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.

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

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

Government: Take A Stand. Stop Junk Promotions. Stop The Diabetes Epidemic

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.

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