How to scale digital health in a post Covid world

The ten weeks to June 2020 brought more seismic change in healthcare than the previous ten years. Before the crisis, digital adoption was slow; the hundreds of smaller organisations that together form the NHS each had their own priorities and operational requirements. That created a labyrinthe of commissioning processes for innovators to navigate.  

Of the digital tools many GP practices already had – video conferencing and electronic prescribing, for example – usage typically remained low. Healthcare professionals either didn’t have enough trust in new systems, the time to implement them, or the training budget to get to grips with them. Healthcare lagged far behind other sectors in digital transformation.

Not any more. Red tape is out and “move fast, [don’t] break things” is in, as clinicians nationwide turn to tech to reach patients they can no longer see in person. Almost three quarters (71%) of patients are now accessing healthcare via either telephone or video consultations, up from 26% a year earlier, while only 7% are attending face to face appointments

In a stark departure from old ways, procurement for the video conferencing platforms that make this possible took just two days. NHS Digital, meanwhile, successfully launched Microsoft Teams for 1.25 million healthcare professionals – the health service’s largest ever rollout of its kind – in a matter of weeks. As Sarah Wilkinson, NHS Digital CEO, put it, the “time-consuming blockers” have been eradicated.  

Now the benefits of these technologies have been realised, we’re unlikely to see a return to the pre-crisis form of care delivery. That’s the first legacy of Covid-19. 

It’s not the only one; the second, more pressing legacy is the tidal wave of patient demand on the horizon as many thousands of people who’ve avoided seeking care, or had operations postponed, or suffered illnesses gone undiagnosed, enter the health system en masse. There’s lots of evidence to suggest that large numbers of people have been in real need of treatment they haven’t received, for whatever reason, since the crisis began. 

In Italy, national statistics showed mortality in conditions other than covid-19 increased by around 12,000 over the five weeks to the end of March, with cancer patients at particularly high risk. According to the Royal College of GPs, overall clinical activity in the UK has been down by around a quarter during the crisis with hospital beds lying empty, suggesting a similar trend in the UK. A&E attendances are down 57%.  Doctors warn of a “ticking time bomb”.

When we find a vaccine, these trends will be reversed – and may very well overwhelm the system more completely than we feared would Covid-19.

There is, however, a way to mitigate that risk: digital health interventions. Just as video consultations are already improving patient outcomes at scale by maintaining access to care, digital platforms for managing long term conditions will increase patient self-efficacy and reduce reliance on healthcare professionals, diagnostic platforms will streamline the care pathway and free up clinicians’ time, and e-triage will create efficiencies in urgent care delivery and reduce hospital waiting times.  

That’s just three examples among hundreds of clinically validated digital health innovations. The potential for change is huge. But in order to realise that potential, first we need to make sure these innovations can be scaled safely, quickly and effectively – and win the confidence of the patients who use them. 

We can achieve this by:

1. Investing in the frameworks that build trust

The opportunity to deliver new health interventions is enormously promising. But there are still major hurdles along the way; many of the current legal, regulatory and evaluation frameworks for digital health haven’t kept pace with innovation, and they’re not fit for purpose.   

AI, for example, will power much of the healthtech of the 2020s – but gaining regulatory approval for this technology ranges from difficult to impossible. AI innovators need to align with multiple rulebooks from multiple organisations (the MHRA, NICE, CQC and ICO all currently play a role, among others), and that takes time – lots of it – and hinders progress. In machine learning, the most complex area of AI, no route to NHS approval currently exists at all, because we simply don’t know enough about how it forms decisions and whether it can be used safely in practice. 

So we must make it simpler and faster for innovators to prove their technologies, by investing more in the capability – through the NHS AI Lab, for example – to create effective regulation for digital health. 

2. Taking lessons from the trailblazers on engaging users

We have a lot to learn from the sectors which have already succeeded in digital transformation at scale and at pace. 

Take banking, a highly regulated environment with a centuries-long tradition of doing business in the same way. App-based challenger banks like Monzo, which counts over 2 million users, have overturned that tradition and brought large numbers of customers online, primarily by focussing on user experience. Monzo is designed with users, not for them, and the big six are now scrambling to catch up. 

Or retail: there are lessons for healthcare in the omni shopping experience – the seamless transition from offline to online interactions and vice versa – that forward-thinking brands have created. One example is the Starbucks loyalty card: unlike traditional, physical cards, it exists only within the Starbucks app – but users can check and credit their points balance over the phone, on the Starbucks website, within the app or in person in-store. Just as a patient should be able to update their electronic health record in real time on their way to a GP surgery, Starbucks customers can update their account in the queue for the till. 

These are insights we can apply to healthcare; by focussing first and foremost on the end user and, crucially, making it easy, we can rapidly accelerate user adoption.

 3. Designing to bridge social divides

A major risk of the current pace of transformation is that existing social divides will be exacerbated. Recent research showed introducing new technologies for self-managing long term conditions, which disproportionately affect the more vulnerable groups in society, may in fact disadvantage them further still; around 10% people in the UK lack internet access, rising to as many as 25% of those with a disability. 21% of adults, typically in the poorest communities, lack basic digital skills, while 16% are unable to fill out an online form. 

This is why post-covid health interventions need to be universally available, both online and offline, and built for all people; co-creating digital health products with the people who use them is key. Then we must check, and double check for readability and ease of use, keep all content free from judgement or blame, and, most importantly, provide ongoing, human support. 

 

 

 

Bridging social divides with healthcare technology

Technology is transforming our relationship with healthcare. For the first time, apps, wearables and online video consultations are giving people with long-term conditions immediate, effective support to self-manage their health and wellbeing, without the need to visit a healthcare professional in person. Now, that’s become more important than ever. 

But there’s a risk: As this tech crosses the divide from clinical validation to deployment at scale – and at pace – some of those who would benefit most may be left behind.

Research by the Social Market Foundation, a think tank, found that introducing new technologies for self-management may in fact disadvantage some of the most vulnerable groups in society further still. That’s because there’s an assumption of circumstances which may not reflect reality; around 10% of people in the UK lack internet access, rising to as many as 25% of those with a disability. 21% of adults, typically in the poorest communities, lack basic digital skills, while 16% are unable to fill out an online form.

So how can we ensure these groups can get what they need from a digital health intervention? 

“Based on my experience at both local and national levels, perhaps the most important lesson of all is that becoming a digitally enabled healthcare provider isn’t about replacing analogue or paper processes with digital ones,” says Niti Pall, Medical Director, KPMG Global Health Practice.

“For me, the technologies that have released the greatest immediate benefits have been carefully designed to make people’s jobs or the patient’s interaction easier, with considerable investment in both the design of the tool and the redesign of ways of working.” 

We asked four other leading industry experts what that design process should look like.

Meera Vijayaraghavan, Senior Innovation Associate, National Innovation Centre for Ageing: Involve users in development. 

“The best way to keep people connected with new technology is to involve them from the beginning. Especially if you are developing a solution for people with specific needs, such as the ageing population, and not just in a tokenistic way. The technology might feel intuitive to those who design it, but this is often not the case for many users.” 

John Grumitt, Vice President, Diabetes UK: Make the content accessible. 

“Strive to make all content free from judgement or blame. Avoid a formal or clinical tone of voice and keep sentences and paragraphs short and clear. Provide links in context, at the point in the content where they are most relevant or useful. And take care to ensure that new content is only presented when the reader has demonstrated a clear understanding of previous content.”.

Joanna Causon, CEO, Institute for Customer Service: Understand each individual’s own needs. 

“Technology has to be designed by a customer person rather than a tech person, and you have to see it through the customers’ eyes. What does that actually feel like? How do you know that this will make people’s lives easier?”

Matthew Cripps, Director of Sustainable Healthcare, NHS England & NHS Improvement: Provide ongoing, human support. 

One thing that technology can never replace, although it can provide effective value-adding platforms for, is conversations between a patient and clinician. These are where ‘customer-centricity’ best occurs – both to help the person determine what is best for them, and to help the ‘system understand what actions and models would be ‘customer-centric’. Technology supports, and in many cases, can enhance this, but only by enabling better human-to-human interaction.”

Changing Health is a provider of personalised, digital behaviour change programmes for Type 2 diabetes management, Type 2 diabetes prevention and weight management. Learn more about digital inclusion in healthcare in Changing Health’s white paper “Will the algorithm see you now? Putting user centricity at the heart of healthcare technology” here.

 

There’s only one kind of AI that matters in the NHS – and it might surprise you…

Artificial Intelligence (AI) is set to make precision medicine a reality; improving outcomes by delivering exactly the right care, to the right person, at the right time. So, there’s much talk of the ‘robots taking our jobs’ – but we’re not there yet. In the meantime, it’s important to remember that artificial intelligence won’t be replacing the most valuable form of AI in healthcare any time soon… actual intelligence.

Every element of care delivery relies on human intelligence and human experiences, from how we train and reimburse healthcare professionals to planning how best to deploy them. Automation may well create efficiencies in some of those processes, but replacing people with artificial intelligence doesn’t just require technology; it requires a vast infrastructure too, which currently doesn’t exist.

We can liken the shift towards machine learning in healthcare as moving from petrol cars to electric ones. Electric cars have been in fashion for a decade already, but because of the lack of infrastructure – in this case, charging points – sales pale in comparison to their petrol counterparts. 

That’s not to understate the possibilities of innovation; we’ve already moved from horses to cars by building thousands of petrol stations, from candlelight to electric bulbs by laying cables across the planet, from landlines to mobile phones by creating global wireless networks. 

But in healthcare, there are mountains to climb on the regulatory landscape. AI, and digital health technology more generally, has moved so quickly that the NHS, FDA and other regulators have struggled to keep pace. 

At the moment, AI-powered health technologies are regulated as Class II medical devices, similar to an insulin pump or a pregnancy test kit, and therefore considered “medium risk”. That means that before the product can be taken to market, it must either undergo a lengthy approval process, or innovators must prove it’s equivalent to an already approved device. In the FDA’s own words, their “traditional paradigm of medical device regulation was not designed for adaptive artificial intelligence and machine learning technologies.” 

Not forgetting, of course, patient attitudes to AI-powered healthcare. Changing Health’s own research showed the majority of people are at least open trying digital alternatives to traditional healthcare – but would they trust an algorithm on a life or death treatment decision? Perhaps not. 

It’s most likely we’ll see a third form of AI take centre stage in the 2020s: augmented intelligence. Technology will support healthcare professionals to make decisions, not make those decisions for them. In doing so, artificial intelligence will ensure those professionals are even better at their jobs – and harder to replace. 

Changing Health is a specialist provider of personalised behaviour change programmes for Type 2 diabetes management, prevention and weight loss. 

 

All eyes on Europe: the gold rush for health tech investors

Digital health continues to captivate venture capitalists around the world. 2019 was the second largest ever year for funding in this sector, totalling $7.5bn globally – a fraction below the 2018 record of $8.1bn. That compares to just $1.2bn in 2010.

As health systems’ needs and patients’ attitudes evolve, data-driven approaches to treating and preventing long term conditions are transforming how we access care. Disruptors are taking us closer to precision medicine and true patient-centricity, improving outcomes at scale with tech. They may have no training at all in medicine, but bring expertise in data science and analytics, computing and behavioural economics to the table for the first time.

California has historically been the hotbed for health tech innovation, making West Coast companies the most popular beneficiaries of VC funding by far. San Francisco alone saw 131 health tech deals in 2018, with London and Beijing in joint second place with 21 each. 

But the tables look to be turning. Unicorns on this side of the Atlantic are closing bigger and bigger deals, fast catching up to, and in many cases outpacing, U.S. rivals. It was London’s Babylon Health which closed 2019’s biggest health tech deal, raising $550m from Saudi investors to develop diagnostic software for its remote care platform. The company is now valued at more than $2bn. 

 

 

Overall deal count in Europe is declining, but average deal size increased in 2019. 

 

 

Average deal size in the U.S. decreased over the same period.

Also delivering remote GP consultations via video is Swedish start-up KRY, known as LIVI in the UK, which last week closed a £118m, Canadian-led funding round to develop its product in France, Sweden, Norway and Germany and compete with Babylon in the UK. Led by former NHS Chief Digital Officer Juliet Bauer, the company plans to include a partnership with UK high street chemist Boots, allowing customers to speak to a clinician in-store via video. 

Doctolib, listed in Paris is, too, removing barriers to accessing healthcare consultations with its digital platform for booking appointments, raising €150 million last year in a U.S. led round to accelerate its growth in France and Germany. More than 11 million people already seek appointments through its site each month. 

Tel Aviv based Healthy.io raised $60m to expand its ground-breaking platform for smartphone urinalysis, the only FDA-cleared and CE-approved home urine test equivalent to lab-based devices, while AMBOSS, of Berlin, secured 33 million to develop its medical learning platform dedicated to helping future physicians succeed on their exams.

Start-ups have become scale-ups 

These ever larger rounds show how quickly the European market, and the systems supporting it, matured in 2019. The ‘enablers’ of digital health innovation – that is, regulators and governmental organisations – are smoothing the route to market for earlier stage start-ups, and allowing for clinical validation at scale for those at mid stage.

Germany, for example, is the world’s largest integrated health market but had lagged behind in adopting digital health at scale, until the Bundestag passed the Digital Supply Act in November 2019.

The new legislation provides a “fast track”, 12-month trial process for formal approval of new digital health products. Any doctor in Germany can also now formally prescribe digital health app for the first time, reimbursed by the country’s statutory (and universal) health insurance. They can also be paid to provide remote consultations with patients and, for the first time, offer information about digital health on their websites. 

Even in Switzerland – where in contrast to the national policymaking of Germany, each of the 26 cantons can choose their own rules to create a regulatory labyrinthe – enablers have been clearing the way for digital health startups to scale more quickly. 

eHealth Suisse, a governmental organisation, exists to maintain the “flow of information between the Confederation, cantons, communities, specialist organizations, professional associations, the private sector and the population, while the Swiss Conference of Cantonal Health Directors (GDK), meanwhile, is coordinating policy between the cantons.  Together, the two organisations are boosting competition and growth in health tech, while also supporting innovators to remain compliant of each canton’s individual rules.

And here in the UK, Health Secretary Matt Hancock is, of course, champion of all things digital. Having launched a entirely new NHS organisation, NHSX, to accelerate digital innovation in healthcare, health service chiefs now plan to “take a step back and let the innovators innovate”. They’ll move to a demand-led system of “collaboration, iterative development, testing and learning in real-world settings.”

That’s good news for patients and innovators alike; a more hands-on approach to adopting new treatments in the UK, spearheaded by a dedicated NHS organisation, means commissioners can horizon scan more effectively while digital health companies can clinically validate and scale their products more quickly.

Europeans are open to digital alternatives to their usual care 

At the same time, European patient attitudes are changing, as people recognise that digital health can often meet their needs more quickly or easily than visiting a healthcare professional in person.

Our own poll of over 4,000 people in the UK found the majority (54%) are now either enthusiastic or willing to try remote care in the form of a video consultation delivered via smartphone. Being able to do it from home and not needing to travel to a GP surgery were commonly cited reasons.

A similarly sized study of U.S. consumers, meanwhile, found the majority (53%) would still rather see a healthcare professional in person, even if it meant waiting longer to do so. 

Attitudes in some corners of the continent have changed still faster. In the Netherlands, more than 70% of people with a chronic disease are now open to digital alternatives to their traditional healthcare, such as “monitoring at home or video calling with a doctor or nurse practitioner.”

Leading the way is Sweden, where the Government has pledged to “be the best in the world at using the opportunities offered by digitalisation and eHealth’ by 2025”. The tech-savvy population are often some of the world’s first to adopt a digital solution en masse; cashless society, for example, is close to a reality in Sweden. Healthcare is no different. Many Swedes are keen to use tech to take a more active role in managing their own wellbeing, and policymakers are “willing to try new technology to alleviate rampant health care costs“, making Sweden the perfect test market to take digital treatments from clinical validation to delivery at scale. 

The opportunity for health tech VCs 

Those twin forces: more open, flexible, progressive policy and a market of 500 million people increasingly open to digital health, have created a major opportunity for health VCs. Now is the time to watch for Series As and Bs in growth markets, particularly in Western and Northern Europe, among innovators with a team and technology built for scale. This is the gold rush of the coming years.

Changing Health provides digital, personalised programmes to create behaviour change at scale, closing a £3 million Series A funding round in December 2018.

 

Debra achieves Type 2 diabetes remission in 3 months

Debra was in shock. A routine visit to a new GP had come with some unexpected news. “To be honest,” the GP told her, “It’s your diabetes I’m worried about.”

She’d had no idea she had Type 2 diabetes, and she didn’t know how to manage the condition either. Conscious of the waiting room filling with other patients, the GP began reeling off a list of actions Debra should take to keep things under control. “He was giving me all this information so quickly,” Debra says. “There was just too much to take in at once.”

“But I thought, there’s no way I’m living with diabetes for the rest of my life. I’m going to make a change. He offered to get me on the Changing Health app, and I started straight away.”

The Changing Health programme combines digital education, which breaks down guidance on diet and diabetes into a single straightforward course, with one-to-one support from a behaviour change coach.

Carl Lumsden, one of the Changing Health coaches, was assigned to support Debra. “She sounded a bit overwhelmed by all the information her GP had given her,” he says. “I suggested she take it in easy steps, focus on making manageable changes to her diet, and don’t do too much at once. It’s the smallest battles that win the war!”

Little swaps, it turned out, can make a big difference: substituting pasta, Debra’s go-to evening meal, for brown cauliflower rice, and fruit for vegetables and protein.

Combined with some of Carl’s most tried and tested motivational techniques – setting SMART short- and long-term goals, writing them on post-it notes to leave around the house, involving others in lifestyle changes – soon Debra was seeing real progress. By the time of her second coaching phone call, she had lost a total of 8kg.

 
At the same time, Debra’s understanding of diabetes, diet and weight loss had rapidly improved. “The app was so helpful – I learnt so much about how my carbs affect my blood sugar – slow release carbs, fast release carbs – all kinds of things I had no idea about before.
“And Carl had the answer to all my questions, telling me what to google; every time, I had more questions, and he always had the answer!”

Three months after she began the programme, Debra visited her GP again – and there was news this time around too. Her diabetes was in remission.“I did it!” she says. “Now I feel 100% better. I’m walking to the bus stop every day, tracking my steps, fitting as many into my job as I can. I’m about to go on a self-catering holiday, and I’m going to cook all my meals fresh so I can keep up my diet.

“Before, I was down in the dumps, sometimes I just felt like I couldn’t be bothered – I’m so much more energetic now! So I’ll keep it up for the rest of my life. I was so determined to get better. To anyone considering starting the programme, I’d say don’t be embarrassed and just give it a go – if you’re like me, then there’s a lot to learn – but that help is there for you.”

Losing weight has got complicated. Will digital health make it simple? 

It’s never been harder to make informed decisions about how we eat. As our increasingly busy lifestyles necessitate more convenience foods and less cooking from scratch, identifying what constitutes a “healthy” meal and managing our weight effectively isn’t always possible.

Take hidden sugars: they’re everywhere we look, added in large quantities to all manner of “health foods” (granola, packaged fruits, salad dressings, yoghurts) and, to complicate matters still further, given a baffling array of different names – dextrose, barley malt, agave nectar, ethyl maltol – the list goes on (and for quite some time). 

So we may, perhaps, rely instead on a long established way of moderating our diet: counting calories. But here too, things are not as simple as they seem. The calorie, as a measure of energy consumption, cannot accurately determine the effect of any particular food on weight gain or weight loss. We digest and metabolise calories in a number of different ways; 1000 calories of complex carbs each day, for example, produces very effects on our waistlines to 1000 calories of protein. The time of day we consume those calories presents another variable. Then there’s the calorie count itself: one US study found that labels on American packaged foods (legally) misstate it by an average 18%, and it can vary further still depending on the preparation.

While around two thirds of products on supermarket shelves do now display their nutritional content more clearly in the form of traffic light labelling, currently only voluntary in the UK, whether consumers are consequently making healthier purchasing decisions remains to be seen. A can of coca cola, for example, contains 39 grams of sugar, more than one and a half times the entire recommended daily intake for a 7-10 year old – yet the can displays three green lights out of four. Childhood obesity, meanwhile, continues to rise.

Best to find some advice we can rely on, we may think, in the same place we look for everything else: Dr Google. But online searches make things no less complicated. University of Glasgow research published earlier in 2019 found that of the nine most popular online influencers making claims about weight management, several of whom are Twitter Verified implying celebrity status, only one of them provides accurate and trustworthy information.

The rest instead provide opinion presented as fact or fail to provide evidence-based references for their claims. Of the 10 most recent meal recommendations published by each of the influencers, the research found, not a single one met PHE criteria on nutrition. The same can be said even of ostensibly more credible national media titles; some publish highly misleading headlines on the best diet for people with Type 2 diabetes almost daily. 

When the guidance we use to help us make the best choice, whether in the form of ingredient lists, nutrition information on packaging, online searches or whatever else, breaks all four of the fundamental rules of successful behaviour change – it isn’t easy, nor attractive, nor social, nor timely (E.A.S.T) – is it any wonder so many of us struggle to lose weight and keep it off?

There may, however, be a solution in the making – and it’s already in our pockets. Our smartphones have made it possible to access weight loss support that does take the E.A.S.T principles into account. Digital health platforms expanding across the UK and beyond allow people to find out from an expert health coach how they can fit genuinely healthier food into their normal routine, via in-app instant messaging, over the phone or on a video consultation.

Unlike scouring the web, waiting in line for a five minute GP appointment or shelling out for a private dietitian, digital health platforms make managing our weight Easy, by reducing the “hassle factor” in providing access via a link to a 30 second sign-up page provided directly to the user via email or SMS. A friendly expert can then be on hand to offer guidance instantly, any time and anywhere, simplifying a change in lifestyle by breaking down long term, sustainable behaviours into small, manageable steps. 

They’re Attractive; regular user experience (UX) audits ensure every element of the digital healthcare journey puts the user first. That means using human, conversational language that everybody can understand, removing any unnecessary actions required on the part of the user, personalising “touchpoints” wherever possible and, crucially, taking negative feedback on board.   

They’re Social; talking to other people about our behaviour can be a strong influence on the choices we make. Users have an expert on hand do that whenever they like. By making a firm commitment to another person to achieve a health goal, users are likely to be more confident, motivated, autonomous in making changes.  

And they’re Timely: through push notifications and automated emails digital health platforms can provide encouragement to stay on track when people are likely to be most receptive, taking social, environmental, cultural and a whole range of other factors into account – and help people plan their response when they may be about to slip up. 

As digital health technologies steadily mature, a raft of UK start-ups are currently providing these platforms and programmes through the NHS, for people diagnosed or at risk of Type 2 diabetes. For the first time, they’re making long term, sustainable lifestyle change possible for a group that stands to benefit the most from it. Thousands of people have been empowered to better manage their health already – but the potential is much greater than that. 

In the coming years we’ll see digital health providers partnering with health insurers, employee benefits providers, local council services, even governments – to make simple, effective weight management support available for anyone who needs it. The result? A large scale shift in attitudes towards diet and lifestyle, a better understanding of our nutrition en masse, and ultimately, a healthier nation.  

 

World Wellbeing Week: five unlikely ways countries keep their people healthy

For the first time in our planet’s history, our health is at risk not from having too little to eat, but too much. Developing economies across the world are replicating Western trends in consuming more calories each day as access to cheap, plentiful fast food increases. As a result, the global population is, quite literally, expanding. 

Yet incentivising people to eat less and move more on a national scale can be tricky, as is evidenced by a number of diet and exercise campaigns in the UK that have, so far at least, been met with a lukewarm response. 

These shifts in lifestyle are exacerbated by factors outside our control in certain parts of the world; in Saudi Arabia, for example, where 68% of the population is now overweight, it’s simply too hot to head out for a run. 

So, what are governments and health economies around the world doing about it? Some have taken a novel approach to encouraging their citizens to get outside, get active and boost their wellbeing:

Singapore

The healthiest country in the world (Legatum Prosperity Index 2018) provides every citizen who wants one with a fitness tracker free of charge. The latest iteration even incorporates a heart rate monitor, which gives it more functionality than an (£85) entry level FitBit. Singaporeans are then encouraged to take to the streets in the National Steps Challenge, winning “healthpoints” for every step they clock up around the city. 

Those who amass a certain number of points can redeem them for shopping vouchers and energy bill credits and are prompted to “level up” for bigger rewards. Now in its fourth six month “season”, the challenge also gives participants the chance to win S$60,000 (£34,000) worth of prizes in a grand draw.

South Korea 

Creating “a welfare state, in which the entire population can enjoy wellbeing” would be a stated goal, one might assume, of the Department of Health. Not in South Korea. There it’s the mission of the Korean Forestry Service, which is in the process of creating 37 “healing forests” around the country in a bid to improve citizens’ health and wellbeing. 

The forest trails will wind their way around sports facilities, meditation spaces, rest areas and convenience facilities and have so far succeeded in enticing Koreans to don their walking boots; around 12.3 million, or 17% of the population, visit each year.

Sweden

Some employers in a country consistently ranked as one of the world’s happiest (UN World Happiness Index, 2012-18) are going a step further than encouraging exercise at lunch: they’re mandating it. 

Employees at fashion retailer Bjorn Borg, water company Kalmar Vatten and construction consultancy Rotpartner are all required to head to the gym on Friday lunchtimes and get a weekly workout in. Other employers, meanwhile, contribute up to 5,300SEK (£466) per year for their employees’ sporting activities, which is tax deductible.

There’s a wealth of evidence to suggest that taking some exercise during the working day is a win-win for both employers and employees; one Stockholm University study found that teams who fit 2.5 hours of exercise into the normal working week are happier and more productive – and get at least the same amount done as those who don’t.

United Arab Emirates 

A million people took part in the UAE’s #Dubai30x30 challenge in 2018, in which Emiratis committed to 30 minutes of physical activity every day for 30 days. The initiative included 2 “carnivals”, 250 citywide events, and over 8000 classes and activities, while the specially created Dubai Fitness App helped users to track their workouts, find local fitness classes and compete with others.

UK 

NHS Shetland has rolled out “nature prescriptions”, the first of their kind in the UK, to treat conditions including high blood pressure, Type 2 diabetes, heart disease and other conditions. Healthcare professionals will recommend countryside rambling and long walks on the beach for patients to connect with the natural environment around them and involve themselves more in their own health.

 

How to motivate a whole country to get out and get active

What might incentivise us to walk, run and cycle more regularly is a question that’s long puzzled health bodies in the UK. Campaigns like Public Health England’s Health Matters have seen only limited success; as many as 39% of us – that’s 20 million people – remain “physically inactive”, defined as participating in less than 30 minutes of moderate intensity physical activity per week.

This, of course, has implications for population health: 66% of us are now overweight or obese with 12.3 million of us at elevated risk of developing Type 2 diabetes. We’re not alone in our inactivity either; according to the EU Commission’s 2018 Eurobarometer report on sport and physical activity, governments and health bodies throughout the continent face similar challenges.

There’s one country in particular, though, that’s bucking the trend. Renowned for being home to more bicycles than people, the Netherlands is a country of highly enthusiastic walkers, runners and cyclists. 84% of Dutch people own a bicycle, and according to government figures, more than a quarter of all trips by Dutch residents are made on two wheels. In fact, the Dutch walk or cycle more often than almost any other country in Europe: 80% do so with at least some regularity, compared to the EU average of 44%.

So, what is it that makes the Dutch leave their cars at home?

“An important reason for our active lifestyle is that Dutch people are very aware of the positive impact of being active on psychosocial and physical health and happiness,” says Vera Wiegman of Menzis, Changing Health’s private health insurer partner in the Netherlands.

The link between physical activity and wellbeing is well documented. It’s little surprise, therefore, that Dutch residents report some of the highest levels of wellbeing in the world; the United Nations’ World Happiness Report, which has charted satisfaction with life in 156 countries across the globe each year since 2012, has never ranked the Netherlands lower than seventh.

“I do believe that our happiness is correlated to our higher activity levels,” Vera says. “The phenomenon isn’t age-bound – the [Eurobarometer] report shows that, contrary to EU averages, engagement in physical activity is the same across all age groups. Our physical activity is also often seen as a recreational activity, such as cycling or walking in nature, walking the dog and gardening.”

Indeed, the Netherlands is the only EU nation in which “having fun” is the most common reason for exercising; 65% of Dutch people say it’s their primary motivator to get out and get active. In the UK, by comparison, it appears we exercise because we feel we have to, rather than because we want to, with 54% of us doing so “to improve [our] health”.

[credit: Eurobarometer, EU Commission]

Perhaps that, then, is our problem in the UK: for us, exercise usually feels like a chore. But it doesn’t have to be that way.

“Adopting positive lifestyle habits is not about radical crash diets and gruelling gym routines,” says Changing Health’s Professor Mike Trenell. “Quite the opposite. The way to make a change that lasts is to find one you can sustain – one you can fit into your normal routine without struggling to keep it up.

“Turning exercise into something into something we can enjoy at the same time is one of the most effective motivators to get more active, whether that’s getting off the bus early and losing yourself in an audiobook, relishing some healthy competition at spin class or meeting new friends in dance or yoga groups.”

“Compared to most people in the EU, the Dutch citizen has a more structural, social way of engaging in physical activity, since we’re more likely to be a member of a sports club or fitness centre instead of being not committed to such an organisation,” agrees Vera.

“Dutch people are motivated to engage in physical activity to relax, have fun and be with friends.”

The science supports that view: one study into behaviour change for people with Type 2 diabetes, on which Changing Health’s programmes are based, explored which context of lifestyle change is most effective in facilitating long term success. Social influences came top, followed by social role and identity to a peer group.

“Everybody’s routine, circumstances and personal preferences are different, and we should take these individual factors into account when recommending lifestyle changes,” Professor Trenell says. “But almost everybody can find a form of physical activity they can enjoy, and perhaps share with others; it’s just a matter of working out what that activity is. Taking a leaf out of the Netherlands’ book could well be the key to improving our health and wellbeing as a whole nation.”

Read more about motivation to make lifestyle changes in Changing Health’s white paper, Personalisation: the secret ingredient to lasting lifestyle change.

 

The five step secret to becoming the person you want to be

We all have our own ideas of success – perhaps climbing the career ladder, becoming fitter and healthier, or embracing new personal experiences – but there’s one thing we all have in common. We want to make the impossible possible.

​How can we do that? By setting workable goals to keep us focussed, every step of the way.

Experts in behavioural psychology say there’s an art to goal setting. Like George T. Doran, a city planning hotshot who made a name for himself by helping lacklustre managers get their projects off the ground. Doran pointed out that by using a specific technique, which he called S.M.A.R.T goal setting, we can create a practical structure for achieving things that aren’t easy to achieve.

The technique is invaluable for the Changing Health behavioural change coaches. We’ve found that it’s one of the best ways to help our clients lose weight, feel better and ultimately, transform their lives.

This is what S.M.A.R.T goal setting looks like:

  • SPECIFIC: target a specific area for improvement
  • MEASURABLE: quantify, or at least suggest, an indicator of progress
  • ACHIEVABLE: agreed and attainable
  • RELEVANT: reasonable, realistic and resourced, results based
  • TIME BOUND: time-based, time limited

Here’s an example: let’s say you want to lose weight. That’s great – but you could define your goal more clearly to boost your chances of success.

That means applying the S.M.A.R.T method:

  • SPECIFIC: “I want to lose weight so I can feel good in my favourite dress again”
  • MEASURABLE: “To fit into my dress I’ll need to lose around 3kg”
  • ACHIEVABLE: “If I can reduce my portion sizes, and cut-out sugary drinks, I can accomplish my goal”
  • RELEVANT: “I know I can do this. I lost some weight two years ago, so I know this is a realistic target”
  • TIME BOUND: “I’d like to wear my dress at the summer party on August 20th”

And suddenly, a vague ambition to “lose some weight” becomes a clearly structured goal with a timeline to make it happen. Showing off your lovely summer dress at the party just became five times more likely.

So remember: when you’re setting out your goals, think SMART!

Author Carl Lumsden is a Changing Health Behaviour Change Coach with a background in health and fitness.

Type 2 diabetes remission: how simple swaps changed Janice’s life

Janice had Type 2 diabetes. She was stuck in some unhealthy habits – drinking four cans of coca cola a day, eating three-person portions of pasta, binging on pringles – and she needed help to make a change. In January 2018 she was diagnosed with an Hba1c level of 89, indicating a severe lack of glycaemic control.

And make a change is what she did. It began when, soon after her diagnosis, her GP referred her onto Changing Health’s Transform programme for diabetes management. Transform combines a course of digital education on diabetes with personalised behaviour change support from a lifestyle coach, and aims to give users the psychological tools to sustain a positive health behaviours over the long term.

She got off to a flying start. Kirsten, her lifestyle coach, was impressed; Janice had already begun prepping her meals in advance, swapping carbs at lunch for a healthier alternative, and dancing each night to an exercise routine – and lost a kilo in a week as a result. While it’s important to start with small changes, Janice felt she could do more, so Kirsten worked with her to set a clear, achievable short-term goal for physical activity: three brisk, 10 minute walks per day on the way to work, at lunchtime and on the way home.

By March, Janice had accelerated her progress, decreasing her portion sizes, increasing her fluid intake, cutting out crisps, swapping white bread for wholemeal and potatoes for sweet potatoes.

“She wanted to know more about the carb and sugar content of fruits and vegetables,” Kirsten says. “So I gave her a document about GI of foods and a link to a website that could be useful too. I told her carrots are quite high in GI and sugar, but they’re still vegetables and better than other things you could be eating!”

“I was very honest with Kirsten,” says Janice. “She was equally honest back, and without being judging – she was supportive and positive. I wasn’t very active – partly because I was ill and partly because of the weather, and we spoke about my frustrations with that. We discussed mini exercises I could do during the day.”

May rolled around, and it was time for another visit to the GP. There was some excellent news: Janice had reduced her HbA1c to just 55 in four months. She was well on the way to reversing her condition for good.

“I kept making swaps – I like to go to concerts, so I swapped beer for sparkling water. I haven’t touched Coca Cola, no red meat, no processed foods – I’m eating lots of fish, veggies, grilled halloumi. My partner enjoys the new diet too. I’d led him astray to be honest, but he’s just brilliant – he supports me every day”

The last time Janice and Kirsten spoke, in July, things were looking even better. Janice had reduced her HbA1c to 42 – meaning she no longer had diabetes! She’d now lost a total 14.8kg on the programme, and dropped two dress sizes to boot.

“Janice has been amazing throughout her journey on the Changing Health programme,” Kirsten adds. “She recognises that the changes she’s made are long-term lifestyle changes, rather than a short-term fix. She deserves this fantastic news!”

Does Janice have any advice for others in her position? “Be honest. That’s the key, that’s the tough thing. When I’ve been low, I’ve rung up Kirsten and beat myself up, but she looks at the bigger picture. She’s brilliant. I’ll miss her.”

If you want to go fast, go alone. If you want to go far, go together

More people in the UK are at risk of developing Type 2 diabetes than live in London, Birmingham and Manchester combined: 12.3 million. In March, yet more evidence emerged suggesting our increasingly sedentary lifestyle habits, combined with tempting supermarket deals and a series of cunning marketing campaigns by Big Food (see: how Cadbury’s promoted comic book about its Freddo chocolate character on YouTube, circumventing rules that prevent HIFSS products being targeted at children), are only exacerbating the problem.

It’s welcome news, therefore, that NHS England has this month significantly expanded the scope of the Healthier You Diabetes Prevention Programme (DPP). Already the first such programme in the world to be rolled out nationwide, and with participants having already lost a total weight equivalent to that of four London buses, the DPP will now support 200,000 people per year to transform their lifestyles and reduce their risk of developing Type 2 diabetes.

What’s remarkable about the DPP isn’t just its ambition in preventing Type 2 diabetes at such scale; it’s also how many healthcare organisations – wellness communities, face-to-face education providers, digital behaviour change providers, tech specialists – are working together to make that ambition a reality.

This is the first time the DPP has included a digital stream; from July, the DPP’s classroom support providers will partner with five other companies (Changing Health, Liva Healthcare, OurPath, Oviva and WW) to make the DPP accessible any time, anywhere – and in whatever format works best for the participant.

All the evidence shows we can achieve better results by working together than when we go it alone. Changing Health’s 12 month study on motivation to prevent Type 2 diabetes, published on Diabetes Prevention Week 2019, compared how people with risk factors for Type 2 diabetes (overweight) reduced their weight with the aid of either a personalised behaviour change programme, or such a programme combined with support to maintain a very low calorie (1200-1600 daily) diet in the form of a recipe and meal plan book by dietary experts Carbs and Cals.

While weight loss at month 12 was broadly the same for both groups on average (4.5kg, n=149), the striking difference was in how quickly the participants shed those kilos; during the first month, around 10 times as many participants in the group receiving two forms of support achieved ≥3% weight loss as in the group on a personalised behaviour change programme only. Such rapid weight loss presumably boosted many participants’ motivation to continue in their lifestyle change and build on their success.

These results are, in part, Changing Health’s justification for creating partnerships with several other global leaders in aspects of preventative health; with dacadoo, which builds health engagement platforms, we can now provide behaviour change programmes to a much bigger population around the world. With Ingeus, on the DPP, we can increase access to diabetes prevention support and improve uptake in the UK. And with our most major partnership, to be announced later this quarter, we can take a huge step towards achieving our mission of empowering millions of people to make lifestyle changes that last.  

In short: companies and organisations are doing ever more interesting and innovative things in the space of lifestyle change and, so far, doing a sterling job in working together to drive positive lifestyle changes and prevent Type 2 diabetes at population level. As the DPP’s expansion proves, we’re gaining momentum and fast. Let’s keep it up.

Why language matters: Is medical jargon harming patients?

In the run up to the Diabetes Professional Care Conference (Nov 14-15), I had the privilege of gaining insight from one of their esteemed speakers, Anne Cooper, on the importance of Language in diabetes. I hope you enjoy the piece.

“My son hates being called a diabetic. He’s a person, not a condition. He doesn’t like being asked if he is ‘well controlled’ either – I told him to reply with ‘no – I scream & shout and pee on the floor’”- Caryn, mother of a child with Type 1 diabetes

When we talk to people with diabetes, language matters. It really matters.

When we talk to people with diabetes, language matters. It really matters. “We” is anybody around those who live with the condition: GPs, nurses, dieticians, employers, family, friends. Language can make us feel great or make us feel worthless; our choice of words might heal old wounds or open fresh ones. Caryn’s son knows that from experience, and so too do millions of other people with diabetes around the globe.

“Language creates an environment where people can be more or less resilient,” says Anne Cooper, a founding member of the NHS-backed Language Matters working group, who has Type 1 diabetes and helped to develop a new set of recommendations on how to talk to people with the condition. “Labelling influences how you behave – if you’re cared for with positive use of language, you can better self manage.

“I remember, as a nurse, walking down the corridor and hearing a doctor talking to staff about his next clinic. He said ‘I’m off the see the diabetics’. They’re people who happen to have diabetes, and although caring for people is hard and we’re all under a lot of pressure, we’ve got be careful not to move away from a person-centred approach.”

“Would you introduce a child as myopic?” asks another parent whose son lives with diabetes. “I doubt it very much. So why say ‘diabetic’? The phrase ‘non compliant’ is awful too, and it doesn’t reflect the fact that everyone is doing their best. Maybe not the same ‘best’ as someone else, or even their best ‘best’ but just the best they can at that moment.”

The stigma of being called, for example, “a diabetic” or “non-compliant” can make a lasting impact; one recent literature review showed the use of such terms can be stressful for the individual and reduce the likelihood of their attending healthcare appointments and self-managing their condition effectively. Feedback from a focus group of people with diabetes (n=68) in a 2018 qualitative study showed that many commonly used words and phrases can be damaging to their self-esteem:

  • Judgment: “compliance/adherence,” “control,” “controlled/poorly controlled,” “lazy,” and “good/bad”
  • Directives: “should/shouldn’t,” “have to,” “need to,” and “can/can’t”
  • Labels: “diabetic” and “brittle”
  • Misinformation or disconnection: “you’re fine,” “normal,” and “cure”

Yet for people with Type 2 diabetes, who make up around 90% of all people with diabetes in the UK and 40% of whom have at least three comorbid chronic diseases, framing the conversation correctly can be a serious force for good in empowering people to make healthy lifestyle changes.

“The general idea behind increasing people’s motivation is to focus on the good things to accumulate the energy and enthusiasm to carry on and to build confidence in being able to deal with problems,” says Dr Lucy Rechakova, KTP Associate (Health Psychology) at Changing Health. “For example, you could use positive framing, like ‘we could improve…’ instead of ‘this isn’t very good’.”

“Another thing is to focus on what the person’s done well in the past – and there is always something people have done well, that worked, that they can repeat to start with and make the lifestyle change feel less like a major change. Celebrating success, however small, is important to keep up the momentum.”

Indeed, as a survey study asking patients about their experience with health care providers at the time of diabetes diagnosis n = 172) showed, reassuring messages from healthcare providers are associated with less diabetes distress and better self-management at 1 to 5 years after diagnosis.

Small changes in the way we talk to or about people with diabetes can have big implications for their health.

Clearly, making small changes in the way we talk to or about people with diabetes can have big implications for their physical and mental health. More positive, collaborative and jargon-free language is vital. As Diabetes Australia points out in their ground breaking position statement on this issue, and to quote Rudyard Kipling: “words are, of course, the most powerful drug used by mankind.”

Nudging for good: How health psychology can tackle child obesity

It’s a curious paradox that as the Western world becomes more prosperous and its population lives longer, some of the most preventable health crises are rapidly escalating. One of the first and foremost among them: childhood obesity.

The stats make for alarming reading: one in three UK children are overweight or obese before they finish primary school. Of these, 40% will become obese adolescents. The vast majority of whom – 75-80% – will become obese adults at severely heightened risk of developing Type 2 diabetes and other health issues.

The causes of child obesity aren’t homogenous; hereditary, physiological, social and environmental factors can all play a role. But there’s no doubt that ever since the end of WWII in the West, and more recently in developing countries, there’s been a surplus of calories in the food we consume. As Susan Jebb, professor of Diet and Population Health at the University of Oxford put it this week, the situation in which food is readily available for most people has arrived in the blink of an eye in evolutionary terms.

Industry appears indifferent. Take Starbucks, for example, which pledged to slash added sugar in its drinks in alignment with the Government’s Childhood Obesity Plan. That didn’t stop them marketing a “short-sized” hot chocolate for kids with a whopping 20.1g of added sugar – more than the entire recommended daily limit for 4-6 year olds. Starbucks is by no means alone.

So how can we address the problem? If the corporate world is unable or unwilling to step up to the task, we’re left with two options: ‘hard’ measures (regulation), or ‘soft’ measures (promoting, assisting and allowing healthier choices).

There’s a strong case for the latter. By applying psychological insights, or ‘nudge theory’, we can encourage or guide behaviour without mandating or instructing. “’Nudging’ has been used by advertisers for decades,” says Dr Leah Avery, Head of Health Psychology at Changing Health. “That has contributed to an over-consuming society, and in turn, the obesity epidemic. In a sense, we need ‘counter-nudges’ to combat those used by advertisers.”

Even the subtlest of nudges can be highly effective in facilitating positive behaviour change. In New Mexico, USA, a simple change in the design of a shopping trolley was shown to help people make better decisions about the food they buy. Researchers marked a line with yellow duct tape across the width of the trolley, and added a sign asking shoppers to place fruit and vegetables in front of the line and everything else behind it. The result was a 102% increase in sales of fruit & vegetables (at no loss of profitability to the retailer).

In Iceland, LazyTown, a popular childrens’ TV show, features a healthy superhero motivating children to eat healthily and be active. In partnership with the Icelandic Government, children aged 4-7 were sent a LazyTown “energy contract”, signed with their parents, in which they were rewarded for eating healthily, going to bed early and being active. One supermarket chain rebranded all its fruit and vegetables “Sports Candy” – LazyTown’s name for healthy food – and saw a consequent 22% increase in sales. Since LazyTown hit the airwaves in 1996, Iceland has become one of the only countries in the world in which child obesity levels have fallen.

There’s promise closer to home too. A partnership between LazyTown and the UK Nudge Unit led to the launch of the Change4Life programme, Public Health England’s flagship initiative for preventing childhood obesity. This year’s Change4Life campaign, encouraging parents to look for ‘100 calorie snacks, 2 a day max’ provides parents with money-off vouchers for healthier snack options including malt loaf, lower-sugar fromage frais, and drinks with no added sugar. A survey of 1001 mums who used the Change4Life Sugar Smart app found 96% of those with children aged 5-11 had reduced their families’ sugar intake.

Tesco, the chain which first embraced the behavioural insights approach by removing sweets and chocolate from its checkout aisles, has this month devised another way to nudge people into making healthier choices. Its ‘little swaps’ basket comparison will be displayed at the front of stores to highlight lower sat fat, salt and sugar alternatives to the most popular childrens’ products. The comparison busts the myth that healthier choices cost more too.

Image: Tesco PLC

Nudges alone, however, will not suffice. Government policy must also play a role. “Regulation is a powerful influence on behaviour,” says Stephen Greene, Past President International Society of Pediatric and Adolescent Diabetes. “Just as Government was central to the banning of smoking indoors in public places, the supply of food to children in schools, labelling, the use of unhealthy products – they should all be looked at both locally and centrally to influence what’s going on.”

“Legislation, nudges and group and individualised interventions are all needed to tackle the public health challenges we’re facing,” agrees Dr Avery. “Efforts on these fronts should be co-ordinated and robustly evaluated.”

Professor Greene adds that we need to see some real cultural shifts in how industry produces and distributes food, and how consumers eat it. Perhaps that’s not too far out of sight. “In the same way one dinner lady inspired Jamie Oliver to change attitudes to food in schools across the country, we’ll see a shift in attitudes to sugar over a generation. The understanding is dawning that sugar has played such a big role in childhood obesity.”

In a world in which the next generation is set, for the first time, to be less healthy than the last, that understanding can’t come soon enough.

Personalised care is key to prevention – it’s now being scaled

The way we’re supported to manage our health is changing, fast. That much was made clear in the NHS Long Term Plan, published last month, which set out a blueprint to make the health service “fit for the future” by combining the latest tech. with a renewed focus on prevention to save an additional half a million lives.

One of the most welcome elements of the Long Term Plan is a pledge to make a comprehensive model of personalised care “business as usual” across the NHS. One-size-fits-all approaches are rarely the most effective when it comes to population health – and will no longer be the norm as health professionals prioritise what matters most to each person when making care decisions, allowing individuals to play a more active role in managing their own health.

According to the Long Term Plan, a comprehensive model of universal, personalised care comprises six key components:

  • Shared decision making
  • Enabling choice
  • Personalised care and support planning
  • Social prescribing and community-based support
  • Supported self-management
  • Personal health budgets and integrated personal budgets

The rationale for greater personalisation is clear: more than 40% of people want to be more involved in decisions about their care. Only around half (55%) of adults who live with long term conditions such as diabetes feel they have the knowledge, skills and confidence to manage their own health and wellbeing on a daily basis.

Giving people more of the knowledge, skills and confidence they need to manage their health improves their “patient activation”. Individuals with a higher level of activation, typically gauged by Patient Activation Measure (PAM) scores, are more likely to benefit from health interventions, adopt healthy behaviours, and see positive health outcomes and lower costs to their health economies.

Research by the University of Oregon suggests the annual cost differential between a patient who stays high in activation and one who stays low in activation over a 12 month period, once demographics and health status are accounted for, totals $2,000. That’s a 31% difference.

For our part, we’ve learnt at Changing Health that what’s absolutely fundamental to improving our service users’ activation, shaping healthy lifestyle behaviours and ultimately, preventing Type 2 diabetes at scale, is to make it simple. That means guiding people to fit positive changes – such as aiming for 10,000 steps a day, reducing carbohydrate intake, whatever they need to do – into their own existing routine.

But of course, everyone’s routine is different. That’s where the psychology is crucial; to facilitate change, you first need to understand which behaviours you’re trying to change and what kind of behaviours they are. Helping somebody to avoid an intentional unhealthy behaviour, underpinned by a certain attitude – “I know I shouldn’t have that cake at the coffee shop, but I’ll burn it off later!” – requires a different approach to helping them break out of a habit – eating lunch on the go each day – because the two behaviours are undertaken at different levels of awareness.

Gaining a thorough understanding of each Changing Health user’s own individual behaviours, then offering personalised lifestyle recommendations, is how we make long-term behaviour change sustainable for each person.

The outcomes speak for themselves. In a trial of digital behaviour change programmes for Type 2 diabetes management conducted by the North West London Collaboration of CCGs, a personalised approach increased Changing Health users’ PAM scores by an average of 10 points. That equates to a 20% lower risk of hospitalisation and 20% greater medication adherence, alleviating the strain on scarce healthcare resources in an area of the UK with a diabetes population of around 130,000.

As the NHS rolls out this new model of care across the health system, millions of people stand to benefit. Individuals will enjoy a more positive experience with their healthcare provider and improved quality of life. Clinicians will, research suggests, see improved job satisfaction. Health inequalities, meanwhile, are likely to fall as people in areas with greater socioeconomic challenges, who are more likely to live with long term conditions and stand to benefit the most from improving their activation, gain a better understanding of their health. These are exciting times.

Meet the author John Grumitt, Changing Health Chief Executive, on our team page. Attending Diabetes UK Professional Conference 2019? Come and say hello at stand F42, and pick up a white paper on the psychology of lifestyle interventions, personalisation and Type 2 diabetes.  

How to become a healthier you – on a vegan diet

Changing Health lifestyle coach and resident vegan Jadine answers your questions on how to live a healthy, happy lifestyle, free from animal products.

So, what do vegans eat?

Vegans don’t eat any kind of produce that comes from an animal. That includes the obvious ones: meat, fish, poultry, dairy, eggs and honey – and the not so obvious ones: gelatine, milk powder (found in some pizza bases), gummy sweets, some kinds of crisps and vegetable stock contain animal products too.

Instead, vegans live on a plant-based diet, made up of grains (like bread and pasta) pulses (like beans and chickpeas), vegetables, fruit, and nuts. Vegans eat the same kinds of meals as everyone else – from curries and chillis to pizza and pasta – but with a few substitutions in the ingredients.

What kind of benefits will I see?
  • Weight loss, which decreases your risk of developing cardiovascular disease, high blood pressure or fatty-liver disease too.
  • Better glycaemic control or in other words, maintaining normal blood sugar levels for more of the time.
  • Being more aware of what you’re eating – If you’re working towards cutting out animal products, you usually need to plan ahead, or take a closer look at what’s in your food. This is a really important skill to have when you’re making lifestyle changes.
So far, so good. But I have Type 2 diabetes. Is it suitable for me?

Yes! In fact, it might even help you manage your diabetes better than any other approach. Clinical trials have shown a low-fat, plant-based diet keeps your blood glucose more balanced than any other diet usually recommended for people with Type 2 diabetes(1).

There’s also evidence that compared to meat eaters, vegans have a lower BMI and less fat on the body and around internal organs; they’re all factors that help your body regulate its blood glucose properly(2).

Can I eat what I want, as long as it’s plant-based?

Like any lifestyle choice, it’s important to follow a balanced vegan diet. Just being vegan doesn’t necessarily mean you’re living healthily; some ‘accidentally vegan’ foods aren’t healthy at all. Foods like:

  • Classic Oreos (and lots of other biscuit brands)
  • Certain flavours of Doritos and other crisps
  • Doughnuts
  • Most breads
  • Gelatine free gummy sweets

And remember: being vegan means avoiding animal products as far it’s practical to do so. Your health comes first. So never skip meals!

Instead, plan ahead. When you already know what you’ll be eating in the week ahead – and with so many places on the high street offering tasty, plant-based meals these days, being avoiding animal products is easy as (plant-based) pie.

Where should I start?

Here’s one of my favourite vegan recipes – it’s healthy, budget-friendly and packed with good stuff.  

Mexican bean soup with tortilla chips and avocados

  • Fry some onion & garlic until it’s tender and golden
  • Add chilli, smoked paprika, 400g canned tomatoes, black beans and coriander  
  • Cook for 1 minute, then add vegetable stock
  • Bring to the boil, then simmer for 15-20 minutes
  • Season with salt and pepper, then blend until smooth
  • Serve into bowls, top with avocado & tortilla chips, chilli and coriander – et voila!

 

References

  1. https://www.ncbi.nlm.nih.gov/pubmed/19386029
  2. https://veganhealth.org/type-2-diabetes-in-vegans/

How one GP saved thousands on diabetes care

The best approach to reversing Type 2 diabetes is a hotly contested subject. While experts agree that sustained weight loss is a fundamental part of the process, the diet a person should adopt to achieve that weight loss, and improve their glycaemic control, is less commonly agreed upon. Some studies have shown promising results for the very-low-calorie-diet approach, while others suggest the Mediterranean diet holds the key to success. What Dr David Unwin discovered in 2013 was that for certain diabetes care patients, a low carb diet may trump all others.

Conventional wisdom at the time was to medicate rather than prevent, with prescribing budgets eaten up by diabetes drugs as diagnoses soared across the UK. Dr Unwin had spent a quarter of a century recommending traditional drug treatment for diabetes care, in line with NHS treatment guidelines.

Improved Diabetes Care With Low Carb Diet

Then he stumbled upon the low-carb approach. Championed by prominent advocates diabetes.co.uk and others, the diet showed serious promise in improving glycaemic control for people with diabetes. He began recommending it to his patients as an alternative to medication and, so as to fully understand the difficulties his patients may face in sticking to low-carb, also adopted the diet himself.

“Back in 2013, our GP practice had a very ‘drug centred’ approach to Type 2 diabetes,” he says. “Lifestyle medicine was almost unheard of. The partners felt that rather than going on about dietary carbs I should concentrate on seeing properly sick people. This meant the only way forward was to work for free in my own time on a Monday evening. My wife came in to help me staff the surgery.

“After six months, the partners could see my results were beating what they could do with drugs, particularly when the first few patients managed to come off medication. Initially I was unsure about the low carb approach so I joined my patients on the diet and we learnt together, trialling recipes we found on the internet. We even arranged practice based cooking demos.

Diabetes Care That Could Potentially Save NHS Millions!

In 2015/16, Dr Unwin’s practice saved £40,000 on drugs. To put that in perspective, if every one of the UK’s 7,435 practices were to make an equal saving, the NHS would be £297 million better off each year. So the practice partners were, by then, firmly on side – but challenging official treatment advice across the whole of the health service was another matter entirely.

Dr Unwin was very vocal about his patients’ successes with low-carb online and in the press, publishing extensive research into the approach as an alternative to drug therapy. He also developed a peer-reviewed e-learning module for GPs explaining the science behind the low carb approach, its impact on glycaemic control and how to discuss it with patients, which won him the prestigious accolade of NHS Innovator of the Year. Last week, it was chosen by the Royal College of General Practitioners as its Course of the Month for November.

“My generation of doctors was brought up with a deep distrust of ‘the media’,” he says. “My partners were worried the first time I appeared in The Daily Mail. Despite the risks I feel the internet is democratising medicine – making relevant information so available.

“I have come to feel we can’t just ignore the internet; it’s not going to go away, so we should join in. It’s a great way to ‘find your tribe’ and become more effective. The low carb movement has a huge presence on social media. There are risks though, particularly around the temptation to give advice. So often I have to explain we supply general information online. Personal advice is something you get from your own doctor!”

Continued Efforts To Promote Lifestyle Change

For the next three years, David plans to continue encouraging doctors to promote lifestyle change over medication. “I think the idea of reversing type 2 diabetes or more properly putting it into remission without drugs is probably a valid goal for about 50% of people with diabetes.

“The longest remission in my practice is 9 years. I feel this is such a hopeful message, that there is so much people can do themselves to make a difference by cutting back on the dietary sources of glucose.

“I know that for my first 25 years of medicine I failed to make this clear enough and was too quick to prescribe lifelong medication. My goal is to help other doctors tap into the wonderful potential of people to help themselves.”

Dr David Unwin will share insights from his experience at Diabetes Professional Care 2018, 15:15-15:45 Wednesday 14 November. Register for your free place at https://www.diabetesprofessionalcare.com

Type 2 diabetes support for 150,000 Mancunians

Changing Health’s behaviour change programme is now available to provide 150,000 people living in Greater Manchester Type 2 diabetes support, as part of a suite of digital resources to help them better manage their condition and live healthier lives.

The NHS England and Innovate UK funded initiative makes diabetes support available from a range of providers any time, anywhere via a one-stop shop web platform, Greater Manchester Diabetes My Way. Users will benefit from digital education on lifestyle and personalised, one-to-one behaviour coaching, delivered by Changing Health, alongside tools for easier sharing of glucose monitoring data and care records with healthcare professionals.

The Idea Behind Changing Health’s Type 2 Diabetes Support Programme

The scheme was launched with the aim of giving people with diabetes all the skills and knowledge they need to play a more active role in managing their condition, by adopting positive diet and exercise habits and learning how to maintain lifestyle changes over the long term.

Type 2 diabetes support in Greater Manchester has in the past been limited to classroom education programmes, which are often inaccessible for those unable to travel or take time off work, or who have learning difficulties. Digital tools overcome these challenges, and in some cases, have been shown to improve uptake of diabetes support by more than 500%.

In addition to improving the support on offer for people with diabetes, the initiative is also likely to deliver significant cost savings for healthcare delivery in Greater Manchester, with fewer complications arising from the condition, fewer hospitalisations and fewer A&E attendances.

Here’s what the experts have to say

John Grumitt, Changing Health Chief Executive, said: “It’s great to be selected as one of the Greater Manchester Diabetes My Way providers and build on the evidence that with access to the right support, people with diabetes can make big changes in their lives and manage their condition more effectively.

“Health Secretary Matt Hancock shared his vision last week of delivering more patient-centric care, facilitated by digital tools. Greater Manchester Diabetes My Way will play a key role in making that vision a reality.

“We know that a large proportion of people with Type 2 diabetes want to make a change in their lives – but often, they simply aren’t sure how best to go about it. This initiative aims to change that.

“Where previous behavioural interventions faced some major practical and financial challenges, today’s launch is a win-win: people with diabetes are empowered to sustain long-term lifestyle changes, while healthcare providers benefit from better communication with their patients, better health outcomes and a lesser administrative burden.”

Naresh Kanumilli, SCN Clinical Lead for Diabetes, said: “This has the potential to be a real game-changer in Greater Manchester. With a large and growing Type 2 diabetes population, we need to adapt to the modern world and harness the power of new digital technology to embrace changes in how we support people living with diabetes.”

ENDS

Notes to editors

  • Wave 2 of the Innovate UK Test Bed funding programme has agreed a grant of £975,000 towards the £1.2m project cost, with the remainder contributed by the industry partners involved.
  • John Grumitt, Changing Health CEO, is available for interview
  • Case studies of people who have achieved diabetes remission using digital tools are available.

Diabetes: It’s Time To Tackle Lifestyle Misinformation

People with diabetes can’t always tell fact from fiction. And with the internet awash with conflicting sources of information on diet, exercise and glycaemic control, it’s easy to see why. In the space of just two weeks, the Daily Express alone published or republished 17 clickbait headlines on diabetes, often misleading, and designed to appeal to readers’ fears about their health.

Here are a couple of them:

Of course, that’s not to understate the public health crisis currently facing the nation – a recent estimate by Diabetes UK suggested a record 12.3 million people are now at elevated risk of developing Type 2. But we urgently need to stem this flow of misinformation.

Even the broadsheets can be prone to misrepresenting scientific evidence. The Guardian, for example, ran in August with the headline “No healthy level of alcohol consumption, says major study”. That referred to a major mata-analysis of 694 studies to work out how common drinking was, and a further 592 that assessed the health risks, accounting for a total 28 million people and published in The Lancet.

The researchers found that for each extra drink consumed in a day, the harm increased, and that the lowest level of harm was zero drinks – the basis of the Guardian’s headline. It isn’t, however, that simple.

The study showed that 918 in 100,000 people who consume one drink a day can expect to experience an alcohol-related health issue. Yet 914 of those people will experience such a health issue no matter what, meaning only four in 100,000 do so as a direct result of consuming one drink a day(1). The study also did not account for other factors that may have been the actual cause of harm – drinkers are more likely be poorer and to smoke, for example.

Again, this is not to understate the risks; it’s beyond doubt that drinking is detrimental to health. The point, however, is that misleading headlines create a widespread lack of understanding what constitutes an achievable, healthy lifestyle – with significant implications for public health.

Many people are unaware, for example, that consuming carbs, not fats, is what typically leads to weight gain. Another common misconception is that Type 2 diabetes is a sign of having eaten too many sweets, rather than too much bread and pasta.

Peer support groups for diabetes can be tenuous in reliability too. A 2011 study of health social networks, published in the Journal of the American Medical Infomatics Association, found that only 50% were aligned with clinical practice recommendations (n=10).

Users of Changing Health’s programme for diabetes management, which combines evidence-based education on diabetes with behaviour change support, consistently tell us they were overwhelmed by the sheer volume of conflicting viewpoints on diet they had found online. Their GPs typically only have the time to hand them a stack of leaflets, and while the NHS website goes some way to helping, there’s more that could be done.

We must counter this deluge of misinformation by providing more people with clear, evidence-based guidance and support. If we don’t, there’s only one likely outcome: incidences of diabetes will continue to rise and with them, the strain on health economies across the nation.

1: New York Times, 28 August: https://www.nytimes.com/2018/08/28/upshot/alcohol-health-risks-study-worry.html

Personalised Support For Patients Could Save The NHS Millions

Knowledge and confidence are a potent mix. That much has been made clear this morning, as new research from the Health Foundation shows that if people with long-term conditions were provided personalised support, a staggering 436,000 emergency hospital admissions and 690,000 A&E attendances could be avoided entirely.

The findings confirm the conclusion I reached with Professor Mike Trenell of Newcastle University in 2015: that when people know what to do and they feel they can do it, they can achieve incredible things. It was on that basis that we founded Changing Health, delivering behaviour change programmes for people with Type 2 diabetes.

Many people with Type 2 don’t know how to properly manage their condition. There’s a wealth of information to take in, with too much misinformation online, and GPs rarely have enough time to give their patients much further guidance than a stack of leaflets.

But if we could give everybody with Type 2 diabetes a comprehensive understanding of diet, exercise and how lifestyle impacts on the condition – and then empower them to act on that understanding – the implications for public health are enormous.

How Would Personalised Support Work?

The Health Foundation report makes a number of recommendations on how to achieve this: primarily health coaching, peer support and greater access to apps. All have been shown to improve patients’ PAM (Patient Activation Measure) scores, which predict an individual’s engagement with their health and healthcare based on over 400 peer-reviewed studies.

Indeed, a trial of Changing Health’s programme in the North West London Collaboration of CCGs found that personalised support for diabetes, including lifestyle coaching and digital education, results in a 10-point PAM increase – enough to boost patients’ score by one level (out of a total four).

According to the Health Foundation, if we can give just the lowest ability patients (level 1) the knowledge and the confidence to manage long-term conditions as well as those at level 2, we could prevent 504,000 A&E attendances, and 333,000 emergency admissions per year. That equates to 5% of all emergency attendances, and 6% of all emergency admissions in England each year.

On an individual level, we see this science in action every week as more people with Type 2 diabetes put their condition into remission. Once people know how, for example, complex carbohydrates affect their blood sugars, and they’re given a motivational boost on a regular basis, they’re often able to cut out the bread and the pasta – and begin reducing their HbA1c. It’s simply a matter of providing that support in the first place.

Technology Simplifies Personalised Support

Fortunately, we’re seeing increasing recognition among healthcare providers that, as the Health Foundation points out, there’s a very broad spectrum of ability and confidence among people to manage long term conditions, and different approaches are needed accordingly. At the same time, technology is enabling the delivery of more personalised support for such conditions, improving patients’ self-efficacy in managing them and, as a result, living happier, healthier lives.

For Type 2 diabetes the outlook does, then, look promising. But diagnoses are still rising, and the clock is ticking. We must act fast.

Digital DPPs are turning the tide on prediabetes

With a record 12.7 million people at elevated risk of developing Type 2 diabetes in the UK, the need to help people change their lifestyles en masse has never been more acute.

Patients already diagnosed with Type 2 are typically very aware of the need to move more and eat more healthily, but struggle to translate their intention to change into sustained action. People with prediabetes, on the other hand, can be more difficult for healthcare professionals to engage with a behaviour change intervention.

Their perception of risk is generally lower; the lack of any physical symptoms leads some to question whether they actually have a health issue and whether changes are required at all.

What Do The Studies Say About Prediabetes

According to one study, people with prediabetes consistently underestimate their probability of developing Type 2; 84% considered themselves at low, very low or negligible risk. Indeed, many people with prediabetes only find out about their condition when they visit a GP with an unrelated issue, rather than on a regular check-up for diabetes as the NHS recommends.

Others are hindered by outcome expectancies. They recognise the need to change, but feel any attempt will be hopeless and so accept that they will simply remain in their current habits and that developing the condition is an inevitability. As food is perceived as a necessity for life, low outcome expectations can be further compounded by feelings of frustration and deprivation when healthcare professionals advise making changes to a dietary intake.

Digital DPPs Accept The Challenge

But digital DPPs, often dubbed “Prevention 2.0”, are addressing these challenges. By making support available on a smartphone or tablet, anytime and anywhere, digital DPPs are reducing the “hassle factor”, leading to significantly higher uptake; one digital trial in London’s Waltham Forest, for example, saw a 500% increase in just 14 days.

When a user can work through a DPP in their own home, in their own time, completion rates are much higher too, improving on users’ understanding of how prediabetes affects their health and increasing users’ risk perception of more serious health issues in the future if they don’t act on their healthcare provider’s recommendations.

Trials in behavioural economics have shown that when a complex goal, such eating more healthily, is broken down into a series of easier actions (eg eating five a day), outcome expectancies can be significantly improved. On a digital DPP, participants can set their own clear, achievable short-term goals and can refer back to them on their phone at any time, boosting motivation to sustain a healthier lifestyle over the long term.

Instant, one-click referral systems also reduce wait times between referral and access to just minutes – as opposed to weeks or sometimes months for a face-to-face DPP – minimising drop-offs as people become demotivated over time without support.

Digital DPPs therefore show serious promise in improving access to support – among even the hardest to reach groups – and overcoming the psychological barriers to sustaining lifestyle changes for people with prediabetes. As the NHS scales access to such programmes across the UK, turning the tide on diabetes has never seemed more possible.

Type 2 Diabetes Reversal – In 5 Steps

Author Holly Hart, MSc, is a qualified Health Psychologist and one of Changing Health’s lifestyle coaches. This article is based on real life case studies, including two users who achieved Type 2 diabetes reversal in 10 weeks between April to June, 2018..

People with Type 2 diabetes usually know they need to make a change, and they have the motivation to do so. But their self-efficacy – that is, their beliefs about their capabilities to succeed – is often low; they perceive significant barriers preventing them from sustaining a healthier lifestyle.

There are, however, some useful techniques to help people with diabetes overcome the barriers to change and translate their motivation into action.

Here are the 5 steps based on my experience supporting people to assist with Type 2 diabetes reversal

1) Letting people know that good food can be cheap

Many people think fresh, “healthy food” is more expensive (it doesn’t have to be!), while others may be hampered by a lack of social support – often key to success. Some may worry that eating as a family may require the entire family to change their diet, and some may have been disillusioned by a lack of success when trying to make lifestyle changes in the past.

2) Making education simple

People with diabetes report that one of their biggest barriers to making the changes they need to is a lack of access to education and information. Those who do receive guidance from their healthcare provider often tell us that there was too much to take in, too quickly, and they ended up with only a limited understanding of how their condition affects them. We tend to provide links to websites and tell people what to search for online instead, so they can learn at their own pace in their own time.

3) Showing that dieting doesn’t mean no food

A common misconception we find among people with diabetes is the idea that following a diet means cutting out your favourite food and getting up at 4am for an exercise class. In fact, the simplest lifestyle changes are typically the key to successful management or even remission of diabetes. The inspirational success stories you get to hear as a coach are testament to this approach, and communicating to patients that their lifestyle changes don’t need to be radical can transform their outcome expectations.

Debra, a Changing Health user who recently achieved Type 2 diabetes reversal in 10 weeks, did so by making only “little swaps”, like pasta for cauliflower rice, so a healthier diet didn’t feel like a chore to maintain. It’s also important to avoid warning people with diabetes about what will happen if they don’t make a change; research has shown this doesn’t work.

Instead, we find that listing the benefits of a healthier lifestyle can be much more effective, particularly those which impact the most on everyday life: improved cognition and memory, better concentration, reduced tiredness and feeling less out of breath when walking the dog or taking the children to the park. focusing on past successes (identifying and emphasising previous, successful attempts to initiate lifestyle change) has been linked to optimal care consultations and better clinical outcomes.

Pairing this with discussions about how to overcome barriers that have occurred in the past, or might come up in the future, enables the patient to think more positively about making a change and this positivity is key.

4) Setting achievable goals from the outset

Healthcare providers can also support patients on their journey towards a healthier lifestyle by encouraging them to set clear short, medium and long-term goals. SMART goals – specific, measurable, achievable, realistic and timely – keep patients focussed every step of the way and have been proven to be effective in improving outcomes.

If patients write these goals down, the chances of success are even higher – up to 42%, according to new research. Changing Health coaches suggest users write down their progress so far on post-it notes and leave them in prominent places around the house, boosting their motivation to keep going when times are tough.

5) Personalising the approach to support

Every individual is at a different stage in their behaviour change journey and so it’s important to take their unique circumstances into account. Ultimately, it’s about re-framing the conversation to focus on their own possibilities of success, rather than the consequences of failure, at every point of contact.

The biggest lesson I’ve learnt, though, is that while people with diabetes don’t often realise that transforming their health can be a straightforward process – once they do, they’re bound to surprise you.

Watch Sheinaz, a GP Practice Manager who achieved Type 2 diabetes reversal with Changing Health, tell the story of her weight loss journey in NHS Digital’s short film

Type 2 Diabetes Reversal | How Did She Do It?

Meet Sheinaz. She’s a GP Practice Manager in Gateshead, Newcastle, and she was largely sceptical of the power of digital interventions to help people Type 2 diabetes change their lifestyle and better manage their condition. Until she tried one out for herself.

On 13 January 2018, Sheinaz was diagnosed with diabetes. Her GP told her that her HbA1c level, an indicator of blood glucose control, was at 52. That meant her condition was under control – but only just. It was enough to motivate Sheinaz to begin making some big lifestyle changes, and when her GP offered to refer onto the Changing Health programme to help her do so, she accepted – albeit with some reservations about whether it would be of much use.

Changing Health Programme

The programme comprises a course of digital education on diabetes to improve participants’ understanding of how diet impacts on their condition, combined with one-to-one lifestyle change coaching from an expert in health psychology and behavioural science.

“I was devastated to hear the diagnosis, absolutely devastated” she says. “I just thought, ‘I have a healthy diet, I do all the things I could possibly do, what more can I do?’ Going to a group session wasn’t really sustainable for me, and the other option was having a health app.

“When you’re being monitored by your GP practice you’re only seen once a quarter, so I thought having the app available will help me to maintain that consciousness of the long term condition I have, and it’s an alternative that actually works better than seeing your GP”

As Sheinaz worked her way through the programme, her preconceptions of digital health apps changed entirely. She was moving more. She had more energy. With a few pointers from her lifestyle coach on the best changes to fit her own circumstances, soon she was cooking tasty, healthy meals every day, building positive habits into her daily routine rather than treating weight loss as a chore. “I increased my physical activity on a daily basis using the app, and having my own personal health coach really helped too.”

It was a complete change of mindset for Sheinaz – and it paid off. In just ten weeks she had lost 18lb, or a little over 8kg. Then came more good news.

It Really Happened: Type 2 Diabetes Reversal

“I spoke to my GP on the phone. He said ‘you don’t have diabetes’ – I said ‘yes I do, I was diagnosed ten weeks ago!’ – and he said ‘well your blood sugars are normal; you’ve reversed your diabetes.’”

Sheinaz was ecstactic. And six months on from the original diagnosis, she’s living a whole new life. “In myself I feel better, my memory’s much better… I’m sleeping really really well, bouncing with energy, and bouncing with confidence. I love the diet and I’ve got so much energy as a result, and I’m still losing up to half a pound per week but I never feel like I’m on a diet.

The Changing Health programme was designed to empower users not only to adopt healthier habits, but crucially, to keep them up – for good. That looks promising for Sheinaz. As of mid-July, she’s now lost a total of 24lb and dropped two dress sizes.

“I can still use the app and the coaching sessions for another six months, but I don’t really need them; it’s become a habit now. I’m being creative about cooking, and I’m eating less carbs, but you know what? I don’t miss them at all.”

Reversing Type 2 diabetes: one year on

In July 2017, Tina C, a Fire Prevention Officer from Northamptonshire, achieved something incredible. She had been diagnosed with Type 2 diabetes two years earlier and needed medications to keep her blood sugars in check day by day. She was feeling lost, was struggling to keep a check on her diet, and things were getting worse.

Then came the call from the BBC. A second series of the hit documentary How to Stay Young was on the cards, and Tina had been selected to participate. If she was up for it, she would embark on a strict, 12-week diet and exercise plan supervised by Changing Health’s Professor Mike Trenell, with the aim of reducing her “real body age”. She would undergo extensive testing at four, eight and twelve weeks to assess everything from her weight and blood glucose levels to quality of sleep and cognitive function.

Tina accepted. The diet took some serious willpower; calories were reduced to just 800 per day, with each meal logged in the Changing Health app alongside Tina’s daily physical activity levels for her lifestyle coach to feed back on. It was a dramatic shift from Tina’s normal habits, but she kept it up.

Success At Reversing Type 2 Diabetes

Fast-forward 12 challenging weeks, and there was big news. Watched by millions across the UK on BBC1, Professor Trenell gave Tina the results from her final round of tests. Had she walked in and there and then, Professor Trenell told her, he wouldn’t say she has diabetes. He’d say she haddiabetes.

She was gobsmacked. She had taken control of her health and transformed her life. And a year on, she’s kept it up. “It’s been a difficult year with some big challenges,” she says. “Sometimes your mind gets unfocussed, you end up comfort eating – in April I lost my way. It was the first time I’d felt like that, and it disappointed me.

“But then, 6-8 weeks ago, something reclicked; I’ve gone back to being strict with myself, logging my foods and exercise in the Changing Health app and re-reading the learning content. It’s really important to have the facts, because when you do you realise you’re in control. I reminded myself that my health is something I can change. It is possible.”

Reversing Type 2 Diabetes With Low Carb Diet

Perhaps the most drastic change in Tina’s lifestyle over the past year has been her meal choices. “I used to just load up on carbs, thinking they would fill me up – not realising that carbs actually turn to sugar in your blood! Now I’m eating a lot of vegan meals and plant-based foods… and sugar-free baking has changed my life! I use a lot a cacao in my cake recipes; it’s just a matter of getting your taste buds used to it.

“The recipes in the Changing Health app have been really useful too. All kinds of foods I didn’t even know about have become staples… Chia seeds, for one, have become a massive part of my life. I have to think of unhealthy foods as evil. I’ll allow myself a treat on very special occasions, for example I baked a normal cake for a 40th birthday, and I’m going to have a slice!

“I make sure that on 6 days a week I’m brilliant, so on the 7th day I can have a glass of wine or something a little naughty! My strategy is to picture my own long-term health. I keep a couple of pics on my phone of how I was before, just to remind myself.”

Beating Diabetes With A Little Help From The Hubby

There’s no doubt that Tina’s husband’s support has been invaluable too; together they’re quite the team. “He gave up six months of his life to lose weight with me and support me through completely changing my diet and starting a regular exercise routine and if he can do it, I can too. I was having a tough time in April, and without him, I would’ve self-destructed. But now I feel so much better. You just feel more positive when your diet is good and when I’m healthy I get through things. I feel really different in how organised I am – literally just ticking things off my to-do list all day!”

“We’ve got two businesses that I help out with; and we always look for different solutions to get the energy we need for a long day without eating sugar. Planning is very important. I’m back down to 1000 calories temporarily so this morning, for example, I had chia seeds and soya milk, for lunch it was chickpea falafels and a green salad, and this evening we’ll have chicken fajitas without the wraps.”

“Having the Changing Health app on hand is like having a little buddy in my pocket. When my husband isn’t there, it’s a constant reminder: what have I eaten this week? It’s engaging, nice to look at and the content is easy to understand.”

“Ultimately, the power’s in your hands to change your health. I still can’t get my head around how I made that difference and changed my life. It’s not expensive, it’s not a lot of work, it’s just you and your mindset. If somebody gave you that chance, if somebody told you could do it – why wouldn’t you?”

Watch Tina’s moving account of her experience reversing Type 2 diabetes

Changing Health sponsors event of the year for diabetes professionals

Diabetes Professional Care 2017 brought record numbers of delegates to London’s Olympia conference venue, with over 3,000 healthcare professionals involved in the prevention, treatment and management of diabetes attending to learn about the latest developments in this area of care.

This November’s event looks certain to be an even bigger hit, and Changing Health is for the first time to become an event sponsor as well as an exhibitor. The sponsorship is another major milestone for Changing Health in what will be the company’s most eventful 12 months to date.

Changing Health will be presenting new data to inspire healthcare providers and commissioners, showing how personalised support for behaviour change can be highly effective in diabetes prevention and management, helping patients lose weight, lower their HbA1c and significantly reduce complications. The data supports the need for a new, highly personalised approach to diabetes care outlined in the company’s first White Paper, published in May.

Now in its fourth year, DPC quickly became a key diary entry for those looking to find new perspectives on diabetes care, according to Event Director Toby Baker. “We were acutely aware at the time that there wasn’t an accessible forum which provided free, high-quality, relevant information education to all those who come into contact with people with diabetes and related conditions, not just the specialists.

“We wanted to bring together all these people under one roof to share knowledge and best-practice whilst also easing the strain on a cash strapped NHS who cannot afford to fund expensive passes to events base. Our 2017 event was our biggest and best yet and we were delighted to welcome over 3200 visitors across the two days.”

A diverse range of delegates are expected to attend, including diabetes specialist consultants and diabetologists, hospital doctors, consultants, GPs, diabetes specialist nurses, diabetes CCG leads and commissioners. For those interested in lifestyle change interventions for people with diabetes, DPC2018 will feature a Prevention & Obesity in Practice track, one of eight in total, with highlights including:

  • The NHS Diabetes Prevention Programme: progress and implementation. Matt Fagg, Programme Director, NHS Diabetes Programme
  • Why “eating less and moving more” may not lead to sustainable weight loss – the science unravelled. Dr Trudi Deakin, Chief Executive & Consultant Research Dietician, X-PERT Health
  • Childhood obesity and T2 diabetes – spotting it early and tools for combatting it. Charlotte Hawitson, Children’s Dietician, Multispeciality Outpatients Department
  • Childhood Obesity & Transition to Adult Services
  • Treating Obesity in the UK – Drug, Surgical, Diet & Lifestyle Management
  • How behavioural science can transform clinical outcomes for diabetes – Changing Health

Diabetes Professional Care 2018 will held on 14-15 November at Olympia, London and is, as ever, free to attend for all diabetes healthcare professionals. To register your interest, visit https://www.diabetesprofessionalcare.com/

Government: Take A Stand. Stop Junk Promotions.

With almost two thirds of the UK adult population now either overweight or obese, there’s universal recognition that something must be done to avert a full-blown public health emergency. Many policymakers, on the recommendation of leading public health experts, are looking first to junk food marketing for dealing with the obesity epidemic.

It’s clear that marketing has played a central role in our steady weight gain over the years; Public Health England estimates 40% of food bought in the UK is done so at a discount, increasing overall consumption by 22%. That’s more than anywhere else in Europe. Viewers of family TV shows like The Voice see 12 adverts for junk food within an hour.

What Is The Government Doing To Avert The Obesity Crisis

The Government’s role in averting the obesity epidemic, however, is subject to dispute. A number of measures have been floated; alongside the sugar levy, which came into force last month, a cross-party proposal to ban “buy one get one free” offers on junk food is gaining momentum, as is a plan to curb junk food TV advertising before 9pm, while a mandatory traffic light labelling system appears to be almost certain. London mayor Sadiq Khan last week opened consultations on a ban on junk food advertising on London’s public transport network.

But free marketeers argue that such “nannying” by the state restricts consumer choice with no benefit to public health. Some even suggest that the rising figures of the obesity epidemic are artificially inflated to justify these “intrusive” policies. “Who benefits from over-egging childhood obesity rates? As usual, powerful people with killjoy aspirations are the most likely to spread bad data far and wide,” wrote Kate Andrews of the strongly free-market Institute of Economic Affairs (IEA) in City A.M earlier this month.

Is The Obesity Epidemic Fabricated?

Who are these ‘powerful people with killjoy aspirations’? Have Jamie Oliver, Sadiq Khan et al fabricated the obesity epidemic just to spoil the party? Meanwhile, who benefits from suggestions that controlling the marketing of harmful products is detrimental to consumers? For a start, many of the conglomerates that fund the IEA, including, British American Tobacco, Philip Morris and Japan Tobacco International, amongst others, although the organisation is notoriously opaque in this regard. Perhaps understandably.

“Such policy proposals make it harder for adults to live their lives freely,” Ms. Andrews continues. Again – questionable. If we can’t make ‘free choices’ without the influence of a marketing campaign, rather than a rational assessment of the facts, aren’t they actually quite the opposite?

Controlling junk food marketing more tightly is about limiting the number of times we’re prompted (be that a supermarket offer, a daytime TV ad, or a billboard on the tube) to buy unhealthy food we don’t need on a whim. The odds of being obese are more than twice as high for young people who report seeing junk food advertising every day. These policy proposals will restrict exposure to such advertising,  but they don’t curtail our freedom to buy what we want to.

The sugar tax doesn’t prevent us from buying six-packs of Coca Cola, but it’s shown promise elsewhere in reducing overall sugar consumption; in Mexico, where 70% of the population is overweight or obese, it’s already driven a 7.6% fall in sales of sugary drinks. If the trend is replicated in the UK, that’s a clear win for public health at very little expense to the everyday consumer.

Lifestyle Intervensions Can Curb The Diabetes Epidemic

The obesity epidemic is a multidimensional issue and so must be the approach to reversing current trends. As I argued in a previous Linkedin post, mandating alone will not change behaviour at a national level. A combination of ‘hard’ legislation, ‘soft’ nudges and individual and group interventions are all needed to encourage people to make healthier choices.

What’s certain is this: we’ve been bombarded with junk food promotions for decades. We’re consuming more calories than ever before, with disastrous results. The only real opposition to the proposed regulations comes from those who stand to lose out on profit. Government should boldly ignore the protests of the corporate lobby and curb the constant and ever-present influences to buy high-calorie, sugary foods. To the benefit of us all.

Lifestyle coach Carl on preventing Type 2 diabetes

I became a lifestyle coach to make a difference in people’s lives. The way the Changing Health programme works, assigning each user a personal coach and delivering ongoing one-to-one support over weeks and months, gives me the opportunity to do that. We can explore every client’s needs and tailor-make our behaviour change programme to suit them.

Many of the people we coach have already digested learning content on Type 2 diabetes and how to better manage the condition. However, they’re rarely equipped to put that knowledge into practice. That’s where we come in!

Changing Health user Pat, aged 71 and one of my clients, can vouch for this. She described her experience as “life-changing”.

For years, she struggled to keep her weight under control. She tried lots of approaches, like WeightWatchers and Slimming World. The problem she faced was not losing the weight; it was keeping it off once her initial diet phase was over. It’s something we see often, and the reason we only promote lifestyle changes that are sustainable over the long term.

Before she reached out to Changing Health for help, Pat was diagnosed as prediabetic after an annual check-up at her local GP surgery.

We agreed on limiting her daily calorie intake to 1,200-1,600, and I asked Pat to write this goal down, and leave it on show around the house somewhere – since research shows this makes you 42% more likely to achieve success! She adopted the low-carb approach, replacing some of her carbs with vegetables and healthy fats and proteins, which keep her fuller for longer.

One of the most effective behaviour change techniques I’ve used with Pat has proved to be self-monitoring. I asked her to use the photo food diary in the Changing Health app, which I can then review. She told me it makes a big difference; not only can she keep a tab on her diet, but she knows I can see her meals, so she tries harder to keep up the good work. She finds the app’s weight tracker and step-counter helpful too, keeping her disciplined and focussed on her goals.

She loves baking, but as we know, this isn’t the healthiest hobby if it’s not enjoyed in moderation. So we agreed that a good way to overcome this and still continue with this hobby was to either halve the ingredients used or bake twice as much with her usual amounts. Perfect!

Three months on, she’s living her new, healthier lifestyle to the fullest. She’s more motivated than ever; since she’s lost weight, she’s feeling the cold more when she goes for a walk. But that’s not an excuse stay in; instead, she went out and bought a good pair of thermal socks and gloves!

Her blood sugar levels speak for themselves. Since beginning the Changing Health programme, Pat’s blood sugar has decreased by 14%, which means it has returned to healthy a level and she’s no longer on her way to Type 2 diabetes. She’s also lost 3.6 kgs, reaching her target weight, and crucially – is managing to maintain it. She’s reduced her BMI too: from 28 to 26, meaning she’s no longer classed as overweight.

She credited her success to having a lifestyle coach on hand for support. As she put it: “The fact that my lifestyle coach is keeping track of my meals and exercise on the Changing Health App is very encouraging and positive.’’

The lesson I’ve learnt from Pat, and many other of my former clients, is this: You’ve always got it in you to make a change for the better. You may just need a little help.

 

The Silver Bullet For Population Health? Personalised Care

Personalised care may be the solution, considering that most of us can’t exactly make rational decisions about what we eat. We, as a nation, know full well that consuming too much sugar and fat, and too few vegetables and fruit, is detrimental to our wellbeing and longevity. Yet the vast majority of us do it anyway.

The National Diet and Nutrition Survey (NDNS) published by Public Health England in March showed that in 2014-16, adults consumed on average 4.2 portions of fruit & vegetables per day, fewer than PHE’s recommendation of 5 per day – to which just 31% of adults adhere. As a result, only one third of the UK population is not overweight.

So why do we make these choices? Information and guidance on nutrition is widely available. The argument that “not everybody can afford to eat healthily” is – at least in 2018 – a myth, as was recently evidenced by Changing Health lifestyle coach Holly Hart in her mission to document an entire week’s worth of healthy, tasty cooking for just £20.76.

The answer lies in behavioural psychology. We often make rapid decisions on what to eat based on habitual, social and environmental factors – “it’s takeaway Friday”; “everyone’s heading to a steakhouse”, “I’m hungry, and I’m drive past McDonalds on my way home from work”.

Overcoming these psychological factors is not easy. Many people need support to do so. Some face-to-face interventions, such as WeightWatchers and Slimming World, can give people a better understanding of how they could eat more healthily and assist in weight loss, but don’t equip people with the repertoire of psychological tools needed to sustain such a change over the long term.

Changing Health Provides Personalised Care

More personalised care, however, can be highly effective in translating motivation into new behaviours that become firmly established over time. Changing Health’s team of expert lifestyle coaches, trained in health psychology techniques, help programme users to make this happen.

Coaches devise a unique programme to each user’s individual needs, which requires a thorough understanding of that user’s current lifestyle habits to identify barriers to change. Open-ended questions and active listening are therefore crucial from the outset.

As Carl Lumsden, Changing Health Coaching Team Leader, puts it: “Lifestyle coaching offers us the ability to explore every client’s needs and tailor make our behaviour change programme to suit them. I often find that many users have digested all the guidance on diet and exercise. They know they need to make a change. However, they’re rarely equipped to put this into practice.”

Setting SMART (Specific, Measurable, Achievable, Relevant, Timely) goals, from skipping takeaway fridays to walking home from work, is key to success. For example, research shows that those who write their goals down, share them with a mentor or friend, and provide regular updates on progress are 33% more likely to achieve them.

Reflecting on and summarising interactions shows users their coach has listened to them and understood, while feedback on performance, social support and prompts and cues are all important for continued motivation.

Personalised interventions have been proven effective in better engaging people with their health and healthcare, and facilitating long-term behavioural change. If they can be adopted at scale, the implications for public health are boundless.

Changing Health’s behavioural science white paper will be published on 16 May 2018 at the Primary Care Conference, NEC Birmingham. Meet the author Mark Williams on our About Us page.

7 Easy Steps For A Better Night’s Sleep

Sleep duration and quality are now widely accepted as important factors in the prevention and management of mental health7, cardiovascular,and metabolic conditions including type 2 diabetes1.

Normal sleep is characterised by reduced consciousness, little or no nervous activity and inactivity of nearly all voluntary muscles1. Sleeping for too long, or not enough, poses potential risks of obesity and Type 2 diabetes; optimum sleep should be seven to eight hours each night. There is a 9% relative risk of developing type 2 diabetes for each hour of shorter sleep, and a relative risk of 14% for each hour of longer sleep4.

So do people with Type 2 diabetes get the right amount? Taking a generalised view from available research, the simple answer would be: absolutely not. Sleep impairment is more common in females, but is prevalent among both genders7.

Reasons for this include:

  1. Lifestyle choices: excessive drinking, smoking, inactivity
  2. Societal/economic pressures: Shift work, unemployment, etc5.
  3. Associated medical conditions: Fatigue, depression, neuropathic pain and obstructive sleep apnoea (OSA) 5
  4. Circadian mal-alignment: Some people are either morning types (they find it relatively easy to get up early in the morning but also go to bed early) or evening types (they go to bed later and find it difficult with early starts). However, evening types are twice as likely to develop type 2 diabetes compared to morning types3

 

Here Are 7 Easy Steps to Better Sleep

  1. Get a sleep assist device, like a CPAP (continuous positive airwave pressure) on recommendation from your GP. This can help in reducing blood pressure and HbA1C levels2
  2. Exercise more. If you have problems keeping up with being active due to other associated conditions, speak to a medical professional
  3. Master your body and consult a dietician or nutritionist to help guide you through food choices and meal times that match your body clock.
  4. Speak to your employers about your condition and try to work out productive working times that would not impact on your health negatively.
  5. Stick to a sleep schedule as this can help regulate your body clock. There are medications like exogenous melatonin that help in the management of circadian rhythm disorders6. Speak to a sleep specialist if you have problems sticking to a particular bedtime.
  6. A bed time ritual like mediation could be the key to good sleep
  7. Ensure you sleep in a comfortable room (with appropriate bed, pillows and mattress) devoid of distractions.

 

References

  1. Brady, E. M. and Hall, A. P. (2016) ‘Sleep and type 2 diabetes mellitus’, Practical Diabetes, 33(1), pp. 23–26. doi: 10.1002/pdi.1993.
  2. Guest, J. F., Panca, M., Sladkevicius, E., Taheri, S. and Stradling, J. (2014) ‘Clinical outcomes and cost-effectiveness of continuous positive airway pressure to manage obstructive sleep apnea in patients with type 2 diabetes in the U.K.’, Diabetes Care, 37(5), pp. 1263–1271. doi: 10.2337/dc13-2539.
  3. Merikanto, I., Lahti, T., Puolijoki, H., Vanhala, M., Peltonen, M., Laatikainen, T., Vartiainen, E., Salomaa, V., Kronholm, E. and Partonen, T. (2013) ‘Associations of chronotype and sleep with cardiovascular diseases and type 2 diabetes’, Chronobiology International, 30(4), pp. 470–477. doi: 10.3109/07420528.2012.741171.
  4. Shan, Z., Ma, H., Xie, M., Yan, P., Guo, Y., Bao, W., Rong, Y., Jackson, C. L., Hu, F. B. and Liu, L. (2015) ‘Sleep duration and risk of type 2 diabetes: A meta-analysis of prospective studies’, Diabetes Care, 38(3), pp. 529–537. doi: 10.2337/dc14-2073.
  5. Vetter, C., Devore, E. E., Ramin, C. A., Speizer, F. E., Willett, W. C. and Schernhammer, E. S. (2015) ‘Mismatch of sleep and work timing and risk of type 2 diabetes’, Diabetes Care, 38(9), pp. 1707–1713. doi: 10.2337/dc15-0302.
  6. Wilson, S., Nutt, D., Alford, C., Argyropoulos, S., Baldwin, D., Bateson, A., Britton, T., Crowe, C., Dijk, D.-J., Espie, C., Gringras, P., Hajak, G., Idzikowski, C., Krystal, A., Nash, J., Selsick, H., Sharpley, A. and Wade, A. (2010) ‘British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders’, Journal of Psychopharmacology, 24(11), pp. 1577–1601. doi: 10.1177/0269881110379307.
  7. Zhu, B., Quinn, L. and Fritschi, C. (2017) ‘Relationship and variation of diabetes related symptoms, sleep disturbance and sleep-related impairment in adults with type 2 diabetes’, Journal of Advanced Nursing, (October), pp. 689–697. doi: 10.1111/jan.13482.
  8. Sleep Foundation: Healthy Sleep Tips