Saturday, July 26, 2008

The Century of Behavior Change

There are two books that I frequently recommend for patients. The first is Stretching by Bob Anderson (ISBN-13: 978-0936070018), which many patients have found very helpful in helping them start and maintain a stretching routine.

The other book I recommend frequently is Mindless Eating, by Brian Wansink (ISBN-13: 978-0553384482). I don't have commercial interest in either book, by the way. Mindless eating is a terrific book about the many unconscious decisions we make about food every day, and how you can use those mindless decisions as means to eat healthier.

I definitely endorse the book, but the subject of this post is to comment on a tangential comment that Brian Wansink made in Mindless Eating. I hope I am not violating any copyright laws by quoting him here (I am new to the legal aspects of blogging) ...

On p. 205 of the paperback edition listed above, he writes:
"The 19th century has been called the Century of Hygiene. More lives were saved or extended due to improved understanding of hygiene and public health than by any other single cause. We learned that rats were not house pets and that it's a good idea for doctors to wash their hands before surgery.

The 20th century was the Century of Medicine. Vaccines, antibiotics, transfusions, and chemotherapy all helped contribute to longer, healthier lives. In 1900, the life expectancy of an American was 49 years. In 2000, it was 77 years.

I believe the 21st century will be the Century of Behavior Change. Medicine is still making fundamental discoveries that can fight disease, but changing everyday, long-term behavior is the key to adding years and quality to out lives. This will involve reducing risky behavior and making changes in exercise and nutrition. There isn't a simple prescription that can be written for such behavior change. Eating better and exercising more are decisions we need to be motivated to make."

I very much agree with the sentiments of Brian Wansink- I do think that the biggest health gains for the United States, and probably most other industrialized countries as well, will be in complying to healthier lifestyles.

Last year at the annual meeting for my field of medicine, the American Academy of Physical Medicine and Rehabilitation (AAPM&R), I was having lunch with a colleague, and he remarked that in his clinics, he had bimodal patient populations. Rather than seeing gradations in activity levels, he basically had two distinct and non-overlapping populations- the very active, and the sedentary. I don't have data to support that this is in fact true, but speaking to my colleagues and on my personal anecdotal experience, I believe it to be true.

Not surprisingly, the very active population appear to be living much healthier lives. First off, they are more active, and they enjoy being active. Second, as a group, they don't smoke, drink moderately, do not engage in many addictive behaviors (although many are workaholics, so I suppose that is an addiction). They are sociable, with strong community and family interactions. I don't know for fact that they are living longer, but since so many of them are golfing, playing tennis, and cycling into their 80s, I am willing to guess they are living longer and healthier lives than the sedentary population.

As for the sedentary population- well, they live a different life. They look older- it is not uncommon for a sedentary 30 year old patient to appear older than a very active 50 year old patient, despite otherwise similar demographic characteristic. Many more of the sedentary patients smoke (although not all do). I cannot comment specifically about drinking behaviors- anecdotally, both groups seem to drink similar amounts, but the sedentary group does seem to have a higher percentage history of substance abuse. The sedentary patients also, as a group, seem less happy.

I think the management for both groups is quite different. For the very active group, when they have a problem, it is much more likely to be an acute problem that can be acutely addressed, and they quickly go back to being very active.

For the sedentary group, the problems are more likely chronic in nature, and often require chronic treatment. And the key chronic treatment they need is lifestyle change. Thus, I think this ties in to Brian Wansink's idea- this needs to be Century of Behavior Change. I, and most other physicians I suspect, have more sedentary patients. It is a growing group, both in numbers and waistline.

I don't mean to downplay the very real and very significant changes in other aspects of medicine we will see. We will continue to see life changing breakthroughs in medications, radiation technology, imaging modalities, surgical techniques and instrumentation- all of these.

My sense, though, is that these breakthroughs, as a group, will have a higher impact on those patients who are already in the (smaller) very active grouping- it may help them improve their active lifespan by 10 years and their overall lifespan by 15 years- these are really big gains, and I don't want to dismiss them.

But .....

If we are able to basically convert a patient from a sedentary lifestyle to a very active lifestyle- well, I think that is a much more substantial gain. I think the improvement in years of quality life improvement might be, roughly estimating, 30-40 years, with perhaps another 10 years of additional total lifespan. That's an enormous change- certainly comparable to the gains produced by the Century of Hygiene of the Century of Medicine.

Let's take a hypothetical patient as an example:
43 year old man, father of two young daughters, visits a physician with a chief complaint of low back pain for 5 years. He works in sales, and spends much of his life on the road, which limits his diet to things he can eat in the car, and he certainly has little time for exercise, since most of his time at home is devoted to being a good father for his daughters and a devoted husband to his wife. Both he and his wife smoke 1-2 packs daily, which they typically do either while driving, or while drinking a few beers while watching TV after they've put the girls to bed.

A traditional medical model may focus on his chief complaint symptom of low back pain. And it may provide him transient relief for his low back pain. However, without addressing his sedentary lifestyle, he will likely have recurring problems, whether in his back or elsewhere. Furthermore, he made enter into a cycle of frustration with the health care system, feeling medicine is helpless to help him

Obviously, a better model is needed. I think the traditional "body part" focused approach to musculoskeletal care has failed to address his greatest need- lifestyle modification.

Let's call this patient Bob. Bob has entered a pattern many of us do, typically as we enter our late 20s- you know the right things to do, but the very priorities of life- work, spouse, family- the external obligations make one feel unempowered to take control of your life and do the things you need to do.

So, our first role as a physician is to be an advocate for the patient- let them know they aren't alone, and someone has their back.

Our second role as a physician is to let Bob know that he DOES have a choice, or in fact many choices. This is a simple concept, but in my opinion, an incredibly important concept that is often not stated explicitly to the patient, if not outright ignored. Bob needs to know that he empowered to make choices in his life. This insight alone is often enough to let him make positive changes in his life that will help promote a more active and less sedentary lifestyle.

Tangent: In psychology, they need to use an animal model for depression. It's usually difficult to pick out the depressed rat in a crowd, since they don't usually paint their toe-nails black and where goth t-shirts. So one animal model they use is called "learned helplessness." The animal (usually a mouse or rat) will be set in a series of conditions that no matter what they do, they never win. For example, they may be shown a series of levers that could produce different amounts of food, but no matter which lever they use, they can never win. They "learn" that they are helpless to determine there own fate. Psychologists can track the behavior, and interpret it as mirroring depression.

Most humans can relate to the experience of learned helplessness, and it's about as good a definition of depression as there is out there (as another tangent, I do actually believe that the learned helpless model is a more useful model than the technical DSM-IV criteria that most psychologists and psychiatrists use that, for reasons I hope to discuss in another post, I believe is seriously flawed). For example, think of the worst serious relationship you've ever been in- at the point just before the relationship ended, there is often a point where both partners feel that no matter what they do or say, it's not good enough- well, that sounds an awful lot like learned helplessness, and it's certainly not a pleasant feeling. It's depressing.

Let's get back to Bob- his chief complaint is that of low back pain, but his chief barrier is a sedentary lifestyle. And it is likely that the chief barrier to modifying his sedentary lifestyle to a more active lifestyle is a sense of learned helplessness- namely, that the behavioral modifications necessary for him to become more active seem outside the realm of his model of control.

Acknowledging this set of concerns is valuable in of itself. Getting back to Brian Wansink's proposition, though- I do think this is the Century of Behavior Change. I think the biggest gains we will see in the United States will be figuring out different approaches to help him modify his behavior so the Bob's of the world can become less sedentary and become more active.

And I think we are well on our way- the first step to answering a question is to actually know which question to ask.

I do not think this progress is easy. One reason that medicine has devolved into it's current simplified one-joint model for treating musculoskeletal conditions is it's for the most part easier. Developing models that consistently work for modifying behavior for a healthier lifestyle is genuinely difficult. It doesn't mean it shouldn't be emphasized.

Look, developing the germs theory and appropriate hygiene was hard, but we did it, and we are better off for it. Similarly, the development and utilization of some of the advanced medications of the past century was hard, but it made a huge impact. It was worth the effort.

Medicine is now ready to take on the next stage- Behavior Change. It won't be easy, but we can do it, and our patients deserve it.

In future posts, I would like to touch upon some of the best advice I've seen for encouraging behavior change.

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