APPENDIX 4: SEMINAR ON BEHAVIOUR CHANGE
INTERVENTIONS TO PREVENT AND TACKLE OBESITY HELD AT THE HOUSE
OF LORDS
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
Discussion
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.
Discussion
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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