Thursday, October 6, 2016


One of my favourite areas of psychology has to do with the study of persuasion, and of the cognitive biases involved with this.

There are two very important researchers who have written extensively about this:  Robert Cialdini (an expert in the psychology of persuasion), and Daniel Kahneman (an expert in the psychology of cognitive biases).   

Cialdini: Persuasion
I highly recommend that everyone be familiar with Cialdini's work, because it relates to making good decisions in the modern world.  Cialdini has spent decades studying the persuasive techniques which are used in sales and marketing, with the rigorous and thoughtful eye of a scientist and experimental social psychologist.  A problem with Cialdini, however, is that his books seem too focused on an audience of business people and marketers. 

Kahneman: Cognitive Biases
Kahneman's work focuses more on the cognitive mechanisms that affect judgment, and this area is an important complement to Cialdini.   Kahneman is the only psychologist to have won the Nobel prize!  His psychological work is very relevant to economics--it is a quantitative look at how human cognitive biases affect all decision making, including small and large economic or financial decisions.  
Why is this Important?
Cialdini -- and probably Kahneman too -- are most appreciated by people in the business community, especially marketers, since their ideas are likely to help any business earn more profit.  But I think these ideas should be part of everyone's knowledge base, since they will help us all to protect ourselves from being influenced by marketing in an unwelcome way.   Not just obvious marketing, such as commercial advertising, but also subtler forms of "marketing," such as experiencing persuasive forces in the workplace, in the media, in politics, and even in our personal or social lives.  

Persuasive Factors
In his initial work, Cialdini described 6 factors contributing to persuasion:
1) Reciprocity.  If someone gives you something, you will be more apt to give something back, including your approval or support!   If you are treated to lunch, you will be more likely to comply with someone's request afterwards!  This is a normal, natural thing, and even part of good social skills...but be careful about this, because sometimes the person giving you a free lunch may have an agenda to change your mind about something that you would otherwise not want to change.  A very troubling example of this in current events is of extremist groups providing free food, shelter, and other care to people in need...while helping people in need is wonderful, it also leads the people receiving this help to be more likely to join the extremist group!   We can address this problem politically by making a big effort to help people in need long before an extremist group does, rather than focusing only on military solutions to such problems!  

2) Consistency. Once you have done a certain action, or agreed to a certain thing, or committed in a small way to a certain thing, you are more likely to go further with that same thing in the future.  If you once joined a particular political party, you will be much more likely to keep supporting it in the future, even if you would otherwise disagree.  If your parents and grandparents have always supported a certain political or religious group, you will be more likely to also support the same group, since it could seem inconsistent, or even a "betrayal," to change your mind or your actions.  This consistency can be a great thing--it is part of maintaining a personal or community culture.  But it can also cause people to be "stuck" with ideas or behaviours which are unhealthy or harmful, yet with a resistance to change.   Marketers use this phenomenon all the time, by encouraging you to become a "member" of a points plan for a particular business, to have consumer "loyalty" programs, by having you formally endorse one of their products, which leads to a long-term tendency to choose the same products again.   
Be careful about this one!  Consistency is good, but not if it prevents us from changing our mind when change is needed.  Some of the most disastrous events in world history happened when people's consistency and commitment led them down a dark path...

3) Social Pressure, or Social Proof.  If you see that something is becoming more popular, you are more apt to support it.  Suppose you are starving in the woods, and you see bushes with berries on them.  You are not sure whether they are poisonous or safe.  If you see other people happily eating those same berries, you will obviously be reassured that they are safe, and you will happily pick some berries for yourself!  In this case, social proof is very useful and protective.  But marketers routinely use information about social proof to push us to support things or buy things.  Even the polls that we see in the media can have this effect:  if someone claims that a particular candidate is soaring in popularity, many people will be more likely to join in and support that person as well.  This effect is especially pronounced if the social proof comes from people who are similar to us in some way.  For example, if you are shown that most people who are around your age, and who come from a similar ethnic background, and who share similar cultural interests, are all supporting a particular political candidate, you will be more likely to be persuaded to support this candidate as well.  
Once again, this is a normal and often efficient way to make decisions in life, by assessing the decisions that similar people are making already.  It is what Kahneman calls a "cognitive short-cut."  

But marketers use this factor all the time, to push us to support things, or to buy things, that we otherwise would not want.   

4) Liking.  If someone you really like asks you to do something, or to change your mind, you are more likely to comply!  This is again a completely normal, understandable, and often useful human behaviour.  But be careful with this one!  Marketers, politicians, and even people in your social circle could sometimes push you to make decisions you otherwise would not make, just by being nice, and by being "likeable."  The stereotype of a "con man" usually includes being physically attractive, charming, and superficially likeable.  Be careful not to let these factors affect your judgment more than you want!  

5) Authority.  This is a huge factor, both in the marketplace and in a professional work environment.  It is another very useful cognitive short-cut to assume that an "expert" has good advice.  Often the expert or authority (such as a famous doctor or researcher) really does have useful advice and wisdom!  But people are easily prone to shutting off their critical judgment if they are told something by an expert.  In many cases, an expert may have a particular agenda for change which is not directly related to their expertise.  And in many cases, a speaker may be granted more "authority" or expert status than is reasonably warranted.  For example, it is a tradition for speakers at a meeting or conference to be introduced with a glowing biographical vignette, summarizing a list of very impressive credentials, degrees, awards, and a publication record.  These facts may be completely accurate, but it is important to know that this introduction will increase the speaker's persuasive influence over the audience...While this is often useful and reasonable, it could also often give the speaker license to influence the audience about all sorts of things that are outside of their expertise!  

I have seen this in my work very often:  a speaker with impressive credentials is greatly respected by the audience.  The speaker's ideas about treatment strategies (e.g. medication or therapy approaches for treating depression) or about health care policy (e.g. how to set up an efficient medical system) are accepted by the audience in a much more uncritical way, with much less reasoned debate, than would be the case if the same ideas were shared without the introductory eulogy about credentials!  

Be careful when you see a commercial featuring an esteemed expert or authority endorsing a product.  The information you hear should be considered seriously, but remind yourself that you may exaggerate the validity of this information, simply because you respect the expert's authority.  Always question authority!  Don't reject it outright, but always question it!  

6) Scarcity.  If you know that something is rare, or disappearing, you are more likely to desire it more.  This factor is routinely used in sales and marketing:  if a particular product is "disappearing fast,"  or if you are told it is your "last chance" then you are more likely to be interested in it.  If you are guided to believe that you have some kind of rare, special, personalized knowledge about something, then you are more likely to act on it. 
In marketing and politics, the fear of loss can have an exaggerated influence on people's decision making.  The fear of loss of security or safety can lead to a greatly increased focus on policies addressing this (e.g. military or policing issues).  While it is reasonable to focus on such things, ironically the fear involved can distract attention away from other policy factors which would ultimately have a much better chance of improving safety (such as enhancing diplomacy, improving education, focusing resources on eliminating poverty, etc.) 

In Cialdini's more recent work, we could add another factor, one which Kahneman has talked about extensively as well.  It is something which all the other 6 factors incorporate to some degree as well:  

7) Guided Attention & the Focusing Illusion
If our attention is guided towards something, we are much more likely to assume that this thing is important, and that it has some causal influence.  A magician or illusionist routinely makes use of this...most magic tricks involve carefully guided attention, so that we don't notice the magician fooling us, right in front of our eyes!   I encourage you to look at some YouTube videos showing clever illusionists using this phenomenon; here's a good example:

This factor is arguably the most powerful of all persuasive influences.   When a person or a group is focusing on something, we will be guided into thinking that this focus is more important and causal than it really is, and it will prevent the person or group from asking other important questions!  

Cialdini gives a good example of this, having to do with the journalists who were allowed to cover a recent war.  The journalists were given unique, unprecedented "embedded" access to soldiers in their daily lives.  On the one hand, this allowed a valuable transparency about the goings on in the war.  It led to a focus upon the daily dramas in the life of a soldier:  the harsh climate, the food, the camaraderie and bonding with fellow soldiers, and especially the heroism, bravery, and self-sacrifice involved in the battles.   As a result of this focus, the viewers would form an understandable and healthy attachment to the human stories on the battleground, and would form a completely normal and healthy admiration for the bravery and nobility of the soldiers.  But--because of this, the viewer would be less likely to question the strategy of the war itself!   

The manner in which a story is focused upon can distract us from asking other questions about the story, which may need to be asked!  

In a work environment, there could be a new policy scheme, which in some ways could be similar to the example could involve honourable, devoted, intensive efforts from many warm-hearted people, all of whom nobly striving towards making things better.  But once such a plan is in action, the attention of the group becomes focused upon the daily "battles" and human dramas associated with enacting the plan.   The group is much less likely to question the strategy of the plan itself, even if the plan is unhealthy or harmful.  

One can see this in political movements:  supporters of a particular political party or candidate are working very hard, are forming strong social and emotional bonds with the cause...they are motivated honourably, often with strong wishes to make the country better.  There are daily struggles with polls, with debates, with interviews, with criticisms from opponents...these struggles are analogous to a battlefield.  The stories involved with the battles are dramatic and engaging, and the media on both sides of the battle are eager to focus on them.   But because of this, supporters are likely to simply focus on continuing the battle they started, rather than pausing, reflecting, thinking deeply, and being willing to change their strategy or beliefs if necessary and morally right.   


So, this is what I mean by "GroupThink."  It is going along with what other people are thinking...due to reciprocity, consistency, social pressure, liking, authority, and the focusing illusion...we then risk getting caught up in things that aren't good for us.  

"GroupThink" can often be efficient, to get certain tasks done.  If everyone in a group is constantly stopping, reflecting, and questioning themselves, then the group's actions could be frozen...but we must always at least be aware of how powerful "GroupThink" is, and how it affects all of us.  The antidote for this, the way to keep this force balanced, is to always be willing to question things!  

Be willing to question others, even authorities, even people whom you really like!  Be willing to question yourself!  Just because you have thought, felt, or done a certain thing for a long time doesn't mean you can't change your mind, your feelings, or your actions!   

Be aware that there are powerful persuasive factors in our lives, all around us...we don't have to be afraid of them, but we do need to know that it can be easy to follow these factors passively.  We can live healthier, happier, more satisfying lives if we take some time to step back, think carefully about our decisions, and be willing to speak up!  

Friday, September 16, 2016

Mental Health Care Triage

What is Triage?

"Triage" is a term used in medicine, referring to the process of deciding the order in which patients should be seen and attended to, if many are waiting.

If you are waiting for something, such as for a table at a restaurant,  the first person to arrive is served first.  An even higher priority is also given to people who have made "reservations," or who have arranged their appointments in advance.

In an emergency room, a different system is needed.  Even if you have been in the waiting room for several hours with a broken ankle, a person just arriving with a heart attack must be seen right away, before you!   It generally would not work to make "reservations" at the emergency room, except maybe if you are on your way in an ambulance.

Triage involves not only deciding what order in which patients should be seen, it also involves deciding what type of service should be provided to each person.

If everyone with abdominal pain was sent to a surgeon, it would be inefficient...most cases of abdominal pain do not need surgical treatment.  If these non-surgical cases were all seen by the surgeon, then the surgeon would be too busy to deal with the true surgical emergencies!

In mental health care, it can be efficient to have a triage process.  But how to do this?


The most common strategy is to offer some form of "assessment" which then could guide a triage decision.  This usually would involve an interview.  It could involve filling out questionnaires.  Based on the results of the interview and the questionnaire results, a decision could be made about whether some form of counseling might be needed, or perhaps a visit to a physician, a referral to a psychiatrist, or even an urgent trip to the hospital.   In other cases, a bit of simple reassurance, simple lifestyle or self-care advice might be really helpful.

The benefits of an efficient triage process would be that others in the system could then see clients or patients whose particular problems or levels of severity were well-matched to the skills of the particular caregiver.  All caregivers in the system would spend less time dealing with situations that were outside their scope of experience or expertise.

Potential Problems 

What are some of the potential problems of a mental health triage process?

1) The first issue has to do with the reliance on a single interview, and on questionnaire data.  In a great many cases, this is an efficient, helpful process.  But in some cases, an ongoing relationship is needed to understand mental health issues.  People may not be willing to share sensitive issues with someone who will only be seeing them once.  People may not be willing to divulge sensitive information in a questionnaire, which will then be handed in to a stranger.   Some people may have a very clear reason to desire a therapeutic relationship of a particular type, without wanting to explain their reasons in detail to a stranger who would only be seeing them once.

So the triage system, involving interviews and questionnaires, must have the flexibility to accommodate situations of this type.  Basically, it should have strong consideration for patients' or clients' wishes for privacy, discretion, confidentiality, and therapeutic resources, while not being rigidly adherent to questionnaire or interview data.

A simple remedy for this problem can be for individual patients or clients to have the ability to make a direct request for a particular type of care, without having to "jump through the hoop" of a triage assessment visit.  Many people who desire a therapeutic relationship will not benefit from going over their history with a stranger who will not be seeing them in the future.  In fact, the triage step will just add to their stress, and could lead to a feeling of having to negotiate yet another bureaucracy.

2) The second issue has to do with the quality of life of people working in the system.  In my experience, emergency psychiatry is a very stressful area of mental health care.  Practitioners in this area can often become burned out or even cynical over time, if this is the only type of work that they are doing.  The reasons for this are not simply related to the severity of the problems seen in the emergency room:  it is also because emergency workers usually do not follow the patients or clients after their emergency visits.  Therefore, they do not get to see their patients or clients recover!  They may not have the satisfaction or enjoyment of working with someone over a period of time, and seeing their progress.    Furthermore, if they are only doing emergency or triage tasks, their clinical skills for doing other types of ongoing health care will weaken or atrophy.  

I believe that a big part of the joy of being a therapist or a physician, involves getting to know your clients and patients on an ongoing basis, sometimes for long periods of time.  It can be demoralizing and stressful to only be seeing people a single time, or only be seeing people who are severely ill.

There is a simple remedy for this problem:  in any triage system, or emergency care system, it can be valuable for different staff to take turns doing triage tasks.  Each staff person should also have the opportunity, at other times,  to follow some patients or clients for ongoing care.   This would help staff to maintain better morale, and to maintain better clinical skills beyond "assessment."

3) A third issue has to do with the risks of a supposedly "efficient" system becoming more and more like a mechanical or impersonal bureaucracy.   As questionnaire-based systems become more and more prevalent, we may start talking more and more about "PHQ-9" scores, and less and less about a person's story.   Furthermore, score-based assessments in mental health may lead to false conclusions about what is truly helpful.  For example, a person in great distress may enter an emergency room on a Friday night with an extremely high score.  That person might have an unpleasant experience on a stretcher in a noisy hallway on Friday night, then a frightening experience on a busy emergency ward for the next day.  On Sunday afternoon, the symptom questionnaire may be repeated, yielding a greatly reduced score.  The conclusion may be that the emergency room experience was profoundly helpful!   In this case, the symptom score diminished because of the passage of time, and perhaps because of a physical place that was safe in some ways.  Other types of harms may well have been done because of this experience (for example, the person may dread ever having to go to the hospital again), but this harm would not be detected on a cross-sectional symptom scoresheet.   The harm would be apparent, however, if we were to have a conversation with this person rather than just give them a questionnaire.

Symptom questionnaires are very imperfect guides, and should never be the foundation of any type of health care, especially in mental health  (see my previous post about questionnaires:  I do think they have their role, and people could be invited to use them, but there is a risk of both the patient or client, and the caregiver, paying too much attention to questionnaires, and too little attention to other aspects of care or need.

4) A fourth issue has to do with allocation of health care resources.  While triage could improve efficiency, and allow more people to get the help they need, it could also in some cases be an unnecessary bureaucratic hurdle.  The same money and resources spent on a triage system could instead be spent simply hiring more counselors, who could manage their own triage.  In many private counseling regimes, a person seeking a counseling relationship is already "self-triaging" and can inquire on their own with the therapist about the possible types of care available or needed.  

This issue is similar to the Electronic Health Records (EHR) issue:  an innovative device, triage system, or "model" may be useful in some ways, but it must always be in service of a higher value, which is to provide personal, empathic, attentive, ongoing care to those who desire it, and to allow a healthy, balanced, meaningful work environment for therapists.

Wednesday, September 14, 2016

Electronic Health Records (EHR)

Electronic health records allow for a variety of improvements in medical practice and health care:

Communication between physicians can be improved.

Lab results can be coordinated and exchanged efficiently, with a reduction in the chance of results being overlooked.

Patients or clients of a health care service can become more directly involved in perusing their own health records, and therefore could have a more empowered, active role in their health care.

Some systems can also allow prescriptions, other treatments, and symptoms to be tracked efficiently over time.

Patients could also contribute information (such as providing a history, filling out questionnaires about symptoms, etc.) directly into the system, which could make the clinical time with a health care provider more efficient and more personal, less focused on "data gathering."

Problems with EHR

Yet, there are a variety of problems associated with the use of computerized health record systems.  

Impact on Rapport

I think the worst problem is the potential impact on rapport during a health care visit.  If your physician or therapist is fumbling with a keyboard, and staring at a screen, instead of paying attention to you, this is poor quality of care, and threatens the therapeutic relationship.  This is potentially harmful to clients or patients, and is also potentially harmful to the well-being of the physician or therapist.  

You could compare this to having an "appointment" with a friend...if your friend is busy checking a cell phone or typing on a computer keyboard during dinner, or during a forest walk, the technology will harm your friendship!  When such behaviour becomes more frequent, more of a norm, more trendy, people tend to simply go along with such things, rather than insist that the device or gadget be turned off.  I think it would be better to complain to your friend about it instead, and to insist on having a conversation, or to insist on just walking quietly through the forest together!  

In some of the meetings I have attended over the past few years, I have seen people enthusiastically talking about new apps and gadgets in therapeutic settings (such as collaborating with clients using an ipad), yet part of the irony of these meetings was that the presenters or audience members were themselves so engrossed with their laptops or with their other gadgets that they had very little eye contact or social connection with those around them, and perhaps not a lot of awareness that their gadget-preoccupation was even a bit of an annoyance to their neighbours.  

Corporate Influence: 20 Billion Dollars!

Another problem with electronic records has to do with economic factors.   The EHR market is worth about $15-20 billion dollars globally, and is growing rapidly! *   This is enough money to fund 400 000 therapists, each earning $50 000 per year.

The corporations producing EHR software and machinery profit financially from sales. Clinics or hospitals using EHR will need educational sessions with representatives of the tech companies.  This is a potential conflict of interest issue:  it is similar to having medical education sessions organized and led by pharmaceutical reps.  The educational sessions are marketing opportunities for representatives of the EHR software company to consolidate adherence to a product.  Much of this education is sincerely useful for staff and beneficial for clients or patients, and the educational sessions may come with sincerely positive intentions.   But there are biases favouring a continuing business relationship with the software corporation, separate from considerations of patient or client care.  

Literature Review of EHR Problems

What does the academic literature have to say about this?  We have a pertinent article just published:  Susan Hingle, in Annals of Internal Medicine (Sep 6, 2016, doi 10:7326/M16-1757), reviews the use of electronic health records. Here is a quote from this article: 

Sinsky and colleagues confirm what many practicing physicians have claimed: Electronic health records (EHRs), in their current state, occupy a lot of physicians' time and draw attention away from their direct interactions with patients and from their personal lives. Observers documented that for every hour of direct clinical time with patients, physicians spent 2 additional hours on EHR and desk work, and physicians reported spending up to an additional 1 to 2 hours of after-hours personal time completing documentation and EHR tasks. These observations have important implications for patient care and outcomes...A recent study found that physicians who use EHRs and computerized physician order entry have decreased satisfaction and a higher risk for professional burnout. Physicians who burn out are at a significantly greater risk for depression and suicidal ideation, and there is also concern that they are more likely than satisfied colleagues to provide lower-quality patient care and to leave clinical practice early, although this is difficult to fully measure...Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system that will redirect our focus from the computer screen to our patients and help us rediscover the joy of medicine.

Here is another article, expressing similar concerns, from the Washington Examiner, published in October 2014 by Richard Pollock:

Another critical article, from the point of view of nursing staff in a hospital:

Here's a good article published in 2016 by Suzanne Coven, in Stat:

Despite these concerns, I do acknowledge the potentially useful role of computers, electronic records systems, therapeutic apps, etc.  But I think this gadgetry must never be focused on at the expense of highly personalized care for each client or patient.  As I have said elsewhere, I think these innovations can be truly great advances, but they can be a bit like giving children gifts at Christmas or birthdays:  children may get excited about a new toy, and may even become conditioned to expect more and more expensive toys as time goes by.  The toys may be great toys!  They could even be "educational"!

But the "gift" that children (and all the rest of us) really want and need is care and attention from loved ones.  Without this, the toys are worthless, and may even cause the children to have a deteriorating, materialistic quality of life.  

The impact of gadgetry and computers in health care affects not only clients or patients, but also caregivers, clinicians, therapists, and office staff.  It is important to consider staff quality of life, and staff satisfaction with work, as essential components in choosing health care strategies.  "Efficiency" and "optimal data collection" may seem to be desirable goals, but such efficiency is insidiously negative if it does not allow for a healthy workplace environment.  This is similar to managing a nation's economy:  a bottom-line view of maximizing economic efficiency may lead to increased overall financial wealth in a society; this is easy to measure, and therefore could be irresistible for policy-makers to follow.   But such optimization of efficiency and wealth can often lead to a decline in the morale and well-being of the population, if it is not balanced by other factors.  A reduction in efficiency, if it means more time for family, and better care of the environment, can sometimes lead to far greater wealth than anything money can buy.  

So in order to move forward with this issue, I do not suggest that we abandon EHR technology.  It is a potentially useful and innovative tool.  But we must never let our tools or toys distract us from providing a caring, empathic, human interaction.  We must never let a pursuit of efficiency or the acquisition of data have a higher order of importance  than caring, empathic, personalized health care. And we must be wary of corporate influences on health care policy, especially when large amounts of money are involved.

If you are affected by this issue, I encourage you to offer constructive feedback to your health care provider.     

Thursday, August 18, 2016

Psychiatrists diagnosing public figures

I was reading an article today discussing the ethical problems involved when psychiatrists or psychologists apply a psychiatric diagnostic label to a public figure.

One big focus of objection in this article had to do with giving a "diagnosis" without actually seeing the person or doing a proper assessment.   Another concern had to do with the propriety of using a "professional voice" as a mental health care specialist to influence a political matter directly, possibly using diagnostic terminology that could have a pejorative quality.  In this case some of the terms of concern include "narcissistic personality disorder."

It's an interesting issue.  My addition to this debate may seem to support both sides of it!  First, I think it is somewhat arrogant on the part of psychiatrists to assume that they ever have some particular diagnostic wisdom, even with ongoing "assessment." Diagnostic terminology such as "narcissism" should be optional, informal language to be used, if at all, with the patient's consent and endorsement, for the purpose of helping the patient improve health.

One particular diagnostic label is arguably determined more exclusively by a person's observed behaviour, and that is antisocial personality.  Evidence about a pervasive pattern of past criminal acts, cheating, cruelty, etc. contribute to the use of the "antisocial" or "psychopathic"  label.  In this case, the motive of such terminology can go beyond that of offering the patient optimal care:  this type of "diagnostic" consideration relates to public safety, for example to evaluate the degree of risk a violent offender or abusive person might have to harm others in the future.

It may be that in some cases a professional such as psychiatrist might have more experience seeing people with potentially dangerous behavioural phenomena, such as antisocial personality, and have some ability to recognize and voice the risks associated with this.  With some cases of antisocial personality, it is possible for there to be an attractive and charming persona which can act as a sort of disguise, leading others to greatly underestimate risks.

I think it is deeply ethical to warn the public about such things.

But, I think it is unethical to wield a diagnostic label as part of some sort of pejorative, rhetorical attack against anyone.

I also think that specialists such as psychiatrists should be a great deal more humble about diagnostic opinions in any case.

A compromise, in my view, could be to voice general concerns about potentially dangerous behavioural syndromes, to share the opinion that such dangers can coexist with a charming and popular personality, and therefore to encourage great caution about following political trends, without very careful reflection on the cognitive biases that can occur in such situations.

This is the same kind of advice a marketing expert or a social psychologist might give to someone who is shopping for a used well-informed about the risks!  The seller may have great integrity, but there is the risk of the seller only having a "facade" of integrity, and of telling you whatever you want to hear, in order to sell you a defective car at a disastrously high price.  There are some ways to be more accurately informed about such integrity, such as by considering patterns of past behaviour involving the person in question.

Psychiatrists should be able to speak freely about political matters, but there are ways to do this without a potentially unethical and inappropriate foray into diagnostic labels.

Wednesday, August 17, 2016

Sugar and Mental Health

There are a lot of people who make dietary recommendations.  It can be hard to figure out whom to believe.

There is a huge amount of money involved in food marketing, weight loss marketing and programs, and books about nutrition.  According to ABC News, the U.S. weight-loss industry brings in about $20 billion of revenue annually.  Another source claimed a worldwide market of a staggering $500 billion or more, for industries related to weight loss.

The issue of weight loss and food policy is a sensitive one, given the high prevalence of obesity as well as eating disorders in the modern world.   These nutritional and metabolic problems are associated with strong feelings of depression and anxiety, negative thoughts and belief about self, guilt, shame, and frustration.   Of course, there are life-threatening physical consequences of obesity as well as of other eating disorders such as anorexia. 

There are now some good documentaries available describing the history and dynamics of the food industry, particularly the industries which supply sugar and corn syrup.  For example, the films "Fed Up" (2014) or  "Sugar Coated" (2015) introduce the viewer to troubling information about large corporations sweetening the world's diet, despite abundant evidence of dangers to health.  The sugar industry has been compared to the tobacco industry, in the way that health concerns have been minimized or suppressed.   A lot of commercial advertising and other marketing directly targets children from an early age; many children associate various sweet food products with play activities, friendly cartoon characters, free toys, etc.  Some fast-food manufacturers sponsor health-related events or even resources for terminally ill children; while such charitable work is admirable, recent documentaries encourage us to consider it comparable to a cigarette manufacturer or a cocaine dealer sponsoring similar charities.   If we associate these companies with such altruism, we may be more apt to feel good about consuming their products.

Ironically, sugar itself is a required component of human metabolism.  Glucose is the main fuel for the brain.

Yet, the best way for the brain to obtain this glucose is from a diet low in sugar!  Pure sugar or other simple carbohydrates in the diet cause a sudden surge in blood glucose, triggering a cascade of hormonal changes.  Aside from the insulin response, there is a surge of pleasure from consuming sugar, which triggers an addictive behavioural sequence.

A habit of consuming sweetened foods leads to a reduction in the consumption of other nutrients.  As one develops a habit of eating sweeter things, non-sweet food items are likely to taste more bland.  It is hard for many people (especially starting off in childhood) to nurture a taste for vegetables when there are candies, ice cream, cake, cookies, or chips to choose instead.

As a component of improving mental and physical health, it is worthwhile to greatly reduce the amount of added sugar in the diet.  This reduction would be satisfying, not only due to direct improvements in your health, but also because you would be shifting your financial support away from a massively wealthy and arguably corrupt food industrial complex, towards a more wholesome industry of local farmers.

Smaller intakes of sweets and simple carbs are likely to improve your appreciation of the esthetics of other food.  Cutting sweets is not some kind of spartan sacrifice!  It will lead to greater joy and hedonic pleasure in your meals!  As you reduce sugar, your "addiction" to it will subside, allowing you to savour the tastes of all other foods, without the flavours being swamped by sweetness.  If you do end up having an occasional sweet treat, you will be able to enjoy it more thoroughly, with a smaller amount of sugar needed in the recipe.