The Secrets to Behavior Change: Principles and Practice

by Natalie Digate Muth, MD, MPH, RDN, FAAP on May 07, 2015

Let go of the need to be an “expert.” Truly listen to clients and help them create small miracles in their lives.

The ongoing and stubborn health epidemic in the United States, combined with healthcare reform and a growing body of behavior change research, has sparked a revolution. It has become clear that “expert advice” does not translate into behavior change for people who are not ready to change. After all, despite doctors’ orders, nearly a third of prescriptions are left unfilled (Tamblyn et al. 2014). Despite federal dietary guidelines, the average American’s food intake lines up with MyPlate recommendations on only 2% of days (NPD Group 2011). And even though physical activity guidelines are clear, 80% of Americans do not meet them (CDC 2013a). Americans spend $60.5 billion on weight loss each year (Marketdata Enterprises 2013), but over two-thirds of Americans over age 20 struggle with excess weight.

As the health conversation shifts from expert pontification to a collaborative, person-centered approach, fitness professionals can increase their impact and relevance by learning how to help clients make meaningful and lasting behavioral changes. The following primer highlights key principles, explains how to develop the skill set to translate them into action, and presents a case study that uses the “5 A’s” (Ask, Assess, Assist, Advise and Arrange) as a framework to put it all together.

Eight Key Behavior Change Principles

Understanding human behavior, and how to change it, is a robust and complicated science with numerous theories. Many scientists spend their entire careers trying to “unpack” and describe the subject. Here are a few of the most practical principles that every health and fitness professional should know:

  1. Changing ingrained behaviors is hard. Behaviors are rooted in habits, and habits are difficult to break. After all, the brain forms habits as “shortcuts” so we can focus attention elsewhere. Many clients’ unhealthy behaviors have been ingrained for decades. In some cases, it may be more effective and enjoyable to create new habits rather than make drastic changes to break old ones. In fact, B.J. Fogg, PhD, an experimental psychologist at Stanford University and founder of the Tiny Habits® program, advocates just that. He has found that a trigger (an existing habit such as brushing your teeth) plus a very small version of a wanted behavior that occurs after the trigger (a push-up after brushing your teeth) plus instant celebration (“I rock”) is an effective—and not overwhelming—way to create a new habit. To learn more about this method, visit http://tinyhabits.com.
  2. Effective interventions are tailored to a client’s readiness to change. A client who has never considered changing, but is being pushed by others to do so, may benefit from behavior modification information in the sense that it may lead to contemplation. However, don’t expect the information to suddenly compel the person to act.

    Consider a smoker. Most smokers know that smoking is bad for them and is a leading cause of cancer. However, repeatedly sharing this information is not likely to make someone quit, especially if the smoker feels that the immediate benefits outweigh the risks. But over time, this information may sink in and compel the person to begin thinking about change. The sidebar “Tailoring a Behavior Change Intervention” shows you how to use a readiness ruler to assess a client’s openness to change and how to tailor an intervention accordingly.

  3. The old methods rarely work. It’s becoming common knowledge that simply providing nutrition information or exercise guidelines to people who are not already motivated to make a change is not effective. In fact, when asked what one tip he would share about behavior change, William R. Miller, PhD, a psychologist and cofounder of Motivational Interviewing, replied by email: “I suppose it would be that unhealthy behavior is seldom due to a knowledge deficit. What smoker doesn’t know the risks? People get stuck in ambivalence about behavior change, and the helper’s ‘righting reflex’ of telling them what to do is unlikely to make much difference. Change is promoted by calling forth people’s own motivations for change.”

    If you have to talk someone into change, any results will be fleeting. On the other hand, someone who is in the midst of change (and already committed) may benefit tremendously from information or expert advice. The best way to proceed is through an elicit-provide-elicit approach (Miller & Rollnick 2012):

    • Elicit: Ask open-ended questions to understand the client’s current grasp of the topic.
    • Provide: Ask permission to share information. If the answer is yes, make the information highly relevant to the client.
    • Elicit: Check back in with the client to make sure he understands the information.
    Using this method respects the key principles of adult learning, which state that adult learners need to feel that information is relevant, practical and based on previous knowledge (Knowles et al. 2011).
  4. Motivational interviewing is highly effective for people who are ambivalent about change. Motivational interviewing was first described more than 40 years ago, when it was used and studied as a tool to help alcoholics quit drinking. Since then, its efficacy with regard to a wide range of behavior changes has been proven through hundreds of scientific research studies (reviewed in Miller & Rollnick 2012). Without a doubt, this communication approach helps people who are ambivalent move toward change. Fitness professionals who gain some degree of proficiency in motivational interviewing will see immediate value. See the sidebar “An Introduction to Motivational Interviewing” for more.
  5. When a client argues against change and you argue for it, the client is even less likely to change. This principle is from motivational interviewing, but is so important that it warrants additional discussion. When trying to convince a person to change, it’s natural to want to make a strong, persuasive case. However, this approach triggers a defensive reaction, prompting the client to defend her position and strengthen her resolve not to change. By contrast, evoking arguments for change from the client can be helpful. As Miller and Rollnick state: “Most simply put, evoking is having the person voice the arguments for change. Although the righting reflex is to voice these arguments oneself, it can be counterproductive. People talk themselves into changing, and are commonly disinclined to be told what to do if it conflicts with their own judgment” (Miller & Rollnick 2012).
  6. Nudges add up. Brian Wansink, PhD, of Cornell University, has published groundbreaking research on behavior change, mostly demonstrating how small environmental changes can lead to big behavioral changes. For example, when health conference–goers ate at a buffet with healthier foods at the front of the line and less-healthy options at the back, they ate 31% fewer less-healthy items than conference-goers who ate at the same buffet when healthier foods were at the end of the line (Wansink & Hanks 2013). Wansink refers to this environmental redesign as a “nudge.”

    As a fitness professional, you can put this nudging principle into effect in two ways. One is to help people rearrange some of their basic behaviors and practices; for instance, suggest placing fruits and vegetables in easily visible containers front and center in the refrigerator. Another is to provide gentle nudges to spark change; send a quick text message to check in and see how a client’s day is going, for example.

  7. Environmental factors are more powerful than individual choices. The bigger picture must be included in any effort to help someone change. Environmental factors are often referred to as “social determinants of health” and include things like housing, transportation, social networks, food security, education, and access to health care. A key aim is to make the healthy choice the easy choice. Fitness professionals can help their clients and communities by becoming involved in local advocacy efforts to make healthy food more widely available and affordable. Another example is to create or support efforts for active transportation and for built-in physical activity opportunities in schools and workplaces.
  8. You can’t make someone change, but you can help bring forth their own motivation to change. No matter how badly you want it, you can’t make someone else change. However, if you have a solid understanding of behavior change principles and a basic understanding of how to put these principles into action, you can draw out a person’s internal motivation to change. What comes next is powerful and lasting.

Key Skills for Health and Fitness Professionals

Just as receipt of health, nutrition or fitness information rarely translates immediately into a sustained behavior change, knowing key behavior change principles is not the same as developing the skill set to apply them. In fact, it takes a lot of practice to become proficient at coaching behavior change. To put the eight key behavior change principles into action successfully, it is essential to develop five skills:

  1. Learn and practice good listening skills. This is much harder to do than it sounds, and fitness professionals get little to no training in it. One useful pneumonic device for developing this skill is OARS: open-ended questions, affirmations, reflections and summarizing.
    • Open-ended questions can’t be answered with yes or no. They typically start with words such as “What . . . ,” “How . . . ,” “Tell me more about . . .”
    • Affirmations endorse and encourage a client’s successes. For example, if a client makes a positive change, an affirmation acknowledges it: “You’re getting strong! Those push-ups looked easy today.”
    • Reflections restate what you heard the client say. Reflective statements may begin with “It sounds like . . .”: “It sounds like you are frustrated because you feel you are working hard but not getting the results you want.”
    • Summarizing is similar to reflection, but instead of reflecting on one or two statements, summarizing reflects on a longer conversation. For instance: “We talked a lot about how you have gained significant strength over our past 2 months working together, but because your weight has not changed, you feel the program isn’t working and would like to make some changes.” Even if you are way off, the reflective statement will prompt the client to clarify and elaborate.
  2. Develop empathy. Empathy is the ability to imagine what it feels like to be the other person. Continually developing and demonstrating empathy is necessary when working with people who are trying to change their behaviors.
  3. Unlearn the “righting reflex” (aka the “expert approach”). While listening skills are not usually taught to fitness professionals (or most other health professionals), developing a sense of expertise is rewarded and encouraged. When working with clients who are ambivalent about change, it’s important to resist the urge to provide “the perfect solution.”
  4. Apply adult learning principles when sharing information. Adult learners retain and act on information best when they are motivated and the information is necessary to know, autonomy-preserving, based on prior knowledge and experiences, ready to be received and problem-centered (Knowles et al. 2011). Respecting these principles is key when informing your clients.
  5. Build in accountability. A coaching intervention with no plan for follow-up or accountability is unlikely to be sustained. That does not mean clients must always be accountable to you, but you should help clients develop systems that will keep them accountable to themselves and/or others.

With a client’s permission, record one coaching session where you practice these principles. The coding tips in the sidebar “How to Tell If You’re Doing It ‘Right’” will help you score your developing skills.

Putting It Together

The U.S. Preventive Services Task Force offers a framework for practitioners to use when coaching or counseling behavior change. The framework translates the key behavioral change principles into action and is referred to as the “5 A’s”: Ask, Assess, Assist, Advise and Arrange.

Consider the case of Steve, a 45-year-old man who was recently diagnosed with prediabetes and advised to see a health coach to help him act on the recommendation to exercise for 150 minutes each week and lose 7% of his body weight. He reluctantly shows up for the first appointment.

  1. Ask if it is okay to discuss the issue in more detail. Use open-ended questions.

    Health coach: Hi, Steve. It’s a pleasure to meet you.

    Steve: Hi. You, too.

    Health coach: So please tell me a little bit about what brings you here today.

    Steve: Well, my doctor told me I have prediabetes and if I’m not careful I am going to get full-blown diabetes and have a higher risk of heart disease, eye trouble, kidney trouble, nerve trouble and an overall terrible life.

    Health coach: Wow, that must have been pretty tough to hear. What do you think about all of that?

    Steve: I’ve got to admit, it shook me up a little bit. But, you know, if I can’t enjoy life, what’s the point? A lot of my favorite things are bad for me. My doctor recommended I see you to try to help me lose weight and get more exercise, but I’ve got to tell you—I’m not sure that I’m onboard with this whole thing.

    Health coach: But you came anyway.

    Steve: I guess so.

    Health coach: In a perfect world, what would you like to get out of our working together?

    Steve: Well, I’m not sure. I guess I’d like to lose the weight and be a little more active in a way that doesn’t bore me to tears and take all of the enjoyment out of life.

    Health coach: I see. Would it be okay if I asked you a little bit more about some of your behaviors to get an idea of where we are starting, and then we can talk more about where we should go, if anywhere?

    Steve: I guess so.

  2. Assess baseline health and fitness behaviors as well as readiness to change.

    Health coach: Tell me a little more about what you eat on a typical day, starting with when you wake up.

    Steve: Well, I wake up around 7:00. I skip breakfast. Eat lunch at about noon. I work a lot, so I usually eat out. Then I snack a bit in the car on the way home. Eat dinner together with the family. My wife is one heck of a cook. I have to admit, we do eat dessert most nights. Then I watch television before going to bed.

    Health coach: I see. And what about your usual physical activity?

    Steve: That’s easy. I don’t do any. At the beginning of the year I went to the gym a couple of times a week. But I haven’t been there in some time.

    Health coach: Does anything stand out to you as something you’d want to work on?

    Steve: You know, I’m not sure I want to do this. I’ve already tried all kinds of fancy diets and workouts and, well, here I am.

    Health coach: I see. So you’re not really ready to make any changes.

    Steve: It’s not that I’m not ready, per se. It’s more that I’m just not sure I have the time to commit to this right now.

    Health coach: Okay. So you’d like to wait, and maybe we can reconnect again in a few weeks?

  3. Advise specific behavior changes based on readiness, and with permission.

    Steve: Yeah, well. You know. I don’t know if I really want to have to come to a specific place and work out around other people or meet with you—no offense. Is there anything I can maybe do at home?

    Health coach: Sure. I can understand that. Since you asked, I would be happy to give you a couple of tips for things to consider at home. Would you like to focus on physical activity, nutrition or something completely different?

    Steve: I’d like to start with my eating. I think I could make some changes there. I know I should be eating breakfast.

    Health coach: So let’s talk about that then.

  4. Assist in setting goals, addressing barriers and securing support. Agree on next steps.

    Steve: I think I could eat breakfast. What do you recommend?

    Health coach: Does anyone else in your family eat breakfast in the morning?

    Steve: Yes. My daughter does. She’s really health conscious. She has a plain yogurt with a little granola and some fruit in the morning. It always looks pretty good.

    Health coach: That sounds pretty good. Healthy, too.

    Steve: Yeah. I should really take some tips from her. I wonder if she would help me to eat a healthy breakfast. Kind of hold me accountable, too.

  5. Arrange for follow-up. Build in accountability.

    Health coach: That sounds like a great plan. Would you like to test that out for the next week or so and see how it goes?

    Steve: Sure.

    Health coach: Would it be all right if I checked back with you in a week, and we can just see how many times you were able to get in breakfast with your daughter?

    Steve: Yeah. That would be nice.

    In this scenario the health coach worked with a client diagnosed with prediabetes who was ambivalent about making changes. The health coach used motivational interviewing techniques, including open-ended questions and reflections, to help the client identify his own motivations and solutions (if he was ready to make them). The health coach also used the 5 A’s to guide the conversation. By the end of the first meeting, the client had decided he would start with something small: eating breakfast in the morning.

The Change Coach

Clearly fitness professionals can play a key role in helping to improve health in their communities. It starts with understanding where clients are at, meeting them there, and then helping them put the pieces in place to translate intentions into action, and ultimately meaningful, lasting behavior change. n

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References

CDC (Centers for Disease Control and Prevention). 2013a. Adult participation in aerobic and muscle strengthening physical activities—United States, 2011 Morbidity and Mortality Weekly Report, 62 (17), 326–30.

CDC. 2013b. National Center for Health Statistics. FastStats. Obesity and overweight. Accessed Mar. 27, 2015. www.cdc.gov/nchs/faststats/obesity-overweight.htm.

Knowles, M.S., et al. 2011. The Adult Learner (7th ed.). New York: Taylor & Francis.

Marketdata Enterprises. 2013. The U.S. Weight Loss & Diet Control Market (12th ed.).

2013. Lynbrook, NY: Marketdata Enterprises.

Miller, W., & Rollnick, S. 2012. Motivational Interviewing: Helping People Change. New York: Guilford.

NPD Group. 2011. New federal dietary guidelines and MyPlate icon are a sharp contrast to what’s actually on Americans’ plates, reports NPD. Accessed Feb. 21, 2015.

www.npd.com/wps/portalnpd/us/news/press-release/pr_111213b/.

Tamblyn, R., et al. 2014. The incidence and determinants of primary nonadherence with prescribed medication in primary care: A cohort study. Annals of Internal

Medicine, 160 (7), 441–50.

Wansink, B., & Hanks, A.S. 2013. Slim by design: Serving healthy foods first in buffet lines improves overall meal selection. PLOS One, 8 (10), e77055.

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About the Author

Natalie Digate Muth, MD, MPH, RDN, FAAP

Natalie Digate Muth, MD, MPH, RDN, FAAP IDEA Author/Presenter

Natalie Digate Muth, MD, MPH, RD is a board-certified pediatrician, registered dietitian, and ACE Health Coach. She is committed to providing evidence-based nutrition and fitness information to health professionals and consumers alike in a way that is logical, practical and directly applicable to readers’ lives. She has authored over 100 publications and book chapters, all which are based on the latest scientific evidence and presented in a manner that is easy-to-understand and apply. She is Director of Healthcare Solutions for the American Council on Exercise (ACE) having written the nutrition chapters for each of ACE’s textbooks, the ACE Fitness Nutrition Manual and Specialty Certification, and recorded several Webinars and online courses. Furthermore, as a spokesperson for ACE, the largest fitness certifying and advocacy organization in the country, she informs broadcast and print media outlets throughout the U.S. on pertinent nutrition and fitness issues. She is author '"Eat Your Vegetables!" and other mistakes parents make: Redefining How to Raise Healthy Eaters'. She presented a similar topic at IDEA World 2009; the video is available for purchase through IDEA. Certifications: ACE, ACSM and NSCA