Psychology in Health Behaviour Change & Weight Management

Michele Gray, CPsyChol

Specialist Health Psychologist

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Background info

• 80% cardiac rehabilitation; 20% weight management and bariatric services

– Common factors

• Recognition of risk factors

• Lifestyle issues & long term behaviour modification

• Aims & Objectives for today (with both hats on)

– Explore health behaviours in general

– Discuss eating behaviours and weight management issues

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Changing Lifestyle in the last 2 decades.

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Social and Health Impact of Obesity

• 2015 :- 58% of adults in Wales were classified as overweight or obese

• The Foresight report estimates that obesity related illnesses will cost the NHS £22.9bn by 2050

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Welsh Health Survey 2014

0%

10%

20%

30%

40%

50%

60%

70%

Smoker Maximum dailyalcohol

consumptionabove

guidelines

Binge Drinkers 0 active days aweek

Overweight orobese

Menaged 16+

Womenaged 16+

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Welsh Health Survey 2015 data

• 59% of adults were classified as overweight or obese

0

10

20

30

40

50

60

70

BetsiCadwaladrUniversity

Hywel Dda PowysTeaching

AbertaweBro

MorgannwgUniversity

Cwm Taf Cardiff &Vale

University

AneurinBevan

Wales

Percentage of adults overweight or obese by local authority

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Common Psychological Issues in WLS patients (BPS Obesity in the UK 2011)

– High levels of self criticism and shame, low self-worth, low self esteem

– Low levels of confidence, motivation and belief in the ability to achieve change

– Mood disorders (depression, anxiety, etc)

– PTSD/Trauma response

– Self sabotaging behaviours

– Addictive behaviours

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Other Psychological influences

Emotions

Depression, Anxiety, Sadness, Shame, Guilt, Frustration, Anger,

Avoidance

Putting things off; friends, leisure, work, activities etc. until weight loss achieved.

Blame

My weight means: - “I’m a failure”

“I’m not good enough”

Thought Patterns

“I’ll start tomorrow”

“Now I’ve had one, one more won’t make a difference”

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Psychology and Health Behaviours

• People often have a complex relationship with their unhealthy behaviours.

• Social groups and family members with unhealthy behaviours can influence each other.

• Low motivation, confidence and self-esteem can also impact life-style choices; particularly with regard to dealing with uncomfortable emotions or stressful situations.

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Blaise Pascal, Pensées, (1670)

“People are generally better persuaded by the reasons which they have themselves discovered,

than by

those which have come into the

mind of others.”

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Self-efficacy (Bandura, 1977)

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So …to effectively change a person needs to ...

• Recognise that a behaviour change is needed, desirable and beneficial to them personally

• Be motivated to make the change

• Believe that they are able to make the change (perceived self-efficacy/have confidence)

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Shaping Beliefs

Past experience vs. Future expectations

“I’ve tried it all before (Atkins, 5/2, weight watchers, slimming world .... ) and not

succeeded in the past, so why will this time be any different?”

“Nothing will ever change”

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Making Change Personal

Tell me about how this behaviour (or change) affects a typical day in your life?

– How do you feel about ……

– What do you like about ……

– What do you dislike about ……

– How would this fit (change) into your life ……..

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“I can resist anything except temptation” Oscar Wilde

BARRIERS TO CHANGE

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Common misconceptions & Challenging beliefs

• Diet = deprivation

– Think about adding extra food rather than taking food out – think nutrition not diet

• Add extra vegetables to each meal

• Add a piece of fruit to midday snacks

• I can’t exercise because I can’t go to the gym

– Any activity is better than none

• Walking is a great exercise – a few steps extra with each activity can add up

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Common Barriers to Change

• Beliefs

– Is it really important?

– Do I need to?

– Can I do it?

• Priorities

– Time

– Cost

– Commitment

• Knowledge

– How / where to start

• Social Stigma

– What will people think?

• Other

– Conscious or unconscious reasons not to change • Fear, Attention, Benefits

etc

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Common barriers in my bariatric clinic

• Comfort

• Distraction/Boredom

• Guilt

• Social/family pressure

• Impulse/Habit

• Addiction

• Punishment

• Defiance/Control

• Grief

• Food aversions

• Depression

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Addressing ‘Barriers to Change’

• Habit/Impulse – Raising awareness

• Boredom/Depression– Mindfulness

• Social/Family/Emotional pressure – Coping strategies

The main area of help we can offer is to help people challenge their beliefs, highlight their motivation and set their own, realistic goals

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Goal Setting - It shouldn't be all about giving things up

Strategy Target

Traditional ApproachDiet=Deprivation

• Stop eating certain foods

• No more chocolate/cake/treats

• No fried food, fast food or take-away’s

Healthy Eating

Approach

• Portion control

• Smaller plates / portions

• Try adding new (or extra) food

• Fruit juice once a day

• Extra vegetables with main meal

• Replace certain foods

• Boiled / baked potatoes, rice or salad with meals

• Fruit as a mid morning snack

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Stages of Behaviour change (Prochaska and Dclemente)

Stage 1Precontemplation

Stage 2Contemplation

Stage 3Preparation

Stage 4Action

Stage 5Maintenance

Why should I change?

I don’t want to change.

I want to be fit and healthy.

I’m going to find out what I need to do and how.

I’m making changes to my diet and getting more exercise.

I have new healthier life-style habits.

I don’t have a

problem.

I’m worried. I’ve started

to feel unwell.

I really need to make

some changes.

I am doing it!I’ve started

making healthy changes

I’ve done it -the changes are now part of my daily

routine

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Therapeutic strategies

• Motivational interviewing

– Helps people to articulate the pros & cons of change

– Empowers people to take steps toward change

• Mindfulness

– Helps people to pay attention to how and why they eat, and make certain food choices

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Motivational Interviewing(Miller & Rollnick 1983)

A collaborative, person-centred

form of guiding patients to elicit and strengthen motivation for

change.

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Motivational Interviewing - Theory

• The more you confront and persuade, the more the patient will resist (as Pascal noted in 1670)

• Counselling style - elicit internal motivation

• Gentle & active listening

• Respect for patient values & autonomy

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Information Exchange

• It’s a two-way process - encourage patient to be active participant; to identify & discuss goals and, most importantly, barriers

• Ask permission before providing information, and leave interpretation to patient, but check on understanding

• Role with resistance– Be respectful

– Everyone has different priorities and points of view

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Importance and Confidence

Scaling Questions (on a scale of 0-10)

• How important is it for you to …… (e.g. lose weight)

• How confident are you that you will succeed?

Not important Very important

0 1 2 3 4 5 6 7 8 9 10

Not confident Very confident

– Why are you at ‘x’ and not at ‘y’

– What would help you to get to ‘y’

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MindfulnessJon Kabat Zinn

Paying attention to the present moment in a

non-judgemental way

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Mindfulness A Different Approach to Eating and Weight Management

Aims : -• Increases awareness of different types of hunger,

and the experience of eating.

• Develops a new relationship with hunger and eating

• Raises awareness of ‘hunger’ as a response to external stimuli as well as biological need

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Mindful Eating

• Eating mindfully is not about what you eat, but HOW and WHY you eat

• By paying close attention to the taste, texture, and sensations of eating, you can get more enjoyment out of food and build awareness of bodily reactions

• Mindfulness raises awareness of the experience of hunger and what has prompted the feelings of hunger

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Mindful Eating - HungerWhat type of hunger do you respond to most often?

• Eye hunger: Eating even when you are full; such as after seeing the dessert menu

• Nose Hunger: Smell, and anticipated flavour, entice you to eat

• Mouth Hunger: Looking for particular flavours and textures (sweet, savoury, melting, crunchy etc)

• Cellular Hunger: The difference between what you need and what you want

• Mind Hunger: “A bit of what you fancy does you good”; “I deserve a treat”; “I’ve had one so I may as well have another”

• Comfort Eating: Foods that alleviate boredom and stress

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Mindful Eating – Texture/SensationWhat type of texture/sensation are you looking for?

• Crunchy

• Soft

• Brittle

• Melting

• Chewy

• Liquid

• Cold

• Hot

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Mindful Eating – Texture/SensationFood swaps – ideas patients have come up with

• Chocolate biscuits Crunchy/Sweet sensation

– Sliced apple with low fat chocolate mouse

• Ice Cream

Soft/sweet/cold sensation

– Yogurt, sugar free jelly, blended and semi-frozen fruit

• Evening munchiesCrunchy/Brittle/Sweet sensations

⁻ Sliced banana on toast or crispbread

⁻ Nuts in their shells and grapes

⁻ Chopped vegetables and humus

⁻ Chopped fruit and diet yogurt to dip

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Mindfulness in practice

• Why are you hungry? What kind of hunger is it?

• How hungry/full are you?

Starving Satisfied Stuffed1 2 3 4 5 6 7 8 9 10

– Aim to eat at around 3 – 4

– Aim to stop eating at around 6 – 7

– If you are looking for a specific texture or sensation will it pass, or is there a healthier choice?

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Ways to Eat Mindfully

• Eat sitting at a table so you can concentrate on the food. No electronic gadgets!!

• Be aware of the tastes and textures you are looking for. If you have a ‘food’ craving can you make a healthier choice?

• Learn to recognise different hungers by delaying eating when you feel hungry. Does the feeling pass with distractions?

• Be aware of portion size. Try switching to a smaller plate and try to make each meal last at least 20 minutes.

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To Summarise• There is more to weight loss than the usual ‘eat less – move

more’ advice. Many people have a complex relationship with their health behaviours.

• There is a need to help people recognise this and develop coping strategies; but it must be done with the persons’ permission and input.

• Health behaviour change is the individuals responsibility – you can’t make someone change if they don’t want to. But sometimes you can help them want to.

• Sometimes there is more to a persons health behaviours then meets the eye. There may be an unconscious motivation for the person to remain the same in spite of the health risks. This is called a Secondary Gain.

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Secondary Gains

• Secondary gains “benefit” people in a way they usually don’t recognise

• For example, remaining overweight :

– Can affect mobility and prevent people from working

– May be a good excuse not to seek relationships

– Can maintain a ‘sick’ role of needing care

– Can be a physical ‘excuse’ for mental health problems such as depression

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When they lose weight, some people find their body more repulsive than when they were fat. If they don’t come to terms with their altered body image they will frequently put the weight (and often more) back on again.

One of the Other Cons of Change

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Applying Evidence to Practice

Key Messages:- Addressing Change

• Help patients set their own SMART goals which they feel are achievable for them

• Find out: -• When/why did they first start having weight problems?• What is their motivation? How confident are they?• What are their ‘barriers to change’? • What might help them achieve their short and long-term

goals?

•Be aware of possible Secondary Gains that might need addressing separately

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