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Eat healthy, move, reduce stress, be happy, surround yourself with a loving and supportive community, get sufficient sleep. These are the foundational tenets of healthy living, and they seem simple to implement…or are they?

There must be a reason why there are so many blogs, vlogs, books, webinars, programs, and experts out there to help people live a healthier life to prevent and reverse chronic disease: actual behavior change can be hard. And it takes much more than just knowing the right steps to take to embody a healthier lifestyle that optimizes your health, especially one that is tailored to your preferences, circumstances, and bio-individuality.

Numerous barriers to lifestyle change exist, and most may sound familiar to you either due to your own struggle or that of someone you know. Common barriers include:

• Ability
• Ability to plan and monitor
• Beliefs surrounding health
• Cost of the change
• Emotions related to the change
• Environment, such as weather or places to exercise
• Ideas regarding the value of healthy behavior change
• Injury or illness
• Lack of knowledge
• Limited social support
• Personal choices and preferences
• Psychological factors such as attitude, confidence, persistence, determination, and motivation
• Support from healthcare professionals
• Time

You may not encounter all of these barriers, and there may be some you have that I have not included on this list. Regardless of the exact barrier, recognizing them is often one of the first steps toward overcoming them for sustained behavior change. But that is not the only action step to take.

Are there science-based strategies proven to benefit people looking to get out of their ruts or habitual living and change their lives to live a healthier life, whatever that may look like to the individual? Let’s see what the literature has to say.

Habits vs. Decisions

Habits and decisions are interconnected. However, there are a variety of factors involved in how our decisions become habits. Think about your eating habits. How often do you eat something out of habit or routine compared to a true desire to eat the food itself at that moment? Or, if you want the food (say popcorn at the movies), how long do you actually taste and enjoy it before you are swept away into the distractions of the entertainment and the habitual nature of consuming popcorn while watching a movie?

This discussion takes us into the realm of mindful eating, a topic for another time, but it also makes a big point about how strongly habits and routines play into our health—for good or not.

We talk a lot about habits, but what exactly is a habit? One definition of habitual behaviors is that they are “automatically elicited by environmental cues, due to the activation of mental cue-behavior associations, which strengthen through repeated performance in a consistent context.”

Because of the external triggers associated with habits, these external cues can also be used in behavior change activities as a way to implement certain things rather than a person having to consciously think about doing something. That is, they are automatic. That is why some behavior change experts recommend adding new habits onto already existing habits, known as habit stacking.

Ultimately, habits are complex, most likely involving much more than simple stimulus-response. As neuroscience research continues, we will learn more about them and how they are beneficial or detrimental to health and other aspects of life.

There is often emotional baggage and history behind habits, making them even harder to break and adopt a healthier habit, especially when individuals have previous experiences in which he or she tried and failed to make the changes. The distress of not being able to get out of a rut or make a change may also further enhance the psychological distress impeding the behavior change, keeping someone in a cycle of desire to change without the ability or success to do so. This negative loop can impact self-esteem, self-efficacy, and other measures needed to successfully make changes as well.

Despite not fully understanding the complexity of habits, habit-breaking, and habit-forming, many studies into behavior change rely on the influence of habits on behaviors, such as dieting and exercise. Although many people say it takes 90 days to form a habit, studies into habit formation found it can take anywhere between 18 and 254 days, depending on the individual and the action.

Four steps to habit formation based on one study include:

• Intention
• Translating into action
• Sustaining action
• Repeated performance

To expand, you have to decide to do something, turn that into some type of action, and continue to do so over time. For example, you can decide to eat more vegetables, so you have that intention. Then, you buy vegetables and cook them for one of your meals one day. The next day, you do the same and so on until it becomes habitual, and you no longer have to focus as strongly on it. It becomes automatic, even if you still have to make some conscious decisions.

To continue the same example, the automatic habit is having vegetables in every meal, but the conscious decision may be which vegetables for each meal. Of course, people often get into a rut even when eating healthy, with all decisions becoming automatic so they simply create the same meals all the time rather than eating a variety of foods, the benefits of which I’ve discussed more in this blog. 

Successful behavior change is not just about the actual behavior. Changing the intention can also positively impact behavior and promote behavior change. 

How do habit-based interventions fare in practical application? Well, in one randomized controlled trial, using habit-based interventions, both creating new habits and stopping old ones, led to weight loss at a 12-month follow-up. At the end of active treatment, those in the group who formed new habits lost an average of 3.3 kg, while those in the breaking old habits group lost an average of 2.9 kg. Comparatively, the control group lost 0.4 kg. After 12 months, those in the new habit group lost an additional 2.4 kg, and those in the habit-breaking group lost 1.7 kg. About 65% of the participants reduced total body weight by at least 5%. Thus, adding new habits was slightly better than breaking habits in this study, but using any type of habit-based intervention was better than the control.

Another randomized trial using a similar habit-based intervention for three months found that not only did the participants in the group using the habit-based intervention lose more weight (a mean of 1.68 kg compared to 0.84 kg), but they also increased their self-regulatory skills, a mean increase of 0.8%. The effect occurred even in those with lower levels of self-regulatory skills at the start of the trial. Since self-regulatory skills can play a role in effective change—interventions that also increase these skills remain valuable tools for sustainable change. And, another randomized trial divided participants into three groups, two habit-based intervention groups and one control group. The two habit-based groups lost significantly more weight than the control group and continued to lose weight after their follow up.

Behavior Change Theories in Practice

There are many different theoretical and practical behavior change concepts. One article found 15 behavior theories, including control theory, deterrent theory, self-determination theory, social cognitive theory, goal-setting theory, and theory of planned behavior. Another review article found 82 theories of behavior and behavior change.

A systematic review on behavior theories found a whopping 117 theories, of which 100 met their inclusion criteria. The researchers found five overarching, interconnected themes, especially in those for behavior change maintenance rather than just initiation of new behavior patterns.

These included:

• Motives – sustainable change requires at least one long-term motivation for continued maintenance of the new behavior
• Self-regulation – continued maintenance of behavior and regulation of the change with looking at how to overcome any potential barriers that may appear
• Habit – the new behavior becomes automatic
• Resources – physical and psychological resources in place that support the new behavior over the long term
• Environmental and social influences – support from friends, family, social network as well as a conducive environment to maintain the behavior

This pattern of themes makes sense. For a behavior to continue, the person has to have motivation beyond a temporary reason—and intrinsic motivation works even better. The motivation may change and adapt, but some type of motivation needs to remain for a behavior to continue. Checking in about how things are going from time to time and making adjustments based on new knowledge and information also influences whether a behavior sticks. If it becomes automatic, it is much easier to continue, as we’ve discussed.

Furthermore, having the resources to continue and the support to do so also makes a difference. If a person wanted to eat only organic food but cannot afford to do so long-term, their behavior will likely stop even if they have the willingness to continue. An individual who has learned to exercise regularly and eat a healthy diet whose family does not support it will not last long, especially if that person is also in charge of meal planning for the whole family and does not wish to cook two meals or have a daily battle over the menu.

Behavior and action are complex, with many different influences on the outcome, including motivation, habits, resources, and the context of the situation, such as opportunity, cultural contexts, and peer pressure. Some behaviors also come from a more instinctual place, such as based on a fight-or-flight response, making them more automatic than even a habit.

When talking about behavior change methods and their efficacy, an important concept frequently overlooked is whether the end goal is to implement an action (e.g., start exercising or start eating more vegetables) or stop an action (e.g., quit smoking, stop eating processed foods). Does this matter in what actions you take to make the new behaviors stick? In one review article, they found most of the behavior theories did not change the methods depending on the ultimate goal. Rather, they would incorporate substitute behaviors when trying to decrease a behavior.

There are many studies about the various theories behind behavior and behavior change, and there are too many to cover every single one here. Additionally, many studies looking into behavior change theories do not always look at the long-term effects. This makes it harder to compare the efficacy with those studies that do look at long-term impact. Finding effective behavior change models for long-term, sustainable change is valuable for helping people make the changes they want for lasting results, rather than following a model comparable to the yo-yo dieting where change happens only for a short period.

Much of the literature focuses on discussing the models or testing hypotheses on animals rather than seeing them in action. Let’s review a few key ones that incorporate one or more behavior change model into randomized controlled trials in humans.

Cognitive Remediation Therapy

One type of behavioral change strategy is a modified version of cognitive remediation therapy (CRT). This technique improves executive function and focuses on looking at how someone thinks and then applies new ways of thinking into everyday life.

In one study using CRT on habitual behaviors contributing to obesity, mainly sedentary lifestyle and unhealthy diet, researchers found that CRT improved executive function, which assisted in breaking habits for improved healthy changes. The researchers also felt cognitive flexibility may play an important role in reducing unwanted habits and overall ability to disrupt habitual behavior.

Transtheoretical Model and Motivational Interviewing

One well-studied behavior change model is the transtheoretical model that incorporates the six stages of change:

• Precontemplation – change is not even on a person’s radar even if they practice an unhealthy behavior
• Contemplation – an individual has realized there might be a need to change but remains unsure
• Preparation – a person is ready to change
• Action – the change is in process
• Maintenance – a person has changed a behavior and is now incorporating ways to maintain it over time
• Relapse – the person reverts to older behavior patterns

One randomized control trial incorporated the transtheoretical model and individualized intervention with usual care for managing obesity. In 97% of the intervention group, changes were noted in diet, biochemical markers, and reduced body mass index compared to the control group. A randomized controlled trial found that participating in 10 workshops using the transtheoretical model led to an improvement in body perception, weight and BMI, and diet compared to the group that simply increased physical activity and participated in open-group education about nutrition. A recent systematic review reported that most studies found the transtheoretical model of behavior change effective, especially in making healthier behavior changes to prevent or treat chronic disease.

A closely related behavior change technique is motivational interviewing, which uses a patient-centered approach to behavior change that evokes intrinsic motivation as well as action steps based on the person’s own ideas, often coached or guided by a professional. Many professionals adopt motivational interviewing techniques to complement the transtheoretical model, helping individuals find motivation and action steps to move through the stages of change.

Studies have found this technique effective. One randomized controlled trial compared usual care to a nurse coaching program for patients with diabetes. The nurse coaching program incorporated motivational interviewing and remote health programs. The patients in the coaching program had significant improvements in self-efficacy and a decrease in depressive symptoms compared with the control group; however, the results were not sustained at 9 months.  Another systematic review found it likewise beneficial for lifestyle changes as well as supporting psychosocial needs of cancer patients and survivors. It has also been found effective in making changes beneficial for type 2 diabetes.

Rewarding Behavior

One long-standing concept behind behavior change theory is rewarding the new behavior. Is it an effective strategy for long-term behavior change?

One study investigated reward and intrinsic motivation in flossing and taking a vitamin C supplementation. The rewards in the study were pleasure, intrinsic motivation, and positive outcome expectations (looking at perceived benefits of doing the actions). The study designers hypothesized that these positive rewards would lead to automaticity through increasing repetition and that stronger rewards would lead to increased repetition and thus greater increases of automation of the habit. They found that pleasure and intrinsic motivation positively correlated with automaticity, while perceived utility and benefits did not have the same association.

A Cochrane Database systemic review found that monetary rewards may benefit behavior change in smoking cessation. In the 33 included studies, financial incentives led to behavior change that lasted long-term in mixed-population studies.

Thus, rewards may provide some motivation to make the change, but ultimately, the motivation and rewards need to be more intrinsic rather than extrinsic for a continued impact on long-term behavior.

Group Interventions

Social support can be a major factor in successful behavior change. In one study that looked at an intervention to change five behaviors, including increasing fruit and vegetable intake, physical activity, reducing red meat consumption, increasing multivitamin use, and smoking cessation that was self-guided found that those who identified and sought support from another individual had a 61% greater reduction in multiple risk behavior scores, and those who had more than one had a 100% greater reduction.

Many workplaces have started to implement health components to benefit their workers, and as a byproduct, their productivity. Churches and other communities have likewise done so, and there are many studies on group behavior change programs as well. Group interventions generally have a positive response, likely due at least in part to the additional component of social support and motivation to make healthy changes, as discussed below.

One systematic review on workplace programs in shift workers found sufficient evidence pointing to benefits for physical activity and weight loss, but not enough for healthy eating, and no studies reviewed sedentary behavior. The programs in the different studies differed, often with more than one target outcome and multiple components that included group activities – including competition, behavioral modification, individualized goals, and incentives being common among the different programs. A systematic review on workplace interventions using resistance-based training led to benefits for preventing and managing upper extremity musculoskeletal disorders. Another review confirmed this conclusion; however, there were limitations to the benefits of the program.

A study examined the results of 35 churches that participated in a Faith, Activity, and Nutrition program and the effects the group program had on physical activity, fruit and vegetable behaviors, and health efficacy. The study found that members who perceived more opportunities, pastor support, and messages of support had greater improvements in physical activity and fruit and vegetable intake.

There are many reasons why community-based programs, especially in places where individuals already go such as work or faith-based communities, provide a promising space for effective behavior change programs. People can learn together how to shop for and cook healthy foods, and they can attend exercise programs, especially if they are at the locations. Their friends and coworkers can also hold them accountable through making plans to go do something together.

Using Tools

There are so many tools on the market for healthy behaviors, from apps to fitness/diet trackers and beyond. Do these work…and can they facilitate behavior change?

One systematic review and meta-analysis found that using IVR systems (interactive voice response—automated telephone calls) led to a small but significant positive impact on increasing physical activity and adhering to medication. There was no statistically significant impact on diet or alcohol consumption.

One randomized study examined a web- and mobile-based app that included self-reporting of exercise and food intake, personalized feedback, practical tips, tricks for healthier behaviors, suggestions for programs or activities, weekly assignments and challenges, and other social interactions. Those who used the app lost more weight and waist circumference after 38 weeks compared to the control group (a median 1.01 kg weight loss, 0.78% loss of body fat percentage, and 1.79 cm decrease around the waist). The subgroup focused on weight loss had an even greater result.

One study looked at non-professional caregivers and the effectiveness of a smartphone app-based intervention program intended to improve mental health, perceived caregiver burden, and personal satisfaction. The app-based intervention included 28 days of recommendations for mental health, activities, motivational quotes, and the ability to register as part of the app’s community. One hundred and thirteen caregivers completed this study. At 3-month follow up, personal satisfaction, self-control, prosocial attitude, ability to problem solve, and interpersonal relationship skills all increased.

One systemic review and meta-analysis including 41 studies analyzing the effectiveness of app-based nutrition intervention effectiveness found that app-based interventions improved healthy eating patterns, health outcomes, blood pressure, blood lipid profiles, and reduced obesity. The interventions included goals, planning, feedback, monitoring, information on nutrition, and social support.

Popular tools for monitoring health habits are wearable trackers, which may simply track physical activity or may also track sleep, heart rate variability, and more. Generally, users find them useful and appealing for improving eating habits and physical activity habits and modestly helpful for improving eating patterns. In the study, 81% of those who currently used fitness trackers felt it impacted their physical activity, and 51.3% of previous users felt the same way. They did not seem to have the same effect on making dietary changes, as only 40.2% of current users felt they improved their diet, and 13.5% of former users did. The number of people who felt the trackers improved their sleep was even less, with 24.1% of current users and 10.8% of former users feeling there was an impact on sleep from using the trackers.

Tools may not work as well as designed. A systemic review looking at long term weight management using wearable technology in overweight adults found that, while the devices did not demonstrate benefit compared to other methods of intervention, participants did lose weight over time. Additionally, the review concluded that devices could improve weight loss outcomes.

The changes may not be permanent. One randomized controlled trial found that people who were using a smartphone tracking app did reduce their weight, BMI, waist-height, body adiposity, and waist and hip circumference. The group using the tracking app also increased light physical activity time. However, these behavior changes were not permanent, and improved biomarkers and behaviors diminished at 12 months follow up.

Tools may or may not work. It may depend a lot on the person rather than the tool as to whether the tool is beneficial and complements a behavior change intervention or whether it ends up ineffective or even worse than not using the tool. It is also important to note that although users may find them handy, the technology is not always valid or reliable. Based on one systematic review, tools may be more accurate with step counts versus energy expenditure. However, these tools remain key potential aspects of a protocol for implementing healthy lifestyle changes, especially as technology improves and becomes even more embedded in our lives.

Conclusion

So, what does this mean for you? Well, at the core, behavior change is possible and you can make healthy changes last. However, it is not an easy task. There are many ways to go about enacting these changes and getting them to stick—and one way that works for one person may not work for another.

The most important thing is to find the one that works for you, including using tools if you feel that could assist you. It may take some trial and error before you find sustainable change. Motivation plays a role, as do many practical components such as whether you have the time and the resources to do so—and the desire to perform actions to reach the goal.

There may be additional work you need to perform on your self-regulatory skills to improve your ability to implement an intention, and you may need to think outside the box to find other actions to take to meet your ultimate goal. For example, increasing physical activity does not have to mean you go to the gym, run, or swim. There may be other ways to increase physical activity that adhere to your pursuits, such as parking farther away from where you need to be or taking the stairs instead of the elevator.

For sustainable behavior change, it often takes support. This may come from your social and familial community or a place such as your work or spiritual community. However, many find it beneficial to work with professionals well-versed in behavior change models, such as therapists, health coaches, and nutritionists.