Thursday, 29 January 2015

Information Prescriptions for Diabetes - Backward or Forward Step?

At first glance, the information prescriptions for diabetes, launched this week, seem like a great idea. Take someone who attends their GP with blood glucose/cholesterol/blood pressure levels that don’t match the recommended targets and give them a takeaway - a bright, shiny A4 sheet describing how they can do better. Simple! And very quick, the all-important consideration for many hard pressed primary care professionals.

So that’s that problem solved, then.

The trouble is, as many of us know only too well, that a fix like this is highly unlikely to make much of a difference to the underlying reasons why someone might have these high levels – whether it’s because of the stresses of coping with difficult family or work circumstances (supporting your sister who’s ill with cancer, or looking after your grandchildren 3 days a week so your son can make ends meet with 3 jobs) or by actual choice (the schoolteacher of a class of 5 year olds who needs to make sure he doesn’t have a hypo during lessons).

We also know that ‘one size doesn’t fit all’. For some, the written word is easy and a pleasure, for others, torture and incomprehensible. And in any case, with all the other bits of paper that often accompany a medical appointment, will it see the light of day again from the pocket or bag it’s been placed in, once the person exits the building?

For many, information prescriptions will be offered after discussion and in response to specific questions that might be raised, and that is of course, the intention. However, for equally many others, they may be seen as a convenient way of ‘solving’ a clinical problem and ticking a box that flashes up on the computer screen – ‘this person needs an information prescription. Tick here when completed’. We hear that information prescriptions have been well received by people with diabetes and health professionals in the areas where the scheme was piloted. This is welcome news, but as is well-known, finding people to approve a development in a research situation and in ‘real life’, are not the same thing.

The medical model is one where people are told what to do by health professionals and expected to do it. This works really well for acute conditions, where there is relief in sight in quite a short time and / or the immediate consequences may be dire if instructions are not followed. For example, taking antibiotics for a severe infection that might otherwise result in hospital care being needed. To use a diabetes example, taking increased amounts of insulin with very high blood glucose levels during illness, to avoid life-threatening ketoacidosis in Type 1 diabetes.

The medical model is no good at all for helping someone live with a long term condition like diabetes, that depends mostly on self management, day in, day out. People with it need to make multiple daily decisions, choices and act accordingly, without a doctor or nurse’s say-so, or even in sight. The skills people need to make these decisions are usually not included in the ‘top down’ approach the medical model embraces.

Information prescriptions smack far too much of the medical model. What happens if people still have less than desirable (from the health professionals’ point of view) numbers next time, post-information prescription? Will they simply be issued with another, and another until they finally ‘obey’? or will they be cast out of the door, not to return until they have sorted themselves out to the satisfaction of the health professionals? Equally, what about those who would like the information contained in the prescriptions, but are ‘well controlled’? do they miss out on having their questions answered because they are not deemed ‘bad enough’ to qualify for an information prescription?

A way forward is not to medicalise even further, the encounter between someone living with diabetes and their health professional, when it comes to meeting the challenges of daily life. Rather, it’s to personalise things more. A really quick start to this, using the information prescription model, might be to have a message flashing up on the health professionals’ computer screen that incites them to congratulate a person who has achieved the recommended targets and discuss their success and how they might maintain it.

Thankfully, there is a model, which is gradually achieving recognition and implementation support in NHS circles. It’s known as personalised care planning, or PCP, which we’ve talked about and promoted on many occasions, as a system-wide solution to appreciating that people themselves are in charge of their condition and the choices they make each day are the only ones that will make a difference to the resulting ‘numbers’.

The job of the health professional in PCP is not to pontificate, order, tell, force or even cajole the person into submission to their will, but to share their ‘numbers’ with them and invite them to identify their own problem areas, goals and ways they wish to address them. Only through this process can they get anywhere close to addressing what, on the surface may look like a ‘non compliant diabetic’.

Information is everywhere and people can choose what works for them best. What’s needed is not a prescription, but a menu and support to explore it, and continued discussions of what’s worked in subsequent consultations. Fortunately, the idea of a local ‘menu’ is included in personalised care planning guidance recently published by NHS England, and is already being used in some areas. In the meantime, our own ‘SD Signposts’ is available for anyone to download and start to use, according, if they wish, to their personal learning style.

Health professionals may find more benefit from moving from information ‘prescribing’ to people with diabetes, to information ‘sharing’, which will be much more effective, not only for reducing the clinical ‘numbers’, but also frustration and time spent ‘telling’ – that’s our prescription for guaranteed satisfaction!

Monday, 26 January 2015

The Blueprint to Weight Loss?

In our first guest blog, clinical psychologist and specialist in emotional eating, Dr Jen Nash gives us plenty of ‘food for thought’!

We are in the midst of an overweight and obesity epidemic and whilst current health education messages are doing well to raise our awareness of the need to ‘eat less and move more’, we know for every person who can implement this advice, there are many more who struggle. This leads to a sense of failure and increased hopelessness, for both the individual who is overweight, and the healthcare professionals involved in their care, who quickly reach the limits of their perceived ability to help them.

Traditional medical and diet advice seems to treat weight loss as if it is a logical, rational process – for example, there is often an assumption that education alone leads to behaviour change. But knowledge doesn’t always lead to desired change, does it? How do we know this? Partly because many NHS health care professionals themselves struggle as much as those who they help – if not with their weight, then perhaps with their choices around alcohol, exercise, nicotine and other health decisions.

If we are increasingly aware of what we ‘should’ be doing to care for our health, what gets in the way of being able to implement these recommendations? Oftentimes we will sigh, “I’m just not motivated”.

I’d like to suggest that you ARE motivated! You don’t usually have to ‘motivate’ yourself to get dressed in the morning, or clean your teeth, or kiss your child goodbye, or turn up for work. You probably don’t talk about ‘getting motivated’ to do these tasks of life. Why? Because these activities are in line with your identity, your self-esteem and your values. You value your child feeling loved as they go to school, so you organise yourself to wave her off in the morning. You value not breathing your garlic breath from last night’s dinner on your colleagues, so you organise yourself to make time to brush your teeth in the morning!

So we are all motivated to do EXACTLY the right thing for us, given not just one, but two aspects of our experience:
1. Our knowledge + information
2. Our emotions + values

Medical and health educational models are great at the first part – imparting knowledge and information - but where in our health care settings are we talking about emotions and values?

These conversations are largely absent when it comes to discussing diet and weight loss, yet it is our emotions and values that are the bridge between ‘knowing something’ and ‘doing it’. These are the guide to all our decisions in life; including our decisions about our health and what to eat. Psychological models address emotions, but access to a clinical psychologist for people with obesity, whilst recommended by national guidelines, is extremely limited in current services.

‘The EatingBlueprint’ is a novel way for non-psychologists to start addressing the psychology of weight loss, without the jargon and potential stigma of some of the traditional psychological approaches. It is based on a blend of evidence-based psychological therapies (including solution-focussed, dialectical, compassionate, mindfulness, cognitive-behavioural and attachment approaches, for those who are interested in the detail!).

The logic of the blueprint is that trying to simply follow a diet to create the body/weight you want, without looking at the emotional ‘mindset’ about eating, is like trying to build a house before laying the foundations.. Strong foundations are needed to build a house – and a blueprint is needed as a guide. The EatingBlueprint is designed to support the development of the emotional mindset foundations necessary for both weight loss success and maintenance. To continue the analogy, the blueprint for the house’s foundations contains rooms, and in the EatingBlueprint, these ‘rooms’ are:

1. Forgiveness
2. Focus
3. Fun
4. Feelings
5. Foresight
6. Fables
7. Framework
8. Future
Let me talk you through the ‘rooms’

1. Forgiveness
The blueprint begins by normalising the idea that it is difficult to lose and maintain a healthy weight. We are fighting a biological, psychological and environmental/social world that is set up to promote weight gain, and the person is not “wrong” or “bad” for being overweight. This step is designed to provide relief from shame and stigma and set the scene for an approach that isn’t about success or failure, rather one that involves self-discovery.

2. Focus
This area aims to encourage the noticing and overcoming of “mindless” eating. While it is usual to eat mindlessly for non-hunger reasons occasionally, we can be helped by the use of strategies to interrupt frequent mindless eating. This can be encouraged using a simple question: “WHY am I eating?” or, simply, “WHY?” WHY is an acronym that stands for:

Remembering to pause before eating is challenging – so, in the short term, the person is invited to use a reminder on their dominant hand or wrist (e.g. a charity band - members of the EatingBlueprint receive a subtle wrist band as a reminder). This is just a short-term strategy until the automatic nature of eating becomes interrupted.
This invites the person to ask themselves, “Am I really hungry? How physically hungry am I, on a scale of 0–10? If I’m not hungry, what AM I hungry for?” (e.g. for a break, as a reward, for a distraction, to cheer myself up or to bond with someone).
This relates to saying ‘yes’ to the food or ‘yes’ to whatever the person is truly hungry for. If the person is physically hungry, this involves saying “Yes” to food and eating. If the person is not truly hungry and still eats, that’s okay too. Change takes time and the act of simply pausing brings an awareness to what was an unconscious process.

The power in this area is to help the person to discover what they are truly “hungry” for and ask themselves whether they can get their hunger met by something other than food. In time, they can begin to say ‘yes’ to this identified need, instead of the food.

The areas of the blueprint that follow are designed to help increase the flexibility to choose between a range of responses to food.

3. Fun
Eating is pleasurable and entertaining and it can become “a friend”. The person may need help to look for ways to increase non-food sources of pleasure and entertainment when there is an urge to eat for non-hunger reasons.

4. Feelings
It is common to use food to “stuff down” emotions that are not easy to express. It is a skill to be able to express emotions authentically to both ourselves and others and we often need strategies to express emotions rather than to dull them with food. The EatingBlueprint provides a template for identifying and expressing feelings in ways other than through food.

5. Fables
These are the family stories and rules about food, spoken and unspoken. Phrases like “eat your vegetables before having dessert” and post-rationing sayings such as “don’t waste food” and “finish everything on your plate” have value, but we need to question the modern day utility of these ideas and create more helpful narratives that serve us.

6. Foresight
To continue to maintain a healthy we need to know ourelves, learn from previous life experiences and manage their thinking styles relating to food. This step encourages the person to plan ahead and learn from the “predictability of life” (e.g. Christmas and meals out) and think about how to use this self-knowledge to experiment with new behaviours. It also invites the person to challenge the “good/bad” rules of diets using cognitive behavioural therapy techniques.

7. Framework
Weight loss isn’t a solo journey. The impact of family influence, the physical environment and handling social events are all crucial. The person needs assertiveness skills to be able to say “no” to the “feeders” in their lives, and to spot the signs of sabotage, often by well-meaning but threatened loved ones. The blueprint aims to provide these skills.

8. Future
Weight loss is a skill, yet we don’t treat it as being in this paradigm. Like learning to drive a car, it is a process that requires coaching and facilitation, and “mistakes” and “slipups” are an integral part of the journey that need to be welcomed. The blueprint teaches how to “update the default” and stay solution-focused on the weight loss journey.

The Psychology of Weight Loss in the NHS
None of the areas of the EatingBluprint are 'rocket science', so why aren’t we systematically addressing them? Arguably, because obesity is treated within a medical model, and considered a medical/educational problem, not an emotional or psychologically related one. NHS Clinical Psychologists and therapists are generally limited to offering structured cognitive behavioural therapy (CBT), in an individual or small group format, as recommended by UK national guidelines, so these ideas aren’t particularly available to staff to utilise.

Do people struggling with obesity need to work with a Clinical Psychologist? Controversially, I say perhaps yes, because there is quite a body of evidence that suggests many who routinely use food for emotional regulation have a history of psychological issues. The incidence of trauma, childhood abuse, sexual abuse, low self-esteem and depression is high among people who are obese and in those presenting for weight loss surgery. Despite this, access to psychological services for obese people has been limited to screening for psychiatric disorders in preparation for bariatric surgery.

Whilst certainly surgery is an option for some, if we view obesity as (in part) a problem with emotions, then bariatric surgery is attempting to put a plaster on a very deep emotional wound. This may go some way to explain why this type of surgery is less successful than expected. Achieving and maintaining a healthy weight requires skills of emotional regulation and the ability to tolerate distress - in other words it takes a highly developed person. We need to widen the scope of clinical psychology and other health professionals working in the field of obesity, to empower people with:
• skills to be able to identify their emotions
• strategies to make a choice other than food

So the person is in control, not the food

Interested in finding out more about the EatingBlueprint?

The EatingBluerint is a 12-week online weight loss support programme, that empowers members to master their inner relationship with eating, through bitesize videos (10-30 mins each) with accompanying ‘experiments’ to implement new weight loss skills in daily life. If you’re someone struggling to lose weight, or a health care professional interested in using the EatingBlueprint method in your routine consultations, you can get your Free E-Course – ‘Why the F*** Are We So Fat?!’ by visiting the PsychBody website

Training workshops in the EatingBluperint Method can be organised by contacting Dr Jen Nash, Clinical Psychologist directly at or via

What do you think of Dr Jen’s ideas? Share your response and insights here and let’s discuss this important issue and this unique way of looking at it

Wednesday, 21 January 2015

Designer Diets - or Common Sense?

The recent BBC series investigating personalised diets made fascinating watching and seemed like very good science. People were tested for the type of eater they were and then asked to follow a diet that addressed their particular type. Briefly, the three types of eater were ‘emotional’, ‘constant craver’ and ‘feaster’. The people involved in the experiment seemed more than happy to accept their ‘diagnosis’ and all of them successfully lost weight.

More than that, there seemed to be a palpable sense of relief among the participants that there was a ‘real’ cause for them being overweight. For example, in the case of the ‘feaster’ group, there was an actual hormonal inbalance, which was demonstrated to be corrected with the recommended eating programme. For ‘constant cravers’, their genes played a large role, and ‘emotional eaters’ often had experienced loss or deprivation or developed particular meanings for food, that eating or ‘comfort eating’ helped them to deal with. For us, this was a real highlight. So often, being overweight or trying to lose weight is fraught with other peoples’ judgment, criticism or ‘quick fix’ answers, which can add to an already present sense of failure and self-blame and makes shedding the pounds much harder to achieve.

We don’t know if there was anyone with diabetes in the study – probably not, as those with existing medical conditions may well have been excluded for valid research reasons – but it occurred to us that the recommendations for each of the groups would be equally safe, even ‘generalisable', for anyone wishing to lose weight, whether to enhance their diabetes management or to prevent getting Type 2 diabetes, regardless of what type of eater they are.

This is where the ‘common sense’ bit comes in. All the diets and tips recommended in the programme are not the proverbial ‘rocket science’, but well known and tried and tested ways to lose weight, which have already worked for millions of people, regardless of their ‘eating type’.

You can take the BBC online test on the programme website to identify your eating type and read more about the whole project. However, it’s completely possible, as in our case when we took the test, that you don’t fit exactly into any category. Maybe, there is also a ‘mixed eater type’ group, where you recognise elements of each eating type in yourself, perhaps at different times in your life?

In this case, there may be a danger that the success of this programme and its findings that there may be a ‘designer diet’, might have the opposite effect and put those of us in the possible mixed category above, off dieting altogether, perhaps by creating a response such as ‘there’s no diet that will help me lose weight, so it’s not going to happen and so I might as well not bother trying’?

The truth is, that if you aren’t able to, or don’t want to, know which type of eater you are, but you do still want to lose weight, you may well benefit from the plans put forward for all of groups. So, while we celebrate the success of this new way of looking at losing weight and look forward to its follow-on findings, there’s also the equally massive message - don’t let not knowing your ‘eating type’, or not belonging to a particular designer group, put you off!

We’ve set out the principles that were recommended for the groups and in general below, so you can take your pick and give them all a try if you want, to see what combination works for you. There will be one!

For added motivation and inspiration, you might find our booklets ‘Tips for a Lively 2015’ and ‘How to Make your Healthy Living Wishes a Reality’ both useful and inspiring. They are completely free and available to download from our website now!

Principles for successful losing weight (brackets show the particular group a principle might help most)

• Always eat breakfast – can reduce cravings later in the day
• Eat slowly – helps your body tell your brain when you are full, via hormones (Feasters)
• Eat high glycaemic index foods – again helps to feel full for longer (Feasters and Constant Cravers)
• Get support from others – online, face to face or in groups (Emotional Eaters)
• Gain insight into what food and eating means for you and how you behave around food, including professional help if you need it (Emotional Eaters)
• Eat soup – helps to feel fuller - and very comforting!
• Try Intermittent Fasting – minimum 600 and maximum of 800 calories on each of 2 consecutive days a week and eating normally, but healthily as possible, for the rest of the week – stops you feeling ‘deprived’ of food (Constant Cravers)

Wishing you success in your dieting plans, whatever they involve!

Friday, 2 January 2015

Promoting Prevention

Wonderful news to start the year! NHS England's implementation intentions for the 'Five Year Forward View', the latest plan for the NHS, include a national prevention programme for Type 2 Diabetes. Work on this is to begin imminently this year and will be developed and delivered in partnership with Diabetes UK.

It's a hugely important development that yes, could save taxpayers' money through less burden on the NHS, but more importantly, save people themselves the emotional stress and further physical ill health that diabetes can bring. As someone with Type 2 diabetes once memorably told us, 'Type 2 diabetes doesn't come alone to the party, it also brings its friends'- unwelcome friends as it turns out, which include high blood pressure, raised cholesterol, heart, foot and eye problems.

Prevention has been shown to work. Identifying and making people aware they are at risk is the first step and to an extent, this is already being done in the form of the NHS health check. A prevention programme will build on this and actually DO something about the risk. Hopefully, people at risk will be given individual, practical and most importantly, motivating, support and opportunity to do what's needed, that is to become more active each week and to lose some excess weight if they have any. Granted, that can be hard for some people, but not nearly as hard as trying to deal with those unwelcome 'friends' at the diabetes party, further down the line.

We sincerely wish this programme every success, will be watching its evolution carefully and stand ready to promote its delivery. Happy 2015!