Ultimately, WHEL concluded the diet did not affect breast cancer prognosis, but the study had been remarkably successful at something else: helping women change their eating patterns.
So “what are the components of an effective intervention” for behavior modification? asked Pierce, who before WHEL had written extensively in the early 1990s on tobacco control programs in California and how they could effectively reduce smoking.
To determine specifically what works to help change behavior, Pierce said he looked back much farther in history. He took cues from William James, “who is sometimes called the father of American psychology.”
In his 1890 treatise on habits, James observed that successful motivation requires abrupt change and strong, immediately enacted resolve. Most evident, however, was that lasting change comes first from within the individual.
James wrote that people have to arrange their environment to reinforce their motive, put themselves in situations that encourage the new way, make a public pledge to enhance their resolve and not accept any exceptions until the new behavior is securely rooted.
“How do we achieve a long-term change in habitualized behavior? Because that’s really what we’re talking about with middle-age women who have many, many years practice of their current eating pattern,” Pierce said.
Greeting Pierce (c) in Masur Auditorium are NCI Cancer Prevention Fellowship Program staff (from l) Tamika McKay, fellowship program director Dr. David Nelson, Studly Auguste and Katherine Ross.
|Pierce says, “If it’s not fun, then [study participants are] not going to do it. They’re going to drop out of it…In behavior change, unless the person is prepared to do something themselves, the chances that you can make a difference to their behavior are much, much smaller. You’ve got to have evidence that they’re willing to do something.”
The study used a client-centered counseling approach that “emphasizes the importance of all decisions for change being made by the participants themselves. Coaches can assist in that effort but we can’t tell them what to do.”
WHEL incorporated the James observations in four phases: Build motivation, help implement self-regulatory mechanisms, help consolidate change into everyday life and help prevent relapse. At an initial meeting with study participants, a nutritionist presented the scientific evidence for adopting a diet with more fruits/vegetables, described the perceived risks and benefits and reviewed social norms and environmental influences. Slide shows and food demonstrations helped illustrate the targets and goals of the study.
An explicit goal was that participants leave the motivation sessions “convinced that the diet could influence cancer recurrence and enthusiastic about trying the new eating pattern.”
Pierce said researchers were careful to choose enthusiastic nutritionists to present the slide shows. In addition, within 2 weeks of the info session, lay coaches made follow-up phone calls to the women. These calls emphasized participant responsibility and outlined the role of the coach as well as the participant’s strategy and that of any supporting cast members in the participant’s environment.
“The concept is, this study’s got to be fun,” Pierce stressed. “If it’s not fun, then they’re not going to do it. They’re going to drop out of it…In behavior change, unless [people are] prepared to do something themselves, the chances that you can make a difference to their behavior are much, much smaller. You’ve got to have evidence that they’re willing to do something.”
After each phase, researchers evaluated both the group contacted by coaches and the control group. Pierce said the intervention group had already begun to change their eating patterns significantly before the behavior change coaching officially began. Already the behavior-change-via-coach model was proving effective.
The first phase of behavior change coaching was termed “exploring maximal change.” In this phase, WHEL coaches helped participants set goals, monitored participants’ performance for them and helped the women judge their own performance, encouraging the use of self-rewards. At the end of this phase—6 weeks into the study—participants were consuming the plant-based dietary pattern of 5 daily servings of vegetables, 3 fruits, 30 grams of fiber and 20 percent energy from fat.
“[Participants] need to take ownership and set their own goals,” Pierce pointed out. “Goals should be proximal and short term—what can they do in a day, what can they do in a week, not what they can do over a year…The problem that people have doing this on their own is that they’re overambitious. And that jeopardizes the change attempt. The work of a coach here is to make sure [goals are] challenging but achievable.”
Ross presents a framed event poster to Pierce.
Photos: Bill Branson
After the first 6 months, WHEL data showed a remarkable nearly 80 percent increase in veggie intake by participants who had to change their behavior the most—those whose baseline vegetable consumption was the lowest at the start of the study. After 6 years, those same women were maintaining about a 55 percent increase in eating vegetables. They had successfully incorporated the new diet into their lifestyle.
For future studies, Pierce said, researchers are considering ways technology—smartphone apps or increasingly popular sensor devices, for example—might help with long-term behavior change, particularly with self-monitoring during the phase when participants need to consolidate changes made in the first 6 weeks into their lifestyle.
In total, each participant received 30 calls at $50 per call. “Fifteen hundred dollars is really not a lot for an intervention,” Pierce noted.
Throughout all four phases, he said, it was clear that study participants themselves were their own best motivators. Coaches provided a sounding board for coping strategies and recipe ideas, helped women keep track of details and kept participants from judging themselves too harshly—or quitting—whenever short-term goals were not met.
“It’s really not social support we’re giving them,” Pierce explained, but a measure of accountability. “They will never change just because they’re getting coached…but [intervention calls] give them a way to talk about the diet and what they’re doing that’s non-judgmental and doesn’t [otherwise] affect them in their everyday life.”
Sponsored by NCI’s Division of Cancer Prevention’s Cancer Prevention Fellowship Program, Pierce’s full lecture can be viewed online at http://videocast.nih.gov/summary.asp?Live=14358&bhcp=1.