If you made a New Year’s resolution last month, have you kept it? If not, you are not alone in abandoning your plans to lose weight, get to the gym, or quit smoking. By the time February rolls around, it is estimated that 80 percent of resolutions have already failed.
“Behavior change is hard,” says Donald Edmondson, PhD, director of the Center for Behavioral Cardiovascular Health at Columbia University Irving Medical Center. “Yet sustaining healthy behaviors is one of the most important things people can do to live long healthy lives. According to a recent study, human behavior accounts for almost 40 percent of the risk associated with premature, preventable deaths–like heart disease, cancer, and stroke–in the United States.”
Despite the importance of behavior on health, interventions designed to help people change their behavior are often not effective in the long term.
There’s been a lot of work done to help people change their behavior, but we really don’t have many successful interventions to help people maintain those changes over time.
“There’s been a lot of work done to help people change their behavior, but we really don’t have many successful interventions to help people maintain those changes over time,” says Jennifer Sumner, PhD, assistant professor of behavioral medicine.
The NIH’s Science of Behavior Change (SOBC) program is looking to change that by encouraging researchers to use new ways to investigate behavior change.
We spoke with Edmondson, Sumner, and Karina Davidson, PhD, executive director of the Center for Behavioral Cardiovascular Health, who are leading SOBC’s Resource and Coordinating Center, which provides resources to behavioral researchers. (More information about the SOBC program and the research it supports can be found in a special issue of Behaviour Research and Therapy published this month.)
Q: Why is it so difficult to stick to new behaviors? Because it sounds so easy: take a daily blood pressure pill, go to the gym.
DE: Sure, it might sound easy to just “take a medication” or “fit in a workout,” but these are actually effortful behaviors that can be easily derailed, especially during busy or stressful times. It’s not that people are undisciplined or lack willpower if they can’t start or keep up with changing their behavior in particular ways. In order to take a daily blood pressure pill, you have to remember to take it at the same time each day, and it’s easy to forget when you are juggling an overwhelming to-do list for work, personal, and family responsibilities. Similarly, keeping up your new evening exercise routine is no longer so simple when you have to stay late at the office or help your kids with their homework.
Even though we know that it is incredibly challenging for people to both start and maintain behavior change, we don’t fully understand the underlying basic processes that explain why behavior change is or isn’t successful for individuals. That’s what we are working to uncover with SOBC.
Q: It sounds like the first step to finding better methods to help people adopt healthier behaviors is to help researchers identify new ways to study behavior. How are you helping them do that?
JS: Almost 10 years ago, the NIH started the SOBC program because they realized that the science, up to that point, wasn’t consistently helping people to change their behavior. It seemed clear that new ways to effectively design and implement behavioral interventions were needed in order to address this issue.
SOBC promoted a new approach to behavior change research, one focused on identifying the underlying mechanisms that bring about behavior change. The goal is to move the field toward an experimental medicine approach that really focuses on identifying those underlying processes. With this method, researchers explicitly identify, measure, and influence a proposed mechanism of behavior change and then test if a change in the mechanism results in a change in behavior.
Columbia is the organizing hub for supporting this national network of research. Currently, we have eight teams of SOBC scientists who are employing the experimental medicine approach in their research on behavior change. We support the work that they are doing, while also communicating the broader SOBC mission.
Q: Why is it important to identify how an intervention—say a calorie counter for people trying to lose weight—works? If you look back at cancer treatment, no one knew how the first chemotherapies worked, they just knew that they killed cancer cells.
KD: If we knew we had interventions that worked for everybody, we wouldn’t be as motivated to try to figure out why they’re working.
Right now, we don’t have a host of behavioral interventions that consistently help people change their behavior. To use the cancer analogy, researchers soon learned that one type of chemotherapy didn’t work for everyone, and that’s why cancer researchers seek to understand why a treatment works. By understanding how the treatment affects molecular targets inside the cell, treatments can be personalized for each patient’s cancer.
If we knew we had interventions that worked for everybody, we wouldn’t be as motivated to try to figure out why they’re working.
In behavior change research, we still have a black box between the intervention and the effect on behavior. We have the ironic problem that if an intervention worked, it’s possible it did so because the mechanism hypothesized was correct and operated as intended. It’s also possible that the intervention worked but in no way engaged or influenced the hypothesized mechanism. So our goal at SOBC is to open up the black box. To look at what’s going on “at the molecular level,” so to speak.
Having a systematic, rigorous, and common method focused on mechanisms of behavior change that is widely implemented in the field will be a huge shift for behavior change science. At present, measuring mechanisms of change is not a standard part of clinical trials, and SOBC is working to make that the case.
Q: Can you give us an example of how the SOBC method is being used in research?
KD: One SOBC research team, led by Leonard Epstein and Warren Bickel, focuses on the prevention of type 2 diabetes in individuals with prediabetes. Preventing the conversion to type 2 diabetes requires a number of behavior changes: being more active, eating healthier, and taking medications.
Epstein and Bickel are testing if delay discounting—the tendency to value smaller rewards now over larger rewards in the future—is a mechanism that influences these health behaviors in those with prediabetes.
By using the SOBC approach, they are establishing that this hypothesized mechanism can be measured in reliable and valid ways. And they are demonstrating that delay discounting can be influenced with an intervention called Episodic Future Thinking, which entails thinking in specific ways about future events.
Ultimately, they will examine whether changing delay discounting via this intervention results in changes in health behaviors like medication adherence. If so, then they will have identified a mechanism underlying successful behavior change in this patient population.
Q: So do you envision a time in the future when a person who is having a hard time quitting smoking goes to his doctor for advice, and she gives him certain tests that identify what mechanisms are interfering with that behavior change and recommends treatments based on those results?
JS: The work of SOBC is trying to move us in that direction, and I think we would consider it a huge success if we get to the point where we have those kinds of tailored interventions.
By applying a rigorous, mechanism-focused method to behavior change science, our ultimate goal is to inform the development of more effective interventions that are designed to directly engage key mechanisms of behavior change. We have a ways to go to get to that point, but SOBC aims to play a major role in unifying and mobilizing researchers in the field to get us there.
Q: Given that we don’t have a host of mechanism-informed behavior treatments yet, what do you suggest for people looking to make long-term changes?
DE: Engaging in practices that take you off “autopilot” and help you make informed decisions that are in line with your goals can help with behavior change. Reminding yourself of the positive future benefits you’ll receive as a result of changing your behavior (e.g., being able to walk with ease when you are 85 years old or being present for the birth of your grandchild) can help you make choices that pay off in the long term.
Paying attention to the times when you are stressed and identifying triggers of stress responses can also help you anticipate and navigate potentially challenging situations that could derail healthy behaviors. Having people in your life who support your efforts at change and who troubleshoot challenges that arise can be a big help as well. Even though successful behavior change is difficult, it’s not impossible, especially when you can leverage support that helps to keep you on track.
Donald Edmondson is director of the Center for Behavioral Cardiovascular Health at CUIMC, associate professor of behavioral medicine in the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, and principal investigator of SOBC’s Resource and Coordinating Center.
Karina Davidson is vice dean of organizational effectiveness and professor of medicine and psychiatry at the Vagelos College of Physicians and Surgeons; chief academic officer at NewYork-Presbyterian Hospital; executive director of the Center for Behavioral Cardiovascular Health at CUIMC’ and principal investigator of SOBC’s Resource and Coordinating Center.
Jennifer Sumner is assistant professor of behavioral medicine in the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, and co-investigator of SOBC’s Resource and Coordinating Center.