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EDITORIAL

DOI: 10.1111/nbu.12001

From awareness to action: Can knowledge about what constitutes a healthy diet and lifestyle be translated into sustainable behaviour change?
Behaviour has been dened as anything a person does in response to internal or external events (Hobbs et al. 2011); therefore, by implication, Behaviour Change requires a change in response to those internal or external events. For the British Nutrition Foundation (BNF), the subject of behaviour change arose following a conference on physical activity held in 2011, which had been developed with the support of an expert group comprising members of BNF council and advisory committees with expertise in the area of physical activity and behaviour change. When the Foundation asked this expert group how it could usefully build upon work to incorporate both physical activity and nutrition into the BNF communications strategy, they suggested that behaviour change should be the theme of the next BNF conference. This culminated in the BNFs 45th Anniversary conference held in June 2012, Behaviour change in relation to healthier lifestyles (summarised in this issue by Wells et al., pp. 1007) and in the production of this special issue, which includes papers from invited speakers at this conference, as well as key opinion leaders/ researchers working in the eld. The Foundation exists to deliver authoritative, evidence-based information on food and nutrition in the context of health and lifestyle, but the ultimate aim of providing this information must be to inuence changes in behaviour that will benet the health of the population. Partnerships that the BNF has with academia, industry, policy makers, health professionals and educators are key to ensuring the Foundation gets expert input from a range of disciplines and that the information it provides is evidence-based and that it is cascaded to those who can use it best and/or those who can benet most. The unique partnerships of the BNF mean that the Foundation can play an important role in ensuring that emerging evidence from academic research can reach practitioners, policy makers and industry partners. Behaviour change in relation to healthier lifestyles is a complex topic but good evidence exists on how behaviour change can be supported. The BNFs 45th Anniversary conference was an opportunity to share this evidence on behaviour change and to debate how we could use this information to translate the evidence on the health benets of increased physical activity and better nutrition into action; that is, what are the evidence-based interventions for successful and sustainable behaviour change in diet and physical activity at both an individual and population level? Around the world, life expectancy has increased (World Bank Group 2012) as a consequence of better control of infectious diseases, whilst the diagnosis and treatment of the big killers such as heart disease and cancer have improved (House of Lords 2005). However, developed and developing countries around the world suffer from high levels of non-communicable disease such as type 2 diabetes, cardiovascular disease and cancer, the risk of which are signicantly affected by lifestyle factors and these are all co-morbidities associated with obesity (WHO 2004). Britain is now the most obese nation in Europe. Health inequalities between rich and poor have been getting progressively worse (HM Government 2011). The majority of the UK adult population is now overweight or obese (NHS Information Centre 2011); have intakes of nutrients such as salt, saturated fatty acids and non-milk extrinsic sugars above recommended levels; and, are not consuming enough bre, fruit or vegetables (Bates et al. 2012). On the other side of the energy balance equation, the Health Survey for England based on objective measures (i.e. accelerometry) found that only 6% of men and 4% of women met recommendations for physical activity, by achieving at least 30 minutes of moderate or vigorous activity on at least 5 days in accumulated bouts of at least 10 minutes (NHS Information Centre 2008).

Correspondence: Professor Ashley J. Adamson, Professor of Public Health Nutrition, Human Nutrition Research Centre and Institute of Health & Society, William Leech Building M1.151, Newcastle University, Newcastle upon Tyne NE2 4HH, UK. E-mail: ashley.adamson@newcastle.ac.uk

2013 The Authors Journal compilation 2013 British Nutrition Foundation Nutrition Bulletin, 38, 14

Editorial

Overweight and obesity represent probably the most widespread threat to health and well-being in the country. Obesity has a profound impact on both the health and wealth of the nation. Excess weight costs the NHS more than 5 billion per year and has a serious impact on economic development. The Governments Healthy Lives, Healthy People: A call to action on obesity in England (HM Government 2011) stated that to tackle overweight effectively, we need to adopt a life course approach, and also called for a balance of effort between prevention and treatment, as well as some support for those who are overweight or obese. Prevention or treatment requires sustained behaviour change, which, in turn, requires evidence on effective strategies for behaviour change. The application of this evidence in the formulation and implementation of health-related policy and conducting of health-promoting practice is critical to success. We live in a time where there is a plethora of information regarding how best to incorporate a healthy diet and lifestyle into our lives. Although large amounts of information may lead to confusion in some areas, it is likely that many people are already aware of what they are supposed to do; for example, the Food and You survey commissioned by the Food Standards Agency found that 99% of respondents said that eating fruit and vegetables was very or fairly important to them, 94% said that eating less salt was important and 92% said that limiting foods high in saturated fat was also important (Prior et al. 2010). The social media campaign Change 4 Life run by the Department of Health in England has achieved high levels of awareness in the population. However, as described by Wyness and OConnor (2013) in this issue (pp. 11519), a study evaluating the impact this awareness had on the behaviour of a group of families with young children found that awareness was not translated into any measureable changes in their behaviour. Indeed, it has been suggested that the public has become so overloaded with health messages that they may be in danger of switching off (Watson & Wyness 2013, pp. 239). Why is it then, that when there is so much information available regarding the need for behaviour change in relation to our diet and physical activity levels, that people do not actually put this into practice? Perhaps the key to understanding this apparent paradox lies with a better understanding of the precise mechanisms behind behaviour itself. In this issue, Atkins and Michie outline lessons from behavioural science in relation to successfully changing eating behaviour (Atkins & Mitchie 2013, pp. 305). The authors describe the COM-B model of behaviour, which states

that for any behaviour to take place, people must have the capability, opportunity and motivation to take action. Considering this kind of framework in the context of a real-life change in behaviour perhaps explains why it is not so straightforward to encourage people to act in ways we consider to be healthy. Taking increased consumption of vegetables as an example, are the UK population clear as to why it is important for them to eat more vegetables? Furthermore, do they actually understand what more equates to; and, do they have the necessary skills to select, prepare and cook them? Do they have ready access to purchase vegetables and can they afford to do so? How are the messages about increasing the intake of vegetables, or indeed, to follow any healthy lifestyle behaviours, transmitted and received in the context of the wider environment, when we are all exposed to an environment where opportunities to enjoy tasty energy-dense foods lie round every corner, advertising promotes promise of joy and contentment and, where physical activity has been engineered out of our dayto-day living? Can individuals motivation be sufciently strong so that they will prioritise this behaviour over and above other competing behaviours? In their article, Atkins and Michie outline the key principles to designing behaviour change interventions, based on current evidence in behavioural science to help ensure that interventions are designed and evaluated according to key principles of behaviour change (Atkins & Mitchie 2013). Trying to halt and ultimately reverse the obesity epidemic is a key priority in public health for the current government Call to action on obesity (DH 2010). The Foresight Report in 2007 identied 108 different internal and external factors that potentially affect energy balance (Butland et al. 2007) and concluded that an energy balance (or imbalance) is determined by complex multi-faceted systems of determinants (causes), in which, no single inuence dominates. It is clear that altering energy balance in order to lose weight and maintain weight loss requires numerous different behaviours within the context of an already complex environment that generally encourages overconsumption and sedentary behaviour; that is, the obesogenic environment in which we all live (Swinburn et al. 1999). In a review of the challenges of sustaining the behaviour required for weight loss and maintenance in this issue, Stubbs and Lavin (2013, pp. 522) describe the need for a transition in behaviour when shifting from a weight loss regime to a weight maintenance phase. For example, increasing physically active behaviours may not be realistic for someone who is obese when rst

2013 The Authors Journal compilation 2013 British Nutrition Foundation Nutrition Bulletin, 38, 14

Editorial

starting to lose weight, but according to the National Weight Control Registry in the United States, evidence suggests that those who are most successful at maintaining weight loss are typically very active individuals (Stubbs & Lavin 2013 pp. 522). Self-management and monitoring were also identied as important behaviours for weight loss (i.e. at an individual level) and these were targeted by Carter et al. (2013, pp. 804) using a smartphone application (app) to record food intake and physical activity. The app provided a daily calorie allowance for users and enabled them to record what they ate and drank, as well as how active they were, providing instant feedback on their remaining calorie allowance. Feedback also included a weight loss chart, total energy intake and expenditure graphs, and weekly SMS updates on their progress, along with individualised tips specic to the users needs (Carter et al. 2013, pp. 804). Interventions in the area of healthy eating and physical activity that include selfmonitoring with at least one other self-regulation technique (such as goal setting, receiving feedback on performance, reviewing goals) have been found to be at least twice as effective as those that did not (Michie et al. 2009). Therefore, novel methods to encourage self-regulation may be a particularly useful tool in future interventions to aid weight loss. Given the variety and scope of papers presented in this special issue of Nutrition Bulletin and also considering the large body of work already established on the theory and practice of behaviour change, it is clear that there is much work to do in this important eld of health-related research. Many questions remain about how best to improve/enhance nutrition and physical activity behaviours for the greater good of the UK population, but perhaps a better understanding of the precise nuts and bolts of behaviour change theory and how best to implement this will take those developing and implementing health-related policy, those working in the eld of nutrition and health, and indeed policy, a step in the right direction. However, as concluded by Foresight (Butland et al. 2007), preventing obesity is a societal challenge, similar to climate change. It requires partnership between government, science, business and civil society.

Professor Ashley J. Adamson Professor of Public Health Nutrition Human Nutrition Research Centre and Institute of Health & Society, Newcastle University, UK; Bridget Benelam Senior Nutrition Scientist British Nutrition Foundation, London, UK.

References
Atkins L & Mitchie S (2013) Changing eating behaviour: what can we learn from behavioural science? Nutrition Bulletin 38: 305. Bates B, Lennox A, Prentice A et al. (2012) National Diet and Nutrition Survey Headline results from Years 1, 2 and 3 (combined) of the Rolling Programme (2008/20092010/11). London, Department of Health. Butland B, Jebb S, Kopelman P et al. (2007) Foresight Tackling Obesities: Future Choices Project Report, 2nd edn. Government Ofce for Science, Department of Innovation Universities and Skills: London. Carter MC, Burley VJ & Cade JE (2013) Development of My Meal Mate a smartphone intervention for weight loss. Nutrition Bulletin 38: 804. DH (Department of Health) (2010) Healthy weight, healthy lives: a cross-government strategy for England. London, Department of Health. Available at: http://webarchive.nationalarchives.gov.uk/ 20100407220245/http:www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/documents/digitalasset/dh_084024.pdf (accessed 7 November 2012). HM (Her Majestys) Government (2011) Healthy Lives, Healthy People: a call to action on obesity in England. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_130401 (accessed 7 November 2012). Hobbs L, Campbell R, Hildon Z et al. (2011) Behaviour change theories across psychology, sociology, anthropology and economics: a systematic review. Psychology and Health 26 (Suppl. 2): 31. House of Lords (2005) Ageing: Scientic Aspects. Report from the Science and Technology Committee: Volume 1. The Stationery Ofce: London. Michie S, Abraham C, Whittington C et al. (2009) Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychology 28: 690701. NHS (National Health Service) Information Centre (2008) Health Survey for England. Summary of key ndings. NHS IC. Available at: http://www.ic.nhs.uk/pubs/hse08physicalactivity (accessed 15 January 2013). NHS (National Health Service) Information Centre (2011) Health Survey for England 2010: Trend Tables. NHS IC: London. Available at: http://www.ic.nhs.uk/pubs/hse10trends (accessed 15 January 2013). Prior G, Hall L, Morris S et al. (2010) Exploring Food Attitudes and Behaviours: Findings from the Food and You Survey 2010. Food Standards Agency: London.

Acknowledgement
The Foundation would like to thank the group of experts from BNF Council and the Scientic Advisory Board: Professors Ken Fox, Janice Thompson and John Blundell, who steered the development of the BNF conference on behaviour change.

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Editorial
Wells V, Wyness L & Coe S (2013) The British Nutrition foundationss 45th anniversary Conference: Behaviour change in relation to healthier lifestyles. Nutrition Bulletin 38: 1007. WHO (World Health Organization) (2004) Global Strategy on Diet and Physical Activity and Health. WHO: Geneva. Wyness L & OConnor (2013) Emerging science. Nutrition Bulletin 38: 1159.

Stubbs J & Lavin J (2013) Weight control and behaviour change. Nutrition Bulletin 38: 522. Swinburn B, Egger G & Raza F (1999) Dissecting obesogenic environments: the development of a framework for identifying and prioritizing environmental interventions for obesity. Preventive Medicine 29: 56370. The World Bank Group (2012) Life expectancy at birth, total (years). Available at: http://www.data.worldbank.org/indicator/ SP.DYN.LE00.IN (accessed 29 November 2012). Watson R & Wyness L (2013) Dont tell me what to eat Ways to engage the population in positive behaviour change. Nutrition Bulletin 38: 239.

2013 The Authors Journal compilation 2013 British Nutrition Foundation Nutrition Bulletin, 38, 14