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ESRC Obesity, Food and Physical Activity Seminar Presentations

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We are the Bristol Social Marketing Centre (BSMC), based at The University of the West of England in Bristol. Here you can view the full set of presentations from our recent ESRC funded 'behaviour change' seminar on Obesity, Food and Physical Activity. The seminar took place on 11th September 2014 at The Royal Society, London. Speaking at this event were:

Dr Geof Rayner (Chair)
Professor Susan Jebb OBE
Dr Harry Rutter
Professor Ken Fox
Professor Colin Greaves
Dr Justin Varney
Professor Gabriel Scally

This was seminar 2 of 9, and details of the other topics in the series can be found here: http://www1.uwe.ac.uk/bl/research/bsmc/esrcseminarseries.aspx
Alternatively you can follow the blog for updates: www.esrcbehaviourchangeseminars.blogspot.co.uk
Or follow us on Twitter: @bchangeseminars

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ESRC Obesity, Food and Physical Activity Seminar Presentations

  1. 1. ESRC Behaviour Seminar (2) 11 September 2014 Obesity, food and physical activity Some introductory considerations... Geof Rayner
  2. 2. Continuities from first ESRC behaviour seminar • Understanding behaviour requires an interdisciplinary perspective, that is to say looking across disciplines • Behaviour, and the focus on changing behaviour, have risen as ‘policy themes’. This too requires analysis. • Differences exist in terms of purpose. For some changing behaviour is a technical matter (from public order to public health); for others it raises broader questions (ethics, ideology, democracy, sustainability). • There is a huge diversity of theories, models, interests and foci. Any consensus on theory or preferred policies might be unrealistic, but might there be consensus on points of agreement and/or disagreement?
  3. 3. The theorisation of behaviour • The word ‘behaviour’, since its origination in English in the C15th (as comportment), has become extended to any form, type, or quality, of behaviour, ranging from human behaviour to organisations, processes, even inanimate matter. • Public discussion– mediated by opinion formers - defaults to a narrative of individual behaviour, with minimal discussion on the determinants of behaviour or social environments shaping behaviour. • Behaviour is the focus of rich social scientific traditions. Considerations of the social basis of human behaviour and human reflectiveness is central to pragmatism (Pierce, James, Mead, Dewey), developmental and social learning theories (Vigotsky, Piaget, to Bandura), and critical theory (Habermas, Joas) – and many more theoretical approaches. • Neoclassical economics departs from this unity of view by virtue of its commitment to methodological individualism. ‘Behavioural economics’ adapts behavioural themes to an otherwise neoclassical stance.
  4. 4. Mead: the principal theorist of the social character of ‘mind’ and ‘self’ • Mentality on our approach simply comes in when the organism is able to point out meanings to others and to himself. This is the point at which mind appears, or if you like, emerges…. It is absurd to look at the mind simply from the standpoint of the individual human organism; for, although it has its focus there, it is essentially a social phenomenon; even its biological functions are primarily social. (My emphasis) George Herbert Mead. "The Biologic Individual", Supplementary Essay II in Mind Self and Society from the Standpoint of a Social Behaviorist (Edited by Charles W. Morris). Chicago: University of Chicago (1934): 347-353.
  5. 5. Experience and reality • The immediate experience which is reality, and which is the final test of the reality of scientific hypotheses as well as the test of the truth of all our ideas and suppositions, is the experience of what I have called the “biologic(al) individual.”…[This] term lays emphasis on the living reality which may be distinguished from reflection…. Actual experience did not take place in this form but in the form of unsophisticated reality. (My emphasis) George Herbert Mead. "The Relation of Mind to Response and Environment", Section 17 in Mind Self and Society from the Standpoint of a Social Behaviorist (Edited by Charles W. Morris). Chicago: University of Chicago (1934): 125-134.
  6. 6. Implications • While reflectedness (or reflexivity) defines humans, a large part of human behaviour is unreflected upon. • Humans exist within social environments, these having biological and material underpinnings. • Unreflected human behaviour links to primary necessities, what ecological (visual) perception theorists (Gibson & Gibson) call ‘affordances’. • Modern habit theorists (eg Bargh) consider unreflected behaviour through the conceptual lens of ‘automaticity’. This is applied to affordances like food (Cohen) or energy artefacts and processes. Gibson, E. J. (1969). Principles of Perceptual Learning and Development. New York, Appleton-Century-Crofts Gibson, J. J. (1986 (1979)). The Ecological Approach to Visual Perception. Hillsdale, New Jersey, Lawrence Erlbaum Associates.Bargh, J. A. and T. L. Chartrand (1999). "The Unbearable Automaticity of Being." American Psychologist 54(7): 462-479. Wyer, R. S. (2014). The Automaticity of Everyday Life: Advances in Social Cognition. New York, Taylor & Francis. Cohen, D. A. and T. A. Farley (2008). "Eating As an Automatic Behavior." Preventing Chronic Disease 5(1): 1-7.
  7. 7. What are the implications for population weight? • Human biology and physiology is biologically set, it is the environment which changes, with implications for physiology. • Changing physiology has been extensively mapped by ‘biological standard of living theorists’ (some reject this terminology) • The first diet/nutrition transition was positive. (Fogel)The new transition transfers the focus from height to weight (Komlos). Fogel, R. W. (2004). The Escape from Hunger and Premature Death, 1700-2100: Europe, America and the Third World. Cambridge, Cambridge University Press. Komlos, J. (1995). The Biological Standard of Living in Europe and America 1700- 1900. Studies in Anthropometric History. Aldershot, Variorum Press. Komlos, J. and M. Baur (2004). "From the tallest to (one of) the fattest: the enigmatic fate of the American population in the 20th century." Economics & Human Biology 2(1): 57-74, Floud, R., et al. (2011). The Changing Body: Health, Nutrition, and Human Development in the Western World Since 1700. Cambridge, Cambridge University Press. Floud, R., et al. (2011).
  8. 8. Body-mind shaping factors • Diet/Nutrition Transition – disease consequences predicted by Dubos from 1950s to Popkin today. • Energy Transition –Lotka’s evolutionary view that successful species take more energy/exergy from environment (exosomatic energy) is today seen as physiologically and ecologically maladaptive. (Georgescu-Roegen to Roberts & Edwards) • Cultural Transition – ‘Consumerisation’ overtaking cultural traditions and community, (Bauman), including role and meaning of food. Dubos, R. J. (1968). So Human an Animal: How We Are Shaped by Surroundings and Events. New York, Transaction Publishers. Popkin, B. M. and P. Gordon-Larsen (2004). "The nutrition transition: worldwide obesity dynamics and their determinants." International Journal of Obesity and Related Metabolic Disorders 28(Suppl 3): S2-9. Lotka, A. J. (1922). "Contribution to the Energetics of Evolution." Proceedings of the National Academies of Sciences 8: 1947. Lotka, A. J. (1925). Elements of Physical Biology. Baltimore, Williams and Wilkins Co. Georgescu-Roegen, N. (1975). "Energy and Economic Myths." Southern Economic Journal 41(3): 347-381. Bauman, Z. (1998). Work, consumerism and the new poor. Buckingham, Open University Press Roberts, I. and P. Edwards (2010). The Energy Glut: the Politics of Fatness in an Overheating World. London, Zed Press.
  9. 9. Current research • The current research effort on diet, nutrition and body weight is vast (but is it inconclusive?) • Foresight gave a systems account of obesity, with individual behavioural factors at the margins. Systems behaviour – the ‘obesity system’, seen as significant determining influence. • The focus on obesity and on behaviour is justified – but the focus, framing conventions, and policy implications need to be scrutinised. • What are the implications of population weight gain for societal governance? • Is the narrative of ‘obesity’ a de facto medicalisation of nutritional, biophysical and cultural circumstances, now spreading world-wide irrespective of behavioural traits and cultures?
  10. 10. What is needed to tackle obesity, why is progress slow and what needs to be done? Professor Susan Jebb Department of Primary Care Health Sciences University of Oxford susan.jebb@phc.ox.ac.uk
  11. 11. Foresight Obesity Project Tackling Obesities: Future Choices Initiated by Prof Sir David King, Government Chief Scientist AIM: To produce a long term vision of how we can deliver a sustainable response to obesity in the UK over the next 40 years www.foresight.gov.uk
  12. 12. Societal influences Individual psychology Biology Activity environment Individual Food activity Consumption Food Production
  13. 13. Developing a strategy: The portfolio response • Systemic change across the system map • Interventions at different levels: individual, local, national, global • Interventions across the life-course • A mixture of initiatives, enablers and amplifiers • Short, medium and long term plans for change • Ongoing evaluation and monitoring
  14. 14. Societal Influences Biology Activity Environment Individual Activity Food Consumption Food Supply Individual Psychology
  15. 15. Interventions are needed at multiple levels Foresight, Tackling Obesities: Future Choices, 2007
  16. 16. A life-course approach e.g. changing the nutritional balance of the diet 0-6 months Breast feeding 6-24 months Improved weaning advice 0-4 years 4-16 years 16-65 years 60+ Nutritional Transformation Guidelines standards of school food for for workplace pre-schools canteens Nutritional standards for elderly care Rigorous food procurement/provision standards in public institutions
  17. 17. Amplifiers Enablers Initiatives Examples Specific programmes of action e.g. school meal standards Education/information e.g. nutritional labelling Wider environmental policies e.g. controls of marketing, fiscal measures Definitions Amplifiers are key to shifting the system and population profile as a whole but cannot act if the other elements are not in place Enablers are ineffective alone but essential to underpin the effectiveness of other interventions (necessary but not sufficient) Focused initiatives are Interventions aimed directly at tackling obesity or a particular at risk group
  18. 18. Generation 1 (current adults) Generation 2 (current children) Generation 3 Generation 4 Impact Rises: combination of sustained approach and increase in options available ensures impact rises over time Options Increase: range of interventions possible will increase as time progresses Culture & values around food & activity shift over time?
  19. 19. A model of continuous improvement to integrate science and policy developments Stimulation of additional research Development of policy Credible review of evidence New scientific advances Refinement of policy Evaluation of policy
  20. 20. Foresight core principles for tackling obesities • A system-wide approach, redefining the nation's health as a societal and economic issue • Higher priority for the prevention of health problems, with clearer leadership, accountability, strategy and management structures • Engagement of stakeholders within and outside Government • Long-term, sustained interventions • Ongoing evaluation and a focus on continuous improvement
  21. 21. Trend in obesity prevalence among adults Health Survey for England 1993-2012 (3-year average) 30% 25% 20% 15% 10% 5% 0% Prevalence of obesity Women Men HWHL HLHP Adult (aged 16+) obesity: BMI ≥ 30kg/m2 Patterns and 23 trends in adult obesity
  22. 22. Why is progress so slow? • Inconsistent messages – to individuals, organisations and policymakers • Incomplete evidence base for action – what will work, in what context, chicken and egg challenge of developing/evaluating policy • Whose responsibility? • Poor engagement with private sector • Limited public demand/acceptability • Short-termism
  23. 23. Why is progress so slow?  Inconsistent messages – to individuals, organisations and policymakers  Incomplete evidence base for action – what will work, in what context, chicken and egg challenge of developing/evaluating policy  Whose responsibility?  Poor engagement with private sector  Limited public demand/acceptability  Short-termism This is in twice? Thank you susan.jebb@phc.ox.ac.uk
  24. 24. The puzzle of public health evidence Harry Rutter | @harryrutter
  25. 25. Approach
  26. 26. Evidence
  27. 27. Evidence trajectories Time Hunch-based Level of activity Evidence-based
  28. 28. The dangerous olive of evidence… All possible interventions Evidence of effectiveness Evidence of cost-effectiveness
  29. 29. Source: Swinburn et al, Lancet 2011 + research difficulty
  30. 30. ‘Behaviour change’
  31. 31. Source: Swinburn et al, Lancet 2011 Behaviour change
  32. 32. Source: Swinburn et al, Lancet 2011 Changes in behaviour
  33. 33. Conclusions • Need to grapple with, but not get bogged down by, complexity • Existing approaches skew evidence towards the individual • This reinforces societal and political focus on individual responsibility • Need to move upstream – in both evidence and action • The main driver of behaviour change is the environment
  34. 34. Consideration of the self as the central agent for change in physical activity and weight management Ken Fox Emeritus Professor of Exercise and Health Sciences University of Bristol ESRC Behaviour Change Seminar Series [2], September 2014
  35. 35. Key issues facing public health interventions requiring volitional change • Difficulties in attracting and recruiting the ‘health needy’ (inactive and/or overweight) • Difficulties in sustaining behaviour change
  36. 36. I don’t exercise because…. • it is too exhausting and painful B • it does not help me lose weight B • it will make me look muscly B • it will make me want to eat more B • I do not have the time V • I am not the sporty type SP • I always got left behind at school SP • I am too embarrassed SP I came to SW to lose weight not to exercise I have never been an exerciser. Its just not something I would do. Its not me. I could never pluck up the courage to go to one of those fitness clubs I like swimming but could not face going to the swimming pool
  37. 37. I exercise because…. • it puts me in a better mood • it makes me feel like I have achieved something • it helps me manage my weight • my body feels better • it’s a great crowd to be with • it helps me keep my blood pressure down • the leader is a lot of fun. • I know it will do me good in the long run
  38. 38. The First Law of Human Behavior Campbell, 1984 “Each human organism exists to maintain or increase its sense of its own excellence” • Seek out and persist in behaviours which produce a sense of success • Avoid situations which bring a sense of inadequacy or failure • Make the best of outcomes through self-serving biases
  39. 39. Self-esteem • Overall feelings of worth • Being OK depending on what you consider makes up being OK • The sum of the balance sheet for successes and failures as measured against aspirations • Consequences are emotional and behavioural • Strong impact on mental well-being • Can be the source of defensiveness and irrationality
  40. 40. Multiple dimensions of self SELF-ESTEEM Work Spiritual Social Physical Shavelson, Hubner and Stanton, Review of Educational Research , 1976
  41. 41. Customising the self: Values and importance Self-values Sub culture Culture Individual Conformer Individualist
  42. 42. Multiple dimensions of self SELF-ESTEEM Work Spiritual Social Physical Shavelson, Hubner and Stanton, Review of Educational Research , 1976
  43. 43. Self-esteem and the physical self: The public self SELF-ESTEEM PHYSICAL SELF-WORTH Sport Competence Strength Conditioning Body image Confidence and perceived competence The Physical Self-Perception Profile (Fox & Corbin, 1989)
  44. 44. The Physical Self-Perception Profile: Importance filter (Fox & Corbin, 1989) SELF-ESTEEM PHYSICAL SELF-WORTH Sport Competence Strength Conditioning Body image
  45. 45. Levels of specificity of self-perceptions SELF-ESTEEM Physical Self-Worth Sport competence Attractive Body Soccer competence Feeling fat Shooting competence Feeling hips too fat Feeling able to score Feeling hips too big for dress
  46. 46. Importance of physical self-perceptions • Way we present ourselves to the world (the public self) • Highly influential on self-esteem (r=0.6-7) • Physical self-worth has mental health properties independent of self-esteem • Can be modified through physical activity interventions • Predict physical activity (particularly for males) • 70% of physical activity participation in 18 year olds • Primary reason given for not being physically active in middle age adults “ I’m not the sporty type” • Social physique anxiety predicts avoidance of formal exercise settings • Predicts future uptake of activity in males in a weight management setting
  47. 47. Self-determination theory • Route to self-esteem is through intrinsic motivation
  48. 48. Intrinsic-extrinsic continuum Intrinsic (emersion?) (persuasion?) Extrinsic (coersion?) Payment Weight loss Prize Pleasure Mastery Fitness Competition Body image Status Competence Autonomy Friendship Mood
  49. 49. Self-determination theory • Route to self-esteem is through intrinsic motivation • Key to motivation is through psychological needs satisfaction • What can physical activity and/or weight management offer? :- • Need for perceived competence/confidence • Need for autonomy, sense of ownership • Need for sense of belonging, relatedness
  50. 50. Key SDT strategies • Language changes from instruction and prescription to facilitation • Increase participant competence and confidence through incremental mastery goals • Engage participants in choice decisions and encourage ownership “you made it happen” • Build behaviors into a new identity • Maximise the social benefits including belonging, support, and contribution • SDT fits well with motivational interviewing, some aspects of CBT, self theories, achievement goals theory (task v ego)
  51. 51. SDT-based interventions: Project ACE
  52. 52. Considerations for public health interventions 1. Difficulties in attracting and recruiting the ‘health needy’ (inactive and/or overweight) • Much more effort to segment target populations and understand the demands of their cultures and common psychological needs • All intervention research needs to start with a phase on identifying needs, barriers and facilitators of the target population • Funded research needs to be dedicated to recruitment challenges and strategies How much of this is understood by commissioners and coordinators?
  53. 53. Considerations for public health interventions 2. Difficulties in sustaining behaviour change • Intervention strategies should be based on psychological needs satisfaction What can the behaviour offer that produces long term buy in? “Physical activity makes me feel alive again” • Think less of the behaviour and more in terms of what can cause a shift in identity so that the self is invested in the behaviour – the Skoda principle. “I am now an exerciser” How much of this is understood and implemented by programme leaders and health professionals?
  54. 54. So how would you spend your millions? Education, education, education …. of individuals of professionals of policy makers On how to help people make better and healthier lives for themselves
  55. 55. What should be on the UK's future 'behaviour change' menu for tackling obesity? Colin Greaves
  56. 56. This talk … What we know What we need to know Policy, practice and research
  57. 57. What do we know about supporting lifestyle change? • Population level interventions (environment, food choice, taxation, bans) • Bariatric surgery (23% WL at 2-3 years and 16% at 10 years) • Obesity drugs • Lifestyle change interventions
  58. 58. EXAMPLES OF SUCCESS: WEIGHT LOSS AT 12 MONTHS N Weight Loss (Kg) 1. Wadden et al, Arch Int Med 2010; 170:1566-75 2. Knowler et al, NEJM, 2001;346:393-403 Pop Clinical trials Look – AHEAD [1] 5145 7.9 T2D US DPP [2] 3234 6.7 IGT
  59. 59. EXAMPLES OF “REAL WORLD” SUCCESS: WEIGHT LOSS AT 12 MONTHS Real world trials Early ACTID [3] 345 2.4 T2D Weight Watchers [4] 200 2.8 3. Andrews et al, Lancet 2011;378:129-39 4. Jebb et al., Lancet 2011;378:1485-92 Obese /ow N Weight Loss (Kg) Pop
  60. 60. EXAMPLES OF SUCCESS: PHYSICAL ACTIVITY Based on objective measures at 12 months N Change Pop Yates et al. [5] 57 1902 steps /day IGT Early-ACTID [3] 345 33 mins /wk mvpa T2D 5. Yates et al, Diab Care, 2009;32:1404-10 3. Andrews et al, Lancet 2011;378:129-39
  61. 61. WHAT WORKS FOR WEIGHT LOSS? • Comprehensive reviews of evidence on diet and physical activity promotion [6] • Plus expert opinion => IMAGE guidance on diabetes prevention [7] => NICE guidance on Diabetes Prevention (2012); Behaviour Change (2013); Obesity (2014) 6. Greaves et al, BMC Pub Health 2011; 11:1-12 7. PaulWeber et al, Horm Metab Res 2010; 2:S3-S36
  62. 62. WHAT WORKS FOR WEIGHT LOSS? 1. Target diet and PA 2. Use established behaviour change techniques 3. Engage social support (esp. family) 4. Maximise contact time or frequency /N contacts 5. Self-regulation techniques (Goal setting; Self-monitor; Feedback; Prob-solving; Review goals) 6. Exploring reasons for change and confidence about change (e.g. motivational interviewing) 6. Greaves et al. BMC Pub Health 2011; 11:1-12
  63. 63. NICE PH38: DIABETES PREVENTION All the above, plus … 7. Use a person-centred, individually tailored, empathy-building approach 8. Gradually build confidence, setting achievable and sustainable goals 9. Provide information on benefits and types of lifestyle changes needed 10.Use a group size of 10-15 11.Allow time between sessions, spreading them over a period of 9-18 months
  64. 64. HOW MUCH DO THESE THINGS MATTER?
  65. 65. Content associated with effectiveness 8. Dunkley et al. Diabetes Care 2014;37:922-33 0 -6 -4 -2 2 4 6 8 10 12 Number of NICE guidelines met Weight loss (Kg) 12 mths Number of characteristics present (NICE PH38) 0.3 Kg extra weight loss per recommendation implemented
  66. 66. NICE PH49: BEHAVIOUR CHANGE All the above, plus … • Tailor interventions to meet participants' needs and life-context /barriers /motivations • High quality training
  67. 67. 1 trainer 200 trainees The importance of training 20,000 patients Invest Here!!
  68. 68. INTERIM SUMMARY • We are getting quite good at weight loss • We have solid recommendations on intervention content – and interventions that follow the guidance work better • Improving training quality might be important
  69. 69. MAINTENANCE 9. Dansinger et al, Annals Int MeDda n2s0in0g7e;r124070:471-50 2007
  70. 70. THEORY USE IN INTERVENTIONS FOR MAINTENANCE OF WEIGHT LOSS - SYSTEMATIC REVIEW Stephan U Dombrowski, Keegan Knittle, Alison Avenell, Vera Araújo-Soares & Falko F Sniehotta s.u.dombrowski@stir.ac.uk @sdombrowski
  71. 71. Intervention vs Control - 12 months - FIPS - Int - FIPS - Int Internet Experimental Control Mean Difference Mean Difference Mean -3.63 0.4 -10.4 -5.7 -3.9 -4.7 5.4 6.08 -5.81 -7.5 1.54 -12.88 -12.97 -15.7 -13.35 -10.8 -5.85 1.2 1.2 0.77 -6.16 -5.82 3.9 1.3 3.1 SD 9.84 5 6.3 5.9 5.9 6.9 5.81 4.72 7.26 7.85 6.26 12.44 7.63 14.29 7.37 8.65 6.39 5.47 5.94 5.99 7.66 7.56 5.28 6 7.5 = 0.94; Chi² = 37.39, df = 24 (P = 0.04); I² = 36% effect: Z = 4.33 (P < 0.0001) Total 15 52 32 30 77 77 28 29 26 48 35 19 18 19 19 23 20 83 72 210 341 347 23 105 104 1852 Mean -1.54 0.6 -10.4 -10.4 -4.2 -4.2 4.67 4.67 -2.09 -4.36 6.16 -5.67 -5.67 -5.67 -5.67 -4.14 -4.14 3.7 3.7 2.4 -4.73 -4.73 5.6 3 3 SD 6.49 4 9.3 9.3 7.9 7.9 6.58 6.57 5.03 5.23 7.61 6.9 6.9 6.9 6.9 4.86 4.86 6.22 6.22 6.17 7.25 7.25 5.2 5.7 5.7 Total 15 55 14 14 39 39 14 14 17 52 32 4 4 4 4 8 7 40 39 209 170 171 27 53 52 1097 Weight 1.3% 7.6% 1.6% 1.6% 4.3% 4.1% 2.5% 2.7% 2.9% 4.7% 3.4% 0.6% 0.8% 0.6% 0.8% 1.8% 2.0% 5.7% 5.4% 10.1% 9.1% 9.2% 4.1% 6.9% 6.2% 100.0% IV, Random, 95% CI -2.09 [-8.06, 3.88] -0.20 [-1.92, 1.52] 0.00 [-5.34, 5.34] 4.70 [-0.61, 10.01] 0.30 [-2.51, 3.11] -0.50 [-3.42, 2.42] 0.73 [-3.33, 4.79] 1.41 [-2.44, 5.26] -3.72 [-7.39, -0.05] -3.14 [-5.78, -0.50] -4.62 [-7.97, -1.27] -7.21 [-15.99, 1.57] -7.30 [-14.93, 0.33] -10.03 [-19.36, -0.70] -7.68 [-15.21, -0.15] -6.66 [-11.54, -1.78] -1.71 [-6.27, 2.85] -2.50 [-4.76, -0.24] -2.50 [-4.89, -0.11] -1.63 [-2.79, -0.47] -1.43 [-2.79, -0.07] -1.09 [-2.44, 0.26] -1.70 [-4.62, 1.22] -1.70 [-3.62, 0.22] 0.10 [-2.02, 2.22] -1.56 [-2.27, -0.86] IV, Random, 95% CI -10 -5 0 5 10 Favours experimental Favours control 10. Dombrowski et al, BMJ 2014;348 Meta-analysis of 45 weight loss maintenance intervention RCTs => Intervention helps -1.6Kg [-2.0, -0.9], p=0.04 But how much? Initial mean weight loss was 10.8Kg
  72. 72. Behaviour change techniques used Technique % arms Self-monitoring 58 Barrier identification /problem solving 58 Provide instruction on how to perform 56 the behaviour Goal setting (behaviour) 40 Plan social support 39 Relapse Prevention 28 Pretty much based on self-regulation + social support
  73. 73. Does use of theory matter? Theory based: -2.2 [-3.0,-1.4] No theory: -0.04 [-1.1, 1.0] Dombrowski et al, Personal Communication, 2014
  74. 74. The Perri cluster • 5 Step Problem Solving Model • Orientation (understanding the process) • Specifying the problem • Brainstorming possible options and goal setting • Coping planning /problem-solving • Self-monitoring and feedback Pro-active self-regulation. Main focus on problem-solving
  75. 75. MAINTENANCE: The PESO study 11. Teixeira P et al. Int J Beh Nutr Phys Act 2012;9:22 N=149 women
  76. 76. MAINTENANCE RESEARCH (the current state of play) In order to change a behaviour, you first need to understand it
  77. 77. SOCIAL CONTEXT ENVIRONMENT COGNITIONS STABLE WM UNSTABLE WM EMOTIONS PHYSIOLOGY PERSONAL CIRCUMSTANCES SOURCES OF TENSION Force of habit Disruption of needs fulfilment  Negative script Cognitive fatigue RESILIENCE • Self-regulation • Manage external Influences • Personal insight • Develop automaticity • Identity shift • Motivation
  78. 78. Implications for intervention Assess and develop components of Resilience • Self-regulation – Set boundaries; monitor; plan coping responses • External influences require dynamic management – Problem solving skills – Social skills and support: co-option vs dependence – Impulse control • Habit-breaking and habit-forming techniques • Facilitate insights – What needs does food fulfil in my life? – How else can I address these needs? • Facilitate change in self-concept (e.g. autonomy) Poltawski & Greaves, 2012 In Prep
  79. 79. Interim summary • We are developing an understanding of how WL maintenance works and what intervention components are most promising • However, there is much more to do and much scope for improvement
  80. 80. How can we move forward strategically?
  81. 81. Current practice • Tiered services roughly allocated according to risk • Short-term solutions (12 weeks) • Often no evidence base • PHE disaggregated from the NHS (Costs separated from cost-savings ) • Politics (5 year cycles) and research funding (3-5 year cycles) reinforce the focus on short-term outcomes
  82. 82. Suggestions for moving forward • Use what we know to inform current commissioning /practice. EDUCATION NEEDS TO BE INTEGRATED WITH RESEARCH • Evaluate current practice. RESEARCH NEEDS TO BE INTEGRATED WITH PRACTICE • Multi-disciplinary research: Social, policy, biological, psych • Innovation to increase effectiveness or reduce costs. Esp from practice. PRACTICE TO BE INTEGRATED WITH RESEARCH • Longer-term perspective (policy and research) • Invest in high quality training. RESEARCH HAS TO BE INTEGRATED WITH EDUCATION • Implementation research. PRACTICE NEEDS TO BE INTEGRATED WITH RESEARCH AND POLICY
  83. 83. We need a strategic, managed approach to connect policy practice and research
  84. 84. Who needs to be involved? • Policy makers – Local authority H&WB boards? – National policy-makers (PHE, DoH, Research Councils) • Practitioners – Website /app designers, commercial intervention providers, voluntary sector • Providers – Voluntary sector, NHS, commercial • Researchers • Educators /trainers
  85. 85. Basis of NCSCT = learning outcomes, training curriculum and evaluation of delivery
  86. 86. Conclusions
  87. 87. Thank you!
  88. 88. SUSTAINING PHYSICAL ACTIVITY I have found only one RCT reporting objectively measured PA at 24 months [10] - there were no significant effects Di Loreto et al. [11] report HbA1c reduction of 0.7% at 24 months alongside an increase in self-reported PA 10. Opdenacker et al, Prev Med 2008 11. Di Loreto et al, Diabetes Care 2003;26:404-8
  89. 89. How?
  90. 90. How?
  91. 91. What we need to know How to support change in diet and PA How to achieve long-term diet change How to achieve long-term PA change Achieve the above in diverse populations How to maximise uptake Most effective training methods How to do it at lower cost (e.g. digitally) Overcome implementation challenges Create learning systems so that delivery evolves
  92. 92. What else do we need to know? What population approaches work best What kind of support is best used alongside surgery or drug interventions What are the health economics of WLM
  93. 93. Ongoing research • Maintenance interventions • Digital media interventions • What makes groups work? • Impulsive behaviours
  94. 94. EXTERNAL INFLUENCES INTERNAL INFLUENCES A M E R A C Individualised assessment for influence management Functional analysis of eating and PA behaviours Impulse management skills Self-regulatory up-skilling Techniques for habit changing CBT techniques for o Self-concept o Thinking style
  95. 95. Can we afford to do nothing?
  96. 96. Health economics (NICE 2014) • A programme costing £100 or less where 1 kg of weight is lost and maintained for life will be cost-effective • For programmes costing £500 per head, it is estimated that an average 2 kg weight differential must be maintained for life to achieve cost-effectiveness • People over 50 stand to gain more
  97. 97. Specific BCTs included # Weight Loss % arms Weight Loss Maintenance % arms 1 Provide instruction on how to perform the behaviour 45 Prompt self-monitoring of behaviour 58 2 Prompt self-monitoring of behaviour 43 Barrier identification/problem solving 58 3 *Provision of food with recommended dietary composition* 27 Provide instruction on how to perform the behaviour 56 4 Teach to use prompts/cues 25 Goal setting (behaviour) 40 5 Barrier identification/problem solving 23 Plan social support/social change 39
  98. 98. Existing options • Weight Watchers (ITT: 2.5 to 2.8 Kg vs control @12mths) – Jebb et al. Lancet 2011; Jolly et al. BMJ 2011 • Counterweight (ITT: 1.3kg @12 mths, no control) • Ad hoc primary care or dietitian led programmes – No evidence (Jolly et al. BMJ 2011) • Other commercial programmes – Limited /no good quality evidence (Jolly et al. BMJ 2011) • FFIT (ITT: 2.5 to 2.8 Kg vs control@12mths) – Hunt et al. Lancet 2013
  99. 99. Existing options Weight Watchers looking good, but ... • Doesn’t work for >50% and high dropout in trials • Not everyone’s cup of tea (esp. men) • Weight goes back on for those who stop attending (Truby et al, 2006)
  100. 100. Maybe need some experimental commissioning?
  101. 101. Prevention of diabetes • High quality clinical efficacy trials show that diabetes is preventable through changes in diet and physical activity FDPS [7] • Reduced diabetes incidence at 3.4 years by 58% • Effects driven by weight loss • ~15% less T2D per Kg [8] 7. Hamman et al, Diabetes Care 2006;29:2102-07 8. Tuomilehto et al, NEJM 2001; 344:1343-50
  102. 102. NICE PH53: MANAGING OVERWEIGHT AND OBESITY (2014) All the above, plus … • Make gradual, long-term changes • Explain the benefits of even relatively small amounts (e.g. 3%) of weight loss
  103. 103. Investigation of evidence into practice Evidence Training Practice Behaviour change techniques Manuals
  104. 104. FUTURE CHALLENGES • Increasing efficiency: Group-work, Digital technologies, self-delivery, better BCTs • Tackling impulsive /hedonic behaviours • Maintenance • Delivery: Intervention Fidelity, Training • Political will: To achieve success on a large scale will need serious investment
  105. 105. Systematic Review of WLM RCTs Overall 45 studies included • Lifestyle n=23 • Drugs n=6 • Meal Replacement n=5 • Diet n=3 • Supplements n=3 • Physical Activity n=3 • “Other” n=2 Dombrowski, S. U., Knittle, K., Avenell, A., Araújo-Soares, V., & Sniehotta, F. F. (2014). BMJ, 348.
  106. 106. What should be on the UK's future 'behaviour change' menu for tackling obesity? Dr Gabriel Scally MB BCh BAO MSc DSc FFPH FFPHM(I) FRCP MRCGP
  107. 107. ‘The mission of public health is to fulfill society's interest in assuring conditions in which people can be healthy.’ Institute of Medicine, Committee for the Study of the Future of Public Health. The Future of Public Health. National Academy Press, Washington, 1988.
  108. 108. “Medicine is a social science, and politics is nothing else but medicine on a large scale.” Rudolf Virchow 1821-1922
  109. 109. 10 Greatest Achievements of Public Health in the 20th Century • Immunizations • Motor-Vehicle Safety • Workplace Safety • Control of Infectious Diseases • Declines in Deaths from Heart Disease and Stroke • Safer and Healthier Foods • Healthier Mothers and Babies • Family Planning • Fluoridation of Drinking Water • Tobacco as a Health Hazard MMWR April 02, 1999 / 48(12);241-243
  110. 110. The difficulty here, of course, is that some people do not like wearing seat belts and to force them to do so would be an infringement of personal liberty. Prevention and health: everybody’s business 1976
  111. 111. Two fundamental propositions • Men and women make decisions every day that affect their health and that of others. But they rarely make those decisions under circumstances of their own choosing. • Different aspects of human functioning will require a different balance of action between the individual and collective but rarely, if ever, will it be only one or the other.
  112. 112. Nanny State or Pontius Pilate State?
  113. 113. What is the role of the government in these matters? Is it largely the duty to educate, and to ensure that undue commercial pressures are not placed upon the individual and society? Prevention and health: everybody’s business 1976
  114. 114. “Permit me a few categorical statements, for dogmatism has a certain role in the realm of vacillation.” Norman Bethune
  115. 115. Six lessons on making public health change happen 1. Great progress can be made through having a focussed approach, dedicated staff, an adequate and protected budget and a delivery chain that reaches into and supports communities across the country. 2. Where cross-Whitehall commitment and resourcing is put in place it can be very effective, but getting inter-Departmental buy-in is not at all easy to achieve.
  116. 116. Six lessons on making public health change happen 3. The financial pressures of urgent healthcare needs can lead to the neglect of prevention and the siphoning off of funds from public health programmes. 4. It isn’t possible to change the health of the population without offending at least some of the vested interests that make profit out of some of the things that make us unhealthy.
  117. 117. Six lessons on making public health change happen 5. Spending on social marketing or un-evidenced ‘screening’ programmes is seductive because it gives the instant appearance of doing something, but can be both ineffective (perhaps even damaging) and wasteful of time and resources. 6. Investing in improving health is for the long term. Judgements about investment must take that into account.

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