Changes to Health-Related Beliefs: Difficult and Slow

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My friend was worried and annoyed. Her husband of many years was having digestive issues (aka constipation) and she knew why. “He refuses to eat anything with fiber,” she told me. “He has this thing about not eating any carbohydrate, even something like bran cereal, because he thinks it will affect his memory. So he eats only protein, fat, and maybe some lettuce occasionally. And instead of getting fiber from his food, sometimes he takes a fiber supplement. I keep telling him that he should eat a normal diet, but of course I am his wife so he won’t listen to me.”

Her words echoed in my head when I came across a recent post by Dr. David Johnson, M.D., a professor of gastroenterology. Was he listening to our conversation before he wrote about gastrointestinal changes caused by what he terms our “Western diet”? He blames the high intake of protein and low intake of high fiber foods as promoting a reduction in the diversity of gut microbes, i.e., an increase in chemicals associated with inflammation such as cytokines and slow motility.

His recommendation for a food plan that we should follow is not novel; indeed it is one that is mentioned whenever anyone talks about a sensible diet, not just for weight loss but for sustained health. It is, of course, the Mediterranean diet. Even though the nations bordering the Mediterranean Sea are culturally diverse and may have their own unique food ways, they all tend to be high in fiber, and low in animal protein and saturated fat. The consumption of vegetables, fruits, unsaturated fat, and low-fat dairy products (think yogurt) is higher compared to our typical Western diet.

But most important to this gastroenterologist is the high fiber content of the Mediterranean diet. He mentions the two forms of fiber: soluble, which gets digested, and insoluble, which moves through the intestinal tract. The latter promotes water absorption and gut motility, particularly in the colon.

I can and will send Johnson’s article to my friend, but wonder if her husband would read it and possibly be sufficiently convinced to alter his diet? As she explained, his avoidance of many of the foods on the Mediterranean diet verges on obsessive. This was in part influenced by the articles he read several years ago when he decided to stop eating carbohydrates, all dairy products, and any starchy vegetable. He is convinced that doing otherwise will decrease his longevity, lead to cognitive deficits, and cause him to gain weight.

But how to convince him to change? Indeed, how does one convince another to alter behavior because continuing it may lead to health issues like obesity, or nutritional deficiencies? A lead article in this most recent issue of The New England Journal of Medicine addresses this problem as related to the health effects of climate change. How can a health care professional translate statistics about a situation that might affect health so that the patient will respond by changing/improving behavior?

One answer is to put the information in as easy-to-understand terms as possible; relieving the cognitive burden is what this is called by the authors. Another, of course, is to make the information relevant to the patient, but not based only on anecdotes. If one relates the information about how a particular behavior improved the health of one individual, the patient may dismiss it as not being relevant to his or her situation. Rather, my friend’s husband should be told by his doctor, for example, that “2 out of 3 patients following a grain-free diet had gastrointestinal problems similar to his, and when they ate more fiber, their gut health improved.” Maybe such an approach would cause him to change his food habits.

However, simply communicating information about how to improve one’s health, be it through a better diet, more exercise, more sleep, or even stress-reduction techniques, is not always, or even often, effective. If it were, everyone would be normal weight, fit, not sleep deprived, and relaxed. One reason why presenting this information fails to change behavior is that the patient doesn’t seem to recognize the negative health consequences of his or her current behavior. It is easy to ignore the relationship between eating just another couple of cookies, going yet another day without any physical activity, staying up late at night, or forgetting to have some private, relaxation time every day and being obese, unfit, sleepy, and stressed. And lecturing the patient, or my friend’s husband, about this relationship may fall, as the saying goes, on deaf ears.

An alternative approach is to bargain with the patient or husband. “Try this: try eating some high fiber carbohydrate for a week, or commit yourself to walking 20 minutes every day for a week, or turn off the lights before midnight for a week or find time to relax.” The time commitment in which to carry out these changes should be short, say a week or two. And the individual must be reassured that should he or she choose to return to the former less healthy lifestyle after a week or two, there will be no criticism.

If a positive effect from the small change in behavior does occur, this may be more convincing than statistics, reviews, general arguments, and scientific articles. Of course, maintaining the change is not automatic. Keeping a diary during the week of change is useful, especially if the individual is likely to revert back to the former behavior after the week is up. Seeing a record of the positive health effects of the small changes may be an inducement to continue the new behavior, or perhaps try again after a week or two.

And as the 19th-century writer Alexandre Dumas (Count of Monte Crisco, The Three Musketeers, The Man in the Iron Mask), said, “Nothing succeeds like success.”