October 1, 1999

What We Know about Unhealthy Behaviors and How You Can Change Them

We pride ourselves on our intelligence but we still engage in many unhealthy behaviors — eating and drinking to excess, smoking, abusing drugs. Can doctors and therapists help us stop these unhealthy behaviors? The answer appears to be yes. But, and this is an important factor, whether you can be helped depends on how you answer when your doctor asks you how you've been.

Two explanations have been offered for unhealthy behavior. The first is that some people lack knowledge about the harmful effects of substance abuse, smoking and obesity. The alternate explanation emphasizes that people engaging in unhealthy behaviors do not correctly weigh the health/lifestyle pros and cons regarding participating or not participating in these behaviors.

While some obese people differ in their energy metabolism from thin people, it is also clear that some of the obesity in America is the result of eating foods considerably in excess of the amount which Americans know is healthy for them.

Virtually all women and most men recognize that lowering weight is desirable, so a lack of knowledge isn't the problem. While some obese people differ in their energy metabolism from thin people, it is also clear that some of the obesity in America is the result of eating foods considerably in excess of the amount which Americans know is healthy for them. The attempt to control food intake by dieting is nearly universal at some point in the lifetime of American women. Studies of incoming college freshman women show that only 8 - 13% of women are non-dieters. With the median age of onset of dieting close to age 12, it is unlikely that the message is not getting to young women or is arriving too late. Yet the average American weight continues to go up. So why do people who know better continue to eat too much?

Why We Do What's Not Good for Us: Mixed Messages and Impulsiveness

In the area of substance abuse, there is, perhaps, even better data documenting that knowledge isn't the problem. Studies of several school-based substance abuse prevention programs found that these programs definitely increased students' knowledge regarding the health risks of these substances but, unfortunately, had no effect or, sometimes, even increased the rate of substance use. So, once again, it seems quite unlikely that a simple lack of knowledge is what prevents people from avoiding harmful behavior.

Anti-substance use and anti-obesity messages do not occur in a vacuum. Young people at the age when they begin using drugs (and all of us in general) get both anti- and pro-smoking, anti and pro-drinking, and anti and pro-drug use messages every day. Our cultural airwaves carry the message that smoking is sophisticated and associated with sexuality at the same time that they offer reports about its terrible effects on one's health. Similarly, competing messages occur regarding the potential pleasure and risk associated with alcohol drinking and cocaine use. Perhaps an even more intensely contradictory message is delivered via food ads — we hear how creamy and good tasting certain foods are, promising a positive experience, while, at the same time, the dieting, health, fitness, fashion and entertainment industries present us with images and information that being thin is to both desirable and healthy.

So, in each case, we receive two distinctly different messages. A positive message about the short-term benefits or pleasures of the use of cigarettes, drugs, alcohol and rich foods and a negative message about the long-term problems associated with these behaviors.

Unhealthy Behaviors: Choosing Short-Term Benefits Over Long-Term Risk

How we contend with these mixed messages turns out to be key to whether we pursue healthy or unhealthy behaviors. We humans are not always particularly good at weighing out the problems of short-term benefit and long-term risk. In fact, researchers have shown that human beings differ dramatically in (1) their tendency to pursue short-term benefits and (2) their tendency to avoid taking risks. Over the years, they have studied and identified the temperament and personality types, as well as important genetic determinants, that make it more likely a person will engage in risky behavior and opt for short-term pleasure over long-term benefits.

One area of work has examined the tendency to "novelty seeking" — how likely a person is to take action in response to novelty and/or signals of reward or relief of punishment. For example, many adolescents often begin smoking as novel behavior that seems to offer relief from feeling they are not as "with it" or popular as they'd like to be. At the other end of the spectrum of behavior are those who are more focused on avoiding harm.

A fear of harm can still play a useful role in motivating healthier behavior; it can also, perversely, become a motivator for unhealthy behaviors.

Novelty seeking and harm avoidance have been linked to various aspects of the harmful behavior choices. People who evidence early alcoholism are significantly higher on the dimension of novelty seeking than are other individuals. People with alcoholism and antisocial behavior, a pattern of criminal behavior characterized by a lack of regard for others, also are low in harm avoidance. High novelty seeking is also a major determinant in the initiation of smoking. Bulimic patients (those who engage in binge eating on high sweet, high fat foods) are higher in novelty seeking than are anorexics who typically restrict their food intake.

But this is just a piece of the picture. Everyone has both qualities simultaneously. A fear of harm can still play a useful role in motivating healthier behavior; it can also, perversely, become a motivator for unhealthy behaviors. Alcoholics, who also were fairly high in their desire to avoid harm, were more likely to achieve prolonged abstinence from alcohol compared to alcoholics who have not recovered.10 However, both bulimics and anorexics see themselves as avoiding the harmful effects of obesity, even as they engage in binge-purge and starvation behaviors that are definitely harmful. Thus, there appear to be temperamental differences in the degree to which people are eager to pursue new reinforcers, such as drugs and food, and the degree to which they are careful to avoid harm.

Those high in novelty seeking and low in harm avoidance are thought to be most impulsive. People who are highly impulsive tend to think in a way that makes them vulnerable to the short-term rewards offered by many high-risk behaviors even though they recognize the negative consequences involved. In laboratory situations, where impulsive people are forced to make decisions about pursuing rewards and taking risks in computerized tasks, studies have found that, when both rewards and punishments are involved, highly impulsive individuals are much more likely than non-impulsive subjects to continue to perform a behavior in the hopes of achieving a reward even as the punishment increases. Compared to the less impulsive, in a reward vs. risk situation, they behave more quickly and give themselves less time to consider their options. When highly impulsive people were forced to slow down and consider the results of their behavior, they were much more liely to make a harm-avoidant choice.

One Helpful Strategy: Slow Down and Then Decide

So, here's a solution to the mixed message problem (i.e., short term pleasure from substance use or binge eating and only long term punishment from cancer, cirrhosis and obesity) faced by an adolescent or adult. Slow down the decision-making process. Learn not to respond impulsively, consider more of the results of your behavior and, then, you'll find you may make better choices.

How Your Doctor Can Help You Engage Your Own Desire for Harm Avoidance

The next time you see your doctor, bring up health concerns you may have. If you are worried about your weight, your alcohol consumption or sedentary lifestyle, enlist the doctor's help. Studies have shown that a general doctor, even within the constraints of brief appointment times and all the other much-maligned aspects of modern medicine, can still have an impact on health related behaviors. In one study of people who drank more than 35 drinks per week and who received brief advice from a physician to reduce or stop alcohol, as well as a self-help booklet, weekly diaries and a written contract in the form of prescription signed by the physician, there was a twofold reduction in alcohol use, fewer episodes of heavy drinking and improved liver function test levels.

Another study compared simple advice (a five minute session on sensible drinking or abstinence), brief counseling, which included a 15 minute session on self-help manual and extended counseling (initial brief counseling and three or more monitoring visits). All three interventions were compared with a control group who only had a 30-minute interview prior to random assignment. In this study, these brief interventions had a significant effect on average alcohol consumption and the intensity of heavy drinking. Differences from these kinds of brief interventions were found to last for as long as six years in follow-up.

..[W]orking with your physician or therapist, you can begin to help yourself by engaging your own risk-avoidant qualities. This first act will make it easier for risk-avoidant qualities to take hold...

While it's not yet clear why these brief interventions work, most have several components in common. First, when your doctor identifies the problem or supports your concern regarding unhealthy behaviors, your motivation to quit is increased, in part, perhaps, by simply clearly calling attention to the issue. Second, the information, provided by the doctor regarding the harm unhealthy behaviors take on the body, may increase the motivation of those with sufficient harm avoidance, for they will now be more aware of the costs involved in their unhealthy behaviors. Third, these interventions frequently involve pointing out alternative positive reinforcers (such as good health, having more energy or money or living longer for one's children) that can motivate healthy behavior. Fourth, almost all of these interventions ask the participant to introduce some delay in their decision, so that they have some time to reflect on short-term benefits vs. long-term harm.

What You Can Do

When your doctor asks how you've been, you should bring up any worries you may have regarding unhealthy behaviors, no matter how trivial they may seem. Whether it's overeating or undereating or drinking or gambling, your physician's interest and suggestions are going to register with you in a beneficial way. For their part, doctors are learning that it can be beneficial to ask what some may perceive as insulting questions about alcohol and fat intake or smoking. Armed with this information, you and your doctor can then begin a discussion about steps to take.

In the end, it is you, and you alone, who must move away from unhealthy behaviors. But working with your physician or therapist, you can begin to help yourself by engaging your own risk-avoidant qualities. This first act will make it easier for risk-avoidant qualities to take hold and give you a better chance of stepping away from unhealthy behaviors.
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