If you have ever felt exasperated at the resistance to change in personal behaviour that would alter the trajectory of someone’s choices, health and wellbeing, you are not alone.
Hundreds of books, thousands of articles, millions of consultations and trillions of frustrated inner thoughts have been presented as solutions, explanations and disillusionment. So, what we are saying, is you are not alone. Indeed, you may be someone that finds internal rationalising easy and yet finds the momentum needed to change your own behaviour to alter your life’s trajectory impossible – so how do we engage people we have been asked to help to make and sustain positive change?
In part this possibility and aim needs to be reflected by the understanding that health behaviour and associated change or pattern development are not simply regulated by conscious intention – i.e a deterministic set of objectives, but rather that many of these actions are driven by non-conscious and nonintentional processes. Which to simplify greatly means that a desire or intent to beneficially alter behaviour is then disrupted due to a tempting alternative.
We propose that the potential for information-based interventions or simply knowledge driven determinants is fundamentally limited, given that it is based on a view of human behaviour that is at odds with psychological and neuroscientific evidence that much of human behaviour is not actually driven by deliberation upon the consequences of actions, but is automatic. Cued by stimuli in the environment, resulting in actions unaccompanied by conscious reflection.
Here is the crux….. to make change requires the outcome to be achieved without the easy, tasty or socially engaging option getting in the way, in effect the process needs in part to be managed by developing automatic behaviour patterns. Sounds great doesn’t it, simply switch into auto health mode and all adverse distractions will fade away.
You see, whilst intentions have important effects on behaviour, their influence is limited by nonconscious processes that are particularly important in health behaviour, such as habits and impulses, which are hard to control and are triggered by specific situations in one’s daily life. In other words, an action previously performed in a certain context can be triggered automatically by a contextual cue, leading to nonconscious effects on behaviour that may inhibit or prevent change.
You will have observed that throughout our day, we shift between two broad categories of behaviour. On the one hand, we may act in a reflective manner, directing ourselves toward particular goals, aware of our motivations and actions and able to halt or modify them should the need arise. But in other instances, we act without reflection, responding to our surroundings in complex ways while our thoughts may be far removed.
Our current environments tend to expose us to cues that activate short-term hedonic goals, such as indulging in tempting food or drink that provide immediate pleasure. This is often at the cost of long-term investment goals, such as optimising health, introducing and maintaining exercise or stress reduction or controlling alcohol intake for the sake of health later in life. In order to improve the nonconscious regulation of health behaviour, situational cues need to activate situated conceptualisations of long-term investment goals, rather than of short-term hedonic goals only – in effect an unconscious decision-making process that facilitates change in behaviour that is sustainable.
So how can this be applied in the context of a clinical process, where time is short, objectives often wide and inputs highly variable?
The following 5 principles that help convert actions into habits will likely already form part of the motivational engagement you use, but revisiting them in the context of clinical and behavioural objectives may help you and your patient to progress to self-generation of patterns that favour long term health.
- Target the individuals who value the primed goals – by which we mean seek out clear objectives from the person seeking help rather than overlaying your perceived goals on them.
- Tap into the right reasons – seek to connect with emotive and sustainable objectives and then apply intent and establish patterns of change.
- Use effective cues – align their intentions and goals with others who have achieved or are achieving change that fit contextually into their social and environmental circumstances.
- Attract attention at the right time – by which you will help them identify where unconscious triggers currently exist and need goal orientated plans to reset the unconscious experiential events into new positive and beneficial actions.
- Ensure the health goal is possible and desired. – choose an outcome beyond reach or capability and you will set up to fail, build in steps and small positive outcomes that can be measured and qualified.
Turning healthy actions into habit is a desirable target for behaviour change interventions because their well-entrenched and situated cognitive structures allow us to perform a variety of behaviours in our daily lives in an efficient manner, without requiring conscious intentions and awareness. – In simple terms look at your consultations as a habit inducing dynamic, and whilst goal setting is a target, the process of attaining it should, where possible be embedded in the determination of creating persistent supportive habit generation.
If the purpose of your professional life is to induce the induction, management and sustainability of health and vitality, not simply the absence of disease, you must first look in, and then project out.
The establishing of a core set of principles that shape, and in part define who you are will be determined by various intersecting influencers, life related experiences and the learnt or inherited ability to critically review and appropriately contextualise these values.
Once propagated and set on a path of evolution there is an inevitable temptation to transpose these personal experiences onto the person seeking your guidance.
Of course, many of the core elements linked to functional and lifestyle medicine are immutably transferable, but are they the primary point of mutual agreement? By which I mean does the deterministic element of knowledge transfer (perceived or real) overlay reflect that needed by the recipient, when in many cases listening to their story and then retelling it allows far more effectively for a mutual path to be elucidated.
For while primary prevention is a desirable aim, people attending your consultation room are often not adequately motivated by the possibility of future pain (physical or emotional), which in part accounts for why lifestyle as ‘medicine’ has not been willingly embraced across multiple disciplines.
Albeit that is slowly changing as the landscape of the 20th and 21st centuries have seen big changes in the nature and prevalence of disease. The shift, as you are only too aware has been from a predominance of infectious diseases to a predominance of non-communicable, chronic diseases; a cross-over now accepted as an almost inevitable ‘rite of passage’ in advanced and increasingly in emerging market economies.
However, individuals are motivated by present pain or loss of function, and a growing body of evidence is showing lifestyle interventions to be efficacious for the management and, in some instances, treatment and reversal of chronic conditions – that is, for secondary prevention.
So, the dialogue between yourself and the recipient is of course predicated on the idea of a shared decision making, yet as you know many seeking help are lost, unable to find a way forward, for a multiplicity of social, personal, economic, educational and psychological reasons. For every rational motivated person that presents the majority of the others are in a state of seeking – by which I mean they need a path, a route with milestones not so far apart as to be unrealisable and a guide, a mentor and a supporter – as changes they undertake are rarely in isolation from their peers and family.
One way to drive this process forward is through the power of narrative or story – except in this case it is a rewriting of their story in the context of time and ending at where they are today. To understand and make sense of the world, humans tend to structure the stream of time and events into a story with a beginning, middle, and end. History represents the desire for not only a true and reliable report of events, but also a way to understand the present as an outcome of the past. Every individual has a personal and family life story that entwines in their health presentation.
Your retelling of this story with a structural time line – a short health biography allows the recipient to ‘hear’ the antecedents’ triggers and mediators in the journey, presenting them with the capability to recognise where strategic decisions or events have provided opportunity for intervention.
This process has the power to make the shared decision to change have meaning because they have now seen themselves present within the context of a story – their own! Your skill is to add insights, place relevance on points of intervention, negotiate a mutual aim and in doing so bring order to their often-chaotic perception of illness.
Practice the delivery of narrative, metaphor and nuance, never underestimate the power of hearing your own hard to understand health needs being chronologically explored and intellectually explained within the context of care and transfer of power to the recipient.
How do you make decisions, not just in clinical work but in life? Do you ponder, obfuscate, data gather endlessly, look for hints or clues, match outcomes with risk benefit analysis or have a random set of parameters that are defined by mood and time?
Do you qualify decisions based on an abstract level of importance or keep a mental decision tree in your head that allows a structured approach that you have become reliant upon; are these processes knocked off course by emotion, stress and wellbeing or ultimately led by these?
What about clinical decisions? The ones that require some careful thought and analysis. After all, the process of clinical decision-making is the essence of everyday clinical practice. This process involves an interaction of application of clinical, biomedical, nutritional and lifestyle knowledge, problem-solving, weighing of probabilities and various outcomes, and balancing risk-benefit. A key task in this process is to balance your personal experience and prevalent knowledge.
Your clinical decision-making is the process of making an informed judgement about the treatment necessary for your patients/clients. This process is complex involving several important steps in which patient/client involvement is essential. This is sometimes referred to as shared decision making (SDM) a collaborative process in which practitioners and patients/clients work together to select tests, treatments and health management or support packages, based on clinical evidence and their informed preferences and values. It explicitly acknowledges the fact that there is usually more than one way to treat a problem, including ‘no treatment’ and patients/clients may require help to weigh up the benefits and harms of the options in order to determine the best choice for them.
There is good evidence that SDM benefits patients, improving the quality and appropriateness of clinical decision making. A Cochrane Review of 115 randomised control trials found that use of patient decision aids leads to improved knowledge and more accurate risk perceptions among patients, greater participation in decision-making, and more appropriate treatment decisions.
Yet, to make these shared decisions, some level of knowledge beyond a vacuous series of conversational memes are needed, they are needed to anchor points for critical analysis. Yet information alone is not enough. You still require awareness of the overarching meaning of the information. Plus, it also necessitates separating the information which is relevant for a particular decision from that which is not. You have to add context to the variables. i.e. discard irrelevant information and figure out which facts are relevant for this precise situation.
Yet the very flexibility of lifestyle intervention can make this process hard to apply, all the more so if the contextual knowledge base is embedded in strategies that are comfortable to the practitioner and yet incompatible to the client – how many times have you tried to mould a person to your preferred model, rather than listen, engage and share the journey? – it takes skill courage and confidence as well as experience to do this. Something that comes from application, and the process of action as well as recognition of emotive, intellectual, social and other barriers that may mean the decision is not a fully rational one. After all, your recommendations should be all about connecting with reality, not with a false version of events filtered through a lens of cognitive biases and shortcuts.
One of the criticisms by health care professional about Nutritional Therapists, health coaches and others is that their decision-making process is exactly that – one that is inextricably poor because their context is corrupted by biases promulgated by teachers and peers without adequate independence or critical determination of validity – for which the randomised controlled trial has become the pedestal upon which so much hubris is heaped by these enthusiastic public protectors.
Of course, there is validity in these comments, there are clear examples of poor decision making going on right now. You will have issued advise that in retrospect was wrong, inappropriate and without justification, or you may have used a protocol devised by someone for a named condition or conditions and felt worried and anxious when it either did not work or made the recipient feel worse. But be comforted, nobody makes perfect decisions, but some are clearly better at decision making than others, and in clinical care we should always strive to be better.
Whilst there is no hope of you ever being able to keep up with all the data that emerges on a daily basis, there is a deep responsibility to reflect, engage and explore changes and evolutions of interventional options, of the type you are trained to use. This can include peer to peer conversations, reading of papers or journals, attending CPD and CME events and of course using experience as a guide – however, one of the very first places to start is to recognise that you can’t just look at our own personal experiences or use the same mental recipes over and over again; we have all got to look at other disciplines and activities and relate or connect them to what we know from our experiences and the clinical world we live and work in.
To conclude – making decisions in lifestyle and nutrition needs a shared process of engagement, a willingness to review and disengage from historical patterns of application as knowledge evolves, a desire to be more open to critically analyse peers and their recommendations and yet retain a willingness to action something – after all, as with anything you practise if you do it right, the more you do it the better you will get.
As you begin to apply these processes you will recognise some fundamental changes to your thinking. In particular, you will become much more aware that your ‘beliefs are grayscale’. That is, despite your inner experience suggesting otherwise that they are not black and white and that you have for years held levels of confidence in your beliefs about how the world works that are less than 100 percent but greater than zero percent. This is a positive state of being as, even more importantly as you go through your clinical practice and encounter new ideas and new evidence, that level of confidence fluctuates, as you encounter evidence for and against your beliefs. Eventually a position of comfort that allows you to modify your opinions with objective information should evolve:
Initial Beliefs + Recent Objective Data = A New and Improved Belief.
… each time the system is recalculated, the application of care and SDM journey should become more secure in its application and outcomes more predictable.
The process of life creation is one of nature’s great wonders, none more so than in the creation of new humans. This process seemingly unhindered for thousands of years has produced a global expansion in population numbers of billions. Today 384,701 people will be born and 156,936 people will die, resulting in a net gain of 227,765 humans (give or take a few thousand). This year 140 million babies will be born and 57 million people will die and with each new life comes opportunity and risk.
Geography, social standing, education, parents and peers all have a role to play in the health and safety of the baby, with long term implications for their ability to function and thrive.
One of the interventional areas open to you in your typical clinical care is that of preconception health, of which nutrition and nutritional status plays an important role. The preconception period it has been suggested in a new paper should be redefined according to (1) the biological perspective—days to weeks before embryo development, (2) the individual perspective—a conscious intention to conceive, typically weeks to months before pregnancy occurs, and (3) the public health perspective—longer periods of months or years to address preconception risk factors, such as diet and obesity. In effect significantly extending the previously recognised 12-week preconception.
The preconception period presents a period of special opportunity for intervention; the rationale is based on life course epidemiology, developmental (embryo) programming around the time of conception, maternal motivation, and disappointment with modest or ineffective interventions starting in pregnancy.
Adolescence (a period of frequent conception) might represent a particularly sensitive period as unhealthy life-style behaviour—e.g., smoking, poor diet, and eating disorders—often originate in the teenage years. These preconception risk factors can set patterns that have a cumulative effect on the health of the baby all the way througth into adulthood and for future generations, as shown by mounting evidence of the long-term effects of poor maternal nutrition and obesity for the child. So say the authors of a recent Lancet Series.
During work undertaken for the series the researchers assessed the nutrition of 509 women aged between 18 and 42, thus approximately of a reproductive age, as recorded by the UK National Diet and Nutrition Survey. Their findings concluded that 96 per cent of the women have iron and folate dietary intakes that are less than ideal when preparing for pregnancy.
A typical diet in high-income countries, characterised by a high intake of red meat, refined grains, refined sugars, and high-fat dairy, is also lacking in several important nutrients (including magnesium, iodine, calcium, and vitamin D. Their analysis in the UK showed that many women of reproductive age will not be nutritionally prepared for pregnancy, since they do not meet even the lower reference nutrient intake (RNI) amounts, which applies especially to young women and mineral intake. 77% of women aged 18–25 years had dietary intakes below RNI daily recommendations for iodine and 96% of women of reproductive age had intake of iron and folate below daily recommendations for pregnancy. Of specific concern is that adequate folate concentration in pregnancy (red blood cell folate concentration above 906 nmol/L) for prevention of neural tube defects is hard to achieve through diet alone.
In the UK and Australia, more than nine out of ten young women reported consuming fewer than five fruit and vegetable portions daily, in effect failing to comply with the public health message promulgated through the best efforts of government agencies. As the diet of a young child is determined largely by the mother, this aspect has important implications for future child health.
The authors of the first part in the series explore a number of confounding factors that also play into risks of health, but qualified their view on micronutrient status by saying: Although every effort should be made to correct micronutrient deficiencies in women once pregnant, there is a growing consensus that the greatest gain will be achieved through a life-course approach or continuum of improved nutrition in children, adolescents, and young women contemplating pregnancy.
Therefore, if you are considering, or clients or family members are considering or planning for pregnancy, the evidence suggests that significant changes to lifestyle, food and supplementation will confer greater advantage to the health of the child and parent than waiting until pregnant to make the changes. Are you advising your prospective mothers accordingly?
Recently there have been several early stage developments in the delivery of changes to medical education, namely the recognition of the absence or insufficient knowledge on the role of nutrition in the management and reversal of complex non-communicable diseases.
I am one of 4 people who developed a 1-day masterclass for GPs and medical professionals who must operate in a very time constrained clinical environment and yet still deliver meaningful proposals for people to change their behaviour patterns. This is an entirely different type of care than can be developed over 60 minutes, yet they are now empowered to engage with their patients in a way that creates partnership – and believe me when I say that the impact on their clinical life and their patients is already being felt in hospitals and GP surgeries around the UK.
It is in general appreciated of course that only long-term and consistent dietary pattern can benefit human health, or conversely, induce inflammation and increased oxidative stress if an unhealthy diet is followed, that leads to chronic disease. To convert this knowledge beyond a public health message and the ‘eat a balanced diet’ sop to many thousands of people daily, takes commitment and intervention, and to intervene you need to know the what, why and when.
Some practitioners have raised comments that this ingress into clinical training by medical professionals will see a loss of business for them, as patients that turn into needy clients have their need met by the local GP. Yet nothing could be more wrong or more disconcerting. A three-year training in nutritional therapy or other nutrition courses is very different from the short training being offered to GPs, yet every hour they spend becoming enthused with the power of lifestyle change means that your clinical expertise becomes better appreciated and understood.
Even the massive organisation that the NHS is cannot be sustained, so economic reality will drive the need for different approaches including eventually spinning out clinical care to NTs, as at a cost of £11bn a year on direct NHS costs and the same again on indirect costs of type II diabetes alone, will bring the organisation to its knees.
If you were able to catch the BBC Radio 4’s food programme you will have heard how various small changes are occurring, but more importantly how these are being welcomed by the trainees. Never in my clinical life (over 35 years) has there been such a receptive audience and whilst there remain sceptics, this is the way forward for the country and the world in terms of health delivery.
But an article in The Times by Clare Foges on 2nd April suggested that “If our health service is to be affordable long-term, and if it is to be fair, then we need to talk about deserving and undeserving patients.” She goes on to say: “The NHS crisis is a personal-responsibility crisis, so when it comes to what is rationed, what is prioritised, and who pays more for the NHS through their taxes, the axe should fall on those whose behaviour has impacted their health, not on those who have done nothing to bring about their condition. Where possible and reasonable, the “undeserving” patient must be made to pay for their lifestyle choices, whether financially or through the de-prioritisation of their treatment.”
Now there is much in her argument that you may be nodding with, but we all know changing behaviour is tough, for everyone, and if the primary clinician is to catch this risk early, he or she needs specific skill sets to be able to direct, guide, cajole and encourage – hence the need for more training.
The NEJM has created a free online training plan for clinicians to help them learn how to change behaviour pointing out that all patients are not the same. Even in the case of the same diagnosis, there are differences in what individual patients want out of their care (outcomes) and what is important to them along the way (processes). Trying to achieve a good result without understanding how a patient defines “good” requires assumptions that often lead providers astray. Why not sign up
Finally, a paper: The influence of diet on anti-cancer immune responsiveness out in March 2018, eloquently pulls together numerous immune related events mediated by foods and food concentrates, a worthy one for your repeat read collection and ideal for the family member who still does not get why you do what you do!
- Soldati L, Di Renzo L, Jirillo E, Ascierto PA, Marincola FM, De Lorenzo A. The influence of diet on anti-cancer immune responsiveness. J Transl Med. 2018 Mar 20;16(1):75
At the end of any connection, in addition to the length and quality of life, one important outcome of care is peace of mind. When a care episode is over, it matters to patients/clients whether they feel confident that all that should have been done was done, independent of other outcomes. Confidence is built through good communication, a sense of teamwork among different providers, and the belief that the provider(s) cares about the patient.
Mostly, as practitioners focussed on the responsiveness of the innate and acquired immune system in the gastrointestinal tract, the circuitry of interest has been associated with the transmission of messages from the gut to the brain – so much so that the information in the other direction has been largely ignored or diminished in clinical relevance.
Yet the brain-gut dialogue offers numerous opportunities for synergistic management of disturbed immune and endocrine pathway. Your brain as you know is the major organ through which you experience the world, yourself and others. When it’s healthy your experience of life becomes magnified. But when it’s broken and imbalanced it can become a source of stress, fatigue and burnout. So how do you create a healthy brain? The answer lies in your physiology…
The health of your brain depends on the health of your cells. And the health of your brain cells relies on three key elements: fuel, activation and a nurturing environment. Your brain – just like your body – needs food, exercise and a healthy environment to survive. But when we say exercise here, we are not just talking about physical exercise like walking or running. We are also referring to all the different sensory experiences you have on a daily, moment by moment basis. All of this bioenergetic information feeds your brain and allows it to thrive. You see, sensory experience is one of the major drivers of the growth and maturation of your brain and nervous system. The sounds you hear, the food you taste, the aromas you smell – all of this energy gets transduced into tiny electrical signals that enter your nervous system by way of receptors and nerve pathways. These nerve pathways travel up your spinal cord or enter your brainstem to get to your brain – feeding it, fuelling it with the sensory food that your brain thrives on.
Just like you can go to the gym and train and build stronger muscles, you can also do things to build a stronger brain due to the revolutionary process known as neuroplasticity. Through specific, repeated sensory exercises coupled with awareness you can literally restructure and strengthen the areas of your brain that you would like to enhance. As an example, if you want to improve your focus and concentration you can train your frontal lobes through meditation. If you want to get better at music you can train your temporal lobe to be able to better distinguish between different notes and rhythms. If you want to get better at tasting different wines, you can train your orbitofrontal cortex to pick up subtleties in flavour. And if you want to get better at skateboarding or martial arts or figure skating you can train your cerebellum and vestibular system so you feel more solid and grounded and balanced.
Dr Titus Chiu a renowned expert in these processes, gave his first UK presentation on his remarkable interventions called SENSORIgenomics for us just recently, and the attendees were simply thrilled to hear what he had to say; sensible, practical tools to add value to your existing skill sets. Luckily, we have recorded his 90 minute webinar and are making it available for purchase – so if you have clients with anxiety, gut problems, poor concentration or are experiencing post trauma brain deficits, why not set aside some time and learn what simple techniques can be employed to help them recover. Using sight, sound, smell, taste, touch, vibration and proprioception– you can learn how to drive neural activation in a process known as SENSORIgenomics. To watch book here
On the week beginning 20th February 2017 the product Zen and its derivatives were discontinued. Whilst we are sad to see it go, we have prepared a range of alternatives to help you and your clients thrive.
Michael and Antony have identified alternatives to the 200mg of Zen product by Allergy Research.
N-Acetyl Cysteine in the Treatment of Obsessive Compulsive and Related Disorders: A Systematic Review
For people with obsessive compulsive disorders the condition can be extremely exhausting. For practitioners and clinicians the condition is very frustrating to manage and to bring relief safely and reproducibly. The use of the nutrient N-Acetyl Cysteine as an adjunctive intervention has been explored in a small number of clinical trials, this review paper takes a systematic approach and brings together the evidence to help determine if this single intervention has any clinical value. Read the rest of this entry »
Across the world there are chronic diseases affecting the lives of many, most of which are preventable or modifiable by appropriate lifestyle changes. Yet currently politicians are unwilling to legislate change, to force behaviours that in turn diminish the costs to the individual and to society. Read the rest of this entry »