Dr. Robert Haynie, the Dean of Student Affairs and Hypertension specialist at Case Western Reserve University School of Medicine often tells interviewing students, “If you could get people to quit smoking, maintain a healthy weight, drink alcohol in moderation and practice safe sex, you would be the greatest doctor in the history of doctors.” If one really thinks about it, that is clearly a true statement. Most determinants of health occur outside a doctor’s office, which is both empowering and disheartening. It means that the patient has the power and ability to improve his or her own health, improve quality of life and delay mortality, but also means that poor choices can never be rectified by even the best physician with the most advanced medicine.
We see this very clearly in our current obesity epidemic. While many of us are caught up in any number of carbohydrate-reduced, organic or gluten-free diet fads, we continue to miss that, no matter what diet we are choosing, we are eating too much of it. A recent study predicts that 42% of all Americans will be obese by 2030, and 11% will be severely obese, defined as a Body Mass Index (BMI) > 35. While there are many studies using mathematical models to make bold predictions, this one is particular useful because it accounts for a number of factors that are known to affect food choices and weight such as age, gender, education, employment status, marital status, as well as prices of groceries, fast food, gas and alcohol. The 42% prediction actually indicates that the obesity epidemic is slowing down over time (the previous predictions were for a 51% rate of obesity by 2030).
Still, we can do better. I could go on talking about the extent of the problem and tell a cautionary tale that has been told so many times before, but I’d rather focus on solutions, indeed, a way that we can fight back. It starts with one complicated question: What motivates you to change? We all have the capacity to change and have done so many times in our lives, even in personal or difficult situations like controlling a bad temper or cutting back on credit card spending. The same ideas and principles can be applied to health-related behavior choices like quitting smoking or losing weight.
When it comes to decision making, we judge based on three main factors: amount of benefit of that choice, when the benefit will occur, and what the probability of the benefit occurring is. We place the highest value on present rewards and discount the value of any reward that is delayed or is not 100% likely to occur. We are good at making the right choice when only one of these factors is in play, but if two or more of these factors are changing at the same time, we struggle to make the correct choice. It is the reason why someone who knows that eating a brownie instead of a bag of carrots will increase his or her weight and increase the risk of heart disease in the future. The present benefit of eating the brownie is tangible and real; the negative of heart disease is of unknown magnitude (one cannot know what having heart disease is like before having it), unknown delay (heart disease could begin in one year or thirty years) and unknown probability (some people who are overweight/obese don’t get heart disease). All of these unknowns make it nearly impossible for a health care professional to educate a patient enough that they truly understand the possibly dire consequences and try to avoid heart disease by eating a healthier diet and exercising.
Focusing on present negatives or positives can be a more effective strategy. For example, emphasizing that losing weight can reduce knee pain, make breathing easier or make buying clothes easier are all rewards that can be attained in the short-term. The problem here is, we tend not to think about these things while standing in line staring at the brownie in the display case at lunchtime. So even if a patient agreed with his or her doctor that losing weight could improve knee pain and even felt a difference last week playing with his or her daughter, he or she may not be thinking about the benefit or reduced knee pain on Monday at lunchtime. Even if the memory of reduced knee pain did come up, it may not be enough to overcome the temptation of a brownie right this minute.
Is there anything we can do to overcome this? If we realize that change, like every other behavior is a very emotional entity, we can overcome the present bias towards the brownie and learn to choose avoiding the risk of heart disease in the distant future. People who are successful at change are in a mental state of change prior to making any attempt at altering something in their life. It is why so many people change schools, change jobs, move from city to city and even date one person to the next with ease; when we are mentally in the right mode, change can be downright easy.
To get ourselves in that motivated state, primed for change, we can borrow a page from Nike advertising. Nike and many other companies use advertising that says almost nothing about the actual product being advertised. Rather, the advertisements show images or video of famous people performing impressive physical feats while wearing Nike apparel, saying a catch-phrase in a motivational voice and ending with the Nike logo and the profoundly motivating and famous words, “Just Do It.” It is a brilliant technique. It creates a very positive, motivated and adrenaline-pumping feeling that is tied to the word Nike and the Nike swoosh. On re-exposure to that Nike swoosh, this time on a shoe or tee shirt, any consumer would want to buy it, often times without really knowing why.
The same approach could be used by doctors and other health professionals to motivate patients to eat healthier and exercise more. Change is hard, but if we are reminded of the times that we have made important changes because we chose to, we also remember that change means something new and refreshing. That change has been done in the past and has turned out for the best. Spending a few minutes of a visit talking about change, motivation and more specifically about a time in which a patient changed something significant could make a huge difference in future efforts to modify behaviors. By this method, we turn the emotional aspect of the mind from a barrier to change into an instrument of change. The problem with this approach is time; it is a slow and time-consuming process to coax one’s mind into a condition in which it is primed for change. Given the catastrophic consequences of obesity to our health and our economy, we may have no choice but to make the time.
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