In 2008, Ralph Keeney from Duke University published a paper called Personal decisions are the leading cause of death. It proposed that most premature deaths in the USA are caused by the decisions people make every day. According to Keeney, heart disease and cancer aren’t America’s biggest killers; it’s the decisions people make – to smoke, to eat crap, to sit on the couch – that lead to these diseases and in turn cause premature death.
In a world where lifestyle is the leading cause of death and disability, the promise of digital health is alluring. In an ideal digital health system, genomics provides citizens with their individual risk profiles for disease, allowing them to reduce this risk by making corrective lifestyle changes. Unprecedented in healthcare, digital health has the opportunity to provide genuine preventative and personalised healthcare for the first time.
But this is not yet reality as numerous obstacles impede digital health’s rise. We’re acutely aware of many of these challenges, but there is one that is seldom acknowledged – human foible.
Genomic risk: a tickle or a nudge?
As I alluded to above, an assumption of digital health is that if people are given information they’ll change their behaviour. If you have an increased risk of developing type 2 diabetes, so the assumption goes, you’ll reduce this risk by increasing your level of physical activity, eating a healthy diet and dropping a bit of weight.
But a decade of research examining the influence of genetic risk communication on behaviour change suggests genomics is no panacea. A comprehensive review concluded that “genetic information has little impact on behaviour” change. The review examined the effect of genetic information on cancer screening, smoking cessation, diet and exercise behaviour change. Although cancer screening rates did improve, the communication of an elevated risk of a number of diseases had little impact on smoking cessation, diet or physical activity.
A study conducted shortly thereafter showed similar results. Over 2000 people who received a Navigenics genome wide test were followed up 6 months later to assess how their test results had changed their behaviour. Although intention (not actual behaviour) to get certain screening tests increased among individuals with an elevated disease risk, there were no discernible influence on important lifestyle changes such as diet and physical activity.
When discussing the outcome of this study in his wonderful book, The Creative Destruction of Medicine¸ Eric Topol stated that “changing behaviour to improve lifestyle – to lose weight, exercise more and eat healthy foods – is one of the greatest challenges in health care, and there have not been any major success strategies to date”.
Indeed, our inability to change our behaviour for the better has puzzled great minds as far back as Aristotle. And the scientific literature, too, is strewn with research showing information, in many circumstances, has little impact on behaviour change. Public health campaigns, for example, though effective for encouraging new behaviours, have limited influence on changing behaviours that are repeated regularly – i.e., important lifestyle factors like eating, smoking and exercise.
Considering our lifestyle has a huge influence on our health and risk of developing a chronic disease, the difficulty in changing these behaviours should worry digital health enthusiasts. Particularly as it seems personal genomics, on its own at least, won’t save the day.
Are wearables the answer?
But digital health has other tricks up its sleeve. The solution, or part of it, may lie in the many apps, wearables and internet-enabled devices that quantify our steps, nutrition, weight and sleep.
Tracking behaviour is a core element of most proven behaviour change techniques. On top of that, many of these tools, if used correctly, help to change behaviour. For example, in some studies:
- Pedometers have been shown to significantly increase physical activity (activity trackers are really just glorified pedometers);
- regular monitoring of weight has been associated with greater weight loss maintenance after 2 years (think Withings’ or Fitbit’s wireless bathroom scales); and
- digital monitoring of food intake has been shown to be equivalent to paper-and-pencil methods for its effectiveness in promoting weight loss (i.e. MyFitnessPal).
But, we run into problems here too.
As a recent article in the Journal of the American Medical Association points out, tracking behaviour is not enough to change behaviour. If it was, health professionals could hand their clients a fitness tracker and a wireless scale and walk away. Tracking behaviour is insufficient because it neglects one of the most powerful drivers of human behaviour: our habits.
The problem with bad habits is that they are masters at sabotaging our goals. If, for example, you resolve to eat healthy but also have a well-established hamburger habit, it’s very likely the habit will overpower your clean eating goal most of the time. The power of habits over our best intentions has been demonstrated many times in areas such as exercise and nutrition so it’s no wonder activity trackers aren’t helping us change our lifestyles.
The Old + The New
As I’ve written previously, digital health has not yet developed the tools to quantify, predict and change our bad habits. Until it does, we can’t rely on technology alone. Health professionals with a nuanced understanding of human behaviour are still required.
An excellent example of this combination is Omada Health. Omada offers online lifestyle coaching aimed at preventing type 2 diabetes through exercise, good nutrition and weight loss. Omada has essentially digitised a landmark lifestyle intervention called the Diabetes Prevention Program and added smart technology (fitness tracker and wireless scales), online health coaching, and a private social network for its clients. The program was assessed against the original face-to-face Diabetes Prevention Program and results show Omada’s program is more than twice as effective as the original. And, staggeringly, it’s almost ten times more effective than standard health and wellness programs. It’s no wonder Omada was ranked in the top 50 most innovative companies for 2015.
As Omada’s success points out, tracking behaviour is insufficient to change it. But when you combine wearables and internet-enabled devices with expert advice from health professionals then behaviour change is improved above and beyond traditional approaches.
A diabolical problem
Motivating sustained behaviour change is hard work, even for the most talented health professionals. Yet regular criticisms of activity trackers and health apps continue. That we expect so much from activity trackers points to a lack of basic knowledge about behaviour change. We need to move beyond simplistic rational thinking and integrate a comprehensive perspective of human behaviour in order to get the most out of the apps, wearables and devices that comprise the internet of healthy things.
This includes, but is no limited to, a better understanding of how habits work; the thinking patterns that derail us when trying to make lifestyle changes; building proactive coping methods that are superior to self-medication with drink, smoke or food; and teaching people the required skillset (e.g. buying, preparing, and cooking food) so they can eat a nutritious diet. As companies like Omada Health have shown, the combination of traditional health coaching with digital health technology can work wonders and we need more of these businesses… And that’s why I created Smart Habits.