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 higher1. 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’2. 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’.
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 outcomes3.
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 Ornish4 and Caldwell Esselstyn5. The power of this intervention, as opposed to a less disruptive dietary shift, is that participants obtain immediate results6. 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.
As going out to eat is so much a part of our modern-day culture (and obtaining ready-made food quickly), having restaurants and cafes where participants could find foods that met the requirements of their newly prescribed diet was very important. I was surprised by how receptive many local restaurants were. I mailed each a letter explaining the scope and purpose of the research, and invited them to consider adding a meal to their menu. I followed up with a phone call and arranged to meet the manager and/or chefs, taking along example pictures of meals and recipe books to make it easier for them to visualise the possibilities. During the course of the initial study, we had six different eating establishments agree to place meals on their regular menu. We provided them with a sticker they could display in their window, and of course informed participants about available menu items.
Sessions were run at the local polytechnic, who initially donated their space free of charge and provided the chef tutors. We partnered with a local native plant nursery to supply vouchers as birthday gifts. A local health food shop a participant worked for helped supply B12 supplements and also began stocking other items consistent with the dietary requirements.
4. Create a supportive group environment
The average age of our participants was 56, with an average BMI of 29. So some may have wondered if two second-year doctors from out of town with an average age of about 30 and average BMI of about 19 could relate to their situation and provide the support they required. It seemed prudent to have a representative ‘on-the-ground’ and to act as an intermediary to bring feedback to us from the participants.
We invited a patient I had helped shift to a plant-based eating pattern about 6 months earlier to volunteer as group mentor. He attended all meetings with the facilitators as well as being involved in all lecture and cooking sessions with participants. He taught one of the cooking sessions and even stepped in to run a session by himself on an evening when we were unavailable. Having someone local and relatable who was ‘walking the walk’ made the changes being asked of participants seem more achievable and provided inspiration.
I cannot overstate how important I think this contribution was. If you do not have access to a prior ‘success story’ then media with testimonials from individuals as similar to your group as possible could be used. Films including ‘Forks Over Knives’ (the American College of Lifestyle Medicine even have this available as a CME module), ‘Eating You Alive’, and ‘What the Health’ all include such stories and give participants a broad overview of the basics of a plant-based diet.
We endeavoured to create a group session environment that was casual, friendly, and welcoming: both social support and group cohesion appear to be important for health behaviour change7. The polytechnic provided a well-equipped, spacious, and aesthetically pleasant space adjacent to the teaching kitchen. Before each session started there was time for people to catch up for a bit with each other, the group mentor, the doctors, and the program coordinator, and even make a cup of (caffeine-free) tea.
Creating a positive, low-pressure environment appeared to help many of the participants feel comfortable sharing their stories and observations with each other7. This support I feel is probably the greatest advantage of the group session format, and this was corroborated by many participants feeding back. It is worth considering how you can replicate and optimise this in the setting of your own intervention. Even in the setting of counselling individual patients, perhaps there is a support group they can be referred to. Online groups can also be a source of encouragement and support.
5. Get ‘hands on’
A novel aspect of the intervention we created was a heavy emphasis on the practical aspects of adopting a plant-based lifestyle. A large component of our course (almost half of all sessions) involved participants cooking plant-based meals themselves, under chef guidance. This meant that over the 12 weeks, participants became well-versed in the practical skills they needed to successfully prepare tasty plant-based meals at home. This was particularly useful for those who had not been the primary meal preparer in their household and/or were not especially confident cooking for themselves.
While the lecture component of the sessions was important, people were more interested in the ‘how’ than the ‘why’. This has been both my experience and also that which I have had related to me by colleagues working on similar projects. Our intervention was designed to teach participants how to eat plant-based much more so than why they should.
Because our participants attended twice each week for 12 weeks, problems and questions they had encountered in their home and community environments could be addressed and problem-solved during sessions by the doctors or even (and increasingly so towards the end of the program) by the other participants. All of our participants lived in the same community. Therefore, we were able to engage in strategies to make changes to this environment, making it more conducive to longterm adherence to the lifestyle changes.
Dr Luke Wilson is a New Zealand-based General Practitioner and co-founder of Two Zesty Bananas.
More articles from Luke:
- Wright N, Wilson L, Smith M, Duncan B, McHugh P. The BROAD study: A randomised controlled trial using a whole food plant-based diet in the community for obesity, ischaemic heart disease or diabetes. Nutr Diabetes 2017 (7), eXX; doi:10.1038/nutd.2017.3
- Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997 Sep–Oct;12(1):38–48.
- Hibbard JH, Greene J, Shi Y, Mittler J, Scanlon D. Taking the long view: how well do patient activation scores predict outcomes four years later? Med Care Res Rev. 2015 Jun;72(3):324-37. doi: 10.1177/1077558715573871.
- Ornish DM, Brown SE, Scherwitz LW. et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. Lancet.1990; 336:129-133.
- Esselstyn CB, Gendy G, Doyle J, Golubic M, Roizen MF. A way to reverse CAD? J Fam Pract 2014; 63: 356–364b.
- McDougall J, Thomas LE, McDougall C, Moloney G, Saul B, Finnell JS et al. Effects of 7 days on an ad libitum low-fat vegan diet: the McDougall Program cohort. Nutr J 2014; 13: 99.
- Middleton KR, Anton SD, Perri MG. Long-Term Adherence to Health Behavior Change. Am J Lifestyle Med 2013;7(6):395-404. doi:10.1177/1559827613488867.
This article has been written for the Australasian Society of Lifestyle Medicine (ASLM) by the documented original author. The views and opinions expressed in this article are solely those of the original author and do not necessarily represent the views and opinions of the ASLM or its Board.