Best Behaviour: Rolling out Change
This month, Naked Neuroscience is back at the Rosenthal Symposuim conference on changing behaviour for the healthier, organised by the UK Academy of Medical Sciences and the US National Academy of Medicine. How can healthy behaviour changes be implemented in individuals and across a whole population? Plus, we’re plucking out a couple of papers from the latest neuroscience research, with the help of some local experts.
In this episode
01:21 - Does lack of sleep make things more painful?
Does lack of sleep make things more painful?
with Helen Keyes, Anglia Ruskin University; Duncan Astle, Cambridge University
This month, cognitive neuroscientist Duncan Astle from Cambridge University, and perceptual psychologist Helen Keyes from Anglia Ruskin University glanced over the latest neuroscience papers. Helen looked at a paper about whether how you sleep can affect how you experience physical pain the following day, and Duncan found a study linking memory recall and depression. First up, Helen told Katie about the pain study...
Helen - It's really interesting, they got 25 participants into the lab and established everybody's baseline sensitivity to thermal pain by attaching a little pad to your leg and asking you when things were painfully hot. Then these 25 people went through enforced waking where they were kept awake doing pleasant things in the lab for eight hours, and then the next morning at 8.30 AM, they were put in an fMRI scanner and their pain thresholds were again measured with those same stimuli.
And now those same 25 people came back on a separate occasion when they'd had a full night's sleep in the lab, put in the fMRI scanner again and again their pain sensitivity thresholds were measured.
Katie - So what did they find then?
Helen - They found that following acute sleep deprivation, two things happened in the brain that made you experience pain more. So first of all, the part of the brain that responds to touch and pain, the somatosensory cortex, activity there increased following acute sleep deprivation. And secondly, the part of the brain that's involved in decision making so the straitum and the insular cortex, this part of the brain usually modulates pain responses and tells your brain “don't worry about this pain”, responses there were blunted so it didn't respond so much after acute sleep deprivation.
Katie - So the brain was literally more sensitive to what may have been pain that wasn't such a big deal before?
Helen - Absolutely. In those two ways, it responded more to the pain and the bits that would dampen the pain stopped responding.
Katie - So what are the implications of this then? Because lack of sleep, even mildly so, can be very very common in everyday life.
Helen - Absolutely and the follow up study they did where they did an online study asking people about their everyday sleeping patterns using a sleep diary and their experiences of pain in the subsequent days showed exactly that. That even minor changes to your sleeping patterns led to a greater experience of pain in the subsequent days.
Katie - OK. So bottom line, what should someone take away from this?
Helen - Medical practitioners might be interested to see that actually a prescription of sleep might be quite helpful to patients who are in a lot of pain, but also our everyday habits if we're feeling quite down and quite stressed and quite in pain with things, we might be able to think back on our own lives and see whether the night before we've had enough sleep, and that could be contributing to our pain.
Katie - Perhaps take sleep a bit more seriously?
Helen - Absolutely.
Secondly, Duncan Astle delved into a paper about how memories of life events link to vulnerability to depression, and he told Katie Haylor about it.
Duncan - They followed a sample of 427 adolescents who were at elevated risk of developing depression and they followed them over a year. And at the start of the year they asked all the subjects to perform an autobiographical memory test. So subjects are given cue words and they have to use those to generate memories from their own kind of personal history. And they also assessed symptoms of depression.
The subjects were all seen again at the end of the year, and they measured the same things and they also measured cortisol, so cortisol is a hormone, so it's a way of measuring stress response in these people. Those who were better able to recall positive memories at the start of the year, at the end of the year they had reduced symptoms of depression and reduced levels of cortisol, so we think reduced stress.
The theory that the authors have is that being able to better recall positive memories helps buffer the response to stress and that's why you have reduced cortisol levels a year later and reduced symptoms of depression. And they were able to test that by comparing these relationships in people who had experienced at least one stressful life event during that year, versus those who hadn't. And these relationships were strongest in those who had experienced a stressful life event. So the positive memories became beneficial in those who had experienced a stressful life event.
Katie - Do you know if this would work for people who actually haven't had a particularly stressful life relative to people who have?
Duncan - There's no harm in trying. So the data show that it's most effective in those who experience stress. Now of course the thing is you don't know when you're going to experience a stressful life event. So the implication is that by getting practiced at recalling more positive memories, you are gradually making yourself more resilient to future stresses that could be just around the corner.
Katie - So could this be used in a clinical or psychological setting?
Duncan - Well new treatments for depression are sorely needed. And this study implicates autobiographical memory as a potential target for therapies that aim to reduce responses to stress and symptoms of depression. And actually there are other groups here in Cambridge who are working to develop new interventions that target autobiographical memory and try and train people to get better at being more flexible, and being more positive in their memory recollection, with the aim that that might help reduce symptoms of depression.
Katie - Okay. And key point takeaway from this study, what would you say?
Duncan - It's really important that we practice and become proficient at recalling positive experiences that have happened to us and that doing that is a really important part of making ourselves resilient to stressful experiences that we may encounter in the future.
Simple rules
with Paul Aveyard, Oxford University
What behavioural strategies work when trying to change behaviour on an individual level? Katie Haylor spoke to Paul Aveyard, family doctor and behavioural medicine expert from Oxford University. First up, Katie asked, with the wealth of health messages out there about things like smoking and over-eating, how difficult is it to help people change their ways?
Paul - It's one of the barriers that sometimes doctors feel that “look, I'm just preaching to people who already know what they ought to do and just don't want to do it”. But actually that's not true. A lot of people, at least to me as a doctor, express a desire to do something about it and the knack if you like is to offer people some practical way forward that they can take action, preferably there and then, to do something about it. If you can move the conversation into that area, then you're likely to make progress with your patients.
Katie - So is that the difference between saying "take this leaflet you can go away and look at some links", and "I could sign you up for a weight loss course right now"?
Paul - Yeah, usually it works much better if you can make that action not dependent on their initiative. After all stuff gets in the way, we all have busy lives. A lot of people just have a feeling that "I could perfectly well stop smoking, lose weight, do whatever it is that the doctor has been asking me to do by myself". But actually the lesson is that we know that these programs help people but they don't always appreciate the value that they hold. So taking action put that program in the way of people, when you have the opportunity, is a really important part of our work.
Katie - OK. So perhaps effort or a bit of cognitive effort to go online and book that course or whatever it is is one barrier. What other barriers are there to people adopting the healthy behaviours they might very well know is the best thing to do?
Paul - Well they're all the sort of barriers that you know we've all faced when we've made our New Year's resolutions right? “One of these won't matter”, and then before we know it one becomes two becomes more. So all of these and the environment around us constrains our ability to make changes.
But just because those barriers are there, doesn't mean that you shouldn't try. There are lots of examples where if people can be put in the way of effective programs, they will make progress and move forward. We have good evidence that these very brief interventions that I was talking about, that doctors can make, do prompt people to make changes. Most people don't succeed in the long term, but enough do to mean that it's not only cost effective but actually cost saving.
Katie - So in terms of what your research has informed works, signing up to for instance a weight management program. Can the same thing be said of smoking?
Paul - Yes it can. We know that for example if people were to leave a consultation with medication like nicotine replacement or like tablet treatments that we have, or be referred to a stop smoking clinic, well those are the best things that they can do to give themselves, maximize their chance. So our task as a nation really is to get more people to try to make changes in the first place and to get more people to use an effective means to help them change their behaviour, in the second place. And there are a variety of tools that we can do to use that, a very key one is what your doctor says to you when you go and see them.
When people are thinking health, that prompts the self-regulatory part of their brain to be more active and that means that they're much more likely to want to take action on the doctor's advice at that moment, than if they were just caught cold with advice to stop smoking.
Katie - So we're actually using neuroscience to capitalize on people's behaviour to help them change it?
Paul - Yep.
Katie - You mentioned seizing the moment, are there any other particularly successful case studies that we can use and learn from?
Paul - What helps people is to have very simple rules about what they can and can't do. After all changing your behaviour is in some ways a bit of a boring task. You've got to take something you like doing and not do it or at least not do it half as much as you might like to. If you can keep a very clear rule for yourself about what you will and won't do, you are more likely to be successful.
So let me give you an example. People who are stopping smoking, they can say to themselves “I'm trying to stop smoking”, right? Or they can say to themselves “I'm a non-smoker now. That's just not what I do”. And it turns out that the people who say that second thing "I'm a non-smoker now", they're drawing on their sense of identity, who they are as a person. And that strengthens their resolve and they're much less likely to go back to smoking than the people who say "I'm trying to stop smoking".
Another example is the “not a puff” rule that we have in smoking which is simply that once you pass this day, called the quit day, your absolute golden rule is do not smoke at all. And again that relates to the neuroscience and the sort of neurobiology if you like of learning and addiction and the extinction that occurs as a result of sort of not smoking, gradually the drive to smoke will lessen. It's sort of anti- Pavlovian learning that's going on there.
We know that these simple rules help bolster people's resistance to temptation. We see that in weight loss interventions as well where things like meal replacement programs, so a very simple rule, eat that, don't eat anything else, turns out to be easier to adhere to that kind of rule than, oh here's the kinds of foods that you ought to be eating. You'd think the latter would be more sustainable and better in the long term but the reverse is true.
And indeed that can lead on to effective population strategies. So Tesco or any other big supermarket could perfectly well produce, and to some extent they do produce, calorie-controlled meal replacement programmes, its actual real food, that's already packaged, you know? This is a breakfast, this is your lunch, this is your dinner. You could imagine that there was a commercial opportunity for them to produce a kind of whole program that gives people a rotating, interesting diet but nonetheless actually is lower in energy than they might otherwise have. And because it all comes as “just eat this” it's actually an easier diet to stick to than the sort of usual approach where you're left to try to make healthy choices.
Katie - Is it palatable though? And I don't mean the food, I mean the idea of being told what to do, because some of us aren't very good at that!
Paul - I think one of our principles that we started the day with here was that the overwhelmingly big breakthrough is there is no single breakthrough, and there's certainly no single way for a person to lose weight. The best way is - as we always say - the way that you feel you can stick to. But on average this is what the research evidence is showing, that these meal replacement programs which are currently provided by diet companies, those are more effective than the educating you about your food way. But that doesn't mean that that's true of everyone of course.
16:18 - Population diets
Population diets
with Martin White, Cambridge University
What are the best strategies for helping a whole population alter their eating habits? Katie Haylor spoke to Martin White, a population health expert from Cambridge University. First up, Katie asked, what factors go into deciding what to eat in the first place?
Martin - One of the key things is that in the environment in which we exist, there are lots of cues that that influence our behaviours. You come out of your office and you're walking down a high street or something thinking what shall I have for lunch? There are lots of cues there that are saying to you “come into my store”, “come and buy my food”, marketing, advertising, the presence of different kinds of outlets. The price point will be an important consideration. You might have a budget in mind for your lunch.
Cultural factors as well. So you may have grown up with a particular diet, you may come from a particular culture, or there are maybe just things that you like and things that you don't like, but there are literally hundreds of different factors that affect us. But the environmental cues are really important.
Katie - There are already some behavioural interventions from a population level. Things like the Five a Day campaign I guess would be one. Can you give me a few more examples of ones that currently exist in the UK?
Martin - At a national level Public Health England has a range of things, so quite a lot of them are kind of those kind of marketing campaigns like Five a Day that you mentioned, Change for Life campaign and so on. That's about conveying information essentially.
Then they're involved in other activities that are more aimed at changing the food environment. There's a lot of activity within Public Health England at the moment working with the commercial food sector to see whether they can change the kinds of foods that are available, reducing portion sizes, reducing sugar content, reducing total number of calories and so on. So that's some of the work that's kind of going on in the background.
Another approach which is gaining some traction now is regulation. In 2018, we had introduced in the UK the first fiscal measure in relation to food so the soft drinks industry levy which is a levy on manufacturers and importers on sugary drinks, charging manufacturers a small amount for each litre of soft drink that they sell or import that contains high amounts of sugar, it's actually a two tier levy.
Katie - Is this the sugar tax?
Martin - It’s what's called the sugar tax, yeah. And the purpose of it was to persuade manufacturers to take sugar out of their drinks, to reduce the sugar content, so as to avoid paying the levy. So that's an example of a regulatory measure and it's the first of a number that I think we'll see in the UK in the future. The Childhood Obesity Plan which was published in June 2018 includes half a dozen or more different regulatory measures that involve things like restricting advertising and encouraging labelling within the food industry and so on.
Katie - You're assuming that it's going to be accessible to people, I guess. People need to be able to access that information. It needs to be in the right language. They need to be able to read, and so on and so forth. How accessible are current measures to encourage people to be healthier when it comes to food?
Martin - Yes that's a very good question and these interventions differ in terms of the extent to which they require active engagement of the individual in order for the intervention to work. And that's really important because the more active engagement an intervention requires, the less likely it is to be effective. But in particular, in people who have difficulty engaging with that kind of intervention.
So for example you mentioned food labels. For people to really interact with nutritional labels, they need to be literate. They also need to be numerate, and then they have to start making choices based on that information. Those characteristics are patterned socio-economically within the population. So poorer people are the most likely to have problems with literacy and so on. It is really important and in our research we've come to the conclusion that government needs to focus much more on what we call low agency interventions, so ones that don't require the individual to make these conscious choices.
Katie - The thing is, most of us know we're eating too much, despite knowing this we still hear about this looming obesity crisis. So just knowing isn't enough. What's going wrong?
Martin - You have to think about this as a system level problem. The most convincing explanation of the obesity crisis is that we have a system that is delivering too many calories to the population. That system is the commercial food system. This is a quite a big challenge because we're used to developing interventions that are aimed at persuading individuals to change their behaviour, but the behaviour we need to change here is that of the food industry. That's why the soft drinks industry levy is so well designed and so powerful because it's really aimed at changing behaviour within the commercial sector.
Katie - From the research that you've done, what kinds of strategies work, when it comes to introducing effective behaviour change, for the maximum amount of people?
Martin - At the moment we're busy evaluating the soft drinks industry levy, we haven't published any results yet but the results are looking very promising. So I think that kind of fiscal policy is going to be very effective. There's a range of other things we can do and I think that what we'll need is a whole range of different measures in order to actually make a real difference to obesity. There's talk of further restrictions on advertising of unhealthy foods, pushing those beyond 9pm, what's called the 9pm watershed. There’s talk of restrictions in the online advertising of food, what we've seen is a dramatic rise in the online advertising of foods, alcohol, gambling and so on. The digital space is an entirely new space for marketing unhealthy commodities.
And then there are other kind of measures as well, other sorts of policy measures which can be helpful. We've had a series of regulations introduced in the UK about school food and I've been involved in evaluating those over the last 10 years, and what we find is that when you regulate the food that can be presented at a school lunch, the lunches become healthier. So when you introduce nutritional and food standards. That has a good impact. One of the interesting things we found is that it doesn't just have an impact on what kids eat at lunchtime, but it also has an impact on their total food consumption across the whole 24 hours.
Katie - So I'm guessing having interventions where effectively people don't really need to change their behaviour that much. Maybe that's the best option?
Martin - Yeah it's more about whether people have to make these very conscious choices and that requires some kind of effort to make that choice. But yeah if you can eliminate the choice element then that's the most effective way to go and that's exactly the principle of the soft drinks industry levy. It takes the decision out of ordinary people's hands and it just means that what's available on the shelves has less sugar in it.
Katie - Simple?
Martin - Simple, and a good thing! Individuals will always be responsible for their own choices. People will still make choices and there still will be lots of choices to make out there. But the important point is that the research shows that if we can make the environments healthier, then it makes those choices easier. In other words the healthier choices become the obvious and easier choices.
23:08 - Healthy gaming
Healthy gaming
with Barbara Sahakian, Cambridge University
Whether it’s one or one million people, changing behaviour - it seems - is no easy thing. And adding mental health problems into the mix presents further challenges. Barbara Sahakian is a cognitive neuroscientist at Cambridge university, who’s interested in improving cognition and motivation in people with neuropsychiatric disorders and brain injuries. Katie Haylor spoke with Barbara, asking firstly about cognition, and how this relates to behaviour...
Barbara - Cognition is really all about the way that you think, of course, and your thinking affects your behaviour because what you decide to do or not do will affect what you actually act on, and do and choose in different situations. So cognition is extremely important, and we need to keep our cognition and also our wellbeing at very high levels throughout our whole life course. So part of what I'm very interested in is how can we promote good cognition and wellbeing? So from a neuroscience perspective, behaviour change requires motivation and top down cognitive control by prefrontal cortex, which stops you engaging in maladaptive or harmful behaviours.
Katie - OK, so the prefrontal cortex is a specific, quite special part of the brain right? There's a lot that goes on there.
Barbara - And it's very well developed in humans and that helps us with our decision making. It also helps us to deal with novel situations.
Katie - And this top down processing that you mentioned, what is that?
Barbara - The motivation is kind of the reward when you want behaviour change. It's helpful to motivate people you know rewards and things like that actually get people interested in doing something. And we know that very well with children but also with adults, different rewards make you want to engage in different activities and promote good health and things like that. And that's part of what I call our hot cognition. But we also sometimes have a sort of stop. We all know that when you go out with your friends and you’re drinking if you're going to drive you decide “oh I'll have a non-alcoholic drink”. That is really your dorsal lateral prefrontal cortex and other areas of your frontal cortex helping you to make a good decision for that behaviour that “I'm not going to take that drink of alcohol because I know I'm going to drive later on”.
Katie - It's like you've got the accelerator pedal and then the brake pedal. And it's a constant kind of switching between the two. Is that an accurate analogy?
Barbara - Quite a good one actually. It's not quite so simple because there are all these individual differences that people have in terms of their genetics for instance for risky behaviour and things like that. But basically the brain often works in that way, that we have the promotion mechanisms and then we have the stopping mechanisms, and they're really to get us at the optimal level of our behaviour so that we can function as best as possible in an environment that's changing all the time.
And so that's why it's so important that we have both the motivation to pay attention to the relevant things and do the right behaviour, but also that we have stopping mechanisms that will make us reflect on “well is this really a good idea?” and “how will I feel about this tomorrow?” and that kind of thing. Looking ahead, planning and things like that, we also have to think about that when we're making decisions.
Katie - How does this relate to conditions that you study?
Barbara - Well the easiest way to explain it probably is in terms of substance abuse. So frequently people may impulsively try substances of abuse, they find it very pleasurable perhaps, and they start using them recreationally, and then eventually they start using it habitually. So they are really driven to use these substances, but the brake isn't working so well so the top down cognitive control to stop them doing this behaviour is not really as strong as it should be. That's why it's very good to intervene very early when people are able to modify their behaviour so they don't get addicted or they don't end up in a compulsive mode of trying to seek drugs of abuse.
Katie - And does this same system work for other public health challenges like obesity or smoking cessation?
Barbara - Some people actually call these behavioural addictions, a lot of these things do fall into the compulsivity range. Not all forms of obesity do, but there are some people who are more or less compulsive eaters and that would sort of fall under the behavioural addictions. It's still an area of controversy whether behavioural addictions really are addictions or not. But the same form of compulsivity may happen.
And so gambling is another one of these things where people start to do it and it might be you know harmless and they're enjoying it and so forth, but later they feel compelled to do it. And actually it's causing a lot of harm but they can't stop. So it's that type of thing you need the stopping mechanism and it's good to have a good reward system because we do need to be motivated to go do our jobs and other things like that, to do difficult things that we may need to do, we need to feel motivation, so it's good to keep our motivation up and we know that in certain patient groups, say for instance, people with schizophrenia who have problems in motivation, it's very hard for them to want to do things. So that system is very important too. But we have to keep it under control so that we're enjoying ourselves but we're not causing ourselves any harm or other people any harm and disadvantage.
Katie - So bearing in mind the motivation and control, what does your research suggest we can do to help people who might be suffering from psychiatric disorders?
Barbara - At the moment what I'm doing is a lot of work on cognitive training. Now cognitive training has been shown to improve cognition, as you train you can see that it's strengthening certain neural networks in the brain. But the problem is that at the moment usually you have to come into a hospital. So it might be expensive, you might need a specialist to help you train, and a lot of the patients who are training, say patients with schizophrenia, or patients with mild cognitive impairment (which is a very early stage of Alzheimer's disease) find it rather tedious so they don't really want to do it.
And some of the studies with cognitive training unfortunately dropout rates can be as high as 40 percent. So what I've done in my work is to think about well how can we cognitively train people and get them to do this work but really enjoy it and have it engaging? And also I want to individualize it because people have different levels of cognitive ability and we want to make sure that they're progressing in their own program, a bit like a brain gym where you have your own personal trainer.
So what I've done is to work with a games developer and my laboratory, Tom Piercy, we've developed these games which are based around neuropsychological and neuro-evidenced, and we've tested them in people with mild cognitive impairment. These are elderly people in their 70s and we've also used a different game called Wizard which is for people with schizophrenia, but also for healthy people at the more challenging levels.
And we find that these games, they really enjoy doing them and they improve their cognitive function, they improve their episodic memory which is the everyday memory that we use. So when we're, you know, trying to remember where we left our mobile phone in the house or we're trying to remember where we left our car in amulti-storey car park. That's episodic memory. It's the first memory to go in Alzheimer's disease and in both Alzheimer's disease and schizophrenia, episodic memory has been shown to link to functional outcome, you know how well can you do your job, how well can you function around your house, how well do you engage in different activities. So it's how you behave as your activities of daily living which is how you're behaving in your normal environment. So that's a really good way to get this generalized behaviour change because this kind of cognition is so closely linked to our everyday activities.
Katie - What about going beyond the groups of people who specifically suffer with psychiatric disorders? Can this gamification of brain training, can it be used for the average Jo?
Barbara - Absolutely. So we've just been working on a game called Decoder. A lot of people have come to me and they've said “I'm having trouble, I'm getting distracted all the time at work”. The way that we work these days where we're checking our texts, we're checking our emails, we've got multitasking to do. Sometimes you come home at the end of the day and people say to themselves “well I've been busy all day but I don't seem to have achieved my goals, I haven't got any one thing completely done”. So this is really to help you focus your attention, stay with a big challenging job and then you'll have your goal completed.
Katie - With these games that you've designed, is the prescription as it were for long term use or can you work really hard with your game, your cognition improves and then you're all set?
Barbara - I think it will have some carryover, that's really what you're saying, like how long does it last? And we haven't really studied that very carefully so I can't really say for sure. But it's really meant to be something that you do all the time. You wouldn't stop going to the gym and expect your physical health and all the gains that you got from working in the gym to carry on forever. It's something that you have to keep doing on a regular basis, and that's really what the games are meant for. They strengthen a neurocircuitry in the brain and it's a kind of use it or lose it. And the idea is that you should be boosting it every now and then and trying to get even better. Cognitive enhancement is something we should be trying to do, the more we can do it, the better we can boost our cognition and boost our wellbeing, the better off we'll be.
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