Behavioral change is the best prevention of future diseases

David Utley, M.D. · March 30, 2022 · Short URL:

Technology scales this underutilized practice via 24/7 connections and data

If there’s one lasting message the COVID-19 pandemic left on society, it’s that good health can prevent the severity of future pandemics. More than nine out of 10 people who died from COVID-19 had comorbidities like hypertension, diabetes, cardiovascular disease, obesity, and pulmonary disease. According to the Centers for Disease Control and Prevention (CDC), many of these comorbidities can be avoided, reversed, or eliminated by making healthier choices.

But cognitive dissonance sets in during times filled with anxiety, and unhealthy habits form at a time when wholesome ones are desperately needed. Fatal drug overdoses shot up nearly 30% over a 12-month period ending April 2021, according to the CDC. Binge drinking jumped 21% during the COVID-19 pandemic. Another study showed that half of Americans gained weight, exacerbating an existing obesity crisis. Our own data at Pivot revealed that 25% of tobacco users said they increased their smoking, and many people began using tobacco for the first time during the pandemic. The consequences of adverse behaviors are elevated as a result of COVID-19 and other deadly diseases.

If there’s ever been a time when the tiny supercomputer in our pocket should be leveraged to prompt us to make better lifestyle decisions, now is the time. In spite of the emotional downside of reward-seeking behavior on social media, mobile technology has the potential to make a huge impact on managing chronic conditions. This largely includes connecting people with loved ones, doctors, nurses, coaches, and therapists, all of whom can motivate constructive changes that turn into good practices.

At Pivot, our mission is to help tobacco users embrace better habits and turn away from using tobacco completely. As a leading behavior that contributes to all chronic conditions faced today, smoking claims the lives of 8 million people annually world-wide, nearly threes times that of all COVID-19 deaths.  Fortunately, the majority of tobacco users want to quit, and 50% make an attempt every year.  But most fail, because the person does not seek or can not access evidence-based tobacco cessation services.

Pivot’s goal to influence behavior at scale using data and technology is shared by many large healthcare stakeholders across the ecosystem. In this piece, I explore how we’re collectively driving behavioral change initiatives forward and the challenges we still face. 

A bad habit is a chronic condition

The first step in prompting human beings to begin reversing their unhealthy behaviors? Rethink how we approach those behaviors in the first place.  You can not change behavior quickly…. It is a lifelong process.

“We view these issues as more along the lines of a chronic condition than an acute one,” Douglas Nemecek, Chief Medical Officer, Behavioral Health at Cigna's Evernorth, told me. 

“We can't expect individuals to stop smoking or drinking or lose weight in 30 days and never have a problem again. We need to take a long-term approach much like we do with someone with diabetes. If they've been in the hospital five times in the last five years, we don't say, ‘Hey, they failed,’ and give up; we keep treating them.” The same consistency and persistence should be used for those who smoke, binge eat, and lead sedentary lives, all of which often lead to not just diabetes, but other metabolic conditions.   

Bryce Williams, Vice President of MindBody Medicine at Blue Shield of California, expressed a similar sentiment. “My philosophy is largely, ‘if at first you don't succeed, try, try again.’”Blue Shield offers what he called “frictionless switching,” which allows members to switch into different programs to find the ones that work best for them. “We believe what you're really working on is not necessarily, ‘will I be successful with this quit attempt?’ or ‘will I be successful with this weight loss?’ or ‘will I be successful with this exercise routine?’ What you're really working on is just your own learning journey over the years, and how to build those habits,” Williams said. “And that doesn't happen in eight or 12 weeks.”

In other words, helping someone change an adverse behavior as a long-term condition takes the pressure off being successful right away while building the muscle to keep trying. Importantly, making sure there are flexible and simple offerings that are easy to adopt means a greater seamless experience that won’t act as a hurdle to the member. To get someone to do in something consistently, it has to be effortless enough they’ll do it even when they’re not motivated.

24/7 access, personalization and data 

Motivation matters. There is a saying that it takes 10 years to create an overnight success. Same goes with changing behavior. A change in behavior on one day isn’t a habit. A habit is consistent ongoing behavior. This requires effort and encouragement, and often multiple nudges. Heretofore motivational speeches or advice came intermittently. Continuousness wasn’t a logistical reality. Even today, the predominant way a doctor promotes preventative care is to say after seeing a patient, “Don’t smoke; don’t drink, exercise and eat an apple a day. See you in a year.” That works for few people. Irregular but more frequent engagements work better, but even that’s not optimal.

“When Cigna started case management programs, coaching was all telephonic,” said Evernorth’s Nemecek. “We called you, we left a message and we hoped you’d call us back. Then we tried to engage you with repeated calls. That’s not an engaging mode of interaction.” 

Today, the multiplicity of touchpoints enables people to receive reminders and nudges, and react in their own terms and timing. “Virtual care has made care available when and where patients are willing to raise their hand and engage. Whether by text message, by app, or in person if that’s what they choose, all of these options improve our ability to get more people to be aware and then take action,” Nemecek added.

Meeting people where they are also means knowing who they are and their context, or some people say social determinants of health: where they live, their income, their insurance plans etc. In other words, their surroundings. 

“We have to account for all the permutations and combinations of what needs to work across the country and localize it and personalize it,” said Rajeev Ronanki, President of Digital Platforms at Anthem, Inc., the health company that covers 45 million lives within its family of health plans. “Something that works in Palo Alto might not work in Nashville and vice versa. To get this right, we think about integration at scale and reimbursement models right up front so we solve for some of those tougher challenges immediately and then map a flexible, concrete plan,” he told me.

“When we look at what the ultimate scope of any one solution is going to be, just having 1,000 or 1,000,000, or some subsegment of our population using it isn’t enough. We need to make it available and sensible to everyone.”  Democratization of care is the ultimate goal.

Personalization isn’t just about modifications around a person’s socioeconomic and demographic profile, but making them aware of their physiological progress. At Pivot, our breath sensor measures carbon monoxide a user’s breath. Measuring this biometric variable every day to reveal just how much smoke a person’s body is exposed to is a motivator to change, just like a person who sees how many steps they’ve taken on their wearable encourages them to take even more steps. 

The right messaging around behavior change

COVID-19 wasn’t just a forcing function for virtual care, it enshrined behavioral change - a la socially distancing and mask wearing - as a powerful preventative measure to alter population health. There is a sense of refreshing irony to push behavioral change as preventative health policy while trillions of dollars are spent sustaining the current medical industrial complex that focuses very little on prevention. 

Imagine spending just billions backing behavioral change health policy around what we know works: good diet, exercise, mental fitness, sleep, tobacco avoidance, alcohol moderation? “We don’t need anymore evidence that diet and lifestyle are good for preventing chronic conditions,” said Blue Shield’s Williams. “It’s the most clinically effective, cost-effective, least risky, least invasive and yet under-prescribed and under-utilized treatment. Part of my life’s journey is to make this standard messaging.”  In other words, the jury is not out.  Prevention works.

Indeed, messaging can be powerful. As I mentioned above, social media has a way of driving emotion that can lead to certain behaviors. As we also know it has a way of mobilizing action. Just look at the trucker convoys, the latest in massive demonstrations bringing like-minded people together for a cause. Harnessing that power to inspire is something every astute healthcare executive is studying. “We can borrow a bit from what’s worked successfully for social media and companies that create their value proposition based on consumer engagement,” said Anthem’s Ronanki. “We want to improve health outcomes so our goal is to engage members to address whole person health – to quit smoking, lose weight, sleep more, and eat better. All this seems intuitively obvious, but few people follow through with the best choices. It’s also far more difficult when you’re delivering that message through one of our health plans.”

When a doctor delivers a message, people respond, Ronanki pointed out. To amplify a message to health plan members, the effectiveness rate is about 80% when a doctor affiliated with Anthem is the deliverer. If Anthem sends out a message to a member, the response rate drops to about 15-20%.  We should collaborate and arm the primary care physician with scalable proven cost-effective mobile solutions to treat these chronic conditions like tobacco cessation.

Global movement afoot

When it comes to preventative medicine, and getting out in front of chronic conditions, we know what works best: diet, exercise, good clean living. It is, as Blue Shield’s Williams stated, underutilized and under-prescribed. Yet there is a paradigmatic shift underway when it comes to approaching health. COVID-19 made it resoundingly clear, the healthier one was, the less risk the virus posed.

Technology enables us to spread that positive message, continuously and personally. It puts data right in front of a person who is then influenced to change by the constant reminder of what’s happening real time inside their bodies. We have a lot more to do, but we’ve already made many inroads as an industry and society since Pivot began more than five years ago. 

Our mission is to drive behavioral change and now is the time to do it. There was a collective change in behavior when COVID-19 was nigh and the messaging drumbeat was loud and clear. If we prioritized these other illnesses and the benefits of lifestyle behavioral change with the same vigor, the impact would be game-changing. We can do it, now it’s a matter of whether the healthcare industry has the motivation and conviction to do so.

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David Utley, M.D.

President and CEO (founder) for Pivot in Redwood City, California, a digital health company innovating in the tobacco use cessation space.

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David Utley, M.D.

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President and CEO (founder) for Pivot in Redwood City, California, a digital health company innovating in the tobacco use cessation space.