to McGill U School of Dietetics

1
to McGill U School of Dietetics Human
Nutrition 27 Nov 08 Food consumption
patterns to reduce and prevent obesity David
Booth School of Psychology, College of Life
Environmental Sciences, University of Birmingham
(U.K.) http//www.psychology-people.bham.ac.uk/peo
ple/david.booth Project with Louise Thibault,
Nutrition, McGill U, Quebec Caroline Chesneau,
INA Paris France Seolhyang Baek, Nursing,
Dongguk U, South Korea Antonio Laguna-Comacho,
Nutrition UAEM, Mexico / Psychology Bham U, UK.
2
Slowing the rise of obesity Obviously, exercise
more and/or eat less!!
3
Slowing the rise of obesity Exercise more and/or
eat less, as a society (?)
4
Slowing the rise of obesity Exercise more
and/or eat less, as a society, after big changes
(?)
5
Slowing the rise of obesity Exercise more
and/or eat less, as a society, after big changes
(?) No, obesity is not solely an issue of
societal reform, e.g. public health
interventions, governmental
regulations, responsible
businesses. No doubt, we need all that but of
the right sort. In the first instance, obesity is
not even a societal issue at all. Its the
individual who is obese or becomes
overweight and has to find ways to exercise more
and/or to eat less.
6
Slowing the rise of obesity Exercise more
and/or eat less - each individual within
current environment and biology -
permanently, i.e., maintained across changes in
own lifestyle.
7
Slowing the rise of obesity Exercise more and/or
eat less - each individual within current
environment and biology - permanently,
i.e., maintained across changes in lifestyle.
Which feasible exercising or eating patterns are
most effective at keeping weight
off?
8
Slowing the rise of obesity Exercise more and/or
eat less - each individual within current
environment and biology - permanently,
i.e., maintained across changes in lifestyle.
Which feasible exercising or eating patterns are
most effective at keeping weight
off? The societal problem is lack of such
research and for long past (gt 50
yr).
9
Slowing the rise of obesity Exercise more and/or
eat less - each individual within current
environment and biology - permanently,
i.e., maintained across changes in lifestyle.
Which feasible exercising or eating patterns are
most effective at keeping weight
off? After we get some of this
evidence, we can start looking for the further
evidence needed to start reducing obesity in
individuals and preventing overweight even. -
then (NEXT TWO SLIDES)
10
Slowing the rise of obesity Exercise more and/or
eat less - each individual within current
environment and biology - permanently,
i.e., maintained across changes in lifestyle.
Which feasible exercising or eating patterns are
most effective at keeping weight
off? Educate all in such evidence on the
behaviour-patterns to change avoid
overweight when unhealthy BMI becomes likely,
and reduce obesity when needing to lose some
more weight - the same energy-balance
affecting habits for prevention and reduction
of obesity.
11
Slowing the rise of obesity Exercise more
and/or eat less - each individual within
current environment and biology -
permanently, i.e., maintained across changes in
lifestyle. Which feasible exercising or
eating patterns are most effective at
keeping weight off? Educate all in this evidence
on the patterns to change when unhealthy BMI
becomes likely, or when needing to lose more
weight. Environmental reform to prevent lapsing
from each change, also according to
evidence on that.
12
Slowing the rise of obesity THE ISSUES FOR
RESEARCH Which feasible exercising or eating
patterns are most effective at lowering
weight? What environmental changes would
support avoidance of unhealthy fattening
by preventing lapses from such patterns?
13
enABLEr/s evidence-networking
individual diffs. secure, anonymised
evidence-based evidence-generating
Application of databases for research
services Better Living all QoL outcomes
e.g. healthy weight, vigour, bodily comfort,
.... Education validated
information personally tailored in
culture's own terms research /
services universities-based
to public http//wwiyc.org
what-works-in-your-circs
professionals
14
Research into effective behaviour
(comprehensively across habitual patterns) The
list is rather short still. 1. Alan Blair with
Vivien Lewis DAB (UK AFRC 1987-1991) Main
bivariate analyses A.J. Blair et alii (1989)
Psychology Health Supplementary multivariate
analyses of same study (all done in
1989-90)- Blair, A.J., Lewis, V.J., Booth,
D.A. (1990) Appetite emotional eating
self-efficacy Booth, D.A., Blair, A.J., Conner,
M.T., Lewis, V.J. (1991). In Y. Oomura et al.
(Eds.), Progress in obesity research 1990.
Libbey. sensory preferences (sweetness) weight
control Blair, A.J., Lewis, V.J., Booth, D.A.
(1994) Appetite attitudes, emotional eating
self-efficacy Booth, D.A. (1996). In A. Angel
et al., Progress in obesity research 7. Libbey.
hunger/satiety Booth, D.A., Blair, A.J.,
Lewis, V.J., Baek, S.H. (2004) Appetite PCA
on least fattening habits 2. Simone French with
Robert Jeffrey D. Murray (Pound of
Prevn) S.A. French et alii (1999) International
J. Obesity 23, 320-327. 3. Joachim Westenhoefer
associates (Lean Habits Study, Germany) J.
Westenhoefer et alii (2004) Int J Obesity 28,
334-335. 4. Vicky Drapeau co. with Angelo
Tremblay (Québec Family Study) V. Drapeau et
alii (2004) Am J Clin Nutr 80, 29-37. No other
study that Ive yet seen covers a full range of
specific behaviour. November 2008 nothing
such that cites any of the above.
15
Research into effective behaviour
(comprehensively across patterns) (1) A.J. Blair
co (1989) as in Booth et al. (2004) Most
fattening customs of eating In the English
Midlands F1A energy in or with drinks between
meals Correlation Self-described
pattern of with wt. loss
eating and drinking over 1 year Avoid
calories between meals, in drinks and snack
foods 0.31 Avoid sweet extras
(biscuits, cakes, sweets, chocolate)
0.26 Eat fresh fruit salad instead
of higher-calorie foods 0.21
Score combining the above three
0.28 I.e., cutting out energy intake between
meals is the most important least fattening
habit
16
Research into effective behaviour
(comprehensively across patterns) (1) A.J. Blair
co (1989) as in Booth et al. (2004) Most
fattening customs of eating in the English
Midlands 1A energy in or with drinks between
meals Full exploitation of such PSYCHOSOCIAL
evidence requires translation into the
PSYCHOBIOLOGY, e.g. (in this case Factor 1A),
timings and sizes of the snack and the meal
before. Measure the effects of late mixing on
gastric emptying Calculate long-term
consequences for body weight (Booth Mather
1978 also Booth IJVN Swiss Nutrition Society
1988)
17
Snacking that is fattening NOT a snack in the
sense of a light meal NOT eating a snack-food
(if part of a meal). Energy sources consumed
between regular meals, e.g. in or
with drinks an hour or more before a
mealtime. Snacking can be addictive - NOT because
of palatability of the food snacked on NOT
because of pleasure or reward from sweet (or
salty) taste or from crunchy or succulent
texture NOT because of weakness in satiety.
Ingestive movements on any nibble / sip
available after a meal are associatively
conditioned by glucose from (unsweet, fat-free)
starch in that food/drink item.
18
Research into effective behaviour
(comprehensively across patterns) (1) A.J. Blair
co (1989) as in Booth et al. (2004) Most
fattening customs of eating in the English
Midlands 1B high-fat foods/cooking
Self-described pattern of Correlation with
eating and drinking wt. loss
in 1 yr Avoid unnecessary fat in
meals 0.23 Avoid fat in cheese and
cream 0.20 Keep fat down when using
spreads 0.21 Score combining the
above three 0.22 Full exploitation of this
PSYCHOSOCIAL evidence requires
translation into the PSYCHOBIOLOGY of the
mouthful Fat does satiate strongly but late
after its ingestion, e.g., through
glucose-sparing oxidation of fatty acids in
the triglycerides still in chylomicrons
long after the meal.
19
High-fat foods are fattening - NOT because high
palatability increases volume eaten NOT
because of a high-fat behavioural phenotype.
Deposition of adipose fat requires energy to
synthesise fatty acids from acetate produced from
dietary carbohydrate or protein, unlike
deposition from dietary fat. Eating of high-fat
foods is learnt by custom NO texture, aroma or
taste of fat across all high-fat foods NO
innate preference for fat-based creaminess or
crunchiness. NOT weakly satiating like
protein, delayed metabolic satiation.
Traditional or prestigious foods are often high
in fat, e.g. (in UK) foods that store well
(because of low water activity), foods for
masculine image of men (great British
breakfast red meat).
20
Research into effective behaviour
(comprehensively across patterns) (1) A.J. Blair
co (1989) as in Booth et al. (2004) Most
fattening customs of eating in the English
Midlands Dieting OR Extreme exercise
Correlation of 1-yr weight loss
Self-described habit
frequency of habit Predicted to be
counterproductive (unsustainable, hence
de-motivating -gt yo-yo) Eat slimmers meal
replacements for one or more meals a
day - 0.05 Predicted to spend extra energy but
not to be maintained hence yo-yo dieting Do
vigorous exercise regularly -
0.09 Predicted to spend extra energy and to be a
maintainable routine Walk or cycle whenever
possible 0.04 Might help identify
(expertise) and/or sustain (motivation)
weight-losing habits Go to a slimming club or
weight reduction class 0.11
21
Research into effective behaviour (comprehensive
of the patterns) (1) A.J. Blair et alii (1989)
Psyc Health D.A. Booth et alii (2004)
Appetite Strengths Practices asked about edited
from words by members of public - edited into
smaller number by using examples from public
(AL-C now getting publics own groupings of new
examples) Reported weights prospectively at 0
and 12-14 months. Bivariate analyses from
factor-analytical latent variables. Measured
behaviour at the end of the study period.
RCTs confound effectiveness of package with
adherence to it cp. Knauper et al.
05 (McGill Psychology) re self-set
rules. Blair et al. also assessed beliefs in
efficacy of each practice, plus
psychological barriers, e.g.- low
weight-control self-efficacy, emotional
eating, not eating self-efficacy chronic
dieting (restraint), lack of reasons for
action (attitudes)
22
Research into effective behaviour (comprehensive
of the patterns) (1) A.J. Blair co (1989) as in
Booth et al. (2004) Weaknesses Only one year
tracked - need longer for obesity-adequate
measure of persistence Direct questions about
frequency of practices - unreliable
heuristics (e.g., P Slovic P Sedlmeier T
Betsch, Etc.) - need timing of two most
recent episodes to calculate real frequency
(over the exact period since the
earlier occasion). Analysis only of final
frequency - need change in frequency to
measure cause of weight change Only two points
and so no crossed time-lags possible - needed
to measure effect of behavour on weight as
distinct from wt on bhvr, or both from 3rd
factor causing both changes
23
Research into effective behaviour (comprehensive
of the patterns) (2) S.A. French, R.W. Jeffery,
D. Murray (1999) IJO 23, 320-327 Reliable
associations (N 1120) (only these phrases in
the Tables are available)
Strategy Loss (g/wk) P lt t2D
Reduce calories 27 0.0001 Eliminate
sweets 27 0.0001 x Increase
FV 23 0.0001 x Reduce food
amount 20 0.001 Decrease fat
intake 14 0.001 Less hi-CHO food 30
ns x Eliminate snacks 23 ns
Increase exercise 16 ns
while strategy
in use
24
Research into effective behaviour (comprehensive
of the patterns) (2) S.A. French, R.W. Jeffery,
D. Murray (1999) IJO 23, 320-327 Strengths
Large number (23) of so-called specific weight
control behaviors Four successive years of
data from N 1120 (Pounds of Prevn study) The
years duration of use of each practice
recalled Prevalences reported (yet again) these
may screen for feasibility Weaknesses
Behavioural patterns not specific in analysis,
nor defined in report Wordings developed by
researchers ??recognition by participants
Orthogonal latent factors not extracted Current
behaviour not measured at time of weight
measurement hence an association over the
year (or 4y) is fallacious because
weight stays at asymptote only while behaviour
persists. Raynor, Jeffery et al. (2008) did not
replicate in N 5145 over 1 year in t2D
for cutting out sweets, increasing FV, eating
less hi-CHO food.
25
Research into effective behaviour (comprehensive
of the patterns) (3) Westenhoefer co. (2004)
IJO Physicians group counselling 4-5 months,
initial meal-replacement formula follow-up of
weight at 3 years. Odds ratio for reduced weight
at 3 years (N 1247) practices improved or
maintained from 2mth to 12mth /
lapsing Multiple-items score OR P lt
Avoid fatty or sweet foods eat FV 1.81
0.001 Avoid snacks/nibbles regular
meals 1.71 0.001 Focus on eating within
meals 1.36 0.05 Active lifestyle take
exercise 1.35 0.05 Control of emotional
eating stress 1.31 0.05 WSP99 Flexible
Control of eating 1.30 0.05 (?an
experimenting approach) WSP99 Rigid
Control of eating 1.18 ns Eat smaller
amounts of food 1.17 ns J Westenhoefer,
AJ Stunkard V Pudel (1999) IJED 26,
53-64.graduated vs all or nothing
26
Research into effective behaviour (comprehensive
of the patterns) (3) Westenhoefer et al.
(2004) Strengths Prospective from 2-12 months
of change to 0-3 years outcome Dietary and
movement practices tracked at 2, 12, 24 and 36
mth Weaknesses Investigators chose the wordings
of the behavioural reports. Unclear distinction
between actual action and intention/attitude.
Specific behaviour patterns (and motives)
combined for analysis. Opportunity taken The
specific behaviours were counted, even though not
quantitated - highest success rate (61
with 3y wt loss) with 7 improvements
maintained at 1y - 52 success at mode of 5
improvements (quarter of sample).
27
Research into effective behaviour (comprehensive
of the patterns) (4) Drapeau et al. Tremblay
(2004) AJCN Weight adiposity change in 6 years
at 6y, more/less/same of10 food gps and
food portions in 3-day record Less increase in
measures of fatness (weight, body fat ,
waistline etc.) (all 6) recalled more fruit and
fruit products recorded more whole
fruit recalled less fat and fatty
foods recorded less full-fat milk (not
independent of fruit) (some) recalled less sugar
and sweet foods effects (above) reduced
by allowance for 3-d recorded PA Strengths
Assessed intakes of particular foods at final
weight measurement Measured weight and 5
indices of adiposity at both time-points
Factored out physical activity and other food
habits Weaknesses Recalled changes in
consumption were not specific to foods No
intervening measures between 0 and 6 years
28
Research into effective behaviour Behaviourally
comprehensive studies Most other work does not
track any sorts of behavioural pattern Psychobeha
vioural associates merely psychometric
scale scores (restraint, depression etc.)
should be treated as supplementary outcomes
and/or motivational moderators (Blair et al.,
1989 Lewis, Blair, Booth, 1992a,b) Important
selective studies Coakley et al. Willett
(1998) IJO 22, 89-96 4y prospve N19.5k
snacking fattens, not fat intake (except oldest)
TV no vigorous PA Knauper et al. (2005)
Appetite on self-set rules in wt. control
persistence (compliance) usually confounds
effectiveness Disconfounding is possible
only if change in each behaviour is tracked
during weight loss not done by the
best RCT so far (DPPRG, 2002 NEJM)
weight still increasing at 2y, while PA
relapsing no dietary data
29

• Research into effective behaviour
• comprehensive across specific self-described
  patterns
• Follow-up extend Blair et al. (1989) as in
  Booth et al. (2004, 2007)
• Research trainees pilot at McGill with updated
  methods
• particularly weekly tracking and cross-lagged
  analyses (Baek)
• - localised (shift culture) to Montreal, French
  language students
• Concluding part of this talk
• using Symposium (2006) slides on
  http//epapers.bham.ac.uk
• Research students project at Brum
• nutrition graduate / obesity dietitian for a
  degree in psychology
• First year strengthen different parts of the
  methods
• e.g. update elicitation categorisation of
  descriptions
• validate recall of self-described
  activities
• Second year onwards weekly reporting weight
  timings of bhvr
• multiple-baseline to asymptotic weight
• persistence antecedents of lapses

30
Theory of enABLE research method 1. A
subcultures consensus descriptions of customs
objectify communicable patterns of activity.
31
Theory 1. A subcultures consensus descriptions
of customs objectify communicable
patterns of activity. 2. Autobiographical memory
can time episodes of an activity as
accurately as a diary record can.
32
Theory 1. A subcultures consensus descriptions
of customs objectify communicable
patterns of activity. 2. Autobiographical memory
can time episodes of an activity as
accurately as a diary record can. 3. A sustained
change in frequency of a custom of
eating or moving about will change body weight
towards asymptote over a few
weeks.
33
Theory 1. A subcultures consensus descriptions
of customs objectify communicable
patterns of activity. 2. Autobiographical memory
can time episodes of an activity as
accurately as a diary record can. 3. A sustained
change in frequency of a custom of
eating or moving about will change body weight
towards asymptote over a few
weeks. 4. Change to a frequency that is
sufficiently prevalent in a culture will
be maintained indefinitely, along
with the asymptotic change in body fat content.
34
Theory 1. A subcultures consensus descriptions
of customs objectify communicable
patterns of activity. 2. Autobiographical memory
can time episodes of an activity as
accurately as a diary record can. 3. A sustained
change in frequency of a custom of
eating or moving about will change body weight
towards asymptote over a few
weeks. 4. Change to a frequency that is
sufficiently prevalent in a culture will
be maintained indefinitely, along
with the asymptotic change in body fat
content. 5. Antecedents to lapse from change can
be identified in food supply, transport
and built environment, and evidence
found for effective changes in them.
35
Varieties of intervention Measurement (tracking)
only observational Multiple-baseline with
tracking quasi-experimental Multiple baseline
tracking in RCT experimental versus other
wordings of behaviour-changes
36
The McGill pilot study (observational) Method
(with some short-cuts) 1. Consensus descriptions
elicited in one culture (UK) were
localised to another culture (Quebec French)
by investigators as participant observers,
checked by back-translation to Englands
language and environs. 2. Exact current
frequency is given by the reciprocal of the
time difference between the last two
occasions. 3. Effect on weight of maintained
change in frequency of a custom after the
first week (or 2 weeks) was measured by
correlation between the changes, 4. Effects of
initial and changed custom frequencies on
behaviour change maintenance (and weight change
maintenance for an effective custom) were
expressed as dose-response slopes.
37
Design Convenience sample of French-speakers in
Montreal 21 recruited 14 completed the planned
6 weeks of the study 12 women and 2 men, ages
18-46 years. At the same time of day on the
same day of the week, on a questionnaire in
French, each reported body weight (weighed that
day on the same scales) and recalled the last two
timings of carrying out each of 26 customs of
eating and/or drinking and 6 customs of moving
about.
38
Analysis Correlations of changes in behaviour and
weight (1) Results are expressed here as r x 100,
where r is Pearsons product-moment correlation
coefficient. Where data are seriously skewed,
Spearmans correlation of ranks, rho, should be
used instead. If only one pattern of energy
intake or expenditure changes in frequency in a
given week, correlation with weight change can in
theory be perfect (r 1.0). With such a small
sample, the observed r values are highly
unreliable. When N is adequate for good
estimates of effect size, the 95 confidence
limits of r should be given.
39
Correlations of changes in behaviour and weight
(2) Positive values indicate that the activity is
fattening. Negative values indicate an effective
slimming habit. Test of the causal
hypothesis Frequency change correlates with
later Weight change. This is a rather
severe test, discounting weight lost in 1st week
or two (though 1st week is mainly
water). Cross-lagged control Weight change
does not correlate in the same direction
with later Frequency change. Correct the
r-value measuring Frequency on Weight by
subtracting r-value for Weight on
Frequency. Effect of belief on
behaviour Weight change correlated in the
opposite direction with later Frequency
change indicates action on a correct belief
as to what can produce that change in weight.
40
Evidence for eating that slims in Francophone
Canada correlation of amount of one change in
first week of that change with amount of the
other change in subsequent two weeks r
x 100 r x 100 rF,W - rW,F
rW,F/rF,W Activity (described Freq 0-1
Wt 0-1 Cross-lag Strength in French
) Wt 1-3 Freq 1-3 corrected
of belief smaller meal a -63 -50
-13 - vegetables in meal -85
54 (-85) 0.6 cheese, dairy cream b
-93 38 (-93) 0.4 food with added sugar
-25 58 (-25) 2.3 sucreries en
surplus -30 45 (-30) 1.5 a
smaller than normal. b des matières grasses
animales sic sous forme de ...
41
Customs that slim in Montreal (described in
French) Means of correlation values (r x 100)
available from up to four lags
behaviour-Frequency change over one week (F0-1)
or two weeks (F0-2) and Weight change over the
next week (W1-2,W2-3) or two (W1-3,W2-4).
Mean Mean Mean Mean Pattern
of behaviour Freq Wt on
cross-lag strength on Wt
Freq corrected of belief smaller meal
-62 -43 -60 0.9 vegetables in
meal -28 -9 -14
3.0 cheese, dairy cream -70 17
-48 0.2 food with added sugar -6
45 -6 4.3 sucreries en surplus
-10 16 1 - take exercise
until tired -34 -28 -15 2.4
(mean) difference from two of the four (or one
of the three) lags available
42
Customs that fatten in Montreal (described in
French) Frequency change over one week (F0-1) or
two weeks (F0-2) and Weight change over the next
week (W1-2,W2-3) or two (W1-3,W2-4) - mean
values Mean Mean Mean
Mean Pattern of behaviour
Freq Wt on cross-lag strength
on Wt Freq corrected
of belief use fat in cooking/prepn 59 20
57 - drink alcohol 53 -48
(40) 1.1 choose fibre-rich foods
55 11 31 - eat fruit or salad
73 7 65 - aerobics/un club
sportiv 75 18 62 -
43
Other ways to test the causal hypothesis e.g.,
correlation (unlagged) of a persisting change in
frequency of an activity with the amount of
weight lost Less food than normal in a meal
Increase in frequency with greatest decrease in
weight
Each persons biggest change in frequency during
a period of consistently up or down change
Decrease in frequency (briefly) with (almost) no
change in body weight
Change in weight (kg t1 t2)) over whole period
of change
44
Does maintenance of changed frequency of a
practice depend on how frequent the custom was or
is? Less food than normal in a meal
Number of weeks
Number of weeks
down up
Starting frequency (times per week)
Frequency change in first week of change
Change in frequency increase of eating smaller
meals is maintained for longer if frequency
starts higher.
No sign of effect of size of increase in
frequency. (Sharp decreases were not well
sustained.)
45

• The bigger picture for research (1)
• The psychobiological long haul (Booth, 1988)
• study of the mechanisms of appetite and its
  sating,
• and of vigour and its fatigue
  
  .
  
  
  physically energetic
• - by itself, such work cant show how to control
  weight
• yet the mechanisms of choice and its
  satiety/fatigue
• must be measured, in order to work out how to
  support these psychosocially
  identified maintainable least fattening
  customs,
• e.g. through supply of foods, transport,
  leisure, etc.

46
The bigger picture for research (2) Psychosocial
short-cut (B 88) Generalise and differentiate
from personally tailored locally valid evidence
Track changes in behaviour components -
causal evidence without experiment - the only
way to rescue obesity RCTs from
unusability and invalidity.
47
The future for enABLEr/s Provide service through
the research Generate research through
services Begin to educate the public (
professionals) in personally tailored locally
valid evidence to inform a succession of changes
each 1-3 weeks, - especially of eating habits
when a more sedentary lifestyle
begins. Create demand on commercial and public
providers To change supply in ways that evidence
shows to support effective maintainable patterns
of individual behaviour.
48
Thank you for your attention SPARE SLIDES Bio
49
Bio David Booth has research doctorates in
biochemistry and in psychology. One of his main
areas of research since 1964 has been the neural,
digestive, metabolic, sensory and social
influences on, and effects of, choices and
intakes of foods and drinks, and how all these
causal processes interact in the individuals
life. One major effort has been to characterise
and to measure the least fattening customs of
eating within local environments. This talk will
highlight a pilot study conducted in this School
that is now being extended by a nutrition
graduate and obesity dietitian from Mexico who is
studying for a research degree in Psychology with
David and colleagues at the University of
Birmingham.