Creating a lifestyle intervention for your community
Dr Luke Wilson describes the key ingredients of a successful community-based lifestyle intervention, drawn from his experience as co-creator of the groundbreaking BROAD Study.
About 4 years ago, a colleague of mine and I embarked upon an ambitious project. We created a novel community-based lifestyle intervention for a group of 33 people in Gisborne, New Zealand (population: 36,600) with either a BMI of 25 or higher with type 2 diabetes, ischaemic heart disease, hypertension, or hypercholesterolaemia, or a BMI of 30 or higher. During our experience working on the wards at Gisborne Hospital we had seen the damage that chronic disease was inflicting upon this small, semi-rural community.
In our last year of medical school, we had both interned in Santa Rosa, California alongside lifestyle medicine pioneers including Dr John McDougall at the McDougall Program and Dr Michael Klaper at the True North Health Center. So we already knew that a move towards plant-based nutrition would prove extraordinarily effective in treating patients with these conditions, now it was just a matter of putting this knowledge into action.
Gisborne is the region with New Zealand’s highest rates of socioeconomic deprivation, obesity and type 2 diabetes. For myself, a major motivation for the project was to sow the seeds for a transformative change within a community that really needed it, and I feel that this was the greatest achievement of the program and its participants.
My second hope for the project was that it might inspire you, as a fellow lifestyle medicine practitioner or advocate, to establish similar projects within your own community. Given this could be established in Gisborne, New Zealand, largely just through the combined efforts of two recently graduated doctors, it can surely be achieved almost anywhere by just about anyone!
I have chosen a few aspects you might find worthy of consideration when designing your own intervention:
1. Select people who are motivated to change
I highly recommend screening and considering ‘stage of change’ when selecting participants. Most will be familiar with the Prochaska and DiClemente Transtheoretical Model, which describes six ‘health of change’. We measured ‘readiness for change’: participants were asked to rate their agreement with three statements: ‘Something has to change’, ‘Something has to change now’, and ‘I have to change now’. Essentially our intention was to identify whether a participant was in the ‘Preparation’ stage and ready to take action. As it turned out, likely because participants were invited to participate, then required to complete several rather extensive forms and an in-person interview, these ratings may have been somewhat redundant. Nonetheless, almost without exception eventual participants rated all 3 of these statements ‘strongly agree’ or ‘agree’.
As lifestyle medicine practitioners we know that there are multiple factors that influence ability and motivation to make lifestyle changes, and to maintain these. Our interventions are a limited resource, so considering which individuals are most likely to benefit and succeed makes sense. In research, this does compromise ‘external validity’. But in the real world, this helps us get the most ‘bang for our buck’.
Recently, a participant from our initial group even established Gisborne’s first cafe with a whole foods, plant-based focus.
Taking on a group of highly motivated and energised participants, who are more likely to succeed, results in the generation of a number of advocates and role models for your intervention. These success stories can sweep the less motivated within their families and community into action through their enthusiasm, and also increase the likelihood of further investment and participation. In Gisborne, former participants have volunteered as mentors, been employed in further projects, and funding has ultimately been secured from local trusts . Recently, a participant from our initial group even established Gisborne’s first (perhaps even Australasia’s first?) cafe with a whole foods, plant-based focus. Success breeds success.
2. Be aware of benefits that motivate
There was a lot more interest among the participants than I anticipated in short term benefits and outcomes, and I now believe these are the primary motivator for most people. While as health professionals, we often focus on changes in indicators of long term outcomes (e.g. risk factors for chronic disease) most of us are naturally short-term focussed. Participants were ecstatic about how good they were looking and feeling. As Dean Ornish explains, the ‘joy of living’ is a very powerful motivator.
That said, the most popular lecture I created was entitled ‘Know Your Numbers’. It explained what health-related ‘numbers’ meant: weight and ‘ideal weight’, cholesterol, blood sugar and HbA1c, BMI, and blood pressure. Following this session, participants were much more interested in their results, and they became something they could use to track their own progress. This also has applications in the context of medical practice generally. Taking the time to explain to patients the significance of risk factors and providing the information so they can track them themselves is likely to increase patient activation, which itself has been associated with improved health outcomes.
The power of this intervention, as opposed to a less disruptive dietary shift, is that participants obtain immediate results. This provides immediate evidence that their changes are working and therefore worthwhile persevering with.
Our intervention shifted participants to a whole foods, plant-based diet. This is the intervention we had observed being so transformative for patients in Santa Rosa, and that had already been used so effectively by Dean Ornish and Caldwell Esselstyn. The power of this intervention, as opposed to a less disruptive dietary shift, is that participants obtain immediate results. This provides immediate evidence that their changes are working and therefore worthwhile persevering with. It also means they rapidly begin receiving highly reinforcing unsolicited positive feedback from friends and family, who notice changes in appearance, energy levels, and mood.
3. Involve and engage your community
By partnering with different groups in the community we provided additional support for the participants which made their environment more conducive to continuing with the lifestyle changes they had been prescribed. We also generated interest in the program in the wider community, and many of these changes would make it easier for people who were not involved in the study to make healthier food choices too.