In the fifth and final post in our series remembering Professor Jane Wardle and some of the contributions she has made to the field of behavioural science, Dr Becca Beeken writes about Jane’s work on the Ten Top Tips and habits.

Novel approaches to weight management

As part of Jane’s pioneering work on obesity, she developed novel, evidence-based methods for weight control. Jane recognised that there was a real need for weight loss advice for the general public that is easy to communicate, straightforward to follow, and applicable across a variety of lifestyles. She also acknowledged that while most weight management programmes talk about ‘habits’, they often just mean things we do all the time, and it’s usually in the context of breaking bad habits. Jane was one of the first behavioural scientists to explore whether we can teach people to form healthy habits, using habit formation theory.

According to psychological theory, habits are (relatively) automatically triggered actions that are formed through repetition in a consistent context, which makes them more and more automatic. Jane and one of her PhD students, Pippa Lally, asked people to pick a simple healthy behaviour, such as doing 50 sit ups, and then instructed them to repeat it in a consistent context (e.g. after their morning coffee). They showed that as time went on, individuals performed the behaviour more often, and they also reported that it felt more automatic- it was becoming a habit. Based on this study, Jane worked with the charities Cancer Research UK and Weight Concern to develop the Ten Top Tips.

The Ten Top Tips is a simple leaflet, which describes a set of ten simple energy balance behaviours that can be turned into habits. The leaflet explains the habit model and how to repeat the behaviours in a consistent context. Jane believed that this kind of intervention, which requires very little time to explain and is easy to understand, may be beneficial in primary care where time is short and effective advice for weight management is needed. Weight management advice that promotes permanent behaviour change is particularly important, because not only is losing weight very difficult, keeping the weight off is notoriously hard. Jane felt the Ten Top Tips could meet this need through helping people to make small changes that would become automatic over the longer term.

Jane led a large randomised controlled trial in obese adults in primary care (GP practices), across England, comparing weight loss in patients receiving the Ten Top Tips vs. ‘usual care’. This was the first time an intervention explicitly based on habit-formation theory had been delivered in the primary care context, and importantly the first evaluation of a simple weight loss advice leaflet. Jane and her team found that that the Ten Top Tips led to significantly more weight loss over 3 months than usual care, with 16% of patients achieving at least 5% weight loss; twice as many as in the usual care arm (8%). At 2 years over a quarter (27%) of patients who received the Ten Tops Tips had achieved at least 5% weight loss, suggesting patients maintained the changes made to their behaviours in the first few months after receiving the Ten Top Tips; they had become ‘habits’.

Jane’s work on the development and evaluation of the Ten Top Tips represents an important milestone for translational behavioural research. The Ten Top Tips could offer a low cost option for weight management in primary care and it has already been widely disseminated across the UK as part of Cancer Research UK’s Reduce the Risk campaign, which aims to raise the awareness of the avoidable risks of cancer. Her research group are continuing to take this important work forward, with new studies exploring the effectiveness of habit based advice for cancer survivors-‘Heathy Habits for Life’, and adapting the Ten Top Tips for families with overweight children-‘Tips for Tots’.

As I have discussed before, the relationship with cancer and weight is complicated. However, it is not only of interest to find out how weight impacts on cancer development, but also what happens to people’s weight once cancer is diagnosed and how this relates to cancer survival. For example, medication to treat cancer might make people more prone to weight gain. This could be problematic for people who are already overweight or obese before they were diagnosed with cancer, because an unhealthy weight has been linked to a higher chance of a cancer coming back. Alternatively, it is possible that a cancer diagnosis acts as a ‘teachable moment’ which may motivate people to change their lifestyle. This may help to avoid the cancer coming back after treatment.

Our researchers looked in two large studies, one with people from the UK, and one from the US, at how BMI changed over time in people diagnosed with cancer; and those who stayed cancer-free. Importantly, they also looked at how weight change differed according to people’s weight status before diagnosis, as emerging evidence has indicated that weight loss may improve the prognosis for cancer survivors who are overweight or obese at the point of diagnosis.

Over a four-year period, there was no difference in weight change between normal weight cancer survivors and normal weight cancer-free individuals in either the UK or the US. However, obese cancer survivors in the UK lost an average of 1.48kg vs. cancer-free obese individuals who lost an average of 0.25kg; and in the US, obese cancer survivors lost an average of 2.35kg in comparison to cancer-free obese participants who gained an average of 0.53kg. These results indicate that being diagnosed with cancer has little impact on weight in individuals who are a healthy weight, but is associated with significant weight loss among those who are obese.

Given that there was very little weight loss in normal weight cancer survivors vs. those who were obese, these results suggests that obese cancer survivors may have made a conscious effort to lose weight and to keep it off. However, it is also possible that people who were obese were diagnosed with cancer at a later stage (I discussed here why this is often the case), and that their weight loss was due to their cancer being more advanced, or treatment having taken a greater toll on the body. Unfortunately, the researchers had no data on the stage at which cancers were diagnosed, or whether the weight loss they observed was intentional, so we cannot say which of these options is true. It is important to do more research to see how weight loss relates to cancer survival to investigate whether keeping a healthy weight after a cancer diagnosis really has benefits for surviving longer.

Given that, on the whole, treatment for cancer is getting better, more and more people will survive cancer. Therefore, it is really important to find out what can be done for cancer survivors to improve their quality of life and to ensure that they remain cancer-free.

Reference:

Jackson SE, Williams K, Steptoe A & Wardle J (2014): The impact of a cancer diagnosis on weight change: findings from prospective, population-based cohorts in the UK and the US, BMC Cancer , 14:926  doi:10.1186/1471-2407-14-926

http://www.biomedcentral.com/1471-2407/14/926/abstract

Negative attitudes towards obese individuals therefore remain one of the ‘last socially acceptable forms of prejudice’ . One has only to glance at the ‘comments’ section of media reports discussing obesity to realise that obese people are openly subjected to labelling and stereotyping, and some outright abusive attacks. Unfortunately, stereotypes of the overweight and obese are held across all segments of society, including those working in health and social care .

Despite solid evidence (and frequent discussion on this blog) showing conclusively that whole host of factors contribute to excessive weight gain,currently, responsibility for maintaining a healthy weight rests solely with the individual. Therefore, people may think that stigmatising those who ‘refuse’ to conform to the ‘societal imperative’ is justified . Some may go even further and claim that stigmatising overweight and obese people would encourage them to lose weight. However, when our researchers looked at the scientific literature surrounding stigma and weight loss, there was little evidence showing whether this was actually true.

To find out whether weight and the experience of stigma are related in some way, researchers from our department looked at data from 2,944 UK adults over four years who participated in the English Longitudinal Study of Ageing (ELSA), a study of adults aged 50 or older. Participants are weighed and measured every four years, and asked questions on a range of topics every two years.

To assess stigma, participants were asked how often they encounter five discriminatory situations: ‘In your day-to-day life, how often have any of the following things happened to you: 1) You are treated with less respect or courtesy; 2) you receive poorer service than other people in restaurants and stores; 3) people act as if they think you are not clever; 4) you are threatened or harassed; 5) you receive poorer service or treatment than other people from doctors or hospitals. Responses ranged from ‘never’ to ‘almost every day’. Participants who reported discrimination in any of the situations were asked to indicate the reason(s) they attributed their experience to from a list of options including weight, age, gender, and race. The researchers considered participants who attributed experiences of discrimination to their weight as cases of perceived weight discrimination. Because many participants reported never experiencing discrimination, the researchers divided responses to indicate whether or not respondents had ever experienced discrimination in any domain (never vs. all other options).

Of the 2,944 eligible participants in the study, 5% reported weight discrimination. This ranged from less than 1% of those in the ‘normal weight’ category to 36% of those classified as ‘‘morbidly obese’. Men and women reported similar levels of weight discrimination.

However, those who reported experiencing weight discrimination gained more weight than those who did not over the 4-year period. On average, after taking baseline differences in BMI, gender, age and personal wealth into account, people who reported weight discrimination gained 0.95kg whereas those who did not lost 0.71kg, a difference of 1.66kg.

However, because this study looked only at the relationship of perceived stigma and weight gain, we cannot conclude that stigma caused weight gain – it could also be that weight gain increased perceived stigma, or that a third factor influenced both weight gain and stigma. To conclusively establish whether stigma indeed causes weight gain, we would have to run a controlled experiment with at least two groups of similarly overweight people, where one group is subjected to stigma over a period of time, and the other one is not, and then measure their weight at the end of the study. Of course, such an experiment would be highly unethical, given the damaging effects of stigma on psychological health. Another limitation of this study was that discrimination was assessed two years after the initial weight measurements and two years before the final measurements, although the researchers controlled statistically for this.

However, regardless of its limitations, this study showed that weight discrimination is definitely not associated with weight loss. This means that there was no evidence for the idea that stigmatising overweight and obese individuals would motivate them to lose weight. in many cases, it may even hinder weight loss. Therefore, we should work towards removing prejudice and blame from weight loss advice and should focus on positively supporting those who are trying to lose weight. One way may be to teach active coping strategies and increasing acceptance-based elements into weight loss programmes because this has had some promising effects. Furthermore, we will need to continue highlighting the complex causes of obesity rather than relying on simplistic representations, and increase work to acknowledge and address weight-related stigma, to make the ‘last socially acceptable form of prejudice’ unacceptable.

Article link:

Jackson, S. E., Beeken, R. J., & Wardle, J. (2014). Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity, n/a.  http://onlinelibrary.wiley.com/doi/10.1002/oby.20891/full

The increasing prevalence of weight-related diseases have led health organisations world-wide to advise overweight and obese people to lose weight.  Indeed, the notion that weight loss is generally ‘a Good Thing’ for people who are overweight (BMI 25-30) or obese (BMI ≥30) seems to have been taken on board by the wider society.  Rightly or wrongly, magazines are full of stories, tips and tricks on how to achieve the ‘perfect’ weight, and the diet industry’s worth is estimated to be several billion pounds.   In a recent study of over 9000 overweight and obese adults, over 60% reported that they were ‘trying to lose weight’.

Undoubtedly, even losing relatively small amounts of weight (5% of body weight) will reduce the risk of many obesity-related conditions and diseases, most notably, diabetes, heart disease and stroke.  There are also many reports that weight loss has psychological benefits.  Most commonly, people said that they had improved energy levels, and felt less depressed after losing weight.

However, when researchers from our department looked more closely at the evidence for improvements in depression, it became clear that most of these reports came from people in weight loss trials.  Interestingly, mood improvements often occurred before any weight was lost in these studies, and were not related to the actual amount of weight lost.  This suggests that factors other than weight loss per se may have been responsible for the reported mood improvements.  One explanation is that personal contact (which is a central part of most weight loss trials) may have been responsible for people feeling less depressed by providing support during the weight loss process.  Furthermore, it is likely that people who take part in weight loss trials are very different from the ‘average’ weight loser in the population, so we cannot say that findings from trials will also be true for most people in the UK.

When our researchers looked for studies that used big samples that were representative of the population, they found results from only two studies, the Health and Retirement study, and the Health ABC study.  Curiously, both of these reported slight increases in depressive symptoms in people who lost weight.  However, because these studies also included healthy weight people, and did not look at whether people wanted to lose weight, or lost weight because they got ill during the study period or had significant stress in their lives (which is often related to both weight loss and depression) it was difficult to determine what the reason behind this puzzling finding was.

Therefore, our researchers set out to explore the relationship between weight loss and depressed mood in the English Longitudinal Study of Ageing (ELSA), a large cohort, representative of the UK population that has been going on for over 12 years.  The good thing about ELSA is that it includes lots of measures on all sorts of topics, so that it is very unlikely that people take part because they feel strongly about a certain issue, and it weighs and measures all of its participants every four years so does not rely on self-reported data.

For this particular analysis, the researchers decided to only look at overweight and obese people because these are the people who might be advised to lose weight; a sample of 1979 people.  They also used data telling them about participants’ intention to lose weight, their mood (using an established scale for depressive symptoms), any life stressors or illnesses that occurred during the study period, and blood pressure and triglyceride levels (which were used to check that people benefitted physically from weight loss in the expected way).

The results showed that people derived typical physical benefits from weight loss, with blood pressure and blood test results improving over a period of four years.  However, just like in the other two studies, our researchers found that overweight and obese people who lost at least 5% of their body weight (which is recommended) over four years were nearly twice as likely to be depressed than people who were weight stable, even when taking life stress and onset of illness into account.

However, this study was not able to determine cause and effect, so it is impossible to say whether weight loss caused depressed mood, or whether depressed mood caused weight loss or a third factor that was not measured caused both weight loss and depression.  It is important to investigate these findings further in order to establish why these results were observed, and why they differ so greatly from those reported in weight loss trials; especially since there are so few other studies out there at the moment that could hint at an explanation.

People often think that losing weight will make them happier, but these findings suggest that weight loss may not always be a positive experience.  In fact, the psychological ‘costs’ of weight loss might explain why many who do successfully lose weight struggle to keep the weight off in the long term.  However, this is not to say that people should not attempt to lose weight – after all, people in the study got physically healthier.  Rather, it seems important that service providers are mindful of the possibility that weight loss may worsen mood, and to perhaps include an assessment of mood in their weight loss programmes.  It may also be sensible for anyone trying to lose weight to be aware of any on-going mood changes and to seek psychological support from health professionals or even friends and family if they begin to struggle.

Article reference:

Psychological Changes following Weight Loss in Overweight and Obese Adults: A Prospective Cohort Study

Jackson SE, Steptoe A, Beeken RJ, Kivimaki M, Wardle J (2014) Psychological Changes following Weight Loss in Overweight and Obese Adults: A Prospective Cohort Study. PLoS ONE 9(8): e104552. doi: 10.1371/journal.pone.0104552

Promoting dieting for weight loss and weight maintenance is often criticized, because of the widely held belief that restricting food intake is the beginning of a slippery slope, leading to overeating and eating disorders.  However, a recent review by our department investigating the literature of dietary restraint shows that this may not be the case.

The idea that restricting food intake would lead to uncontrolled binge eating stems from laboratory studies from the 1970s.  Counter to expectations, people reporting that they were trying to lose weight by eating less (restrained eaters), ate more than unrestrained eaters when offered unhealthy but tasty food after being encouraged to break their diet by drinking a high calorie milkshake.  They also ate more than others after drinking alcohol or when they were upset.  These observations led to the belief that trying to control eating with one’s intellect rather than instinct can lead to less sensitivity to feelings of hunger and fullness, and cause people to overeat when their guard was lowered.  At the same time, research pinpointed dieting as a precursor of eating disorders, such as anorexia nervosa and bulimia nervosa, which further strengthened the lobby against the restriction of food intake.

However, closer examination of the research showed that the methods used to classify people as ‘restrained’ or ‘unrestrained’ eaters may have contributed to the findings.  For example, some of the questions asked to find out whether people restrict their food intake were actually assessing tendencies to eat in an uncontrolled way.  The links between restrictive eating and binge-eating were even less clear when considering the artificial lab setting in which participants were persuaded to break their diet, and then presented with an overwhelming amount of tasty food and told to eat as much as they wanted.

Furthermore, in the current environment, it may well be that a person eats less than desired, but still eats more than would be needed to keep weight stable.  Eating only one chocolate cake is better than eating two, but still, it can hardly be considered beneficial to your health!  This means that measuring food restriction alone may not be such a good indicator of successful weight management.  People who report restricting how much they eat may simply be the ones most likely to overeat.

Support for the positive effects of food restriction comes from real world examples.  In overweight individuals, where overeating is common, restricting food intake is related to lower body weight.  Findings from weight loss studies also show that the people doing best are the ones who vigilantly pay attention to what and how much they eat and don’t binge eat. In fact, evidence from studies with people suffering from binge eating has shown that gaining control over the amount of food eaten is related to fewer binge episodes.

So, how come the myth about the relationship between food restriction and disordered eating behaviour persists? The devil here may be in the detail of how people restrict their food intake. People who are following rigid, rule-based, ‘all-or-nothing’ eating are more likely to react with overeating and disordered eating once their rules are broken than people who take a more flexible approach, limiting rather than totally eliminating certain foods, and compensating for ‘off’ meals at the next meal or with an extra hour at the gym. Identifying oneself as a ‘dieter’ seems to be related to more rigid rules about eating and so may be undermining weight loss efforts.

The key to successful weight management may lie not in restraint per se, but in self-control. The ability to forego immediate rewards in pursuit of higher goals seems to be a skill that, once acquired, is not limited to successful weight management, but extends to other areas of life such as success at work, and better management of time and finances.  Although the capacity to control one’s desires seems to be partly inherited, the good news is that people can also be trained in self-control.  Learning how to control emotions, monitoring and evaluating one’s own  behaviour, setting goals, acquiring more beneficial problem-solving skills and thinking up action plans for resisting temptations have all been shown to enhance self-control.  The view that restraint is always ‘bad’ may need to be revised and the distinction between ‘rigid’ and ‘flexible’ restraint should be given more consideration.

The bottom line is that exercising a little restraint may not only benefit your weight but also your wallet, as long as it does not turn you into a rigid, miserly and overly concerned kill-joy.

Article Reference: Johnson, F., Pratt, M., Wardle, J. (2011). Dietary restraint and self-regulation in eating behavior. Int J Obes (Lond) doi:10.1038/ijo.2011.156.

How self-monitoring tools and participation in online support groups assists weight loss

The internet can be a wonderful place, with hours of fun to be had looking at unlimited amounts trivial information, bad adverts and cats doing the craziest things. However, new research by our research group suggests that the Web may have benefits for those looking to shed the pounds and stay fit, too.

Dr Fiona Johnson and colleagues used data collected from a commercial online weight-loss programme (Nutracheck) to see if individuals monitoring their diet and exercise levels using the software more regularly were more likely to lose weight.  The programme is an online platform which helps users track diet and exercise goals in addition to providing weight charting software, information about nutrition and health and an online forum. With over 3500 subscribers’ data to look at, there was enough information to see which techniques worked best and for whom. What the researchers wanted to find out was whether men and women used the programme differently, and whether any particular parts were more effective than others for losing weight.

The main finding was largely unsurprising – the more often people logged into the programme the more weight they lost, demonstrating the benefits of encouraging users to return frequently to online weight loss programmes.  There were also differences between the genders. Using online support forums was a better route to weight loss for women, whereas recording exercise levels seemed to increase success in men. Looking a little deeper in the data reveals yet more interesting patterns. Overweight or obese men and women that used food diaries the most were substantially more likely to lose over 5 % of their body weight (an amount which is likely to have health benefits) than those who logged their food consumption less diligently. Overweight and obese men seemed to benefit particularly from exercise diaries, with the most engaged being the most likely to shed significant amounts of weight.

We all knew it – consistency is the key. Just sticking to actually using the programme you spent your precious money on will help fight the flab. If you are a man, making note of how often and how long you spend exercising and toning your Adonis body appears to be the route to success. And if you are a woman, chatting about the experience of weight loss and dieting will help even more. So what are you waiting for? Stop looking at crazy cats and get logging!

Reference:

Johnson, F & Wardle, J. (2011) The association between weight loss and engagement with a web-based food and exercise diary in a commercial weight loss programme: A retrospective analysis. International Journal of Behavioural Nutrition and Physical Activity. 8:83 doi:101186/1479-5868-8-83

Susie (susanne.meisel.09@ucl.ac.uk)