# **C. Individual decision-making that affects NCD habit formation**

When it comes to caring for one’s health, individuals are asked to make frequent decisions, often without adequate information or the ability to interpret and use information. Behaviors may not be viewed as health risks, or may be driven by a motivation completely unrelated to health. For example, lack of knowledge on the nutritional content of a meal can lead to unhealthy eating, either due to a misperception of the nutritional content of a given meal, or because the decision was made without nutrition as a salient factor. The same is true for lack of knowledge about how to interpret nutritional information or to connect information (e.g., about calories and protein) with foods and serving amounts using the information provided on food labels. Interventions that have changed food labeling by simplifying it and increasing salience suggest that information presentation is as important as its provision. For example, a regulatory change in Chile mandated that a simple warning about high calories and high sugar be placed in front of products in store displays. This change led to a reduction in the consumption of sugary cereals by consumers adjusting their beliefs regarding how healthy certain cereals were (Barahona et al., 2020; Araya et al., 2020).

Information, however, needs to be aligned with individual motivational factors that can affect NCD formation. These factors are related to the internal, both reflective and automatic, processes influencing decision making and human behavior. Present bias, our tendency to value instant gratification more than future benefits, and time inconsistency, our tendency to be impatient when choosing between receiving benefits today and receiving them in the future, are two examples of these automatic processes. The emphasis on the short term at the expense of the long term occurs because people perceive the present as tangible, while the future is abstract and hypothetical. Present bias creates self-control problems that affect many health behaviors, from exercising, eating healthy foods, and getting a mammogram to other preventive or protective health behaviors (defined by effort today and benefits tomorrow). Benefits today versus costs tomorrow factor in when people smoke, overeat, skip health visits, and more (Luoto & Carman, 2014). A short-term gratification focus is at odds with healthy habit formation. Reflexive thinking that continuously prioritizes instant gratification (watch television over exercising) or impulses to smoke, drink, or eat unhealthy foods can end in unhealthy habits being formed.

Another psychological barrier informing NCD formation is overconfidence; both overestimating one’s performance and over-ranking one’s performance relative to others. Overconfidence explains risk-taking behavior, including risky health behaviors. Some people understand heart attack and cancer risks from unhealthy behaviors such as overeating and smoking but tend to believe themselves less vulnerable to negative outcomes than their peers, even if they adopt risky behaviors (Khwaja et al., 2007, Khwaja et al., 2009). Della Vigna and Malmendier (2006) show overconfidence in habit formation related to exercise: many gym members overpay, as they exercise too little, and propose overconfidence about future selfcontrol as one possible explanation for such observed behavior.

Arni et al., (2021) measured health perception biases -- their label for overconfidence -- using objectively measured cholesterol and blood pressure in Germany and found that 30 percent of the population have biased perceptions about their cholesterol levels. The researchers also found that about 30 percent of respondents overestimated their rank in the population health distribution by at least 30 ranks relative to a reference group. Furthermore, greater overestimation of own health was associated with more engagement in unhealthy behaviors, such as consuming unhealthy food, not exercising, and sleeping fewer hours. This 11