The Long and Winding Road

Making big lifestyle changes—like switching from junk food to health food—isn't easy. You're more likely to succeed, research suggests, if you think of change as a journey.
 

Roy S. began smoking cigarettes sporadically at age 15 and was hooked by age 18. He first tried quitting in 1979, as a college student. "I lost a $20 bet on that one," he says. Over the years he made three more attempts to quit; all failed.

He prepared better for his last try, in 1992. Months beforehand, he stopped smoking in his car and inside his home, and he timed his quit date so he could use the newly marketed nicotine patch. "But I think I would have been successful even without the patch," he says. "I was tired of nicotine controlling me."

This time, he made good use of the relaxation techniques he had learned in two earlier stop-smoking classes. And as an incentive, he decided to buy music CDs with the money he'd save on cigarettes.

It worked: Roy recently celebrated his 10th tobacco-free year.

His experience is typical for someone making a major behavioral change, says Kathleen Welshimer, an associate professor of health education at SIUC. Be it giving up smoking, overhauling one's diet, or becoming a regular exerciser, she says, research shows that we go through stages on our way to permanent change, and the road is seldom straight or smooth.

"We don't just wake up one morning and say, 'By gosh, I'm gonna eat a low-fat diet from now on' and achieve success. It usually takes multiple tries," says Welshimer. "As we move toward success there are cognitive and practical skills we need to develop. We have to see things a different way, do things a different way. At each stage there's homework we have to do to move us along."

Much early research on stage-based behavioral change was done with addictions, such as smoking or drug abuse. With addiction, of course, the goal is to stop the behavior. "But with lifestyle changes like exercise and diet, we're constantly having to make decisions," says Welshimer, whose research focuses on diet and nutrition. Changes in these complex behaviors come stepwise too, studies have shown. 

In the pre-contemplation stage we may be learning about a health-related issue but don't yet plan to change our behavior. In the contemplation stage we've decided to change fairly soon, and in the preparation stage we're figuring out how to go about it. In the action stage, we're systematically trying out changes. And in the maintenance stage, we've sustained our new behavior for several months and are trying to make it a permanent habit.

Sounds simple enough, but it's the doing that's the hard part. Negotiating each stage requires us to do certain things—increase our knowledge, evaluate our feelings, change our thinking or our environment, find incentives and rewards, seek help from others, and so forth. Stepping up from contemplation to preparation and action can take a long time. People often yo-yo between action and contemplation, and maintainers can fall off the wagon.

"Relapse is common; it should be interpreted as part of the learning process, not as failure," says Welshimer. "You're learning new things every time you try." Understanding that change is an evolutionary process helps people feel more in control, she adds.

In the late 1990s, with funding from SIUC and the Illinois Council on Food and Agricultural Research (C-FAR), Welshimer and Carol Boushey, an assistant professor of food and nutrition at SIUC, studied stages of change in relation to people's nutritional intake and weight. One of the things they found was a big difference in diet between the action and maintenance stages. 

"The people who had maintained better eating habits for a substantial period of time were eating much less fat, much more fiber, and much more fruit and vegetables than the people who had started in the past six months," Welshimer says.

"Once you've been at it awhile, you find more things you can change. Perhaps you're becoming more confident, and probably your taste in food has changed."

She and doctoral student Cathy Ludwig Bell, a registered dietitian, went on to develop a web-based nutrition program to help people improve their diet stage by stage. The program, called Step Up to Good Health (STEP), also was underwritten by C-FAR. It aims to help people eat less fat, more fiber, and more fruits and vegetables: the big three dietary goals for good health.

"I've never been much of a computer person," Welshimer admits, "but I'm pretty much sold on this as a strategy for education. Interactive technology allows the consumer to pick and choose what meets their needs." 

The STEP web site has a section for each nutrition goal. Each section first asks the user a question—for example, "Do you eat five servings of fruits and vegetables every day?" The five responses the user can select from ("No, but I'm planning to start in the next 30 days," "Yes, I started in the last six months," etc.) are linked to pages with information, motivational tips, and strategies geared for their level of change.

That's key. For instance, "contemplators" might be overwhelmed by the detailed nutrition data needed by action-takers. They're more likely to benefit from suggestions about small dietary changes they can start with that other people have found helpful.

In 1999 and 2000, Welshimer and Ludwig Bell tested the emerging components of STEP with focus groups of community residents and SIUC students. Some groups were made up of people who had not yet begun eating more healthfully; others were made up of people who had changed their diets recently or long-term.

Both groups rated the helpfulness of various activities and were asked how STEP's messages at each stage squared with their experience. They were also asked about strategies, incentives, and barriers to change. That input allowed Welshimer and Ludwig Bell to fine-tune the program.

Later test groups of college students and low-income parents have given STEP good reviews, says Ludwig Bell, who evaluated student satisfaction with the program for her doctoral dissertation. 

She and Welshimer are now applying what they learned with STEP to a project involving kids, diet, and computers. With a $119,833 grant from the U.S. Department of Agriculture through Purdue University, they're helping design a CD-based educational program on calcium for sixth-grade science and health classes. The work, which also involves researchers in Hawaii and New Mexico, is part of a larger project on bone health in early adolescence directed by Carol Boushey (now with Purdue).

Why teach pre-teens about calcium? Because the biggest risk factor for osteoporosis is low calcium intake during adolescence, Welshimer says.

"For girls in particular, when they hit menarche, that's when they really begin to lay down bone very fast for the next 8 to 10 years," she says. "And that's also when girls stop drinking milk so much and start worrying about their weight. So at the very age when they need the most calcium, American girls are reducing their intake. That's alarming. To make a difference, you need to educate kids before puberty."

Welshimer and Ludwig Bell have used stages-of-change theory in designing a curriculum and computer "games" to build kids' skills in choosing foods to get enough calcium. Next year the grant team will try out the program in classes around the country. They'll test the students' knowledge and bone density before and after, and compare the results to those from a control group. Welshimer will help evaluate the findings.

She and Ludwig Bell also plan to do more research on helping adults make dietary changes. In particular, they say, research is needed on how best to help people avoid backsliding. The main complaint in the evaluation of STEP was that testers who were "maintainers" wanted more information geared to them. 

But suppose you're not yet a maintainer. What if you've abandoned your New Year's resolution to exercise regularly or to eat less fat? Try again, of course—but smarter. 

"A common problem is that we try to do too much at one time," says Ludwig Bell, who explains that people often jump from contemplation to action without sufficient planning.

"If you relapsed, there was something you needed to know or something you needed to get under control that you hadn't yet," says Welshimer. "You're going to want to make this change again, so ask yourself what got in your way this time."

Focus on the immediate benefits of change and not on an ultimate goal, she adds. "Tell yourself you're going to change how you eat because it's good for you and makes you feel better. Don't peg it to how many pounds you want to lose."

And relax. "It's really a lifelong process. You need to take baby steps."
 

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