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.

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

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

Diabetes and Sleep: 7 Easy Steps For A Better Night’s Rest

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 with Type 2 Diabetes

  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