BY DR JANE OGDEN, PROFESSOR IN HEALTH PSYCHOLOGY
Failed dieting is a product of what’s in our heads and triggers in the environment. Successful dieting seems to be the result of life events, a belief that things can change, a shift in the costs / benefits of eating well, investment in initial weight loss, a sense of renewed control, a new dietary regimen and a new identity as a healthier thinner person. Bringing about successful weight loss and maintenance is a matter of avoiding those factors that lead to failure and maximising those factors that contribute to success. This involves behaviour change. This paper will describe some useful strategies that can be used to change behaviour and then illustrates how they can be applied to maximise the chances of successful weight loss and maintenance. Finally this paper outlines one key resource available to anyone wanting to help others change their behaviour; the relationship with the client.
Some useful behaviour change strategies
All behaviours are learned through the four key mechanisms of modelling (watching others), repetition (doing it over and over), reinforcement (any source of reward) and association (being linked with internal factors such as mood or external factors in our environment). Changing behavior therefore involves unlearning the old behavior and learning the new behavior using these same mechanisms in the following ways:
Modelling: We can change our behavior by watching those around us and focusing on the behaviours we want to copy. Therefore if you want to change your behavior it is helpful to surround yourself with people who behave in the desired way, to make yourself attend to those who behave more healthily and to try to discount those that do not. This is known as modelling.
Repetition: The best predictor of future behavior is past behavior as we are creatures of habit. But the difficult stage is often to get a behavior to become a habit in the first place. At the beginning of behavior change it is necessary just to keep repeating a behavior over and over so that it starts to feel more normal. This can be facilitated by using the mechanisms of reinforcement and association which will now be described.
Reinforcement: Any behavior is always more likely to reoccur if it is reinforced or rewarded in some way. This can be through someone else smiling, praising you or showing pleasure, through self reward in the form of stickers on a sticker chart, treats, gaining or saving money or just self praise. But however it comes, praise will help to make a new behavior happen again. And positive reinforcement is always far more effective than criticism which can often just lower people’s self esteem or mood rather than change their behavior.
Association: Any behavior will become associated with internal factors such as mood or external aspects of the environment. Changing behavior therefore involves making new associations so that the newer healthier behavior becomes more positive and the older unhealthier behavior becomes more negative. This can be done through images of unhealthy foods, a heart surrounded by fat or talking more positively about being healthy.
Behavior is driven by cognitions which can also be changed through the use of ‘Socratic questions’ which form the basis of Cognitive Behavioural Therapy (CBT). This involves searching for evidence to see whether any given cognition is actually backed up by anything. For example, if someone says ‘Nothing I do makes me lose weight’ then ask ‘has your weight ever gone down?’. Then if they say ‘well I lost weight when I had flu last year’, say ‘did you eat less when you had flu?’. That they will start to see that their weight is linked to their behavior.
3. Sense making
Life is full of both positive and negative events yet how we feel about our lives often relates to how we make sense of our world rather than what is objectively happening to us. Sense making is central to behavior change as we tend to develop coherent stories about the cause and solution to any given problem. So if we believe ‘I am overweight because of my hormones’ then we will also believe ‘I need a drug to help me lose weight – there is nothing I can do’. Changing our behavior would not make sense within this model of our health. However, if we believe ‘I am overweight because I eat too much’, or ‘my knees hurt because I don’t do enough exercise’ then ‘eating less’ and ‘doing more’ would seem to be the perfect solutions. Behaviour change requires a shift towards beliefs about causes which include behavior as a means to encourage the uptake of behavioural solutions. This can be achieved using CBT as
One of the simplest ways to promote behavior change is to set goals and make plans. These should be clear and specific describing the what, where and when of any given behavior. In psychology these are sometimes referred to as ‘implementation intentions’ and refer to goals such as ‘I will eat fish and rice for lunch at 12.00 tomorrow’ rather than ‘I will eat more healthily’. In the broader health literature the best goals are said to be SMART which requires them to be Specific, Measurable, Attainable, Relevant and Timely. Plans and goals help to change behavior.
Motivational Interviewing (MI) is very commonly used to change behavior. MI focuses on the notion of cognitive dissonance which is the uncomfortable feeling people get when there is a mismatch between how they see themselves and how they are behaving. For example, if you think ‘I am a sensible person who takes care of myself’ but ‘I eat too much and am making myself ill’ you will feel dissonance. MI tries to make the dissonance worse based upon the premise that this increased dissonance will push people to change what they do. This is achieved by asking people to describe the costs and benefits of their behavior, then feeding these back to them so that they can see the gap between one set of beliefs about themselves and what they are doing. So if you are overweight you might think ‘I like eating a lot as it helps me manage my emotions’ AND also think ‘my weight is making me miserable’. If these mismatching thoughts are then fed back to you, you should then think ‘time to change how I eat’.
6. Using emotion
For many years health promotion campaigners believed that fear was the best strategy to change behavior. But we know that people often block information when it makes them frightened. Blocking can be prevented either by using images which seem to be easier to hear than just text or by helping the person to feel good about themselves beforehand. So if you say ‘you are really good at xxxx’ then say ‘but you need to change your behaviour’ people are more likely to listen and less likely to block any advice you have.
7. Self monitoring
Habits are often mindless and occur without thought. One strategy to make it more mindful is to self monitor which makes behavior more conscious and less automatic. This can be achieved by making plans as described above. But it can also be helped by simple tricks such as taking a shopping list to the supermarket, eating at a table with a plate and knife and fork or going to a club once a week to be weighed.
Using these strategies to make weight loss happen.
Paper 2 on ‘Why weight loss is hard’ outlined some of the lessons we can learn from those who have successfully lost weight and kept it off. It is also, however, important to know how to make weight loss happen. This section will now illustrate how the behaviour change strategies described above can be used to promote successful dieting. This can be achieved through a 5 step approach to successful dieting.
Step 1: Finding the trigger to change
Successful weight loss and maintenance is often triggered by a life event. Yet we can’t make life events happen which is problematic if we are to try and promote successful dieting. But we can turn every day events into these ‘teachable moment’ by methods of Socratic questions and sense making and seeing these events as an ‘opportunity’ rather than a problem.
Step 3: Creating a new behaviour regimen
Research exploring failed and successful dieting indicates that a new behaviour regimen is necessary if you are to lose weight and keep it off in the longer term which requires a change in what, where, when and why we eat. This involves a range of strategies including planning and self monitoring so as to eat in a more mindful way and reframing food as meals not snacks.
Step 4: Managing the environment
Our behaviour is clearly a response to what’s in our heads and the triggers in our environment. Ideally we would all be able to reprogramme what’s in our heads so that we can ignore these triggers and just do what, where, when and why we plan to do as described above. But this can be hard at times and extra help is needed to manage both the home environment and the world out there. This involves planning and goal setting when you shop or cook and what exercise you do, self monitoring when you eat and simple avoidance of triggers which may make you behave in unhealthy ways.
Step 5: Paving the way forward
The final step towards successful and sustained weight loss involves paving the way forward towards a renewed sense of control and ultimately a new identity as a thinner healthier person. This involves carrying on with all the steps described above. It also involves coping with failure and a process of reinvention which can be achieved through planning, cognitive restructuring, sense making, reframing, simple repetition and modelling. In particular success requires a focus on any achievements made and an ability to lets slips or failures go without letting them turn into ‘what the effects’, feelings of guilt and self blame and subsequent eating for comfort.
These 5 steps, supported by a range of behaviour change strategies should help people change their behaviour for the longer term.
The key resource for those helping others lose weight
Hopefully, by now it is clear that although weight loss is hard, it can happen. It should also be clear how to help others more effectively. But there is one key resource that those helping others can also draw upon to make weight loss more likely; the relationship with the client.
Being liked: At its simplest, if clients like you they will want to please you and will be far more likely to follow your advice. So remembering their name, reflecting on what you have talked about in the past, smiling, listening, humour, warmth, being nonjudgmental and being supportive will all help to build a good relationship.
Offering reinforcement: You are in the perfect position to be the reward system for anything the client does. People are far more motivated by the carrot than the stick so offer positive reinforcement whenever you see anything they have done that is a step in the right direction.
Having follow ups: The best predictor of weight loss maintenance by far is having longer follow ups. So the more you can keep seeing people the better they will do. This may be because each time they see you, you use your behavior change strategies to help them. It might be because they want to please you because they like you. Or it might simply be that by coming back over and over weight loss stays as their goal.
What you say: The way you speak about health, food and exercise can change the way clients think. So call healthy food ‘tasty’, ‘crunchy’ and ‘nice’ not ‘boring but good for you’; describe exercise as ‘fun’, ‘exciting’, ‘good for your mood’, ‘a way to let off steam’ rather than ‘healthy’ and ‘necessary’.
What you do: You are also the client’s ultimate role model for what you do. And if they like you, they will want to be like you. The pressure is therefore on to show them that you have a good relationship with food, eat well and that you enjoy being active.
Weight loss that lasts into the longer term is hard to achieve but there are a range of behavior change strategies that can help. This paper has described these strategies and illustrated how they can used at each of the 5 steps to weight loss maintenance. It has also highlighted the extra key resource available; the relationship with the patient. Good luck!
Ogden, J. (2018). The Psychology of Dieting. Routledge: UK
Written by ACA Contributor Dr Jane Ogden BSc, PhD, CPsychol
Jane Ogden is a Professor in Health Psychology at the University of Surrey where she teaches psychology, vet, nutrition, dietician and medical students to think more psychologically about health. Her main research areas are eating behaviour, obesity management and parenting around food. She has published 7 books including ‘The Psychology of Eating’; The Good Parenting Food Guide’ and ‘The Psychology of Dieting’ (due out Jan 2018) and over 180 research papers. She is a regular contributor to the media in terms of radio, TV, social media, magazines and newspapers and is passionate about making research accessible for a lay audience.