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VOL. 6 • NO. 10
Why do we continue unhealthy behaviors knowing that they are detrimental to our well-being? Former first lady Nancy Reagan’s slogan “Just say no” was a simple, but ineffective solution. Economics, environment and culture are powerful stimuli. And so are habits.
© June 2012
Researchers funded by the National Institutes of Health (NIH) are taking a closer look at what happens in the brain as habits form. “Understanding the biology of how we develop routines that may be harmful to us, and how to break those routines and embrace new ones, could help us change our lifestyles
and adopt healthier behaviors,” Dr. Nora Volkow, director of the National Institute on Drug Abuse, recently wrote in the NIH News in Health. Generally, we are creatures of habit. We perform daily routines, such as bathing and combing our hair without giving them a thought. We’re on auto-pilot as we drive to work. In one sense, these habits are good, according to Volkow, as it frees up the brain to concentrate on other matters. Habits form not only from repetition but also from the stimulation of the brain’s reward centers. Often these habits are not particularly good. When we indulge in behaviors that bring us pleasure, such as smoking, using drugs or eating too much food, the brain releases dopamine, a chemical responsible not only for motivation, compulsion and perseverance, but also for pleasure. In other words, our brains become hardwired to crave and continue bad habits. That does not mean that it’s impossible to change. It means that change is just not easy. There is not one set of rules for change. One size does not fit all, but there are some rules that apply across the board. One must first recognize and accept the habit and acknowledge that change is necessary. In addition, goals for change should be specific. Instead of vowing to exercise, be more exact. How often will you exercise? What type of exercise? There are several models of behavior change, but one of the most applied and tested in the health care field is the transtheoretical model (TTM) developed by psychologists James Prochaska and Carlo DiClemente in 1983. TTM has been successfully applied to health related behaviors such as smoking, diet, exercise and safe sex practices. Practitioners have also used it to change mental health
related behaviors, including alcohol, drug abuse and stress. The theory behind TTM is that at any given time, a person is in one of five different stages: precontemplation, contemplation, preparation, action and maintenance. People move from one stage to the next without skipping since each stage offers preparation for the one following. The time frame to remain in each level depends on the individual. In precontemplation, a person has no conscious intention of making a change, while in the contemplation stage the person is considering a change, but has not made a commitment to a particular action. In preparation, people acknowledge the need to change and are developing an action plan, such as membership in a health club. Action occurs when the person has actually modified behavior, such as to stop smoking. Maintenance occurs once the person has practiced the new behavior for six months. Counselors readily admit that it can take several rounds of these stages for a permanent change to occur. Smokers quit, then quit again. Many new health center memberships go unused. That’s to be expected. Relapse is common, perhaps even inevitable. Experts often look at these relapses as partial successes. People know why they failed and can hopefully avoid that response the next time around. Some make the mistake of relying solely on willpower to change unhealthy habits. Mental health professionals warn that willpower is like a muscle and fatigues when used too much. A recent issue of Mayo Clinic Health Letter cites examples of how self-control may be more effective in changing certain behaviors. For example, a person using sheer willpower to curtail drinking will decide to keep Habits, continued to page 4
Take the first step … again and again Sonia Booker, 79, is good at keeping secrets. She was able to keep her cigarette smoking hidden from the parishioners at Holy Tabernacle Church where she was a choir member and usher. She even tried to keep it from her doctor. “I was ashamed,” she admitted. But she couldn’t keep the secret from herself. The constant hacking cough and the escalating cost of cigarettes finally got the better of her. She did answer truthfully when the doctor asked her about her smoking habits. She thought the answer “now and then” would do, but the doctor’s quick response was “Stop.” Like most people, it was hard for Booker to change this behavior. She started smoking around the age of 25 because her friends did. At one time she was up to two packs a day. Even the health warnings that began to surface 50 years ago did not have an impact. “We can hear and not pay attention,” she explained. Eventually, circumstances changed. Though Booker had not made the decision to stop smoking, certain events began to get her attention. The doctors found a spot on the lung of her sister, who was also a smoker. The health
warnings began to scare her. Booker quit — again, and again and again. Therapists warn that relapses are common. Booker started again after the death of one of her sons. She noticed, however, that she began to taper off without even trying. “I could be out most of the day and not even think about smoking,” she said. “When I came home and saw the pack sitting there, I automatically grabbed one.” The first step toward healthier habits is to recognize and accept the unhealthy behavior — without recriminations. “Don’t judge yourself,” explained Dr. Nicole Christian, a resident in psychiatry at Massachusetts General Hospital (MGH). “We are indeed creatures of habit.” Motivation to change is key — and individual. Outside encouragement is helpful, but the need to modify a habit comes only from within and is particular to each person. Generally, the biggest impetus to change is that people get tired of their behavior and its ramifications. “When they get to the point that ‘enough is enough’ that’s when the change begins,” she said.
Sonia Booker (left) and her son, Carl, formed a buddy system to support each other in their efforts to stop smoking. (Ernesto Arroyo photo)
And change should be measured in small victories. “Many people try to do too much at one time,” said Christian. “Take small steps.”
For instance, if you smoke 10 cigarettes a day, cut it down to nine. If you are trying to exercise, a vow to exercise five
Booker, continued to page
To find the right mix, your doctor should work with you to:
Prescription painkillers: A double-edged sword Ever break a leg? Have surgery? Hurt your back? Easing the pain that follows helps you heal better and feel happier all-around. Keep in mind, though, that as choices for strong prescription pain relief have expanded in recent years, unexpected dangers have multiplied, too. That’s because the potent painkillers called opioids can be unintentionally addictive, particularly if used improperly. A few examples of these prescription drugs are the short-acting Vicodin (hydrocodone), Percoset (oxycodone), Tylenol with Codeine and the long-acting OxyContin (oxycodone) and fentynal. In the 2010 National Survey of Drug Use and Health, a
startling one in twenty Americans 12 and older reported having misused such painkillers. The steadily rising tide of prescription drug abuse has many serious consequences, warn experts at the Centers for Disease Control and Prevention (CDC). Accidental overdoses of prescription pain relievers have more than tripled in the past decade, killing more Americans than heroin and cocaine combined. And for every deadly overdose, nine people enter treatment for substance abuse, 35 wind up in the emergency room and 161 report drug abuse or dependence.
Healthy strategies for easing pain
“Our goal as physicians is to strike the right balance of pain relief. We want to prescribe wisely without undertreating or overtreating pain,” said Dr. Jan Cook, medical director of Blue Cross Blue Shield of Massachusetts. “Often, a mix of healthy strategies is the best way to ease pain.”
• Assess addiction risk. An honest risk assessment for addiction helps you and your doctor make the safest, most effective choices for medication. Your doctor will ask about family history and personal experiences with drugs, alcohol, sexual abuse and mental health issues that may influence addiction. • Prescribe the right level of pain relief. Long-acting drugs like OxyContin aren’t the right choice for pain that will be short-lived (after surgery, for example). And even a shortacting, strong painkiller like Tylenol with Codeine isn’t needed if Tylenol alone will suffice. No matter what medication is prescribed, your doctor will recommend the lowest dose that eases your pain. That lessens risk for unpleasant side effects. • Explain the emotional side. Fear of pain worsens your perception of it. Stress and loneliness may also make pain feel worse. Stay ahead of pain by taking medications on a schedule before it escalates. Try coping skills that help you relax and stay connected (see below). • Make sure you understand the plan. Ask your doctor these questions: How long is the pain likely to last? If medication is prescribed, when should I take it? For how many days? What can I do if the pain isn’t well controlled? When should I step down to a lower level of pain relief? When should I stop taking pain medication? • Look beyond medications. Drugs are not the only way to manage pain. Ask your doctor what else might help for your situation. Icing injuries offers good temporary relief. Lower back pain often responds to regular, gentle exercise. Warm showers, water aerobics or limbering up with tai chi, yoga or stretches may be part of a plan to ease arthritis pain. Acupuncture and biofeedback may alleviate pain from various sources. Awareness helps, too. Ask yourself when your pain is worse — in the morning? In the middle of the night? When you’re alone? After certain activities? — And when it’s better. This can help you and your doctor devise ways to handle it.
Build up coping skills
How do you cope with pain? Many people try to numb it with alcohol or drugs. Some overeat. Unfortunately, strategies like these create additional problems. Set a safer course for yourself and be a better role model for children by trying healthier coping skills, such as these: Ask for help. Unhealthy behaviors like substance abuse or overeating are hard to stop on your own. Gain support through groups like Alcoholics Anonymous, Narcotics Anonymous or Overeaters Anonymous. Group or individual psychotherapy can provide much-needed emotional and psychological support and strategies to help you handle chronic pain. Ask your doctor about these options. Support your body. Try to get enough sleep and eat a healthy diet. Reach out. Family, friends and support groups (online or in-person) can help you feel cared for and connected. Let people know how to help you. Stay engaged. Try not to let pain block out the world around you. New interests provide a healthy distraction and may expand your circle of friends, too. Be active. Gentle exercise eases stress, back pain and arthritis pain. Walking, swimming and tai chi are good examples. Relax. Breathe slowly and deeply through your nose, counting up to four as you inhale, and then down from four as you exhale. Do for three to five minutes or longer. Or try tensing and releasing muscles of your body, starting at your toes and moving section by section toward your face. Yoga, tai chi, visualization and meditation are excellent for relaxation, too.
Make your home safe
Never leave prescription painkillers lying around. More than three out of four children, teens and adults misusing these drugs stole or received them from someone else who was prescribed pain medication. Store all drugs safely. Use them only as prescribed. Properly dispose of unneeded or expired painkillers by asking your pharmacy, police department or local trash and recycling program about drug take-back programs. If none is available, the US Food and Drug Administration (FDA) recommends mixing medicines (do NOT crush tablets or capsules) with an unpalatable substance such as kitty litter or used coffee grounds, placing the mixture in a container and disposing it in your household trash to avoid harm to others. For more information visit the drug section of the FDA’s website.
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Questions & Answers
The transtheoretical model defines five stages a person goes through to change unhealthy behavior, such as smoking, drug abuse and overeating. According to the psychologists that developed the model, a person must go though each phase without skipping in order to realize its benefits. Yet, one size does not fit all. The length of time and the activities in each phase depends on each individual. Precontemplation
A person has no conscious intention to make a change; there is lack of awareness of a problem. Example: “Obesity runs in my family. There’s nothing I can do about it.”
2. Can the brain differentiate between good habits and bad habits? Habits develop because of repetition. They are normal and allow us to do many things without much thought. This frees up the brain to do other things. Both good and bad habits can form in this way. Habits that are enjoyable can trigger the brain pleasure centers.
There is increased awareness that the behavior is a problem and a person is thinking about changing. Example: “I know my weight is causing me medical problems, but I’m too busy to worry about it now.” Preparation
The individual is making realistic plans to change. Example: “I made an appointment with a dietitian to help me choose healthier foods.” Action
The changed behavior is in place, and the person is practicing alternatives to avoid unhealthy behavior. Example: “Stress is a big cause of my overeating. I practice yoga now to reduce my stress.”
3. Does age impact the success of changing unhealthy behaviors? While it may be a bit easier for children to change unhealthy behaviors, anyone at any age can change unhealthy behaviors. However, the reasons for change may differ by age. For instance, a study found that smokers over the age of 65 quit smoking primarily due to a major health condition, while younger smokers reported cigarette cost and tobacco odor as reasons for quitting. 4. Why is it important to know your triggers? Habits can be linked in our minds to certain people, places and activities. Avoid going places where you’ve usually smoked. Stay away from friends and situations linked to problem drinking or drug use. You can develop a plan to avoid the triggers to bad habits.
Contemplation
Relapse
David C. Henderson, M.D. Psychiatrist Massachusetts General Hospital
PROGRESS
1. If a person has difficulty changing a bad habit, does that mean that he or she is weak? No, it does not mean he or she is weak. Pleasure-based habits may release a chemical in the brain called dopamine. This chemical strengthens the habit and makes it difficult to change. When he or she is not engaged in the habit, dopamine creates a craving to do it again.
A change of habit
Maintenance
The new behavior has been practiced for at least six months. Example: “To prevent a relapse, I avoid restaurants that offer buffets.”
Counselors warn that relapses are common and that people recycle through some stages several times. Instead of viewing a relapse as failure, however, consider it an integral part of the change process. For more information on the transtheoretical model, visit www.umbc.edu/psyc/habits/content/the_model/index.html.
5. Is there a connection between stress and unhealthy behaviors? Yes, there is a strong connection to stress and unhealthy behaviors. In general when people experience stress, they look for solutions to reduce the stress. Some may find a solution in tobacco, others in sugar. As mentioned before, some habits may release dopamine and activate the pleasure center of the brain, and thereby temporarily reduce stress. 6. If a person is trying to stop smoking and lose weight, is it best to tackle both problems at the same time? It’s best to focus on one bad habit at a time to increase success. One way to kick bad habits is to actively replace unhealthy routines with new, healthy ones. If you can replace a bad habit, even drug addiction, with another behavior, like exercising, it may work for some people, but not everyone. These alternative behaviors can counteract the urges to repeat a behavior to smoke or overeat. A modest change in lifestyle such as improving food selection and adding exercise, can allow a person to use proven techniques to stop smoking (such as nicotine replacement or medications that reduce the urge to smoke or decrease the pleasure associated with it) and avoid turning to overeating to activate those pleasure centers. However, implementing a crash diet while trying to stop smoking may not be effective. 7. Is going cold turkey the best way to change an unhealthy behavior? No, this is unwise. The brain will crave the dopamine associated with the unhealthy behavior. If it is a drug addiction, there can be dangerous withdrawal symptoms as well. Willpower can be temporarily drained, which can make it harder to resist the behavior the next time around. Practicing different types of self-control can strengthen your self-control. So more than one strategy to eliminate the behavior may be helpful. 8. How does a parent influence healthy behavior in a child? Parents are the key in addressing unhealthy behaviors in their children. Parents however, have to walk the walk. Healthy food choices and active lifestyle in parents can model for children and help them make healthier choices. 9. Is there a point at which it becomes impossible to substitute an unhealthy behavior with a good one? No, but it may take numerous tries to get it right. 10. When should someone seek professional help to change behavior? One should seek professional help when numerous unsuccessful attempts have been made to change the behavior. Or when the consequence of the behavior is jeopardizing one’s health, mental health, family and social relationships, employment and other factors in a person’s life. The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician.
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Habits, continued from page
cal conditions that could profit from regular liquor in the house for visitors, but vow not exercise — diabetes, high blood pressure and to drink. A person practicing self-control, on a steadily increasing waistline. the other hand, vows not to not keep liquor This awareness still did not spur an in the house at all. action plan, but an A1C of 9.1 did. The A1C People with emotional disorders, such as test measures how well the body has constress and anxiety, have an even more difficult trolled glucose, or blood sugar, for the past problem changing behavior since stress is two to three months. In diabetics a reading often the cause of that behavior. Dr. James below 7 is desirable. “That was a wake up Jackson, an African American professor of call,” Wright admitted. psychology at the University of Michigan, It was a wake up call for his doctor as found an unexpected paradox in recent well, who referred him to Body By Brandy Fitresearch. ness Center & Day Spa in Roxbury. Exercise He discovered that some blacks adopt was now a prescription rather than an option. certain behaviors, such as smoking and According to Wright, he is well within drinking, to cope with the action phase environmentally proof his change. He duced stresses. While exercises four days those are unhealthy a week. Occasionbehaviors, they noneally, he misses a theless contribute to day, but tries not to. lower rates of mental “It makes it harder disorders among the next time,” he blacks, according to admitted. Jackson. However, that For Wright, is a high price to pay the gym is unavoidfor a positive outcome. able — it is located That practice plays between his work a significant role in and his home. In higher rates of physical this phase it is health problems. important to be These results may clear about his mopartially explain the tivation. He is. He Although Stephen Wright is familiar with higher incidence of needs to lower his the transtheoretical model of change, it obesity and the lower A1C and his BMI. rates of exercising and was still difficult to apply the model to A support syschange his behavior. Wright now works out healthy eating among tem is also essential at Body By Brandy Fitness Center & Day minorities. to keep him on Spa in Roxbury. (Ernesto Arroyo photo) Stephen Wright, track. That support 58, is well versed in TTM. He learned about comes from his wife, who is also a member it while working with drug abusers. But he of the gym. They work out together at times. is also quick to point out that teaching these Wright has not hit the “maintenance” changes and applying them personally are phase of change yet. According to TTM two different issues. a time period of six months or more is It wasn’t drugs that caused Wright prob- needed to reach that level. He has three more lems. His predicament stemmed from lack months to go, but so far so good. of exercise. Wright said that he has exercised There are a couple of other habits off and on throughout life, and played sports Wright says he must work on. He’s a in high school. smoker, but he’s taking it one habit at a time. In recent years, exercise has been mostly Wright has a definite plan. He knows that off. Advancing years, a demanding job and exercise can add years to life. He also said family responsibilities began to intrude on his that he recognizes the difficulty in making time to work out. It’s not as though he didn’t behavioral changes to lifestyle. know the medical benefits of exercise. He “I need a few years,” he said. “It’s hard did. And he also knew that he had three medi- but doable.”
Take a deep breath Chronic stress can cause bad habits, such as excessive smoking and drinking and compulsive overeating — all behaviors that are detrimental to one’s health. The relaxation response is one technique that has been found to reduce stress. The following is the generic technique of the relaxation response taught at the BensonHenry Institute at Massachusetts General Hospital: 1. Pick a focus word, short phrase or prayer, such as “peace.” 2. Sit quietly in a comfortable position. 3. Close your eyes. 4. Relax your muscles, progressing from your feet to your calves, thighs, abdomen, shoulders, head and neck. 5. Breathe slowly and naturally. 6. Don’t worry if thoughts intrude. Dispel them and continue. 7. Repeat your focus word, phrase, or prayer silently to yourself as you exhale. 8. Continue for 10 to 20 minutes. 9. Practice the technique once or twice daily. Good times to do so are before breakfast and before dinner. For more information visit massgeneral.org/MindBody
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Break bad habits Avoid temptations
If you always stop for a donut on your way to work, try a different route. Keep fatty foods, cigarettes, alcohol and other tempting items out of your home.
Replace unhealthy behaviors with healthy behaviors Exercise, practice a favorite hobby or spend time with family.
Prepare mentally
If you can’t avoid tempting situations, prepare in advance. Plan how to handle temptations and mentally practice what you plan.
Enlist support
Ask friends, family and co-workers to support your efforts to change.
Reward yourself for small steps
Give yourself a healthy treat when you’ve reached a small goal or milestone. Source: Spring 2012 NIH MedlinePlus
Booker, continued from page 1
Another tool Christian recommends is an “appreciation journal” in which a days a week will in all probability end person writes down every day things he in failure. “Try one day a week,” she or she enjoyed or achievements no matadvised. When you’ve mastered that, ter how small. “People tend to be more try two. optimistic when they use the journal,” People tend not to recognize sucshe said. cesses — they’re looking at too big Booker had another sort of motivaa picture. “We have to learn to pat tional spark — an anti-smoking TV spot ourselves on the back,” she said. “We by the Boston Public Health Commisneed to feel good about ourselves. The sion. An actress warned of the dangers of smallest positive change is a step in the smoking; a toll-free number (800-QUITright direction.” NOW) was listed on the screen. “I was Christian is smoking at the a student of the time,” said Booker. Benson-Henry “I got right up and Institute at MGH made the call.” which espouses the That was Feb. mind/body theory. 26, 2011 and she Mind/body medicine has not looked teaches individuals back. how to take control She admits of their lives, use that she needed a their own healing bit of help to stay power to reduce on track. That help stress and other negacomes in the form tive behaviors and of her son, who thoughts, and thus quit the day before maintain or regain she did. They lean health. on each other to The relaxation prevail. Nicole Christian-Brathwaite, M.D. response, which is According to Resident in Psychiatry pivotal to mind/body Booker she did not medicine, adopts deep Massachusetts General Hospital change too many breathing and repetihabits. She still tion of a sound, word or phrase while associates with friends who smoke. She setting aside intruding thoughts. Sudallows smoking in her house. She has den urges for unhealthy behavior, such made a few accommodations, though. as a cigarette, can be put aside by deep “I don’t drink coffee anymore,” she breathing. said, acknowledging the camaraderie Christian described the pairing of the of caffeine and nicotine. And she takes relaxation response to mindful eating, a a brandy only every once in a while. technique which forces the eater to delibAlcohol is another trigger. erately pay attention to what and how one So far so good. Her coughing eats. It involves eating slowly, savoring stopped a month after she stopped every morsel while absorbing the texture smoking. She now has money for and smell of the food. Mindful eating, ac- other uses. She knows she has saved a cording to Christian, enables a person to penny here and there — and added an eat more slowly but feel full on less food incalculable number of healthier days — a boon to those trying to lose weight. to her life.
Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.