Correction to This Article
A Jan. 2 Health article misidentified the chairman of the department of health, behavior and society at the Johns Hopkins Bloomberg School of Public Health. His name is David Holtgrave, not John Holtgrave.

Are You Really Ready To Clean Up Your Act?

By Anita Huslin
Washington Post Staff Writer
Tuesday, January 2, 2007

We're fat. We smoke. Drink too much. Don't exercise enough. And our stress levels are off the charts.

We're killing ourselves, and we know it. And yet we carry on -- overeating, lighting up, slumping in front of the television and throwing back another beer -- inspiring some of the greatest thinkers in the worlds of genomics, neuroscience, biochemistry and evolutionary psychology to ponder the Big Mac of medical questions:

Why is it so hard for people to change?

Is it possible that we're missing a self-discipline gene? Unlikely, though recent research synthesized by the National Academy of Sciences suggests there may be combinations of genes and environmental factors that make it hard for some people to maintain control over their habits.

And every year, as if we had learned nothing from our past, we renew our vows to change. Then we crack open our wallets. In recent years: $63 billion on low-carb, low-fat, low-sugar, low-calorie foods; more than $1 billion on smoking cessation products and programs; $46 billion on diet and fitness programs, drugs and surgeries. At the same time, the nation's health-care industry spends hundreds of billions to treat preventable illnesses in a process that H.L. Mencken recognized decades ago: "The true aim of medicine," he said, "is not to make men virtuous; it is to safeguard and rescue them from the consequences of their vices."

In the end, what doctors and studies and experts have pointed out is that the thing that really helps to change behavior is something hard to measure but ultimately powerful.

Change comes from the heart, not the head.

The Roots of the Problem

Except, in many cases, when the emotion concerned is fear. As a motivator for personal change, fear is a poor performer.

Consider: Doctors at Washington University School of Medicine in St. Louis found that among a group of smokers who had had surgery to remove early-stage lung cancer, nearly half picked up a cigarette again within 12 months. Most started smoking within two months. In another study by researchers at Johns Hopkins University, nine out of 10 patients who'd recently had coronary bypass surgery failed to take steps to improve their nutrition, exercise more and reduce stress.

After former Disney chief executive Michael Eisner underwent an emergency angioplasty for a blocked artery, he at least tried to change, in part by taking up yoga and hiring an instructor to come to his house every day. Eventually, however, "doing yoga mostly became a way to offset the stress of making it to appointments in the first place," he writes in his autobiography, "Work in Progress." "After several weeks I quit, rationalizing that my life would be far less stressful when I stopped trying so hard to relax."

If, as the U.S. Surgeon General has suggested, some 70 percent of the nation's ailments can be prevented by more exercise, better diet, reduced smoking and improved environment, then the holy grail of the public health world has been the identification of those common denominators among the people who are able to successfully change.

Kelly Brownell, founder of the Yale Health, Emotion and Behavior Laboratory, points to a complex calculus of intellectual, emotional and often physical incentives at play in breaking bad habits. The most important factors, to his mind, address the individual's trouble spots along the way.

"If you tend to struggle when you're lonely, then creating some kind of social network [may help conquer bad habits]. If you struggle when you're depressed, then getting help for depression makes sense," Brownell says.

Until people recognize the underlying triggers that led them to the unhealthy habits in the first place, all of the motivating messages in the world will fail, behavioral experts suggest. But getting in touch with the catalysts for their bad habits can unleash powerful forces for change.

One 45-year-old professional writer -- who asked not to be named in order to speak more candidly -- described how she lost nearly 100 pounds over three years after doing some heavy soul-searching. "I had to think, 'Why do I do things that aren't so healthy?' and think about what motivates me, not only to be healthy but also what motivates one to not be healthy. What was I getting out of that?"

It is when people fail to develop healthy coping mechanisms that they fall back on bad habits such as smoking, according to John Banzhaf, George Washington University law professor and executive director of the District-based anti-smoking group Action on Smoking and Health. "And then a cigarette is no longer enough, so you go to alcohol. And on and on."

It's much easier to reach for the short-term relief of a double cheeseburger, a cigarette or a couple of cocktails and ignore the possibility of health problems down the line. And even threats along the lines of 'You're going to die unless . . . ' can have a numbing effect, research shows.

"Sometimes a little whack on the head is a way to kind of wake somebody up," says John Kotter, Harvard business professor and best-selling author on change. "But imagine whacking them on the head every five seconds for three months."

In the end, he says, fear is a difficult motivation to sustain.

Which brings individuals back to the complex process of recognizing the triggers that prompt unhealthy behaviors and then developing mechanisms to anticipate them and recover from slips when they occur, Brownell says.

Brownell, who has criticized the seductive marketing of the fast-food industry, was the first to promote the controversial idea of a "Twinkie tax" on unhealthy foods.

In communities such as urban Baltimore where obesity is a problem, Johns Hopkins researchers have found that more effective than threats on billboards, warnings on products or lectures from a doctor are the development of new habits within social groups. Peer opinion leaders and group support, they believe, are among the most critical aids to change, whether you're aiming to lose weight, quit smoking or exercise.

"If you want to change and maintain behavior over time, you need people who are going to be supportive of those changes," says John Holtgrave, head of the recently established Health, Behavior and Society Department at Johns Hopkins Bloomberg School of Public Health.

Carrots and Sticks

If support alone were the answer, then the United States' $10 billion self-help and support industry would have cornered the market as agents of behavioral change. However, if the smoking cessation efforts of New York are any example, it's going to take more than that.

Despite several years of public education campaigns and outreach efforts to discourage smoking in public places, there was little impact on the rate of smoking, according to the city health department. But starting in 2002, the city imposed an all-out ban on smoking in public places, and, according to the department, some 200,000 people quit within the first two years. Now, of course, the city is after trans fat, in hopes of giving its residents a leg up on their diets. And the District ushered in its new smoking ban yesterday.

The stick approach, however, is generally more effective as a wide-scale change agent than an individual motivator, researchers say. Which is why some health insurance companies are now charging higher premiums to policyholders with unhealthy habits, and some companies have chosen not to hire smokers.

Employers such as L.L. Bean and Sodexho have imposed their own sort of "Twinkie tax" on junk foods, raising the price of sweet and salty snacks dispensed in their cafeterias and using the profits to subsidize healthier foods. Whether such pricing incentives will do what willpower can't remains to be seen. But there appears to be broad agreement that public health initiatives are barely in the fight for consumers' attention, in part because their eat-your-spinach messages are being drowned out by companies that are deeply committed to getting already overfed Americans to buy more food, by tantalizing them with Dora the Explorer cookies and oversize lattes.

"Marketers hardly limit themselves to rational appeals," says Richard Daynard, a Northeastern University School of Law professor who was involved in early tobacco litigation and has now turned his sights to the obesity problem. "In the public fantasy, the rational appeals are supposed to balance people's decisions."

What does work in terms of bridging the gap between public knowledge and personal health, he believes, is something the tobacco wars revealed.

After the American Legacy Foundation launched its "Truth" campaign to billboard what it said was the coverup of evidence about smoking's deleterious health effects, consumers complained of having been burned by the tobacco industry.

"You've got to go to issues that get people emotionally upset, get to their guts, get to where people live," Daynard says. On the healthy eating/exercising/stress-reduction front, "I don't think the battle's actually even begun."

Which should not deter individuals from taking on their own resolutions, says Rick Botelho, professor of family medicine at the University of Rochester and author of books on motivation and behavioral change.

"The good thing about New Year's resolutions is that people who make them are twice as likely to succeed as people who don't," he says. "The bad thing is very few people change spontaneously. There's no question the more you try, the more likelihood you are going to achieve success." ยท

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