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By Dr Rebecca Mathews MAPS, Dr Helen Lindner FAPS and Angela Nicholas

Introduction

The current climate in Australian health is one of increasing concern about the sedentary habits and weight problems of the general population. Embedded within this are serious concerns about epidemic rates of diabetes and obesity (Zimmet & James, 2006). In the general population these concerns have resulted in an increased awareness of the need to monitor health behaviour. Research shows that most people at some point in time have indicated an intention to change something about their eating habits or activity levels. Given this increased community focus on health behaviour, it is important for health professionals to have an understanding of how individuals work to change their health behaviour and the challenges they face.

This year's National Psychology Week (NPW) survey investigated two aspects of health behaviour: eating habits and physical exercise. An online survey was developed to gain information on the process individuals undertake when making changes to eating habits and physical activity, their level of success in making and maintaining changes and the strategies they adopt.

Levels of success in achieving behaviour change

A total of 1,289 people completed the survey (751 females, 129 males, and 409 who did not specify their gender). Almost all respondents (97%) indicated that they had at some time attempted to change their eating habits. Fewer participants reported having attempted to change their physical activity (73%), although this still represents a large proportion of the sample.

The extent to which participants reported having succeeded at changing their eating habits is presented in Figure 1. Only 2 per cent of respondents did not make the intended change. For 22 per cent of participants trying to change their eating habits, the change lasted no longer than a few weeks or months before they lapsed back into old habits, and 39 per cent reported that, although they generally feel they have made the change, they do not always stick to it. Nevertheless, 26 per cent of participants had maintained the change for longer than six months and 12 per cent of participants, who reported having changed their eating habits in the last six months, were maintaining the change.

Figure 1: Level of success reported by participants following an attempted change of eating habits.

With regard to changing physical activity, again only a very small proportion of participants reported not having made the change at all (2%), and 20 per cent of participants reported having made the change but it lasted only a few weeks or months. A larger group of participants (30%) reported that they made the change but do not always stick to it. However, 14 per cent of participants who changed their physical activity up to a period of six months ago reported having maintained the change and 33 per cent of participants reported having changed something about their physical activity over six months ago and have continued to maintain the change. These results are presented in Figure 2.

Figure 2: Level of success reported by participants following an attempted change of physical activity.

 

Participants’ weight characteristics

The need for greater success in achieving lifestyle change was clearly evidenced by other Figure 3: The percentage of participants grouped into the categories underweight, normal weight, overweight and obese based on their BMI score.survey results. Eight hundred and twenty four participants provided information that enabled a Body Mass Index (BMI) to be calculated. A BMI is a mathematical formula using height and weight measurements that provides a general indication of whether weight falls within a healthy range. Less than half of the participants (44%) recorded a BMI in the normal weight range. A small number of participants were underweight (2%) according to their BMI. However, a considerable number of participants had a BMI identifying them either as overweight (31%) or obese (23%). The percentage of participants falling into these groups is depicted in Figure 3. Given the small number of participants in the underweight group this group was not included in statistical analyses reported.

Figures for overweight individuals are consistent with those recently released by the Australian Government (Biggs, 2006) where it was reported that 32 per cent of adults met criteria for being overweight in the period 2004 to 2005. However, the number of individuals in the current study who were classified as obese is higher than the 16 per cent of the population indicated in the Australian Government report. This difference could be due to the specific characteristics of the participants in the present sample, who responded to recruitment for an online survey on eating and physical activity behaviours.

Participants were asked to state whether they currently have a problem with their health, weight, or level of fitness. Those whose BMI placed them in the obese group generally acknowledged their weight difficulties (89%), whereas only just over half (53%) of the overweight group reported having a weight problem, and 17 per cent of those whose BMI placed them in the ‘normal' weight range reported that they had a weight problem. For the normal weight group this may have been a recognition that they had difficulty maintaining a healthy weight.

A higher number of individuals in the obese group reported a problem with their fitness (73%) when compared to the overweight (59%) and normal weight groups (39%) [X2(2) = 64.56, p <.000]. When considering general health, fewer participants acknowledged a health problem (obese group = 53%; overweight = 33%; normal weight = 24%) [X2(2) = 47.86, p < .000]. Such findings indicate that many individuals, especially in the obese group, do not perceive that they are overweight, have a fitness problem, or have a general health problem.

Coping and emotional responses

The online survey also included the Health Assertiveness Scale (Braun, 2004), a standardised scale of coping ability. A significant positive relationship was found between respondents' level of coping and their success in changing both eating habits (r = .390, p < .000) and physical exercise (r = .459, p < .000). While these results cannot be interpreted as improved coping leading to success, as this is likely to be a circular relationship, they do nevertheless emphasise a need to further explore the importance of the development of specific coping skills for successful behaviour change.

A series of one-way between groups ANOVAS explored the outcome for different BMI groups on measures of coping, negative emotions (such as anxiety, anger and low mood), self-esteem, expected outcomes from making changes in health behaviour and perceptions of risk associated with not changing health behaviour. Due to the large number of comparisons, a conservative criteria (<.001) for significance was used to reduce the experiment-wise Type 1 error rate. Results of these analyses are reported in Table 1.

A significant difference between the BMI groups was found on a number of measures. The groups differed significantly on a general measure of health coping. When considering responses related to attempts to change eating habits, the groups differed significantly on measures of self-esteem, negative emotions, perception of health risk in not changing behaviour and expected outcomes. In looking at responses to changing physical activity the groups were significantly different on measures of self-esteem and on the perception of health risk in not changing behaviour. In addition, there was a significant difference between the BMI groups on the reported level of success in changing both eating habits [F (2,799) =8.023, p <.000], and physical activity [F (2,781) =5.174, p =.002]. Post hoc tests (using the Tukey HSD test) identified that on all measures the obese group differed significantly from the other groups in the direction shown by the means.

These results demonstrate the greater levels of negative mood, lower self-esteem, and poorer health behaviours reported by individuals with obesity than other individuals. While everyone is likely to benefit from professional assistance to change health behaviour, the findings suggest that those individuals who are obese are likely to be most in need of professional assistance such as that offered by psychologists who are trained experts in both behaviour change and mental health.

Table 1: Means, Standard Deviations and statistical values for the normal weight, overweight and obese groups on coping, self-esteem, perception of risk and outcome expectancy.

Strategies for change and professional help seeking

Figures 4 and 5 provide the results on the types of strategies participants reported using to change eating habits and physical activity. For both eating habits and physical activity, ‘willpower' was described as the strategy most often used, with ‘joining a gym or sporting group' also high on the list for both health behaviour changes.

 

Figure 4: The proportion of participants reported to have used these strategies to assist in changing eating habits.    Figure 5: The proportion of participants reported to have used these strategies to assist in changing physical activity. 

 

Despite a large proportion of those responders attempting to change their behaviour being unsuccessful in the long term, only a small percentage had sought professional help when trying to make their behaviour change. Over half of the participants (55%) did not seek any professional help to change their eating habits. Figure 6 shows results for participants seeking professional help to change eating habits. Those who did seek professional help were most likely to get help from a weight loss organisation (12%), a personal trainer or gym instructor (12%), or a medical practitioner (10%). Surprisingly, fewer people sought help from professionals who are more highly trained experts in health education or in changing health behaviour such as a dietitian (7%), or a psychologist (3%).

Similarly, few people who reported attempting to change physical activity sought professional help to do this. As seen in Figure 7, the professional help most likely sought was from a personal trainer or gym instructor (17%), with fewer people reporting having sought help from a weight loss organisation (2%) or a medical practitioner (3%). Again few people sought help to change physical activity from specialists such as psychologists (1%), exercise physiologists (1%) and dietitians (1%).

Participants also provided a range of open-ended responses identifying the approaches used by professionals that they found helpful. Although a small proportion of participants reported that they received information about useful strategies and techniques to change health behaviours, the majority of respondents identified that they received nutrition or physical activity-specific information. Participants rarely mentioned tips about how to implement these recommendations. That is, they tended to report receiving information about what it is they should be doing, but did not mention receiving any information on how to put strategies for change into practice.

The low use of psychologists to assist with behaviour change may indicate that psychologists are not perceived as professionals able to assist in behaviour change, that they are not readily thought of as a source of this expertise, or that they are less accessible for this purpose than others (such as gym instructors and weight loss organisations). This under-utilisation of psychologists for assisting in behaviour change occurs despite research evidence to suggest that individuals who undergo lifestyle-behaviour change programs achieve more sustained behaviour change outcomes. Such programs include those with a cognitive-behavioural focus (such as psycho-education, goal-setting, strategies for overcoming barriers, relapse prevention strategies), and those involving motivational interviewing techniques (Arkowitz & Westra, 2004).

 

Figure 6: Proportion of participants seeking various types of professional help for changing eating habits.    Figure 7: Proportion of participants seeking various types of professional help for changing physical activity. 

 

Promoting the role of psychology in assisting behaviour change

The survey results highlight the difficulties individuals experience in making and maintaining behaviour change. The findings also demonstrate the under-utilisation of psychologists to assist in this process. The important contribution that psychologists can make in lifestyle change appears to be overlooked or not well understood by the community. There is a need to promote recognition of the role of psychologists in the physical health domain. In addition, respondents' comments suggest a lack of useful implementation strategies provided by many of those professionals who were utilised. Psychological strategies aimed at increasing motivation to change, in addressing barriers to change and in enhancing maintenance of change, are important treatment options provided by psychologists.

The survey findings suggest that psychologists need to continue to campaign for increased recognition of the role of psychology in the health domain. Psychologists have an important role in multidisciplinary teams working closely with other professionals such as dietitians and exercise physiologists. At an organisational level we need to continue to promote the role of health psychology to Government, medical practitioners and allied health professionals, and in multi-disciplinary health research.

On an individual level, psychologists with specialised training in health behaviour change should continue to promote their own expertise, and encourage more wide-spread knowledge of health psychology as a growth area. Psychologists can communicate directly with GPs, practice managers and other health professionals to inform them of the role a psychologist can play in assisting their patients to improve their health outcomes.

References

Arkowitz, H., & Westra, H. (2004). Integrating motivational interviewing and cognitive behavioural therapy in the treatment of depression and anxiety. Journal of Cognitive Psychotherapy, 18, 337-350.

Biggs, M (2006). Overweight and obesity in Australia E-Brief: Online Only issued 5 October 2006. Retrieved 23 October 2006 from www.aph.gov.au/library/INTGUIDE/SP/obesity.htm.

Braun, K. (2004). The role of illness perceptions, depression, anxiety, and health assertiveness, and the impact of CBT intervention on attendance and adherence to cardiac rehabilitation programs. Unpublished DPsych thesis, La Trobe University, Bundoora, Victoria, Australia.

Zimmet, P. Z., & James, W. P. T. (2006). The unstoppable Australian obesity and diabetes juggernaut. What should politicians do? The Medical Journal of Australia, 185, 187-188.