by Carolyn Thomas ♥ @HeartSisters
In a classic understatement, U.K. researchers Drs. Michael Kelly and Mary Barker observed that “most efforts to change health behaviours have had limited success.”(1)
No kidding. Right now, even as you read this, academic researchers are applying for (and getting) grant funding to study smokers who don’t quit, couch potatoes who don’t get off the couch, or heart patients who stop taking their cardiac meds. I’m betting my next squirt of nitro spray that these studies will no doubt conclude that, yes indeed, those people DO need to change their behaviours, and “further study is required”. . .
You would think that having had a cardiac diagnosis would be all the motivation anybody would need to quit smoking, or take their pills, or say NO to Tim Hortons maple dips. And you might also think that all freshly diagnosed heart patients would listen carefully to their doctors’ advice on changing unhealthy behaviours. For some people, a wake-up call like a serious cardiac event is indeed a powerful motivator to change.
Yet behaviour scientists continue to report that most efforts to convince heart patients to embrace cardioprotective lifestyle changes are generally pretty dismal.(2)
Consider the results of the PURE study for example, published in the Journal of the American Medical Association. Researchers in 17 countries followed over 7,500 patients diagnosed with cardiovascular disease, and here’s what they learned:
• 48% of smokers continued to smoke
• 65% did not exercise
• over 60% did not improve their diet
• 14% had adopted not one single lifestyle improvement
When Kelly and Barker looked at research findings like the PURE study, they bluntly concluded that “the extensive body of evidence of how to bring about behaviour change is consistently ignored because policy makers are seeking simple non-scientific answers to complex problems.”
Their paper in the journal Public Health lists six common errors that can get in the way of even the most well-meaning health-related behaviour change attempt:
Error #1. “It is just common sense!”
The advice-giver’s argument here is that it’s obvious what needs to be done, so just get on with it. But if healthier behaviour choices were only about making simple changes, then we’d all be making them already. Consider also eminently common-sensical – yet dismally failed – public health campaigns, like Just Say No to Drugs.
Error #2. “It’s all about getting the message across”
This approach argues that if we could only come up with the correct message with just the right words, then everybody would change when they hear that brilliant message. It’s what scientists call the “stimulus-response” model of behaviour (“I hear the message, and I immediately respond to it”). Might work well with lab rats, but not so much with humans. And when messages do work (as they have done during massive national quit-smoking public health campaigns, for example), they are part of a sophisticated multi-level strategy of broad, consistent policy messages over many years.
Error #3. “Knowledge and information drive behaviour”
Behavioural scientists warn against believing that information from an expert source is a driver of behaviour change. The traditional medical hierarchy models of the doctor–patient relationship imply that patients have an information deficit and doctors will remedy this deficiency. But just look at the struggles around communicating precautionary public health information during the pandemic! Another example: new diet fads. Personally, I’ve been on a diet (or going off my diet, or going back on a diet) since age 13. I don’t need more information about losing weight. I know how to lose weight (because I’ve been losing – and gaining it back – for years) and have been a Lifetime Member of Weight Watchers since 1977. But we also know that most diets fail, not because people haven’t yet bought Mark Hyman’s latest diet book, but because, as Kelly and Barker explain, knowledge and information alone do NOT drive behaviour.
If they did, mirrors and bathroom scales would be all we ever need.
NOTE: Please read “Women’s Heart Disease: an Awareness Campaign Fail?“ for a shocking example of how years of awareness-raising of women’s heart health has not only failed to raise awareness, but women’s awareness has actually declined over the past decade.
Error #4: “People act rationally”
Error #5: “People act irrationally”
Here’s a paradox: it’s not true that we always act rationally, but the opposite is not true either. We’re not always irrational. Kelly and Barker warn that it’s arrogant to assume people consume alcohol, chocolate, or junk food because they are simply behaving stupidly. They also cite research on women living in poverty who have still found money to buy cigarettes.(3) When asked why, the women said that sitting down for a smoke was the one opportunity in the day they had a chance to do something completely for themselves. In this context, smoking was not an irrational thing to do. Humans know what they’re doing, and they can account for their choices in meaningful ways which make complete sense to them – even when they make little sense to others. It is important not to dismiss the explanations people give for something they do or don’t do just because medical evidence dictates that this ‘something’ carries a health risk, and especially if you’re the one who’s been telling them to change (because policing decisions you don’t approve of may mean they’ll stop telling you the truth).
Error #6: “It is possible to predict accurately”
The Public Health paper suggests that public health policy is often driven by a naïve desire to predict things (“If we can raise their awareness, people will change for the better”) – rather than to understand what led to the things happening in the first place. Kelly and Barker point out differences between individual behavior choices and group behaviour patterns in society. While we can describe patterns in great detail, they say, we don’t have “sharp-edged tools with which to tackle health inequalities, the obesity epidemic or rising alcohol consumption rates.”
Some suggestions that might work instead from Kelly and Barker include the following:
1. The nudge: Many of our behaviours are driven by automatic responses requiring little brain engagement, often triggered by our environment (like those chocolate bars staring at you in the grocery checkout line). The ‘nudge’ refers to making small changes in the physical or social environment that make specific behaviours more likely. I need to do this all the time. Two of my own longterm small nudges that seem to work for me:
- 1. keep a Tupperware bowl of sliced raw veggies in the fridge for afternoon snacking (if they’re there, I’ll happily eat them, but if not, who knows what I’ll reach for when I’m tired or hungry?)
- 2. I get my walking shoes/socks ready the night before, and place them where I’ll see them first thing in the morning.
2. Evolution of social practice: When my Dad decided to quit smoking in 1951, his friends immediately asked him if he were sick. In that era, real men smoked, and glamorous women smoked. My parents, like all of their friends, kept a cigarette box, a lighter and ashtrays in the living room for visiting company. The only way that this golden age of tobacco acceptance changed, according to Kelly and Barker, was when smoking stopped being primarily defined as a glamorous or manly social practice, and became defined not only as a serious health problem, but downright disgusting. It took decades for this social change to happen. Behaviour change was involved, but only as one part of a multi-part approach, and as Kelly and Barker claim: “We will need similarly comprehensive and robust approaches to deal with alcohol misuse or the consequences of physical inactivity – not facile and simplistic platitudes.”
3. Approach goals, not avoidance goals: Behavioural scientists tell us that framing any goal with an approach message (moving you toward a particular objective) is almost always more successful than an avoidance message (moving away from what you don’t want).4 As I wrote here, an avoidance goal (“Do this to lower your numbers so you won’t have another heart attack”) is far less effective than an approach goal (“Do this so you’ll feel good and sleep better!”)
♥
Q: What has helped most to motivate you to change an unhealthy behaviour?
1. Michael P. Kelly, Mary Barker. “Why is changing health-related behaviour so difficult?” Public Health, Vol: 136, 2016. 109-16
2. , J et al. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences: (2012) 67B (3): 279–288 October 9, 2011.
3. H. Graham. “When life’s a drag: women, smoking and disadvantage.” (1st ed.), HMSO, London (1993), p. 1993.
(4) Elliot, A. J. & Sheldon, K. M. (1997). Avoidance achievement motivation: A personal goals analysis. Journal of Personality and Social Psychology, 73, 171-185.
I’ve been busy this week cuddling my new grandson Zachary, so this post is based on one originally published on Heart Sisters in July 2018.
♥
NOTE FROM CAROLYN: I wrote more in my book about what works – and what doesn’t work – in motivating heart patients to change behaviours. “A Woman’s Guide to Living with Heart Disease“ is available in bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
See also:
-For healthcare professionals who are sincerely interested in learning more about the frustrating mysteries of motivating behaviour change, read about Minimally Disruptive Medicine as described by Mayo Clinic’s Dr. Victor Montori (author of the equally profound little book “Why We Revolt“).
–First the Big Change, Then the Big Transition
–Why don’t patients take their meds as prescribed?
–First, There Was Compliance. Then, Adherence. Now, Concordance!
Heart Sisters 
Great Post. Thanks for sharing this information.
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There are two things I do that help me MOST of the time:
1) Whenever add something in rather than taking away. Similar to your #3 suggestion. Make an effort to add in fresh vegetables and fruits to your diet rather than removing all less than healthy foods. The plan is that they become the habit and edge out the unhealthy choices.
2) With exercise, start with an amount that you can be successful at, even if it is just a 5 or 10 minute walk. Success breeds success and increasing the amount gradually will feel good.
I still struggle with exercise. And I trust my body that if the exercise is making me feel worse instead of better it may not be right on any given day.
Learned advice is everywhere. The choice to follow or not and why we do or don’t follow it is Individually motivated and more complex than any scientific study will ever figure out.
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Hi Jill – such important advice! I loved the “add to” theory – especially to introduce more healthy choices. Success does breed success, as the late great tennis star Arthur Ashe said: “Start where you are. Use what you have. Do what you can.” Great place to start those small successes, I think.
Behaviour science is a very different animal than medical science – and this focus can help to inform our healthcare professionals what DOESN’T work as effectively as what DOES work in helping to support their patients!
Take care, stay safe. . . ♥
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One thing I have seen in my own life and in similar friends is that we Know what is right and we Do what is right up to the extent we physically can, but our results don’t match the medical diagnosis of improving.
For instance, I have struggled to lose weight since my 30s. I eat better than most anyone and am a vegetarian. I never ever lose weight and many of my attempts at weight loss diets/pills/programs/fasts have only increased my weight. I am 100% at will power. I have seen every imaginable doctor and nutritionist and health coach. No one knows why I am not just naturally at a “normal” weight.
Now, the arthritis in my hips and knees is serious and I can no longer exercise and dance like I used to which compounds the situation. What I am saying is that I and others like me would be labeled/are labeled as those non-compliant people – but we are complying! It just doesn’t change the scales.
My son is young, healthy and strong. He is vegan and eats very little carbs, no sugar, and he runs and bikes or swims miles every day as he has for years. He is now in training for a triathlon. But he is a big guy and no way would a doctor’s scale and codes say anything except he “should” lose 100 pounds.
If he isn’t able to lose, no one can! I have a friend who eats like a bird. Most people would starve on what little she is able to consume. She had bariatric surgery several years ago. But she only lost a few pounds, never got thin, and would never weigh-in as a success story in a doctor’s office, yet she has been 100% compliant.
I think we are set up to be failures by standards and formulas designed for someone’s idea of a ideal body that most people can never attain. Maybe the numbers say society is so overly obese because the “ideal” numbers don’t fit the real bodies out here. Maybe people ARE trying to do their best to overcome challenges and change their habits, but their numbers don’t prove it. I myself had LOW cholesterol, Low blood pressure Low sugars and perfect blood levels – yet had a major heart attack at age 61. Even the doctors were shocked and confused.
Maybe sometimes – or, I dare say, most of the time – people ARE doing the right things but the end result is still the wrong thing. Just like you can’t legislate common sense, common sense is no guarantee against disaster.
I wish some of the data and statistics showed the numbers of people like me and sooo many others. Maybe then the medical community and researchers would work on trying to find solutions for every body and type and not bias their knowledge on a stereotype.
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Hello Lyn – thanks for weighing in with what I believe is a relatively common reality: all it takes is an injury or pain to interrupt our “normal” physical activity routine, and the results can have such a powerful impact. For the past two months, I’ve been struggling with intense heel pain due to plantar fasciitis and I cannot believe how debilitating and distressing this breathtaking pain is – plus my long daily walks along the ocean aren’t possible right now!
Your comment about numbers not telling the whole story reminded me of an article I read recently on BMI (Body Mass Index). Apparently, when the former actor/California Governor Arnold Schwarzenegger was in the prime of his bodybuilding career, he was 6’0” and weighed 235 pounds, thus a BMI of 31, putting him in the BMI range of “obese”. I don’t think so. . .
It’s discouraging for those who are doing the best they can if the numbers doctors care about don’t reflect the effort being put forth!
Take care, stay safe. . . ♥
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Thank you for hearing me and for all the heart blogs. You have really helped me through.
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Oh, Lyn, I’m so sorry for your struggle! The strength you have to keep doing the right things in spite of your body not “complying” is both heart breaking and awe-inspiring. You go girl! Sending you a huge hug! {{{Lyn}}}
Holly
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Thank you so much Holly!
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I read your article with close attention, as it’s a question I’ve often asked myself. What motivates me to make lifestyle changes? It’s certainly not external forces. I think it may be a combination of factors: Do I feel better almost immediately from that change? Are there factors that encourage me to go back to my original behavior? Do I have tools to help me stick with change, even when that change doesn’t seem to be helping?
For me, my diagnosis of Type 2 diabetes was a huge change (though, honestly, long expected). The most important factor in helping me maintain near-normal glucose levels is my glucose meter. The instant feedback of normal or high numbers helps me stay motivated. The second big factor was totally unexpected but very welcome – I lost about 90 pounds, and have kept it off by eating very low carb for over 12 years. And both of these points led me to daily walks or other exercise, as that helps keep my glucose numbers near normal, and helps maintain the weight loss.
What can sabotage my efforts are the disinterest of medical staff, family members who continue to eat high-carb diiets (often offering things that they know I “shouldn’t” eat), other health issues that don’t respond to my glucose control, dealing with serious mental health issues stemming from childhood and medical trauma, and possibly some drug interactions from the various health issues. I want external positive feedback, but really don’t ever get it. And our culture is strongly oriented toward behaviors that just don’t support what I have to do to feel the best I can manage.
Change has to come from within, but external factors can stonewall change. I honestly can’t think of something a doctor could say to me that would help me stay motivated with my very stringent lifestyle changes.
Except possibly a recognition by the medical professionals of what I’ve had to give up and what I’ve accomplished in spite of it – a YOU GO GIRL! would be nice. More tools would help. US “health” insurance companies severely restrict the use of glucose test strips, with the excuse that American Diabetes Association discourages their use for Type 2s, and the companies that make the strips charge an incredible amount of money for them. I finagled until I got a nearly-unlimited supply, so I still have that instant feedback. But in the face of the other discouragers, sometimes that’s just not enough to keep me trudging.
Because it is, forever and always, a trudge.
Holly
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Thanks Holly for your thoughtful response. You’ve become your own expert in making wholesale changes – and keeping up with those decisions to change – for over a decade. You deserve a great big “YOU GO GIRL!” from every clinician you see! Sadly, some docs seem quicker to note areas where we need “improvements” while ignoring tremendous accomplishments like your own.
You’re so right. Change has to come from within FIRST. That’s why researchers who study the social determinants of health (things like race, trauma history, housing, complex health needs, poverty, education, etc etc.) keep reminding healthcare professionals they need to care about these issues in their patients). Yours is a good example of how, even when keenly self-motivated, patients can still face situational obstacles from the very people we’d expect to be our biggest cheerleaders!
Take care, stay safe. . . ♥
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Holly – I highly recommend the continuous glucose monitoring devices like Freestyle Libre. My endocrinologist put in the authorization and my Medicare Advantage plan pays for all the supplies. You apply the monitor Patch once every 2 weeks and can take readings all day every day.
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Thanks, Jill, for the suggestion. I will ask about it, but couldn’t even get the use of a temporary glucose monitor recently, though my endo authorized it. And the time I did get one for a few days, the endo I had then totally dismissed wings of 100 points (US system) in spite of 30 g of carb / over 100 minutes on a treadmill each day. So I’ll just keep on trudging – though, honestly, I don’t think a CGM can tell me more than my meter can at this point!
What’s really sad about this is the proven link between uncontrolled diabetes and the development and worsening of heart disease. But somehow the fragmented nature of our “specialist” medical system just doesn’t act on that connection…
Holly
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TO HOLLY: You Go Girl! Yay!
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Thank you, Lyn! I guess it really means more to hear that from someone who walks the walk rather than medical personnel who just talk the talk.
Holly
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