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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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.

23½ Hours

A quick question: can we limit our sitting and lying to just 23½ hours a day?

The Weight of the Nation

HBO’s new mini-series, The Weight of the Nation, is tough to watch in the beginning. The health consequences of obesity are dire and so are the numbers: 68% of US adults and 18% of children are overweight or obese. But there’s hope as well: people are able to change their habits and environments, if they commit to it, have realistic goals and social support, and figure out which changes they can do in their lives.

Incidentally, the CEO of Weight Watchers, David Kirchhoff, just published a book called Weight Loss Boss about his own personal journey in weight loss and, even more importantly, weight maintenance. I got a free copy at Mobile Health conference and I have to say, it’s actually a very good book (despite the obvious promotion of Weight Watchers). He is totally honest about his own failures and bad habits, and there are no magic tricks: it’s just portion control, physical activity, staying away from unhealthy food, and arranging your environment to support healthy eating. Basically:

1. Eat vegetables, fruits, lean proteins, whole grains, and low-fat dairy
2. Avoid junk food
3. Watch portion size
4. Exercise daily
5. Repeat

Kirchhoff talks a lot about environmental influences and he’s been heavily inspired by the research results of Food & Brand Lab. In his book and in his presentation at Mobile Health, he praised a certain Dr. Brian Wansink and his lab of their clever research several times! It’s great that Weight Watchers have incorporated this into their program.

It’s habit and lifestyle change, not willpower or temporary dieting. Small habit changes was really what Mobile Health was also all about – I’ll soon write more about key insights from the conference.

Healthy mind in healthy body

I’ve been going to this improvisation class every Saturday for the last four weeks. It’s been a fun and liberating experience, and I’d recommend it to anyone who sometimes struggles with being too much inside their heads and not being present in this moment. Blurting out the first thing that comes to my mind isn’t something that I usually do, but it’s something that I should do more. Heck, if I reveal my stupidity that way, at least I’m being honest about it.

Another great thing with improv is its physicality – moving around, expressing yourself with your body, interacting with imaginary objects, being a puppet for a puppeteer. I chatted with this white-haired, wise, sarcastic man who’s a social worker in his other life and feels that improv is everything he needs in his work: listening, accepting, being there, having energy. He gave me a great piece of advice: “Any time you feel you’re not present in this moment, do something physical.”

One of the big problems with the work that most people do nowadays is that it is very far from physical. And the problem with exercising after work is that for many people it’s a chore instead of fun. (I sometimes feel that way too, but right now I’d give a whole lot to be able to just run outside and go as far as my body can carry me. Bloody stress fracture.)

So, the last thing I want to do is to develop applications that would encourage people to spend yet more time with their computers or mobile phones. I’d love to encourage people to take a moment to relax, go to spend time with other people, go out and enjoy nature, be aware of their surroundings, and do something good for the sake of doing good. And try not to destroy this beautiful planet.

The planet is really beautiful.

We often talk about saving time. We eat fast food and ready-made meals, drive cars instead of waiting for a bus, shorten words in emails, fly instead of taking a train, make up excuses to end conversations. But what are we saving that time for? Everyone’s still busier than ever – trying to make more money to keep up with the Joneses. Fargo, the excellent (albeit gory) film by Coen brothers is an extreme example of the horrid things people can end up doing just to get more money. Shallow Grave is another one, on a smaller scale.

But I digress. It’s becoming a bad habit. I was going to talk about mental well-being, which in a nutshell is composed of three things: feeling that you’re doing what you want to do (and knowing what that is), being supported by other people, and feeling confident and satisfied with yourself. (Some may recognize the similarities to the three basic needs in Self-Determination Theory – it’s not a coincidence.) I think that if people feel good about themselves, then it doesn’t matter if their physical health isn’t super-fantastic.

Mental health predicts physical health in teens, according to this study.

Depression and anxiety are starting to be as serious problems as obesity in terms of societal burden. Also, they are linked to obesity: depressed people are 60% more likely and anxious people 30% more likely to be obese than those without either of the disorders. Reasons? Common socioeconomic and perhaps hereditary risk factors, topped with physical inactivity and emotional eating triggered by loneliness and low mood.

Depression and anxiety are relatively easy to treat, I’ve heard. That’s why they should be screened out among obese people. Nutrition counselling and exercise programs won’t help if you don’t believe in your ability to achieve results, if you don’t see any reason to try, or if you don’t have anyone who cares.Online interventions for depression and anxiety could help enormously with this population, but I don’t know if they’re used in such a way yet. Anyway, some programs that are in real clinical use include:

• FearFighter (anxiety, phobia, panic attacks). Used in UK since 2006, recently launched in Denmark and the Netherlands.
• Beating the Blues (depression). UK since 2006.
• CRUfADclinic (depression, anxiety). Australia.

And probably more, but can’t think of them right now. These require a clinician’s referral. In Australia (and in the whole world, actually) there’s also eCouch which is open for anyone. They have modules for depression, anxiety, social anxiety, relationship breakdown, and loss & grief. That’s a pretty good selection already.

So. I said I don’t want to encourage people to spend more time with their computers, but going through programs like these can be a great help and a good first step for people with depression or anxiety. Unwarping warped thinking requires some guidance and processing.

Now, why don’t we have programs like that in Finland yet?

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.

Stress and obesity

I like walking to work every day, especially because I can see and hear something like this on the way. The sound of flowing water is music to my ears. Even though I didn’t actually grow up next to a river or a lake, I’ve always found that being close to water soothes my nerves, and swimming in a lake is one of the most relaxing things for me.

I’m not the only one who feels that way: exercising outdoors actually is better to mental well-being than indoor activity. More importantly, contact with nature enhances overall well-being and relieves stress.

Why is this relevant in terms of healthy eating? Well, for one, stress and obesity have a strong link. Stressed people not only tend to have unhealthier lifestyles (such as too much snacking and junk food, too little exercise), but their metabolic system also seems to respond to stress by starting to conserve more energy. And sleep deprivation, which usually goes hand in hand with stress, messes things up even more: it distorts hormonal balance and makes you want to eat more. The poor body is in the state of alert and tries to prepare for potential dangers ahead.

Simply put, not sleeping enough makes you stupid, slow and fat.

The good news is that getting enough sleep and learning to manage stress in a healthy way returns the body to its normal state, making it easier to lose those extra pounds. Everyone can learn to relax, focus on the present moment, and take time to do things that they truly want to do. One example of this is mindful eating: eating slowly and savoring the tastes, appreciating food and also its production and preparation processes.

Technology can support people in the initial steps of learning. For example, mobile intervention programs with 2-4 weeks duration can teach simple relaxation and mindfulness techniques, and provide tracking tools that increase users’ awareness of their behavior and its consequences. Kinda like a low-cost personal coach in your pocket.

So, that’s what I would like to do. Develop such interventions that motivate and help people get started, establish some new habits, and find their own way towards their good life. I don’t think that these kinds of applications should even aim for long-term usage,  except for periodical check-ups to see if users have fallen off the track and need some encouragement to pull themselves together again.

Saving the world

While waiting to get my hands on an extremely interesting dataset, I’ve had some time to generate ideas and check if someone else has already implemented them. Most of the time that has been the case. Of course, the world is getting so old that there probably are no new ideas anymore lying around to be discovered. Reuse, recycle – that’s a virtue too.

Anyway, I happened to come across an article that struck a chord in me: “Save the world, prevent obesity” by Thomas N. Robinson. He talks about social and ideological movements with behavioral goals that can also help to prevent obesity. For instance, the growing awareness of the finity of natural resources has compelled many people to change their eating and physical activity behaviors. The main reason for this is not a desire to be healthier, it’s just a side effect of the changes that are driven by ideology.

For example, not all vegetarians are vegetarians just because they think that animals are too cute to slice and dice, or that animals taste bad. Some avoid eating meat because it takes about nine times more energy to produce a pound of (red) meat compared to vegetables, grain, beans, or seeds. Ethics and health (for intensively produced meat; the thought of digesting something that’s been stuffed with antibiotics and hormones isn’t particularly enjoyable) are just additional factors that make it easier to stick to the decision. Similarly, walking and using public transportation can be means to keep the carbon footprint small. Increase in physical activity is a nice side effect.

People aren’t motivated by their personal health until they’ve lost it, as we’ve known for a long time. Our values and other interests play a much bigger role in determining what we choose to do every day and how we prioritize things. After all, health is just your own responsibility, whereas pursuing other values usually have social and societal consequences. So, focus on saving the world (without going to extremes) and you save your health too as a by-product?

The cause that you are fighting for doesn’t necessarily have to be environmental sustainability or social justice. For instance, taking care of kids’ healthy eating is an extremely valuable goal, and that’s what these guys at Smarter Lunchrooms are doing. I think it’s great how they’re truly improving population health with simple, low-cost changes.

UPDATE August 2017: Five years later, it seems that Smarter Lunchrooms isn’t the silver bullet it was claimed to be, and the research about it hasn’t been reported objectively. See, for example, http://reason.com/blog/2017/08/29/junk-science-behind-smarter-lunchrooms.