Changing Environments for Healthy Habits: Uncertainties and Challenges

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1 Changing Environments for Healthy Habits: Uncertainties and Challenges Theresa Marteau University of Cambridge Catalina August 2017

2 Changing Environments for Healthy Habits I. The Problem II. Changing Behaviour i. changing minds (targeting conscious processes) ii. changing environments (targeting non-conscious processes) III. Changing Environments to Change Behaviour i. uncertainties ii. challenges

3 The Problem = Our Unhealthy Behaviour Ø 63% premature deaths worldwide Cancer Cardiovascular disease Diabetes Ø Eliminating these would prevent: 75% of Diabetes and Cardiovascular disease 40% of Cancers AND reduce health inequalities by about 50%

4 Our Unhealthy Behaviour in the UK in the USA 17 % smoke 15 % 25 % drink at harmful levels 23 % 65 % overweight or obese 74% 95 % inactive 80%

5 Changing Environments for Healthy Habits I. The Problem II. Changing Behaviour i. changing minds (targeting conscious processes) ii. changing environments (targeting non-conscious processes) III. Changing Environments to Change Behaviour i. uncertainties ii. challenges

6 Risk Information: Not Personalised

7 Risk Information: Personalised

Risk Information: Personalised Does this

risks does not change behaviour to reduce

8 Risk Information: Personalised Does this risk information change our behaviour? From 18 studies... Communicating genetic-based disease risks does not change behaviour to reduce these risks Hollands, French, Griffin, Prevost, Sutton, King, Marteau BMJ 2016

9 Targeting Conscious Processes Personalised Risk Information Four Reviews.. I. Any disease - Genetic biomarkers Hollands et al BMJ 2016 II. III. IV. Cardiovascular disease - Any biomarker Usher-Smith et al BMJ Open 2015 Cancer - Any biomarker Usher-Smith et al under review Any disease - Any biomarker French et al Ann Behav Med 2017 Little or No Behaviour Change

Perception of Threat Not big enough Behaviour Even if

10 Why doesn t risk information (always) change our behaviour? Less effective Information More effective Information Perception of Threat Not big enough Behaviour Even if motivated to change Environments have a strong influence on much of our behaviour

11 Keep in Mind Essentially, all models are wrong but some are useful George Box 1989

12 Dual Process Models of Behaviour Environmental Cues behaviour Non-conscious Fast Feeling Habits Conscious Slow Thinking Goal-directed behaviour Strack & Deutsch Pers Soc Psych Rev 2004 Bari & Robbins Prog in Neurobiology 2013

13 Changing behaviour: Two broad approaches Targeting Conscious Processes to. Resist Environments Targeting Non-Conscious Processes by Changing Environments

14 Environmental cues shaping our behaviour without awareness Social judgements & warmth of drink Voting & ballot order Wine buying & music

15 Cues in Environments Shaping Behaviour SIZE PRESENTATION Properties of objects or stimuli FUNCTIONALITY INFORMATION AVAILABILITY Placement of objects or stimuli Hollands et al BMC Public Health 2013 Hollands et al Nature Human Behaviour 2017 POSITION

16 Cues in Environments Shaping Behaviour.to reduce consumption of Food, Alcohol and Tobacco

17 Size

18 Size g = 85 calories g = 95 calories Eating a sandwich for lunch every day in 2013 is 7,300 calories more each year than in 1993

19 Plate Size inch inch inch inch

20 Size: Systematic Review Aim To estimate the impact of different portion, package or tableware sizes on selection or consumption of: food alcohol tobacco 72 studies

21 Size: Effect on Food Consumption The larger the portion, package or tableware, the more people eat...regardless of body weight or gender...which means... Hollands, Shemilt, Marteau, Jebb, Lewis, Wei, Higgins, Ogilvie 2015

22 Size: Effect on Food Consumption Making sizes smaller for all foods and tableware on all occasions could reduce energy consumed by up to: 16% in UK adults = 279 calories a day 29% in US adults = 527 calories a day

Tableware: larger = serve more Capacity Perception Size cues

23 How does Size cue Consumption? Size cues how much we take o Pack size: larger = take more o Tableware: larger = serve more Capacity Perception Size cues how we eat or drink Delboeuf illusion o Small portions & tableware = smaller bites & sips

24 Portion Size Effect: Bottomless soup bowl experiments Evidence = largely outside of awareness Refilled vs Normal bowls Ate 73% more soup (14.7 vs. 8.4 ozs) Perceived ate same (5.4 vs. 5.4 ozs) Rated fullness same (5.1 vs. 5.7) Wansink, Painter & North Obesity Research 2005

25 Size and Alcohol

26 Size of wine glasses in England Zupan, Evans, Couturier, Marteau under review 2017

27 Wine Glass Size: Impact on Consumption Bar & Restaurant in Cambridge Pint Shop Common Serving sizes 175 ml 750 ml (bottle) Series of 2 week periods alternating glass sizes A Standard glasses B Larger glasses C Smaller glasses Larger Standard Smaller Pechey, Couturier, Hollands, Mantzari, Munafo, Marteau BMC Public Health 2016

28 Wine Glass Size: Impact on Consumption Bar & Restaurant in Cambridge Pint Shop Wine sales 14% higher when 175ml served in Larger glasses Larger Standard Smaller Pechey, Couturier, Hollands, Mantzari, Munafo, Marteau BMC Public Health 2016

29 As you would imagine, we ve started using the larger glasses, which I know wasn t the reason behind the study from Cambridge University s point of view. James Hickey, Pint Shop

30 Internal and External Influences on our Behaviour Environmental Cues behaviour Non-conscious Fast Feeling Habits Conscious Slow Thinking Goal-directed behaviour

31 Changing Environments for Healthy Habits I. The Problem II. Changing Behaviour i. changing minds (targeting conscious processes) ii. changing environments (targeting non-conscious processes III. Changing Environments to Change Behaviour i. uncertainties ii. challenges

32 #1 Uncertainty Cues to Target for Greatest Enduring Behaviour Change

33 Cues to Target for Greatest Enduring Behaviour Change i.e. healthy habits? I. Building the Evidence Base on Physical Environments i. Field & Lab Experiments ii. Evidence synthesis II. Integrating Evidence using a Complex Systems Perspective i. Cues from the multiple environments we inhabit - Ø physical, digital, economic, cultural, social and many more ii. Acting singly and in combination iii. Evaluated without assumptions of simple linear causal relationships

34 Complex Systems: e.g. Obesity System Influence Diagram Obesity UK Foresight Report 2007

35 Changing Environments for Healthy Habits I. The Problem II. Changing Behaviour i. changing minds (targeting conscious processes) ii. changing environments (targeting non-conscious processes III. Changing Environments to Change Behaviour i. uncertainties ii. challenges

36 #1 Challenge Changing Cues in Our Environments

37 Our Environments Public Sector Private Sector

38 Policy options for changing behaviour Eliminate Choice Levels of Intervention Restrict Choice Taxation Change Defaults Effective Provide Services Provide Information Acceptable Diepeveen, Ling, Suhrcke, Roland, Marteau, BMC Public Health, 2013

39 Acceptability of Interventions to reduce consumption of sugary drinks Acceptable % Predictors of Acceptability o Perceived Effectiveness o Perceived Fairness o Environments cause obesity 0 Size Shape Location Taxation Education Petrescu, Hollands, Couturier, and Marteau PLoS One2016

40 Industry Responses to Interventions to Reduce Consumption Predictors of Acceptability o Perceived Effectiveness o Perceived Fairness o Environments cause obesity

41 Changing Environments for Healthy Habits I. The Problem Four sets of behaviour, socially patterned = most premature deaths II. Changing Behaviour i. changing minds (targeting conscious processes) at best = small, unscaleable effects i. changing environments (targeting non-conscious processes) promising III. Changing Environments to Change Behaviour i. uncertainties cues to target for greatest enduring change ii. challenges legislating for environments for healthy habits

Changing Behaviour: Targetting non-conscious and conscious processes

Changing Behaviour: Targetting non-conscious and conscious processes Professor Theresa Marteau Behaviour and Health Research Unit Centre of Excellence for Public Health Northern Ireland 25 th November