The what vs the how of changing health behaviour

I’m really grateful for the response to my first post on inclusive health behaviour change - both people working in this space, and friends and family, found that something about it resonated with them (which is exactly what I’d hoped!)

Your feedback form responses (you can still complete it here!) and various conversations over the last couple of weeks have got me musing about the distinction between what changes we need to make to our behaviour, and how we implement those changes and stick to them.

I had expected to come into this to explore the latter - the “how”. My background is as a behavioural scientist: I’m expert in understanding why people are behaving the way they do, and implementing solutions to (hopefully) change it. For example, if we take a simple behaviour like eating your 5-a-day or going on a daily walk, the bit that I would focus on is setting goals and plans, habit-forming strategies, or providing the right persuasive messaging to make those behaviours more likely. I would not be focussing on whether 5-a-day is enough or which fruit and veg to choose, or whether a daily walk is “enough” or the right exercise for you.

However, what I’ve learned this week is that many, many people are still not clear on the “what” in this space. I’ve been quite immersed in this world of anti-diet, intuitive approaches, and fat-positive health, but it’s easy to forget that it might be quite new to a lot of people. People might assume that I can advise them on the best nutrition or exercise strategy for them - but the truth is that I’m just not qualified to do this (but there are plenty of people who are). Like, I’m not the doctor who prescribes the specific medication that you need - I just help you to remember to take it.

I wanted to use this post to share some of the core approaches for the “what” of changing health behaviour, and to start to muse around what the “how” might look like. However, this also raises a question for me - do I want to restrict myself to the “how”?

The what

There are various ways that we can approach our health in this space. I wanted to briefly talk through some of the core “behaviours” that have been useful to me. I won’t go into these in depth, but I have started collating some resources for further reading/listening, if you’re keen to learn more!

Intuitive eating

Intuitive eating is an approach to health which was created by two dieticians. It is not a diet, and the aim is not to lose weight - it’s more about listening to your body when eating and making food choices. If you’ve never dieted or “struggled with your weight”, this might seem obvious and simple - if, like me, you’ve dieted a lot, it can (initially) be difficult. It’s based on 10 core principles:

Rejecting diet culture: Proactively removing all traces of diet culture from your life (e.g. social media, books, “diet” foods, throwing away your scales!)
Getting to know your hunger: learning to feel when you’re hungry and then, get this: EATING 😱
Letting go of food rules: Give yourself unconditional permission to eat the foods you normally avoid. Once they’re not “forbidden”, you’ll likely crave them less.
Finding pleasure in food: Food is AMAZING - allow yourself to enjoy it. Focus on what you love about what you’re eating.
Challenge the food police: That’s the little voice in your head that makes you feel guilty or tells you you’ve been “bad” because of what you’ve eaten. Reframing these thoughts can help.
Cope with your emotions with kindness: If you struggle with emotional eating, be kind to yourself, identify other coping strategies, but also accept that “emotional eating” is actually OK!
Body compassion: Bodies are different sizes and shapes. Reflect on your beliefs about yours and other people’s bodies (following lots of fat women on socials helped me!)
Feel your fullness: Once you’ve worked on the above, work on recognising when you are comfortably full.
Intuitive movement: Move your body in ways that bring you joy, not with the intention of shrinking it.
Gentle nutrition: eat enough, try to achieve some balance between food groups and enough variety, be flexible to your life’s demands, and think about adding things in rather than taking away (e.g. adding in veggies rather than substituting carbs for them).

These principles are based on Tribole & Resch’s original intuitive eating principles, and Laura Thomas’ slightly revised version (which you can read about in her book).

Intuitive movement

Joyful movement and intuitive movement are approaches to physical activity which focus on tuning into your body's signals and responding to them, rather than adhering to a strict workout schedule or program. Rather than thinking about what you should do, instead focus on how your body feels to determine what to do, how much, and for how long. This piece from Katherine Kimber gives a really good overview of how to get started, including:

Focus on how you feel, during and after the exercise
Forget weight loss, and focus on the health benefits exercise will give you (you might even want to cover up the “calories burned” number on your treadmill!)
Make it enjoyable - choose activities you love, mix it up to get a variety, listen to music/a great podcast, and get rid of trackers.
Make a plan for how you’ll fit exercise into your day - but don’t be super detailed or rigid
Rest, if that’s what your body needs (sometimes a lie in will be better for you than a run!)

“Prescribed” or functional exercises

This category of behaviours most experienced by people living with or recovering from a disability, health condition, or injury. Essentially, it’s a specific type of exercise you might “need” to do, for the health and functioning of your body. Perhaps you’re perimenopausal, and have been told you need to do strength training, or your physio has given you rehab exercises, or you live with a joint condition and need to do regular resistance training to maintain function. When we’re in these situations, we often know what we should be doing, but haven’t quite got the hang of doing it on a regular basis - something that the evidence suggests is a common problem.

The how

So if that’s some of the “what”, how do we actually get people starting and maintaining behaviours like these?

Prescribed or functional exercises

For prescribed or functional exercises, there is a lot of evidence on how to improve adherence. Techniques such as social support, goal setting, providing demonstration or instruction for the behaviour, and rehearsing the behaviour might help people adhere to them. What’s not yet clear is whether behaviour change techniques like these are commonly used in clinical practice - i.e. are they actually being used with patients. There’s also a bit of a disconnect between these types of exercises, and the “intuitive movement” approach outlined above - given that there isn’t a lot of choice, and they may not feel “joyful”.

Therefore, the “how” that I’m keen to explore here is:

Bringing existing evidence-based behaviour change techniques into the hands of more people (e.g. by getting more providers using them)
Blending some of the learnings from an intuitive movement approach to these types of exercises. It might seem challenging to make stretches and squats fun, but I suspect that tapping into motivation using things like Self-Determination Theory might help (more on this in the future!).
- In my own personal case study, I would say that the Chimera Health programmes do an excellent job of increasing the level of challenge to really tap into our need for competency and mastery.

Intuitive approaches

In diet and exercise more generally, “evidence-based” interventions tend to commonly use techniques such as goal setting (e.g. aiming to lose a certain amount of weight, or to meet a step goal) and self-monitoring (e.g. weighing yourself, keeping a food diary, or wearing an activity tracker). However, the evidence on how well techniques like this work is mixed.

The thing that I’m more interested in is whether these commonly used techniques are applicable in this weight-neutral, intuitive paradigm. Techniques like monitoring weight and physical activity levels, and setting goals around these, feels very much at odds with the frameworks of intuitive eating and movement. Can they therefore be adapted to this paradigm, or should we be looking for something else altogether? We could say that “these things are intuitive, so we don’t need to actively use behaviour change strategies - but it’s worth acknowledging that while these “new” ways of eating and moving might be “enjoyable” in some way, it still takes active work, because:

It could be very different from what we’ve done before (especially if we’ve been ingrained in diet culture), and take some work to “unlearn” old habits and “relearn” new ones
Life gets in the way - so even when we actively enjoy something, work/time/family commitments might make it more difficult
Other, passive but appealing activities can draw our time and energy (I’m looking at you, Instagram)

Some initial thoughts I have about applying behavioural science in this area:

We could focus on the active work required for adopting these intuitive approaches e.g. setting goals and celebrating achievements for doing a chapter in your intuitive eating workbook
Use things like self-monitoring for some of the “noticing” and interoceptive activities required - e.g. making a note of how you feel after every exercise session
Where we’re asking people to make plans for their behaviour (e.g. I’ll go for a run after work), also use “coping plans” to allow for flexibility (e.g. if I’m tired, then I’ll go for a short walk instead - just as much as I can manage)
Setting goals around experimenting to what works for you (e.g. set a goal to try 3 new types of exercise over the next 2 weeks, then reflect on what you most enjoyed)

Some providers are already actively using behaviour change techniques and strategies - for example, Laura Thomas’ intuitive eating workbook, “How to Just Eat It” includes various practical reflection activities, and journaling (a kind of self-monitoring). I’d be really keen to understand how people engage with these activities (if you have experience of this, please let me know!)

Which path to take?

So my intention was originally to focus just on the “how” - but is it enough?

It’s the space I have the experience to contribute to, as a behavioural scientist - I am definitely not a physical therapist or nutritionist/dietician. The way I would do this is to either:

Work via existing providers, providing them with the tools and frameworks to enhance their work - or by using their amazing content (with permission, of course!)
Support people who already have the “what” nailed - i.e., they know what they need/want to do, but they’re struggling to put it into action.

But there is also a possibility of engaging with the “what” myself - this would probably require quite a bit of extra training, but would potentially mean that I can have more impact.

So what do you think - is the “how” enough for me to focus on? Reply and let me know!