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.”

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.

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.