If research strongly supported one simple behavior as significantly improving the likelihood of you living healthier longer, would you do it?

We all know that some will adopt that behavior and more. Others will attempt, flail, and fail. Still others will nod and go back to life as normal. So why is there so much variance in the response to change one behavior?

In a world where there is so much information, let’s select the easy-to-condemn habit of cigarette smoking. Smoking is bad. Probably every health-related organization on Earth says smoking is bad. Smoking is associated with undesirable forms of death: cancer, heart disease, emphysema, and others. Statistically, the negatives outweigh any possible benefit smoking may offer. Intellectually we know this, and, yet, many of us just keep on puffing. Why?

Back in the Counterculture movement of the 1960’s, knowledge said “Bad drugs are bad.” Knowledge stated if you take this drug this will happen. If you smoke that, that will happen. Knowledge and advertising campaigns did little to stop anything. It did help people who only wanted to experiment to know exactly what they wanted to experiment with. This was clearly a situation where “a little knowledge is a dangerous thing.” It completely missed what made people unable to stop using drugs after the experimentation.

While we know that knowledge matters, why isn’t it enough?

Unfortunately, too many behavior-change interventions focus on knowledge only without considering the individual’s actual behavior to change. Too often behavior change interventions sit on a foundation of poor assumptions:

  • It is just common sense to do this — because we all use common sense 100% of the time;
  • Success lies in the messaging — if you say “why” they should change just so, then they will change;
  • I’m an “expert” so you should listen to me, believe me, and do as I tell you — because we always listen to the experts;
  • Any rational individual can see this is the best thing to do — because we are 100% rational; and (my personal favorite)
  • If you can just scare people enough — they’ll change.

Consideration of the above are important, but they overlook the obvious . . . why are you doing what you are doing?

Behavior change should examine the events leading up to the undesirable behavior:

  • What is the event / poor behavior (event A)?
  • What happened immediately preceding event A? That becomes event B.
  • What happened immediately before that event B? That becomes event C.
  • What happened immediately before event C? That becomes event D

This reverse engineering the poor behavior identifies the chain of events that the behavior depends upon to exist. The solution is not to fix the bad behavior but rather to address the chain of events that support it. The challenge is to identify the series of events that lead up to the final behavior.

A true example of this was when Pam, RD, CDE confessed she had a problem. In response to the need for “something sweet” at the end of the day, she had gone from eating one cookie to four or five cookies a night. She could tell she was gaining weight. She was seeking advice.

Consider: (1) Pam as was a Registered Dietitian and Certified Diabetes Educator — she was knowledgeable. (2) Was the problem the “something sweet” or the 4 to 5 cookies to satisfy the craving?

One question was asked: What kind of cookie are you eating? The “something sweet” was Pam’s favorite cookie.

Recommendation: buy a different cookie — something plain but sweet.

Outcome: A week and a half later Pam confessed that she no longer craved that “something sweet.” Eureka! As behavior change goes, that was easy.

Another example is an individual who struggles with money yet finds the money to buy cigarettes. Why? A soak in the tub might be a healthier option. Finding time to soak in the tub seems unachievable . . . the kids begin crying the moment the bathroom door closes. Sadly, no one seems to care if you sit on the porch and smoke your life away. Compromise: can we smoke less?

Changing behavior is complex. William Polonsky, PhD, author of Diabetes Burnout. What to Do When You Can’t Take It Anymore, recommends being mindful of how “life gets in the way” before we can address behavior change. What are the chain events that end up in not doing changing to a healthier option?

Bottom line: As healthcare professionals we need to accept the things we cannot change; support our patients on their paths to change the things they can; and work toward wisdom to know the difference. Knowledge alone will not create the behavior change we seek.