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Kicking the habit: The Fix interview with Charles Duhigg

There’s a diagram in every chapter of the book that is a simple line drawing of a habit loop. Can you explain what that is?

What we know from neurological experiments is this: there’s a cue, which is a trigger for a behavior. Then the routine is the behavior itself. And finally, there’s a reward. When people think about habits, they tend to focus on the routine or the behavior. But what we’ve learned is that it’s actually the cues and rewards that have this huge influence on how habits unfold and how to change them.

Alcoholics Anonymous will deliver a reward that’s similar to drinking. AA encourages people to develop alternative habits that help them stop drinking.

How does the AA methodology fit into the “cue, routine, reward” cycle?

When AA first emerged, what was notable was that it had a relative lack of science in its background. There wasn’t a lot of scientific rigor, which raises the question as to why AA has been so effective. In the last decade, researchers have started looking at AA seriously for the first time. The conclusion they’ve come to is that AA works because it creates a new routine for the habit loop.

When people change their habits, they need to find a new behavior that’s triggered by the old cue. If you used to have a bad day and come home from work, that’s the cue. Then you’d go to the bar; that’s the routine. And then you’d have a relief of tension; that’s the reward.

Alcoholics Anonymous uses a similar cue and reward. But instead of going to the bottle, they suggest you go to a meeting, where other members will try to guarantee you can have an emotional, cathartic experience. You’ll be invited to talk about your problems. Alcoholics Anonymous will deliver a reward that’s similar to drinking. AA encourages people to develop alternative habits that help them stop drinking.

You write about how AA isn’t just about changing habits—you argue, in fact, that habit replacement alone will eventually fail. The x factor, you say, is faith. Can you explain that?

There are some basic questions about Alcoholics Anonymous. Why is AA so effective? Why can some people curb their habitual dysfunctions around alcoholism and addiction but then relapse during stressful periods? Why do some people experience stress acutely and others don’t?

One of the findings, when looking at these inflection points, was that the people who made it through had some type of faith or belief in the process and the program and in their own ability to avoid relapse. There’s a huge element of faith. The group experience is designed to allow people to practice faith and belief.

Researchers believe that being able to believe in yourself and your ability to withstand temptation is like a muscle. You have to practice it to get good at it. AA gives you an opportunity to practice [flexing that muscle]. There’s faith in a Higher Power; faith in fellow attendees; faith in oneself. The theory is, by the time you hit a crisis, you’ve practiced believing in yourself and it’s that much easier to stay committed to [sobriety].

One of the most interesting things you write is that habits can’t be erased—they can only be replaced. That’s obviously important information for someone trying to quit drugs or smoking or eating junk food. What’s the difference between eradicating a habit and replacing a habit?

We know from neurological studies that once you establish the brain circuitry associated with a specific habit, it never goes away. It’s the nature of how neurology works. Behavior is represented in our brain by a neural pathway. As the behavior becomes more automatic, the pathway becomes thicker, which makes it easier to perform.

If you stop doing that behavior, the pathway doesn’t go away; it just goes dormant. The next time you are in an environment with the same cue and reward, the pathway will be reactivated. You can’t extinguish a habit. The best you can do is hope to avoid the specific cues and reward. [If you’re trying to replace a bad habit with a healthy one,] the best thing to say is not “I’m going to stop doing x”; it’s to say, “I’m going to do y instead,” in a way that responds to a similar cue and provides a similar reward. You want to essentially say, “I’m going to overwrite that old pathway.” That’s more much effective.

When you were writing about sweeping institutional changes at the multinational, multi-billion-dollar company Alcoa, you talked about keystone habits. What is a keystone habit, and what are the effects of changing a keystone habit?

Keystone habits relate to the idea that some habits have more power than other habits. They set up a chain reaction. For example, when people start exercising, they tend to start eating better; it spills over. People who exercise also have a higher tendency to use their credit cards less, to procrastinate less at work, and to do their dishes earlier in the day. That makes less sense, though, because going running doesn’t seem to have anything to do with how frequently you use your credit card. But what researchers think is that exercise habits are keystone habits: they spill over into other types of patterns because there’s something about some habits that change a person’s self-image. Someone might think, “The type of person who exercises habitually isn’t the type of person who spends money senselessly.” And by targeting keystone habits, you can create a disproportionate change in your life. Other things begin to change automatically.

There’s also a fascinating chapter about Tony Dungy, the football coach. You describe how he trained his players to “react” habitually to everything they saw on the field rather than making discrete decisions in every situation. How much of building healthy habits is training yourself to react to specific stimuli instead of actively making choices?

A habit is always a reaction. It’s always triggered by a cue. There’s always a reactive element as opposed to a cognitive, proactive element. You can make choices to develop certain habits. I think that’s what Tony Dungy did. He said to his guys, “You’re going to have habits [no matter what], but I just want to give you better habits: habits we design, rather than habits that emerge on their own.”

People can do the same thing. They can design a particular habit and then rely on that to shape their life.

In one chapter, you interweave the story of a woman who lost hundreds of thousands of dollars to casinos with that of a man who killed his wife while sleepwalking. You argue that she ought to be held financially responsible for her losses because she was aware that she had developed a harmful habit while the sleepwalker had no awareness that he was capable of killing in his sleep, and thus shouldn’t be held responsible. Can you explain that?

The more we learn how to change habits, the more that confers responsibility upon people to change their habits once they are aware of them. Ignorance is a defense up to a point, but once you learn about and understand yourself, and once society gives you more and more tools [for change], you have a responsibility to take advantage of those tools. The difference between the murderer and Angie is that the sleepwalking murderer had no idea he might end up killing someone. He was devastated by the fact that he had committed this crime. He’s never forgiven himself for it. But when it comes to Angie Bachmann, she could anticipate that she was going to gamble all this money away. She had even quit gambling once before. She deserves our sympathy; it wasn’t her fault alone. But at the same time, once you know you have a problem and that there are programs to address that problem, you have a responsibility to address it.

Nina Emkin holds degrees from UCLA and Sarah Lawrence and has written for The Fix about relapse and coming out as an alcoholic, among many other topics. She lives inLos Angeles.

New study: This is how you “keep it off”

Just in time for your “Christmas in July,” a new study published in the prestigious journal JAMA (free full text here) tells us how we should eat to help “keep it off” or maintain our energy expenditure in a healthy way. As many people can attest, (temporarily) losing weight can seem easier than maintaining that weight loss. This is because the body acclimates to weight loss by reducing its energy expenditure (kinda like conserving water in times of drought). This new study looked at how different types of diets affect energy expenditure after a period of weight loss. So, let’s get into the details.

What did they do? They recruited 21 folks who were overweight or obese

Study design (Fig 1 from the paper). Click on the figure for larger view.

(mean BMI of 34.4) and between 18-40 years old. They had them go through a 4 week baseline period followed by a 12 week weight loss program to achieve at least a 10% weight loss. Following the weight loss, there was 4 week weight stabilization period before participants tried three types of diets that were matched on caloric content for four weeks each in a randomized order. The main outcome measure was resting energy expenditure, with secondary measures of total energy expenditure, hormone levels, and metabolic markers.

So what did these three maintenance diets look like? The three diets included a low-fat diet (what most people will tell you to eat - whole grains and lean meats); a low glycemic index diet (avoiding foods that spike blood sugar levels and insulin release); and a very low carbohydrate diet. This figure shows the major differences between the three diets using data from the paper.

Differences between the three diets (adapted from Table 1 of the paper). Click on the figure for larger view.

What did they find? First, as expected, losing weight resulted in reductions in resting and total energy expenditure (see below). However, eating the very low carb diet resulted in the smallest decreases in energy expenditure from the pre-weight loss baseline. And (this is almost too good to be true), these differences in energy expenditure were not due to differences in physical activity. In fact, while on the very low carb diet, folks had higher energy expenditure in spite of engaging in less physical activity!

Energy expenditure and physical activity (adapted from Table 3 of the paper). Click on the figure for a larger view.

Second, what happened to all of the markers that we might worry about when one is eating the very low carb diet that is high in saturated fat and cholesterol and low in fiber? Well, the results below show that insulin sensitivity was best on the very low carb diet, HDL (good) cholesterol was best on the very low carb diet, triglycerides were best on the very low carb diet, and systolic blood pressure was not best, but markedly improved relative to pre-weight loss on the very low carb diet. So far, so good…

Biomarkers on the three different diets (adapted from Table 3 of the paper). Click on the figure for a larger view.

But of course, nothing is perfect and the authors note that C-reactive protein (a marker of inflammation) tended to be higher with the very low carb diet and urinary cortisol (a marker of stress) was higher on the very low carb diet. Nonetheless, leptin levels were quite improved and the authors note that participant ratings of hunger and well-being did not differ between the three diets.

Additional biomarkers on the three diets (adapted from Table 3 of the paper). Click on the figure for a larger view.

So, what do we take away from this? This study has several strengths in that it included an initial weight loss phase with baseline assessments, the presentation of the diets was randomized, and the study used a crossover or within-subjects design so each person could serve as his/her own control. However, there are also several limitations, which include the relatively small sample size (N=21) and the relatively short duration of the test diets (4 weeks). It would be interesting to see longer-term results in a larger sample of people, but it is also always easier to design a perfect study than to conduct one.

As for the conclusions, we’ll leave it to the authors:

“In conclusion, our study demonstrates that

  • commonly consumed diets can affect metabolism and components of the metabolic syndrome in markedly different ways during weightloss maintenance, independent of energy content.
  • The low-fat diet produced changes in energy expenditure and serum leptin that would predict weight regain. In addition, this conventionally recommended diet had unfavorable effects on most of the metabolic syndrome components studied herein.
  • In contrast, the very low carbohydrate diet had the most beneficial effects on energy expenditure and several metabolic syndrome components, but this restrictive regimen may increase cortisol excretion and CRP.
  • The low–glycemic index diet appears to have qualitatively similar, although smaller, metabolic benefits to the very low-carbohydrate diet, possibly without the deleterious effects on physiological stress and chronic inflammation.
  • These findings suggest that a strategy to reduce glycemic load rather than dietary fat may be advantageous for weight-loss maintenance and cardiovascular disease prevention.
  • Ultimately, successful weight-loss maintenance will require behavioral and environmental interventions to facilitate long-term dietary adherence.”

And, that’s what we do here at Dan’s Plan. Cheers to these authors for a really great and important study.

Have a Happy (and safe) Fourth of July folks!

Reinforcement in action and good public policies

Earlier this week, we wrote about behavioral principles including positive reinforcement, negative reinforcement, and punishment. Today, we bring you two examples of folks putting those principles into action.

1) The first example comes from my own town of Bloomington, IN. When we first moved to Bloomington, we were surprised on garbage day when we saw that everyone’s trash had been picked up except ours! Not quite sure whether this was some sort of a hazing for the new folks (we do live in a college town, after all), we asked the neighbors what was going on. Their response, we didn’t use a trash sticker.

In Bloomington, each 35 gallon or 40 pound can, bag, or piece of trash must have

A sheet of trash stickers from the city of Bloomington, IN

a $2 trash sticker attached to it. The stickers (see right) can be purchased at any grocery or hardware store. As such, Bloomington residents are essentially punished for generating garbage.

Now, we’ve talked about some of the limitations of punishment and those limitations apply here as well. Some people will try to evade the punisher by dropping off their garbage in dumpsters around town. However, the trash stickers are only part of the story…

The city also picks up recycling “for free.” (note: there is obviously a cost for picking up recycling, but the resident does not endure the “pain of paying” with each bin put out to the curb). The beauty of the policies is realized when they are paired together. Garbage generation is punished at the same time that recycling is reinforced. Together, the two policies set up a strong incentive for individuals to “convert” as much waste as possible from trash that must be paid for at the curb to recycling that is picked up for free. Very clever (and effective) indeed (note: if you look carefully, these contigencies are actually stated on the stickers - another smart design!).

2) The second example comes from the city of Washington DC (although similar programs exist in California, Maine, Massachusetts, and Rhode Island). In DC, the Unity Health Care Upper Cardozo Clinic distributes “fruit and vegetable prescriptions,” which provide $1 per family member per day to be spent at Farmers Markets ($112 per month for a family of four). This clearly helps reduce the cost of buying fresh and local produce, and is a good incentive in its own right. Folks who have studied the programs have reported that:

  • 66% of people ate more fruits and vegetables as a result of the program and 38% improved their body mass index
  • The program also brought new customers to farmers markets. More than half of families that received fruit-and-vegetable prescriptions had never, or rarely, been to a farmers market

So, think about how providing these vouchers or reinforcers contrasts with

Example of a farmers market voucher

punitive or punishing policies such as taxes or bans (on soda pop, etc.). It is not to say that those policies are not effective at reducing the consumption of whatever is taxed or prohibited, but when implemented alone, they do not necessarily result in folks engaging in alternative behaviors such as buying fresh, local produce.

And it doesn’t end there. There were other effects associated with providing incentives for folks to go to the market. From the Washington Post article: “Anecdotally, the program is inspiring families to embrace other aspects of a healthful lifestyle, Lambke says. One family got friends to join the program. Another tried out a new walking trail. ‘The best quote was a kid who came back to me and said that the thing he liked about the program was that his parents played with him more,’ Lambke says. ‘Oh, man. That was awesome.’”

But is it cost-effective? In Lambke’s opinion, “They come back once a month. It’s not a huge amount of money. In the broad spectrum, when we think about how much we spend on Lipitor every year, it is a cheap, cheap intervention. And arguably more effective.”

I couldn’t have said it better myself - have fun at your farmers markets this weekend folks!

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