Tools
Behavior Modification for Lifestyle Improvement
Introduction
Lifestyle is central to a person's disease risk and overall health. Numerous health conditions are caused or exacerbated by unhealthy behaviors such as smoking, physical inactivity, excessive alcohol consumption, and poor dietary habits.[1] Estimates suggest that unhealthy behaviors were directly responsible for more than 23 million deaths and 36.5% of disability-adjusted life-years in 2017 alone.[2]
Day-to-day behaviors have profound implications for both short- and long-term health outcomes and quality of life.[1] Positive or health-enhancing behaviors promote well-being, reduce disease risk, and improve quality of life. Health-enhancing behaviors include avoiding harmful substances (e.g., alcohol and tobacco), maintaining adequate physical activity levels, good nutrition, sufficient sleep, and stress management.[3]
On the other hand, negative or health-compromising behaviors refer to those which increase the risk of developing disease, reduce well-being, and worsen the quality of life. Health-compromising behaviors include physical inactivity, substance abuse, and chronic excess calorie intake.[3]
While the importance of maintaining healthy behaviors has been extensively documented in the medical literature, habits and behaviors remain unchanged at the population level. Studies have shown a decrease in the number of adults adhering to healthy behaviors in the United States.[4] Between 1988 and 2006, the percentage of US adults adhering to 5 key health behaviors (not smoking, avoiding excessive alcohol consumption, eating five or more fruits/vegetables per day, exercising more than 12 times per month, and maintaining a healthy body weight) decreased from 15% to 8%.[4] Furthermore, it is estimated that adhering to a healthy lifestyle could prolong life expectancy by 14.0 years for female adults and 12.2 years for male adults in the US.[5]
Over the last decades, organizations, public health agencies, and healthcare professionals have started to highlight the importance of maintaining healthy habits. There have been many awareness and health promotion campaigns at the population level. However, the efficacy of these campaigns on behavioral outcomes remains controversial.[6] It is estimated that mass media health communication campaigns in the United States promoting behavior change have an average positive effect size of 5%.[7]
Understanding the factors influencing behavior is crucial to developing effective interventions and improving adherence to a healthy lifestyle. Human behavior is a complex phenomenon that involves changes or actions related to external circumstances.[8] When discussing health behaviors, multiple factors have the potential to facilitate health-compromising behaviors or interfere with health-enhancing behaviors.[9]
A person's intention is the motivation to perform a behavior or attain a goal.[10] In other words, an intention is an instruction that a person gives themselves to perform or omit a specific action, such as "I will exercise for 30 minutes" or "I will stop smoking."
Even though the behavior is considered to be voluntary, it is not always aligned with a person's intentions. Health-compromising behaviors are hard to stop, and health-promoting behaviors are challenging to adopt, so intention alone is not necessarily a predictor of behavior change.[11] The intention-behavior gap refers to the discrepancy between what a person intends to do and what the person does. The odds of a person being able to act according to their intentions can be influenced by internal (eg, beliefs, skills, knowledge) and external factors (e.g., time, money, social support).[10]
Understanding the intention-behavior gap can help healthcare professionals understand the difficulties that patients encounter when seeking behavior modification and allow for implementing strategies that address such problems and improve adherence to a healthier lifestyle.[12]
Interventions targeting health behaviors should be tailored to the patient's place on the intention-behavior spectrum, promoting intention formation when patients don't feel ready to change or don't recognize the need for modifying behavior (increasing motivation), facilitating initiation when intentions have been formed (making a plan), reinforcing behavior when action has been taken (staying on course), and providing support when lapses occur (getting back on track).
Issues of Concern
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Issues of Concern
Many health-related behaviors have been described in the medical literature.[13] However, a large part of the literature has focused on a small number of categories that have shown to be strongly associated with health outcomes, including diet quality, body weight, physical activity, smoking avoidance/cessation, and limiting alcohol consumption.[14] For this reason, interventions prioritizing behavior modification in these categories will likely substantially impact health outcomes associated with most chronic non-communicable diseases.
Diet Quality
Although some specific aspects of nutrition remain controversial within the scientific community, most health professionals agree that a healthy diet is one of the most powerful tools to promote health and enhance well-being.
Regarding health-compromising dietary behaviors, studies have shown an association between high saturated-fat diets and increased levels of low-density lipoproteins (LDL) and very low-density lipoproteins (VLDL), linked to atherosclerotic cardiovascular disease.[15][16] Nutritional guidelines emphasize that adults in the United States consume too many calories, saturated fats, sodium, and added sugars and don't consume enough fruits, vegetables, and whole grains.[17]
According to the US Department of Agriculture, the critical aspects of a health-promoting dietary pattern include eating within calorie limits and prioritizing nutrient-dense foods and beverages. Regarding specific food groups, recommendations include eating enough fruits (1.5 or 2 cup-equivalents/day) and vegetables (2 or 3 cup-equivalents/day) as well as legumes, whole grains, nuts, seeds, and nutrient-rich sources of protein, while limiting the consumption of added sugars, saturated fat, and sodium.[17]
Body Weight and Body Mass Index
Even though weight and BMI are biomarkers more than behaviors in the traditional sense, they have been used as behavioral risk factors that reflect an individual's energy balance over time (the relation between energy intake and energy expenditure, regardless of diet quality).[3]
Although not without limitations, body weight and body mass index (BMI) are strongly related to health outcomes. A high BMI can indicate a chronic state of excessive energy intake associated with excess adiposity, insulin resistance, and metabolic derangements.[18]
Abnormal BMI values can be an easy and valuable tool for identifying and addressing health-compromising behaviors. However, it is crucial to consider individual characteristics to avoid misclassifying individuals with a normal body composition as overweight or obese (e.g., athletes) or overlooking individuals with a normal BMI and abnormal body composition (e.g., patients with sarcopenia and high adiposity). For the general population, maintaining a normal BMI should be advised.[18][14]
Physical Activity and Exercise
Exercise activates the body's stress systems and generates a response that leads to beneficial physiological adaptations.[19] Physical inactivity and sedentary behaviors have been associated with adverse health outcomes, with research showing a strong and inverse dose-response relationship between physical activity and cardiovascular disease.[20]
Recommendations from the US Department of Health and Human Services state that individuals should engage in moderate-to-vigorous physical activity, increase movement, and reduce time spent sitting. It is important to note that current guidelines recognize that any activity is always better than nothing, meaning that health teams should avoid placing too much pressure on patients and celebrate even small changes in physical activity levels.
Basic recommendations for adults in the United States include performing between 150-300 minutes per week of moderate-intensity activities or 75-150 minutes of vigorous exercise (ideally spread throughout the week). Additionally, guidelines recommend muscle-strengthening activities involving major muscle groups two or more days per week.[20]
Moderate or No Alcohol Consumption
Excessive alcohol consumption is a significant risk factor for disability and early death. However, there has been considerable debate within the scientific community regarding moderate alcohol consumption and health outcomes.[21] Although some studies have suggested the benefits of drinking in moderation versus complete abstinence, such studies have been questioned due to methodological concerns.
Current health recommendations state that daily alcohol intake should be limited to two drinks or less for men and one drink or less for women, emphasizing that drinking less alcohol is better for health.[14][17] It is also important to note that current guidelines state that some individuals should abstain from drinking alcohol, such as pregnant women.[17]
Smoking Avoidance
Smoking tobacco is one of the most health-damaging behaviors. Studies have shown that smoking has a solid and causal role in multiple diseases, including coronary artery disease, chronic obstructive lung disease, and cancer.[22]
Smoking cessation has been a prominent theme among health promotion campaigns for decades. Recent studies have shown decreased smoking rates thanks to financial, educational, and regulatory interventions.[14] Tobacco avoidance is a central component of a health-promoting lifestyle, and smoking cessation should be recommended.
Health-Behavior Modification Theories
Behavioral medicine and psychology research has led to the development of multiple theories and approaches to health-behavior modification. Studies have sought to identify factors that promote action and reduce the intention-behavior gap. To this day, over 30 behavior modification theories have been described.[23] These theories generally seek to conceptualize the relationship between thoughts, beliefs, choices, and behaviors.[24]
There is considerable overlap between behavioral models, and no single theory or approach has shown to be superior in clinical practice. Many of these theories have been criticized and questioned for not having enough evidence to support their efficacy, demonstrating a low predictive power in clinical trials, and lacking objective guidance on how they should be used in evidence-based practice. [24]
Because of the significant and often contradictory differences between approaches, practitioners should prioritize those studied in the clinical setting to create reasonable and patient-centered interventions that avoid over-relying on specific strategies that may be inappropriate for individuals with different psychological and physiological needs.
Within the many behavior modification theories currently available, some theories and approaches have received more attention in behavioral research and health-promotion interventions.[23][24] These theories provide a general framework for predicting behavior, allowing healthcare teams to design patient-centered interventions for health-behavior modification and lifestyle improvement.
Habit-Formation
In psychology, habits are described as automatic actions triggered by contextual cues associated with their execution. Common examples include washing hands (automatic action) posterior to using the toilet (contextual cue) or putting the seatbelt on (automatic action) posterior to getting inside a car (contextual cue).[25]
Habit theory has been particularly popular among behavior modification strategies because once a habit is formed and consolidated, behaviors persist without conscious motivation or interest in performing the action in question.[25] Habit strength depends on the frequency and consistency with which the automatic action is performed and is a strong predictor of behavioral maintenance even in the presence of time constraints and mental stress.[26]
Habit formation is believed to consist of three stages: the initiation phase, where the new behavior and contextual cues are established; the learning phase, where the behavior is repeated in response to the contextual cue to increase habit strength; and the stability phase, where habit strength plateaus and the behavior persists with minimal effort or conscious deliberation.[25]
It should be noted that the time it takes to build a habit can vary depending on multiple factors. However, studies have shown an average time of 66 days to form a new habit, with longer times for habits with increasing levels of complexity. Providing habit formation advice in healthcare has been shown to promote long-term behavior change.
Self-Determination Theory
The self-determination theory proposes that behavior modification largely depends on an individual's motivation and describes two types of motivation (autonomous and controlled) that represent the reasons for which an individual engages with a specific behavior.[13] According to this model, autonomous motivation comes from the self, reflects intrinsic goals (personal choice or interest), and increases the odds of persisting with behavior without reinforcement or contingency. On the other hand, controlled motivation comes from external goals (gaining reward or avoiding punishment), which tend to be accompanied by a sense of obligation, reducing the odds of engaging with a given behavior without external contingency.[13]
Reasoned Action and Planned Behavior Theories
The theory of reasoned action (TRA) suggests that behaviors are under volitional (voluntary) control and that a person's intention to engage with a specific behavior is the most critical predictor of that particular behavior.[23] The TRA was later updated to the theory of planned behavior, which includes perceived behavioral control as a concept representing an individual's belief of what stops or facilitates their behavior.[23][24]
According to this theory, the strength of the intention to perform a behavior is related to the likelihood of the behavior being performed. This theory has been criticized for overly relying on rational constructs that do not consider emotions or spiritual beliefs as influencing behavior.
Health Belief Model
The health belief model (HBM) proposes that behavior changes depending on the balance between the benefits and barriers of taking action.[23] The HBM considers perceived susceptibility (risk of developing consequences due to a maladaptive behavior), perceived threat severity, perceived benefits of changing the behavior, perceived barriers and costs involved with taking action, and environmental and socioeconomic values.[24]
This theory has been criticized for having a weak predictive power for health behaviors and not including the positive effects (cognitive reward) of health-compromising behaviors.[23][24]
Social Cognitive Theory
The social cognitive theory suggests a dynamic and continuous interaction between behavior, the individual, and the environment. According to this theory, awareness of health risks and benefits is necessary but insufficient for behavior change. The proponents of this theory argue that a person's expectations and beliefs influence health behavior about their confidence to act.
In this model, behavior modification is primarily conditioned by a person's health status, confidence in their ability to change, and perception of potential barriers that may get in the way of taking action. According to the model, individuals can perform the desired behavior if they believe they are in control and perceive few or no external barriers. [23]
Health Action Process Approach
The health action process approach (HAPA) is a social-cognitive model that aims to identify and target the processes that determine the enactment of future health behaviors in two distinct phases, a motivational (pre-intentional) phase and a volitional (post-intentional) phase.[27] This model promotes health behavior modification through phase-specific interventions that increase motivation at the pre-intentional phase and support behavior maintenance and recovery after intentions have been acted upon.[27]
According to this model, intention formation during the motivational phase depends on a person's risk perception (perceived susceptibility to developing specific health conditions or outcomes), action self-efficacy (perceived capability of performing a particular behavior), and outcome expectations (perceived likelihood of obtaining desired results through the new behavior).
On the other hand, the HAPA proposes that intention implementation (acting on intentions) is determined by action planning (how, when, and where a specific behavior will be performed), coping self-efficacy (beliefs about being able to overcome future barriers or obstacles that might interfere with the behavior), coping planning (identifying potential barriers and anticipating strategies for overcoming them) and recovery self-efficacy (perceived likelihood of being able to recover from failed attempts of performing the behavior). Research on the health action process approach supports addressing phase-specific determinants of health behaviors, especially those related to self-efficacy constructs.[27]
The Transtheoretical Model of Change
The transtheoretical model of change (TTM) categorizes individuals based on their readiness to modify their behavior (stage of change) and proposes different ways of approaching individuals depending on their stage.[24]
According to this model, individuals will be more likely to engage in behavior modification if they are approached in a manner that fits their current attitude toward changing their behavior.
The stages described in this model include:
- Precontemplation: The individual is unaware of the potential benefits of modifying behavior and has no intention of taking action. An individual in this stage will benefit from interventions directed toward education and increasing awareness.
- Contemplation: The individual is thinking about modifying behavior but is not yet committed to taking action in the near future (ambivalent). Individuals in this stage benefit from interventions directed towards identifying barriers and misconceptions and encouragement to consider making specific plans for behavior change.
- Preparation: The individual has started to take steps towards engaging with the new behavior (planning) but is not yet acting on intentions. Individuals in this stage benefit from setting specific goals, being assisted with practical aspects of planning, and receiving positive reinforcement to increase confidence (self-efficacy).
- Action: The individual has started taking action (engaging with the new behavior). At this stage, interventions include reinforcing positive behavior and social support strategies and addressing (and solving) any concerns associated with implementing the new behavior.
- Maintenance: The individual continues engaging with the new behavior after a significant amount of time. At this stage, interventions should aim to identify factors that could increase the risk of relapse and develop coping strategies in anticipation of any potential disruptions that can interfere with the new behavior.
The TTM has been popular in clinical practice due to its appeal and practicality in designing interventions. However, it has not remained free from criticism. Critics of the TTM state there is not enough direct research to support the clinical effectiveness of interventions based on stages of change, with some meta-analyses showing that interventions using the stages of change were not superior to interventions not using the model.[23][24]
Barriers to Behavioral Counseling
In practice, numerous barriers can interfere with behavioral counseling, such as the absence of training, lack of practical tools, and the time constraints frequently experienced in the clinical setting.[28] Healthcare teams should identify these shortcomings and develop strategies to minimize their impact. Because physicians are often overburdened with large patient numbers, and limited time, referrals should be provided to ensure that efforts are adequate. Depending on each patient's needs, teams should be able to provide referrals to psychologists, behavioral therapists, registered dietitians, exercise specialists, nurses, and social workers.
Relapse and Non-Adherence
Occasional behavioral interruption (relapse) is considered a normal part of the behavior modification process and should be expected to some extent.[29] Individuals require continuous support from friends, family members, and healthcare professionals to achieve long-term behavior maintenance. Even with solid intentions and motivations, sickness, responsibilities, holidays, or family emergencies can easily result in relapse. In the event of an interruption, patients should be encouraged to return to the behavior and identify strategies that may help prevent relapse.[30]
Clinical Significance
Lifestyle improvement is essential for preventing and managing many of the current most common medical conditions. For example, lifestyle modification alone is considered appropriate as initial management of diabetes in motivated patients with an A1c below 7%.[31]
Behavior modification interventions for lifestyle improvement must be personalized and consider an individual’s characteristics and circumstances. Patients with different social, economic, and physical environments should not be expected to benefit from the same approach, even when they share a similar risk factor.[23]
Healthcare teams should engage in a patient-centered discussion that identifies potential barriers (such as cost, time constraints, or limited access to resources) and facilitators (e.g., enjoyment and social support) to develop a realistic and sustainable plan for lifestyle improvement.
Patient-centered discussions can be enhanced through strategies such as those included in motivational interviewing (MI), which has shown to be an effective counseling strategy for resolving ambivalence and eliciting behavior change through identifying and discussing patient values and goals.[32][33]
Studies in the clinical setting have shown MI to be effective in improving cardiovascular health, diet quality, weight loss, and glycemic control. For successful motivational interviewing, healthcare teams must ask non-judgmental, respectful, and compassionate questions to help the patient identify motives, barriers, and strategies for overcoming obstacles for change. Essential components of motivational interviewing include asking open-ended questions and providing affirmations, reflections, and summaries (OARS).[33]
Other Issues
Pharmacological Interventions to Enhance Behavior Modification
In some cases, behavior modification can be enhanced by pharmacological interventions that modulate physiological pathways involved in behavior regulation. Although these interventions don’t eliminate the need for voluntary and conscious lifestyle improvement, they can facilitate behavioral maintenance and improve health outcomes. Because some of these strategies are underutilized, healthcare teams need to know about these interventions and present them as an option to eligible patients that can benefit from them.
Weight Loss
Weight loss is crucial to lifestyle interventions for common conditions such as hypertension and diabetes. While weight loss is classically attempted through diet alone, some medications have been shown to enhance (not replace) lifestyle modification significantly. Semaglutide has been of particular interest in recent years because of the magnitude of the weight reduction that has been seen with its use.
Semaglutide is a selective glucagon-like peptide-1 (GLP-1) agonist that is helpful in the regulation of appetite and glucose metabolism. Studies in adults with obesity or overweight with weight-related medical conditions have reported a mean weight reduction of 14.9% with lifestyle interventions and Semaglutide, 12.4% more than what was seen with the same lifestyle intervention and placebo.[34]
Current evidence suggests that the weight reduction seen with semaglutide results from direct and indirect effects on the brain that lead to reduced appetite and decreased energy intake. Semaglutide is currently approved for weight loss in patients with BMI equal to or higher than 30 kg/m2, or patients with a BMI equal to or higher than 27 kg/m2, and more than one weight-related condition such as hypertension, type 2 diabetes, or dyslipidemia.
Smoking Cessation
Smoking cessation is considered to be the most effective behavioral measure in the prevention of many cardiovascular conditions.[35] However, smoking cessation remains a major challenge even in highly motivated patients. Smoking cessation has been associated with increased reward value of hyper-palatable foods, leading to increased energy intake, increased lipoprotein lipase activity, and subsequent weight gain of as much as 10 kg (22 lb.).[36][37] However, patients should be reassured that the benefits of smoking cessation largely outweigh the risks of short-term weight gain.
Studies have shown that smoking cessation rates can be significantly increased when behavioral interventions are accompanied by pharmacological treatments such as varenicline and bupropion. Varenicline is a selective alpha-4 beta-2 partial agonist of the nicotinic receptor that reduces cravings and withdrawal symptoms while also blocking the binding of smoked nicotine (reducing the reward value). Bupropion is a norepinephrine and dopamine reuptake inhibitor that has also been effective in increasing smoking cessation rates.[38]
Alcohol Cessation
Problem drinking is a significant public health concern. Alcohol cessation is a highly challenging intervention that can also be enhanced through pharmacological agents. However, studies show that alcohol cessation medications are prescribed to less than 9% of the patients likely to benefit from them.[39] Available options include naltrexone and acamprosate. Naltrexone is a non-selective antagonist of the mu, kappa, and delta opioid receptors that reduces alcohol consumption by decreasing the rewarding effects of alcohol. Acamprosate is a pharmacological agent that modulates glutamatergic neurotransmission, which helps maintain abstinence from alcohol.[39]
Enhancing Healthcare Team Outcomes
Behavior and lifestyle play a significant role in improving or deteriorating health outcomes for many of the most frequent medical conditions seen across different medical specialties. While behavior modification and lifestyle improvement are challenging, they are possible and should be a priority for healthcare teams. For better outcomes, behavior modification strategies should be an interprofessional collaboration with valuable contributions from professionals with different backgrounds and scopes of practice.
Physicians can identify behavioral risk factors and behavior-related health conditions and develop treatment plans for lifestyle improvement. Nurses can aid with patient education on behavior modification techniques and provide ongoing support to help patients maintain their behavior. Pharmacists can help manage medication and ensure patients receive appropriate pharmacological support to enhance weight loss and alcohol and tobacco cessation. Dietitians can provide nutritional guidance specific to patient needs and preferences. Behavioral therapists and mental health professionals can assist patients in identifying and replacing maladaptive cognitive patterns directly or indirectly related to health behaviors, provide emotional support, and help increase patients’ self-efficacy. Social workers can help identify socioeconomic barriers to behavior modification and provide alternatives specific to the patient’s situation.
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