Ms Martine Stead's keynote speech 'Losing Weight...Voices of Success' at the SCPN's 'Be Active Against Cancer' conference, Tuesday 4th February 2014.

1. ISM Institute for Social Marketing
Losing weight:
Voices of success
in the BeWEL study
Martine Stead
Institute for Social Marketing
University of Stirling

2. Why BeWEL?
• Adenoma (polyp) increases risk of colorectal
cancer
• While adenoma is treatable, underlying risk
factors can lead to recurrence.
• Evidence that weight loss decreases risk of
adenoma recurrence (as well as risk of
diabetes and related conditions)
Adenoma detection and treatment is a
‘teachable moment’ when patients may be
particularly receptive to lifestyle change?

3. •Annie Anderson (PI)
•Robert Steele
•Shaun Treweek
•Jill Belch
•Fergus Daly
University of Dundee
•Jane Wardle
University College London
•Anne Ludbrook
University of Aberdeen
•Martine Stead
•Jennifer McKell
•Douglas Eadie
University of Stirling
MRC National Prevention Research Initiative:
•Joyce Thompson
•Jackie Rodger
NHS Tayside
•Tayside: Robert Steele
•Ayrshire & Arran: Robert Diament
•Forth Valley: Wilson Hendry
•Greater Glasgow and Clyde: Derek Gillon
NHS Site Collaborators
•Alison Kirk
University of Strathclyde

4. Study Design
• 3 year RCT (2010-2013)
• 4 NHS sites
• n=316 patients randomised (158
per group) to:
– 12 month BeWEL intervention
– Or usual care
 6 months   24 months   6 months 
Pre-trial
development
Recruitment, data collection
& intervention
implementation
Final data collection,
analysis &
interpretation

5. Formative research
• Patients need to:
– Be aware of the risk factors for adenoma
– Be able to relate these to personal behaviours
– To have a shared and accepted understanding of
lifestyle and CRC
• Importance of consultant endorsement

6. Intervention Design
• Three home visits by lifestyle counsellor
• Monthly telephone contacts for next 9 months
Baseline 12 months3 months
 3 Face-to-face
consultations 
 9 telephone consultations 

7. Counsellor Approach
• Use current behaviours (based on diet recall and
accelerometer data) to start discussion
• Identify areas of success vs. difficulties
• Identify implementation intentions in terms of
‘What’, ‘Where’ and ‘When’:
– eg. DIET: decreasing sugary drinks, red meat portions,
chocolate / confectionery or increasing water intake,
vegetable intake, low fat dairy products
– eg. PA: increased movement at work at leisure or in
the home or decreased inactivity at work, TV
watching, sleep time

9. Outcome Measures
• Change in body weight (not adenoma recurrence)
Primary outcome
• Change in:
• Waist circumference
• Cardiovascular risk factors (BP, lipids)
• Metabolic risk factors (glucose, HbA1c, insulin)
• Dietary intake (DINE)
• Physical activity (Accelerometry)
• Self assessed general health (SFQ12)
• Self-efficacy
• Programme acceptability to participants and staff
• Intervention cost
Secondary outcomes

10. Baseline and clinical characteristics at randomisation
Intervention
(n=163)
Control
(n=166)
All
(n=329)
Age (years)
Range
63.5 ± 7.0
50 – 75
63.6 ± 6.7
50 – 75
63.6 ± 6.8
50 – 75
Male gender 120 (73.6%) 123 (74.1%) 243 (73.9%)
Employment status
Retired
Employed full-time
Employed part-time
Unemployed
Other
90 (55.2%)
45 (27.6%)
18 (11.0%)
2 (1.2%)
8 (4.9%)
97 (58.4%)
41 (24.7%)
14 (8.4%)
10 (6.0%)
4 (2.4%)
187 (56.8%)
86 (26.1%)
32 (9.7%)
12 (3.6%)
12 (3.6%)
SIMD* (quintiles)
1 (most deprived)
2
3
4
5 (least deprived)
25 (15.3%)
33 (20.2%)
26 (16.0%)
39 (23.9%)
40 (24.5%)
29 (17.5%)
28 (16.9%)
33 (19.9%)
45 (27.1%)
31 (18.7%)
54 (16.4%)
61 (18.5%)
59 (17.9%)
84 (25.5%)
71 (21.6%)
Data are mean ± SD or number (%) unless stated otherwise. *Scottish Index of Multiple Deprivation

11. Primary Outcome:
Body Weight Reduction
[under review, please don’t quote results without permission]
• For more details please contact Professor
Anderson on a.s.anderson@dundee.ac.uk

12. Primary Outcome:
Body Weight Reduction
[under review, please don’t quote results without permission]
For more details please contact Professor
Anderson on a.s.anderson@dundee.ac.uk

13. Weight change in intervention and control
groups at 12 months
• For more details please contact Professor
Anderson on a.s.anderson@dundee.ac.uk

14. Feelings About Weight Loss:
Qualitative interviews
[under review, please don’t quote results without permission]
Changes to routine produced instant change
for some
“I couldn’t believe how it was coming off, just
going out they walks”.
“The weight they asked me to lose was seven
percent of your body weight, I think I done
that in the first two months”.

15. For some, self-monitoring provided structure and incentive
“I really was proud of myself coming back from holiday. I weighed
myself and I thought I’ve not put anything on. … I’m surprised at how
well I’ve done. That was a surprise. I really thought oh, will I make it?
But I am surprised that I have stuck to it, more than what I did when I
went to Weight Watchers”.
“I liked the fact that it gave me motivation to look
after myself better. I liked the fact that it gave me
goals. I liked the fact that when I would go on the
scales on a weekly basis and I had maybe just lost
that wee bit, the thrill it gave me. Oh you dancer!
[There was one time] they were a wee bit
disappointed with my exercise levels at that time,
and I was disappointed myself … so I made sure it
didn’t happen again”.

16. “I’ve still got young grandweans and I like taking
them to the park. I actually go on the slide.
When I was heavier I wouldn’t, for fear of
breaking it. The first time I did it I fell off it and I
thought how silly. But I can do all these things
now and I feel healthier in myself.
The likes of walking up and down the brae there,
I couldn’t even do that brae. … I must have
stopped two or three or four times going up that
brae. And now I just start at the bottom and
walk right up”.
Tangible everyday benefits:

17. Some were less driven but still made progress on their
own terms:
“ [The counsellor’s] advice was brilliant but I feel fine at
twelve stone. I don’t want to go to eleven stone. … I told
them, I’m perfectly happy with twelve stone. If I can keep
to that I’ll be a happy man”.
Ill-health hindered progress for some:
“I was alright for a day or two and then I would revert
back… a combination of things I suppose. Not having the
willpower and the frustration of not being able to do
things as well, didn’t help - a combination of different
things. … I was disappointed in myself and obviously for
these people who were making the effort to do something
for you. I was a bit disappointed to let them down as well”.

18. Why did some people do particularly well?
• Looking at weight loss ‘super achievers’ (7% and
more) might yield useful insights into:
– The types of people who respond best to weight loss
programmes, and in what circumstances
– The contexts and ways of engagement with weight
loss programmes associated with success
– The types of support which
might best foster success

19. Analysis of super-achievers (n=33) vs. the rest
• No differences in demographic characteristics
• More likely to have attempted weight loss in past (0.002)
• Less likely to rate their health as limiting their activities (0.05)
– both physical and emotional (0.03-0.008)
• No differences in beliefs about risk/preventive factors, or in
confidence in ability to make changes
• Spent significantly more time in daily exercise (in general,
moderate activity and step count, p<0.005-001)
• Consumed significantly less fat (0.02) and more F&V (0.005)

20. ‘Joe’, 70
• One of highest levels of weight loss in the study.
• “I mean I am seventy, if I don’t do it now when would I …? You can’t keep
putting it off for ever, you would be lying there in a box”.
• Worked and played hard – approached BeWEL in same spirit: “Once I make up
my mind to do something, I usually do it”.
• Extensive changes to diet; noticed food labels for first time in his life (“pain in
the butt” when shopping); adopted regime of daily walking.
• Didn’t waste energy on changes to which he was not committed (“Brown rice,
I’d rather jump out the window than eat brown rice”), but wasn’t fanatical
• Developed strategies for managing temptation.
• Appreciated support of his wife and the counsellor, but not dependent on it:
“There was a sense that you had a responsibility to do it honestly and you
know, there is no point in doing it if you are not going to try to get something
out of it … … the ‘I wish’ crowd, they get on the scale and … they say ‘I wished
this morning I was ten stone instead of fourteen’, well you can wish all you
want … You have to put the effort in or it’s not going to happen”.

21. • Motivated by family history of bowel cancer.
• Low self-esteem: a ‘blob’, a ‘wee fat woman in a coat’. Prone to putting
family first: “If Alec was at home I’d make a meal, but if it was just me, I
didn’t see the point of making for just me”.
• Experience of BeWel was revelatory, resulting in extensive changes not only
to lifestyle but to how she understood and perceived herself.
• Gained in confidence which in turn motivated changes to diet and activity:
swimming 2-3 times a week, walking, kick-boxing class. “I started doing more
for me as a person. Before it, I never really looked at me as a person”.
• Allowed herself lapses, ‘moderation’.
• Felt warmly towards study staff and their empathetic approach
which she saw as distinguishing BeWel from a diet regime.
• Little support from family & friends, but took pleasure in others’
recognition of changes: “People that I’ve known for ages, maybe
through my work or through when I was younger, would stop and
say you are looking good.”
‘Liz’, 60

22. • Not a big decision; coincided with personal desire to lose weight.
• Acknowledged BeWel as a ‘kick start’ to subsequent weight loss but
deliberately balanced it with examples of her own influence: already attending
Zumba, recent successful smoking cessation: “I was really being very strong
willed at that point in time. I’d mastered the smoking which had really – I
thought if I can do the smoking, I can definitely get rid of the weight”.
• Less extensive changes to diet than some, largely switching to lower fat
variants. Continued to eat favourite high fat foods but as occasional ‘treats’.
• Despite exceeding agreed weight loss goals, felt frustrated when rate slowed:
“She said ‘oh don’t worry about that. You’ve got a plateau and it will –’ but …
I couldn’t get below that again, which annoyed me”.
‘Aggie’, 67
• Positive but limited relationship with lifestyle counsellor;
more enthused by aids such as weighing scales and
pedometer: “The pedometer…. that was good for me. If I
came home at night and I thought, oh no, I’d make myself
go out another walk come back and oh no, away again, to
try and get the number of steps up. That did help”.
• Little support from family.

23. • Explicitly mentioned adenoma avoidance as motivation for participation
• Knowledgeable about the study, knew all study team by name. “Religiously”
recorded his steps and weight every day and time/speed on treadmill.
• Like Joe, became a calorie expert. Increased intake of rice & pasta; switched
to lower fat bread & dairy; reduced intake of red meat, biscuits, fried food;
cut down alcohol - designated driver for his group of male friends.
• Receptive and open-minded to counsellor’s “wee tips”.
• Regular frequent contact with counsellor –requested two-weekly phone calls
after the home visits. Attributed successful weight loss to frequent contact &
not wanting to let her down: “I said well I’d prefer every two weeks because it
gives me that wee incentive to say to Kath oh I’ve lost another pound or
something like that or a couple of pound you know … and it made me feel
good because I wanted to lose it and she was helping me to lose it you know”.
• Like Aggie, had managed to quit smoking quite easily;
previous experience of exercise group recommended by GP.
‘Ken’

24. So, what can we conclude about factors
associated with ‘super achievement’?
No particular patterns in:
• Socio-demographic profile
• The particular trigger for participation
• Beliefs and knowledge regarding risk and prevention
• Family/partner support
• Dependence on/relationship with counsellor
• Access and resources

25. • Large changes to levels of exercise that became
routine, especially daily walking
• Wide-ranging diet changes but incorporated on own
terms, allowing for ‘unhealthy’ foods in moderation
• Sense of responsibility to self and inner
determination, plus dissatisfaction with status quo
• Motivated by early experience of success
• Drew on previous experience of successful change
• Receptivity & flexibility to new info and advice
But, some common themes

26. Conclusions
• Losing weight is achievable
• For some, considerable amounts were lost, weight
loss was sustained and even increased over time
• No demographic sub-group was more associated
with success – all groups can potentially do well
• Weight loss brought other benefits,
ranging from heightened interested
in food through to transformatory
change in emotional health and
self-image

27. • Triggers for involvement differ
• Patients have different needs in terms of counsellor
contact and input: the key is individual tailoring
• Harness previous experiences of successful change
or self-transformation
• Try to make changes routine (esp PA)
but permit moderation and lapses
• Try to create early experiences of
success
Implications for interventions