that you are eating too much, it is unlikely to drive behavior to make you eat less impulsively. 

I can have multiple apps on my cellphone, to manage my diet, my activity, my sleep, my heart rate, my medications, and my medical records.  Many of these apps are based on the theory that people just need more information about what they are doing and how they are doing it in order to change.  The most elegant apps (technologically) also send messages to your doctor or to a nurse if you or your numbers are out of line.  However the question is whether all these fragmented sources of personal information actually help us to modify our behaviors. 

This focus on making it simple to keep track and give us feedback on our own activities appears on face value to have some benefit.  We can potentially be able to keep records and “share” the information with the doctor or a nurse who can then intervene.  However it also can create information overload for both the person who owns the device and the health professional expected to intervene on the basis of the information.  Benartzi points out the experience from the VA Health System which has wonderful alarms within its medical records which doctors routinely ignore because there are too many alarms and too little time and attention.  It turns out that too much information – too many alarms – leads to a “scarcity of attention” – a term used by Benartzi – and that scarcity is amplified in our screen based world.

Benartzi compares our new use of apps and computer screens to Adam Smith’s treatise “The Wealth of Nations” written in the early stages of the Industrial Revolution.   He writes, “While Smith associated scarcity with a lack of material resources – during the Industrial Revolution, people needed more coal and wood and land – the most important scarcities of the information age are psychological, and caused by our new abundance of information. “ 

When I was a health consultant, advising the Fortune 100 companies on the health programs they put in place for their employees, I would often point out that they were spending huge sums of money on multiple health programs which ranged from weight loss, to stress management to disease management to pharmacy management, each with their own separate information and interventions for their employees and the employee’s families.  I would then tell them that the only thing that they were actually achieving was confusing the hell out of the same people they were trying to influence and whose behavior they were trying to change.   While at that time I admittedly did not know all the decision science behind my consulting point, it turns out that what was obvious to me has now been proved experimentally in numerous studies. 

In the world of apps, it is hard to have a full picture of the person trying to make the behavior change.  Life circumstances may make good diet and exercise virtually impossible due to competing priorities, financial and time constraints, and emotional factors.  It is virtually impossible for an app alone to address these points that are unique to each individual and that are often constantly changing. 

In the article on cell phone weight loss apps, the Duke team makes the point that behavioral change principles are often absent in the app based commercial obesity products.  Current obesity treatment guidelines recognize the need to evaluate optimal frequency and duration of contact on an individual basis which is hard to design into a pure app solution.  They conclude that you need a combined approach that may require “the scalability of mobile technology, the social support of personal coaching, adaptive intervention design and more personally tailored approaches.”

Apps and technology do have a role.  However their role is in making already effective programs and approaches scalable, easy and consistent.  They are facilitators of solutions rather than independent solutions.  Part of our challenge, is how to use these powerful tools, in conjunction with people and other support and operational processes to truly help people to lose weight, control their blood pressure, take their medications and maybe even just enjoy their lives more. 

The apps alone, in providing information, will be hard pressed to address the psychological and life factors that require the personally tailored approaches the Duke authors in the article speak about.  In many ways, our challenge for the foreseeable future is how to harness the power of technology in the search for the more individualized approaches that address people’s health, their life situations, their psyche, and even their spirit in the quest to improve their lives.