Changing Health Behavior is Hard, but Possible

Humans, by nature, are creatures of habit—”set in their ways”—which makes change difficult.

That’s why people aren’t always successful with something new, such as starting an exercise program, beginning a medication regimen or adhering to a new schedule.

Behavior change has two necessary components, according to Sean Eldridge, co-founder and CEO of Gain Life, a technology company focused on behavior design. One part is executive function—conversation, planning, goal-setting and creating routines. The other part is “centered identity” such as your purpose and values.

Eldridge, who is part of the current TMCx digital health accelerator program, created the digital application Gain Life with his co-founders to help individuals change their behaviors.

The team was inspired by psychologist Daniel Kahneman, Ph.D., an Economic Sciences Nobel laureate and author of “Thinking, Fast and Slow.” His work is based on a model he calls System 1 and System 2 thinking. System 1 is unconscious or “fast” thinking while System 2 is conscious or “slow” thinking.

Eldridge’s real-life example of System 1 is buying McDonald’s on the way home versus System 2, buying ingredients to make a healthy meal.

“How you want to change behavior is to take a person from an unhealthy System 1 thinking to System 2—taking control of decisions to be healthy or managing your diabetes—and then back to System 1 making those subconscious healthy decisions,” he added. “When you are lost in the jungle with a machete, you can carve a path, but you don’t know which way to go. If you have that North Star, you have a path and can see where you’re going. That is where Gain Life comes in.”

Aleksander Eiken, medical associate at Leo Innovation Labs, explains the Klikkit smart button to a TMC Expert Forum attendee.

Visual cues

While Gain Life focuses on changing thoughts, Klikkit, also part of TMCx, uses visual signals from a smart button to deliver reminders, through an app, to help people remember their good habits. Klikkit was born out of Danish dermatology company, LEO Pharma.

The technology is based on the idea that when someone creates a new habit, they are telling themselves to do something. That’s why the smart button can be placed on an item such as a jar of vitamins, prescription medication or a vegetable.

Klikkit based its design on the theory of “The Habit Loop”—a neurological cycle discovered by Massachusetts Institute of Technology researchers that governs habits and consists of a cue, a routine and a reward.

The theory suggests that there is greater difficulty in breaking a bad habit than in creating a new one, said Aleksander Eiken, a Klikkit medical advisor.

Klikkit is designed to help a habit stick. When the button is clicked, the app makes a record and monitors progress. If the button isn’t pressed, the user will receive a notification while the Klikkit beeps and flashes.

“Now you have the visual cue, and even more powerful—a light flash and sound,” Eiken said. “The more senses stimulated, the more powerful the reminder.”

Clicking the button develops a “routine” and delivers a “reward.” The person feels accomplishment as the body releases a small amount of dopamine, which keeps people addicted to reward-motivating behavior, he said.

Medication adherence

Depending on the research, building new behavior can take a few months to a few years.

That’s often the case with new medicine—especially for people with chronic diseases who take more than one medication each day. In fact, health care experts estimate that three out of four people do not take their medication as prescribed. And it’s not just one pill per day. The number of people who take five or more daily medications has doubled in the past 18 years.

Susan Abughosh, Ph.D., is hoping to improve medication compliance. The University of Houston pharmaceutical health outcomes and policy researcher recently received $459,000 from the National Institutes of Health to help patients with diabetes and high blood pressure follow their medication schedules.

Poor medication adherence kills 125,000 Americans annually and costs the health care system nearly $300 billion a year in additional doctor visits, emergency department visits and hospitalizations, according to the American Heart Association.

The organization also pinpoints four reasons why people don’t take their medication: they forget, they don’t think it’s working, they fear side effects and because of the high cost of prescription drugs.

Abughosh, an associate professor in the UH College of Pharmacy, plans on taking a more personalized approach to getting diabetes and high blood pressure patients to remember to take their medications by adding customized motivational interviewing conversations between patients and UH pharmacy students to help patients take their meds on time.

The University of Houston’s Susan Abughosh, Ph.D., received a grant to help patients with diabetes and high blood pressure follow their medication schedules. (Photo courtesy of UH)

‘Patients are the experts of themselves’

The motivational interviewing (MI) technique has proven promising in promoting behavioral change, Abughosh said. MI includes asking open-ended questions, positive reinforcement and expressing empathy and understanding.

“Instead of talking as an expert, we train students in motivational interviewing of patients to move them down to behavior change,” she said. “Patients are the experts of themselves, and they have their own reasons why they are not doing it.”

Abughosh is working with Marcia Holstad, a project consultant with Emory University School of Nursing, to teach the students MI techniques. The students will then interview patients by phone during their six-week rotation at Cigna Healthspring, a north Houston health care provider.

For the first year of the three-year grant, the team will identify medication refill patterns by a group of about 15,000 patients who have been prescribed an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), which are commonly used to regulate high blood pressure and diabetes.

Students will make monthly follow-up calls for six months, Abughosh said, and post-intervention data will be examined to see if there has been any improvement for high-risk patients.

“We know that knowledge doesn’t always translate into behavior change, but empathy and reflecting back on the problem actually helps them,” she said. “MI intervention is a powerful tool and could be used in other settings. And, providing the pharmacy students with this kind of resource is a skill they can carry into their own lives.”