Behaviour Change - Science and Technology Committee Contents


19 October 2010

Members of the Sub-Committee present were Lord Alderdice, Lord Crickhowell, Baroness Hilton of Eggardon, Lord Krebs, Baroness Neuberger (Chairman), Baroness O'Neill of Bengarve, Lord Patel, Baroness Perry of Southwark, the Earl of Selborne and Lord Warner. In attendance were Daisy Ricketts (Clerk) and Rachel Newton (Policy analyst).

The speakers were: Richard Cienciala (Obesity Team, Department of Health); Professor Ken Fox (Centre for Exercise, Nutrition and Health Sciences, University of Bristol); Dr Susan Jebb (Chair of the Cross Government Expert Advisory Group on Obesity and Head of Population Nutrition and Health, Medical Research Council Human Nutrition Research); Professor Mike Kelly (Director, Public Health Excellence Centre, National Institute for Clinical Excellence); Professor Susan Michie (Professor of Health Psychology, University College London).

Other participants were: Dr Mike Rayner (Director of the University of Oxford's Public Health and Primary Health Care Division); Dr Julie Waumsley (Chair of the Obesity Working Group, British Psychological Society).

An introduction to the causes of obesity and the role of behaviour change interventions to prevent and tackle obesity (Dr Susan Jebb)

Dr Jebb outlined the changes in the prevalence of obesity among children and adults since 1993; the rate of obesity had continued to increase in adults but had slowed and arguably begun to plateau in children. A number of serious health risks had been shown to arise from obesity.

The factors which cause obesity were numerous and interlinking; some related to the individual directly, and some arose from the environment. Physical activity and levels of food consumption were argued to be the two most important factors in causing obesity but were in part determined by biological factors and also impacted by an individual's psychology and environmental factors.

Evidence about treating obesity through individual level behaviour change interventions had been shown to be strong. Effective treatment options for obesity included bariatric surgery, pharmacotherapy, or diet and exercise interventions. Key elements of successful interventions included awareness and motivation to change, realistic goal-setting, confidence to succeed, improved dietary habits, increased physical activity and self-monitoring of behaviours. The major challenge however was to move beyond individual level interventions and drive behaviour change on a public health scale.

In relation to preventing obesity, there had been few examples of controlled interventions with detailed evaluation, and few were successful in attenuating weight gain. There was greater evidence about how to influence positively diet and activity behaviours but little data on the sustainability or cost-effectiveness of these interventions. Better evaluation of public health interventions was identified as a key area for improvement.

The theoretical base for obesity prevention suggested that changing dietary behaviour required initiatives to make products and the environment healthier alongside initiatives to change people's attitudes and motivation.

The Nuffield Ladder set out the range of public health interventions in increasing order of intrusiveness.[344] Specific evidence about effectiveness was lacking in relation to incentives and disincentives, including marketing practices.

An introduction to the National Institute for Clinical Excellence guidance on behaviour change and obesity (Professor Mike Kelly)

Professor Kelly summarised the key difficulties faced in creating the National Institute for health and Clinical Excellence's (NICE) obesity and behaviour change guidance. Causal relations between interventions and their outcome were distal, and trying to show cause and effect from complex interventions in complex settings was difficult. Data about interventions was compromised as a result of poor planning of the interventions and the lack of specificity about intended outcomes. Behavioural models were selectively applied without reference to the evidence, and causal links between interventions and outcomes were often not articulated. There was confusion about the level at which interventions and outcomes operated, and an absence of systematic evaluation of interventions.

The guidance noted that an intervention plan should be developed on knowledge of the target audience and take account of the socioeconomic and cultural context. The plan should be as specific as possible about the content of the behaviour to be changed and clarify which underlying theories made explicit the causal links between actions and outcomes.

Training should focus on generic competencies, such as critical evaluation of the evidence and the use of clear outcome measures. At an individual level people should be helped to develop accurate knowledge about the health consequences of their behaviour in order promote positive feelings toward the outcome of behaviour change. Interventions should enhance people's belief in their ability to change, help them to form plans and goals for changing behaviour over time, and enable them to develop skills to cope with difficult situations and conflicting goals. Social approval was an important element of successful interventions. Population level interventions should be consistent with those delivered to individuals and communities.

Better evaluation was an important part of the guidance. Where possible, the effectiveness, acceptability, feasibility, equity and safety of interventions should be evaluated using appropriate outcome measures. Funding applications and project plans for new interventions should include specific provision for their evaluation and monitoring.

Changing behaviour in relation to obesity: eating and physical activity (Professor Susan Michie)

Professor Michie outlined the factors which needed to be understood before behaviour could be successfully changed: the context, the nature of the behaviour, the range of interventions available, evidence-based techniques, and the identity of those who need to take action.

Behaviour change had been shown to require simultaneous and consistent intervention at the individual, community and population level. Behaviour resulted from interactions between a person's psychological and physical capability, motivation, and physical and social opportunities. Interventions should address all three of these factors: capability, motivation and opportunity. Motivation encompassed the reflective (deliberative, systematic decision-making) and the automatic (emotion and habit-based) systems.

Arguably current Government proposals emphasised personal responsibility and choice over state regulation of commercial interests. This was based on the premise that behaviours that led to obesity were the result of the reflective rather than the automatic system, and underplayed the role of context, stimulus and emotion in driving people's behaviour. It was argued that this approach did not acknowledge the role of industry in influencing the automatic drivers of food consumption by a variety of subtle persuasive techniques. It was argued that, given the serious harm caused by obesity, the Government had a responsibility to counteract the methods of behavioural control employed by industry.

Evidence from systematic reviews and randomised controlled trials from a range of population groups, showed that weight loss was consistently associated with behaviour change techniques of self-monitoring, goal-setting and review, action planning, information provision, barrier identification and relapse prevention. The NHS Health Trainers Programme was identified as an example of an effective intervention which was based on good evidence. The programme was delivered by trained behaviour change specialists


The role of the food industry in causing obesity, and the extent to which they would help tackle the problem, was discussed. The reduction in salt levels in food was given as an example of a successful voluntary change by industry. It was argued that encouraging industry to get their profits from healthy products would be a big challenge but that collaboration with industry would be necessary to achieve population level changes in dietary habits.

The need to improve evaluation was then discussed. Those who funded research should not provide money to projects unless evaluation was built in from the beginning. Involving people in evaluation was viewed as key; the Health Trainers programme was a good example of where this had been done well. It was proposed that extrapolating from other fields would make a broader range of evidence available; more studies should be done into the effectiveness of interventions rather than the aetiology of obesity, and there should be a greater focus on using logic to extrapolate conclusions rather than straightforward empiricism. Lessons learnt from unintended consequences of interventions should not be ignored.

It was noted that it could be difficult to learn lessons from interventions in other countries. For example, the government of Finland had done much to change eating and activity behaviour. The population of Finland however was small and homogenous; findings could therefore not easily be transferred to large culturally and individualistic populations, such as the United Kingdom's.

The question of whether genetic factors may have led to a plateau in prevalence of obesity was discussed. Against this conclusion was the fact that there were different levels of plateau in high and low-income groups, and in United Kingdom and the United States. Furthermore, studies have shown that if adults were exposed to an environment in which they overate, they all gained weight; no individuals were resistant to weight gain.

The extent to which change achieved by programmes at an individual level could be seen to impact the behaviour of a population, in comparison to that achieved by changes to the macro context, was questioned. Road safety was identified as an area in which the changes to the macro environment successfully changed behaviour. Coronary heart diseases were reduced by individual and population level interventions. Interventions at both levels should be used and could be complementary.

Finally, the relationship between reflective cognitive and automatic processes was discussed. Cognition should be seen as important in treating obesity because the decision to eat less must be a conscious one to overcome the biological drive to eat to meet energy needs. It was argued that cognitive processes were less important in preventing obesity; many interventions at an associative non-cognitive, or automatic, level were effective in changing behaviour. The Government should seek to change behaviour at both a cognitive and an automatic level. It was argued that the Government has particular responsibility for the environment in which people make choices; there would be no point motivating somebody to exercise more if there was no safe space for them to do so.

Applications of behaviour change theory to physical activity interventions (Professor Ken Fox)

Professor Fox outlined the background and purpose of exercise psychology. Physical behaviour was closely related to an individual's self-esteem and self-perception; understanding the meaning and value of a behaviour to an individual enabled an understanding of their motivation. Self-perception and self-determination theories provided useful frameworks for strategies for physical activity interventions. The theories should be tailored for different target groups using pre-intervention qualitative research and social marketing principles.

The challenges in applying behaviour change theory to physical activity interventions included developing a menu of strategies derived from several theories; no one theory covered everything. Randomised controlled trials could be difficult to establish and did not always identify which parts of an intervention produce change. In many interventions robust measurement of outcomes was not achieved. A key element of physical activity interventions was the quality of the leader and good training of leaders was essential.

Examples of successfully delivered, evidence-based interventions included a randomised controlled trial to evaluate physical activity as a treatment for depression by the Universities of Bristol and Exeter, and a project to increase physical activity in older people.

Changes to the environment had been very difficult to get funded and had taken a long time to complete. This should however be viewed as a very important element in making it easier for people to increase their levels of physical activity.

An introduction to obesity policy for England (Mr Richard Cienciala)

Mr Cienciala noted that the new public health white paper would be published later in the year (December 2010),[345] and would provide more information on the Government's approach; he outlined what was already known about that approach. It would be proposed that a new Public Health Service would be created, which would protect public health spending through ring-fenced budgets and weight allocations toward the most disadvantaged areas. It would be proposed that much action on public health would shift to a local level.

Business would have a key role to play alongside communities and local Government, as they could have a huge influence on people's diets and activity levels. The Government would create a new public health responsibility deal with businesses. A number of networks had already been set up on topics including food, physical activity, alcohol and behaviour change, through which businesses could develop and deliver a set of commitments.

The role of central government would be to lead on initiatives which were best done once and at a national level, such as national campaigns. Central government would also lead cross-Government effort and collaborations with businesses. They would ensure a strong focus on data and evaluation; the Government would continue to draw on expert analysis, NICE guidance and other academic literature, including considering the cost-effectiveness of existing interventions and initiatives. On obesity specifically, thinking in these areas was supported by an Expert Group which considered the strengths and weaknesses of the evidence-base, and emerging evidence for policy implications. The National Obesity Observatory had published a standard evaluation framework to support high quality, consistent evaluation of weight management interventions to increase the evidence-base.

Approaches to obesity were summarised as being likely to reflect four key areas: informing, educating and 'norming' behaviour; creating an enabling environment; supporting the provisions of effective services; and facilitating the sharing of best practice, data and evidence. There would be a strong interest on exploring how the latest in behavioural science could be applied and building on lessons learnt from current initiatives, such as Change4Life, the National Child Measurement Programme, the Convenience Stores Programme and Walk Once a Week.


The relationship between public health and public goods was discussed. Reducing obesity should be seen as a public good but was argued to be a matter of health promotion rather than health protection.

The role of businesses was further discussed and scepticism was expressed about the willingness of the food industry to self regulate. The Government had been clear that the responsibility deal networks were an opportunity for businesses to collaborate with Government and make voluntary changes, but if they do not take this opportunity other means of achieving the same end would be considered. It was noted that the Government should be very specific about the changes that they would like industry to make.

The role of the environment in causing obesity was then discussed. Obesity could be considered the logical consequence of the environment; individuals have to make an effort not to be obese. This demonstrated the importance of infrastructure to support healthy behaviours, particularly in relation to physical activity. This was related to the fact that individuals tended to be more motivated to take the easy option; changing the environment could make healthy choices less difficult.

The connection between social norms and self-esteem was noted. An individual's understanding of their self should be understood partly as a reflection of society; where obesity was normal, people would be less motivated to lose weight. People should therefore be educated about the damaging effects of obesity.

The evidence for "nudges" was discussed. Scepticism was expressed about the evidence for "nudges" and the extent to which the concept was promoted for ideological reasons, rather than its practical usefulness. It was noted that piloting and evaluation of nudge techniques was very important to the Government. Nudges were not the only tool available to Government but should be seen as complementary to other approaches.

344   Public health: ethical issues, Nuffield Council on Bioethics (2007) Back

345   Healthy Lives, Healthy People, DH (November 2010) Back

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