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Why wearables don’t work and people don’t floss their teeth

Wearable devices are now a billion dollar business:

Fitbit Reports $712M Q415 and $1.86B FY15 Revenue; Guides to $2.4 to $2.5B Revenue in FY16. Press release.

In a wonderful article from the Washington Post the author reports:

Another friend, a woman in her 40s, explained: “I realized that there were a couple weeks where I took it off because it was making me feel bad when I was ‘failing,’ so why do that to myself?” Steven Petrow

Associated Press pointed out that:

One research firm, Endeavour Partners, estimates that about a third of these trackers get abandoned after six months. A health care investment fund, Rock Health, says Fitbit’s regulatory filings suggest that only half of Fitbit’s nearly 20 million registered users were still active as of the first quarter of 2015. Anick Jesdanun

This is consistent with what my patients are telling me. I’ve seen the same trend with relatives. But it is all very predictable because these devices fail on one fundamental count. People are not logical. Information alone does not lead people to make choices. Humans are driven by emotion and not just information. If that were not the case people would floss their teeth, not text while driving or borrow more than they can afford to pay.

Innovations that rely on people acting on information to improve healthcare outcomes have no longterm future. If we want people to change their choices we need to accept that information alone does not lead to behaviour change. Functional Magnetic Resonance Imaging studies of the human brain have identified that our brains are resistant to change even when the change might be in our best interests. Habits drive our behaviours and are as an old pair of slippers, comfortable, familiar and easy. Change requires us to activate other parts of our brain, expend energy, learn and adopt new habits. Change requires effort which most people find uncomfortable. As a result, change is avoided and the easiest thing is to refuse to heed the message and bin the device.

There are three stages to adopting new behaviours:

  1. Unfreezing current patterns/unlearning old behaviours.
  2. Changing/applying new behaviours.
  3. Embedding new behaviours.

Of these wearables provide information that might get us underway with the first step by getting us to question the status quo. However that is far from what is required to get us to adopt a diet and exercise regimen. This so-called ‘disconfirming data’ is not enough – we can easily dismiss it, ignore it, or deny its validity. Which most people seem to be doing because it isn’t enough to generate new habits. Two other factors that are also essential to get us to the next stage:

  1. We need to accept that something is wrong and
  2. We need to believe that we can do what is necessary.

The ‘something wrong’ is the problem. Many people who are overweight or obese don’t see themselves are having a problem because in most cases the condition is asymptomatic. They may be surrounded by people who are of a similar body habitus and are therefore resistant to any notion that this body shape is in any sense abnormal. Finally for many people the idea that they might be able to change their shape is hard to swallow as in many cases they do not see results after weeks of effort.

For innovators a fundamental message is that there is no quick fix to healthcare problems because fundamentally humans are feeling not thinking creatures and therefore not responsive to messages that only tackle part of the drivers for change.

Picture by Philippe Put

Business R&D approaches may be the salvation of healthcare

There are lots of get rich quick ideas around. Just as there are lots of people who will tell you they can fix the healthcare system. But as the song goes:

There’s a guy works down the chip shop swears he’s Elvis
But he’s a liar and I’m not sure about you. KM

What really works requires knowledge of the business you want to fix, especially when you know what happens when the rubber hits the road, not a decade ago, not even five years ago but last Friday afternoon.

There are opportunities to improve every aspect of healthcare but that requires accepting one fundamental point:

People don’t really care whether their actions will please you or not.

People won’t change to please their doctor, their pharmacist, their mother or their government. They will adopt an intervention because it helps them do what they want to do for themselves. The opportunities lie in understanding how to work within these parameters. This is fundamental when it comes to business and people have made significant headway adopting this paradigm. Here are some ideas that demonstrate the power of knowing something about the needs and wants of the target audience:

  1.  Peerby from Amsterdam enables people to borrow expensive items from their neighbours, rather than splashing out on new products.
  2. Fortaleza Tour in Panama City is a walking tour set up by rehabilitated graduates of the Esperanza Social Venture Club — an organization dedicated to demobilizing Panama’s street gangs, integrating their members into society, and improving the area’s economy.
  3. Peru’s black vultures are well known locally for their natural aptitude for garbage location. In that country by fitting a flock of them with GoPros, the authorities collect real-time GPS data and enable the people to find the illegal dumps across the city of Lima.
  4. The UNPF is currently flying condoms, birth control pill and other medical supplies to the Upper East Region of Ghana using a fleet of long-flying drones.
  5. Many of the hosts on Airbnb are vacation property managers with multiple lettings. There are a number of startups offering management platforms and services that enable them to optimize their sub-letting business. Now, Parakeet is a platform that enables hosts to manage and monitor their property remotely via a cloud-based dashboard and keyless entrance system.

There are numerous examples of such out-of-the-box thinking. These innovations allow people to continue as before, to access equipment they hardly ever use but sometimes need, use their knowledge of a neighbourhood to make a living, use nature to monitor the environment, deploy technology to allow people to make personal choices and facilitate ownership of investment properties. The key aspect in each case is keen observation and insight.

This is needed in healthcare, local solutions that can be scaled to improve outcomes without imposing burdens on patients or practitioners. Nobody is as well placed to make these advances than those who already deliver and or avail of the services.

Picture by Cris

Someone’s son or daughter


There is increasing evidence that overweight and obesity exists in the context of families. There may be something about family dynamics that engenders or maintains the problem with excess weight gain.

  •  A 2004 study in the Journal of Pediatrics found that the biggest factor that predicted overweight in children was if the parents were also overweight.
  • Two-thirds of parents underestimate the BMIs of their children, especially when their children are overweight or obese.

Some data has even suggests trends according to relationship of the adults in the household:

  • Children raised by two co-habiting biological parents had the highest rates of obesity, at 31 percent.
  • But if those parents were married, the children had one of the lowest obesity risks, at 17 percent.
  • Children residing with an adult relative had a high (29 percent) likelihood of becoming obese.
  • But if that adult was their single father, they had a very low risk—just 15 percent.
  • The children of single mothers and those of co-habiting (not married) step-parents had similarly high rates of obesity, at 23 percent.


Non-poor children living with married step-parents had a 67 percent higher risk of obesity compared to similar non-poor children raised by married biological parents.

The authors of the study couldn’t explain why children in married parent households had lower probabilities of obesity.

The final word is:

Information on children’s health and nutrition must reach not only mothers, but the other caregivers (relatives, fathers, step-parents) with whom mothers and children regularly interact. It is also important to ensure that caregivers are in agreement about issues of nutrition and physical activity for children. Augustine and Kimbro

Once again stressing that innovations to tackle obesity need to consider the context in which the person with the problem is presenting for help. That person is someone’s son or daughter. What else are they coping with? Could anything you have done reduce their status to someone who fails to appreciate the first law of thermodynamics? If so, are you going to make a bad situation worse?

Picture by Niccolo Caranti

What will you say to your team in the new year?


Most of what is worthwhile in healthcare is a team effort. It also takes time to make a difference. Crossing the line is far more important than sprinting for a short distance. On this journey there will be disappointment and delay.

What’s more important than having goals is being resilient. Can you cope with the notion that things may not pan out as we planned? If that happens we will find another way together.

What qualifies each of us for the race is our ability to remain committed to the mission even when the hills are steep.

What will make the journey difficult is mainly in your head. The voice that whispers:

Give up now.

Giving up is an option today. It will be an option tomorrow and every day thereafter. But the team will keep going. The race has begun. What we will see along the way may live up to the promise or force us to consider an alternative route. What matters now is that we are on the road and moving in the direction that we have agreed is our goal. There will be respite there will be cheering and waving but in the end it will be effort that will get us over the line.

The race will make us stronger. We have been preparing for this. It doesn’t matter who crosses the line first, the crowd will cheer regardless and the team will have won. Each step brings us closer to our destination. We will be stronger, wiser and closer at the end of this journey. Nothing means more than having each other to share the adventure. It’s not the race that matters but arriving at the destination together ready for the next leg of the journey knowing that we have what it takes to go the course.

Picture by Peter Mooney

You can earn a living without making a difference


I liked him instantly. There was something very refreshing about his willingness to be honest.

I hate my job. I’m 63 and I’m taking orders from men less than half my age. I had hoped that I could retire from my previous job but they privatised the company and a bunch of us were made redundant. So I took what was offered. So now I have to do all this physical work. On my breaks I eat chocolate. It helps me feel better and besides I like chocolate and milkshakes. I say to myself ‘ it has to be good for you its milk right’? Is Pizza OK doctor?

Several different colleagues had seen the patient over the years. He knew perfectly well that chocolate; milkshakes and pizza were a bad idea. A dietician and the practice nurse had seen him. His blood tests exhibited a worrying trend. Nothing that had happened in the intervening couple of years had changed. His job situation was much as it had been when he was first diagnosed with type 2 diabetes. He had been seen at least three times in the previous year and the picture was the same. If he had refused medication that decision was not recorded. I could imagine the conversation, focusing on diet and exercise. He described sleep apnoea and breathlessness on exertion. He struggled to get through each day. His cravings for comfort food and his sugar addiction were showing no signs of abating. For people like him we watch what plays out like a car crash in slow motion. Will he make it much beyond retirement? Will the vascular disease that appears in my crystal ball be averted?

A systematic review on the effectiveness of self-management training in type 2 diabetes concluded that

No studies demonstrated the effectiveness of self-management training on cardiovascular disease–related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited. Norris and Narayan.

Our attempts to advise people like this man scarcely take account of their circumstances. Nowhere in his records did it tell me what this man did for a living, his hopes and dreams or his understanding of this unforgiving chronic condition. What was recorded was that he had received advice to lose weight (tick), to increase his exercise frequency (tick). His blood pressure had been measured at least three times in the past year (tick), lipids (tick), HbA1c (tick), renal function(tick), advised to see an optician(tick) and podiatrist (tick). According to our records he was receiving exemplary care. He was cast as ‘patient’ but not as a ‘person’. We knew nothing about where he lived, who lived with him, where he went on holiday, what he did at weekends, what he hoped to do when he retired. Nothing was noted about why he needs to do manual labour or whether he is in debt. In the fifteen minutes available this time we simply accepted that he was not going to change his lifestyle despite what I could tell him of the potential benefits. In return we shared a mutual concern for the risks he was harbouring. He would start medication and ramp up the doses until his risk for cardiovascular disease was reduced. Not a text book solution but then people are not cardboard cutouts. Our experience was supported by the results of research which reported that:

The core process of integrating lifestyle change in type 2 diabetes was multifaceted and complex. Challenges to the process of integrating lifestyle change included reconciling emotions, composing a structure, striving for satisfaction, exploring self and conflicts, discovering balance, and developing a new cadence to life. These challenges required acknowledgment in order for participants to progress toward integration. Whittemore et al.

Picture by Saxbald

Meet the emotion that drives fresh ideas


Whose choices would be limited by the adoption of your ideas?

  • Users
  • Your boss
  • Funders
  • Your employer
  • Government
  • God
  • All of the above

If the answer included any of the above you will experience the mother of innovation aka frustration. The same can be said of job satisfaction or happiness. Frustration is a powerful emotion to be greeted as the most effective teacher. It can literally drive you to think again so that eventually, some but not all people who experience it will find wisdom if not satisfaction lurking on the other side. Those who refuse to learn her lessons remain in the classroom unhappy. First work out which is the horse and which is the cart.

Two notable examples:

Instagram is changing the way we eat:

While looking at pictures of food can provoke a physiological reaction that makes the observer hungry, taking pictures of food can be an effective means of sticking to a diet. Menulog

Google searches are helping to identify epidemics of infections disease.

One way to improve early detection is to monitor health-seeking behaviour in the form of queries to online search engines, which are submitted by millions of users around the world each day. Ginsberg et al

In both cases the driver- Instagram and Google do not require the user to deploy their services specifically in order to achieve the requisite goals above. Innovations that depend on any one using a tool to solve one specific problem, for someone else, are going to meet our friend frustration.

People’s fundamental needs have been described long ago. First and foremost people need food, fresh air and rest. Then they need to feel their future is secure. After that they want to feel a sense of connection with others and to be valued in their social circle. Then and only then will they to compelled to creatively solve problems for other people.

Neither Instagram nor Google was set up only to help tackle obesity or infectious diseases. Both serve more fundamental needs in human society. How do your ideas fit in this paradigm? Is your latest innovative idea designed to be useful in very limited circumstances? In that case it will be of value to only a limited market and you will please a few people a little of the time. If that’s okay you will you have avoided frustration otherwise it’s back to the drawing board.

Picture by Brent Moore

Don’t curse the dark, light a candle


Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Dylan Thomas

My young colleague recently received the following note from the editors of a well known primary care medical journal:

Thank you for submitting your manuscript, [ Title here], manuscript number XYZ-601-14 Version 1, for consideration by the Most Important Journal of Family Medicine. The editors have completed their evaluation and we regret that we are unable to accept the paper for publication. This decision reflects a variety of factors, including the large number of manuscripts competing for limited space and the paper’s priority relative to others we are considering.

She was especially disappointed because the paper was summarily dismissed. Her submission was a painstaking review of the literature that demonstrates the equivocal evidence for the successful management of obesity in general practice. The paper was co-authored by two senior colleagues and she had been encouraged to submit it as a quality piece of writing. I could show her my collection of similar letters. I have kept them all. It seems, ‘space’ is lacking rather than the value of this young researchers offering. A researcher who will one day become a leader in her profession. Her paper will be published of that there is no doubt but not in that journal. An experience that is all too common for those trying to make an impression in the early part of their career.

Five years ago a team of us decided we’d like to make a small difference to people in this position and so, in 2008,  the AMJ was launched. We administered the journal on a shoe string budget and brought it to the attention of medical students via face book. In the early days it was hard work. In fact it was an expensive and time consuming hobby. Today the AMJ is an established and recognised peer reviewed medical journal, it is listed on most of the major databases and is entirely self sustaining. Some of the papers the AMJ has published have made an enormous impact.  It makes a small but reasonable contribution to the work of people who often find themselves sidelined because editors of the ‘far too important’ journals can’t see the value of their ideas or care how their dismissive and impersonal tone can crush their junior colleagues. And so we say to our colleagues, there is no point cursing the darkness because today with global access a mouse click away, with a little tenacity, it is possible to reach out to many. If only a few like minded people respond what started as a small candle in the gloom may one day become a beacon. At a time when primary care in so many parts of the world seems to be undervalued we need to do a small thing to assist our cause rather than whinging about how unfair it all is.

Picture by Justin McMurray

Primary care is not a panacea


Barbara Starfield’s thoughts still resonate with many of us who work in primary care. Primary care serves to reduce costs in a health care system essentially by keeping people out of hospital.  However, recently there have been attempts to tinker with how the sector is configured in many countries where one would have assumed that no adjustment was necessary.

The demand for general practitioner services continues to rise. It may be tempting to assume that the drivers for this trend are the same as they have always been: infections, gluttony, sloth, ageing, substance abuse, accidents and genetics. And yet the literature records that practitioners know very little about their patients biography. So what does primary care actually do and what does this tell us about the way forward?

We know that seeing a general practitioner is not going to ‘cure’:

  • Divorce
  • Child abuse
  • Boredom
  • Debts
  • Loneliness
  • Poor parenting
  • illiteracy

Seeing a general practitioner for ten or fifteen minutes, even quite frequently, isn’t going to change these circumstances. Perhaps a perceived failure to improve outcomes for people living with these problems is the driver for reform of the sector in parts of the world. At best primary care might help people to cope, at worst it might add to problems through iatrogenesis. Then there is a possibility that our inability to cope has a biological basis and that attempts to deal with the symptoms alone may be misguided. After all such thinking led to at least one Nobel prize for medicine.

If primary care needs to be reformed than the first issue is to recognise the limitations. For those who live in relative poverty, those with multimorbidity, those with competing priorities in complex lives more of the same primary care cannot be the only response to degenerative and chronic conditions.

Picture by Mike Smail

Removing the triggers to unhealthy choices

Much of the work in medicine is persuading people to give things up; tobacco, fizzy drinks, junk food, alcohol. Health professional also need people to do things- take medication, have surgery, keep appointments, exercise and so on. An entire industry profits on persuading people to make such choices and on helping doctors to sell more effectively. BJ Fogg has distilled such business into a simple equation.

My Behavior Model shows that three elements must converge at the same moment for a behavior to occur: Motivation, Ability, and Trigger. When a behavior does not occur, at least one of those three elements is missing. (Behaviour= Trigger+ ( Motivation+ Ability)

Our health and well being depends on how effectively doctors can do this. Notwithstanding that medicine hasn’t always got it right. Not that long ago doctors were trying to persuade people to take up smoking. Perhaps something like this could happen again, but I digress. The point is that health professionals are in the business of selling health messages, services and treatment. Last week I raised concerns about how some elements of this industry has taken to offering data as the key cue to action. Data elicitation and display has become a very profitable business. This week I explore this issue with reference to obesity.

It is often assumed that people make decisions about food and eating in rational conscious ways. However, if this were so, the obesity epidemic would not be happening. People overconsume in response to environmental cues and they lack insight into the extent to which their food choices and eating behaviors are being manipulated by sophisticated advertising and marketing techniques. They also have a limited capacity to sort through the increasingly overwhelming mountains of information and claims about food choices and, as a result, too often choose default option foods high in fat and sugar that, when consumed routinely, lead to chronic diseases. Deborah A. Cohen

So the challenge is trying to persuade people to eat less or at least less often. I offer four pieces of empirical advice to any of my patients who wants to lose weight some of which has come from the extensive review by Cutler, Glaeser and Shapiro:

1. Don’t put anything in your mouth while standing up other than a tooth brush-based on the observation that people consume a lot of calories while preparing food or snacking on the move.

2. Don’t eat other than at a dinning table- people often eat at their desks or worse, in front of the TV.

3. Don’t go shopping when you are hungry- it tempts you to bring things home that will sabotage your efforts to reduce consumption.

4. Don’t eat between meals…Duhhh!

Foggs Behavior Wizard suggests that to persuade people to decrease a behaviour:

  1. Remove the trigger that leads to the undesirable behaviour
  2. Reduce ability to perform the behaviour (make it harder to do)
  3. Replace motivation for doing the behaviour with de-motivators:  pain, fear, or social rejection

So the trigger that leads to the undesirable behaviour is the feeling that you are ‘hungry’. What Fogg recommends is:

When you design for persuasion, you don’t start by manipulation for motivation. That’s what you do last.

Therefore targeting motivation through calorie counting or calorie expenditure isn’t going to work. There are too many hours left in the day after you’ve consumed the few calories you need to lose weight and you have to do an unrealistic amount of exercise to be able to consume more. The real  problem is that people misinterpret four emotions associated with the urge to eat:

  1. Hunger
  2. Thirst
  3. Boredom
  4. Unhappiness

Therefore the trigger is often unrelated to the need for food and more to do with something else that hasn’t been acknowledged. To remove the trigger it must first be recognised as false. Therefore you might substitute or associate with another established trigger – namely answering a mobile phone or checking for email or facebook updates. By associating the urge to eat with checking an app on their mobile phone the person can work out if what they really want is food or something else. To reduce the ability to perform the behaviour (eat that popcorn, cake or choclate bar) the person needs to remove themselves from the place (physical or psychological) where the behaviour takes place- in front of the TV, at their desk at work or on the concourse at the station. This means either finding a new hobby, making a habit of only eating at a dinning table or carrying a bottle of water to and from work. Finally replacing the motivation for doing the behaviour with de-motivators could be part of the proposed solution by offering a diary of the poor choices that have tempted the individual between meals. I look forward to sharing a solution soon. Wearable not required.


Quantified self – the downside

The manufacturers of wearable health tech devices are set to make millions if not billions. Wearables are relatively cheap adjuncts to existing technology. But what difference will they make to the health and well being of the average user?  We have been offered a preview of what these devices can do- monitor your heart rate, blood pressure and blood glucose. Keep track of your respiratory rate, calorie expenditure and sleep patterns. Detect cardiac arrythmias and abnormal brain electrical activity. It sounds good, but so what? If you experience a significant drop or severe rise in blood pressure you are going to notice even before you check the readings- you will feel very unwell. Similarly low blood sugar and dysfunction of the respiratory or cardiac system. Do we really need our smartphone to tell us we aren’t taking enough exercise and eating too much? Or that it’s time to see a doctor urgently? I agree with Jay Parkinson:

The exclusive-to-human part of our brain evolved so we can be creative and manipulate the world around us so we can invent things like the iPhone. And now, the creators of the iPhone want to give us the tools we need to badly do what evolution solved for us hundreds of millions of years ago.

Here’s the problem with this technology in practice:

About 10 percent are “quantified selfers” with an affinity for this kind of feedback; just by looking at the numbers, they are motivated to be more active. An additional 20 percent to 30 percent need some encouragement in addition to tracker data to effectively change their behavior. Kamal Jethwani

Therefore the vast majority of people who buy a wearable device right now will not benefit from that purchase. Those who do, might be amenable to other interventions. Unfortunately much of the data is meaningless or has no impact on long term decisions about health and well being. Sure, a trend in high blood pressure over a few weeks might indicate a need for treatment but a single high reading might be an anomaly or simply confirm that you are excited. Worrying about every little bleep on the chart is not going to add to your quality of life but will detract from it. For a sustained and beneficial change in life style people need more than data. They need motivation and help to workout the benefits of making different choices. They need the undivided attention of a practitioner who understands their needs and assists with a bespoke plan.

Information that we need right now, which our built in human senses may not already have alerted us to is another issue; microscopic haematuria (blood in the urine) proteinuria (protein in the urine), faecal occult bleeding (blood in the faeces), raised intraoccular pressure (high pressure in the eye ball) and changes in moles, breast or testicles will prompt doctors to investigate for sinister causes. Investigations that might lead to the early diagnosis of some costly and treatable or life limiting condition. Acquiring this information doesn’t require you to wear a device continually for a year. The business case for manufacturing devices to do that isn’t as compelling because of a limited market. Enthusiasts for wearables argue that:

Studies are beginning that examine the data from wearables, which is much more granular data about human activity than scientists have been able to access previously. This will answer questions like: how much of an increase in activity, of what type (moderate or cardio-challenging) leads to what degree of health benefit? Todd Hixon

What we may also discover is that there are probably side effects associated with wearable devices. Psychological harm may be associated with prolonged and heightened anxiety and obsession with self. What we won’t discover (and this is a guess) is that there is a short cut to losing weight that doesn’t require any significant effort. We might also discover that there are limited indications for wearable devices and that the market for them is much smaller than we envisage. Parallels exist with some parts of the pharmaceutical industry which has begun to promote ‘illnesses’ that would benefit from it’s offerings. So called disease mongering. We may well find ourselves being circumspect about wearables in the way that we have misgivings about drugs:

…drugs approved for devastating illness, such as clinical depression, are indicated for milder conditions, such as shyness, which is now dubbed ‘social phobia’. Howard Wolinsky

Data is no more the answer to all problems than are drugs. The indications for collecting data have parallels with the indications for prescribing drugs and how and why that data is collected merits thought. Those who promote the use of wearables need to question a trend which isn’t without a downside.