Podcast: Behavior Change with David Schlundt
In this episode of the “Well-Being Experts” podcast, we’re discussing the scientific approach to behavior change. We sat down with Dr. David Schlundt, scientific adviser to Onlife Health, to talk about what motivates people to change their behavior in order to improve their health. We also look at what and why some incentives work while others don't.
“People are tired of hurting; they're tired of being tired; they don't like the sleep apnea in the middle of the night. There are so many things that with obesity and chronic illness that are making people feel uncomfortable. And by starting that pathway to changing some of these behaviors and setting even very modest goals, people can actually feel better, and it doesn't take that long.”
Want to dive deeper into this Well-Being Experts podcast? Here's the full transcript from our discussion with David Schlundt, Ph.D., Scientific Advisor for Onlife Health.
Dr. Schlundt: I think that providing people with incentives particularly to get them started on the process of behavior change is really a legitimate strategy.
Host: This is the Well-Being Experts podcast, and you just heard from Dr. David Schlundt, scientific adviser at Onlife Health. This conversation is all about behavior change.
Dr. Schlundt: People are tired of hurting; they’re tired of being tired; they don’t like the sleep apnea in the middle of the night. There are so many things that with obesity and chronic illness that that are making people feel uncomfortable. And by starting that pathway to changing some of these behaviors and setting even very modest goals, people can actually feel better, and it doesn’t take that long.
Host: On our seventh episode of the Well-Being Experts podcast, brought to you by Onlife Health, we’re discussing the scientific approach to behavior change. Additionally, we’re looking at what and why some incentives work while others don’t. For more content like this, go to onlifehealth.com/resources. Enjoy the conversation!
Dr. Schlundt: I’m David Schlundt and I’m an associate professor of psychology at Vanderbilt University. I’ve been there for 30 years studying people’s health behavior, how to measure it, how to change it, how to promote good health in minority communities and try to address some of the health disparities.
Host: As we’re starting to roll into this now, how about we start just talking a little bit about you and your background, and how you found yourself in this space, in this industry within your approach to science and how all of this plays into the psychology of change and behavior.
Dr. Schlundt: I was trained as a clinical psychologist. I got a Ph.D. at – well, I actually did work at University of Wisconsin and Indiana University, so I’m a Big Ten guy. And I was originally interested in studying what we called social skills. Back when I was in school, assertiveness training was the big hot topic of the day. So I was interested in that and interested in studying people’s social behavior; how they interacted with each other. I got my Ph.D. I went on what they called the clinical internship year, and the first thing I started doing was working in an eating disorder clinic. And that just really, really started to change my interest. The idea that something so normal and so everyday – eating – could get so out of control was just fascinating to me as a psychologist. And it was really very challenging to really try to come up with intervention and treatment strategies for helping people, and changing those behaviors.
It was a time in the early 1980’s when bulimia nervosa was just being discovered, and so we would go on the radio or TV and say, “We’ve got a study on bulimia and this is what it is,” and people would be coming out of the woodwork saying, “Well, I’ve been binging and purging for 20 years. I’ve never told anybody about it. I thought I was the only one. Can you help me, please?” And that’s got me on the road to being interested in the health behaviors.
I did another rotation and worked in a VA hospital with alcohol and drugs, and then I worked a little bit in a hypertension clinic where they were really focusing on nutrition and physical activity, as opposed to medication and the treatment. Then I went on the job market, and at that point I couldn’t find anyone that wanted to hire me to do social skills research, so I stayed in Mississippi there for three years and I worked with something called the Hypertension Prevention Trial. Very interesting. It took people with high-normal blood pressure and put them on different diets: a low-sodium diet, a low-sodium/high-potassium diet, and the killer was the low-sodium/weight loss diet.
That took away everything people liked, yes.
Host: I have a question about – rewinding it back just a moment – when you talked about the findings of people that had a psychological challenge for years on years and they’ve held it to themselves, what surprised you the most about just the way someone’s mind and the way their behavior had been impacted internally – within their own selves – without them really even realizing it for such a long time?
Dr. Schlundt: It was the burden of guilt, really. The guilt and the depression that they had carried for so many years. If you can imagine the measures that they took to hide these behaviors. I remember one young woman who was discovered when the septic tank in the house backed up and overflowed because she had been purging so much food into it that it couldn’t handle it anymore. And then that eventually got her the attention of the psychologist and into a treatment. A lot of it really was the loneliness, the isolation, the depression, the guilt, and the shame. It was really a heavy burden for these women that they carried.
Host: So, that’s one extreme behavior that’s impacting and that’s revolving around health and wellness, and there are other extreme behaviors that are similar to that, right?
Dr. Schlundt: Well, actually, I think there’s a lot of eating behaviors that exist on a continuum. So the very extreme binge eating that you would see in an eating disorder, that’s a very small percentage of the population. But if you think about something like emotional eating – people are using food as a way to try to cope with stress or boredom or anger or depression – that’s actually a much more common behavior. And the research I’ve done suggests that it really is a contributing factor to weight gain for a lot people.
Host: Now, we know that these are things that need to be changed, but when they’re ingrained in someone, it’s connected to a lot of things and it’s hard to change. So, when you’re thinking about how to make small tweaks to try to have a big impact that will hopefully help and transform someone’s life to have that freedom and to be healthier and live a longer-lasting life, are there small things that you can start to adjust and tweak that will hopefully make a compounded change in someone’s life?
Dr. Schlundt: I would say that the process of behavior change really begins with analysis. You really have to understand the behavior and you have to understand the function or role that that behavior plays in a person’s life. So for example, if it’s overeating or emotional eating, you really have to first begin by exploring what triggers it, what’s rewarding it, how do you feel before and afterwards? What would be different in your life if you gave up or changed this? And then you begin to sort of develop strategies for – sometimes it’s finding alternative ways of coping with the stressful situations, and you almost have to do that before you tweak the eating. Or you have to work on those two things together, simultaneously.
Well-being Experts is supported by Onlife Health. With 20 years of industry experience and over 10 million covered lives, Onlife knows how to drive the ongoing engagement needed to create real results. Find out why health plans and large employers nationwide trust Onlife Health as their trusted wellness provider. Visit onlifehealth.com to learn more.
Host: What are some wellness strategies that you’ve seen that have proven to be beneficial for health plans?
Dr. Schlundt: Well, I’ll go all the way back to the Hypertension Prevention Trial. And what we did was we gave people daily diaries and we gave them a sodium counter, or a potassium counter. And we said, “You have a goal. We want you to do 1,500 mg of sodium each day. When you eat the foods, look it up, write it down, tally it, put it on the back, mark it up on this graph on the back of the diary.” And I was incredibly impressed at how powerful that is as a behavior-change strategy. I call it self-monitoring with goal setting. Once you make a behavior sort of visible and you get the daily feedback – I thought it would take people months – particularly in Jackson, Mississippi – to give up salt. And the majority of them could do it in two weeks, and they were down at goal on many days, because they got that feedback and they could say, “Oh, I didn’t realize that fried pickles had so much sodium in them, I guess I’m going to have to eat a fresh vegetable instead.” So, I think to me that’s the core most powerful behavior change technique. And what’s really exciting today, is how all of the technology is making this easier.
Host: Is paying or incentivizing someone, is that really considered behavior change, or do you have to go deeper than that? How does an employer approach that topic to help someone, to make them decide they’re going to change?
Dr. Schlundt: I think that providing people with incentives, particularly to get them started on the process of behavior change is really a legitimate strategy. And again, we go back through the function of behaviors and, “What am I going to get out of this?” So for example, in thinking about motivation, people think it’s sort of a secret magic substance that you have a certain amount of and somehow you’ve got to crank up the motivation. Really, motivation is thinking about what are the costs and benefits to me, how much effort is this going to be, how much money is this going to cost me, how much time is it going to take? And very often people overestimate some of those costs and giving them a little nudge saying, “Well, okay, if you go through this module on improving your eating habits and you get started and you self-monitor for two weeks, we’re going to give you whatever incentive. We’ll give you a gym bag or water bottle.”
Host: Not fried pickles, though?
Dr. Schlundt: No fried pickles, no.
Host: That’s interesting.
Dr. Schlundt: So, I do think incentives really can be a valuable part of it, but essentially what you have to do, though, is get that person to connect to the personal reasons why it’s important to do this or do something different. So these people had high-normal blood pressure. Part of what they were motivated by was, “If I can modify my diet, it may actually keep me from getting hypertension and may prevent me from having to go on medication or may delay how long before I go on medications.”
Host: When someone first has an opportunity to go down that path of change, is the short-term sight of what they see, is it the incentive or do you think the short-term sight of what they’re seeing is them becoming healthier?
Dr. Schlundt: I think that people have a hard time conceptualizing general health as their sort of primary motivation. Very often people get triggered into behavior change when a health issue comes up. Your doctor says, “Oh, look at this blood test. I’m afraid that I’m going to have to tell you that you now have pre-diabetes.”
“Oh, I don’t want diabetes, so maybe I should start doing something about it.”
Sometimes it’s making the negative consequences obvious. So if I think, “Well, if I eat healthy now, 25 years from now I might not get cancer.” That doesn’t motivate people. “If I don’t change my behavior, I may have to go on treatment. I may have to start taking pills, or I may have start having to do insulin injections for diabetes.” That’s a little bit more motivating.
But the best motivation is when you can make it a positive, immediate sort of consequence. And very often, that has to be connected to some intrinsic things. “I feel like I’m in more control over my life. I feel like I am doing the right thing for myself. I feel proud of myself for doing this,” and then with the self-monitoring and goal setting, “I made my goal today.”
So let’s take the activity monitors, for example, the step-counters, when you’re working on getting more physical activity. One of the brands is programmed to buzz on your wrist when you hit the magic 10,000 steps for the day. So my wife and I have this little joke about, “Hey, party on the wrist!” And so that becomes a very tangible, immediate reward. One also did stair climbing and it would send me little messages that said, “You just won your 747 award. You climbed enough stairs to get to 30,000 feet.” So making some sort of positive incentive and making it visible and tangible and giving a person that feedback, that helps motivate them. That helps keep them going. They need to have a larger reason to be healthy, to avoid going on treatment for diabetes, to lose weight.
Host: What I’m curious to hear though is, from the employer perspective, how do you know when that employee – when they really get it? Because so much of the discovery seems to be intrinsic and internal. Is there a way an employer can know when it really clicks and the wellness program they’ve implemented is having a lasting, sustainable impact on their most important asset: their people?
Dr. Schlundt: I think that when people start bragging about it and then start recommending it to other employees, when after six months, you haven’t seen the person that’s in the other department, and all of a sudden they show up 25 pounds lighter. My favorite is if I run a half marathon, I really like to wear that t-shirt to work the next day, like, “Hey, look what I did.” So again, they start to make it sort of publicly known, “I’ve succeeded in something and I am really, really proud about it.”
And I think employers can go about to try to create an atmosphere that sort of facilitates that. A lot of the things they do in the worksite with organizing competitions, or doing interdepartmental competitions, things like that; all of that just sort of makes it more visible and really allows people to begin to say, “I never thought I could do this, but I could. I can now run two miles and I am so proud of myself for doing that. I can now ride my bike for a whole hour without getting off. I can now carry a box up three flights of stairs.”
Host: Now from the employer perspective, we just talked about how they are able to see that impact. Now, let’s look at it from the health plan perspective. So let’s say I am a health plan. What information can I take away from this to help inform my employer groups?
Dr. Schlundt: I think that people need to have some support, particularly to initiate that process of behavior change. I find that we have such a high level of obesity and chronic disease now, and people feel very, very helpless about this. So for example, when I’ve done health surveys, and I put the question on there, “Are you interested in losing weight?” 85% of the people will say, “Yes, I really want to lose weight, or I’m working to keep from gaining weight,” but they’re actually gaining weight. They’re really feeling very helpless and hopeless about it. And very often, it’s because somebody has told them, “You’re 100 pounds overweight now. You really need to do something about it, or you’re going to die.” And the task of losing 100 pounds is so overwhelming.
So people really need help in setting goals, they really need to be given realistic expectations, they really need to be given access to resources. You need to have patience with people, because very often they’re going to have to try three or four times before they’re successful in sort of making and maintaining a behavior change. You need an atmosphere in which it’s, “Well, let’s talk about what you’re willing to do and where you’re willing to get started, and if you’re only willing to start small, fine, let’s work on that, and then let’s help you see that you start to feel better physically and emotionally when you’re able to succeed in meeting some of these goals.” And then part of that is then helping them with that process of self-monitoring and goal setting so that the success begins to be visible, and even brag-able. “Hey, look at my graph. I got more than 10,000 steps 25 of the last 30 days.”
Host: It’s like a new person.
Dr. Schlundt: Well, that’s often what you see. When we ran the weight management programs, for many years at Vanderbilt, I would often see that when we helped people focus on the behaviors, when we helped them set small goals, when we helped them sort of drop some of their all or nothing thinking, “Well, if I can’t lose 100 pounds, what’s the use of trying?” To say, “No, let’s see if we can’t start and get you to lose 10 pounds to begin with.” They would just catch fire with it. They’d say, “Okay, now I’m ready to exercise. And maybe I think I’m ready to stop smoking, too.”
Host: So if we take everything we just talked about regarding the psychology of change, if you had to sum it up into a “why,” why this matters, and why this must be done, how would you articulate that?
Dr. Schlundt: Well, I guess from the individual’s point of view, I’ll go back to the no limitations. People are tired of hurting; they’re tired of being tired; they don’t like the sleep apnea in the middle of the night. There’s so many things that with the obesity and chronic illness that are making people feel uncomfortable, and by starting that pathway to changing some of these behaviors and setting even very modest goals, people can actually feel better and it doesn’t take that long.
So I think the bottom line is that you really – again, get away from the idea that motivation is a magic substance and really thinking that motivation is, “My appraisal of the costs and benefits of different choices that I have in my life,” and begin to help people become excited about making new choices and seeing that they’re very immediate, very tangible, and very worthwhile benefits.
Again, not everybody will take you up on the challenge to exercise or eat healthier the first time. They may be willing to try a little something to start with, but again, often once somebody sees that there are, “Oh, I actually feel better. I’m sleeping better now that I’m walking. This is great,” and, “Hey, look, I just had a party at my wrist!”
Host: What would you say is the ’why’ for health plans?
Dr. Schlundt: For health plans, it’s really cost containment to a very large degree. I like to think about it, let’s say, in terms of diabetes. So that if you’re wanting to promote good diabetes self management – and that’s giving somebody a target blood glucose value, getting them to do blood glucose testing, getting them to begin to pay attention to healthy diet, to getting a little exercise – and you are able to keep that person from having kidney failure, just think about how much dialysis money you’ve saved. You keep that person from having a heart attack, or needing bypass surgery.
So I think from the health plan’s perspective, it’s – from a health plan, you have to take more of a public health approach. And in public health, small changes in large numbers of people add up to big impacts. So if you are looking at a large employee system and you say, “Well, if I could increase the number of employees that are walking three times a week by 10%, it’s not a big thing.” But in the long run, you’re maybe going to keep from incurring some of those really huge costs, like the bypass surgery, like the kidney dialysis.
Host: And for the employer group, there are probably some similarities to that why, but are there some differentiators for the employers of why this matters, and why this needed to be done?
Dr. Schlundt: Yeah, I think as an employer, I think you want your employees to be happy, healthy, and doing well. And really by doing some of these health-enhancing things that you can adjust things like absenteeism, and productivity, employee morale. You don’t want to harass people so they start feeling bad about it, but you want to give them opportunities to make some changes, and get to feeling better, and I think they will be better employees.
Host: I think that answers just about all my questions around the successful strategies to, not just approaching behavioral change, but really trying to make a lasting, sustainable impact. I really appreciate you sharing your insights, because I know you have over 30 years’ experience with this. It’s been really insightful, and I hope we can do this again soon.
Dr. Schlundt: Thank you, it’s my pleasure.