Behaviour change: if it’s so ‘easy’, why do so many studies show it won’t last?

by Carolyn Thomas    ♥   @HeartSisters

Many centuries ago, while I was a volunteer run leader at our local YM-YWCA annual Marathon Run Clinic, my assigned running group each January was the 10-minute milers, whom I affectionately dubbed The Turtles. Our motto: “No course too short, no pace too slow.”   My group members were typically either former runners slowly returning after an injury, or people who were brand new to running. The newbies were as enthusiastic as their freshly-made New Year’s resolutions:  one, for example, declared to me that this was the year that he was finally going to quit smoking, lose 30 pounds, and run a marathon.

To which I replied: “Honey, pick ONE. . .”     .           . 

Group running clinics are (in my completely biased opinion) a terrific way to start running safely. I used to tell my Y groups: “All you have to do on Sunday mornings is put your running shoes on and show up!”  Basically, we were demonstrating an effective intervention in behaviour change together. 

Recreational running is an interesting activity when it comes to behaviour change. Running costs little except a good pair of shoes. Anybody can do it by themselves, just by warming up for a few minutes, then opening their front door and starting to run down the sidewalk. Yet many people pay money in advance to register with Run Clinics like ours just to have other people supporting them in reaching a goal – to complete the Royal Victoria Marathon/Half-Marathon that happen every October. (This weekend, due to pandemic precautions, the race is a Half-Marathon and 8K race; all participants must be double-vaxxed).

That kind of group support worked for run leaders as well.  Knowing that my Turtles were waiting for me to show up at the Y propelled me out the door without any of my usual feeble solo excuses not to run today (“it’s too hot, it’s too cold, it’s too windy, it’s too rainy, it’s too early, it’s too late, I’m too hungry, I’m too full, I’m too tired, or oh! did I mention? I have a blister!”)  Because I’m very skilled at talking myself out of running on my own, I know with full certainty that I never would have run the miles I did over 19 years without this “intervention” group support.

As one runner described her own first Run Clinic experiences :

“Going out for a run with a group is more fun than I thought it would be. I like the meditative aspect of running alone, but running with others felt lighter, less serious, more enjoyable.”   

And activities that are “more enjoyable” are, of course, the ones we are likely to continue doing longterm. This concept applies not only to running (which is admittedly not for everybody), but also to walking, swimming, gardening, golfing, yoga, biking, hiking, kite-flying, chasing grandbabies around or anything else we love doing.  Just do something you enjoy that keeps your body moving every day.

If it’s not enjoyable, it’s unlikely we’ll remain interested in keeping it up. That also helps to explain why we stop doing things – even taking prescribed medications. Most studies estimate that at least 50 per cent of prescribed drugs are not taken. Heart patients are labelled by doctors as non-compliant  when they do that (non-compliant, by the way, is a patronizing term that makes many patients cringe).

One of my readers told me that she hates taking her pills because doing so every morning makes her “feel old and sick”,  reminding her that she’s now a patient. Taking pills isn’t only about medicine – but about how we see ourselves in the world. Realistically, how long do you think a person who “hates” taking pills will continue to take them?

If it’s this hard to convince some heart patients to take pills, it can be even harder to convince them to go out of their way to embrace personal behaviour changes to improve their health (e.g. to quit smoking, to adopt a heart-healthy diet, or to do regular exercise). These behaviours are important because we know that up to 80 per cent of heart disease can likely be prevented by improving as many of our lifestyle decisions as we can.

Calgary’s Cheryl Strachan is a Registered Dietitian and author of “The 30-Minute Heart Healthy Cookbook”  (READER HINT: excellent Christmas gift suggestion!) She recently shared a study on behaviour changes(1), specifically among people who have resistant hypertension (high blood pressure) – the kind  that doesn’t respond to medications. This is not good – we  know that hypertension is a significant risk factor for cardiovascular disease and other serious health problems.  As Cheryl wrote: 

“The interesting finding in this study is that people given intensive support for four months (weekly group diet counseling sessions plus 3-times-a-week exercise at a cardiac rehabilitation facility) lowered their blood pressure more than those given a one-hour lecture, a workbook with a meal plan, and an exercise prescription to implement on their own.”  

That kind of organized group support sounds encouraging. Yet the trouble is that very few studies include longterm follow up with research participants like these once the “intensive support” is over and the research paper is published.

So I wondered what those blood pressure results were like AFTER all that closely monitored research attention ended?

Another study titled “What Happens When the Party’s Over?” published last year in the journal Behavioural Medicine helped to answer that question, this one focused on helping patients increase their physical activity.(2) The study reported that behaviour change interventions can indeed improve the frequency of physical activity in the short term.  But although significant improvements were found compared to the participants’ first baseline assessment, “improvements are generally not sustained after the intervention concludes.”

Or, as Australian behavioural scientist Dr. Dominika Kwasnicka warned in a study published in Health Psychology Review(3):  

“Behaviour change interventions are effective in supporting individuals in achieving temporary behaviour change. Behaviour change maintenance, however, is rarely attained.”

Reality is discouraging, isn’t it? Take diets, for example. I’ve been either on a diet, going off my diet, or coming back to a diet – pick ONE! – since I was 13 years old, and I swear I’ve successfully lost (and then regained) the same pounds over decades.  And yes, I know: diets don’t work. The only time I wasn’t on a diet since age 13 were the years when I was a distance runner. Back then, I didn’t run to lose weight – I ran because I loved running with my group – although one of my running buddies did have a fun T-shirt that read: “We Run For Cheesecake!”  

Cheryl Strachan describes the approach she aims for in her Sweet Spot Nutrition blog as “health-first, not weight-focused” (check our her free video series called “How To Eat Well After a Heart Event“).  As Cheryl recently told me, Registered Dietitians are trained food scientists who generally have more time to spend with clients than our physicians do. “We are able to LISTEN and help people work out food solutions that work for them. I think we end up with a better understanding of the real life implications of dietary advice.”

Which brings us back to behaviour changes, and why we do or do not follow “doctor’s orders”.  One of the key predictors of whether or not we will fill that drug prescription, quit smoking, eat more veggies or exercise as recommended turns out to be our personal relationship with our doctors and our trust in their professional advice.(4)

Being a participant in a behaviour change study must be like having your own weekly Run Clinic – but for non-runners. All that support and attention, but none of the blisters.

And when the study’s positive findings are submitted, peer-reviewed, accepted and published in a journal, researchers can move on, content in the knowledge that they’ve contributed to the literature with their successful behaviour change outcomes.

Or have they?

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1. James A. Blumenthal et al. “Effects of Lifestyle Modification on Patients With Resistant Hypertension: Results of the TRIUMPH Randomized Clinical Trial”.  Circulation; 144:00–00. September 27, 20201. DOI: 10.1161/CIRCULATIONAHA.121.055329

2. Desmond McEwan, Ryan E. Rhodes, Mark R. Beauchamp (2020) “What Happens When the Party is Over?: Sustaining Physical Activity Behaviors after Intervention Cessation”.  Behavioral Medicine, April 10, 2020. DOI: 10.1080/08964289.2020.1750335

3. Dominika Kwasnicka et al. “Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories”. Health Psychology Review, March 7, 2016. 10:3, 277-296, DOI: 10.1080/17437199.2016.1151372

4. F.E. Chipidza et al. “Impact of the Doctor-Patient Relationship.” Primary Care Companion. October 22, 2015; 17(5):10.4088/PCC.15f01840.

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NOTE FROM CAROLYN:  I wrote more in my book about what works – and what doesn’t work – in motivating heart patients to change behaviour. “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).

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Q:   What significant behaviour changes have you made? Any tips on what helped you maintain them?

See also:

-my Runner’s World essay on becoming a former runner

–Why Don’t Patients Take their Meds as Prescribed?

–“I’m Just Not a Pill Person” – and other annoying excuses

–Living With the “Burden of Treatment”

–When “Nudging” Doesn’t Work to Change Patient Behaviour

–How to Avoid Six Common Errors in Motivating Patients to Change