Why is behaviour change so difficult to achieve? Dr Elisabeth Weichselbaum Nutrition Scientist and Consultant ewnutrition.net

Knowledge alone is not enough Plenty of information about healthy diet and lifestyle It is likely that many people are aware of ‘what they are supposed to eat’ Survey in UK 99% knew fruit and vegetables very or fairly important 94% said eating less salt was important 92% said limiting foods high in saturated fat was important Awareness about healthy eating and lifestyle alone has not led to behaviour change Perhaps the key to behaviour change lies in better understanding the mechanisms behind behaviour itself? Food Standards Agency 2010

What factors influence behaviour? Physical Psychological Includes knowledge & skills Reflective processes Automatic processes Social Physical Michie et al. 2011, Implementation Science 6:42

Why is the healthier choice not always the easier choice? Our intentions and plans can only influence behaviour if they generate sufficiently strong wants or needs at the relevant moment to overcome competing wants or needs. Larger, less certain and more distant rewards (e.g. losing weight, stay healthy) Environmental cues + power of immediate and certain pleasure (e.g. of eating chocolate) vs. Marteau 2011, BMJ 342:263-265; Atkins and Michie, Nutrition Bulletin 38:30-35 .

Human behaviour shaped by two systems (Dual Process model) Reflective, goal oriented system Driven by our values and intentions Requires cognitive capacity or thinking space Many traditional approaches to health promotion target this system, i.e. designed to alter beliefs and attitudes Automatic, affective system Requires little or no cognitive engagement Driven by immediate feelings and triggered by environments Strack and Deutsch 2004, Pers Soc Psychol Rev 8:220-47.

Beyond awareness Adults typically make more than 200 food-related decisions per day… …but are aware of 14.4 food-related decisions. Most of our food-related decisions are beyond conscious awareness This is for a good reason Would you get much done if you questioned all of your 200+ food-related decisions? Wansink and Sobal 2007, Env Behav 39:39-106; Chadwick et al. 2013, Nutrition Bulletin 35:36-42

Consumption norms People very easily influenced when it comes to how much they eat Plate size, package size, larger portions in restaurants, larger kitchen ware… They all suggest a certain ‘norm’ or portion size People underestimate this influence and believe they are immune to them Wansink 2010, Psychology & Behavior 100:454-463

Are we aware of influence? 4 Experiments, intervention: A larger serving (double popcorn) Same serving, but in larger package Intervention groups consumed 32% more than control group Only 8% thought they ate more than usual 73% thought they ate about the same 19% thought they ate less Wansink 2010, Psychology & Behavior 100:454-463

Are we aware of influence? When told about the intervention and its effect 52% claimed they did not eat more 31% said if they did eat more it was because they were hungry 15% gave other reasons (special occasion, it was free) Only 2% acknowledged it was because of the environmental cue This means these determinants are not available for the processes of monitoring, reflection and goal-directed behaviour required for successful modification Many people say “don’t know why they are so overweight since they hardly eat anything” Could be explained by fact that many determinants of food choice are beyond conscious awareness Wansink 2010, Psychology & Behavior 100:454-463

The power of habit Strength of habit has a strong influence on behaviour Habit can even override taste (which itself strongly influences food choice) Habitual behaviour is more dependent on environment and less under conscious control Chadwick et al. 2013, Nutrition Bulletin 35:36-42;

The power of habit Fresh Stale Weak habit of eating popcorn in cinema Strong habit of eating popcorn in cinema Meeting room context Cinema Meeting room context Cinema Ate the similar amount of fresh and stale popcorn. Ate less when presented with stale than with fresh popcorn. Neal et al. 2011, Pers Soc Psychol Bull 37:1428-37

Nudging – a possible way to change behaviour Nudging means to change physical or social environment to make a certain behaviour more likely Mainly operates through the automatic, affective system Marteau 2011, BMJ 342:263-265; Thaler and Sunstein: Nudge. Yale University Press 2008.

Does nudging work? Nudging works, although currently often used to drive unhealthy eating behaviour Limited evidence on nudges to encourage healthy behaviour Cumulative nudges in a wide range of contexts may be required to be effective Within enabling legislative and policy environments Marteau 2011, BMJ 342:263-265.

Healthier choice does not equal healthy weight People tend to think of foods as either ‘good’ or ‘bad’ Behave as though healthy foods have ‘halos’ – are perceived to be less likely to promote weight gain Chernev 2011, J Cons Psych 21:178-183.

Which promotes more weight gain? Students and adults were presented with a variety of ‘healthy’ and ‘unhealthy’ snack options + vs. Chocolate 569 kcal 47 kcal Oakes 2005, Appetite 44:317-324; Oakes 2005, Food Quality and Preference 16:447-454

+ The Dieter’s Paradox OR 14% kJ Chernev 2011, J Cons Psych 21:178-183.

Obesity is not a rational choice! Conclusion How can we influence behaviour that lies outside awareness? Could nudging work? How can we avoid stereotype thinking about food? Obesity is not a rational choice!