Fundamentals of Behavior Change
Michael T. Smith, Ph.D.
JHU CENTER for BEHAVIOR and
HEALTHhttp://www.hopkinsmedicine.org/behaviorandhealth
msmith62@jhmi.edu
5510 Nathan Shock Dr., STE 100
Baltimore, MD 21224
410-550-7000 Phone
Aims
1) Brief overview of why health behaviors should be an
important focus in medicine
•
Highlight sleep and physical activity – yellow team
experiential learning
2) Discuss general principles and models of behavioral
change
3) Discuss some tools and techniques to foster sustainable
behavioral change in patients
Why have a residency rotation
focusing on behavior ?
Behavior directly linked to 40% of Actual Causes of Death in US (1990)
75% of $2.5 Trillion in healthcare cost attributable to chronic diseases (diabetes, CVD, etc)
Access to Medical Care
Tobacco
19% (1990) – 18% (2000)
Genetics
Diet/Activity Patterns
14% (1990) -17% (2000)
Estimated U.S. %
Prevalence of Unhealthy Behavior
Fine LJ, Philogene GS, Gramling R, Coups EJ, Sinha S. Prevalence of Multiple Chronic Disease Risk Factors: 2001 National Health Interview Survey. American
Journal of Preventive Medicine. 2004;27(2S):18 –24).
Prevalence of Multiple Unhealthy Behaviors
Fine LJ, Philogene GS, Gramling R, Coups EJ, Sinha S. Prevalence of Multiple Chronic Disease Risk Factors: 2001 National Health Interview Survey. American
Journal of Preventive Medicine. 2004;27(2S):18 –24).
5
Sedentarism:
• 33% of High School kids meet PA Guidelines (60 min/day)
• 48% of Adults meet guidelines (150 mins. moderate / week)
2008 Age Adjusted Percentage of Adults who are physically Inactive
Sleep: a neglected health behavior
Our Soldiers Get it.
Why don’t we?
38% of Adults
Report Insufficient
sleep (CDC)
Kripke et al. 2001, Arch Gen Psych
Self-Reported Total Sleep Time
INSOMNIA:
"Last week I probably slept an average of
two hours a night.
"I couldn't stop thinking. My body was
exhausted, and my mind was still going."
J of Sleep Research
2, 1-12 (2003)
Sleep Duration Increases Diabetes
Risk
•
Experimental sleep restriction to 4 hrs/night for 6
days causes insulin resistance (Spiegel et al. (Lancet, 1999)
•
Sleep duration impacts prevalence of diabetes
Adjusted for age, sex, race, waist girth, caffeine,
alcohol, smoking, and apnea-hypopnea index
Gottlieb et al. (2005)
Arch Intern Med
Sleep is increasingly linked to obesity
Sleep Duration by BMI
Behavioral Risk Factor Surveillance System
Taheri,
2004
General Principles of Fostering
Behavior change in your patients:
# 1: It is all about the relationship
•
Listen to your patient
•
Get to know what is important to them and why
General Principles of Sustaining
Behavior Change: elephant metaphor
Appeal directly to
the emotional beast:
Make it meaningful,
personal, and salient
The rider must establish simple, clear
actionable directions (goal setting) to
steer the beast and maintain course:
Clear the path: Address
external “environmental”
barriers & consider how
environment can be
modified to promote
change
Health Bros, Switch
General Principles of Behavior
Change: promote patient’s autonomy
for change
•
Collaboratively help patients freely
commit to change for their own reasons
on own terms
•
•
Connect reasons to personal meaning and affect
If you are working harder to change the
patient than the patient is, take a step
back.
Pitfalls:
•
Trying to force change or superficially
telling a patient what they should do is
likely to backfire
Experimental Design: Alcohol
Dependence




Rats randomized to control, intermittent free choice
(once per week), continuous free choice, or forced intake
of ethanol
Became dependent on ethanol over 8 months of drug
administration
Animals kept ethanol-abstinent for 3 months, during
which time they showed withdrawal (change in pain
threshold, hyperthermia, inactivity)
Animals then provided self-administration test
Wolffgramm, J., Heyne, A. (1995). From controlled drug intake to
loss of control: the irreversible development of drug addiction in the
16
rat. Behavioural Brain Research, 70, 77-94.
3
2.5
2
g/kg/day ethanol
1.5
1
0.5
0
Controls
Forced
Intermittent
Free Choice
Continuous
Free Choice
Wolffgramm, J., Heyne, A. (1995). From controlled drug intake
to loss of control: the irreversible development of drug
addiction in the rat Behavioural Brain Research, 70, 77-94.
17
Experimental Design : Opiate
Dependence




Rats randomized to control, choice or forced
intake of etonitazene
Became dependent on opiate over 30 weeks of
drug administration
Animals kept opiate-abstinent for 19 weeks,
during which time they showed withdrawal
(change in pain threshold)
Animals then provided self-administration test
Wolffgramm, J., Heyne, A. (1995). From controlled drug intake to
loss of control: the irreversible development of drug addiction in the
18
rat. Behavioural Brain Research, 70, 77-94.
90
80
70
60
50
ug/kg/day Etonitazene
40
30
20
10
0
Controls
Forced
Free Choice
Wolffgramm, J., Heyne, A. (1995). From controlled drug intake
to loss of control: the irreversible development of drug
addiction in the rat
Behavioural Brain Research, 70, 77-94.
19
General Principles of Behavior
Change: Health Belief Model
Seriousness of the risk / disease
Odds it will happen to me ?
Ability to change ?
Reminders / Triggers
Self Efficacy
is King
Using Prompts / Reminders / Triggers
1) Environmental stimuli often profoundly drive behaviors
- Stimulus control (learned associations)
- Unconscious priming
E.g. television food cues >>excessive snacking
2) Applied Behavioral Analysis
Break down chained antecedents of behavior
3) Use salient prompts to trigger desired behaviors
- Premack Principle: pair a low frequency behavior you
want to increase with a high frequency behavior:
- meds after brushing teeth
- push ups after voiding
Meeting the patient where they are:
Stages of Change [Transtheoretical Model (Prochaska & Di Celemente)]
•
Change is not
linear.
•
Relapse is
part of the
process
•
Many think
they ready to
change in the
abstract, but
not ready for
all the steps
Stage of Change Tasks

Precontemplation

Contemplation

Preparation

Action

Maintenance

Awareness,
Concern,Confidence
 Risk-Reward Analysis
& Decision making
 Commitment &
Creating an
Effective/Acceptable
Plan
 Adequate
Implementation of Plan
and Revising as Needed
 Integration into
Lifestyle
Strategies and tools : Contemplation
Cost-Benefit Analysis / Decision Making
Strategies and tools : Contemplation
Decisional Balance: (Cost – Benefit of Changing vs. No change)
Exercising 50 mins, 5X Week
Costs
-
Changing
Not
Changing
-
Fear of work
performance hit
Gym Fees
Breaking routine is
stressful
- Insomnia will return
- Gain weight
- Hypertension
- More anxious / Irritable
- Cognitive decline
Benefits
- Better Health
- Mood enhanced
- More creative
- Better quality time with
family
- More time with family
- More time to meet
work deadlines
Strategies and tools : Preparation
Goal Setting:
Poorly crafted goal: “I want to lose weight.”
Smart goal
Specific:
Measurable:
Action - Oriented
Reasonable:
Time Delineated
Long-term Goal
“I want to lose 1 pound / week for 3 months by:”
Short-term Goals / Steps
1) Decrease alcohol to 2 servings / week
2) Cut meal portion sizes by about 20% and limit red meat to 2X week
3) Limiting snacks to 100 calories of fruits & veggies between meals
4) Walking 10,000 steps, 4 days a week
Strategies and tools : Preparation
Create Social Motivation & Learning
Opportunities:
1) Commitments: We seek to be consistent with our public
promises
a)
Have patient explicitly commit goals to others (remember autonomy)
2) Identify an appropriate Model / Mentor (peer leaders)
a)
Similar to learner with respect to demographics and / or
b)
Individuals admired (power and charisma), e.g. Doctors!
3) Norms:
a)
We are strongly influenced by what others do!
Consider whether peer network helps or impedes & augment
Strategies and tools : Action
Self-Monitoring
Critical to most formal behavioral change interventions:
Must be quick, easy, and usable
National Weight loss Registry (Wing & Phelan, 2005).
-
Characteristics of Individuals who have lost at least 30 lbs and kept weight
off for > 1 year.
-
75% weigh themselves at least 1 X week.
-
90% exercise 60 mins. / day
Take Home Messages
1) Myth: Behavior change is hard
2) Start with targets where patient is ready , confident & able
3) Make it personal (appeal to the beast)
4) Set small realistic SMART goals (75% confident)
5) Use Prompts, triggers, & clear environmental path /barriers
6) Use social learning principles

Make public a personal commitment

Modeling

Norms
7) Self monitoring: must be easy and informative