Research Questions

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course health behaviour Lecture 1
Introduction
Falko Sniehotta, T8 William Guild
Buildingf.sniehotta_at_abdn.ac.uk
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In this course you will learn

• How health behaviour can be described, explained
  and changed using psychological theory
• How to apply this knowledge in behavioural
  domains taking domain specific knowledge into
  consideration
• How understand research contributing the evidence
  we need to address public health challenges

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Requirements for this class

• Read the recommended reading before the lecture ?
  Web CT
• Answer 2 questions about the reading/lecture each
  week
• This is the best possible preparation for your
  exam (11x2 answers).
• Be on time for the Lectures
• Attend, communicate participate
• ? Other courses may require less ongoing effort

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Literature and secondary readings

• I will suggest one paper as background reading
  for each lecture.
• The reading for lecture 1 (today) is not
  compulsory
• Text book
• Conner Norman (2005), Predicting Health
  Behaviour Research and Practice with Social
  Cognition Models In heavy demand.

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Why health psychology? Diseases have changed in
last 100 years. Now, disease is often caused by
behaviour
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Health Behaviour - Mortality and
MorbidityAlameda County Study / Alameda County
Human Population Laboratory

• 7 health behaviours
• - sleeping 7-8 hour a day
• - having breakfast every day
• - not smoking
• - avoiding snacking
• - ideal body weight
• - moderate or no use of alcohol
• regular exercise
• Belloc Breslow (1972), Belloc (1973)
• Belloc, N. (1973) Relationship of health
  practices and mortality. Preventive Medicine, 2,
  6781.
• Belloc, N. and Breslow, L. (1972) Relationship of
  physical health status and health practices.
  Preventive Medicine, 1, 409421.

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The more health practices followed the less
chance of dying in next 5.5 yrs , i.e., health
practices strongly predict survival
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US Mortality, 2001
No. of deaths
of all deaths
Rank
Cause of Death

• 1. Heart Diseases 700,142 29.0
• 2. Cancer 553,768 22.9
• 3. Cerebrovascular diseases 163,538 6.8
• 4. Chronic lower respiratory diseases 123,013
  5.1
• 5. Accidents (Unintentional injuries) 101,537
  4.2
• 6. Diabetes mellitus 71,372 3.0
• 7. Influenza and Pneumonia 62,034 2.6
• 8. Alzheimers disease 53,852 2.2

Source US Mortality Public Use Data Tape 2001,
National Center for Health Statistics, Centers
for Disease Control and Prevention, 2003.
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Further analysis (Mokdad et al., 2004 McGinnis
Foege, 1993)

• Review of epidemiological, clinical, and
  laboratory studies linking risk behaviours and
  mortality published 1980 to 2002.
• Prevalence and relative risk were identified
  during the literature search.
• Mortality data reported to the Centres for
  Disease Control and Prevention were used to
  identify the causes and number of deaths.
• The estimates of cause of death were computed by
  multiplying estimates of the cause-attributable
  fraction of preventable deaths with the total
  mortality data.

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Results (Mokdad et al., 2004 McGinnis Foege,
1993)

• The leading causes of death in 2000 were
• Smoking tobacco (435 000 deaths 18.1 of total
  US deaths)
• Poor diet and physical inactivity (400 000
  deaths 16.6)
• Alcohol consumption (85 000 deaths 3.5).
• Other actual causes of death were
• sexual behaviours (20 000), and
• illicit use of drugs (17 000).

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While smoking is on the decline, physical
inactivity and poor diet are becoming more
prevalent

• The most visible indicator for this trend is the
  obesity epidemic

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Body Mass Index (BMIkg/m2)
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Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
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Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
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How does behaviour affect health?Generic causal
model by Hardeman et al. 2005
? Determinants ? Behaviour ? Physiology
? Health
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The Diabetes Prevention Program A Randomized
Clinical Trial to Prevent Type 2 Diabetes in
Persons at High Risk The DPP Research Group
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Diabetes mellitus type 2

• What is diabetes and what causes Type 2 diabetes?
• Diabetes occurs when the level of glucose (sugar)
  in the blood becomes too high. Normally, after we
  eat, various foods are broken down in the gut
  into sugars which are then absorbed into the
  body. The main sugar is called glucose. To remain
  healthy, your blood glucose level should not go
  too high or too low. A hormone called insulin
  helps to take glucose from the bloodstream into
  various cells of the body. This helps to keep the
  blood sugar normal.
• Insulin is made in the pancreas. In Type 2
  diabetes you either do not make enough insulin
  for your bodys needs, and/or the cells in your
  body are not able to use the insulin properly.
  Type 2 diabetes usually first develops after the
  age of 40. It tends to run in families. It is
  more common in people who are overweight. It is
  also more common in African, Afro-Caribbean and
  Asian people.
• Possible long term complications which may
  develop
• Even a mildly raised glucose level which does not
  cause any symptoms in the short-term can affect
  the blood vessels in the long-term. This may lead
  to complications (often years after diabetes is
  first diagnosed). These include an increased
  risk of heart disease, stroke and poor
  circulation eye and vision problems kidney
  damage nerve damage serious foot problems
  impotence. In general, the risk of developing
  complications is reduced if the blood glucose
  level is well controlled, and other risk factors
  such as high blood pressure are dealt with.

http//www.patient.co.uk/showdoc/27000151/
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Feasibility of Preventing Type 2 Diabetes

• There is a long period of glucose intolerance
  that precedes the development of diabetes
• Screening tests can identify persons at high risk
  
• There are safe, potentially effective
  interventions that can address modifiable risk
  factors

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Modifiable Risk Factors for Type 2 Diabetes

• Obesity
• Body fat distribution
• Physical inactivity
• Elevated fasting and 2 hr glucose levels

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DPP Primary Goal

• To prevent or delay the development of type 2
  diabetes in persons with impaired glucose
  tolerance (IGT)

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Study Design

• 3-group randomized clinical trial
• 27 clinical sites
• Standardized across clinics
• Common protocol and procedures manual
• Staff training
• Data quality control program

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Diabetes Prevention Program Clinics
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Eligibility Criteria

• Age gt 25 years
• Plasma glucose
• 2 hour glucose 140-199 mg/dl (7.8- lt11.1 mmol/L)
• and
• Fasting glucose 95-125 mg/dl (5.3- lt7.0 mmol/L)
  
• Body mass index gt 24 kg/m2
• All ethnic groups
• goal of up to 50 from high risk populations

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Study Interventions
Eligible participants Randomized Standard
lifestyle recommendations
Intensive Metformin
Placebo Lifestyle (n 1079) (n 1073)
(n 1082)
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Primary Outcome Diabetes

• Annual fasting plasma glucose (FPG) and 75 gm
  Oral Glucose Tolerance Test
• FPG gt 126 mg/dL (7.0 mmol/L) or
• 2-hr gt 200 mg/dL (11.0 mmol/L),
• Either confirmed with repeat test
• Semi-annual FPG
• gt 126 mg/dL, confirmed

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Lifestyle Intervention

• An intensive program with the following
  specific goals

• gt 7 loss of body weight and maintenance of
  weight loss
• Dietary fat goal -- lt25 of calories from fat
• Calorie intake goal -- 1200-1800 kcal/day
• gt 150 minutes per week of physical activity

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Lifestyle Intervention Structure

• 16 session core curriculum (over 24 weeks)
• Long-term maintenance program
• Supervised by a case manager
• Access to lifestyle support staff
• Dietitian
• Behavior counselor
• Exercise specialist

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The Core Curriculum

• 16 session course conducted over 24 weeks
• Education and training in diet and exercise
  methods and behavior modification skills
• Emphasis on
• Self monitoring techniques
• Problem solving
• Individualizing programs
• Self esteem, empowerment, and social
  support
• Frequent contact with case manager and DPP
  support staff

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Post Core Program

• Self-monitoring and other behavioral strategies
• Monthly visits
• Must be seen in person at least every two months
• Supervised exercise sessions offered
• Periodic group classes and motivational campaigns
  
• Tool box strategies
• Provide exercise videotapes, pedometers
• Enroll in health club or cooking class

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Interventions
Medications
Metformin- 850 mg per day escalating after
4 weeks to 850 mg twice per day Placebo-
Metformin placebo adjusted in parallel
with active drugs
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Lifestyle Intervention Physical Activity
Results

• 74 of volunteers assigned to intensive lifestyle
  achieved the study goal of gt 150 minutes of
  activity per week at 24 weeks

The DPP Research Group, NEJM 346393-403, 2002
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Mean Change in Leisure Physical Activity
Lifestyle
Metformin
Placebo
The DPP Research Group, NEJM 346393-403, 2002
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Mean Weight Change
Placebo
Metformin
Lifestyle
The DPP Research Group, NEJM 346393-403, 2002
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Percent Taking gt 80 of Prescribed Dose of Coded
Medication
The DPP Research Group, NEJM 346393-403, 2002
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Incidence of Diabetes
Placebo (n1082)
Metformin (n1073, plt0.001 vs. Placebo)
Lifestyle (n1079, plt0.001 vs. Metformin ,
plt0.001 vs. Placebo)
Risk reduction 31 by metformin 58 by lifestyle
The DPP Research Group, NEJM 346393-403, 2002
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Effect of Treatment on Incidence of Diabetes

• Placebo Metformin Lifestyle
• Incidence of diabetes 11.0
  7.8 4.8
• (percent per year)
• Reduction in incidence ----
  31 58
• compared with placebo
• Number needed to treat ---- 13.9
  6.9
• to prevent 1 case in 3 years

The DPP Research Group, NEJM 346393-403, 2002
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Diabetes Incidence Rates by Sex
The DPP Research Group, NEJM 346393-403, 2002
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Time for your questions and suggestions
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Boredom can cause smoking
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Smoking is one of the main causes of death in the
UK

• Active and passive smoking can cause health
  damage.
• Every year around 114000 people in the UK die
  from smoking related illnesses
• Conditions caused by smoking include
• cancers of the lung, mouth, throat, larynx
  oesophagus, bladder, kidney, pancreas and
  stomach,
• coronary heart disease
• stroke and
• chronic bronchitis and other lung conditions.

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Prevalence of smokers in the UK(General
Household Survey, 2002)
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Smoking in the UK
Prevalence of cigarette smoking by age and sex,
2002/03,
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Toxic substancesbio-medical or behavioural model?
behaviour determines health significance
laburnum
tobacco
yew taxus
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Smoking and Gender
Percentage of adults who smoke cigarettes by
sex, GB
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Cessing is possible

• Between 1950 and 1990 the prevalence of smoking
  in the UK decreased by 50
• More than 10 Million British smokers have cessed.
  
• NHS Scotland smoking cessation support
  http//www.canstopsmoking.com/

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Smoking cessation

• For every continued year of smoking over the age
  of 40 yrs, the average smoker loses 3 months of
  life expectancy.
• There is strong evidence from high-quality
  randomised controlled trials to show that
  currently available treatments improve the
  chances of a cessation attempt succeeding
  permanently by between 2.5 and 10 points. For
  each success this brings forward quitting by an
  average of 2530 yrs.
• The major factor limiting the public health
  benefit of treatments to aid cessation is the
  numbers of smokers that use them. At present, the
  most effective treatment combination of
  behavioural support plus medication is used by a
  very small minority of smokers.
• In England (UK), the use of smoking cessation
  treatment in 2008 is expected to save 270,000
  life-years. A major priority for tobacco control
  should be finding ways of encouraging more
  smokers to use the most effective treatments.

R. West and J. Stapleton, 2008
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Physical activity in Scotland
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Scottish Health Survey, 2003
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Barriers towards physical activity
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Behavioural Risk Factors are Modifiable. However,
it is very difficult to change them.
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It is all about behaviour

• Behaviour as determinant of health Health
  behaviour and risk behaviour
• Behaviour as health outcome
• Disability
• Workableness
• Activity limitations
• Participation