Simple rules

Meal-replacement or healthy eating?
20 February 2019

Interview with 

Paul Aveyard, Oxford University


this is a picture of a smoking cigarette


What behavioural strategies work when trying to change behaviour on an individual level? Katie Haylor spoke to Paul Aveyard, family doctor and behavioural medicine expert from Oxford University. First up, Katie asked, with the wealth of health messages out there about things like smoking and over-eating, how difficult is it to help people change their ways?

Paul - It's one of the barriers that sometimes doctors feel that “look, I'm just preaching to people who already know what they ought to do and just don't want to do it”. But actually that's not true. A lot of people, at least to me as a doctor, express a desire to do something about it and the knack if you like is to offer people some practical way forward that they can take action, preferably there and then, to do something about it. If you can move the conversation into that area, then you're likely to make progress with your patients.

Katie - So is that the difference between saying "take this leaflet you can go away and look at some links", and "I could sign you up for a weight loss course right now"?

Paul - Yeah, usually it works much better if you can make that action not dependent on their initiative. After all stuff gets in the way, we all have busy lives. A lot of people just have a feeling that "I could perfectly well stop smoking, lose weight, do whatever it is that the doctor has been asking me to do by myself". But actually the lesson is that we know that these programs help people but they don't always appreciate the value that they hold. So taking action put that program in the way of people, when you have the opportunity, is a really important part of our work.

Katie - OK. So perhaps effort or a bit of cognitive effort to go online and book that course or whatever it is is one barrier. What other barriers are there to people adopting the healthy behaviours they might very well know is the best thing to do?

Paul - Well they're all the sort of barriers that you know we've all faced when we've made our New Year's resolutions right? “One of these won't matter”, and then before we know it one becomes two becomes more. So all of these and the environment around us constrains our ability to make changes.

But just because those barriers are there, doesn't mean that you shouldn't try. There are lots of examples where if people can be put in the way of effective programs, they will make progress and move forward. We have good evidence that these very brief interventions that I was talking about, that doctors can make, do prompt people to make changes. Most people don't succeed in the long term, but enough do to mean that it's not only cost effective but actually cost saving.

Katie - So in terms of what your research has informed works, signing up to for instance a weight management program. Can the same thing be said of smoking?

Paul - Yes it can. We know that for example if people were to leave a consultation with medication like nicotine replacement or like tablet treatments that we have, or be referred to a stop smoking clinic, well those are the best things that they can do to give themselves, maximize their chance. So our task as a nation really is to get more people to try to make changes in the first place and to get more people to use an effective means to help them change their behaviour, in the second place. And there are a variety of tools that we can do to use that, a very key one is what your doctor says to you when you go and see them.

When people are thinking health, that prompts the self-regulatory part of their brain to be more active and that means that they're much more likely to want to take action on the doctor's advice at that moment, than if they were just caught cold with advice to stop smoking.

Katie - So we're actually using neuroscience to capitalize on people's behaviour to help them change it?

Paul - Yep.

Katie - You mentioned seizing the moment, are there any other particularly successful case studies that we can use and learn from?

Paul -  What helps people is to have very simple rules about what they can and can't do. After all changing your behaviour is in some ways a bit of a boring task. You've got to take something you like doing and not do it or at least not do it half as much as you might like to. If you can keep a very clear rule for yourself about what you will and won't do, you are more likely to be successful.

So let me give you an example. People who are stopping smoking, they can say to themselves “I'm trying to stop smoking”, right? Or they can say to themselves “I'm a non-smoker now. That's just not what I do”. And it turns out that the people who say that second thing "I'm a non-smoker now", they're drawing on their sense of identity, who they are as a person. And that strengthens their resolve and they're much less likely to go back to smoking than the people who say "I'm trying to stop smoking".

Another example is the “not a puff” rule that we have in smoking which is simply that once you pass this day, called the quit day, your absolute golden rule is do not smoke at all. And again that relates to the neuroscience and the sort of neurobiology if you like of learning and addiction and the extinction that occurs as a result of sort of not smoking, gradually the drive to smoke will lessen. It's sort of anti- Pavlovian learning that's going on there.

We know that these simple rules help bolster people's resistance to temptation. We see that in weight loss interventions as well where things like meal replacement programs, so a very simple rule, eat that, don't eat anything else, turns out to be easier to adhere to that kind of rule than, oh here's the kinds of foods that you ought to be eating. You'd think the latter would be more sustainable and better in the long term but the reverse is true.

And indeed that can lead on to effective population strategies. So Tesco or any other big supermarket could perfectly well produce, and to some extent they do produce, calorie-controlled meal replacement programmes, its actual real food, that's already packaged, you know? This is a breakfast, this is your lunch, this is your dinner. You could imagine that there was a commercial opportunity for them to produce a kind of whole program that gives people a rotating, interesting diet but nonetheless actually is lower in energy than they might otherwise have. And because it all comes as “just eat this” it's actually an easier diet to stick to than the sort of usual approach where you're left to try to make healthy choices.

Katie - Is it palatable though? And I don't mean the food, I mean the idea of being told what to do, because some of us aren't very good at that!

Paul - I think one of our principles that we started the day with here was that the overwhelmingly big breakthrough is there is no single breakthrough, and there's certainly no single way for a person to lose weight. The best way is - as we always say - the way that you feel you can stick to. But on average this is what the research evidence is showing, that these meal replacement programs which are currently provided by diet companies, those are more effective than the educating you about your food way. But that doesn't mean that that's true of everyone of course.


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