Some insights on fitness and health trackers- Helping? Hurting???

Posted on June 15, 2016

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“An especially useful starting point for an aspiring healthcare company would be to think about ways to deliver a “positive good.”  Most contemporary medicine is generally regarded, economically, as a negative good – something we use or engage in because we have to, not because we especially want to.  While this creates a ready market, it’s also results in a tense and uncomfortable relationship between the “producers” of healthcare – who have often invested a significant amount of resources with the intention of making a profit – and consumers, who have little choice but to pay (or co-pay) for expensive care, and consequently tend to resent it.

Back when I was in the clinic, I remember feeling confused by patients who would complain about the cost of care while seeming to have few qualms about the going on pricey vacations or buying expensive gadgets.  On reflection, however, I think the key difference is that patients at least felt they had a choice about buying a gadget, and liked selecting something they thought they might enjoy.” 

Said in 2011, from What Silicon Valley Doesn’t Understand About Medicine (bolding mine).

If you work in healthcare, or are aspiring to, it’s worth understanding not only do people almost always genuinely not want to see you (there can be some exceptions, personal training for some), but how strongly that feeling might be. Add to this the ever increasing cost of seeing a healthcare provider, and now we venture into animosity. People don’t care you went to school for 30 years. We care we had to leave work to see you, for something we don’t want to be dealing with, that it costs $150 for the 90 minutes we spent at your office, 15 minutes of which was spent with you, 10 of those 15 minutes in which you were staring at a computer screen.

-> There are reasons doctors have a suicide rate 140% greater than the general population. One would assume constantly dealing with people who don’t want to be around you is one of them.

There was a revealing question on Reddit. It was something like “Why don’t people take their medication every day, when they know it will increase their lifespan?” It linked to an article showing the majority of people don’t want to take a daily heart pill, despite it increasing their lifespan. 30% would rather die early than take the pill!

Someone answered “One reason I don’t take my medication is because I don’t want the daily reminder I’m going to die soon. The piece of mind I get by not taking the pills is worth the trade off of dying sooner.”

Continued,

“The opportunity here for technologies companies is to develop an attractive and engaging platform that will warmly incentivize positive behaviors, and help patients nudge themselves in healthier directions.  The business case hinges upon its voluntary adoption, rather than obligatory usage.”

This notion technology of being reminded more of your deteriorating health, having 18 different sounds for 18 different reminders how you need to log your food into MyFitnessPal today, or how it’s time to go for a walk, take this med take that med, that screw putting the calories on everything, but let me take a picture of my food to tell me how many calories is in it, because that will get me to not eat a burger, that people will voluntarily want to do this stuff…Just say it out loud and you realize how farfetched it is.

-> Hmm, perhaps our problem. The Valley doesn’t like to speak out loud. Only in code.

“The results are in for the Scripps Translational Science Institute’s Wired For Health study, and there’s no sugar-coating it: they’re disappointing for those working in digital health. The six-month randomized control trial found no short-term benefit in health costs or outcomes for patients monitoring their health with connected devices.”

Here.

And no difference here.

Annnd here.

And then there is this issue:

“For instance, a recent study from Duke University suggests that what benefits are derived from the apps can often come at the cost of enjoyment, especially in areas such as fitness and exercise monitoring.

“In general, tracking activity can increase how much people do,” the authors say. “But at the same time, measurement has these pernicious effects. Enjoyable activities can became almost like a job, by focusing on the outcomes of things that used to be fun.”

The results emerged across six experiments whereby participants tracked their behavior on apps and recorded their enjoyment levels as they went.  It transpired that whilst people generally became more productive in each task, their enjoyment levels dropped.  What’s more, this outcome emerged even when participants actively chose to use the apps.

“We’re curious creatures and tracking information is very seductive, even for enjoyable activities,” the researchers say. “Simply making it available made them want to look at it, but the very people who self-select into measurement are the ones who are hurt by it.”

This often led to less participation when activities were not being tracked, thus having an adverse affect on how much exercise might be done in future.”

Making healthy living less enjoyable is quite high up on the hierarchy of things we want to avoid.

One justification for the Scripps study finding no benefit,

“We learned a lot, but the fact that it wasn’t a positive trial, with respect to reducing economic burden is probably not so surprising because we only followed the people for six months, and many would project that you need much more follow-up and a much larger sample size to be able to show the burden,” Topol said. “The good part is we didn’t add any burden economically. A lot of people thought, if people have access to their data they’re going to end up tapping more into medical resources. Well, we certainly didn’t see that. So that was encouraging, but obviously we would have liked to reduce the need for emergency rooms and office visits and hospitalizations. That could still be out there, but this is just the beginning of studying that question.”

  1. Six months is plenty of time to see health benefits. This study came out a few weeks after the Scripps one. It tracked people for a year. Same thing. No benefit. Time is not the problem here.
  2. There was a burden, because 1) people using their electronic device more has an economic influence 2) as seen in the other study, happiness can go down when tracking.

My experience has been for those who are already attuned to their health, likely already in good shape, they like tracking and it can help them. But for others (most), it’s inadequate. That’s not to say there isn’t any benefit in it, but it’s currently not at all, and is surely not looking to be, transformative.

What I do with my clients in regards to tracking is recommend they monitor something if they’re having trouble with it. Want to get more steps? Track it for a week or two. Eat less? Track calories for a couple weeks.

But after that, it’s not usually needed, nor do I harp on it. It’s good to get a baseline to really know where you’re at, but once you get that, you tend to know what’s needed from there. Where then maybe every few months, perhaps your weight stalls, you start tracking again to double check things.

Exercise? For my in person clients, I track it for them and barely tell them anything about it. I don’t want them bothered with it. Remote clients tend to see the progress more as they’re reading the programs themselves, but we barely talk about why the progress is what it is. They primarily know the numbers to it, and rarely ask why they are what they are. One reason they hire me is so they don’t have to think about it. I want them primarily doing, not thinking. It’s more enjoyable for them that way.

It’s like playing a sport. If you’re playing basketball and being mindful of your shooting percentage the entire time, that’s not fun. It’s also going to influence how you play. Or even watching a sport. Nobody enjoys sitting next to the person rattling off statistics the entire time. Shut up, have a beer, and boo the other time with the rest of us.

With other things, like blood pressure meds, or diabetes, if the increased prospect of death doesn’t get one to take a pill everyday, good luck making an app or tracking device which corrects that.

Atul Gawande has a beautiful essay called Slow Ideas. He details the differences in adopting certain behaviors. In behaviors which require more from a person, ones which make things harder, “pain in the ass” changes, a human element is likely needed. It’s why salesman say they need seven contacts. (Even with doctors. Just handing them research papers isn’t enough.) It’s why politicians still spend so much time doing things in person. Knocking on doors. Intimate fundraisers. Why a democrat does speech after speech in Iowa, but not in California. They’re asking for “pain in the ass” votes. Persuading people to do one behavior over another. To do something nobody likes to do: give up money. We can learn your views by reading your website; we still want to see you / here you / communicate with you. We don’t want to merely be yelled at on twitter over and over, “Vote for me!”

Martin Luther King Jr. > Any individual protesting on social media ever.

Changing people’s behavior is work. It’s why MLK’s autopsy revealed the 39 year old had the heart of a 60 year old. When he saw an area with problems, he went there. He wrote letters to the people of that place. He did interviews. He didn’t merely take some form of a megaphone, or send mass amounts of junk mail to people’s door step, and yell “Do this!” He went, he marched, he shook hands. He didn’t only ask others to protest the buses, to sit at the white counter, to stand outside courts protesting, to not shop certain places, he did it himself. He went to jail with the others. He knew he should stay in jail as long as the others did, illustrating he deserved no special treatment. Can we expect apps with no humans on the other end to simulate this?

-Wake up in the morning, hit up Facebook, alright now Insta time, ay, who be tweetin’ me???

-Such and such is trending. You know what, I don’t like that either.

-Type 140 characters in “protest”

-Walk out of bed with a little swag, chin held high, “Well today has been productive so far #ChangeTheWorld”

Not coincidentally, the studies which have found some benefit from trackers? They’ve used something like text messaging which attempts to mimic human contact. Like motivational messages. Not surprisingly again, it looks like this needs to be done at a frequency of at least once a week. The studies referenced above, like the one year study, did involve coaching, but only an average of 9 times. 9 follow ups in 12 months is not enough. (Again, discussed in this link.) Imagine if the human contact were once a week or more.

I’ve found the same thing. Only being in contact with people once every couple weeks, or once a month, is rarely enough. If it is enough, they’re the person who probably doesn’t need tracking help anyways. They need the treatment, but not help following it.

We’ve already seen 15 minute sessions with doctors going “You need to lose weight. You need to take your medication. You need to do this this this this this” is futile. Taking these 15 minute sessions and condensing them into daily two second sessions (like a vibration from your phone), do we really expect much to happen from that? Beyond wasting electricity, time, money, data centers, and increasing animosity? True story:

(Well, at least in this case the doctors aren’t on the receiving end.)

Unless we’re talking getting AI to the level it can have regular human conversation and understanding, then we’re avoiding the biggest work element of all this. This idea we’re going to, on a mass scale, hand people an app, device, diet book, workout program, whatever, then be able to say “You’re cured,” needs to die.

And one has to wonder if any technology can change behavior like humans can e.g. if you could make it so someone who was overweight only started hanging out with non-overweight people, can a technology simulate that? (I guess virtual reality is coming to fruition?) Can you simulate empathy when you know the interface has been programmed to be empathetic? Can a technology sweat with you? Or go to jail with you?

There is a great example of this going on right now. Some in the media world have run specials on Trump voters, trying to understand why they’re voting for him. The commonality seems to be he speaks like a non-politician. Like a politician would never be coached to speak. His lack of roboticism seems to be his biggest strength. “He speaks like me.” George W. seemed to have a lot of the same thing. “I could have a beer with him.” I work in a city which is incredibly conservative. People still say this after those eight years.

“What about, you know, how those eight years turned out?”

“Hey, not everyone is perfect. He wasn’t as bad as people make it out to be either. Plus I don’t trust Obama. I just don’t like him.”

How often does likability…trump…facts or logic?

Finally, a blueprint for changing human behavior was made 50 years ago.

“There were weaknesses in Albany, and a share of the responsibility belongs to each of us who participated. There is no tactical theory so neat that a revolutionary struggle for a share of power can be won merely by pressing a row of buttons. Human beings with all their faults and strengths constitute the mechanism of a social movement.”

Martin Luther King Jr., from his autobiography.

Virtually all the tracking devices are aimed at helping the obesity issue. The most recent numbers have us at 37.7% of the United States being obese. That’s a social issue, necessitating a social movement, requiring humans. Giving people a tracker, at least in the way they’ve been done so far, and expecting a social movement is as silly as MLK giving people flyers saying “Don’t be racist,” and expecting that to be enough.

A lot has dramatically changed in 50 years. The deepest elements of human nature have not.

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