Why it’s hard to change unhealthy behavior — and why you should keep trying

Many of us think about changes we'd like to make in our lives. When it comes to health recommendations, we mostly know the drill: Exercise most days of the week; eat a varied and nutritious diet; keep your body mass index between 18.5 and 24.9; get enough sleep; keep up with medical screenings for blood pressure, cholesterol, and blood sugar; get mammograms and Pap smears at recommended intervals; don't smoke; and limit alcohol to seven drinks a week. Reducing stress, improving relationships, and developing new interests or hobbies also contribute to healthy living.

Making healthy lifestyle changes affects not only our risk for disease and the way we feel today but also our health and ability to function independently in later life (see "Lifestyle factors reduce the need for nursing home care"). What we do for ourselves is often more important than what medicine can offer us. Yet making healthy changes is easier said than done. Even when we're strongly motivated, adopting a new, healthy habit — or breaking an old, bad one — can be terribly difficult.

What helps?

Considerable research has been aimed at identifying factors that contribute to successful lifestyle change as well as more effective tools for clinicians — especially in the context of a brief office visit — to counsel their patients on adopting healthier habits. One problem may be that we're motivated too often by a sense of guilt, fear, or regret. Experts who study behavior change agree that long-lasting change is most likely when it's self-motivated and rooted in positive thinking. In October 2006, the Economic and Social Research Council, a British research group, released findings on 129 different studies of behavior change strategies. The survey confirmed that the least effective strategies were those that aroused fear or regret in the person attempting to make a change.

Studies have also shown that goals are easier to reach if they're specific ("I'll walk 20 minutes a day," rather than "I'll get more exercise") and not too numerous (having too many goals limits the amount of attention and willpower you can devote to reaching any single goal). Another recurring theme is that it's not enough to have a goal: You also need practical ways to reach it. For example, if your goal is to stick to a low-calorie diet, have a plan in place for quelling hunger pangs (for example, keep a bottle of water or cup of tea nearby, or chew sugarless gum).

Research has also produced models that help account for success and failure, and explain why making healthy changes can take so long. The expert conclusion is that any effort you make in the right direction is worthwhile, even if you encounter setbacks or find yourself backsliding from time to time.

Lifestyle factors reduce the need for nursing home care

A study published in the May 8, 2006, issue of the Archives of Internal Medicine followed nearly 6,500 middle-aged and elderly people for 20 years. Among the more than 3,500 participants ages 45–64 when the study began, those who were obese, were physically inactive, smoked, or had diabetes or uncontrolled high blood pressure at the start of the study were much more likely to be admitted to a nursing home.

Middle-age smoking increased the chance of a nursing home admission by 56%, physical inactivity by 40%, and uncontrolled high blood pressure by 35%. Diabetes more than tripled the risk. (Middle-age obesity was also associated with higher risk, but the association wasn't statistically significant — that is, the numbers could have resulted from chance.) All of these conditions, of course, can be modified with lifestyle changes.

Change is a process, not an event

There are several models of behavior change, but the one most widely applied and tested in health settings is the transtheoretical model (TTM). First developed in the 1980s by alcoholism researchers James O. Prochaska and Carlo C. DiClemente, TTM presumes that at any given time, a person is in one of five stages of change: precontemplation, contemplation, preparation, action, or maintenance.

The idea is that people move from one stage to the next. Each stage is a preparation for the following one, so hurrying through or skipping stages is likely to result in setbacks. Also, different strategies are needed at different stages. For example, a smoker who's at the precontemplation stage — that is, not even thinking about quitting smoking — probably isn't ready to make a list of alternatives to smoking.

Most of the evidence for this model comes from studies of alcohol, drug abuse, and smoking cessation, but it's also been applied to various health behaviors, including exercise and dieting. Clinicians and health educators use TTM to counsel patients, but you don't need to be an expert to try this approach. Anyone motivated to change can use it to assess her situation and formulate strategies. Below are the TTM stages of change and some ideas about how people move through them:

• Precontemplation. At this stage, you have no conscious intention of making a change, whether through lack of awareness or information ("Overweight in my family is genetic; it's just the way we are") or because you have failed in the past and feel demoralized ("I've tried so many times to lose weight; it's hopeless"). You tend to avoid reading, talking, or thinking about the unhealthy behavior, but your awareness and interest may be sparked by outside influences, such as public information campaigns, stories in the media, emotional experiences, illness, or a clinician's or family member's concern. To move past precontemplation, you must sense that the unhealthy behavior is at odds with important personal goals, for example, being healthy enough to travel or to enjoy your children or grandchildren.
• Contemplation. In some programs and studies that employ TTM, people who say they're considering a change in the next six months are classified as contemplators. In reality, people often vacillate for much longer than that. In this stage, you are aware that the behavior is a problem and are considering doing something about it, but you still aren't committed to taking any action. Ambivalence may lead you to weigh and re-weigh the benefits and costs: "If I stop smoking, I'll lose that hacking cough, but I know I'll gain weight," or "I know smoking could give me lung cancer, but it helps me relax; if I quit, stress could kill me, too!
  
  Health educators use several techniques to help people unstick themselves and move on to the next stage. One is to make a list of the pros and cons of making a change, then examine the barriers — the "cons" — and think about ways to overcome them. For example, many women find it difficult to get regular exercise because it's inconvenient or they have too little time. If finding a 30-minute block of time to exercise is a barrier, how about two separate 15-minute sessions? Could someone else cook dinner so you can take a walk after work? If you feel too self-conscious to take an exercise class, how about buying an exercise tape to use at home?
• Preparation. At this stage, you know you must change, believe you can, and are making plans to change soon — say, next month. You've joined a health club, purchased a supply of nicotine patches, or added a calorie-counting book to the kitchen shelf. At this stage, it's important to anticipate potential obstacles. If you're preparing to cut down on alcohol, for example, be aware of situations that provoke unhealthy drinking, and plan ways around them. If work stress triggers end-of-day drinking, plan to take a walk when you get home. If preparing dinner makes you want a drink, plan to have seltzer water instead of wine. If social situations are a problem, make a list of alternatives, such as going to the movies instead of having drinks or dinner with friends.
  
  At the same time, create a realistic action plan with achievable goals. If you've been sedentary and want to exercise more, start by making it your goal to avoid using the elevator for two-, three-, or four-story trips. Or plan to walk 15 minutes every day. This can help you work your way up to more ambitious goals.
• Action. At this stage, you've changed — stopped smoking, for example (according to Prochaska, cutting down would not be "action" but preparation for action) — and you've begun to experience the challenges of life without the old behavior. You'll need to practice the alternatives you identified during the preparation stage. For example, if stress tempts you to eat, you can use healthy coping strategies such as yoga, deep breathing, or exercise. At this stage, it's important to be clear about your motivation; if necessary, write down your reasons for making the change and read them every day. Engage in "self-talk" to bolster your resolve. Get support. Let others know you're making a change.
• Maintenance. Once you've practiced the new behavior change for at least six months, you're in the maintenance stage. Now you're working to prevent relapse and integrate the change into your life. That may require other changes, especially avoiding situations or triggers associated with the old habit. It can be tough, especially if it means steering clear of certain activities or friends while you work to fully assimilate your new, healthier habit.

Spiral model of the stages of change

Source: Adapted from Prochaska, JO et al. "In Search of How People Change," American Psychologist (Sept. 1992), Vol. 27, No. 9, pp. 1102–1114.

It can take a few rounds

The path from one stage to the next is rarely straightforward. Most people relapse at some point and recycle through certain stages, like a spiral (see illustration). One study found that smokers trying to quit cycled an average of three or four times through the "action" stage before they succeeded. When relapse occurs during the maintenance stage, you may find yourself back at the contemplation or preparation stage — or perhaps all the way back to precontemplation if the relapse was so demoralizing that you don't even want to think about changing.

Relapse is common, perhaps even inevitable. Experts urge people not to be derailed by it but to think of it as an integral part of the change process. You learn something about yourself each time you relapse. For example, you may find that the strategy you adopted didn't fit into your life or suit your priorities. Next time, you can use what you learned, adjust, and be a little ahead of the game as you continue on the pathway to change.

(This article was first printed in the January 2007 issue of the Harvard Women's Health Watch. For more information or to order, please go to http://www.health.harvard.edu/womens.)

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