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Behavior Change: If It Were Easy, Everyone Would Be Doing It

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America's collective risk for chronic disease could be cut by up to 80 percent with lifestyle changes. And although numerous studies have quantified the enormous impact of modifiable behaviors on disease and mortality, little has changed over the past few decades. Rates of chronic conditions continue to rise and the top three behaviors that underlie them -- lack of physical activity, poor diet, and tobacco use -- remain prevalent concerns. It is not that people want to be unhealthy; 70 percent of smokers report that they want to quit, and overweight and obese individuals seeking to lose weight have supported multi-billion dollar diet and exercise industries. It is simply very hard to change health behaviors, especially when so much of society (e.g., sedentary jobs, food marketing), biology (e.g., the body's natural drive to remain at its current weight) and chemistry (e.g., the addictive nature of smoking and many unhealthy foods) conspire against us. If you need firsthand evidence on the challenge of behavior change, just think of an unhealthy habit you have and ask yourself, why haven't you changed it?

Better understanding how to promote behavior change holds vast potential to improve the population's health. Unfortunately, much of that potential remains untapped. The American health care system has invested relatively little in this area, which is ironic given it is one where people need lots of help. A greater focus on behavior change could be hugely beneficial and should include further implementing methods already demonstrated to work as well as investing in the exploration of new and novel approaches.

One such method is Motivational Interviewing (MI), "a collaborative, person-centered form of guiding to elicit and strengthen motivation for change." MI is a counseling method that has been shown effective in eliciting health behavior change; it is a systematic approach to building rapport between counselors and patients that methodically draws out a patient's intrinsic motivation for change and solidifies his or her autonomy in the process. While many clinicians think that they are already engaging patients in this spirit, studies show significant improvement in counseling skills following structured MI training. Although the training is rigorous and takes time, it holds great value and should be considered for more widespread adoption.

Thorough counseling using MI may be the most effective known intervention for health behavior change, but its application is not always pragmatic. While we know that people are most likely to act on health care advice if it comes from their doctor, a few 8-20 minute visits per year make it hard for physicians to partake in in-depth and comprehensive behavior change counseling. This challenge is compounded by the fact that the patients who need the most help with behavior change are often the same ones that have an array of pressing medical issues that require a physician's time to be dealt with. Given that reality, perhaps the most useful model for health behavior change is one in which a physician acts as the primary catalyst in change, and then refers the patient to his or her team (e.g., nurse or social work care managers, health coaches, etc.) for more intensive and regularly scheduled MI-based support.

With that in mind, Dr. David Katz, a well-known expert on lifestyle medicine, along with his team at the Yale Griffin Prevention Research Center, developed the Pressure System Model of Lifestyle Counseling in Primary Care (PSM). The PSM is a simple algorithm that allows physicians to initiate behavior change in just two minutes. This focuses a physician's limited patient time on his or her unique influential power in starting the behavior change process and then leverages other resources in a team and/or community-based approach to seeing it through.

Greater adoption of MI and physician initiated counseling are undoubtedly steps in the right direction, but they do not go far enough. While these interventions are powerful in helping patients realize the "why" behind behavior change, they may fall short when it comes to the "how." This is where health care should consider and test learnings from other disciplines like behavioral economics to provide patients with actionable advice on how to successfully execute behavior change. Simple techniques like removing barriers to desired behaviors (or creating barriers for undesired ones), leveraging inherent biases toward loss aversion in "compliance contracts," or harnessing the power of an audience and social pressure can all go a long way to promote and reinforce successful behavior change.

For example, just imagine if when speaking to you about how to kick your late-night eating habit, your doctor (or other health care counselor) recommended a few very tactical actions:

  • Identify the foods you tend to binge on late at night and ban them from your home (most people's weakness is not in the grocery store but in the kitchen late at night, and this forces you to get in the car and drive to the ice cream shop)
  • Give $200 dollars to your colleague that you will get back only if you do not eat after 9PM for a month (loss aversion says we hate to lose what we already have)
  • Install a small camera in your kitchen to be viewed by your significant other weekly (this very intimate social pressure is likely more effective than all your significant other's verbal encouragement over the last decade combined)

The above advice is likely far more helpful than, "Don't eat after dinner." The proliferation of mobile apps and other technologies only broaden the possibilities of applying behavioral economic principals to health care. Against that backdrop, it is welcoming news that leading health care research institutions like the Robert Wood Johnson Foundation are beginning to delve into behavioral economics. Further research, experiments, and real-life pilots will help medicine learn how to "hack" inherent human biases in the pursuit of healthy behaviors.

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While we haven't yet figured out the perfect cocktail for behavior change, we can do a lot right now simply by investing in and spreading approaches that are already shown to work (e.g., Motivational Interviewing and the Pressure System Model of Lifestyle Counseling). In the longer-term, we should further explore insights from behavioral economics and consider other novel approaches to behavior change that may originate in fields outside of health care.

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