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

1. ESRC Behaviour Seminar (2)
11 September 2014
Obesity, food and physical activity
Some introductory
considerations...
Geof Rayner

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. 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. 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. 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. 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. 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. 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. 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. 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. 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

13. Societal influences
Individual
psychology
Biology
Activity
environment
Individual
Food activity
Consumption
Food Production

14. 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

15. Societal Influences
Biology
Activity
Environment
Individual
Activity
Food
Consumption
Food
Supply
Individual
Psychology

16. Interventions are needed at multiple levels
Foresight, Tackling Obesities:
Future Choices, 2007

17. 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

18. 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

19. 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?

20. 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

21. 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

23. 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

24. 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

25. 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

26. The puzzle of public health evidence
Harry Rutter | @harryrutter

27. Approach

30. Evidence

31. Evidence trajectories
Time
Hunch-based
Level of activity
Evidence-based

32. The dangerous olive of evidence…
All possible interventions
Evidence of effectiveness
Evidence of cost-effectiveness

33. Source: Swinburn et al, Lancet 2011
+ research difficulty

34. ‘Behaviour change’

35. Source: Swinburn et al, Lancet 2011
Behaviour change

36. Source: Swinburn et al, Lancet 2011
Changes in behaviour

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. Multiple dimensions of self
SELF-ESTEEM
Work Spiritual Social Physical
Shavelson, Hubner and Stanton,
Review of Educational Research , 1976

45. Customising the self:
Values and importance
Self-values
Sub culture
Culture Individual
Conformer Individualist

46. Multiple dimensions of self
SELF-ESTEEM
Work Spiritual Social Physical
Shavelson, Hubner and Stanton,
Review of Educational Research , 1976

47. 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)

48. The Physical Self-Perception Profile: Importance
filter
(Fox & Corbin, 1989)
SELF-ESTEEM
PHYSICAL
SELF-WORTH
Sport
Competence
Strength Conditioning
Body
image

49. 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

50. 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

51. Self-determination theory
• Route to self-esteem is through intrinsic
motivation

52. Intrinsic-extrinsic continuum
Intrinsic
(emersion?) (persuasion?)
Extrinsic
(coersion?)
Payment
Weight loss
Prize
Pleasure
Mastery
Fitness Competition
Body image
Status
Competence
Autonomy
Friendship
Mood

53. 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

54. 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)

55. SDT-based interventions: Project ACE

60. 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?

61. 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?

62. 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

63. What should be on the UK's future
'behaviour change' menu for
tackling obesity?
Colin Greaves

64. This talk …
What we know
What we need to know
Policy, practice and research

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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

72. HOW MUCH DO THESE THINGS
MATTER?

73. 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

74. NICE PH49: BEHAVIOUR CHANGE
All the above, plus …
• Tailor interventions to meet participants'
needs and life-context /barriers /motivations
• High quality training

75. 1 trainer
200 trainees
The importance of training
20,000 patients
Invest Here!!

76. 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

77. MAINTENANCE
9. Dansinger et al, Annals Int MeDda n2s0in0g7e;r124070:471-50 2007

78. 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

79. 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

80. 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

81. 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

82. 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

83. MAINTENANCE: The PESO study
11. Teixeira P et al. Int J Beh Nutr Phys Act 2012;9:22
N=149
women

84. MAINTENANCE RESEARCH
(the current state of play)
In order to change a behaviour, you first
need to understand it

85. 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

86. 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

87. 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

88. How can we move forward
strategically?

89. 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

90. 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

91. We need a strategic, managed
approach to connect policy practice
and research

92. 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

93. Basis of
NCSCT =
learning
outcomes,
training
curriculum
and
evaluation
of delivery

94. Conclusions

95. Thank you!

96. 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

97. How?

98. How?

99. 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

100. 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

102. Ongoing research
• Maintenance interventions
• Digital media interventions
• What makes groups work?
• Impulsive behaviours

103. 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

104. Can we afford to do nothing?

105. 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

106. 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

107. 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

108. 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)

109. Maybe need some experimental
commissioning?

110. 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

111. 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

112. Investigation of evidence into practice
Evidence
Training
Practice
Behaviour change
techniques
Manuals

113. 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

114. 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.

115. 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

116. ‘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.

117. “Medicine is a social
science, and politics is
nothing else but
medicine on a large
scale.”
Rudolf Virchow
1821-1922

118. 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

119. 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

120. 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.

121. Nanny State or Pontius Pilate State?

122. 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

134. “Permit me a
few categorical
statements, for
dogmatism has
a certain role
in the realm of
vacillation.”
Norman Bethune

135. 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.

136. 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.

137. 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.