How to encourage lifestyle change in patients

“By managing their health habits, people can live longer and healthier and retard the process of aging. Self-management is good medicine. If the huge health benefits of these few habits were put into a pill, it would be declared a scientific milestone in the field of medicine.”¹

Despite regular claims of the imminent development of medications to prevent aging or mimic the effects of a healthy diet and exercise², these hopes don’t pan out³. The best way to get the health benefits of lifestyle habits like having a healthy diet and engaging in regular exercise is, simply, to practise them!

Theory

When it comes to encouraging healthy habits, it’s difficult to know what to tell people. In the context of disease self-management, the World Health Organisation states, “Simply giving information to patients is unlikely to change behaviour; health care providers must understand the psychological principles … and comprehend that motivating patients requires more than informing them…”⁴. The same is true for helping patients make lifestyle changes to improve their health.

There are at least 83 different theories relating to the psychology of behaviour change⁵, many of which share three general characteristics: ‘the desire for change to achieve a goal’; ‘a belief that a change in behaviour will achieve the goal’; and ‘a belief in one’s own ability to make the necessary change’.

“Yet, despite widespread awareness that improved health behaviours would be broadly beneficial, it remains exceptionally difficult for people to initiate and maintain behaviour change, and it seems clear that we need to develop new and more effective ways to design behavioural interventions to increase their short-term efficacy and their longer-term benefits.”⁶

Experimentation

The Science of Behaviour Change (SBC) initiative of the United States National Institutes of Health, which began in 2009, applied social and behavioural science principles and an experimental medicine approach to identify factors involved in health behaviour that can be targeted to elicit change. The approach involves four steps⁷:

1. Identification of an intervention target
2. Developing ways to measure the target
3. Experimenting to find interventions to engage the target
4. Measuring the intervention’s engagement with the target and its effect on behaviour.

The initiative identified ‘self-regulation, ‘stress resilience and stress reactivity’, and ‘interpersonal and social processes’ as viable, evidence-based targets for health behaviour change⁶. The next stages of the SBC initiative, to work out how to measure and manipulate these targets, are underway.

Practice

Evidence to guide patients through behavioural changes to improve their health will be a welcome advance, but it will likely still be some time coming. Until then, how do we advise patients? What works to drive changes in behaviour?

The Diabetes Prevention Program was among the first evidence-based behaviour change programs, and is effective for reducing body mass index (BMI), achieving a weight loss target, reducing waist circumference and lowering the fasting plasma glucose level in a primary care setting⁸.

Meta-analysis shows that, in general, behavioural change interventions for diet and exercise are moderately effective in achieving behaviour change, with this benefit arising from targeting of goal-setting behaviour and self-monitoring behaviour⁹. A person-centred, supportive counselling approach that encourages autonomy appears effective for maintaining changed behaviours. The mode by which these interventions are delivered does not seem to matter⁹.

The RAINBOW trial combined the Group Lifestyle Balance (GLB) program for obesity and the Program to Encourage Active, Rewarding Lives (PEARLS) for depression, to treat comorbid obesity and depression. It showed small reductions in BMI and depression scores over 12 months¹⁰, and improved quality of life, sleep and functional status at six but not 12 months¹¹.

The studies above did not report outcomes according to sex or gender. This is a disappointing characteristic of the majority of research studies in this area, which makes it difficult to know how the results might apply to practice.

Guiding behavioural change in men

The results of behaviour change interventions to increase physical activity in men were recently the subject of a meta-analysis of 24 independent studies¹². A small effect of behavioural change interventions was observed, equating to an extra 97 minutes of total weekly physical activity. Characteristics of interventions associated with greater effect sizes were:

• Interventions with one or more weekly contacts, compared to fewer than one contact per week
• Gender-tailored programs, compared to those not tailored
• Programs of 12 weeks or less, compared to those lasting 13 weeks or longer
• Interventions based on behaviour change theory, compared to those that were not
• Interventions that used four or more behaviour change techniques, compared to those that used three or fewer.

“Interventions that (i) are based on a theoretical framework, (ii) are tailored to men’s values and interests, (iii) include regular group contact and (iv) employ multiple behaviour change strategies appear most effective”¹².