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FA C T S B E H I N D T H E H E A D L I N E S

DOI: 10.1111/nbu.12003

Dont tell me what to eat! Ways to engage the population in positive behaviour change
R. Watson and L. Wyness
British Nutrition Foundation, London, UK

Introduction
A YouGov survey of a representative sample of 1742 adults carried out in August 2012 found that 48% of British consumers think that the UK Government should not provide advice on what the population should eat and drink, as opposed to 22% who thought they should provide advice (ASI 2012). The survey, which sought to ascertain peoples reactions to various aspects of government activity, found that 2 out of 3 adults disagreed with the statement politicians and civil servants are well-equipped to make personal decisions on my behalf. This may be reected somewhat in the nding that the majority of the British public do not think people in authority should make decisions for them. The biggest opposition to the statement Government should provide advice on what foods people like me should eat and how much to drink was among older people (aged 60+ years) (57% compared with 20% of adults aged <60 years). The report resulted in media headlines such as We may be fat, but we dont like the Government going on about it (The Independent 2012) and 48% say dont tell me what to eat (Daily Express 2012). It was suggested in the coverage that people do not like to be told what to eat because they do not want to follow dietary advice even though they know that they should (The Independent 2012). Overall, the views, portrayed in the headlines, seem to reect an objection to a nanny state among the general public. With this in mind, this paper explores why national food and dietary guidelines were developed, how the general public respond to such guidance, and discusses ways to engage the population in positive behaviour change.

Correspondence: Dr. Laura Wyness, Senior Nutrition Scientist, British Nutrition Foundation, Imperial House 6th Floor, 15-19 Kingsway, London WC2B 6UN, UK. E-mail: l.wyness@nutrition.org.uk

Similar objections to health recommendations have also been reected in the US. Patterson et al. (2001) examined consumer backlash against government dietary recommendations using data from the Washington State Cancer Risk Behavior Survey. In the study a total of 1751 adults (aged 18+ years) were surveyed. Study participants were representative of the Washington State adult population in terms of gender, age, education, household income and body mass index (BMI). Approximately 70% of the participants thought that the US Government should not tell people what to eat and 43% were tired of hearing which foods they should and should not eat. Having said that however, food and dietary guidelines were originally developed to help improve the populations health. It was after the end of the Second World War that nutritionists became increasingly concerned about the UK populations diet and in particular the general publics overconsumption of macronutrients, such as saturates and sugars, as well as the lack of bre in the diet. National food and dietary guidelines were developed in the 1970s to encourage eating more or less of foods which were either low or high in macronutrients of concern (EUFIC 2009). Guidelines on physical activity were also developed a few decades ago, although the rst UK-wide guidelines on physical activity were published in 2011 (DH 2011a). Consequently, national guidelines on diet, physical activity and alcohol consumption now exist and have been developed over a number of decades in response to a number of healthrelated factors. These include the increasing rates of overweight and obesity over the last 30 years [obesity in adults has trebled since the 1980s, with 1 in 4 adults (23%) in England currently obese (a total of 61% of adults are overweight or obese)] (DH 2011b) and increased rates of associated chronic diseases, such as type 2 diabetes, alongside evidence of poor diet and low physical activity levels in the UK population. It is predicted that almost two thirds (60%) of men, half (50%) of women and a quarter (25%) of children aged under 16 will be obese by the year 2050, costing the UK

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National Health Service an estimated 10 billion per year if this trend continues (Go-Science 2007). It is therefore vital that the population engages with advice on how to improve their diet and lifestyle to help reverse this trend. So, what is the best way to engage the population in such a science-related area?

How different people engage with science

Research carried out in the UK by Ipsos MORI has suggested that the population can be clustered into six different groups according to their attitudes towards science (DBIS 2011). This research highlights the importance of having a variety of engagement strategies when it comes to public health interventions. As demonstrated by the Ipsos MORI research, there are a number of different attitudes towards science among the general public. Therefore, to ensure the majority of the population is engaged, several engagement strategies may be required. The clusters identied comprise the concerned, the indifferent, late adopters, condent engagers, distrustful engagers and disengaged sceptics. According to Ipsos MORI, the concerned are the largest cluster representing 23% of the UK population. This group tend to be apprehensive about the intentions of scientists and doubtful that the government has sufcient control over science and technology due to the speed at which this eld is developing. Promoting the relationship between scientists and the government and how they engage in producing public health policy may be a useful strategy with this particular subset of the population. Therefore, approaches such as explaining the precise role of relevant organisations and, the role and membership of the UK Scientic Advisory Committee on Nutrition in advising the government on nutritionrelated policy, could help to engage this cluster. Late adopters are estimated to represent 18% of the UK population. Ipsos MORI describes this group as being more likely to take notice of science when it is put into context and when it relates to their own life and concerns. Interventions such as Englands Department of Healths Change4Life campaign may make the most impact on this cluster, as it provides examples of how small, practical changes can have a big impact on quality of life. Interestingly, using the Ipsos MORI categorisation, the results of the YouGov survey (ASI 2012) can be interpreted as implying that the majority of the British public are distrustful engagers, when in fact the work by Ipsos MORI estimated that they are one of the smallest groups representing 13% of the population. On one hand, distrustful engagers are very interested in science

and feel relatively well informed, but on the other hand they are generally distrustful of the governments role in science and would like the public to play a larger role in making decisions about scientic issues at a policy level. Given that this cluster could potentially be one of the most difcult to engage in behaviour change, they may therefore require a more creative approach involving a wide range of experts, from, for example, psychology, economics and marketing. So, how do the general public respond to national guidance on healthy eating and to healthy eating recommendations provided during interventions to improve their health?

The general publics response to guidance

A systematic review carried out by Boylan et al. (2012) looked at peoples responses to various weight-related recommendations; the ndings of which, should help to provide a best practice guide for developing diet and physical activity guidelines and engaging people in positive behaviour change linked to weight management. The review found that people prefer dietary advice to be simple, clear, realistic and specic in terms of the type and amount of food they should eat (US DHHS 2008). This may help consumers to implement advice. Furthermore, using visually descriptive words such as solid fat vs. oil, as opposed to saturated vs. unsaturated fats, may also help some individuals to understand the message more clearly (Britten et al. 2006). However, evidence suggests that some individuals consider current dietary advice to be too prescriptive (Hart et al. 2003). This approach could lead to a sense of failure among consumers when they do not follow advice for a healthy diet, and may also partly contribute to some consumers rejecting dietary advice (i.e. to avoid failure) (Hart et al. 2003; IFIC 2004). In addition, the terminology used may also be important in an individuals understanding and acceptance of guidelines. For instance, the concept of balance has been found to be poorly understood, particularly information about balancing the intake of high-fat and lowfat foods and precisely how much physical activity one should engage in (Geiger 2001). Furthermore, when discussing weight with some individuals, those who are overweight or obese may be sensitive to the use of certain terms such as fatness and obesity, while the term weight may seem less judgemental and more easily understood when used in conversations regarding weight management (Wadden & Didie 2003). When used in dietary advice, the term moderate (e.g. moderate consumption of fat) has been found to be more

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realistic and achievable than the term low (Geiger 2001). However, in practical terms, the interpretation of moderate could vary widely. Another potential reason why consumers reject government advice on healthy eating is that they nd it confusing, particularly advice around dietary fat (Boylan et al. 2012). It has been found that people are unaware of the fat content of certain food products (Garcia & Piche 2001), do not understand the difference between the types of fat (IFIC 2004) and can misinterpret 30% of energy as fat as meaning 30 g of fat per 100 g (Borra et al. 2001). Having said that however, as this research is now over 10 years old it may not accurately reect current consumer understanding. Although, the headlines mentioned earlier suggested that many people do not like to be told what to eat, some consumers do accept dietary advice. Research has shown that many of these consumers prefer advice to be in the form of positive suggestive statements such as could or how about (Egger et al. 1999), rather than being told specically what to eat. However, again as this research was published some time ago it may not reect current consumer preference. More recent evidence indicates that there is no one size ts all solution to engage the population as a whole (Gately & Curtis 2013). A mixture of engagement methods is therefore likely to be more effective to achieve positive behaviour change at a population level. Another important factor to consider when trying to inuence behaviour is the source of the information being conveyed. The fastest growing sources of information on health and nutrition for young adults are social networking sites such as Facebook, Twitter, MySpace and YouTube. Yet, research suggests that family and friends are considered to be the most important source of information. Interestingly, these are the people, who individuals also engage with, and get information from, on social networking sites (Brennan et al. 2010). Notably, one of the studies included in the systematic review by Boylan et al. (2012), a telephone survey of 1221 US adults (the US Health and Diet survey), found that 74% of participants would not seek dietary nutritional advice from government websites (FDA 2008). This may be because some individuals perceive government sources of information as being potentially biased (Hart et al. 2003), which also seems to be in line with the results from the YouGov survey (ASI 2012). However, Boylan et al. (2012) identied several studies that indicate that health professionals and government agencies are considered trustworthy. Most of the 46 studies included in this review were published in peer reviewed journals in the areas of

health (n = 31), marketing (n = 3), consumer research (n = 2), and education (n = 1), with the remaining literature sourced from government and non-government reports (n = 8) and one thesis. However, the small sample sizes in many of the studies included in this review, alongside a generally female majority within them, may have biased these ndings. Considering all of the aforementioned issues surrounding peoples ability and willingness to follow nutritional and dietary advice from the government or one-to-one advice from health professionals, tailoring information to specic groups or different clusters of the population as identied by the research by Ipsos MORI may be important in bringing about positive behaviour change. There is also good evidence that gender, age, weight and socio-economic status are important in determining perceptions of dietary advice and therefore, in making food choices (van Dillen et al. 2004). For example, men found sports and nutrition, minerals, nutrition and drugs, and carbohydrates more important than women, whereas women expressed a greater need for more information about losing weight. So, how can we engage the population in positive behaviour change?

Ways to engage people in positive behaviour change

Traditionally, health promotion and education have focused on engaging with consciously planned or deliberate types of behaviour. However, attempts to encourage people to make better choices by providing healthy eating advice, or telling people what they should and should not eat do not seem to be sufcient to make a noticeable impact on the dietary behaviours of the general population (Bestwick et al. 2013). The headlines highlighted earlier indicated that people are fed up being told what to do and as such, it is clear that although the vast majority of people know what they should and should not eat, turning intentions into action is extremely difcult. Levels of obesity and the prevalence of nutrition-related conditions, such as type 2 diabetes, cardiovascular disease and some cancers remain too high in the UK. Sadly, if these levels continue to increase the National Health Service will struggle to cope and will be unable to sustain the burden of cost. To date, there has been a vast amount of research on the theory and practice of behaviour change. The complexity of the causes of obesity for example and consequently, the wide-ranging interventions necessary to provoke and maintain change, is illustrated by the Obesity System map (Go-Science 2007). This map shows that there are

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more than 100 internal and external factors that inuence what, how much and how often we eat and/or engage in exercise and, therefore, how able we are to manage our own weight and health prole. Behaviour change interventions need to take this into consideration and adopt a multidisciplinary approach to achieving a healthy diet and lifestyle, including nutrition, psychology, sociology, economics and marketing. In the past, public health interventions were developed with the aim of improving knowledge (which was thought would lead to a change in behaviour), but it is now well recognised that knowledge of a healthy diet does not always translate into healthy dietary behaviour (Bestwick et al. 2013). Advances in our understanding of behaviour change have led to more sophisticated behaviour change interventions being developed, for example, some commercial weight loss programmes and the national Change4Life programme in England (see later). Furthermore, interventions to change behaviour need to be carefully planned to be efcient and effective. It is important that people are effectively engaged in terms of healthy eating messages and encouraged to make positive changes in their behaviour. The research by Ipsos MORI provided some examples of how to engage the different clusters of the population, for example, the concerned cluster could be engaged by scientists communicating to them more about their values and intentions in the work that they do (DBIS 2011). Theories of behaviour change can help to guide both interventions and messaging on public health nutrition to reach specic target groups. There are multiple theories of behaviour change in existence and frameworks that are used to characterise and design behaviour change interventions. A systematic method for choosing an appropriate intervention is necessary to increase the chances of the intervention being effective. Many frameworks exist, each with their own limitations of use (Michie et al. 2011). Michie et al. (2011) recently developed a new framework, encompassing previous frameworks while also attempting to overcome some of their limitations. The proposed framework from Michie et al. is represented by the behaviour change wheel (BCW) (see Atkins & Michie 2013 and Chadwick & Benelam 2013). The Department of Health in each country in the UK realises that achieving a noticeable impact among the general public in terms of positive behaviour change is a complex process and therefore, it is taking the theories of behaviour change into account in its work. The Department of Health is also mindful of the need to engage the general public in ways other than purely providing them with health information, or via

conventional educational techniques, so that individuals will act positively towards current healthy eating advice and ultimately change their behaviour (i.e. their eating habits). The national obesity prevention campaign, Change4Life, launched in England in 2009, uses a social marketing approach to engage specic groups of the population, starting with families with young children, to encourage both a healthier diet and lifestyle. Change4Life encourages a series of small changes in order to help people achieve big results. Using this approach, the British Nutrition Foundation (BNF) recently published a guide entitled Small Changes: Big Gains!, which gives over 100 practical examples of what people could do more or less of, to improve the overall balance of their health and lifestyle (BNF 2012). As the headlines highlighted earlier indicate, people do not like being told what to eat, therefore, suggesting a wide variety of small changes in behaviour that people can choose to implement may perhaps be a more effective approach, as opposed to telling people (e.g. through healthy eating advice) what they should and should not be eating and how much physical activity they should be doing. Having said that, however, the style of delivery is also important and people still need targets/goals to work towards. Therefore, small changes that are easily implemented and incorporated into everyday life may make more of an impact and be easier to sustain in the long-term than changes that seem far too challenging. In addition, once people see that they are capable of making small changes this may encourage them to attempt bigger changes that will have a larger impact. A recent evaluation of the rst year of Change4Life showed high levels of awareness of the campaign in the general population (DH 2010). However, further examination of part of the Change4Life campaign (the family information pack) showed no measurable changes in peoples behaviour (Croker et al. 2012) (see Wyness & OConnor 2013). Although, it is worth mentioning that this study was not without its limitations (i.e. poor response rate and small sample size). Plausible explanations why Change4Life has yet to show an impact on behaviour include the fact that it is likely to take several years for any population-level impact to emerge (e.g. changes in population-level BMI) before being shown to inuence the poor level of engagement of the population groups targeted within the programme (Croker et al. 2012). In retrospect, this may have been improved by tailoring the messages and materials for specic attitudinal clusters as identied by the Ipsos MORI research (DBIS 2011). Overall, given that, evaluation of the

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impact of Change4Life is still ongoing, in time, this will provide valuable insights to improve our understanding of what works and what doesnt in terms of having a positive impact on behaviour change. As the Obesity System map (Go-Science 2007) shows, there are many environmental factors that can affect our weight and health prole. These include, the availability of foods with healthy nutrient proles. The Food Standards Agencys (FSA) salt reduction programme was successful in reducing the average salt intake of the UK population (Wyness et al. 2011) (from 9.5 g/day in 2000/2001 to 8.1 g/day in 2011) (Sadler et al. 2011). The programme involved two main streams of action, working with the food industry to reformulate food products; and, a consumer campaign to increase awareness of the salt content in foods and the impact of salt on health. It is thought that the success of the salt reduction programme was likely due to the population having the capability, opportunity and motivation to make healthy behaviour changes to successfully decrease the levels of salt in their diet (see Michie et al. 2011). The Public Health Responsibility Deal in England (see Buttriss 2011 and DH 2012 for further details) has built upon the FSAs work by continuing to work with industry to encourage progress towards the targets set by the FSA, with a view towards their achievement by the end of 2012, as well as to set new targets following on from this. Much progress has been made, although these challenging targets will likely require innovative solutions in order to be met, e.g. using a new type of salt with smaller, hollow crystals, meaning less salt needs to be used, while still ensuring that the taste and functionality of the foods concerned is maintained (IGD 2012). Continuing with this work, additional salt reduction targets have been set as part of the Public Health Responsibility Deal, specically for the catering sector (Jebb 2012). These targets focus on training and kitchen practices (e.g. reducing the amount of salt used in kitchens by at least 15% within a 2-year period), reformulation and procurement (DH 2012). Overall, this approach (i.e. combining reformulation work with a consumer awareness campaign) recognises the responsibility of a wide range of organisations, as well as consumers themselves in reducing salt intakes. Unfortunately, however, the success achieved with the FSAs salt reduction programme may not be quite so transferable to the reformulation of foods containing other nutrients, such as saturates and sugar. For example, the FSAs saturated fat campaign in 2009/2010 achieved some success, although different approaches (other than reformulation of products) were used to achieve reductions in saturated fat, such as the introduction of low-fat milk via skimming

and introducing changes to animal husbandry and butchery techniques to reduce the total fat. A likely factor inuencing the success of the salt reduction programme is the fact that processed foods account for approximately 75% of the salt in our diets making it particularly amenable to reformulation approaches. The Public Health Responsibility Deal is also focusing on other areas relating to food, such as reducing calorie intake and increasing fruit and vegetable intake, and it is anticipated that the areas covered will be expanded upon in the future to encourage a positive impact on healthy eating in other segments of the diet. Crucially, evaluation of the impact of the Public Health Responsibility Deal is ongoing. Monitoring organisations compliance with the pledges alongside data from the National Diet and Nutrition Survey will provide valuable insight to support future initiatives into what works and what doesnt. As around 1 in 6 meals are now eaten outside the home, one of the Public Health Responsibility Deal pledges is to provide calorie information for food and non-alcoholic drinks. Including the calories on food menus has been mandatory in chain restaurants in New York City since 2008. Following its inception, one study of 168 fast food restaurants in New York City found that 15% of customers reported using the menu calorie information in their food choices, and, consequently, these customers purchased on average 106 fewer calories than customers who did not see or use the calorie information (Dumanovsky et al. 2011). However, other US studies have shown mixed results (i.e. no or only a modest effect) in terms of the effectiveness of menu calorie labelling in reducing calorie ordering and consumption (Swartz et al. 2011). Careful monitoring of the impact of this pledge to provide calorie information on menus in the UK is essential. The recent six-month pilot scheme Caloriewise in Northern Ireland aimed to investigate the practical issues for businesses, as well as consumers reactions and their understanding of the scheme (FSA 2012). The ndings from which (expected later in 2013), should provide more insight on the impact of calorie labelling on consumer behaviour in the UK. Interventions that have shown some success in making positive behaviour changes among the general public tend to focus on altering environmental cues (e.g. the availability of healthy food choices in restaurants or the positioning of healthy food items within supermarkets) to prompt healthier behaviour. Nudging, for example, mainly operates in this way, in that it makes use of social and physical environments to enable people to lead healthier lives, without them having to make a conscious decision or a deliberate change in their behav-

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iour (Marteau et al. 2011). Examples of where nudge interventions have successfully achieved healthy behaviour change were highlighted by Marteau et al. (2011). These included putting yellow duct tape across the width of supermarket trolleys with a sign requesting shoppers to place all of their fruit and vegetables in front of the line. This doubled fruit and vegetable purchasing, whilst placing fruit by the cash register increased the amount of fruit bought by school children at lunchtime by 70%. Having said that however, the cost of food and drink can also have a strong inuence on food purchasing habits, especially in the current economic climate and may therefore impact on the ability to purchase healthier foods (Bestwick et al. 2013) and ultimately inuence behavior change initiatives.

and celebrities have a responsibility to work together to encourage healthy behaviour change to improve the health of the population.

Conict of interest
The authors have no conict of interest to disclose.

References
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Summary
Recent media headlines reported in this article suggested that the general public in the UK do not like to be told what to eat. While there is some evidence that obesity rates have plateaued in children, sadly overweight and obesity rates in adults continue to rise. Public health interventions are therefore crucial to help tackle health problems and to counteract the economic strain on resources within the National Health Service problem. We now know that knowledge alone is insufcient to change behaviour, and the ndings recently highlighted in the media headlines suggest that if consumers are tired of being told what to eat, perhaps we need to think of more novel approaches to educate people and promote health, in order to reach and effectively engage the population. The various theories of behaviour change can help to develop and implement more effective interventions in the future. Given that research suggests that different clusters of the population engage with science in different ways, it may be important for future dietary interventions to adopt several engagement strategies specically tailored to different target groups. Although it can be useful at a population level, it is often difcult to motivate individuals with general healthy eating advice and therefore, such advice often fails to engage individuals to make healthy behaviour changes. The increasing amount of research in this area indicates that more complex interventions are required to solve the complex obesity problem. The challenge therefore, is for experts in relevant disciplines, such as nutrition, psychology, sociology, economics and marketing to work together to derive effective interventions to help to improve an individuals health behaviours. All individuals and organisations, namely health professionals, the food industry, teachers, employers, parents

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