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Obesity- Tipping Back the Scales of the Nation 19th April, 2017


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Obesity- Tipping Back the Scales of the Nation 19th April, 2017

  1. 1. Dr Becca Beeken Senior Research Psychologist University College London
  2. 2. Inspiring Behavioural Change Dr Rebecca Beeken Senior Research Psychologist Department of Behavioural Science & Health, University College London
  3. 3. How?
  4. 4. The traditional approach Information on health risk & what to do Behaviour change
  5. 5. The COM-B system: Behaviour occurs as an interaction between three necessary conditions Capability Motivation Opportunity Behaviour Psychological or physical ability to enact the behaviour Reflective and automatic mechanisms that activate or inhibit behaviour Physical and social environment that enables the behaviour Michie, van Stralen, & West, 2011
  6. 6. Behaviour Change Techniques: Taxonomy Abraham & Michie, 2008 Health Psychology BC techniques drawn from health behaviour models
  7. 7. Successful behaviour change techniques • Michie et al (2009) Meta-analysis of 84 physical activity and healthy eating interventions • Which behaviour change techniques are most frequently featured in effective interventions? • Interventions combining ‘self-monitoring’ and at least one other technique related to self-regulation were twice as effective as other interventions, e.g. goal-setting, providing feedback, rewards…
  8. 8. Commercial programmes are promising From: Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review Ann Intern Med. 2015;162(7):501- 512. doi:10.7326/M14-2238
  9. 9.  A psychological approach to managing eating and physical activity over the long term  Strong emphasis on lifestyle change not dieting  Peer learning OR self-help  Via behaviour change techniques & modified CBT = weight management through permanent lifestyle change
  10. 10. CBT Principles EMOTION THOUGHTS BEHAVIOUR PHYSIOLOGY Helps individuals identify and challenge unhelpful thoughts & beliefs that underlie negative emotions and behaviours
  11. 11. • Used by more than 15,000 adults in the UK to date • Mean weight loss 2.8kg over 8 weeks, 5.3% at 6 months • Over 90% of users report feeling more in control of their eating habits • 98% would recommend Shape-Up to a friend trying to manage their weight Shape Up Audit: Preliminary results
  12. 12. Habit development • Habits are (relatively) automatically triggered actions • Formed through repetition in a consistent context = ↑ automaticity • Can be used to help individuals ‘learn’ healthy lifestyle behaviours Lally et al, Eur J Soc Psychol, 2009
  13. 13. Habit-based interventions • Require less engagement or motivation • Less time-consuming to explain • Easier to implement • Promotes long-term maintenance
  14. 14. WHO?
  15. 15. Jackson et al. (2014). BMJ Open. 3: e003693-e003693 Health professionals can play an important role Only 17% of overweight and 42% of obese respondents recalled ever having received HP advice to lose weight.
  16. 16. WHen?
  17. 17. ‘Teachable moment’- A window of time following an event in which a patient is more amenable to lifestyle change’ Affective reactions Self-conceptPerceived risk Event Teachable moment McBride et al., 2003 Health Educ Res Behaviour change
  18. 18. Effect of advice on fruit and vegetable intake after bowel screening (n=742; 85% follow-up (Baker & Wardle, 2002) Knowledge Intake Pre Post Pre Post Control 4.1 4.1 3.0 3.3 Intervention 4.0 4.7 3.1 4.1 Evidence from intervention studies [shows] that comprehensive interventions are acceptable for asymptomatic subjects targeted for cancer screening. A positive impact on dietary behaviors was observed in all studies, conflicting results were reported for physical activity, and no impact was observed for interventions on smoking cessation (9 trials)
  19. 19. WHERE?
  20. 20. ‘a technique that alters a person’s decision-making context without removing options or changing the incentives in order to promote choice and behaviour in accordance to their own preferences, such as choosing healthy food over unhealthy food in a supermarket’ Nudging
  21. 21. van Kleef et al. BMC Public Health 2012, 12:1072
  22. 22. • We have a raft of effective (ish) strategies for inspiring behaviour change • The who, the when and the where might also be important • Personalised behavioural medicine and digital technologies offer novel approaches • We need to understand how to inspire behaviour change in policy makers & industry • Need to tackle social inequalities • Given the challenge of inspiring change, the importance of establishing healthy behaviours in early life (and preventing unhealthy behaviours) cannot be understated Conclusions & Future Directions
  23. 23. Acknowledgments • Dr Helen Croker • Dr Pippa Lally • Dr Laura McGowan • Dr Susanne Meisel • Dr Claudia Hunot • Nathalie Kliemann • Professor Jane Wardle (1950-2015)

Editor's Notes

  • Thank you very much for inviting me here today. As … mentioned I am a researcher in the newly formed Department of Behavioural Science and Health at UCL, I’m also a trusteer for the charity Weight Concern, and the majority of my research to date has been around the role of behaviour in both cancer prevention and survivorship, so trying to find ways to inspire behaviour change is of real importance to the work I do.
  • SO I’m firstly going to talk a abit about how we might try to inspire behaviour change,
  • Well, the traditional approach would be to simply tell people what they should be doing and why, but we know that this is rarely sufficient. In getting people to change their health behaviours over the logn term.
  • More recently, health psychologists have developed the Com-B model which illustrates that inspiring behaviour change is a little bit more complex than just giving people information. Essentially, people need to feel motivated, so they need to want to do it- either consciously or sometimes sub-consciously, they need to feel they can do it, and they need to feel supported to do it by their physical and social environment

    In addition to tekking people what they should be doing and why- we need to support them by giving them straegties to help change these 3 conditions and in turn change their behaviour.
  • A lot of work has been to try and ifentify the behaviour change techniqes that exist and which work best– I don’t expect you to be able to read this, but essentially it’s an example of a behaviour change taxonomy created by susan michie and colleagues at UCL which lists all the possible technieuqs and links them to the relevant theories so that we can better understand what works and what doesnt

  • So for example, for healthy eating and physical interventions-those behvaiours that mimght lead to weight loss- using the taxonomy susan michie and colleagues were able to identifythat ….
    the ability to plan and monitor your behaviour and outcomes, and change it accordingly (so for example..)
    Most effective – some have argued that these are just the techniques that are just the best reported, but it’s a promising starting point,
  • . These techniques are typically embedded in a number of weight management programmes which have been shown to be proising. This is data from
    A recent review of these programmes, suggests they are typically effective, although slightly less so over the long term- and more data from well-designed trials is really needed on long-term outcomes
    Many trials were short (<12 months), had high attrition, and lacked blinding.
  • One of the programmes that we’ve developed at Weight Concern is very much in line with these commercial programmes, but does frame things slightly differently, and I think In terms of inspiring change framing can be important
  • CBT- basic assumption is that our thoughts, feelings, behaviours and bodily reactions are all interlinked. To change HR behaviours, need to consider underlying patterns of thoughts and feelings.

    EG: Someone visits the doctors and is told they are obese and need to lose weight immediately:

    I’m disgustit’s too late. I’ve spent a lifetime of dieting and bingeing. I can’t change.
    Low mood
    Low energy
    Comfort eat
    Avoid seeing people


    This isn’t going to be easy, but maybe this time I can get the proper support that I need. I have successfully lost weight before, I can do it.
    No major changes
    ? adrenalin & ready for action
    Ask GP to refer to a WM programme
    Join the gym

    A 2009 Cochrane review emphasised that cognitive behavioural therapy significantly improves weight loss interventions

  • We’ve just started to do an audit of the effectiveness of shape up… so again very promising data, but we need more long term follow up and ideally to test it in a rct

    (443 respondents)
    89% established a regular pattern of eating
    86% have increase their level of physical activity
    93% now balance the types of food they eat
    82% have increased the amount of fruit and vegetables that they eat
    89% have set effective lifestyle goals and work towards them
    92% are following the Shape-Up guidance on serving sizes
    87% are better able to manage ‘triggers’ that may lead to unhealthy behaviours
    88% are better able to understand the information on food labels
    93% feel more in control of my eating habits
    96% feel confident and motivated to continue with lifestyle changes I have made
    84% have lost weight
    98% would recommend the Shape-Up programme to a friend who wanted to manage their weight
  • Another area, that I and my colleagues at UCL are increasingly interested in is the role of habits in inspiring behaviour change, and particularly the potential to use habit formation theory in brief interventions to inspire chang
  • That while, cp are promising, they are not everyone- these more traditional behavioural approaches with inherently high demand for commitment achieve limited adherence. Leaflet intervention
    Describes a set of simple energy balance behaviours that can be turned into habits

    Explains the habit model and how to repeat in a consistent context
    Includes a log book for self-monitoring, a wallet sized card with guidance on food labels, and advice on self-weighing

    No further clinical contact

    Set of behaviours associated with significant calorie reduction, Nutritionally sound, Common(ish) in adults, Can be repeated frequently in a consistent situation, Easy-to-recall names

  • Self regulation and automaticity- adding an additional self ruglation tool. To help break habits. (surf the urge)
  • This approach ahs also been used to successful modify parental feeding behvaiours, with children of parents who ahd received a habit based intervention consuming more vegetables, healthy snacks and water than children in an information only control group. SO I think this is a really promising, new approach to helping individuals change their behaviours, and more studies are needed to test it’s effectiveness in differnet contexts and at the population-level.
  • So those are some of techniques and interventions we might use to try and inspire behaviour change, but we also know that certain individuals can inspire behaviour change
  • , in particular, there is increasing evidence that suggests receiving advice from a HP is particularly motivating. this graph demonstrates that in a large cohort of UK adults, those who’d received
  • And many of you may have heard about the latest study published in the Lancet by Paul Aveyard and colleagues, which showed that a 30 second recommendation to attend a weight management programme, at the end of a consultation about another health problem promoted weight loss over a year and was considered by the majority of patients to be appropriate and helpful,
    So I do think health professionals can play an important role, and hopefully some of the work that has been done recently like the bewel trial and 10tt, will go some way to providing them with the reassurance and support they need in order to feel able to inspire behaviour change in their patients
  • There is also increasing interest in the role that timing might play in encouraging individuals to change their behaviour, and this is somewhat linked to who, but I think it’s a really interesting aspect of behaviour- that certain events might inspire change or just push us over that tipping point for a behaviour we’d been considering stopping/starting/changing. These can be positive or negative evnts,
  • But the term in the literature that has been coined for these events is a ‘teachavle moment’, there is an emerging body of evidence around the concept of teachable moments, which are defined as a windor of time individuals might be more amenable to lifestyle change for example, because they feel more worried, or at risk as a consequence of a certain event.

    A number of events are thought to fall into this category, from pregnancy, to a cancer diagnosis, but one moment that has been receiving increasing attention is cancer screening
  • And a review of the work in this area found some evidence that health behaviour interventions delivered at screening can promote behaviour change, particularly for dietary behaviours, However, we don’t know if these interventions would have been just as effective if they had been delivered at another time, and so more work needs to be done around this, in addition to addressing the practicalities of delivering interventions at these particulalr moments.
  • Lastlly, I wanted to talk briefly about where we might try to inspire behaviour change. A lot of the interventions I’ve talked about are in medical settings, have been sought out by the individual, but I think its also important to think about the day to day environment that might also inspire behavioural change
  • And this is somewhat linked to another approach to targeting more automatic processes that has received increasing attention called nudging, which tends to be more of a structural intervemtion and aims to make it easier for people to make a healthy choice. So for example many of you may have noticed the so called healthy checkouts that a number of our supermarkets have adopted- replacing sweets with fruit.
  • And there is some evidence for the success of these approacjes. This data is from a study in the Netherlands by vankllefe and colleagues changed the proportion of healthy and unhealthy snacks available in a hospital canteen, and also varied the position of the snacks to either be at the top or bottom of the shelf. And sure enough the condition in which the most healthy snacks were purchased was when there were more availavle and they were at the top of the shelf.
  • But changes are modest, and more research is needed on long-term effects

  • I’d just like to finish by acknowledging my collaborators who have contributed to the work I’ve presented, and thank you very much for listening.