Obesity lifestyle Change support case study.

In general terms, a disease is classified as physiological changes to organs, cells, and structures (Jastreboff et al., 2019). Classification for obesity is >35 on the BMI scale, it was classified as a disease in 1948 (James, 2008), and although in many cases it is an imbalance of calories consumed and calories expended, researchers deem it a complex, multifactorial chronic disease (Jastreboff et al., 2019).  This metabolic disease is called so, due to systemically raised levels of adipokines, insulin resistance and serum glucose, causing low grade inflammation (Piya, et al., 2013: Pereira & Alvarez-Leite, 2014: Herder et al., 2007).  Multiple factors interact with human biology to produce highly individualized and variable disease development and presentation, as well as treatment responses (Goodarzi, 2018).

Adipose tissue is an endocrine organ, storing both brown and white fat. White fat is stored as energy as triglycerides and is linked to metabolic syndrome diseases. Brown fat known as subcutaneous fat is thought to have protective properties against obesity (Saely et al., 2012). low grade Inflammation is linked to increases in Adipokine hormones within fat to levels which predisposes an individual to disease (Guarner & Rubio-Ruiz, 2015).

The hypothalamus regulates our eating habits through the lipostat system, which measures leptin circulating in the blood stream according to our fat mass, the more adipose tissue we have, the higher volume of Leptin circulates around the peripheries, thus pointing to leptin resistance being the issue, as opposed to a lack of leptin. The feedback mechanism determines our set point, a survival mechanism protecting us against starvation. People with a high BMI have lower levels of Ghrelin, which alongside Serotonin, leptin and Norepinephrine play a role in feeling full. Damage causes a dysfunctional feedback loop, whereby the individual no longer receives the signal of feeling full (Tarantino et al., 2010: Esposito & Giugliano, 2004). Genetically, research has found rare mutations in the MC4R gene associated with increased hunger, binge eating and hyperphagia (Qi et al., 2008: Young et al., 2007) and around 400 other genes thought to play a part in obesity (Meldrum et al., 2017).

 The hypothalamus regulates our behaviours such as sleep and our eating habits. Our eating habits are controlled through the lipostat system, which measures leptin circulating in the blood stream according to our fat mass, the more adipose tissue we have, the higher volume of Leptin circulates around the peripheries, thus pointing to leptin resistance being the issue, (much like insulin resistance) as opposed to a lack of Leptin. The feedback mechanism determines our set point, a survival mechanism protecting us against starvation. Gabba inhibitors are important determinants for eating behaviours and People with a high BMI have lower levels of Ghrelin, which alongside Serotonin, leptin and Norepinephrine play a role in feeling full. Damage is often caused by a high fat, starch and sugar diet creating a dysfunctional feedback loop, whereby the individual no longer receives the signal of feeling full (Tarantino et al., 2010: Esposito & Giugliano, 2004). Genetically, research has found rare mutations in the MC4R gene is associated with increased hunger, binge eating and hyperphagia (Qi et al., 2008: Young et al., 2007). However, there are around 400 other genes thought to play a part it genetically influenced obesity (Meldrum et al., 2017).

Obesity is known to greatly increase the risk to other inflammatory diseases such as Cancers, Diabetes, Cardiovascular diseases and increases susceptibility to lung diseases and acute respiratory distress syndrome, due to chronic low-grade inflammation which causes stress on body systems and reduces the immune system function (Popkin et al., 2020). In women there is a strong relationship to perimenopausal and post-menopausal weight gain and cancers. 1kg of weight gain in short periods of time increases the risk of diabetes significantly (16%) (Nowosad & Sujka, 2021). Untreated diabetes leads to organ deterioration, renal failure, blindness, limb amputation and coronary artery disease (Centers for Disease Control and Prevention, 2011). Overtime individuals risk joint issues and become susceptible to osteoarthritis and chronic Musculoskeletal (MSK) pain and disability (Dieppe & Lohmander, 2005). This increases sedentary time, inability to work, difficulties managing personal hygiene daily living tasks, the ability to live independently into older ages and significantly reduces quality of life (QOL) (Vincent et al., 2010). Common areas of pain are knee’s, lower back and in women with large breasts shoulder pain (Dixon, 2010) Impaired appetite system impaired dyslipidaemia leads to further complications (Karlamangla et al., 2007). Notably, reduced calories prevents brain atrophy and neurodegeneration, increases neurogenesis, and improves mood disorders (Gillette-Guyonnet & Vellas, 2008) and Studies have consistently shown weight loss to reverse inflammatory associated conditions and vastly improve quality of life (Kolotkin et al., 2001). An impaired appetite system, and insulin resistance often accompanies obesity and leads to further complications (Karlamangla et al., 2007). Notably, reduced calories prevent brain atrophy and neurodegeneration, increases neurogenesis, and improves mood disorders (Gillette-Guyonnet & Vellas, 2008) and Studies have consistently shown weight loss to reverse inflammatory associated conditions and vastly improve quality of life physically, psychologically, and socially (Kolotkin et al., 2001).

Depression and obesity are often interrelated, often described as bidirectional as one often increases the other (Chauvet-Gelinier et al., 2019). This may be explained by their shared biological mechanisms of genes, endocrine pathways, and immune-inflammatory and metabolic mechanisms to the brain (van der Valk et al., 2019). The focus is on shared biological mechanisms that may explain the depression–obesity association at different levels, from genes and peripheral endocrine, immuno-inflammatory and metabolic mechanisms to brain (Milaneschi et al., 2019). Appetite, energy homeostasis in the hypothalamus, Pituitary gland and mood regulation within the limbic system and hippocampus all sit within the center and overlap (Ilie, (2020).   Cortisol exposure over long periods cause damage to these structures leading to possible behaviours of seeking energy dense foods and reduced energy expenditure (Bremner,1999: Bagby et al., 2019). Research has shown that the risk of depression increases the more complex the metabolic profile, insulin resistance, hypertension etc, adding to further risk (Ostadmohammadi et al., 2020).  Behaviour studies found that high Leptin production changes both mood and behaviour in mice where they were found to display stress and erratic behaviour symptoms (Subba et al., 2021). Leptin in smaller amounts also produces antidepressant- like effects in mice (Cordeiro et al., 2019).

Anxiety is created by changes in the synaptic plasticity in the prefrontal cortex, amygdala, and hippocampus, a long term hypercaloric diet and corticosterone disrupts the neural circuits (García‐Cabrerizo, et al., 2021). Anxiety is linked to increased cardiovascular disease, obesity, and mortality risk (De Hert et al., 2022) and a lack of sleep, increases the risk of binge eating, especially in adolescents (Kansra et al.,2021).  The gut microbiota influences intestinal metabolic factors effecting anxiety behaviour via the microbiota-gut brain axis (Hattori & Taylor, 2009). There are many studies linking gut microbiota, obesity, depression, and anxiety (Zhu et al., 2021).   Within the 400 trillion cells and hundreds of different species two bacterial phyla named Bacteroidetes and firmicutes when impaired influence obesity (Chen., 2020).  Inflammation increases gut permeability to bacteria, causing systemic inflammation, triggering inflammasomes thought to impact on mood and depression-related processes (Milano et al.,2020).

The Vagus nerve controls the parasympathetic functions as part of the autonomic nervous system, starting at the insula cortex linking to the cranial nerves, organs and down through the stomach and reproductive organs feeding back peripheral body’s states to maintain homeostasis (Deuchars., 2018).  Studies found no drop-in insula activity in obese individuals after a meal, suggesting the vagal detection of satiety signals is faulty, this also occurs in depression and partially contributes to depression manifested with increased eating, whereby the insula showed hyperactivity (van Ruiten et al., 2022).  Furthermore, a faulty reward circuit within people with depression has been found around food as well as antidepression medication causing excessive weight gain (Kuckuck et al., 2022).

Psychologically teasing and rejection often leads to eating disorders, weight gain and noncommunicable disease risk (Oconnell et al., 2021) Societal norms around body sizes are internalized at a young age, and now exacerbated by social media filtered photos which  are known to put a lot of emphasis on how we look and sexual appeal far more than ten years ago as opposed to how healthy we are, leading to emotional pain, stress, low self-esteem, loneliness and mental health issues known to erode healthy relationships with food and our bodies (O’Connell et al., 2021: Chu et al., 2019).

Addiction to food is characterised by symptoms such as continuation of eating after full, unable to restrict meal size, loss of control over food intake and types of food (Mills et al., 2020). Studies using MRIs are able to show activation in the brain after consuming sugar or refined flours, the activity stimulates dopamine release leading to feelings of pleasure, when an individual continues to seek out this pleasure through repetitive processed foods consumption, the dopamine receptors thin, similar to drug use, then the brain adapts and down regulates when it senses to much dopamine has been released thus reducing the feelings of pleasure, leading to increasing consumptions to larger amounts to gain the same feelings (Berridge, 2009). However, this is still a highly debated subject in the research world (Hauck et al., 2020)

Socially, people from disadvantaged or minority groups are at significantly higher risk of obesity and noncommunicable related diseases (Chen et al., 2020). Financially deprived individuals living in obesogenic environments have less choice of fruits and vegetables, often less time and energy for leisure and fewer opportunities to access safe green spaces and exercise facilities (Pan et al., 2021). Stigma and discrimination effects self-esteem and the ability to contribute to society known to increase confidence and well-being (Chu et al., 2019). Further inequalities are caused by Government nonlibertarian policy and media pushing for lifestyle change with onus on the individual through shaming, as apposed to structural policy regulating the Transnationalisation (TNCs) companies and implementing targeted financial support to provide healthy food choice and policy restricting advertising is needed alongside social support and lifestyle change (Long et al., 2020).

Children learn both exercise and dietary behaviours within their home environment. It is widely accepted that children who grow up in families which are inactive and do not eat nutritious food together, have a significantly increased risk of obesity and sedentary behaviours in adult life (Baidal et al., 2020). Studies have found people from affluent areas can afford the protective measurements against obesity such as healthy foods, rent affordability, access to physical activities, holistic health care and they are more likely to receive better health care (Landgren et al., 2020).

Social stigma in the form of negative stereotypes, prejudice and rejection is known to inhibit disease recovery, it is a barrier to seeking help and leads to negative health outcomes (Dolezal, 2022). Despite a wealth of research showing that shaming obese individuals into losing weight leads to demotivation, distrust and often further destructive behaviours such as binge eating, it is still practiced widely in gyms, within peers, primary care and families (Täuber et al., 2018).

Recommendations for lifestyle change

NHS guidance to losing weight follow tiered weight management pathways (Welbourn et al., 2016). The 1-4 pathways start with public health nutrition leaflets, tier 2 is delivered through community nutrition professionals offering diet, nutrition, lifestyle, and behaviour change advice, Tier 3, Clinical non-surgical intensive intervention including specialist dieticians, psychologists etc. tier 4 includes Surgical and non-surgical – Bariatric Surgery for complex obesity with BMI >40 with comorbidities (Jennings et al., 2014: Welbourn et al., 2016). Bariatric surgery is considered alongside intensive lifestyle change support for those with complex morbid obesity (August, et al., 2008). Doctors may also recommend Semaglutide  or similar alongside lifestyle intervention (Wilding et al., 2021). Despite the multibillion-pound diet businesses few interventions have a sustained impact on weight loss, hence the pressure on NHS weight management services (Hazlehurst et al., 2020).

The Government have formed a partnership with weightwatchers business. The programme is effective much like the Atkins in initially losing weight, however adherence is very low, so they have vast repeat custom (Ahern et al., 2011: Dansinger et al., 2005). Psychologically praising people for losing a pound, and berating people for not losing a pound, when it is widely known that bodies respond differently to foods and that often biologically the bodies health will be changing in a positive direction in terms of cardiovascular health and a reduction in inflammatory markers which would not necessarily show on the scales. Further shaming people for not losing a pound in a week is counterproductive and known to psychologically damage individuals who already feel ashamed, lack self-esteem and therefore are likely to push them into a binge eating episode (O'Neil, 2022: Aamodt, 2016).  In studies interventions delivered by weight management specialists yielded better results than weight watchers, and the weight watchers dropout rate was high, however the business can deliver to large groups for a fraction of the price (Jebb, et al.,2011).  Despite the poor evidence on effective weight loss, self-help groups and mobilizing peer support may explain the publics belief in the effectiveness (Djuric et al, 2002).

Whilst there are numerous effective ways to lose weight, weight loss management has been a key challenge (Rothblum et al., 2018). Reducing calories via a restrictive diet is known to cause powerful psychological feelings of deprivation, driving the biological setpoint to kick in,  Although food is thought not to be physically addictive, it is thought that the psychological addiction is very strong, thus the internal signals of emotional stress amplifies until the individual gives into the known behaviour, which will temporarily sooth the alarming feelings, this will likely then lead to feelings of failure, shame and disgust and set off a possible binge eating episode (Rogers & Smit, 2000). It may be far more realistic long term to mobilise social support, engage in food swaps, set small attainable goals, exercise and work through behaviour change support, for long term lifestyle changes (Davis et al., 2014: Mozaffarian et al., 2011).

Guidelines recommend a deficit of 500-750kcals per day, with 15-20% protein, 20-35% fat, (<10% saturated fat), and the remainder in fruit, vegetables, grains and legumes, with a strong emphasis on cutting out high calory drinks and ultra-processed foods (Wadden et al., 2020).

Dietary consumption of long chain fatty acids can initiate inflammatory responses, a Mediterranean diet is a plant based, high unsaturated fat diet evidenced to lower rates of non-communicable diseases and weight loss and influence inflammatory responses as evidenced in a wide range of epidemiological studies (Estruch & Ros, 2020). Inflammatory and oxidative stress can be induced by many lifestyle factors, one being a high fat, ultra-processed carbohydrates, and salt diet, often all in a single portion not found in the natural world (Paula et al., 2017). The Mediterranean diet is rich in Omega-3 polyunsaturated fatty acids which can induce anti-inflammatory responses, as opposed to Omega 6 pro-flammatory acids (Market, 2009). A plant-based diet full of herbs and spices prevents oxygenated and inflammatory stress (Serafini & Peluso, 2016).

There is a large body of evidence around the positive effect of polyphenols on inflammation and gut microbiota present in fruits, vegetables, grains, and tea (Kumar Singh et al., 2019).  Although vitamins and minerals have higher bioavailability, polyphenols are absorbed in the gastrointestinal tract, then metabolized in the intestine and delivered to organs within the blood, unabsorbed compounds are absorbed by the gut microbiota in the colon, aiding good gut health (Rowland et al.,2018).

Virgin olive oil is a large part of the Mediterranean diet, raising questions around the energy density and concerns over portion control as one tablespoon of olive oil contains approximately 120 kcal (Tosti et al., 2018). However, studies have demonstrated that long term adherence to the diet have measured significantly lower BMI’s and weight circumference, with improved endothelial function and insulin sensitivity and shown to reduce markers of oxidative stress (Montero et al., 2012). Some studies showed weight loss as early as two- and four-weeks (Angelico et al.,2021). This was the same for the high energy content within nuts (Ros et al., 2010). One reason for weight reduction is thought to be the high fiber element providing satiety due to longer mastication, inducing more gastric juices and providing slower digestion, emptying rate, absorption and hormonal responses reducing hunger and plasma insulin levels. Studies showed that the peptides such as cholecystokinin was higher in in fibrous diets and even higher in a diet rich in legumes (Slavin, 2005). However, studies have shown once individuals have experienced highly palatable, high GI foods it takes time and effort to convert to a strict low density, high water, fibrous diet in comparison (Schröder, 2007). The fiber casing on whole grains contains magnesium and calcium thought to support insulin sensitivity (Tosti et al., 2018). However, maintenance may prove difficult and require much support from peers and professional support, there is also highlight barriers financially and cost of time (Bayes et al., 2022: Elfhag & Rössner, 2005).

Exercise in the role of weight loss is fundamental for reversing associated cardiovascular, respiratory, endocrine damage and the pressure placed on all organs and body systems from obesity (Mafort et al., 2016). Due to the pressure on the Heart and joints exercise needs to start slowly, cardiovascular and resistance training will support lean muscle mass and a reduction in white and adipokines hormones, overtime muscle and tissue strength will build and reduce musculoskeletal pain (Mody & Brooks, 2012: Vanhees et al., 2012). Exercise is known to positively effect an individual’s mood and endorphins lasting for several hours post exercise, supporting an upward spiral of mental health (Korb, 2015). However, overcoming barriers to exercise requires support and time utilizing behaviour change therapy (Campbell et al., 2019). Exercise benefits an individual’s quality of life both functionally by improving strength and mobility to perform tasks, improving confidence and connection within the community (Mikkelsen et al., 2017). Exercise groups with peers’ aids progression through comradery and support towards the same goals, Social cognitive theory (Bandura,1989) advocates peer learning through mastery of experiences, incremental goals, modelling, and observation to promote sustained motivation and Self efficacy known to predict adherence to exercise. Michie et al., (2008) states that in order to achieve goal attainment the individual must first have the opportunity, the motivation and the capability (Pirotta et al., 2021).  It is also advantageous to be in a routine, studies have consistently shown that people who do exercise routinely are far more likely to stick to it (Rivera et al., 2019). Furthermore, weight loss through healthy nutrition lifestyle changes is far more likely to be adhered to when the individual combines it with exercise (Foster‐Schubert et al., 2012).

Deconditioned clients will need 6 weeks supervised exercise prescription to learn safe techniques, overcome barriers and build rapport with the trainer and group (Campbell et al., 2019).  Suggestions of moderate intensity, increased by 5% of exercise intensity every six training sessions, up to 65% of maximal capacity (Vanhees et al., 2012). Within the first 6 weeks neuromuscular adaptations will take place, providing enhanced proprioception and neural recruitment (Ruegsegger, & Booth 2018). Many adaptations will occur within the cardiovascular system, the heart will build strength, blood pressure will lower and VO2max will improve (Wojtys et al.,1996). The recommended guidelines are 2 sessions of resistance training and 150 minutes of moderate intensity cardiovascular training per week (Umpierre et al., 2011). Depending on the individuals exercise history and obesity profile, the 30mins per day may require splitting in to 3 x 10 mins per day initially (Petridou et al., 2019). Although the guidelines would not be sufficient to lose significant weight without dietary restriction (Swift et al., 2014), estimates suggest using  exercise alone would require 250mins per week to lose 5kg over 6 months (Gremeaux et al., 2012).

Both strength and aerobic endurance training is required to lose weight, strength training is beneficial for weight loss, due to the lean muscle gain speeding up metabolism for longer periods post exercise as well as stimulating adipose tissue lipolysis, it plays a major role in long term weight maintenance and health benefits (Hass et al., 2001), however, it is not sufficient on its own due to long rest periods between sets and extreme care should be taken to reduce risk of MSK injuries (Sword, 2012), endurance exercise is deemed superior at 60-70 max heart rate (Tschentscher et al., 2016). Hit sessions have shown tolerable for individuals with obesity and yield similar weight loss results as endurance exercise, with approximately 40% less time commitment (Batrakoulis, et al., 2020). However, care should be taken on joints and some individuals may not be able to perform HITT due to injuries or disabilities (Romain et al., 2019). Hit workouts and circuits provide both weights and cardiovascular whole-body workouts, thought to be highly beneficial for beginners and particulary useful due to the versatility in adaptation to individual’s needs (Lyznicki et al., 2001). Encouragement of outdoor exercise and time in nature is equally beneficial for mitochondria function, vitamin D, circadian rhythm, and overall energy levels (Plante et al., 2007: Clemente-Suárez et al., 2022).

Pole walking adds stability and multi joint workouts which can be built into interval walking, providing adaptations necessary for positive health profile changes (Spruit et al., 2013). It is important to include behaviour change counselling support, nutritional lifestyle changes (Sarwer et al., 2009), and emphasis on moderate activity throughout the day such as walking, gardening, cleaning the house, dancing, swimming are vital factors for weight loss (Dubnov et al., 2003). Settling an alarm or wearing a pedometer to raise awareness of time being sedentary as well as setting incremental goals to achieve between sessions will significantly increase energy expenditure and reduce cholesterol and blood pressure (Richardson et al., 2008).

Exercise enhances dietary change weight loss; it is widely evidenced that exercise on its own rarely yields desired weight loss (Sarwer et al., 2009). Exercise does play a significant role in long-term weight-loss-maintenance. A large study recorded Spending 2621kcal per week on exercise such as 60mins of moderate brisk walking, or 35minutes per day of vigorous activity jogging was sufficient to maintain weight loss (Ogden et al., 2012).

Smoking and obesity increases the risks of multimorbidity’s considerably (Freedman et al., 2006). although smoking is known to reduce appetite, overtime the negative effects on the respiratory system and cardiovascular system ensure the body systems work much harder to function.  Clogged arteries with toxic chemicals such as nicotine and tar increases the difficulty to exercise physically due to decreased motivation and increased effort (Maiti, 2019). Smoking cessation referral should be encouraged as part of lifestyle change, although benefits may be offset by weight gain, it is important to mobilise support for this (Kos, 2020). Alcohol has been linked to upper body cancers. Ethanol is a carcinogen and also converts to another carcinogen in the body especially if you are a smoker (Rumgay et al., 2021).  UK guidelines are one glass per day for women and two for men or less than 14 units per week (Holmes et al., 2020). Referral to local support such as One Small Step Devon is advised for alcohol support.

Addressing poor sleep is known to have a positive trickle-down effect. A lack of sleep (less than 7 hours or less than 4-5 sleep cycles) over a long period of time can cause mental fatigue, the inability to regulate emotions, metabolism and poor memory recall. Over years poor sleep is associated with plaque build up linked to dementia and Alzheimer’s (Brown, & Bray, 2019). Sleep deprivation has been linked to obesity, metabolic disease, and diabetes. Data has shown restricted sleep increases appetite, altered metabolism and decreased energy expenditure (Chennaoui et l.,2015). Studies suggest that healthy calorie intake and enough sleep duration may act as protective factors for college students against anxiety (Knutson, 2012).  Sleep hygiene awareness workshops is beneficial to reduce many associated symptoms (Gupta et al.,2002).

Mindfulness studies have found significant reductions in anxiety symptoms, psychosocial and quality-of-life in chronic disease patients (Lerman et al., 2012: Carlson and Garland, 2005). Moderate Improvements of stress related illnesses, depression and anxiety, increased quality-of-life, sleep, and functional status were found in a two large meta-analytic review (Hofmann et al., 2010: Goyal et al., 2014). In healthy people compassion was shown to significantly increase healing (Chiesa & Serretti, 2009) and stress, anxiety and rumination decreased (Sharpiro et al.,2007), and mindfulness has been found to reduces biological markers such a Cortisol, increase antibodies, and slow cellular ageing (Epel et al., 2009: Jacobs et al., 2011: Arch et al., 2014). Gratitude is the attitude of I already have a feeling of peacefulness, content, and gratefulness rather than driven by need and discontent (Emmons & McCullough 2003) Gratitude and self-compassion are significant factors for disease recovery (Shcnepper et al., 2020) Mindfulness can be a fantastic way to end an exercise session, leaving participants calm and relaxed for long periods (Alexander et al., 2013).

 Lifestyle change support is crucial to disease recovery (Balanzá-Martínez et al., 2021). Studies show that receiving structured support increases adherence (Nanchahal et al., 2009: Berkel et al., 2005).  Many studies have shown a high drop out rate (50-80%) for treatment of chronic diseases (Wadden et al., 2000), and adherence to weight loss programmes is notoriously poor (Dalle et al., 2013). Social support includes emotional, practical, and educational support, it may be delivered as encouragement, reinforcement, motivational, role modelling, empathy or feedback (Wallace et al., 2000). Social support increases adherence to Lifestyle change by affecting physical and psychological wellbeing, reducing cortisol production, and increasing vagal tone known to improve health (Lerman et al., 2016). Whilst Social support is known to aid the progression of goal setting and provide humanistic support, it is worth noting bullying, control and co-dependency are known negative elements (Burrows et al., 2000). Empowering individuals and providing reassurance through behaviour change therapy could eliminate this (Lv et al., 2017).  The humanistic person centered (PC) approach would ascertain the individuals’ gaps in knowledge and ask permission to offer educational advice and guidance. Individual choice and readiness are paramount to successful lifestyle change (Middleton et al., 2013).

 Motivational interviewing (MI) is PC technique which allows the person to explore their own thoughts feelings and knowledge around a subject (Miller & Rollnick, 2012: Atkinson et al., 2008).  The therapist encourages conscious raising of barriers and fears, through some prompting and much active listening, guiding the person to verbalise their own innate wisdom, thus allowing the individual to understand why they often feel stuck (Levy & Hollan, 1998). Self-regulation theory is complementary to MI and beneficial to increase self-efficacy (SE), allowing the individual to intrinsically set their own goals (Burgess et al., 2017), appropriate gentle challenging of beliefs may be required via the cost / benefit ratios exercise e.g., exercise enhances mood and energy levels and would therefore improve the barrier of feeling tired (Teixeira et al., 2012). The exercise is designed to increase motivation to set lifestyle goals by increasing the perceived benefits and decreasing the costs (Middleton et al., 2013). Utilising Susan Michie's 40 taxonomy behaviour change techniques, the Self-regulation model is evidenced to work well to find intrinsic / autonomous goals in line with core values which will evoke positive feelings and raise self efficacy and motivation to sustain adherence (Allegrante et al., 2019: Schunk & DiBenedetto, 2020). The transtheoretical model is useful to understand where an individual is on the behaviour change journey as well as their stressors and emotional triggers (Patrick & Williams, 2012: Wing et al., 2006: Liu et al., 2018).  Goal setting and Social support are constructs of the social cognitive theory (Wallace et al., 2000). The four constructs include the individuals’ beliefs around their behaviours affecting health, perception of own Self efficacy, capability in making and sustaining lifestyle change behaviours, capability to control behaviours, environmental and peer influences and the belief to overcome barriers (Luszczynska & Schwarzer, 2015). The Com-B model highlights the need of capability, motivation, and opportunity to be present before embarking on behaviour changes (Michie et al., 2008)

Clinics which provide positive, empathetic Social support to increase self efficacy, self-compassion and the relationship towards food, physical activity, their bodies, and themselves prove useful (Schnepper et al., 2020). Healthy lifestyle changes utilizing phone apps to encourage self-monitoring / feedback, monitoring body composition and biomarker changes, control binge eating triggers, work through barriers and emotional turmoil, offer relapse prevention and counselling over a minimum of six months loosing 8KG per six months has shown promising results, this may or may not be in conjunction with NHS clinical interventions (Webb & Wadden, 2017: Wadden et al., 2020:Balanzá-Martínez et al., 2021; Debon et al., 2019: Lv et al., 2017).

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