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Latest Blogs
- Improving what the world eats
by Richard Smith
- Andrew Lansley lead NHS Reform
by Julie Whittaker
- Food and Drink Federation Reception 2010
by Jamie Cronk
- Extreme Anti-Smoking Advert
by Jamie Cronk
- Investment in Innovation – a priority for patients
by Julie Whittaker
Richard Smith's Blog
Country: United Kingdom
Organisation: UnitedHealth Chronic Disease Initiative
Blog link: http://www.3four50.com/blog/richardsmith
Improving what the world eats
19th Jul 2010
High blood pressure is the second main cause of disease burden inAustralia and is only marginally behind tobacco, said Bruce Neal, senior director, research and developmentat the George Institute forInternational Health in Sydney, at a seminar organised by C3,Collaborating for Health. It’s the same in other developed countries andincreasingly in developing countries. Yet Australia spends about $1 billion ayear treating high blood pressure but makes little impact on the overall burdenof disease resulting from high blood pressure. (Half the money goes on drugsand half on doctors and other health workers.) Why is there so little impactand how could Australiaand other countries do better?
Many BMJ readers willknow why the huge treatment effort, which is the same in other countries, hasso little impact—but it’s worth reminding you.
Firstly, it’s people with“hypertension” who are being treated—above a systolic of about 140 mgHg. Butthe risk of developing a stroke, a heart attack, heart or kidney failure, orany of the other adverse effects of high blood pressure increases steadily froma systolic of about 115 mmHg. About half of the adverse effects happen inpeople who have “normal” blood pressure—because although they are at lower riskthere are many more of them (the “prevention paradox.”)
Secondly, only about halfof those who are hypertensive are diagnosed and treated, and, thirdly, onlyabout half of those who are treated have their blood pressure reduced to below 140mmHg. This is the familiar “rule of halves.” But to abolish risk patients needto have their blood pressure reduced below 115 mmHg, and this happens withvirtually nobody. So overall only about 9% of the burden of disease from highblood pressure is countered by drug treatment.
What may be less familiarto BMJ readers is that the same or greater benefit could be achieved by a “goldplated” salt reduction scheme, which would cost about $10-20m, 1-2% of thespend on treatment. Plus the benefit would be additional to that from drugtreatment.
Similar highly costeffective benefits can be achieved by reducing fat, sugar, and energy densityin the processed foods that we all eat, but doctors think a lot about drugs andlittle about nutrition. Like most medical students I spent hundreds of hourslearning about drugs but almost nothing about nutrition—and what I did learnwas mostly about scurvy and other vitamin deficiencies. Sadly, I don’t thinkthat it’s any better now.
Of course, doctors canprescribe drugs, but it’s hard to get individuals, particularly those on lowincomes, to eat less salt, fat, and sugar—because most of what we eat is inprocessed foods. Doing something about food thus means either legislating orworking with the food industry.
Many public health peopleare reluctant to work with the food industry. They think of the tobaccoindustry and its corrupt ways and conclude that voluntary efforts will neverwork. Professor Neal and most of those at the seminar, several from the foodindustry, think differently, pointing out that food is essential whereastobacco is not, companies will reduce (and have reduced) the unhealthy componentsof their foods, and legislating on food and enforcing the legislation are muchmore difficult than doing so for tobacco.
But what should behelpful—no matter whether the way forward is legislation, voluntary codes, or acombination—is global, publicly available data on the composition of processedfoods—and that’s what Professor Neal wants to achieve. These data can then beused to make comparisons with benchmarks of what’s regarded as healthy, amongcountries and companies, and over time.
Such a database hasalready been achieved in Australia,and—to my surprise—it’s mostly a matter of collating existing data. This about50% of the data is supplied directly from food companies. More can then begathered from websites, and some comes from patrolling supermarkets and readinglabels. Random chemical analyses can be conducted to keep everybody honest.
Gathering these data can,Professor Neal believes, have a big impact in improving the world’s foodsupply—a bigger and more cost effective impact than relying simply on drugs.
Please tell the European Commission what you think
8th Jun 2010
Do you favour open access publishing of scientific papers? The EuropeanCommission would like to know—so please answer the survey at: http://surveymonkey.com/s.aspx?sm=tVtzMMsPl83W2yGQ4lZ1uYPwn1WYLpKuMdv7Lcych44%3d& It takes only a few minutes to answerand is, I judge, a well designed questionnaire.
It may well be that you don’tknow what “open access publishing” means, and it’s most unlikely that youunderstand its full implications. (I write this not because I know anythingabout you as an individual but because I know after years of talking toresearchers that most don’t grasp open access publishing fully.) But openaccess publishing is one of the great battle grounds of science and has thepotential to revolutionise science.
Open access publishing means,firstly, that the scientific studies are available for free to everybodyeverywhere and, secondly, that the studies can be reused without permission butsimply with attribution.
The first argument in favourof open access publishing is that it allows access to science to the manygroups who don’t have good access at the moment—patients, the public, people inlow and middle income countries, and, indeed, many researchers, students, andprofessionals in wealthier countries. In the context of chronic disease thismeans that many people interested in or affected by chronic disease could getaccess to science in a way that they can’t at the moment.
Next, ideas are fundamentallydifferent from, say, apples. As George Bernard Shaw wrote: “If you have anapple and I have an apple and if we exchange these apples then you and I willstill each have one apple. But if you have an idea and I have an idea and weexchange these ideas, then each of us will have two ideas.” Ideas proliferateto create new ideas, and we kill many potential ideas by keeping current ideasbehind access controls.
Then open access publishingshould mean that the whole world could have access to all science for lessmoney than is currently spent on scientific journals. This is a wonderful dealfor everybody except the publishers of science who have for years been makingmoney out of restricting access to research, most of it publicly funded,without adding any value to the process of publishing science. (I write this asan ex-publisher of scientific journals.)
Anyway, I shouldn’t beinfluencing you. I’d simply like you to contribute to the survey.
The rise and rise of “polypathology”
3rd Jun 2010
Almost unnoticed by medical schools and health systems the nature ofhealth care has changed radically. The traditional medical model is “patientadmitted, diagnosed, treated, cured, sent home,” and the special role ofdoctors, said one chief medical officer recently, is “diagnosis, diagnosis,diagnosis.” In reality there is little diagnosis and even less curing. Most ofhealth care is now concerned with frail patients, often elderly, with multiplechronic conditions. Indeed, patients with five or more chronic conditionsaccount for two thirds of the costs of Medicare.
Spain, which currently holds the presidency ofthe European Union, has recognised this change, and on Tuesday at a conferencein Granada itlaunched a book entitled When people livewith multiple chronic diseases: a collaborative approach to an emerging globalproblem. (1) The book brings together for the first time what we know—andstill more importantly what we don’t know—about how best to manage these patientsand organise health services to improve their care and independence.
A paper copy in Englishwas made available in Granada,but the book is actually a living document, a wiki, available in Spanish andEnglish to which anybody can contribute. Indeed, 55 people from 18 countriesmade 235 contributions. I’ve urged people before to contribute to the book, andyou can do so at: http://www.opimec.org/equipos/when-people-live-with-multiple-chronic-diseases/
One of the tricky things in addressing this issue isto know what language to use.
Researchers have often used the word “comorbidity,” but theproblem with this is that it assumes a dominant condition. Patients withseveral unrelated conditions—for example, diabetes, chronic obstructivepulmonary disease, and depression—might thus be labeled in three differentways.
Another term, the one we started out with, is “complexchronic disease,” but this is confusing as people may have a singlecondition—perhaps schizophrenia—that presents in a highly complex form that isdifficult to manage.
The book thus comes down in favour of “polypathology” (alsosometimes called “pluripathology”) that puts the emphasis squarely on patientshaving more than one disease. An advantage of this term is that doctors inAndalucia have been using it since 2002. They have defined nine distinctchronic conditions (http://www.opimec.org/equipos/Definicion_Fragilidad_pluripatologia_complejidad/documentos/877/#ante-section-4174 ), and for patients to qualify as havingpolypathology they must have two or more of the conditions.
Using this definition the Andalucian doctors have foundthat some 40% of admissions are patients with polypathology and that thetaxonomy predicts prognosis—that is, the more the conditions the poorer theoutcome. Some 19% die while in hospital, and disturbingly—but not perhapssurprisingly—patients with polypathology who are admitted to hospital are morelikely to die than those not admitted. That’s one reason why Andalucia isredesigning its health system to better serve these patients and has put themajor emphasis on primary care.
Clearly we won’t make much progress with this global issueif we can’t agree on language. That’s why the editors of the book areparticularly keen on comments on the language we should use. Why don’t you tellus what you think? Perhaps you even have a duty to do so.
Competing interest: I am oneof the editors of the book. Like everybody else, I was not paid, but theAndalucian government did kindly pay for my wife and me to travel to Andaluciafor the launch. It also paid for a trip round the Alhambraand a particularly delicious meal in a restaurant across from the Alhambra that was oncethe home of the last Moorish queen.
1. Jadad AR,Cabrera A, Martos F, Smith R, Lyons RF. When peoplelive with multiple chronic diseases: a collaborative approach to an emergingglobal challenge. Seville:Andalusian Government; 2010. Available at: http://www.opimec.org/equipos/when-people-live-with-multiple-chronic-diseases/
A day in village Indian
30th Apr 2010
“The village is the real India,”said an Indian friend, echoing Gandhiand the continuing belief of many Indian intellectuals. “What is the villagebut a sink of localism, a den of ignorance, narrow mindedness, and communalism[putting your own ethnic group ahead of society],” said Bhimrao Ambedkar, whodrafted the Indian constitution and was the first “untouchable” to receive anoverseas education.
Both statements were in my mind as I sat in the house ofthe panchayet (headman) of Jagadeenahalhi, a village of about 600 people inKarnataka and close to Bangalore.I was there with two community health workers, three community health doctorsfrom St John’s MedicalCollege in Bangalore,a catholic college committed to serving the poor, and two colleagues from theNational Institutes of Health in the US. [I may be using panchayetwrongly. It is the council of the village, and after a good bit of time onGoogle I’m not certain that it does mean leader. Somebody will correct me ifI’m wrong, I hope.]
The panchayet was hugely jolly, laughed all the time, andseemed delighted to have us there. He is elected to his position, but serves alternating terms of five years as therole switches between “upper” and “lower” castes. As in Britain, an election is coming, andthe women of the village, whom we met later, joke that this is a good time toget whatever you want.
We are there because we are starting a project to identifypeople in the village at high risk of cardiovascular disease and then usecommunity health workers to help them improve their lifestyle and take anytreatment that might be necessary. The panchayet is pleased that this ishappening and tells us that many people in the village have “sugar diabetes”and that people are dying of heart attacks.
As we leave, he insists that we come and see his field ofcabbages, which is small but well irrigated, and gives me a bag of potatoes.The village has no tarmac road but does have a primary school, and all ourconversations take us back to the teacher, who is clearly a driving force inthe village. We walk past the small houses, some very brightly painted, pastthe water tank where villagers come to collect water, and past dirty ditchesfilled with rubbish and murky water to the house of the leader of a localwoman’s cooperative.
Almost a dozen women are sat on the floor in their brightlycoloured saris, and with the community doctors translating we question them. Theyare a group of about 20 women from the village who all contribute 30 Rupees(around 50 p) each week to create a pool of money that is lent to members ofthe group to perhaps buy a goat or some seed or start a small business. Themoney must be paid back with interest. It’s a microfinance scheme started somenine years ago with the encouragement of the government. The women meet once aweek to thrash out both business and social issues. There are eight such groupsin the village.
Theyare happy to answer any question.
“Whyare there no men?”
“Menare too unreliable?”
“Dothe men object to you forming a group?”
“Theydid at first. Not now. They see the benefits.”
“Doyou lend money for sickness?”
“Yes.”
“Whathappens if a woman can’t pay money back?”
“Wegive her time. We help. We’re friends.”
“Doyou campaign for better facilities for the village?”
“Wedo. We get together and go to the panchayet.”
“Canyou stop the men drinking, smoking, and playing cards?”
“Wetry, but we’re not successful.”
There’slots of laughing as we talk.
Beforewe leave we sit down among them and have our photographs taken. I feel privilegedto have the opportunity to meet them.
Wethen drive to Mugalur, a bigger village where St John’s has built a community healthcentre. On the way we stop at a temple with the brightly coloured, semi-naked Hindugods swarming over the tower of the temple, monkeys joining them, and acollection of blind and elderly people begging outside. We wash our feet andhands and together—Hindus, a Muslim, some Catholics, and an atheist—receive ablessing via the priest from Krishna, who canbe glimpsed deep in the temple covered in flowers.
Atthe clinic we meet “Dr Daisy,” known in the village as “the god of sight” whohas removed over 5000 cataracts, often from people who haven’t been able to seefor years. She can remove a cataract and insert an intraocular lens in aboutfive minutes, and once did 120 in a day. “If I need a cataract removed I’ll goto her,” says one of the community health doctors.
Wealso meet a professor of paediatric orthopaedics who comes to the clinic once amonth to see children with deformities caused by birth injury, cerebral palsy,infections, accidents, and unhealed fractures. He does such a good job that hisclinic constantly grows and adults come as well, but nobody is turned way.“Consanguinous marriages are a big part of the problem” he observes.
Thenwe get to sit cross legged (ever tougher for my old joints) and talk to the 11community health workers, again all women. Some of them have been working withthe clinic for 13 years, doing an ever wider range of tasks. They are paid,have high status in their villages and know everything about everybody.
“Doesn’tknowing so much about people mean that they respect you but keep you at adistance?” I ask, thinking of John Berger’s account of the life of a countryGP.
“No,definitely not,” they answer, clearly thinking my question strange. Their valuecomes in large part from their intimate knowledge of their villages. “It justdoesn’t work to have community health workers from other villages,” observesthe community health doctor.
Afteranswering dozens of questions from us they ask us questions. What are we expertat? My colleagues from NIH explain about their interest in chronic disease.When it’s my turn, I answer truthfully but maybe a touch pretentiously: “I’mexpert at nothing but interested at everything.” This causes the translator andthen the women to explode with laughter.
Onour drive back the community health doctor explains that the villagers havesold all the land around their village for sums that are huge to them. Apolitician has bought the land and will have no difficulty getting it rezonedfrom agricultural land to land for development. Then he’ll build luxury housesto provide homes for the software engineers from Bangalore, which is rapidly swallowing up thesurrounding countryside. The villagers, although temporarily rich, will loseincome, and the traditional village will die. Worst affected will be thelandless labourers who will share none of the payment for the land and the verypoor, the “untouchables,” who cluster away from the village.
Eatingjackfruit and reflecting as we drove back on the quotes that began this blog, Ithought that I’d seen more nobility than ignorance in the villages, but willIndia avoid the urbanization that seems inevitably to accompany development? Idoubt it.
The unrecognised epidemic
30th Apr 2010
About 200 million adults ayear undergo major surgery that is not cardiac surgery, and about 5 million ofthose people suffer a major vascular complication. That, said P J Devereauxfrom McMaster Universityat the Oxford Health Alliance meeting in Delhilast week, is about the same as the number of people contracting HIV each year. But have you ever heard or thoughtabout it? Probably not.
All doctors know that a heart attack or a stroke can be acomplication of major surgery, but very few appreciate the scale of theproblem. That’s probably because they are unaware of the degree of risk and ofthe global scale of surgery. Surgery puts extreme stress on a patient.
Studies conducted a long time ago showed that about 4% ofpatients with cardiovascular disease or at high risk of such disease and about1.5% of others suffered a major vascular complication. But these were smallstudies with a poor method for diagnosing heart attacks: many heart attacks goundetected because they are most likely to happen soon after surgery whenpatients are sedated and been given large doses of painkillers.
Now Devereaux is leading a major international study thatwill include 40 000 patients. They have already recruited over 15 000 patientsand at this point they are confident that they will have over a 6% incidence ofmajor cardiovascular complications at 30 days after surgery. This higher rateprobably has two main causes: a better method of diagnosing heart attacks, andthe fact that surgeons are operating on older and sicker patients.
A previous study found that 415 of 8351 patients had aheart attack and that two thirds of them were asymptomatic. Mortality amongthose who suffered a heart attack was five times higher than among those whodid not, and it didn’t make any difference whether the heart attack wassymptomatic or not.
What should we do about this problem? The first thing is tobe aware of it. Secondly, patients should be told of the risks, and when thelarge study is complete it should be possible to give patients a clear pictureof the risks they face. Some may decide to forego the surgery. Thirdly, Devereauxis launched into major studies to try and find treatments that can reduce therisk. An initial trial of using beta-blockers found that they reduced heartattacks but at the cost of increasing strokes and overall deaths.
I couldn’t help thinking of the many studies I’ve read overthe years that show that much surgery is inappropriate. “Good surgeons,” as thefamous aphorism says, “know how to operate, better surgeons when to operate,and the best surgeons when not to operate.” Maybe there shouldn’t be 200million major operations a year but 150 million.
Five examples of scaling up
30th Apr 2010
Developing interventions thatwork to, say, reduce malaria, combat obesity, or prevent cardiovascular diseaseis hard, but scaling them up to benefit whole populations is harder. Yet theinterventions must be scaled up to make any important difference to globalproblems like malaria, obesity, and cardiovascular disease. The Oxford HealthAlliance meeting in Delhilast month heard about four examples of successful scaling up—and I’ve added afifth.
The first example was from Abu Dhabi, which OliverHarrison, a British doctor, and colleagues have turned into a “livinglaboratory.” http://www.c3health.org/wp-content/uploads/2010/04/Oliver-Harrison-Abu-Dhabi-v-2.pdf They are aiming to measure the risk factors of everyadult in the country, including blood pressure and lipids, and give thempersonal treatments, plans, and targets. They have begun with a cohort ofalmost 200 000 and have screened 94% of them. All of their data will be enteredinto a computer and monitored, but the programme is not all about indiduals.The database, which shows high levels of risk, provides a stimulus and a way ofmonitoring public health programmes of promoting physical activity, workingwith schools and worplaces, improving urban planning, working with the foodindustry, and the like.
The Abu Dhabiprogramme costs $15 per head, but Harrison, both a visionary and a formerMcKinsey consultant, thinks it can be done for as little as $1 per head usingcheaper staff and different methods—so meaning that it could be feasible insome poorer countries.
MEND (Mind, Exercise, nutrition, Do it) is a communitybased programme for preventing and treating childhood obesity devised at GreatOrmond Street that I’ve blogged about before. http://blogs.bmj.com/bmj/2009/12/07/richard-smith-on-scaling-up-to-defeat-childhood-obesity/#more-921Paul Sacher, a cofounder of MEND, described theoriginal programme and how they have scaled it up using software, staff in gymsrather than health professionals, and flexible business models. http://www.c3health.org/wp-content/uploads/2010/04/Sacher-MEND-20100419.pdfThey have managed to reach some 30 000 in the UK, but that’sstill a tiny percentage of all the overweight and obese children.
I’ve also blogged about Agita Mundo, a programme that beganin Sao Paolo to encourage physical activity. Victor Matsudo, who originally wasan orthopedic surgeon, began locally and through fun, branding, partnerships,and highly effective communication, including clever use of the internet,created momentum that engaged politicians, which led to changes in theenvironment that encouraged walking, cycling, and other forms of physicalactivity. http://blogs.bmj.com/bmj/2010/03/29/richard-smith-run-for-your-life/ Matsudothen spread the programme nationally, regionally, and eventually globally,signing up over 20 countries and about 5 millon people for a recent day ofphysical activity.
Discovery is a South African based insurance company thathas developed a programme to pay not for treatment of sickness but to promotewellness. http://www.c3health.org/wp-content/uploads/2010/04/Greg-Morris-Discovery-20100419.pdf People in its Vitality programme all have theirhealth status benchmarked and are then set personal goals to improve it and arerewarded—with a wide variety of rewards including plane and movie tickets—forhealthy behaviour such as exercising at a gym. The more they exercise the morerewards they receive. There is also now a programme that rewards the purchaseof healthy foods.
Vitality is not profitable in itself, but in order enterthe programme you must purchase another Discovery product—for example, healthinsurance. The benefit to Discovery is that it retains people who do well onthe Vitality programme, and they have lower admission rates to hospital andlower costs and shorter stays when they are admitted. These add up tosubstantial savings for Discovery, increasing the company’s profitability.
A fifth example comes from UnitedHealth Group, the companyI work for, and was recently described in the New York Times. http://www.nytimes.com/2010/04/14/health/14diabetes.htmlThe programme aims to scale up an interventionto prevent diabetes shown to work more than a decade ago in a study funded bythe National Institutes of Health. http://www.unitedhealthgroup.com/news/rel2010/Diabetes_Alliance_Program_Fact_Sheet_041310_final.pdf Peoplewith prediabetes—some 57 million people in the US, 85% of them unaware of theircondition—work in groups with a trained lifestyle coach in 16 sessions to eathealthier diets, exercise more, and learn about other behavioural modifications.United has teamed up with the YMCA to implement the programme and it’s free tothose enrolled in United health plans through their employers. Pilots conductedby United show that the health costs of these people can be dramaticallyreduced. United is also partnering with Walgrens, a pharmacist that covers the US, to improvethe care of those with diabetes—again based on evidence based trials.
What do these programmes for scaling up have in common?Vision, an evidence base, tight management of data, attention to costs, clevercommunication, and business like methods.
Competing interest: I workfor the UnitedHealth Group but was not involved in developing the programmesfor preventing and treating diabetes. I have shares in the company, and if theprogramme does well it might raise the share price and I might benefit.
Matlab, Bangladesh
29th Apr 2010
The cholera hospital in Matlab, Bangladesh,has patients in the corridors and every nook and cranny, but as we walk throughthe mood is calm. Most beds have two people, usually a mother and child. Themood may be calm because acute, watery diarrhoea is part of life in Bangladesh, andthe parents and patients know that when they reach the hospital they will betreated effectively for free and that almost nobody dies. The only deaths arethose who arrive dead and in those with diarrhoea complicated by malnutritionor other infections—and even among them deaths are rare. Most people aredischarged within 24 hours. Both wards and corridors are full because one ofthe two peaks of diarrhoea a year comes in April.
The services provided by the hospital in Matlab are part ofan unwritten contract between ICDDR,B (once the International Centre forDiarrhoeal Disease Research,Bangladesh butnow known simply by its acronym) and the people who live around Matlab. Becausethese people have been intensely studied for 50 years: every birth, marriage,divorce, death, and much more is recorded. A community researcher isresponsible for around 7000 people and visits every household once every twomonths (it used to be every month).
Every last detail is known about these people, and everydeath is followed by a verbal autopsy. One finding is that 80% of deaths arenow from chronic disease: the epidemiological transition has been remarkablyfast in this poor, rural community. Many important trials have been conductedamong the people of Matlab—including of oral rehydration therapy, familyplanning, and zinc for childhood diarrhoea. It’s the intensive study and thetrial results that have made Matlab internationally famous, particularly amongthose interested in global and public health.
I was visiting for the second time, and I find it apeculiarly beautiful place. We arrived by speedboat, skimming down the wideriver with its banks of maize, rice fields, palm trees, and buffaloes wading inthe water. Children splashing in the water waved to us, and we waved back.Wooden boats with fisherman were rocked as we sped by—but seemed whollyunconcerned. And we passed the wooden boats with covered tops that are thehomes of nomadic families living from fishing and selling small goods in thevillages.
Our first stop was one of the subcentres where the medicalassistants provide primary care to mothers and children and try to persuadewomen to give birth. Because the people in Matlab have faith in the servicesprovided by ICDDR,B about 70% of women give birth in the centres, whereas inBangladesh as a whole 70% of women give birth at home. If the subcentre can’tmanage a problem, then patients may be transferred to Matlab hospital—byrickshaw ambulance. It takes about an hour. The hospital can’t at the momentperform a Caesarean section, and women who need a section have to betransferred to a government hospital. There are about 5000 births a year, andlast year there were two maternal deaths. Some years there are five or six.
We enter the clinic where women are sat close together withtheir children waiting to be seen. Privacy is not a big issue in Bangladesh, andthe women can see and hear the consultations. Nor is anybody bothered by us,although they do cover their heads as we enter. We seem to be a harmlessdiversion from the waiting. Charts on the wall tell us that immunization ratesare all over 95% and contraceptive prevalence is 75%. (I wonder what the ratesare back home in Clapham, where we are not so intensively studied. Theimmunization rates, I’m sure, are not so high.)
Then we head to a village to meet with a communityresearcher. The road is narrow and raised high and keeps turning at rightangles to make its way through the paddy fields. The intense green of the paddyfields, all tiny but divided only by narrow ditches, stretches away into thedistance. The road is raised because when the monsoon comes at the end of June,the paddy fields will become a lake. Even now approaching the end of the dryseason there are plenty of ponds, and drowning is now one of the commonestcauses of death in children.
The villages are also raised up, and we walk along a narrowpath to reach a village of about 10 houses. There is no electricity, runningwater, or sewerage in many of these villages, but each house is classified intorich to poor quintiles by ICDDR,B. The “rich” houses have tin roofs, the poorones are simply bamboo and other vegetation; most have earth floors, and peoplecook over fires, often burning cow dung. We are standing outside a thirdquintile house. It doesn’t have a tin roof and looks as if the monsoon rainswill easily get through.
We are talking to the community researcher, who tells usthat she knows everyone of her 7000 people. I ask her what she likes most abouther job: “Being able to give women a pregnancy test when they think they may bepregnant and then putting them in contact with the clinic.” She’s been doingthe job a long time and must have seen mothers die though childbirth. I never have,although I know that globally there are about half a million deaths a year. Sheshows us the big hardback book in which she records all the details, which arelater entered into the computer. We are also shown PDAs (personal digitalassistants), which are already used for some studies and will soon be used forall data collection.
As we talk more and more people gather. The children arekeen to be photographed and are excited to see the digital images. As we walkfrom the village the children walk with us, I feel like the Pied Piper ofHamelin.
We drive again through the paddy fields to another village,where we visit the home of one of the community health workers. Her house isthe grandest we’ve seen, two story and brick. Her husband died last year, butas she has done for decades she holds a clinic once a week where she vaccinatesthe children. Many of the babies are tiny, and a quarter of babies are lowbirth weight. Many of the mothers look young, although the legal age formarriage is 18 in Bangladesh.But many women don’t know how old they are, and some will pretend to be olderthan they are.
From the clinic we drive to the hospital and visit thelarge barge that was the beginning of the Matlab surveillance. The researchersslept upstairs and conducted their clinics and studies downstairs. As well asvisiting the diarrhoea wards of the hospital we see to the laboratories and theice cold rooms where the data are entered into the computers. A researchershows us how one woman’s life has been recorded—her birth, marriage, divorce,and second marriage. Divorce seems to carry little stigma and is often“socially” rather than legally arranged. The researchers have 16 choices forrecording the reason for divorce, including “Male debauches” and “Non-deliveryof dowry.” We then visit the new ward where the hospital provides kangaroo carefor babies born prematurely (the baby is skin to skin with the mother).
Finally it’s time to leave. We wave to the crowd as ourspeedboats putter up the narrow river. After passing another cluster of the nomads’boats we reach the broad river and accelerate. The sun begins to go down, and Itry to spot the village we visited. I imagine the people preparing for thenight. Many will presumably go to bed as dark descends at about 7 pm, sleepingperhaps six to a room, and will rise with the dawn. This is a life far from thelife I live. The place is so beautiful it’s possible to imagine the life asidyllic, but much of it must be hard. But, as one of the researchers said to us,people have little and are content with little. Is it true, I wonder? And is italso true that the whole place may be permanently under water by 2040? It maybe.
What to say to a food company
25th Feb 2010
What should you say to a major food company if asked to speak toits senior manages? A friend of mine, a cardiovascular epidemiologist, receivedsuch an invitation and emailed friends asking for advice on what to say.
The context is that some people consider food companies to be liketobacco companies. They are making money out of selling unhealthy products. Themajor difference is that we can imagine—and hope for—a world without tobaccocompanies, but food companies are highly likely to have a continuing (andprobably increasing) role.
This is what I thought my friend should say to the company.
1. You should engage in debate with everybody, even critics whomay seem ignorant and abusive—and your spokespeople should be sure to staypolite no matter how much they are provoked. (I advise this to everybody: speakto your “enemies.”)
2. You should be as transparent as you can possibly be,remembering that very little is gained by keeping things secret.
3. Don't be defensive, but make sure you have something to beproud of .
4. Steadily reduce the harmful components of your food--salt,sugar, fat, etc. You may be surprised how far and how fast you can go.
5. Move steadily into a healthier product range. It makes businesssense as more and more people want healthier foods.
6. Be science driven but always remember values.
7. Be very serious and responsible about the environment,especially carbon and water consumption.
8. Encourage your employees to be as healthy as possible and helpthem in practical ways.
9. Use your marketing power to encourage healthier and moresustainable living.
10. Never be ashamed about making a profit and work to deepenpeople's understanding of the importance of profit. (Many readers may disagreewith this one. People, especially in Britain, are funny about profit,particularly when you consider that we get almost all of our products andservices from for profit companies. I wrote a blog for the Guardian on the casefor profit
(http://www.guardian.co.uk/commentisfree/2008/apr/16/healthybankbalance),and it evoked some very angry responses.)
11. Think boldly and regularly about the future (important for allorganisations).
12. Stay ahead of public and political opinion: don't have to beforced into doing the right thing. (I bet the drug companies would tell themthis.)
13. Recognise your international responsibility and try as hard asyou can to use the same ethical standards everywhere.
14. Recognise the importance of partnership even with partners whomake you feel uncomfortable.
What would you say to a food company?
Reducing chronic disease in Pakistan
7th Feb 2010
Pakistan, like most developing countries, is experiencingrapidly rising rates of cardiovascular disease, diabetes, obesity, and chronicobstructive pulmonary disease, and it has developed a draft national plan forcountering chronic disease. It’s an impressive and elaborate plan, as Idiscovered when I discussed the plan last week with people from the healthministry in Islamabad.It will, however, be an uphill struggle to implement the plan and make adifference.
One problem is attitude. About half the deaths in Pakistan arestill from infectious disease, and many people are understandably againstshifting any resources away from controlling infectious disease. And resourcesare a problem. Pakistanis a poor country, and, as with most of the world, its finances areparticularly shaky now. Annual spending on health for each person in Pakistan isabout $4, enough perhaps for one packet of statins.
Donorsare not keen on funding programmes to counter chronic disease as, againunderstandably, they want to concentrate on trying to achieve the MillenniumDevelopment Goals, which do not include anything on chronic disease.
It’s sensible to prioritise, and one of the challenges withcountering chronic disease is that it needs a wide range of activities, many ofwhich are in the territory of other government departments like finance,agriculture, and trade.
Before the meeting at the ministry I heard Shah Ebrahimfrom the London School of Hygiene and Tropical Medicine talk in Karachi about the beststrategy for countering chronic disease. He advocated improving socialdeterminants like poverty, concentrating on risk factors rather than diseases,and working to improve health systems, particularly primary care. When pushedon short term strategies he said increase taxes on cigarettes, ban smoking inpublic places, make unsaturated oil cheaper, and concentrate on treatinghypertension.
Almost half of men in Pakistan smoke, and some cigarettescost about 6 rupees for 10—about 3p. It may well have the cheapest cigarettesin the world, and cigarettes are smuggled out of Pakistan. Despite the cheapness ofthe cigarettes the government’s income from tobacco exceeds its totalexpenditure on health. Pakistanalso grows a lot of tobacco and has a national body to promote tobacco sales.So government despite signing the Framework Convention on Tobacco Control isvery cautious on tobacco control. Smoking is banned in public places, but thelaw is flouted everywhere.
Then there is the problem of smokeless tobacco, which comesin some 134 different forms, all of them cheap. Half of men and more than aquarter of women use smokeless tobacco, and doctors regularly see people intheir 30s with advanced oral cancer. There is also now a rage for shishas(bubble pipes from Turkey),which are used by 43% of males and 11% of females. Many parents who object totheir children smoking cigarettes do not object to them using shishas becausethey don’t think that they are dangerous.
Then there are problems of implementing WHO advice on dietand physical activity. Most poor people consume far less fat than the WHO recommendation,but it doesn’t seem wise to encourage an increase. Salt restriction can bedifficult because it’s an important source of iodine, and implementing adviceon physical activity is impossible among the many women in Pakistan who are segregated.
Despite all these difficulties I flew back over thefoothills of the Himalayas (did you know that Pakistanhas five of the seven highest mountains in the world?) feeling confident that Pakistan,a country full of ingenious people, will find its own way to counter chronicdisease.
Competing interest. RS is thedirector of the UnitedHealth Chronic Disease Initiative, which together withthe US National Institute for Heart, Lung and Blood Disease funds centresaround the world, including one at the Aga KhanUniversity in Karachi.
A chance to collaborate in a book on complex chron
7th Feb 2010
Would you like to contributeto a book on complex chronic disease? The book has been written for the Spanishgovernment, which currently has the presidency of the European Union and wantsto draw attention to the importance of complex chronic disease.
You probably don’t recognisethe term “complex chronic disease,” but it’s actually the main concern ofdoctors and health systems. Patients with “complex chronic disease” arepatients who have multiple chronic diseases (cardiovascular disease, diabetes,chronic obstructive pulmonary disorder, cancer, depression, osteoarthritis, andany long term condition) perhaps with complications and certainly withpsychological and social components.
In the classic medical modelpatients present with single diseases, are diagnosed, treated, and cured. Thisis ever less of health care, and yet it continues to be the dominant way ofthinking. A tour around any hospital will show that few patients have single,curable conditions and that most have complex chronic disease. Patients withcomplex chronic disease account for most visits to general practitioners, mosthospital admissions, and a huge proportion of health care costs.
So the first reason you mightlike to contribute to this book is that it will deepen your understanding ofcomplex chronic disease.
The second reason is that youcan probably improve the book. We, the authors of the book, very much believein the “wisdom of the many rather than the few.” James Surowiecki in “The Wisdom of Crowds,”Charles Leadbeater in “We-think,” and Clay Shirky in “Here Comes Everybody” alldescribe cases where the many have been able to do what the few could not.(This is a good reading list for those who want to explore further the power ofthe many unleashed by the internet.)
A third reason for you tocontribute is that you might enjoy being part of an experiment. As far as Iknow, few if any medical books have been written in this way.
A final reason is that if youmake an important contribution to the book we will include you as an author.Perhaps you need to boost your CV. Another selfish but far from ignoble reasonis that you might be invited to the launch of the book in Seville (and possibly the Basque country as well)in June.
If you want to contribute—orjust read the book—you should go to:
http://www.opimec.org/equipos/when-people-live-with-multiple-chronic-diseases/
You should click on thechapter where you would like you to contribute, and I urge you to start eitherwith the introduction or the chapter on prevention, which I have written withcolleagues. You can read the chapters in either English or Spanish and contributein either language. You add your contribution in a comment box that is attachedto each section of the chapters.
We, the authors and editors,will read all the comments and revise the chapters and allocate authorshipaccordingly. I hope that you will contribute, and I hope that I may bump intoyou in Seville,where I’ll be happy to buy you a glass of Rioja (even if it turns out thatthere are thousands of you.)
Competing interest: I’m anauthor of one of the chapters in the book but was not paid, and I’ll have topay my own way to Sevilleand for your glass of Rioja.
Scaling up to defeat childhood obesity
4th Dec 2009
Some three million children in Britain are obese, and treatingchildhood obesity is far from easy. To have any chance of responding adequatelyto the epidemic of obesity we need to find, firstly, a treatment that worksand, secondly, a way to scale it up so that it can be delivered efficiently.Both problems are hard, but the scaling up is, I suggest, the harder problem. Iwas therefore impressed to encounter an organisation in the backstreets ofSouthwark that is making real progress with both problems—and already beginningto work not only in Britainbut also across the globe.
MEND (Mind, Exercise,Nutrition, Do it!) is a social enterprise that is research driven and hasdeveloped a family and community based treatment for childhood obesity. Thetreatment has been shown in a randomised trail to be published in Obesity next year to reduce waistcircumference and body mass index and to increase cardiovascular fitness,physical activity, and self esteem.
The treatment comprisesadvice on behaviour change, nutrition, and physical activity. There are 18 twohour sessions delivered over ten weeks by two trained leaders and an assistantto groups of 8-15 children with their parents, carers, and siblings. Thesessions happen in leisure centres, schools and other community venues; andthere are eight on behavioural change, eight on nutritional advice, and 16 withphysical activity. The treatment is highly standardised with training for theleaders, theory and exercise manuals, children’s handouts, programme resources,and teaching aids. There is detailed guidance on how to run each session.
Childhood obesity isconcentrated in poorer neighbourhoods, and MEND is committed to promotinghealth equity. Of the children in the trial half were from ethnic minoritiesand two thirds came from families where the parent or parents were unemployedor doing manual jobs.
Having designed an effectiveintervention, MEND has developed a technology platform to scale it up. Theinternet based Operations Management Monitoring System (OMMS) makes it easy forthe programme manager to organise and monitor the programme and for the MENDteam to quality assure the programmes and to gather data on all theparticipants in the programmes. Some 17 people, mostly in India, have been involved inwriting the software and running the system.
It’s this scaling up thatmost public health programmes don’t manage and makes MEND so important. Programmesare now running at some 350 centres across the country—some paid for by primarycare trusts and some sponsored. Each extra programme means that the unit cost ofservice delivery (total costs divided bynumber of programmes) goes down, making scaling ever easier. MEND has data onsome 12 000 children and have found results similar to those in the randomisedtrial—and importantly many of the children are still from deprived backgrounds.
Childhood obesity is aglobal problem, even coexisting in poor countries with undernutrition, and MENDhas work underway in Denmark,Australia,and US. The latter two are the “fattest” countries in the world, and the US has25 million obese children.
Another importantchallenge for scaling up is selecting the right business model. That can’t beresearch grants as research funders are not in the business of implementing theresults of the research they fund on a large scale, although perhaps theyshould be. Depending on sponsorship is fickle, and sponsorship rarely goes onfor long. The best model is to serve organisations and people who value whatyou have to offer and will pay for it. This approach motivates both the quality andrange of public health services made available. A virtuous circle can begenerated as increased revenue from delighted customers is reinvested inservice improvements.
MEND has successfully demonstrateda sustainable, scalable model but a significant task still lies ahead.. If 15000 children in Britainhave been treated that leaves 2 985 000 who haven’t—and there are hundreds ofmillions in the rest of the world. As Lord Darzi suggests, preventive healthservices, like those offered by MEND, need to be commissioned on an industrialscale if we are to respond effectively to the chronic disease burden.
Countering chronic disease in rural China
27th Nov 2009
The differences between ruraland urban Chinaare stark. Beijing, Shanghai,and other major cities are filled with newbuildings, best illustrated by those built for the Olympics, whereas rural Chinahas as many as 300 million people living on under a dollar a day, more than anyother country. Indeed, Chinacan be described as three countries: a low income country in the West, a middleincome country in the middle, and a developed country in the East.
Peopleliving in the big cities have access to the latest medical technology, whereasthose living in the countryside are served by a “village doctor” (many of themonce the famous barefoot doctors) with limited training. So far most healthresearch has been conducted in large hospitals in the cities, but a newprogramme—the China Rural Health Initiative—plans to build a platform forresearch in rural areas Last week in Beijing I heard the plansfor the initiative.
The China Rural Health Initiative is the flagship programmeof the China InternationalCenter for Chronic Disease Prevention,which is basedat the George Institute China, with PekingUniversity HealthScience Centerits lead domestic partner. There are alsofive partners from five of the provinces closest to Beijing,which together have about 190 million inhabitants, and six internationalpartners, including the George Institute in Sydney,Duke University,and Imperial College.
One of the first studies to be conducted will be a cluster randomisedtrial of training the village doctors and providing community health educationto prevent heart disease and stroke. People in NorthernChina use huge amounts of salt and consequently have high levelsof hypertension and stroke. Many people have a daily consumption of 12 g or evenmore (when WHO recommends no more than 5 g and many think it should be 2.5 g),and poorer people use more salt.
Thevillage doctors will receive training in a simple, low cost, evidence basedpackage for high risk patients that includes regular blood pressure tests, freemedication, and salt reduction and potentially substitution.The doctors will also be given a health education kit and incentivised topractice prevention. The primary outcome measure of the trial will be theproportion of high risk people treated with at least one drug, and secondaryoutcomes will be blood pressure and the control rate of hypertension.
There is also a provisional plan to at the same time conducta trial of community based education on reducing salt consumption. Twenty fivetownships with between 18 000 and 26 000 inhabitants would receive bothinterventions (training of village doctors and community education), 25neither, and 25 each one or the other. The hope is that this will lead to apackage that could introduced across rural China.
A third possible study if funding can be found will be a randomisedtrial of salt substitution with high risk individuals. Families with high riskindividuals would be randomised to receive free salt substitute (containing 65%salt, 25% potassium chloride, which lowers blood pressure, and 10% magnesiumsulphate) or to the control group. A pilot study has already shown that saltsubstitution can lower blood pressure by 5 mg Hg (about the same as one drug),but the proposed trial would look for a reduction in stroke, heart attack, anddeath. Because of the known reduction in blood pressure there is every reasonto expect a reduction in events anddeaths, but the investigators judge that such a trial would lead to a change inpolicy in Chinaand beyond.
It’s possible to do a trial like this in rural China becausemost salt is added by people when cooking, whereas people in Chinese cities andthe developed world receive most of their salt through processed foods.
A fourth possible study, again dependent on funding, wouldtry to validate a method of verbal autopsy. Physical autopsy is not possible inmost developing countries, and the data for the global burden of disease arebased on doubtful evidence. The study would compare the diagnosis reached inthose who die in hospital (the best “gold standard” available) with a verbalautopsy, a series of questions, used with carers one to three months afterdeath. This would be done for the top 20 to 40 causes of death, and if theverbal autopsy proves reliable then a later study would quantify the cause ofdeath across communities.
The great attraction of establishing a reliable platformfor research is that other studies can be conducted without the difficultiesand cost of developing a platform, and already there is interest in studyingbiomarkers, interventions to prevent progression of chronic kidney disease(which is known to be common in rural China), and telemonitoring to speedtreatment of patients with heart attacks. Remarkably, another possible study isa randomised trial of conservative versus surgical treatment of hip fracture;this might be possible in rural Chinabecause it seems that many patients are treated conservatively.
No doubt many other studies will be proposed, and the hopemust be that the result is not simply lots of publications but realimprovements for the vulnerable, poor people in rural China.
Competing interest: RichardSmith is director of the UnitedHealth Chronic Disease Initiative, whichtogether with the National Heart, Lung and Blood Institute is funding the China InternationalCenter for ChronicDisease Prevention.
Chronic disease: “a wicked problem”
18th Apr 2009
Trying to slow the progress of the pandemic of chronic disease sweeping through the developing world is, a “wicked problem” said David Mathews of the Oxford Health Alliance at the summit.
A wicked problem is highly complex, perhaps ultimately insoluble, has no obvious solution and is full of contradictory data; every step forward is possibly a step backwards. Such problems can be tackled only by partnerships devising multiple options for responding and being content with “constructive ambiguity,” whereby partners who may feel uncomfortable with each—like public health practitioners and food companies—concentrate on where they agree and park their disagreements.
It’s easy to be overwhelmed by wicked problems, but I left the Oxford Health Alliance Summit feeling positive not overwhelmed. One good way to approach wicked problems is to “think big, act small, move fast, and leverage like hell.”
The big thinking is to maintain faith that we can make a difference. We know what to do to prevent much chronic disease, and we have seen rates of heart disease and stroke come down in developed countries. There have also been spectacular achievements in some countries with reducing smoking rates, although WHO estimates that only 5% of the world’s population is covered by effective interventions to combat tobacco use.
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Community interventions for health: real progress
18th Apr 2009
I’m trying to break my blogs up into readable chunks, and I want to develop my theme of “think big, act small, move fast, and leverage like hell” by summarising what was said about the community interventions for health, where an attempt is made to redesign neighbourhoods so that “healthy choices are the easy choices.”
The interventions are made in schools, workplaces, health centres, and the whole environment, and ideally the interventions operate not by persuading individuals but by making structural changes like banning smoking in public places, making stairs more accessible, improving public transport, reducing the amount of sugar in drinks, or a hundred other possible changes. Some are large and might require legislative actions, while others are small and easily implemented—like putting notes beside lifts encouraging people to use the stairs.
These interventions require political support and agreement from all the different stakeholders in a community. Indeed, the very act of bringing people together to think how they can redesign their environment is in itself an important intervention. Ideas for change will begin to flow.
These programmes are underway in Kerala, Hangzhou, and Mexico City and are being planned for Leicester, New Haven, Andover, Delhi, and Sousse in Tunisia. Most of the programmes will be rigorously evaluated, although evaluating such programmes is itself close to being a wicked problem.
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Polypill: an historic meeting of leaders
18th Apr 2009
Another way to prevent heart disease and stroke—but not other chronic diseases--is through the polypill, a pill that combines a statin (reducing blood fats), drugs to reduce blood pressure, and aspirin (which makes platelets less likely to stick and so form clots). These drugs work in different ways and so their benefits can be added together. Nick Wald, who spoke at the summit, proposed in 2003 together with Malcolm Law that such a pill could reduce heart attacks and strokes by about three quarters.
Now Denis Xavier, who was also at the summit, and colleagues have begun to test the idea, conducting a trial in over 2000 people in India. They have shown that people will take the pill, it is safe, and it does have the expected effects on reducing blood fats, blood pressure, and platelet stickiness—although the effects were not quite as dramatic as Wald and Law hypothesised. Still, however, one pill that might be available for as little as a dollar a month could prevent more than half heart attacks and strokes.
Tom Marshall, also at the summit, is conducting a trial in Iran and has results similar to those from India.
There seem to five polypills in the world (three from India, on from Iran, and one from Spain), and all but the Spanish one were represented at the summit—making this an historic occasion.
Anthony Rodgers from Australia has helped Dr Reddy’s Laboratories from India make one of the first pills, but in his talk he regretted the slowness of progress. He attributes the slowness to professional conservatism, regulatory hurdles, and lack of market pull. Nevertheless, I was left with a feeling that we are at last gathering momentum, and polypills may be on the market in Europe and the US within a couple of years.
Business innovation in countering chronic disease
18th Apr 2009
Innovation will be essential for tackling chronic disease, but it’s probably less scientific innovation and more innovation in making change happen, getting things done. An example came from Tal Gilbert, head of research and development at PruHealth, a joint venture between the venerable Prudential and the South African company Discovery.
The company offers heavy incentives to people to adopt healthy life styles. Those covered by its policies are given detailed information on what they could do to live healthier lives, guided to companies who can help them by providing healthy foods or access to gyms, and then given “vitality points” for eating healthy foods and exercising. The points become cash benefits. Academic analysis soon to be published suggests that those who collect many points have much lower claims; interestingly and surprisingly the big reductions are in cancer and mental health. (There is the obvious problem of causation, but Gilbert said that those conducting the analysis were well aware of all the methodological problems.)
The importance and difficulties of partnership
18th Apr 2009
“Leveraging like hell” was in many ways the major theme of the conference. Building a jumbo jet was a complex problem but not a wicked one in that there was a clear blueprint. Yet no individual knows how to build a jumbo jet. It depends on many different groups of people with different knowledge and skills, and we are likely to make progress with chronic disease only by bringing together many different stakeholders—politicians, academics, patients, health workers, social scientists, private companies, non-governmental organizations, and many others.
Jonathan Horrell from Kraft Foods UK described the experience in Britain of bringing together government, business, charities, and community organisations in the Department of Health’s Change for Life programme. He is part of Business for Life, and the government’s hope is that industry will contribute some £200m in kind through marketing and creativity. The media and some of the other partners are understandably suspicious that food companies are part of the problem rather than the solution, and building trust among the different groups is proving difficult. “Bilateral trust” among just two groups is not so hard but it’s trust among all that is hard to achieve.
Resources: more on the way
18th Apr 2009
Partnership, ideas, and innovation can achieve little without resources, and lack of resources has always so far been a problem for those trying to counter chronic disease in the developing world. Rajaie Batniji from Oxford University pointed out that about $3 in aid is spent for every death from chronic disease compared with £1030 for every death from AIDS.
Rachel Nugent, an economist from the Centre for Global Development in Washington, described how data from the OECD showed that only around $2m of aid was spent on chronic disease in 1996, but the figure was $56m in 2007, although $31m of that was on “mental health”—in fact conflict resolution. In the same year $1346m was spent on infectious disease. Nugent’s survey of donors did, however, suggest that total funding has increased to over $600m by 2008 with about half of it coming from private donors.
Stig Pramming of the Oxford Health Alliance led the summit towards an upbeat conclusion by announcing that June will see the launching of a Global Alliance for Chronic Disease that will include the government research bodies from the US, Canada, UK, India, China, and Australia. It will initially have some $45m to invest in research.
Let the vegetarian course be the main course
17th Apr 2009
One little thing at the Oxford Health Alliance Summit that appealed to me greatly was the idea that at all formal dinners (and my how I’ve suffered from formal dinners over the years) the main choice would be vegetarian. You’d have to request meat. The idea came from Susan Jebb, the Medical Research Council head of nutrition, in one of the best talks at the summit.
How many people would request meat? Not many is my bet. Many would just never get round to it, and others would feel slightly awkward asking for meat. Meat eating is, after all, one of the main factors destroying the planet as well as giving us chronic disease. I’d never have the nerve to ask for meat even if I was hungering for a rare steak dripping with blood, something I love.
Such a change would be a perfect example of “nudge economics,” whereby the healthy option is presented as the main option and you must opt out to get the unhealthy option. Richard H Thaler and Cass R Sunstein describe “nudge economics” in their book “Nudge: Improving Decisions About Health, Wealth, and Happiness.”
You could, of course, do the same with all courses. Vegetable soup for the first course or maybe no first course at all unless people asked for it. Fruit salad for desert, and perhaps an expected 500m walk between courses unless people opted out.
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