Beyond Carrots… and Sticks

NOTE:  This blog post talks extensively about the book Drive, by Danial Pink.  I purchased this book years ago, and I have never had any contact with Mr. Pink, his representation, or his publisher.  This is 100% my thoughts on the book and how it relates to living with diabetes.  Also, I encourage anyone reading this to go buy the book.

Not too long ago I saw a lot of attention given to the remarks of the incoming International Diabetes Federation President with respect to “fear arousal.”  Many (myself included) took this to mean health care providers should use to some degree fear in their interactions with people with diabetes.  To be certain, the pushback was pretty hard.  

I also chimed in with the following tweet:

This entire Twitter thread had me thinking very much about the motivation behind living with diabetes.  To be clear, there isn’t any “opt out” of diabetes, but to remain on the path, there are many days when just plain habit doesn’t do it, and I need to find some motivation.  

The most familiar motivation structure is the penalty/reward structure.  This is also known as the carrot-and-stick approach.  Meet a certain goal, get a reward (carrot), don’t meet the goal, receive a penalty (stick).  If I had to choose between a penalty and a reward, I would choose a reward structure.  It is just my personal preference. But the reality is that I don’t think carrots and sticks work for managing diabetes.  For the longest time, that is where I was on the carrot – stick continuum, mostly because that was the motivation structure that was familiar to me.

About five years ago, I came across the book “Drive,” by Daniel Pink.  For me, it was one of those fascinating non-fiction books that I could not put down once I started reading.  In Drive, Mr. Pink postulates that behavioral and economic studies have long shown that the typical carrot and stick reward structure only works well under a very narrow set of circumstances.  For pretty straight forward tasks, carrot and stick can be a very good motivator, but for complex tasks, it can actually demotivate people.  His book drive is all about how people working on complex tasks are motivated and stay motivated.  I’m going to expand on that a little bit and try to bend this theory to diabetes management, but first, I encourage everyone to view two short videos to get up to speed.  This first one is a Daniel Pink lecture with marker board animation to make it interesting.  Its about ten minutes, but I think it is time well spent.

The second video is a TED talk given by Mr. Pink.  It covers much of the same ground as the first video, but there are a few interesting additions that are well worth watching:

So now that we are all up to speed, there is one thing I want to address up front.  I believe Mr. Pink’s primary audiences are business managers and workers looking for a better motivational structure.  With this given audience, it is entirely appropriate to discuss pay (salary) and profits.  So a lot of his end conclusions tie back to a better motivated staff will result in better business.  Within the diabetes community, our larger goals are not aligned towards anyones profit or business.  Our goals are aligned with better and longer lasting health.  So keep that in mind.

As detailed in Drive, there are three factors that lead to better performance and satisfaction are; autonomy, mastery, and purpose.

Autonomy – First, a quick note:  autonomy is not correlated with “no rules.”  This is not “Let’s get a bottle of tequila and rummage through our spice rack to find the undiscovered magic bullet to solve diabetes.”  That is not what we are talking about. 

When I think of how autonomy is described in Drive and how it relates to diabetes, my first thought goes to “eat to your meter.”  Isn’t that what we are really saying?  Rather than burdening ourselves with lists of “good” food and ‘bad” food, or setting daily or meal-based numerical goals, have a talk with your health care professional, and eat healthy meals.  Check your BG before and after (y’all know the drill), adjust as needed based on feedback from your meter.  In this way, the autonomy to plan healthy meals and correct as necessary motivates us to find what works and what doesn’t.

Mastery – Mastery is a pretty universal motivational factor for people with diabetes.  The most immediate application I see is to cooking.  Since my diagnosis, I have been working pretty hard to find the right combination of spices and marinades to cook chicken breasts.  I have expanded from my basic knowledge of Italian seasoning and Mexican seasoning to include, jerk chicken, harissa, and I have been recently experimenting with Nando Peri-Peri sauce to make a Portuguese chicken.  I’m getting close.  Next year I will take on Peruvian chicken and hopefully, Puerto Rican chicken fricassee.  As you can see, by applying mastery, I have been motivated to find a variety of healthy chicken recipes.  I use them as part of my rotation of lunches (over mixed greens) and as an entree for dinner.  

Other examples of applying mastery might be to stretching exercises such as Tai Chi, or running your first 5k (or 10K!).  This factor is practically limitless, so long as you make the positive decision to get good at something, the motivation will also come along.

One last note on mastery, there is one other YouTube video on Drive that is worth watching.  This one is not narrated by Mr. Pink, but it does highlight a case of mastery, using the Swedish shipping firm Green Cargo as an example.   It appears about 4:15 into the video. In this example, the firm started doing performance reviews a little different.  Rather than yearly reviews, managers met with their employees monthly to determine if the employees were overwhelmed or underwhelmed in their current job.  The manger then worked with the employee to determine a “Goldilocks” work assignment for that employee.  These assignments are intended to be not too hard or easy, but designed to be a little above the employee’s ability.  As time went on, employees began to master the work of the business, and productivity increased.  Now, think about having a discussion with your HCP and collaboratively working out “Goldilocks” goals for exercise, diet, and wellness.  Wouldn’t that set the table to be more motivated between quarters?

Purpose – If there is one motivation factor that people with diabetes have that the folks in the business world might not, my bet would be on purpose.  Although diabetes may seem invisible to the uninitiated, we see constant reminders of the disease that lives within us everyday.  Our purpose is to meet the challenge of this disease every day, and to wake up the next morning and do it again.  Where I think we could do better is relating this purpose to the everyday.  It is so important to remember the purpose behind the foods we eat, the stairs we climb, and the medicines we take.  If we can take a moment to remind ourselves that we are doing these things for a purpose, they become more important – they become worth doing.

So there you have it.  Diabetes management is a complex task.  I believe (and I hope you might agree) that carrots and sticks don’t work as motivational tools.  We need a different set of rules, and I believe Autonomy, Mastery, and Purpose go a long way to stay motivated when dealing with diabetes.  So the next time you sit down with your health care team, talk about some of these concepts.  

Fear Arousal

UPDATE: A good friend provided me with a link to the #IDF2019 conference in Busan, South Korea. In my opinion, Dr. Boulton’s remarks at the conference are reasonably consistent with the interview referenced below. I encourage everyone to view Dr. Boulton’s remarks. His remarks start at approximately 2:21:45 (h:mm:ss) and are about ten minute in length. Also, watch a little longer to see Renza’s response!

I need to start out with an apology.  Due to the dynamics of a global diabetes online community, I woke up Wednesday morning on the North American east coast and shortly after read the following tweet:

I had not begun to drink my morning coffee, and as my brain took in the tweet, I mistakenly thought the speaker that was being tweeted about was talking about health providers using fear when discussing diabetes with their patients.  I took a few minutes to gather my thoughts and tweeted:

Upon reflection, the waterboard comment was over the top, but I have to apologize for misreading the original tweet too.  As the day progressed through morning, afternoon, and now sunset, I came to the conclusion that I needed to blog about this; and I needed to make sure I had this quote right before I started.  

The quote about fear and diabetes comes from the incoming President of the International Diabetes Federation (IDF), Dr. Andrew Boulton.  To be clear, Dr. Boulton is clearly a leader in the diabetes community.  He has earned numerous awards from diabetes organizations around the world and is a prolific author. He is also a past president of the European Association for the Study of Diabetes.  

That being said, there has been a steady stream of concern coming out of the IDF conference currently going on in Busan, South Korea.  My first indication was the tweet shown above.  Then the following tweet showed up in my feed:

and also the real-time response from the amazing @RenzaS:

So I wanted to get more background to start talking about this.  However, as with almost all conferences, it is difficult to get the presentations and/or speeches while the conference is going on.  Typically, you have to wait for the proceedings to be published.  So I began to look around to find background material.  I had a feeling that Dr. Boulton probably had said these things somewhere before.

Now, I can’t say for certain that this is what was said in Busan, but Dr. Boulton was interviewed back in 2017 by Christine Wiebe at Medscape.  The text of the interview can be viewed here.  It is a pretty quick read, and all of the essentials that we have seen today are there.  Here is probably the key part:

Right now, governments still don’t take diabetes very seriously, especially compared with the attention and funding dedicated to cancer. Leaders of the diabetes community could learn from efforts to raise awareness and drive research in the field of cancer, he said, as well as from efforts to increase cancer screening.

“Fear arousal works,” he says. Many more people now get mammograms and other cancer screenings because they don’t want to die of cancer.

Unfortunately, prevention and screening are harder to “sell” with diabetes.

“The thing is, it’s not very sexy to take off your socks and shoes,” Dr Boulton says, referring to diabetic foot exams.

After reading this, I went back and re-read that original tweet that stirred my response this morning.  That is when I knew I was incorrect.  The Doctor is not talking about health care professionals, he is talking about a marketing campaign based on fear arousal.  Using fear to generate awareness, research, and screening.

There is more too.  Part of the interview touches on the very things that @RenzaS was talking about:

“We need societal adjustments as well,” he says. Cities and buildings need to be designed in ways that encourage healthier lifestyles, such as improving public transportation and walking paths. Advocacy organizations, such as the International Diabetes Federation, need to be more proactive in advancing the diabetes agenda.

So there at least is some common ground to build on outside of the discussion of fear.

So like I said, this is not a transcript of what Dr. Boulton said in South Korea today, but this past interview gives some indication as to the basis of his remarks.

Now, I still stand by the content of my morning tweet. Carrot and stick motivational tools are simply the wrong approach to the complexities of diabetes self-management.  With some time and distance, I now realize that Dr. Boulton was most likely speaking to the audience of non-diabetics, and not people with diabetes.  

After quite of bit of contemplation and thought, I have been trying to find the words to respond to a campaign of fear; even if the campaign of fear is conducted in the name of advocacy, research, and screening.  In addition, it has been my experience that when speaking about chronic or terminal disease, it is best to be as specific as possible, and to not speak in generalities. We all live complex lives and our relationship with disease is also complex, so there is a multiplier effect.  It may be that because Dr. Boulton has spoken in generalities that we are having this conversation at all. The problem is that any response also has to speak in generalities, and I will be the first to admit that Dr. Boulton is a much better speaker than I am.  So just a quick caveat.  I’m going to push forward, but as I do, I don’t wish to offend or misrepresent anyone.  I’m typing through a minefield here, so please, constructive criticism is welcomed, if I get it wrong let me know, I want to learn.  However, please don’t take this personal – that is not my intent.  Also, please go back and re-read the linked article above.  I need to take some quotes here, and I don’t want anyone to lose context.

First, I am uncertain as to what Dr. Boulton is referring to when he says “fear arousal works.”  What is “working?”  Dr. Boulton offers, “Many more people now get mammograms and other cancer screenings because they don’t want to die of cancer.”  So this indicates the comparison of diabetes to cancer (personally, I think this is a poor path to follow).  I posit that the best next step in this course would be to follow-up the subjective language (“many more”) with actual numbers to show the dramatic difference in cancer vs. diabetes screenings and polling data showing concern about a cancer diagnosis vs a diabetes diagnosis.  

On the other hand, I wonder about this approach, painting the cancer community as based in a fear arousal campaign.  Currently here in the United States the American Cancer Society current advertising campaign emphasizes the supportive role of the non-profit organization. Highlighting free rides and lodging around chemotherapy treatments. Patients (or actor portrayal of patient, I’m not sure) are portrayed as hopeful, somewhat smiling, and making aspirational statements about the future.  Maybe the age of fear arousal has passed, at a minimum, it is an interesting juxtaposition given this time and place.

Moreover, when talking about patients, it has been clear to me that people with diabetes are often portrayed as causing the disease themselves.  This is reflected about midway through the subject article with Dr. Boulton: 

“Studies show that about one half of all type 2 diabetes causes could be prevented with lifestyle adjustments, Dr. Boulton notes. But the burden of prevention should’t be placed on individuals alone.”

This is where I think Dr. Boulton may ultimately come up short.  Again, I don’t know what was said at the conference in South Korea, but given the similar themed article from 2017, Dr. Boulton states that half of all type 2 diabetes can be prevented, essentially shaming 50% of the type 2 community (and really shaming all of us, because none of us know if we are in the 50% that he states brought it on ourselves).  At the same time he advocates for what I suppose is a marketing campaign to instill fear in the greater population.  Maybe I’m foolish, but living in a world where millions of people living with a disease are shamed while simultaneously the general population is subjected to a campaign to arouse a fear of the same disease is something more appropriate in Panem, or New Chicago, or The Glade than 21st century earth.  

I believe that Dr. Boulton should be applauded for putting research, advocacy and screening at the forefront of the International Diabetes Federation agenda.  He is a talented and well respected leader in the diabetes community.  However, I do not believe arousing fear is the proper way to move forward.