Compliance on a Healthy Diet

[MikeyG]

Thanks for sharing Dr. Esselstyn's recent audio interview, Jeff. (Shared here: https://www.facebook.com/JeffNovickRD/p ... 4210225125)

We have discussed compliance in the past for intensive lifestyle interventions, and how, for many, it is very easy to deviate from a program's healthy guidelines:
- viewtopic.php?p=447218#p447218
- viewtopic.php?p=445150#p445150

However, Dr. Esselstyn's and Dr. McDougall's recent studies both boast incredibly high compliance:
- 89% in Esselstyn's case (http://dresselstyn.com/JFP_06307_Article1.pdf)
- 80% for McDougall (https://www.drmcdougall.com/misc/2014nl/jul/140700.pdf)

In addition, statements from Ornish, Barnard, and Pritikin seem to reflect similarly high compliance for those who follow their guidelines, even over a longer duration.

With our toxic food environment, I would think that compliance over the long term would be much lower. This low predicted compliance seems to be more reflective of your comments about the challenges of long-term adherence to the program and the reality of the poor state of diet in the developed world. (Here was one example of compliance: viewtopic.php?p=447218#p447218
and on the unhealthy, developed diet: viewtopic.php?p=454543#p454543)

Is there a reason that you can see for this discrepancy between observed compliance in a research setting and actual compliance in a real-world environment? While I would love to be optimistic that a healthy diet can be easily adopted and incorporated by the vast majority (>80%) of the population, the reality seems to be much different. Thus, I would really appreciate any insight you may have on this issue.

Determining how likely individuals are to comply with health guidelines seems like it would be crucial for planning and implementing important issues like health policy changes, and so it appears it would be very important to understand this apparent discrepancy.

Thanks so much for helping us comprehend the issue of compliance and all the other topics you are kind enough to publicly discuss. I look forward to continue to learn from you, and I sincerely appreciate your efforts.

Please have a great day.

Warmly,
Michael

[JeffN]

Great question.

I think there is more to the picture then we just hear (good and bad).

About 18 months ago, I spent an evening with Dr Esselstyn discussing this very topic, trying to understand the reasoning behind why he thought he had such high compliance. I have done the same with Dr McDougall, Pritikin, etc.

Let me find that and I will post it here when I do.

In Health
Jeff

[MikeyG]

Thanks, Jeff.

No rush on finding the discussion. I try to be patient.

I look forward to learning more about your perspective, especially since it seems like you have obtained a great sampling on the subject of compliance with many of the leaders in the WFPB world.

Thanks, again, for all your efforts. Please have a great day.

[JeffN]

Much of this depends on how you define compliance, how you measure it, who is doing the study, what exactly is the intervention and how is it being implemented.

While it may sound simple, it is actually very complicated. For instance, how exactly would you measure compliance to the McDougall program? By the percent fat? If so, what percent? By the percent calories from starches? How many nuts and seeds would be allowed? How many fruits? Do they exercise and if so, how much? How many beans? What if they eat more than a cup a day, is that "non" compliant? How much sugar? sodium? etc etc etc.

If you look into the literature, you will see that compliance has been defined by weight loss, class attendance, dietary analysis, percent fat, blood markers, etc etc and has been measured by either lab testing or self reported and may been done by their own research team or others.

Depending on all the above, you can find compliance rates in the literature as low as 0% (completely dropped out) and as high as 95%. So, how we define it, how it is measured, what was the intervention and how the intervention was implemented, is all very important.

As I described in the recent discussion on medication, even in closed residential WFPB programs and in those who are 100% compliant for the 10- 28 days, we do not see a reduction or elimination of medication in 100% of participants. Nor do we always see the same results in changes in biomarkers as there is always a range. So, again, it depends on how you would measure compliance and success. Based on compliance, they all get 100% but that is not true depending on which biomarker, or how it is measured.

Out of the WFPB diets we see claims of very high compliance rates in our own studies, however studies done by others do not always replicate those same compliance rates. Ornish is the one most studied outside of our own studies and as you can see, some of these outside studies get similar results and some do not.

In this study, we see drop out rates of 48% for Atkins, 50% for Ornish, 35% for Zone and 35% for Weight Watchers. The results for biomarkers depend on which ones you look at, whether or not you include the dropouts or not and at what point you look at them.

http://jama.jamanetwork.com/article.asp ... eid=200094

However, in this study, we saw retention rates of retention at 76-88% but we see the same issues with biomarkers.

http://jama.jamanetwork.com/article.asp ... eid=205916

And in this one we see rates of around 95%

http://www.nejm.org/doi/full/10.1056/NE ... Discussion

In this one on the Ornish program, 27% of women and 21% of the men did not complete the 1-year follow-up. It also points out some very important points in regard to compliance.

http://www.pmri.org/publications/1953.pdf

"They say, women completing the follow-up were younger and more likely to be employed. Men completing the follow-up were more likely to have a history of PTCA (Stent) and a family history of CAD, were more often previous smokers, consumed less alcohol, were living with someone, and cohabitating men tended to have their partner participate. Men who completed the program also expressed greater self-efficacy toward adherence to the program components. There were no other statistically significant differences in demo- graphic, medical, or psychosocial characteristics between those who completed the follow-up and those who did not."

In this one, which uses the DASH diet, we see excellent retention at 18 months of 94%.

http://www.ncbi.nlm.nih.gov/pubmed/1658 ... t=Abstract

However, in regard to impact and biomarkers at the 6 month point of those who stayed in, again, it depends on how you define compliance..

http://onlinelibrary.wiley.com/doi/10.1 ... 147.x/full

and you see similar at 18 months

http://www.andjrnl.org/article/S0002-8223(07)01363-6/abstract


To me, while not as strict as us, I think the National Weight Control Registry and the Premier Trial shows that people can make intensive lifestyle changes and maintain them over time.

National Weight Loss Registry
Weight-loss maintenance for 10 years in the National Weight Control Registry.
Am J Prev Med. 2014 Jan;46(1):17-23. doi: 10.1016/j.amepre.2013.08.019.

http://www.ncbi.nlm.nih.gov/pubmed/24355667


The Premier Trial

Dietary intakes associated with successful weight loss and maintenance during the Weight Loss Maintenance Trial
J Am Diet Assoc. 2011 Dec; 111(12): 1826–1835.
doi: 10.1016/j.jada.2011.09.014
PMCID: PMC3225890

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225890/


And this...

Long-term weight loss maintenance in the United States.
Int J Obes (Lond). 2010 Nov;34(11):1644-54. doi: 10.1038/ijo.2010.94. Epub 2010 May 18.

http://www.ncbi.nlm.nih.gov/pubmed/?term=20479763



Now, in regard to the your comments above, I have worked with several of the programs and, as I mentioned, have spoken directly with Dr Esselstyn about this several times, including again yesterday. Personally, and as you can see from the above comments, I wish that the "compliance" and the "reversal" was much better described and evaluated in his second study. I think it would have only strengthened his claims.

I will add more later to this on the factors that I think leads to high success rates and also the factors Dr Esselsystn has identified.

(to be continued...)

[MikeyG]

Thanks for the feedback, Jeff.

This discussion also reminded me of Dr. Gardner's 2007 A-to-Z Diet study, where patients on an "Ornish" diet were only able to keep dietary fat to 29.8% vs. the recommended 10%. So the failure of the "Ornish" diet was thought to be due to the fact that the dietary guidelines were not adhered to, which we often see in studies that claim a LFWFPB dietary pattern failed to produce positive health effects. (https://www.drmcdougall.com/misc/2007nl/mar/defend.htm)

Dr. Ornish seems to believe that high levels of compliance on a low-fat, plant-based diet are largely due to the participants feeling better through their healthier dietary choices. (http://www.ornishspectrum.com/wp-conten ... dicine.pdf)

Thus, it appears that the low levels of compliance/adherence we see outside of the studies done by the WFPB researchers may be a result of the low-fat, WFPB diets being inadequately prescribed and adopted by the study participants, since LFWFPB leaders seem to find patients willing to adhere to the diets simply by experiencing the positive benefits of doing so.

However, as you have pointed out, long-term compliance may be difficult due to our toxic food environment, and accurately measuring and reporting adherence/compliance can vary significantly based on our definition of these terms.

Thanks as well for this post, on how many fall victim to the minutiae and lose sight of the importance of the overall dietary pattern for optimal health: viewtopic.php?p=454972#p454972

As it appears that a large majority of our research funding is directed toward the minutiae, if you had the choice, where would you like to see that funding directed instead? If Jeff Novick were the new tsar of all our public research funds, what types of studies do you feel would be the most beneficial to furthering the science?

As we already have a wealth of peer-reviewed, published, scientific evidence suggesting that a LFWFPB dietary pattern is incredibly important for optimal health, should we now be studying how best to improve compliance/adherence over the long-term?

(The evidence: http://www.jeffnovick.com/RD/Articles/E ... _Pt_1.html and http://www.jeffnovick.com/RD/Articles/E ... icles.html)

(It also appears you are already making progress on this, with your LFWFPB dietary registry: viewtopic.php?p=450545#p450545

Thanks for taking the initiative, Jeff ).

It would seem tempting to contrast the components of the different LFWFPB dietary patterns to attempt to determine which one is superior, but as we have discussed in the past in terms of effect size, it seems like funding these studies would have less public health impact than other research avenues. (Jeff on effect size and LFWFPB diets: viewtopic.php?p=436326#p436326)

Long-term follow-up of different dietary patterns may also be valuable, if simply to provide more evidence to the public that patterns that deviate from the LFWFPB pattern are not only less beneficial, but also potentially harmful. However, since we already have evidence strong enough to cause US News and other health organizations to vehemently oppose dietary patterns like Atkins and Paleo, but still see large numbers of people choosing to follow these dietary patterns, it appears unclear what level of evidence would be necessary to truly discourage people from following these unfortunate dietary patterns.

Or, at this point, would the money be better spent attempting to create the infrastructure necessary for implementation of the LFWFPB dietary pattern and optimally healthy lifestyle, as the research seems to have already done well to establish the value of these interventions and patterns?

Another possibility would be to have a series of pilot programs, which may already be happening with community-based interventions like Meals for Health and Get Healthy Marshall, to determine how best to promote these interventions in a way to maximize adherence, compliance, and overall health outcomes. As we identified more successful interventions, we could then expand these to encompass increasingly larger populations. Calculating and reporting the savings to healthcare costs could also serve as wonderful motivators for these communities to support the changes, as well.

I look forward to hearing your perspective, if and when you have the time to share it

Thanks again for all the amazing insights and information. I continue to believe that you set an incredible example of generosity, compassion, and evidence-based rigor for the rest of us. I sincerely appreciate all that you do. Please have a great day.

[JeffN]

This discussion also reminded me of Dr. Gardner's 2007 A-to-Z Diet study, where patients on an "Ornish" diet were only able to keep dietary fat to 29.8% vs. the recommended 10%. So the failure of the "Ornish" diet was thought to be due to the fact that the dietary guidelines were not adhered to, which we often see in studies that claim a LFWFPB dietary pattern failed to produce positive health effects.

The question is, why?

Why do we seem to have such high success rates when we do the studies but not when someone else does the study? And why do we not see these same success rates in the actual programs that we see in the studies on these programs.

As anyone here has witnessed, these high rates of compliance are just not replicated in the real world very often, even from the programs themselves. Of course, it depends on how you define compliance and/or success.

When 30-70 people come to the a live in residential program (i.e., Pritikin, TrueNorth, McDougall, etc), and receive intensive education, hands'-on experience, controlled food, and medical care, how many are following the program 3 months later? When 200-400 people come to a 3-5 day WFPB "event' with intensive education, food, etc, how many are following the program 3 months later? How may of the original fireman in the original Engine2 Challenge still follow the program? While we don't have any exact numbers for all of these, it is clearly not 70-90% compliance.

Let's look at WFM. They tried to set it up in such a way as to create an environment as conducive to success as possible. This included sending many of their employees to 8-day residential educational programs, implementing the HSH education program in the stores for customers and employees, making the food readily available in the stores, having pre made food available in the deli and take out and giving the employees discounts on the food and bigger discounts for greater adherence and success. While there are no public numbers available, the success rate is definitely not 70-90%.

Look at some of the stories here. People have been to the 10-day or another event, have been on the boards for years yet still struggle implementing the program and achieving success.

Dr. Ornish seems to believe that high levels of compliance on a low-fat, plant-based diet are largely due to the participants feeling better through their healthier dietary choices.

I think this is part of it but there is much more to the picture.

Thus, it appears that the low levels of compliance/adherence we see outside of the studies done by the WFPB researchers may be a result of the low-fat, WFPB diets being inadequately prescribed and adopted by the study participants, since LFWFPB leaders seem to find patients willing to adhere to the diets simply by experiencing the positive benefits of doing so.

I agree that this is an issue when others/outsiders do the implementation and try to teach our programs but not when it is done by these programs themselves. With outsiders, its hard to teach something you may not believe in, understand, or implement yourself.

However, you are hitting on another very important point. When you do come to one of our programs, you are highly motivated, educated and have pre-selected yourself. Usually there is also a significant health issue. This is much different then when the program is randomly applied to the general population regardless of who is teaching it. If you really think about that, these program should be getting 100% success rates not 70-90%.

However, as you have pointed out, long-term compliance may be difficult due to our toxic food environment, and accurately measuring and reporting adherence/compliance can vary significantly based on our definition of these terms.

Correct. This is why it is more than just "feeling better." As Dr Lisle says, part of the problem is that when in the pleasure trap, doing the wrong thing feels so good and doing the right thing doesn't feel good." Even when one finds success, exposure to the Pleasure Trap can very easily put someone right back there.

We live in a very toxic food environment where there is very little social and environmental support for what we do. This is not always easy for everyone to deal successfully with.

As it appears that a large majority of our research funding is directed toward the minutiae, if you had the choice, where would you like to see that funding directed instead? If Jeff Novick were the new tsar of all our public research funds, what types of studies do you feel would be the most beneficial to furthering the science? As we already have a wealth of peer-reviewed, published, scientific evidence suggesting that a LFWFPB dietary pattern is incredibly important for optimal health, should we now be studying how best to improve compliance/adherence over the long-term?

Yes. 100%. And how best to create an environment supportive to that.

When people finish a program and have seen tremendous results, that is not the real challenge. Of course they do. For me to see someones cholesterol drop from 300 to 150 in 10 days is not impressive. After all, they were locked up for 10 days, had all their food made for them, were under medical care and engaged in an intensive program of exercise, education etc. However, the real challenge is, what do we do to make sure that they have maintained those results 6 months and 1 year later. For me to see someone who has maintained their cholesterol at 150 at 6 months and at 1 year, is very impressive.

If you listened to one of Dr Abramson's talks at one of the ASW weekends, he said this. One of the questions was on, why don't we just teach this way of life to everyone and wouldn't that solve so many of the problems with healthcare. And he said no. That is not the real challenge. Sure, even if we taught the optimal diet to patients, we still have to figure out how to set the system up so it allows for that as right now, MD's can not spend hours with their patients on education and there is no reimbursement for that. We also have to figure out how to get people to comply as it is not that easy. He said this is the real challenge... not just telling his patient to quit smoking or eat better. The real challenge (and where he earns his real stripes as a health care professional/MD) Is when the patient returns in 3 months and is struggling in implementing it. How do you help them then and over the next year or two to implement it. That is the real challenge,

One of the keynote speakers at a recent major mainstream medical conference said, "Whoever figures out the key to continued engagement/compliance, will get a Nobel prize."

And, this challenge is no secret but has been long known.

The guys who ran Esalen watched peoples lives changed week in & week out for 40 years but said, regardless of the program of change & how powerful it was, within a few months the change was no longer being sustained. They wrote a book about this & why they think it happens & what it will take to really have an impact. It's called, The Life We Are Given. It's worth a read (though it proably wont have a lasting impact.)

http://www.amazon.com/gp/aw/d/087477792 ... ot_redir=1

When I first met with John Mackey about setting up the Wellness Clubs at WFM, these were the most important issues to me and this was one of the models we discussed.

Also, the IOM, CDC, WHO, etc all know this and have been publishing info on what it will take to really implement change.

Or, at this point, would the money be better spent attempting to create the infrastructure necessary for implementation of the LFWFPB dietary pattern and optimally healthy lifestyle, as the research seems to have already done well to establish the value of these interventions and patterns?

I agree.

We made substantial progress on smoking because it was much more than just people wanting to feel better. We had interventions and education but also changes in public policy, education, business etc etc, similar to what you see in the above graphic from the IOM. Same with our success with getting people to wear seat belts.

More to follow on what I think the key factors are, why we see 70-90% in some of the studies but not in the real world and why Dr Esselstyn had such a high success rate in his first study.

In Health
Jeff

[MikeyG]

Thanks, Jeff. I really appreciate your perspective, and I look forward to hearing more.

Please have a fantastic day.

[JeffN]

More to follow on what I think the key factors are, why we see 70-90% in some of the studies but not in the real world and why Dr Esselstyn had such a high success rate in his first study.

This is from his study..

http://www.dresselstyn.com/reversal01.htm

Adherence is the key factor upon which arrest and reversal therapy depends. Four techniques were used to promote adherence and reinforce the plant-based diet:

(1) At enrollment, treatment objectives were discussed in an in-depth, 60- to 90-minute interview with each participant and spouse.

(2) Patient adherence and lipid results were monitored through biweekiy visits for the first 5 years. Such immediate recognition in achieving lipid goals is critical reinforcement and provides the patient with real-time proof of success. Visits became monthly during the second 5-year period and have been quarterly for the past 2 years.

(3) Throughout the first year I called each patient on the evening of the clinic visit to review the lipid profile and any needed dietary or medication adjustments.

(4) Several times a year a group meeting was held at my home or the home of a participant to review treatment objectives, exchange menus, and socialize.

Continued frequent patient encounters appear critical to teach dietary knowledge and reinforce new habits. Patients reported that their physician's commitment to the same diet was additional motivation.

In regard to the above points...

These patients were pre-screened and selected and were all highly motivated and had to be local to be able to commit to the program which included local ongoing support and follow up.

The level of professional support and follow-up from Dr Esselstyn was tremendous and way beyond what is often provided or even available anywhere else. In regard to why he provided such support, he likes to quote a cancer researcher named J. Englebert Dunphy who said, (and I am paraphrasing Dr Esselstyn).. "Patients with cancer are not afraid of suffering. Patients with cancer are not afraid of dying. Patients with cancer are afraid of being abandoned by their family and their physician." Dr Esselstyn wanted to be there for them throughout the process. He created what he calls, "a covenant of trust" with each patient.

The support also included biweekiy visits for the first 5 years, monthly during the second 5-year period and quarterly for the rest of the study and group meetings. The group meetings, which were even held at group members houses on a rotating basis, created not only professional support bit also group support amongst the members. They became very supportive of each other.

He also kept the group size small on purpose and even to this day, the groups that he runs at the Cleveland Clinic Wellness Center are kept to 10-13 patients. Every patient, in order to make sure they have family/social support at home, is required to bring a spouse/sibling, or other family member. This limits the whole group to no more than 26.

Lastly, as he likes to say, we only have so many behavior modifications units (BMU). Therefore, he wanted all of a persons BMU's focused on diet/food, which he knew would make the biggest impact. This is why he didn't push exercise and stress management as part of the required program, and made food/diet the main focus.

BTW, this is what Dr Esselstyn means when he says, he has at least demonstrated, "proof of concept."

What this means, is that he has demonstrated that this concept, under a fairly well controlled situation, with a well selected highly motivated group, provided with a fairly high level of support, can achieve these results. He demonstrated the concept is possible.

It does not mean (or prove) that it will work with all people under all circumstances. However, it should work if someone else tries it under the exact same conditions. This is where replication comes in. Others now how to replicate his program, as he implemented it, and show they can get the same results. Then comes application. The program then has to be expanded to larger audiences in real life settings to see if these results can be applied to the greater population.

This is why so far, when someone else has tried to replicate the program and his results in the general population without providing the same "conditions," they do not get these same results. There is much more to this then just knowing the diet and eliminating animal products, refined foods and oils, etc.

If his education material was just given to 10,000 people and they were provided with even some of the same support, how well would they do? As we see from the above references we have listed from some other studies, and as we see here at the message boards, not as well.

As you can see, Dr Esselstyn's study populations was a unique situation and not one that is easily replicable and applicable to the real world as it currently exists. This is why I said earlier in the thread, I think our efforts need to be focused on how to create a culture and an environment that supports these changes so they can be replicable, applicable and sustainable in the world.

In Health,
Jeff

[MikeyG]

Thanks, Jeff. I really appreciate your taking the time to share your perspective, and I always benefit a great deal from any opportunity to learn from you.

Your insights seem to reinforce the reality that it will take far more than just health professionals to design and implement the community-based shifts necessary to really see sustained, public health impacts.

However, we can see from the work of many in the lifestyle medicine community, which I think has a wonderful asset in you, that health professionals can be extremely important in uncovering and implementing the wellness interventions that we can then scale up to benefit the wider population.

It definitely seems like we have some obstacles to overcome in scaling up these benefits, however. In direct legislation, we can observe that the public often pushes back against "sin taxes" that attempt to discourage unhealthy practices by making them more expensive for the individual participating. (Sin taxes: http://en.wikipedia.org/wiki/Sin_tax). One unfortunate example is that there is still significant opposition to anti-smoking legislation, despite the well-established evidence of the dangers of smoking (http://en.wikipedia.org/wiki/Smoking_ba ... -free_laws).

Public education seems routinely recommended as an excellent vehicle for change, especially as a more informed population may be less opposed to health-supporting legislation like sin taxes. However, since education is often a highly political subject as well, there appear to be challenges here, too, as individuals, especially parents, seem extremely wary of "paternalistic" efforts even if the evidence strongly supports them.

Helping society become more healthy does seem to be quite the undertaking. However, it is very encouraging to see the progress that health professionals like you are making in support of that goal.

Thank you, again, for all your efforts, as they are not only educational for me but also, as someone who would like to emulate your incredible work to serve our community, extremely inspirational. Please have a wonderful day.

Warmly,
Michael

[JeffN]

Thanks

I realize I left off one more that Dr Esseslstyn did not mention but Dr Ornish did and I think may be the most important of all of them.

As I posted above from one of Dr. Ornish's studies...

http://www.pmri.org/publications/1953.pdf

"They say, women completing the follow-up were younger and more likely to be employed. Men completing the follow-up were more likely to have a history of PTCA (Stent) and a family history of CAD, were more often previous smokers, consumed less alcohol, were living with someone, and cohabitating men tended to have their partner participate. Men who completed the program also expressed greater self-efficacy toward adherence to the program components. There were no other statistically significant differences in demo- graphic, medical, or psychosocial characteristics between those who completed the follow-up and those who did not."

.. as we can see, he mentioned most of the exact same ones as Dr Esselstyn, highly motivated and family/social support, but also one other, and that is "self-efficacy."

Self-efficacy is the extent or strength of one's belief, perception and convictions in one's own ability to complete tasks and reach goals.

I think that may be *the* individual characteristic/trait that makes all the others possible, at least in the current environment because while the program itself is easy, doing it in this world, is very difficult. Without a "greater degree of self-efficacy," it becomes even more difficult if not impossible due to the lack of social and environmental support for this way of life.

The research on lifestyle behavior change also supports the importance of self-efficacy. There is a full section on it called, "Self-Efficacy Enhancement," in this review paper..

http://circ.ahajournals.org/content/122 ... ull#ref-83

"Self-Efficacy Enhancement

Self-efficacy, a component of social cognitive theory, describes an individual's perception regarding his/her abilities to carry out actions necessary to perform certain behaviors (eg, making changes in diet or lifestyle).20 Perceived self-efficacy is a major determinant of performance independent of an individual's actual underlying skill.20 The strength of perceived self-efficacy is particularly important, as individuals are more likely to both initiate a behavior and continue their efforts until success is achieved if their perceived self-efficacy is higher.20 Thus enhancement of an individual's perceived self-efficacy can be incorporated into interventions to improve the likelihood of successful behavior change. Bandura's theory suggests 4 sources of self-efficacy that can be drawn on and incorporated into intervention strategies to enhance self-efficacy.82 The source with the greatest potential for increasing self-efficacy, mastery experiences, entails having a person successfully achieve a goal that is reasonable and proximal; for example, substituting fruit for a high-calorie dessert or being able to walk 1 mile. A second source, vicarious experience, consists of the individual witnessing someone who is similar in capability successfully perform the desired task; for example, observing patients exercise and improve their physical function in cardiac rehabilitation or watching a nonprofessional prepare a healthy meal. A third source, verbal persuasion, entails the provider persuading the person that he/she believes in the person's capability to perform the task. This is the weakest source for improving self-efficacy, but can be implemented via telephone or other electronic modes. The fourth source, physiological feedback, entails interpreting to the individual the meaning of different symptoms associated with behavior change. Examples include explaining that experiencing fewer symptoms with exertion is related to regular participation in a physical activity program or that feeling less fatigued or more comfortable is related to weight loss.20 An extensive body of evidence indicates that self-efficacy influences behavior change across all the behavior domains related to CVD risk reduction.83–92 Self-efficacy enhancements were incorporated into the interventions of several of the studies that yielded favorable outcomes."

There are many great references from that section to check out.

As described in this above paper, I think teaching self-efficacy should be a core part of these programs. We not only have to educate people on the program and teach them the necessary skills, but also how to actually succeed at them and how to empower them to believe they can and will succeed.

In Health
Jeff

[MikeyG]

Thanks, Jeff. That was amazing, as usual.

I think the emphasis on self-efficacy is a very important concept in all our pursuits, and I really appreciate that reminder.

Thanks for all your efforts. Please have a great day.

[JeffN]

Someone raised some important points about some of the studies but did not want to post them, so I will post them here for them.

I think they are of value to any discussion on this topic. The main point is that the compliance is not exactly as high as stated when all original study members are included and since the discussion is on compliance, drop outs must be accounted for.

From the original study of Dr Esselstyn

http://www.dresselstyn.com/site/study01/

Of the 22 participants, 5 dropped out within 2 years, and 17 maintained the diet

Compliance at 2 years...

17 of 22 = 77% compliance

11 of whom completed a mean of 5.5 years of follow-up.

Compliance at 5 years

11 of 17 = 65% compliance of the 17

11 of 22 = 50% compliance of the original 22

Disease was clinically arrested in all 11 participants, and none had new infarctions. Among the 11 remaining patients after 10 years, six continued the diet and had no further coronary events, whereas the five dropouts who resumed their pre-study diet reported 10 coronary events.

Compliance at 10 years..

6 of 11 is 55% compliance

6 of 17 is 35% compliance

6 of 22 is 27% compliance


From the 12 year follow up study.. (the numbers are slightly different)

http://www.dresselstyn.com/site/study02/

Six nonadherent patients were released within the first 12 to 18 months of the study, and they returned to standard care. By 1998, these patients, who initially had levels of angiographic and clinical disease equivalent to those of the adherent patients, had sustained 13 new cardiac events. The remaining 18 patients adhered to the study diet and medication for 5 years.

18 of 24 = 75% compliance

At 5 years, 11 of these patients underwent angiographic analysis by the percent stenosis method, which demonstrated disease arrest in all 11 (100%) and regression in 8 (73%).14

Compliance at 5 years

11 of 24 = 46% compliance

During the 7 years since the conclusion of the 5-year study, all but 1 patient have continued to adhere to the prescribed diet and medication. Today, 12 years after study inception, the mean total cholesterol of the patients is 145 mgldl (Table I).

If this is one of the 11, then compliance at 12 years

10 of 24 = 42% compliance


I think the point the person raised is important as it highlights the point I am making above. *If* we can get people to follow this program, it works and works very well. That is what Dr Esselstyn means by "proof of concept." However, that is a huge *if* because as we know and see in the above study, if you count everyone who enrolled, the compliance is not high.

This is why I say that the single most important issue to the success of this movement to the individual and to the population is not whether the program works or not, but how to create a culture and an environment that supports these changes so they can be replicable, applicable and sustainable in the world. Otherwise, there is no way this will ever become anything more than a program for those few who are really motivated to do it.

In Health
Jeff

[JeffN]

We are just finishing up a 10-Day program and this issue of long-term compliance was the topic of several discussions both formally in the lectures and informally around the meals.

During one lunchtime discussion on this issue, there was a women sitting with us at the table who had been successfully doing this program for over 30 years. So, I asked, her, tell us what you believe has been the most important factor to your long-term success. She didn't even hesitate and said, easy, simplicity. I keep it very simple.

So I asked, what do you think would be the next most important thing. And again, without hesitation she said, I just don't care what anyone else thinks of me.

Words of wisdom.

In Health
Jeff

[MikeyG]

Thanks for the additional insight into compliance, Jeff. (viewtopic.php?f=22&t=44133&p=463292&sid=1bc3b3e9e845db3f9b7b7830bf5c6ed3#p463292)

Simplicity does seem to be the key to success, especially as we try to make our last ten years as healthful as possible. (https://www.facebook.com/JeffNovickRD/p ... 2366190125)

However, I wonder if the "I just don't care what anyone else thinks of me," perspective that the highly compliant individual expressed could have some pitfalls.

All the individuals who are currently following less than evidence-based wellness practices seem like they would be in much better shape if they were open to outside information, which might allow them to see the flaws in their practices and correct them before any major health issues occur.

Yet you have mentioned before that you find that the most effective means of improving an individual's wellness practices is only after they realize the practices are not working for them. Would that ring true here, too?

So even if the individuals are open to outside information, would it be much more effective to wait to try to provide them with the insight and methods to make real changes in their lives until after they have decided, on their own, to pursue these changes? Again, this returns a quote I recall you frequently citing, "A man convinced against his will is of the same opinion still." It also corresponds very well to your advice that we should not engage in debates on wellness, but simply model the evidence-based methods that you help us identify and hope that the individuals we would like to help decide that they would like to follow our lead, too. (At which point, we direct them to www.jeffnovick.com ).

Thanks for all that you do to help provide us with numerous opportunities to make more evidence-based decisions in our lives. I sincerely appreciate the effort, and I am extremely thankful that you decided to choose the career that you did. My life is far better off due to your influence.

I hope you, and anyone else reading this, are having a fantastic day.

[JeffN]

However, I wonder if the "I just don't care what anyone else thinks of me," perspective that the highly compliant individual expressed could have some pitfalls.

I probably should have clarified the comment and its intent. After they made the comment, I asked them to explain.

What the person meant is that they are not concerned about sitting at the table and ordering and/or having different food. They are not concerned with being different in social situations.

Many of us fall prey to social pressure which can be a very slippery slope, as we wonder how we will handle family, friends, social events etc if we have to be "different." Many find it very difficult to deal with this ongoing social pressure and that is even why one of the keys to long-term compliance is social and environmental support.

To her, that was not an issue.

But, yes, being open to new and credible information, is important.

This was more about, what Dr Lisle might call, the battle for status.

I hope that helps

In Health
Jeff