ISBNPA 2013: Sustainable diet & environmental changes

Halfway through the Annual Meeting of the International Society for Behavioral Nutrition and Physical Activity (ISBNPA 2013), jotting down some impressions and ideas from the conference so far. A more thorough report later on.

• Individual behaviour change should never be the only goal. It’s not enough. We need to change the environment in order to have lasting effects. It’s a long process, but meanwhile, we can help people cope with the environment.
• Translational part in experience sampling and photography studies that examine environment-health relationships is missing. Most of the world doesn’t live in environments like this.
• Theory-based instead of theory-inspired: systematic process of linking theoretical basis to the actual implementation and evaluation. Too many intervention studies don’t use theory properly.
• Program adoption and maintenance is also an intervention: adopters and maintainers need to change their behaviour and be sufficiently motivated to do it.
• We’re all hypocrites in terms of sustainability. How can you advise anyone to eat fish? If all seven billion people on this planet eat sustainably caught fish, it will all be eaten within a year.
• As European consumers, food is the single biggest impact on ecosystem that we are responsible of. Need to think about the entire production chain.
• Autonomy-supporting approach is not a bag of tricks to make a person motivated. It’s a sincere interest and curiosity in the person, a sincere desire to help and support.
• Many say “we don’t want a nanny state, we don’t want government controlling food prices”. But right now we are controlled by big corporations and retailer chains. Is this better?
• We can change the system. And we can change the world.

There is a clear message that environmental changes should be the main focus and the food system needs to change. Climate change is a driver for a more sustainable lifestyle – which also means healthy AND sustainable diet.

This is also the most health-promoting conference I’ve been to. Encouragement to stand up for applauses, standing lunches, small portion sizes, 5-minute walking distance between two conference sites (and two such walks scheduled in the program every day), stair-climbing, fruit for dessert and at coffee breaks. Best attempt in “practice what you preach” so far in academia, although strawberries hardly are the most sustainable thing to eat in May.

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Research in Spotlight

NIH spotlight of Brian, shot at the Science & Engineering Festival that we were at in Washington DC in April. Good stuff.

Techno-bullying

Troublesome news about school lunches that follow the new nutritional guidelines in the US:

• Kids throw fruit and vegetables away and buy junk from vending machines instead. They claim that they go hungry with new school lunches, even though calorie content is about the same.
• Kids who qualify for free school lunches sometimes don’t take it at all because they want to avoid social stigma. Well-off kids take pictures of them and post them on Facebook, ridiculing their economic status. As a result, many kids go hungry and don’t get the nutrients they need.

I do hope that the first problem is solved with a little bit of time. Seems to be a full-blown manifestation of psychological reactance and initial rebellion. Also, it would be great to get rid of those vending machines at schools. Choice architectures – if it’s available and accessible, it will be eaten. Smarter Lunchrooms stuff needs to be used to make those vegetables seem less “gross”.

But it is sad to know that tons of vegetables and fruit are going to waste. Darned cool kids and their poisoned taste buds.

From Punny Business

The second problem, technology-mediated social ostracism, is even more heartbreaking. Having been a target for ostracism in my middle school days, I feel lucky to have survived my teenage years before social media. It’s bad enough to hear derisive comments about one’s value as a person during school hours, but I imagine it must be thousand times worse to see those comments posted online with pictures that may or may not be photoshopped. Even if you have a tough skin, it is quite a lot to handle. Especially if there is really nothing you can do about the circumstances.

Obviously it’s not social media that’s to blame. It’s just a tool that can be used for good or bad. The troubling part is the phenomenon of bullying in itself. I feel that children should learn to understand and respect where food really comes from, and learn to understand and respect their fellow human beings as well. All horrid deeds in human history have started with someone deciding that they are better than other people.

In Finland, it’s free lunch for everyone, regardless of socioeconomic status. It doesn’t solve all problems, but at least it makes people more equal.

SNEB 2012

I attended the Society for Nutrition Education and Behavior Annual Conference in Washington DC July 13-17. This is a brief summary about the conference in general and the main themes that stuck with me, even two months after the conference. The summary of the conference proceedings and many of the presentations are available here.

The garden behind the hotel was a place for quiet, relaxing moments.

As a sidenote: it’s somewhat embarrassing how it’s taken me ages to get this done. Reuniting with my significant other and having a summer vacation right after the conference was wonderful, but it caused this to get stuck midway in the priority pile. Still, better late than never.

Conference

Almost 600 people participated in the conference this year, making the attendance the highest in the past ten years. I might be biased, but I’m inclined to think that one of the reasons was the current president, no other than Brian Wansink. He has the skill to breathe energy and enthusiasm into anything he touches. And based on the talks I had with various conference attendees, the research that Food & Brand Lab does is generally considered not only quirky, but very interesting, original and practically useful as well.

Interest in practical usefulness was apparent in the audience demographics: in addition to researchers, a lot of dieticians, cooperative extension people, and health promotion program planners were present. Exhibition booths included potato and wheat promoters, developers of engaging educational materials, cancer researchers and so on.

Exposing kids to oranges and cantaloupes!

All in all, everyone’s focus was on practical and actionable things in nutrition education and behavior change. The overall theme of the conference was synergy, which encouraged people to find ways to collaborate and benefit from each other’s expertise. I think that the most inspiring thing for me was just talking with all sorts of people and feeling the empathy, enthusiasm, and the drive to learn and to make real changes. Feeling that others genuinely cared about people’s well-being and wanted to make a difference.

Community partnerships

Building partnerships was the focus of several sessions and talks. Not only partnerships between researchers and health professionals, but engaging the entire community: universities, schools, community organizations; researchers, students, activists, educators, parents, farmers, daycare centers, chefs, churches… the list goes on. Two centers, one from west and one from east coast, presented their visions and modes of operation.

• Center for Nutrition and Activity Promotion bridges disciplines to help people eat healthier and be more active.
• Center for Health & Risk Communication works with communities to promote health and social justice.

Both centers started by collecting the resources that were already available and expanded from that. They develop, implement, and evaluate health promoting services, using a lot of students to do the practical work. This is great for everyone: students get practical experience and a taste for civic engagement, researchers are able to focus on coordinating and evaluating, and community members are approached from many directions.

I participated in an exercise to create a network of partners in local community to achieve the objective of a given project. We were encouraged to think outside the box to identify organizations and companies that could be involved, such as grocery stores, environmental activists and so on.

It would be really great to get students more involved in Finland as well, to create actual health promotion projects. Small-scale, of course (at least at first), but it would have been awesome to do something real instead of just writing essays when I was a student.

Simple and cheap

One of the recurring themes was the need for simple and cheap tools to promote healthy choices, as well as the need for healthy choices themselves to be simple and cheap. The first person to talk about this was Sam Kass, the White House chef and advisor in Michelle Obama’s Let’s Move! initiative, which has the goal to reverse childhood obesity. One of the aims is to give parents easy, understandable tools that help them make healthy choices for their kids.

Another example that stuck in my mind was Leon T. Andrews’ “Healthy Cities for a Healthy Future” talk where he showed a series of pictures of a gradual transformation of a cross-section in a city: starting from a barren scene with no sidewalks or biking lanes, ending with a charming pedestrian-friendly cross-section with trees, flower beds, wide sidewalks, crosswalks, clear traffic signs and an entire street devoted to pedestrians. The point was that not everything has to be done at once, it can start from just adding a crosswalk and pedestrian traffic lights, and slowly become so that the entire environment encourages walking and biking instead of driving.

Besides, it makes sense to keep children active and give them nutritious food.

• Healthy kids = better students
• Better students = healthy communities
• Healthy communities = healthy future

The advantages of synergy and partnerships are clear from this perspective as well: what is simple and cheap for one person can be very difficult and expensive for another. That’s why it is crucially important to find the right person to work with. Sharing tips, tricks, experiences, and best practices is equally important. That’s really what education is also about. Technology can help a lot if it’s done right for the target group’s needs and fits into existing routines reasonably well.

Leon T. Andrews is from ChangeLab Solutions, who have collected lots of tools and policies on their website. For example, they have a toolkit for advocates who want to work with city planners to create healthier cities. Maybe something like this could be made more interactive to make it easier for ordinary people to figure out some basic things they could also do to help a little?

International perspective

I met several other international participants in an evening reception and in the International Division meeting. No one else from Europe, though. There was a wonderful woman from Argentina who had started her own initiative to develop educational materials and programs for schools to promote healthier eating and physical activity. She was extremely interested in how to leverage technology to lessen the need for people to travel around teaching, but the problem in Argentina is that schools don’t usually have Internet connections or computers for children. We came to a conclusion that the best way to start would be to develop a DVD for those schools which at least have computers on-site.

Other interesting perspectives included an energetic South Korean woman’s story of the country’s journey of advancing from malnourishment and poverty after the Korean war to being the 11th strongest economy in the world, and a woman from New Zealand who was doing her PhD in food literacy and how to measure it. Food policies in different countries and the sustainability of the entire food systems were also discussed critically.

And I just love hearing different accents from around the world!

Talking about weight

Rebecca Puhl from Yale Rudd Center and Dianne Neumark-Sztainer from University of Minnesota made compelling cases against dieting and weight stigma. Puhl presented research results that demonstrated how obese children are 63% more likely to be bullied, largely because overweight characters are always portrayed in a negative way in children’s media. It’s an awfully big problem because weight-based teasing easily leads to social isolation, lower performance at school, depression or anxiety, and less physical activity. Also, teachers and parents look at obese children more negatively. All this obviously results in increased emotional eating, which makes the original problem worse, which leads into more emotional eating and… you get the picture.

Neumark-Sztainer talked about dieting in adolescence and presented findings from longitudinal studies which showed that dieting predicted binge eating. Stopping a diet was not associated with greater weight gain than persistent dieting. So, diets don’t really work. Instead, I think that helping people form new small habits is the way to go. Figure out what the person can do and how s/he could do it.

We need to be able to communicate with anyone in a sensitive, respectful manner. Health at Every Size approach makes a lot of sense, especially since exercise really should be fun, stress-relieving, energizing activity instead of a dreary obligation.

My posters & technology

I presented two posters about predictors of adherence and water intake advice. Dieticians were more interested in water, researchers more in adherence. I discussed the importance of self-efficacy and mental well-being with a couple of people and got a reference to Ellyn Satter’s Eating Competence approach, which focuses on two aspects in healthy eating, which make a lot of sense:

• The permission to choose enjoyable food and eat it in satisfying amounts.
• The discipline to have regular and reliable meals and snacks and to pay attention when eating them.

Technology had a relatively small role amidst policies, education programs, partnerships and environmental influences. That is perfectly fine, I think. Nevertheless, a couple of posters focused on mobile applications and tablet games aimed for children. There was also a session about enhancing your presence in social media – how to best use Pinterest, Facebook, Twitter, LinkedIn and blogs. It seems to be pretty essential nowadays to have social media presence, but sometimes I wonder how fragmented our time (at least mine) becomes when we start following all these things.

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Recreation

It was so hot that I couldn’t really spend a lot of time outside without melting into a puddle. Nevertheless, we managed to get some walks in. The main attraction nearby was the National Zoo, which held animals from almost all parts of the world. Still, it just doesn’t feel quite right to keep living things imprisoned, even though giant pandas would probably be extinct without zoos by now. What affected me the most was seeing gorillas that were munching on snacks looking bored, orangutans trying to make their beds more comfortable by fluffing up the pile of hay, and other primates leading quiet family lives. Those guys looked just like humans, and I wondered why I was on this side of the bars and they on the other side.

Father’s taking a nap while mother’s nursing the baby.

We also went to see an eating disorder play called “Breaking Up With ED” with a colleague. ED is this nasty fellow who barges in uninvited and generally makes everyone miserable. The play was touching and funny, with monologues from various different characters, either suffering from eating disorders themselves or watching someone else’s suffering.

Next year

Next year’s conference will be held in Portland, Oregon, the healthiest and greenest city in the United States. Apparently, the founders of Portland were cunning fellows who wanted to attract more businesses, so they decided to make downtown blocks only half of the length of standard city blocks. As a result, the city is very pedestrian-friendly.

Apps ad nauseam

This is some sort of a Sunday-evening rant. Be warned.

I’ve spent several hours browsing all sorts of apps and devices for health-related goals, and right now I don’t want to see or try out any of them. I guess I reached the saturation point. Who are the intended users of these thingamabobs? Surely not the ones whose need for intervention would be the highest.

Mothers who struggle with budget and time constraints, trying to do their best to keep themselves sane while preparing food for their families and working two jobs. Businessmen and -women whose days are filled with one meeting after another, sitting in cars and airplanes, grabbing food where it’s available and entertaining clients over one drink too many. And lonely, depressed teenagers and adults who try to fill their emotional voids with food and end up feeling even worse, triggering another binge to relieve their self-disgust.

It is difficult to understand the worlds that other people live in, let alone design fancy gadgets that could help them change their behaviors (if they could afford them or be bothered to try them out). Unhealthy diet and lack of exercise are often just symptoms of deeper-lying issues. Somehow, the simple idea of eating food has become incredibly complicated.

Let’s say that the (obese or at-risk) population can be split into three groups: first group lacks awareness of healthy habits, the second lacks the abilities, and the third one just isn’t motivated. All groups can to some extent be nudged with upstream interventions that make healthy options more available, appealing, and affordable than unhealthy ones. However, downstream interventions that target individuals need to be tailored to their personal needs. And those needs can be really complex. (For instance, the need for cognition. Mine is pretty high, which works against me sometimes – I usually want explanations, it’s not so easy for me to just go with the flow and intuitively follow suggestions or hunches.)

I’m looking for solutions that could work in the real world and actually reach people in need. I think that one channel really can be social media – probably not Facebook, but other online communities which provide a tight social group with similar goals, intimate understanding of problems, and emotional support. We are herd animals and like to flock together. Now, lot of people just lurk on online forums, taking information in but not posting anything themselves. If we would advertise suitable applications among these communities, perhaps we could reach a part of the lurker population. These suitable applications should obviously be effortless to use, somewhat entertaining, and emotionally engaging. Stories are powerful persuaders, and social support is something almost everyone craves.

Not saying that trackers and self-monitoring apps don’t have their place. Of course, a part of the population benefits from habit trackers that serve to increase their awareness of their nutritional intake, activity level, sleep quality and so on. However, most applications assume that people are rational and can change their behavior based on this new self-awareness. For some people, calorie counting and tracking may just feed their obsessions about their diet and weight, when they would in reality need to become more aware of what’s going on in their mind.

I’m not a mental health expert. I’m just someone who’s experienced her share of stress, loneliness and anxiety, and also struggled with sensible eating at some point. And I would like to understand why human beings make their lives so difficult sometimes.

School Meals and Freedom of Choice

Having learned so much about school lunchrooms in the US, I started wondering how things are in Finland nowadays. A quick search in Google Scholar resulted in a couple of articles. One of them was about free school meals and food choices, based on empirical data collected in 2003. They only did questionnaires, not measuring plate waste – waste measurement would probably be quite difficult, since food is self-served. Anyways, they found that a large portion of students weren’t following the plate model and weren’t eating a balanced meal.

School meals have been free in Finland on all school levels since the late 1970s. This could be one cause of Finland’s excellence in the PISA survey. However, the problem is the same as in other countries: students don’t eat everything they should be eating. Another challenge is producing a healthy, balanced meal with very little cost (on average, a bit more than 2 euros). This challenges ties into the first problem, since students’ favorite foods are usually not the ones that would be recommended by health promoters. (As this Finnish news article shows.)

It’s interesting how kids – and adults – develop the simple heuristics based on which they select food. Parents and other adults are obviously important role models, but it can also be those simple things like the color or the shape of the package (“I hate blue, not gonna drink from a blue carton!”) that makes the difference. Understanding of nutritional needs and health effects doesn’t come into picture until later, if ever. In any case, force-feeding kids something that they don’t want to eat and taking away their freedom to choose is not going to work. It doesn’t work for adults, either. Psychological reactance. Nudging towards healthier options and making them more appealing is the better route to go, even if it seems slower.

Role models could also tell how you should *not* act. Just be careful that they don't backfire. (Poster from the great Demotivators collection.)

On a not food-related note, I stumbled upon LEGO Learning Institute’s paper about optimal learning in school. They say that Finland and Denmark could combine the best of both systems – Finland knows how to teach kids to read and do math (regardless their socioeconomic background), but Denmark is better in fostering collaboration and well-being at school. It’s true that the emphasis in school curriculum has been more on the learning and less on the doing together, although I hope that today’s teaching methods are starting to emphasize the latter. That seems to be at least partially the case based on what I’ve heard from my sister (she’s studying to become a teacher, and a great one she’ll be!)

Finally, in the words of Michael Pollan: Eat food. Not too much. Mostly plants. It’s sort of the quote from Arvo Ylppö, “Everything within reason”. The problem with this advice is that people are not that reasonable.

Plate Wasting

My first field trip was last Wednesday to a local elementary school, where we went to measure plate waste after school lunch. We waited in the area where kids usually come to leave their trays, intercepted them and marked down the amount of leftover food/liquid for each item on a tray (none, 1/4, half, 3/4, all). This method of measuring plate waste is called visual estimation, and it’s been shown to correlate closely with waste measured by weighing. It’s also much quicker, more convenient, and so easy that even I could do it.

It was sad to see such an awful amount of food going to waste. I didn’t really mourn that much about things that weren’t proper food such as chocolate milk, rainbow-colored sugary yogurt, or hamburger buns, but I hated throwing away apples that were left untouched, dumping vegetables into the bin, or pouring away unflavored milk. The small comfort is that most of the things went into the compost bin – at least they will be recycled somehow.

Lunch was quite different from what I recall in my hazy memories about elementary school: here, almost everything was pre-packaged and there was no water, just juice and milk. In my school, we had a lunch lady who served us food on our plates, and we could regulate the amount of serving by saying “just a little” or “a lot”, depending on how hungry we were that day. Of course, that’s probably something that varies from school to school both here and in Finland.

It’s been a long time since I’ve been around so many kids at the same time. They were pretty cute (although noisy) and most of them looked healthy and normal-weight. Some of them seemed quite smart and inquisitive, too. One girl was especially interested in what we were doing. She told us that she had eaten everything on her tray, and said that her mother instructs her to only take what she can eat. She also had critical comments about high sugar content in food and unnecessary wasting by throwing away unopened cartons.

There was also some gender-questioning, since my male workmate had a ponytail. We had to answer tricky questions such as “If you’re a girl, why do you have short hair, and if he’s a boy, why does he have long hair?” and “Are you both girls?” I hope we managed to challenge some of the stereotypies they’ve already developed.

Bits and pieces

Some pickings from other blogs:

• Dan Ariely’s new paper says that asking people if they want to downsize their portions is much more effective than calorie labeling in helping people not to overeat. In general, making people stop and think before they make a decision is better in changing behavior than merely providing information. (I think that calorie labeling might be ineffective also because the information is too difficult to interpret. You need to put your brain to process it and make calculations in order to understand what it really means. And even then, it’s still a big step to actual behavior change.)
• Stories are persuasive because they are easy to understand and empathize with. Engaging stories sweep you away and you forget to pay attention to the fact that the narrator is subtly trying to make you shift your attitude. I wish I could learn to write like that – with good intentions, of course. There’s a book called “Made to Stick” in which they presented an acronym that stuck with me. SUCCES: Simple, Unexpected, Concrete, Credible, Emotional, Stories. The more you have of those in your message, the more likely it is to penetrate in your audience.
• Educate parents to prevent children’s obesity. Parents and schools, they’re the main gatekeepers and habit establishers, and therefore the primary targets.

And an opinion piece in LA Times written by two wise men in the Lab. Don’t take all choice away, or you’ll invoke reactance.

January’s crops

The first three weeks have flown by really quickly, so time to pause for a moment and see what I’ve done and planning to do at the Lab. Believe it or not, I’ve been trying to get work done too, not just running around applying for social security numbers, fixing myself a bike, and chasing squirrels!

Mindless Eating Challenge data. I’m currently analyzing what kinds of eating tips are effective for people who want to lose weight. For instance, is it better to ask people to change their physical environment or eating habits, or rely on their willpower? (I personally think that in the long run, all are needed – it’s good to eliminate some of the temptations, but being mindful of what and how one eats is also necessary.)

The dataset consists of about 2000 people who participated in the online National Mindless Eating Challenge a few years ago. Each participant got three eating suggestions that were based on the research done over the years in Food & Brand Lab, and was advised to follow these suggestions for a month. Basically, like this.

The tips are meant to be easy and simple, since small sustainable changes are better than large ones that cannot be sustained, both on individual and population level. Adding 20 minutes of walking to a day, changing one unhealthy snack to a fruit, eating salad first during meals – they don’t require a lot of sacrifice or effort from a person, but they can work as first steps to a lasting habit change. And throwing in some environmental changes, such as using smaller plates, makes it easier not to stuff oneself.

Now if I can just figure out which tips are the best, and perhaps even find some clues for profiling people who benefit the most from certain types of tips…

Habit change interventions. These are still on the drawing board; I’d love to develop some easy, simple, and low-cost interventions that tackle stress management and healthy eating. Could be something similar to Mindless Eating Challenge, but with the added flavor of relaxation/mindfulness, values clarification, and problem-solving strategies. Improving people’s abilities and self-efficacy as well as helping them make concrete changes. All this on web or mobile platform, of course – not for the sake of technology, but because that’s how it would be possible to reach almost anyone.

Lab experiments. I’m quite interested in emotional eating and eating behaviors under stress, and studying these things in a laboratory setting could provide insight in developing interventions for them. Something like making the participants try to complete impossible tasks to increase their stress level, then giving part of the group relaxation or mindfulness exercise, and finally seeing how their subsequent eating behavior is influenced. You can probably guess what my hypothesis of the outcome is.

Even if nothing earth-shattering would come out of it, it would be good to try my hands on this kind of experimental research. During these first three weeks, I’ve participated in one study (wine appraising – just looking, not tasting, unfortunately) and observed another bunch of small studies to gain understanding in their practicalities. The department has a pretty good lab for running all sorts of studies.

Conferences & publications. I’ll try to attend at least a couple of interesting nutrition-related conferences; one is SNEB in July, another could be APHA in October. Even better if I manage to write something presentable there too! Then there’s of course EMBC, which is so near (well, only on the other side of the continent, not the world) and such a big event that I should probably go. Good chance to meet folks from Finland as well 😉

Aaand, some journal papers will also be written, certainly.

Food & Brand Lab class. Some sort of unofficial studying going on too. Brian and Aner teach a course for undergrads, with the purpose of helping them understand consumer behavior by involving them in research. I’ve decided to participate at least in some of the classes, even though I’m old as grit, since they can provide new ideas and perspectives. This week’s class was already helpful: we used a Q-sort method to form categories for 33 different tips and select interesting comparisons to make.

Gotta say that Brian and Aner are both really smart and incredibly friendly. And the list doesn’t end there; in fact, that description fits everyone in the Lab. I feel I’ve been very fortunate to hop from one wonderful workplace to another.

I also really like the university’s motto by the founder Ezra Cornell: “I would found an institution where any person can find instruction in any study.” Although that’s probably one reason why, apparently, Ithaca is the City of Evil in some people’s books. It’s funny how caring about things such as human rights and environment can be seen in that light.

Anyway, it’s a new month now and lots of interesting stuff to be done. I wonder if it will snow in February… it’s only been a handful of days with snow so far, and it feels a bit unnatural. I was told that Ithaca should have harsh winters, but haven’t seen much of that yet.