The Contradictions Within


Childhood Obesity News left off last time with speculation about whether clinical trial subjects, who might otherwise be tempted to somehow violate protocol, could be inspired by altruism to do better. This question is especially interesting for children and adolescents, who already have issues around their relative lack of power in the world.

Can the chance to take part in an important scientific study help to rev up the motivation? Can the vital nature of the mission impress kids enough so they take very seriously the need for full cooperation? Can a simple appeal to scientific integrity inspire them?

Various authorities have explored the issue of ownership, and language is a tool in promoting this idea. For instance, the Cenduit corporation characterizes their experimental subjects as “stakeholders,” which of course they are. The literature for one of their products reads as follows:

Patient Reminders are personalized, automated SMS, email, and voice messages sent to the patient or caregiver. Reminders help stakeholders arrive on time and prepared for their clinic visit. The result is higher quality investigational procedures completed within the time window demanded by the protocol and reduced instances of patient early withdrawal and lost to follow-up.

Perhaps that is a clue. A fertile field for inquiry is how to gain a real investment of commitment from the participants. Dr. Fred Kleinsinger mentions this detail:

I know that the term “nonadherence” has replaced “noncompliance” in some circles because “nonadherence” is less value-laden and does not imply a rigid hierarchical relationship between physician and patient.

Of course, we always hope that people will act in a way that makes sense. Whether undergoing a course of treatment laid out by the family physician, or participating as a subject in a big formal research project, we hope that people will act in ways that benefit themselves, but surprisingly they often do not. We also hope they will do the right thing regarding the study protocol, perform the actions they are supposed to perform, and refrain from the others.

In 2002, psychologist Daniel Kahneman was awarded the Nobel in economic science. His research and writing partner Amos Tversky would have won too, were he not already deceased. Together they proved that humans are not nearly as rational as we suppose. They did what Jim Holt calls “ingeniuous experiments” and discovered more than a score of cognitive biases that can twist our thinking processes into knots of futility.

The two-person team posited the existence of two separate operating systems in each of our minds. For convenience they are called System 1 (automatic, instinctual impulses and reactions) and System 2 (self-control, which is effortful). Kahneman wrote:

Constantly questioning our own thinking would be impossibly tedious, and System 2 is much too slow and inefficient to serve as a substitute for System 1 in making routine decisions. The best we can do is a compromise: learn to recognize situations in which mistakes are likely and try harder to avoid significant mistakes when the stakes are high.

This may seem far afield from obesity, but exactly what is going on when an obese person is confronted by a brand new bag of chips? System 1 urges immediate and thorough consumption, while System 2 struggles to think rationally over the rustling sound of a torn package. By the time System 2 reports in with the logical analysis — “This will not benefit your effort to achieve better health” — the mouth is already experiencing a crunch orgy and a salt rush.

The words of a famous commercial — “Bet you can’t eat one!” — prove true once again, as the heedlessly delinquent System 1 taunts, “Are you kidding? I can eat one whole party-size package! Ha ha ha!”

Your responses and feedback are welcome!

Source: “Patient & Protocol Compliance In Clinical Trials,”, 03/30/15
Source: “Understanding Noncompliant Behavior: Definitions and Causes,”, Fall 2003
Source: “Two Brains Running,”, 11/25/11
Source: “Of 2 Minds: How Fast and Slow Thinking Shape Perception and Choice [Excerpt],”, 06/15/12
Photo credit: cajsa.lilliehook on Visualhunt/CC BY-SA

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About Dr. Robert A. Pretlow

Dr. Robert A. Pretlow is a pediatrician and childhood obesity specialist. He has been researching and spreading awareness on the childhood obesity epidemic in the US for more than a decade.
You can contact Dr. Pretlow at:


Dr. Pretlow’s invited presentation at the American Society of Animal Science 2020 Conference
What’s Causing Obesity in Companion Animals and What Can We Do About It

Dr. Pretlow’s invited presentation at the World Obesity Federation 2019 Conference:
Food/Eating Addiction and the Displacement Mechanism

Dr. Pretlow’s Multi-Center Clinical Trial Kick-off Speech 2018:
Obesity: Tackling the Root Cause

Dr. Pretlow’s 2017 Workshop on
Treatment of Obesity Using the Addiction Model

Dr. Pretlow’s invited presentation for
TEC and UNC 2016

Dr. Pretlow’s invited presentation at the 2015 Obesity Summit in London, UK.

Dr. Pretlow’s invited keynote at the 2014 European Childhood Obesity Group Congress in Salzburg, Austria.

Dr. Pretlow’s presentation at the 2013 European Congress on Obesity in Liverpool, UK.

Dr. Pretlow’s presentation at the 2011 International Conference on Childhood Obesity in Lisbon, Portugal.

Dr. Pretlow’s presentation at the 2010 Uniting Against Childhood Obesity Conference in Houston, TX.

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