Behavioral Medicine

By Leonard H. Epstein, PhD

The primary model in our current health care system is to take care of people after they become sick and need medical care. Given that many chronic diseases can be prevented with changes in behavior, the next stage in medical care is to have a greater emphasis on healthy behaviors.

Obesity, smoking, alcohol use, low activity levels, unhealthy diets and inadequate sleep contribute to the majority of disease burden. The most direct approach to these problems is to help people change their habits so that a healthy lifestyle becomes the default, rather than the exception. In fact, behavioral treatments are the evidence-based treatment for some disorders. For example, behaviorally based weight loss has been shown to be better at preventing people with prediabetes from transitioning to type 2 diabetes than the most commonly prescribed medication, Metformin. Similarly, cognitive behavioral treatment for insomnia is superior to pharmacological treatments for insomnia, both in terms of quality of sleep and duration of treatment effects.

I anticipate, therefore, that evidence-based behavioral treatments will become more available as part of standard medical care. A corollary of this shift in emphasis should be enhanced assessment tools that focus on health behavior. At present, the medical system does a good job of surveilling common diseases (e.g., assessment for early signs of hypertension, cardiovascular disease, diabetes, cancer), but rarely are a person’s diet, exercise, sleep or stress levels assessed. If we are to place disease prevention on equal footing with disease treatment, these factors need to be measured regularly and interventions need to be easily accessible within the medical home model. Prevention means we should be implementing behaviors for an individual’s future benefit, not for how they make them feel in the present. Yet no assessment is currently made of someone’s temporal orientation or whether they can make positive decisions to influence their future health. In the future, measures of important health behaviors and behavioral phenotypes (consistent behavior patterns) will be considered biomarkers of disease in the same way high blood pressure is today.

Another important direction for medical care is to incorporate the use of new personal technologies as a means to encourage and enhance healthy behaviors. These technologies—such as heart rate, glucose and blood pressure monitors—make it possible to improve self-regulation so that people can learn what causes changes in their symptoms and how to reduce them. These devices also provide detailed information that will help doctors make more nuanced treatment plans tailored to individual characteristics.

Efforts to tailor treatments to individuals in order to provide optimal care has been a hallmark of applied behavior analysis for decades. Now these efforts are being recognized as important to medicine as precision medicine. In the years ahead, precision medicine should begin to include behavioral phenotypes, which influence not only the course of a disease but also how well people can adhere to individualized treatment regimens. Noncompliance with treatment regimens is a major barrier to improving health care. Across medicine, innovative experimental designs are being developed to establish the effectiveness of treatments tailored to individuals’ genetics, microbiome, health behaviors, or patterns of treatment compliance.

The future is bright, but much work needs to be done to integrate a focus on health behaviors into routine medical care. UB is well poised to play a leading role in this transformation by incorporating ideas from behavioral health experts university-wide to create a community of scholars in health behavior.