Fascinating article in The Atlantic about weight loss
wanderinglight
Posts: 1,519 Member
I loved this article. It talks about using tools available to us (like MFP, or other online motivational / weight loss programs) is essentially echoing behavior modification systems based on punishment and reward. I liked that the focus was so much on how to keep weight OFF using sensible practices. Has anyone on MFP also used the Lose It program that they talk about?
http://www.theatlantic.com/magazine/archive/2012/06/the-perfected-self/8970/1/
(cut and pasted below as well -- warning, it's long!)
The Perfected Self
B. F. Skinner’s notorious theory of behavior modification was denounced by critics 50 years ago as a fascist, manipulative vehicle for government control. But Skinner’s ideas are making an unlikely comeback today, powered by smartphone apps that are transforming us into thinner, richer, all-around-better versions of ourselves. The only thing we have to give up? Free will.
By David H. Freedman
Frederik Broden
My younger brother Dan gradually put on weight over a decade, reaching 230 pounds two years ago, at the age of 50. Given his 5-foot-6 frame, that put him 45 pounds above the U.S. National Institutes of Health’s threshold of obesity. Accompanying this dubious milestone were a diagnosis of type 2 diabetes and multiple indicators of creeping heart disease, all of which left him on a regimen of drugs aimed at lowering his newly significant risks of becoming seriously ill and of dying at an unnecessarily early age.
He’d be in good company: a 2007 study by TheJournal of the American Medical Association found that each year, 160,000 Americans die early for reasons related to obesity, accounting for more than one in 20 deaths. The costs are not just bodily. Other studies have found that a person 70 or more pounds overweight racks up extra lifetime medical costs of as much as $30,000, a figure that varies with race and gender. And we seem to be just warming up: cardiologists who have looked at current childhood obesity rates and other health indicators predict a steep rise in heart disease over the next few decades, while a report from the Organization for Economic Cooperation and Development projected that two-thirds of the populations of some industrialized nations will be obese within 10 years.
Dan had always been a gregarious, confident, life-of-the-party sort of guy, but as his weight went up, he seemed to be winding down. Then, on a family visit to Washington, D.C., early last year, he and I dropped in on the National Gallery of Art, where 10 minutes of walking left him so sore in one leg that I had to find him a wheelchair. That evening, I decided to say the obvious: He was fast heading to incapacity and an early grave. He had a family to think of. He needed to get into some sort of weight-loss program. “Got any suggestions?” he retorted. As it happened, I did.
Today, my brother weighs 165 pounds—what he weighed at age 23—and his doctor has taken him off all his medications. He has his vigor back, and a brisk three-mile walk is a breeze for him.
Sorry if this sounds like a commercial for a miracle weight-loss program. But in fact my brother did it with plain old diet and exercise, by counting calories and walking. He had no surgery, took no supplements or pills, ate no unusual foods, had no dietary restrictions, embarked on no extreme exercise regimen. He will need to work his whole life to keep the weight off, but he shows every sign of being on the right track. He has changed his eating and exercise habits, and insists he enjoys the new ones more than the old.
In short, Dan seems a lot like many of the people in the National Weight-Control Registry, the research database of those who, despite the popular wisdom that avoiding weight regain is a Herculean task, have kept off a minimum of 30 pounds for at least a year. Most of us know someone who lost weight years ago and has kept it off, and we all see celebrities who claim to have slimmed down for good using plain old diet and exercise, from Bill Clinton to Drew Carey to Jennifer Hudson. But we keep hearing that the vast majority of us—98 percent is a figure that gets thrown about—can’t expect to do the same.
Alcoholics don’t seem to face such dismal prospects, thanks to Alcoholics Anonymous and similar multistep programs, which are widely regarded as effective treatments. With obesity, we’re apparently at a loss for a clear answer. Fads like the Atkins diet slowly fade in popularity after dieters watch the weight return. We’re left with the impression that the techniques needed to permanently lose weight don’t exist, or apply to only a tiny percentage of the population, who must be freaks of willpower or the beneficiaries of exotic genes. Scientists and journalists have lined up in recent years to pronounce the diet-and-exercise regimen a nearly lost cause—a view argued in no fewer than three cover stories and another major article in The New York Times Magazine over the past 10 years, and in a cover story in this magazine two years ago.
All of which is odd, because weight-loss experts have been in fairly strong agreement for some time that a particular type of diet-and-exercise program can produce modest, long-term weight loss for most people. But this program tends to be based in clinics operated by relatively high-priced professionals, and requires a significant time commitment from participants—it would be as if the only way to get treated for alcoholism were to check into the Betty Ford Center. The problem is not that we don’t know of a weight-control approach that works; it’s that what works has historically been expensive and inconvenient.
But now that’s changing. Consider my brother, who has never been to a weight-loss clinic. His program has taken place entirely in his home, at his office, and when he’s out at restaurants or visiting friends and family—and it happens at his convenience, or even automatically, literally without his doing more than lifting a finger.
Early studies of a fast-expanding pool of electronic weight-loss aids suggest that, by allowing people like Dan to construct their own regimen on their phone and computer, these tools could be a key to reversing the obesity epidemic. Applied across the health-care spectrum—to improve senior care, fix sleep problems, and cure addiction, for example—these affordable, accessible tools could radically change the way we conceive of and administer health care, potentially saving the system billions of dollars in the process.
And the basic formula underlying Dan’s weight loss reaches well beyond health. Behavioral technology allows users to gradually and permanently alter all kinds of behavior, from reducing their energy use to controlling their spending. Now, with the help of our iPhones and a few Facebook friends, we can train ourselves to lead healthier, safer, eco-friendlier, more financially secure, and more productive lives.
Ironically, this high-tech behavioral revolution is rooted in the work of a mid-century psychologist once maligned as morally bankrupt, even fascist. But the rise of social media has reoriented our societal paranoias, and more and more people are incorporating his theories into their daily lives. As a result, psychology’s most misunderstood visionary may finally get his due.
In 1965, when Julie Vargas was a student in a graduate psychology class, her professor introduced the topic of B. F. Skinner, the Harvard psychologist who, in the late 1930s, had developed a theory of “operant conditioning.” After the professor explained the evidently distasteful, outmoded process that became more popularly known as behavior modification, Vargas’s classmates began discussing the common knowledge that Skinner had used the harsh techniques on his daughter, leaving her mentally disturbed and institutionalized. Vargas raised her hand and stated that Skinner in fact had had two daughters, and that both were living perfectly normal lives. “I didn’t see any need to embarrass them by mentioning that I was one of those daughters,” she says.
Vargas is a retired education professor who today runs the B. F. Skinner Foundation out of a one-room office in Cambridge, Massachusetts, a block away from Harvard Yard. The foundation’s purpose is largely archival, and Vargas spends three days a week poring over boxes and shelves full of lab notes, correspondence, and publications by her father, who died in 1990. A prim but engaging woman, Vargas can’t seem to help seething a bit about how her father’s work was perceived. She showed me a letter written in 1975 by the then wildly popular and influential pediatrician Benjamin Spock, who had been asked to comment on Skinner’s work for a documentary. “I’m embarrassed to say I haven’t read any of his work,” Spock wrote, “but I know that it’s fascist and manipulative, and therefore I can’t approve of it.”
Skinner’s reputation has hardly improved with time. I shared with Vargas a recent Philadelphia Inquirer article by a science reporter who passed along this assessment of “that famed rat researcher B. F. Skinner” and the behaviorists who followed him: “[They] thought homosexuality was a mental illness that could be cured, usually by giving electric shocks and other painful stimuli to try to create an aversion to homosexual thoughts.”
Vargas could only shake her head. Skinner employed punishment in one early experiment—through a device that delivered a light rap to a rat’s paw—and was so disturbed that he never used it again, arguing passionately and publicly throughout the rest of his life against the use of punishment in school, at home, and in the workplace. And he never had anything to do with trying to change sexual orientation, or any other aspect of identity. Skinner sought to shape only consciously chosen, directly observable behavior, and only with rewards; the entirely un-Skinnerian therapy to which the reporter was alluding is a form of “classical,” or “Pavlovian,” conditioning that trains a subject to reflexively associate a pleasant stimulation with an unpleasant one. The field Skinner founded, known as “behavior analysis,” has overwhelmingly hewed to the example he set in these regards. (And, for the record, “that famed rat researcher” worked, except in his earliest experiments, almost exclusively with pigeons.)
Spock and the Inquirer reporter are typical of Skinner’s critics in their ignorance of his work, yet Skinner’s theory was at its core so simple that it sounds purely commonsensical today: all organisms tend to do what the world around them rewards them for doing. When an organism is in some way prompted to perform a certain behavior, and that behavior is “reinforced”—with a pat on the back, nourishment, comfort, money—the organism is more likely to repeat the behavior. As anyone who has ever taught a dog to sit or a child to say “please” knows, if the cycle of behavior and reinforcement is repeated enough times, the behavior becomes habitual, though it might occasionally need a booster shot of reinforcement.
Skinner himself worked mostly with animals, famously training pigeons to guide missiles by pecking on a video screen placed inside the nose cone. But his followers went on to demonstrate in thousands of human studies that gentle, punishment-free behavior-modification techniques could improve learning, modify destructive habits, and generally help people lead healthier, more satisfying, more productive lives.
Behaviorism exploded in prominence in the 1950s and ’60s, both in academic circles and in the public consciousness. But many academics, not to mention the world’s growing supply of psychotherapists, had already staked their careers on the sort of probing of thoughts and emotions that behaviorism tends to downplay. The attacks began in the late 1950s. Noam Chomsky, then a rising star at MIT, and other thinkers in the soon-to-be-dominant field of cognitive science acknowledged that behavior modification worked on animals but claimed it did not work on people—that we’re too smart for that sort of thing. Then, seizing on Skinner’s loudly proclaimed conviction that communities should actively shape human behavior to promote social justice and harmony, they argued that if behavior modification were to work on humans, it would be a morally repugnant and even fascist method of forcing people to toe an official line.
In 1971, Stanley Kubrick’s seminal film A Clockwork Orange echoed this fear by centering on a government’s attempt to reduce criminal behavior via methods amounting to a brutal caricature of behavior modification: the “debilitating and will-sapping techniques of conditioning” that presaged “the full apparatus of totalitarianism,” as one character puts it. (The movie actually depicts Pavlovian, not Skinnerian, conditioning—a distinction lost on the public.) That same year, Time put Skinner on its cover, headlining its profile “Skinner’s Utopia: Panacea, or Path to Hell?” The overheated charges stuck. By the mid-1970s, the behavior-analysis field had essentially gone underground, its remaining practitioners having moved from prominent universities to relatively obscure ones.
Vargas took me to Harvard to see one of the few signs that her father was once the luminary of its psychology department, or indeed that he was ever there: an odd, cluttered display of circuit boards, random machinery, and a photo of Skinner, placed next to a self-service café in the basement of the psychology building, a curiosity to be contemplated over a cappuccino.
Skinner remains a staple of Psych 101 at most colleges, but typically only for a brief, often sneering mention, as if behaviorism was a strange, ugly fad. “He became a whipping boy for cognitive scientists,” says Dean Keith Simonton, a psychologist at the University of California at Davis, who has studied how his field views Skinner. “Psychology students were taught that his techniques didn’t work, that it was a bad direction for psychology to go in, and that he was a bad person, though he wasn’t. He just got kind of a bad rap.” It was a rap that the public bought wholesale, notes Christopher Bryan, a psychologist at UC San Diego. “There was a notion that there’s something icky about psychological techniques intended to manipulate people,” he says.
It made little difference that holdout behaviorists continued to accumulate evidence that Skinner’s techniques helped tame all sorts of otherwise confounding behavioral problems, including nail-biting, narcotics addiction, child abuse, and, yes, criminal recidivism (no Clockwork Orange–style punishment involved). But the most stunning example was autism: studies in the late 1980s and early ’90s established that behavior analysis, unlike any other treatment, was effective in helping children with autism communicate, learn, and refrain from violent behavior, to the extent that some patients shed their diagnosis. The success with autism pumped money into the field of behavior analysis, leading many of its researchers to look for other big challenges. And by the beginning of the 21st century, there was widespread concern about an obesity epidemic.
That Skinner’s theory could be successfully applied to obesity was no surprise. Decades earlier, when no one spoke of an obesity problem, Skinner had been writing about diet and exercise as an example of how behavior could be modified. In a 1957 paper in American Scientist, he cited a Harvard University study in which rats were conditioned to eat when they weren’t hungry, causing what Skinner called “behavioral obesity.” His followers did not have to reach far for the converse, speculating that an organism might be induced to willingly reduce food intake, were it rewarded for doing so.
They were eventually proved right by Weight Watchers, which launched its “behavior modification plan” in the mid-1970s. The program’s close adherence to Skinner’s basic principles has consistently garnered some of the best long-term weight-loss results of any mass-market program. The key characteristic of Weight Watchers and other Skinnerian weight-loss programs is the support and encouragement they provide to help participants stick with them. (Much the same is true of AA, which is strikingly similar to a behavior-modification program.) Weight Watchers and the other programs do not claim to magically burn fat, or make appetite disappear, or blast abs. They aim to gradually establish healthful eating and moderate exercise as comfortable, rewarding routines of daily life rather than punishing battles of willpower and deprivation.
The specifics may sound familiar: set modest goals (to encourage sustainable progress and frequent reinforcement); rigorously track food intake and weight (precise measurement is key to changing behavior, especially when it comes to eating, since a few bites a day can make the difference between weight loss and weight gain); obtain counseling or coaching (to diagnose what environmental factors are prompting or rewarding certain behaviors); turn to fellow participants for support (little is more reinforcing than encouragement from peers, who can also help with problem-solving); transition to less-calorie-dense foods (to avoid the powerful, immediate reinforcement provided by rich foods); and move your body more often, any way you like (to burn calories in a nonpunishing way).
Study after study proves the effectiveness of this rough Skinnerian formula, which is the basis of the great majority of well-regarded weight-loss programs. “Willpower doesn’t work,” says Jean Harvey-Berino, a University of Vermont behavioral scientist who researches weight-loss methods. “What works heavily relies on Skinner—shaping behavior over time by giving feedback, and setting up environments where people aren’t stimulated to eat the wrong foods.” As the evidence continues to pile up, it’s getting harder to find weight-loss researchers who disagree, says Jennifer Shapiro, a psychologist specializing in weight loss and the scientific director at Santech, a San Diego health-technology firm. “More and more studies demonstrate the effectiveness of behavioral approaches based on Skinnerian reinforcement.”
Not that Skinner ever gets much credit. The experts who run successful behavioral weight-loss programs, including Weight Watchers, seem at best vaguely aware of these techniques’ Skinnerian roots, or choose to downplay them. Instead, they frame their programs in the more fashionable terms of behavioral economics or social-cognitive theory, or offer the nontheoretical argument that they just plain work. But this would have been fine with Skinner, says Vargas. “He used to say that the ultimate worth of a science is in how much good it can do in the world.”
So widely accepted is the long-term effectiveness of Skinnerian weight-loss programs that most well-regarded bariatric-surgery clinics require patients to follow such a program before surgery, in order to prove their ability to avoid regaining much or even most of the weight after—as more than one-fourth of bariatric patients eventually do, according to some studies. Even clinical programs for rapid weight loss rely on Skinner’s tenets. The 25-year-old Weight Management Program at the Miriam Hospital—one of Brown University’s teaching hospitals in Providence, Rhode Island, and the home of the National Weight-Control Registry—is a highly regarded program in which many of the patients are more than 200 pounds overweight. Typically, patients are started out on an Optifast diet, a physician-mediated program that replaces some or all meals with liquids and food bars in order to “give patients some distance from food,” as one psychologist there puts it. But the Miriam program’s goal is for its patients to gradually build healthy eating habits with ordinary food, and to add in daily walks. The program reports that about one-third of its patients keep all the weight off for two or more years. And that figure, which is some 16 times the success rate implied by the “98 percent gain it all back” statistic we keep hearing, turns out to be fairly typical of leading clinical weight-loss programs.
But despite their relative success, Skinnerian weight-loss programs have not become the default treatment for obesity the way AA has for alcoholism. One reason, of course, is that most would-be weight-losers can’t afford these programs (insurance usually won’t cover them) or don’t have the time, patience, or motivation to commit to one. At up to $3,500, the six-month Miriam outpatient program is a relatively good deal, especially compared with Canyon Ranch, which offers a well-regarded residential program for about $1,200 a day.
“We know how to get people to eat healthier and exercise,” says Steven Blair, an exercise and epidemiology researcher at the University of South Carolina. “The question is how to roll out the needed behavioral strategies to 50 million unfit adults in the U.S. Even if there were enough trained counselors to work with that many people, which there aren’t, the cost issues would be overwhelming.”
And there’s another limitation. These programs work by sticking participants in a “Skinner box”—which was, literally, a closed glass box in which Skinner trained his animals; figuratively, it’s an environment that can be tightly controlled and in which behavior can be rigorously tracked, so as to ensure the dominance of the prompts and reinforcements that lead to a desired change. When a patient is “in the box”—that is, actively participating in a formal program—results are reliably good. The bigger challenge comes when people leave the program to plunge back into an environment rife with caloric temptation.
Most programs try to provide remote monitoring and support, but inevitably, many patients let these looser ties dissolve, and then they gain back weight. That’s why these programs tend to report long-term success rates of only about 30 percent. This is a much bigger problem for mass-market programs like Weight Watchers, which don’t charge enough to offer individual coaching or frequent, intimate group meetings. Effective as it is for a highly affordable program, Weight Watchers places its clients in a Skinner box of gossamer walls.
Twelve years ago, Michael Cameron was on his hands and knees in his doctor’s office. He had once been able to do dozens of push-ups, but because he had put on 105 pounds in the five years since college, his arms now shook with the effort of not collapsing to the floor. “What’s wrong with me?” he moaned. His doctor suggested antidepressants. Cameron walked out of the office and had an epiphany. “I thought to myself, I know how to solve this problem,” he says.
Actually, solving behavior problems was what he did for a living. Cameron was an experimental psychologist specializing in behavior analysis at McLean Hospital, Harvard’s teaching hospital for psychiatric disorders, and was the founding chairman of the behavioral-analysis department at Simmons College, in Boston. Amid all the various weight-loss solutions he’d considered, he’d never thought to try his own field’s techniques. Now he asked himself: What would Skinner do?
Cameron looked for aspects of his environment that were abetting his overeating. He worked nonstop at the office, eating very little there, so he was famished when his commute home took him past a long line of fast-food restaurants. After scarfing a meal from one of those, he would come home to a paperwork session conducive to the mindless munching of calorie-bomb snacks—he was particularly partial to peanut butter. He would vow to exercise the next morning but find himself running out the door to work instead. Little by little, he started making changes. He prioritized eating a decent breakfast and lunch, and found a new route home that bypassed the junky restaurants. He came home and immediately prepared healthy snacks, including a low-calorie peanut-based food, so they’d be in front of him while he worked. To kick-start his workouts, he got his gym bag ready at night and left it in front of the door. He religiously tracked his food intake, exercise, and weight, graphing the results to see how his efforts were paying off. He enlisted his colleagues, friends, and family to support him.
Cameron eventually lost more than 100 pounds, and has kept every one of them off in the years since, losing a few more besides. Though he focuses on children with special needs—he’s now the clinical director of Pacific Child and Family Associates, a national chain of clinics headquartered in Santa Paula, California—he also works independently with a small number of clients who want to lose weight. Five years ago, recognizing that he didn’t have time to personally help as many people as he’d like, he started wondering how he could extend his reach. Could weight-loss programs be administered remotely, or even in a semi-automated fashion?
The tools seemed to exist. Plenty of Web-based programs tracked food intake and exercise, and smartphone apps were starting to offer similar options. Videoconferencing allowed not only for remote one-on-one coaching, but also for group meetings. And Twitter made impromptu check-ins, questions, and encouragement easy. “I realized there wasn’t any part of it that couldn’t be done on a screen,” Cameron says. “And that meant it would be easy to scale up.” He started some pilot projects, enlisting graduate students to help coach and lead groups.
It was Cameron’s name I gave to my brother that night—I had heard about his program from scientists in the behavior-modification field. Starting a few weeks later, the first thing Dan did every morning was step on a scale that wirelessly transmitted his weight to his computer, which automatically Tweeted any loss or gain to the other participants in Cameron’s program. Every time I saw him, he’d pull out his phone to read an encouraging tweet from one of them, or fire off one of his own, or plug in the components of the meal he was eating, or check how many minutes of walking he’d logged that day. Sometimes he’d excuse himself for 10 minutes to take part in a group meeting on his laptop.
Over the course of a few months, I watched him gradually transform from the guy who had always piled his plate high with fried chicken and french fries to the guy who seemed genuinely thrilled to cap off a brisk walk with a piece of grilled fish, some beans, and a salad. As the habits set and his weight stabilized near his goal, the formal prompts and supports of the program were slowly “faded.” But the new routines seem to have stuck. (I just called him to check—he weighed 168 this morning.) Cameron has followed up with many of his past clients, and reports that all of them have kept the weight off.
Cameron was ahead of the game, but the world has been catching up to him quickly. Jeff Hyman, a successful serial Internet entrepreneur, spent one week and about $14,000 for himself and his wife at Canyon Ranch three years ago, and was struck both by the effectiveness of its behavior-modification approach and by the realization that the same techniques could be applied online at a much lower cost. He recruited two highly regarded behavior change–focused obesity researchers to design a one-year, Web-based program called Retrofit, which launched late last year.
Retrofit users track their eating and exercise online and have weekly Skype sessions with a registered dietician, a psychologist, and a “mind-set coach.” (If a client loses 10 percent of his or her weight by the end of the year, Hyman doubles these three employees’ compensation for that particular client.) After the year is up, clients can still arrange occasional consultations, and Retrofit continues to monitor their weight via wireless scale, so that a coach can reach out if the number starts to rise. “We have no interest in helping you lose weight” temporarily, says Hyman. “We want you to keep weight off.”
Though Cameron’s and Hyman’s programs create relatively effective virtual Skinner boxes, they don’t solve the cost problem. Retrofit charges about $3,000, and while Cameron hasn’t charged for his services, he calculates that were he doing this for a living, his fees would have to be in that ballpark as well. That’s a bargain for intensive programs of this sort, but still out of range for much of the public. The reason, of course, is that both programs remain dependent on relatively highly paid professionals to deliver the sort of one-on-one behavioral coaching and problem-solving that has always been key to Skinnerian behavior change.
But technology is radically lowering that cost barrier. Today, for absolutely nothing, would-be weight-losers can download many of the key elements of a Skinnerian behavior-modification program directly to their phones and computers. One of the most popular options is Lose It, an app and Web site that allows users to pick a goal weight and a time line for reaching it, and then formulates a daily calorie count accordingly. Lose It then lets users track their eating and physical activity, which they can do by holding their phones up to a food package’s barcode, or by tapping the screen a few times at the start and end of a walk (the app offers a range of activity categories, including guitar strumming, household walking, and sex). Lose It uses this data to provide clear, graphic feedback on users’ daily progress—you might see at a glance that having dessert will send your numbers into the red, but that if you walk for 20 minutes after dessert, you’ll go back into the green.
My wife, who has been struggling with her weight since the birth of our third child nearly two decades ago, started using Lose It late last year. Within three months, she was down to her college weight. Now several of her friends, family members, and colleagues have downloaded the app and are using it to lose weight steadily and comfortably. Lose It’s Boston-based parent company claims 10 million users so far and an average per-user weight loss of 12 pounds—an amount most doctors consider enough to dramatically improve health. Weight Watchers has since released a roughly similar app of its own.
Like most other Skinnerian weight-loss apps, Lose It lets you share your data with others for that all-important social support. But some tools take this sharing much further. Rajiv Kumar and Brad Weinberg, while on rounds as medical students at Brown University six years ago, were struck by the observation that the patients who lost weight or made other difficult changes in their behavior seemed to be the ones who set clear goals and then got lots of encouragement to meet them from friends, family, and co-workers, and especially from fellow weight-losers. Kumar and Weinberg took two years off from medical school to found Shape Up RI, a nonprofit with a Web site that allowed users to compete against one another on weight-loss and fitness teams. Shape Up RI tracked steps walked, miles run, vegetables eaten, and pounds lost, sharing that information among teammates, competitors, and supporters. Today, a for-profit offshoot, ShapeUp, caters mostly to large companies that run team competitions among employees; reinforcement may take the form of prizes, perks, and even money. Kumar, who is now ShapeUp’s chief medical officer, says that the 14,000 employees at one large client have logged nearly 5 billion steps and lost some 41,000 pounds—a shrewd investment for the employer and insurer paying their health-care costs.
Other apps make use of punishment, a technique that Skinner did not approve of but that can be smartly incorporated into an otherwise Skinnerian program. GymPact, an iPhone app, asks users to commit to visiting a gym a certain number of times each week and agree to forfeit at least $5 each time they skip. The app confirms users’ presence at their gym via GPS and charges their credit card if they don’t show up as planned. The company then divvies up the skip fees among those who honor their weekly commitments—so you get reinforced for going, and punished for not going.
So far, the scientific literature is proving these programs effective. When the University of Vermont’s Harvey-Berino studied the effectiveness of online Skinnerian weight-loss support groups, for example, she found that the results in pounds lost were comparable to results achieved by in-person groups. She’s now conducting a larger study with $3.5 million in funding from the National Institutes of Health, which, along with the Centers for Disease Control and Prevention, has increasingly thrown its support behind behavioral approaches to obesity. (Michelle Obama’s “Let’s Move” campaign is essentially Skinnerian, seeking to change children’s environments in ways that encourage them to make small changes in what they eat and how much they exercise; the program is even sponsoring the development of diet-and-exercise apps.)
Abby King, a leading health-related behavior-change researcher at Stanford University, has studied smartphone apps that aim to get older, non-technology-savvy people to move more throughout the day. The study subjects, most of whom had never used a smartphone before, significantly increased their activity. “If it works on them, it will work on anyone,” says King. “Skinner was right-on, in terms of any sentient being from pigeons to humans responding to setting goals, tracking progress, and getting feedback. These tools can provide all that, and can reach into any population to do it.”
Looking forward, improvements in the technology powering these apps should sharpen their impact. “This line of research is beginning to blossom,” says the University of South Carolina’s Blair, who recently helped the school land $6 million in funding for a new center studying technology-driven weight loss and related behavioral changes. “Right now we can get 30 percent of people to change their behavior, which is huge, but we’ll learn to get 40 percent, and then maybe 50 percent.”
One turning point will come when smartphone apps can automatically tailor their recommendations and feedback to an individual user’s behavior, just as a real-life behavior analyst would. In a review study for the International Journal of Obesity, Hirohito Sone, a researcher at the University of Tsukuba, in Japan, concluded that while weight-loss programs that include online tools are already more effective than conventional programs, individualization of these tools will take them much further. Details that these programs may eventually take into account, he says, include “lifestyle and environmental factors like types of job, whom you live with, how busy you are, what ethnic group you belong to, and what kind of activity or type of food and drinks you like.”
That may sound like a tall order for a smartphone app, but software and hardware improve substantially almost month to month. Michael Cameron is investigating developing “smart algorithms” that would take care of much of what he now does in the process of helping people lose weight. “The software will pick up the behavior patterns,” he says. “You might still need someone to have an occasional conversation with the client about the patterns, but as soon as you start automating and guiding decision-making, the need for a person like me becomes much more manageable.”
Cameron helped my brother Dan notice, for example, that he tended to take the longest walks when he set out after dinner, with a family member, and recommended making that a daily routine. A smartphone, by using GPS to track when Dan walked and a family-and-friend-tracking app to note whom he was with, could easily have done the same. Eventually, Cameron says, phones will be able to track swallowing and stomach distension to provide even better analysis of eating habits, without requiring the user to so much as tap the screen.
Dozens of research centers and hundreds of millions of dollars in investment in mobile-health technology have made such capabilities imminent possibilities. “It’s all about finding ways to automate Skinnerian conditioned reinforcement,” says Stephen Intille, a researcher at Northeastern University’s new doctoral program in “personal health informatics.” “You put sensors in phones and throughout the home, you develop algorithms that can infer what people are doing, and then you provide tailored automatic feedback that reinforces the right behaviors.”
The mobile-health field—“mHealth” to those in the know—is a rapidly growing subset of the tech-heavy, preventive approach to health care that was a foundation of the Obama administration’s reform bill. Health-insurance companies and government officials alike are drawn to the ability of smartphone apps to reach tough-to-access patients, to effect long-term lifestyle changes, and to do it all at a very low cost. Weight loss is just one example. Today, an iPhone owner can also download Skinnerian apps to help her stick to her birth-control schedule, monitor her blood sugar, quit smoking, or get more sleep. Mobile health’s potential savings to the health-care system are enormous. A 2010 study by one research firm reckoned that the savings in the United States and Canada from mobile monitoring of patient health could climb to as much as $6 billion a year by 2014. If mobile apps could reduce obesity and its associated costs by just 5 percent, the savings would amount to about $15 billion a year in the U.S. alone. The effect on eldercare would be even larger; a Boston Consulting Group report from earlier this year projects a possible cost reduction of 25 percent, which by one study’s figures would amount to about $30 billion.
This potential has made investment in this technology a no-brainer for health insurers and corporations. Blue Cross and Blue Shield of North Carolina, like many large insurers, offers its members Web-based weight-management and exercise-promoting tools, and is looking into providing mobile apps. “We’re very excited about the potential of these tools,” says Dr. Don Bradley, the company’s chief medical officer. “Up to 70 percent of health-care costs are related to lifestyle. If we can’t control those costs, we can’t keep our products affordable.”
And the outsized effect of simple Skinnerian tools has not been limited to health. Any number of apps allow users to kick other bad habits or cement good ones. Urge, a two-year-old “mobile behavior change company” based in Nashville, offers an app that prompts users to hold off on impulse purchases so they can hit budgeting goals, and reinforces their frugal decisions by tracking money saved for the purchase of a coveted item. Apps such as Habit Maker, Habit Breaker let users choose the behavior they’d like to target, whether it’s saying “thank you” more or going shopping less.
In Silicon Valley and the Bay Area, start-ups hawking these apps are becoming so common that you can’t avoid bumping into their founders. At Palo Alto’s storied University Coffee Cafe, I recently found myself sitting next to a young fellow named Yoav Lurie, who turned out to be running a Boulder-based company called Simple Energy, which uses Facebook as a social-reinforcement tool for conserving energy by tracking, sharing, and reinforcing certain behaviors. The product, like many of its competitors in the booming field of energy-related apps, is sponsored by large utility companies incentivized to reduce their reliance on conventional power sources.
Government agencies are in a similar position to benefit. I was speaking with a manager at the U.S. Department of Transportation about public transit when he mentioned that the agency is testing an app that provides local travelers with various transportation options for specific trips and that could gently reinforce decisions to use public transit by pointing out the extra calories commuters would burn by walking to the station and the carbon they’d avoid emitting by leaving their cars at home.
Of course, none of these tools would have much of a future if the public continued to harbor the kind of Big Brother paranoia that smeared Skinner’s reputation. Should we be wary of utilities that try to shift our energy use or health insurers that try to change our diets? Skinner would have celebrated these efforts, for their capacity to change society on a grand scale. But at what point does the interest of the individual diverge from the interest of corporations or the government—and will we even notice, if we’ve already surrendered all our choices to our iPhones?
The central irony of Skinner’s theory is that to control our behavior, we must accept a fundamental lack of control, acknowledging that our environment ultimately holds the reins. But an individual choosing to alter his environment to affect his behavior is one thing; a corporation or a government altering an individual’s environment to affect his behavior is another. The line between the two scenarios can blur. Nowadays most of us aren’t likely to wonder about the DOT’s motives when it urges us to take the light-rail instead of a cab. If it benefits the commuter, the government, and the environment, then what’s the problem? But the very definition of the Skinner box is that the inhabitant is not in control. In fact, he may not even know he’s in the box.
Julie Vargas, who lives with her husband in the house she grew up in, a few miles from Harvard, showed me her father’s study, which she has left untouched. It turned out to be the crowded basement sanctum of an inveterate tinkerer and gadget guy. Lacking WiFi and Bluetooth in his office, Skinner had jury-rigged strings and all sorts of wooden and cardboard doodads that enabled him to tweak his environment from his desk chair: by hiding the face of a clock he found himself watching, or by turning on a tape recorder that inspired him to organize his thoughts.
Though more advanced in execution, today’s electronic nudges and tweaks are identical in purpose: use what you can control to affect what you can’t. The simple elegance of this concept flips on its head Chomsky’s suggestion that behavior modification treats people as if they were no more intelligent than animals. What distinguishes our intellect from animals’ is not that we can go against our environment—most of us can’t, not in the long run—but rather that we can purposefully alter our environment to shape our behavior in ways we choose.
http://www.theatlantic.com/magazine/archive/2012/06/the-perfected-self/8970/1/
(cut and pasted below as well -- warning, it's long!)
The Perfected Self
B. F. Skinner’s notorious theory of behavior modification was denounced by critics 50 years ago as a fascist, manipulative vehicle for government control. But Skinner’s ideas are making an unlikely comeback today, powered by smartphone apps that are transforming us into thinner, richer, all-around-better versions of ourselves. The only thing we have to give up? Free will.
By David H. Freedman
Frederik Broden
My younger brother Dan gradually put on weight over a decade, reaching 230 pounds two years ago, at the age of 50. Given his 5-foot-6 frame, that put him 45 pounds above the U.S. National Institutes of Health’s threshold of obesity. Accompanying this dubious milestone were a diagnosis of type 2 diabetes and multiple indicators of creeping heart disease, all of which left him on a regimen of drugs aimed at lowering his newly significant risks of becoming seriously ill and of dying at an unnecessarily early age.
He’d be in good company: a 2007 study by TheJournal of the American Medical Association found that each year, 160,000 Americans die early for reasons related to obesity, accounting for more than one in 20 deaths. The costs are not just bodily. Other studies have found that a person 70 or more pounds overweight racks up extra lifetime medical costs of as much as $30,000, a figure that varies with race and gender. And we seem to be just warming up: cardiologists who have looked at current childhood obesity rates and other health indicators predict a steep rise in heart disease over the next few decades, while a report from the Organization for Economic Cooperation and Development projected that two-thirds of the populations of some industrialized nations will be obese within 10 years.
Dan had always been a gregarious, confident, life-of-the-party sort of guy, but as his weight went up, he seemed to be winding down. Then, on a family visit to Washington, D.C., early last year, he and I dropped in on the National Gallery of Art, where 10 minutes of walking left him so sore in one leg that I had to find him a wheelchair. That evening, I decided to say the obvious: He was fast heading to incapacity and an early grave. He had a family to think of. He needed to get into some sort of weight-loss program. “Got any suggestions?” he retorted. As it happened, I did.
Today, my brother weighs 165 pounds—what he weighed at age 23—and his doctor has taken him off all his medications. He has his vigor back, and a brisk three-mile walk is a breeze for him.
Sorry if this sounds like a commercial for a miracle weight-loss program. But in fact my brother did it with plain old diet and exercise, by counting calories and walking. He had no surgery, took no supplements or pills, ate no unusual foods, had no dietary restrictions, embarked on no extreme exercise regimen. He will need to work his whole life to keep the weight off, but he shows every sign of being on the right track. He has changed his eating and exercise habits, and insists he enjoys the new ones more than the old.
In short, Dan seems a lot like many of the people in the National Weight-Control Registry, the research database of those who, despite the popular wisdom that avoiding weight regain is a Herculean task, have kept off a minimum of 30 pounds for at least a year. Most of us know someone who lost weight years ago and has kept it off, and we all see celebrities who claim to have slimmed down for good using plain old diet and exercise, from Bill Clinton to Drew Carey to Jennifer Hudson. But we keep hearing that the vast majority of us—98 percent is a figure that gets thrown about—can’t expect to do the same.
Alcoholics don’t seem to face such dismal prospects, thanks to Alcoholics Anonymous and similar multistep programs, which are widely regarded as effective treatments. With obesity, we’re apparently at a loss for a clear answer. Fads like the Atkins diet slowly fade in popularity after dieters watch the weight return. We’re left with the impression that the techniques needed to permanently lose weight don’t exist, or apply to only a tiny percentage of the population, who must be freaks of willpower or the beneficiaries of exotic genes. Scientists and journalists have lined up in recent years to pronounce the diet-and-exercise regimen a nearly lost cause—a view argued in no fewer than three cover stories and another major article in The New York Times Magazine over the past 10 years, and in a cover story in this magazine two years ago.
All of which is odd, because weight-loss experts have been in fairly strong agreement for some time that a particular type of diet-and-exercise program can produce modest, long-term weight loss for most people. But this program tends to be based in clinics operated by relatively high-priced professionals, and requires a significant time commitment from participants—it would be as if the only way to get treated for alcoholism were to check into the Betty Ford Center. The problem is not that we don’t know of a weight-control approach that works; it’s that what works has historically been expensive and inconvenient.
But now that’s changing. Consider my brother, who has never been to a weight-loss clinic. His program has taken place entirely in his home, at his office, and when he’s out at restaurants or visiting friends and family—and it happens at his convenience, or even automatically, literally without his doing more than lifting a finger.
Early studies of a fast-expanding pool of electronic weight-loss aids suggest that, by allowing people like Dan to construct their own regimen on their phone and computer, these tools could be a key to reversing the obesity epidemic. Applied across the health-care spectrum—to improve senior care, fix sleep problems, and cure addiction, for example—these affordable, accessible tools could radically change the way we conceive of and administer health care, potentially saving the system billions of dollars in the process.
And the basic formula underlying Dan’s weight loss reaches well beyond health. Behavioral technology allows users to gradually and permanently alter all kinds of behavior, from reducing their energy use to controlling their spending. Now, with the help of our iPhones and a few Facebook friends, we can train ourselves to lead healthier, safer, eco-friendlier, more financially secure, and more productive lives.
Ironically, this high-tech behavioral revolution is rooted in the work of a mid-century psychologist once maligned as morally bankrupt, even fascist. But the rise of social media has reoriented our societal paranoias, and more and more people are incorporating his theories into their daily lives. As a result, psychology’s most misunderstood visionary may finally get his due.
In 1965, when Julie Vargas was a student in a graduate psychology class, her professor introduced the topic of B. F. Skinner, the Harvard psychologist who, in the late 1930s, had developed a theory of “operant conditioning.” After the professor explained the evidently distasteful, outmoded process that became more popularly known as behavior modification, Vargas’s classmates began discussing the common knowledge that Skinner had used the harsh techniques on his daughter, leaving her mentally disturbed and institutionalized. Vargas raised her hand and stated that Skinner in fact had had two daughters, and that both were living perfectly normal lives. “I didn’t see any need to embarrass them by mentioning that I was one of those daughters,” she says.
Vargas is a retired education professor who today runs the B. F. Skinner Foundation out of a one-room office in Cambridge, Massachusetts, a block away from Harvard Yard. The foundation’s purpose is largely archival, and Vargas spends three days a week poring over boxes and shelves full of lab notes, correspondence, and publications by her father, who died in 1990. A prim but engaging woman, Vargas can’t seem to help seething a bit about how her father’s work was perceived. She showed me a letter written in 1975 by the then wildly popular and influential pediatrician Benjamin Spock, who had been asked to comment on Skinner’s work for a documentary. “I’m embarrassed to say I haven’t read any of his work,” Spock wrote, “but I know that it’s fascist and manipulative, and therefore I can’t approve of it.”
Skinner’s reputation has hardly improved with time. I shared with Vargas a recent Philadelphia Inquirer article by a science reporter who passed along this assessment of “that famed rat researcher B. F. Skinner” and the behaviorists who followed him: “[They] thought homosexuality was a mental illness that could be cured, usually by giving electric shocks and other painful stimuli to try to create an aversion to homosexual thoughts.”
Vargas could only shake her head. Skinner employed punishment in one early experiment—through a device that delivered a light rap to a rat’s paw—and was so disturbed that he never used it again, arguing passionately and publicly throughout the rest of his life against the use of punishment in school, at home, and in the workplace. And he never had anything to do with trying to change sexual orientation, or any other aspect of identity. Skinner sought to shape only consciously chosen, directly observable behavior, and only with rewards; the entirely un-Skinnerian therapy to which the reporter was alluding is a form of “classical,” or “Pavlovian,” conditioning that trains a subject to reflexively associate a pleasant stimulation with an unpleasant one. The field Skinner founded, known as “behavior analysis,” has overwhelmingly hewed to the example he set in these regards. (And, for the record, “that famed rat researcher” worked, except in his earliest experiments, almost exclusively with pigeons.)
Spock and the Inquirer reporter are typical of Skinner’s critics in their ignorance of his work, yet Skinner’s theory was at its core so simple that it sounds purely commonsensical today: all organisms tend to do what the world around them rewards them for doing. When an organism is in some way prompted to perform a certain behavior, and that behavior is “reinforced”—with a pat on the back, nourishment, comfort, money—the organism is more likely to repeat the behavior. As anyone who has ever taught a dog to sit or a child to say “please” knows, if the cycle of behavior and reinforcement is repeated enough times, the behavior becomes habitual, though it might occasionally need a booster shot of reinforcement.
Skinner himself worked mostly with animals, famously training pigeons to guide missiles by pecking on a video screen placed inside the nose cone. But his followers went on to demonstrate in thousands of human studies that gentle, punishment-free behavior-modification techniques could improve learning, modify destructive habits, and generally help people lead healthier, more satisfying, more productive lives.
Behaviorism exploded in prominence in the 1950s and ’60s, both in academic circles and in the public consciousness. But many academics, not to mention the world’s growing supply of psychotherapists, had already staked their careers on the sort of probing of thoughts and emotions that behaviorism tends to downplay. The attacks began in the late 1950s. Noam Chomsky, then a rising star at MIT, and other thinkers in the soon-to-be-dominant field of cognitive science acknowledged that behavior modification worked on animals but claimed it did not work on people—that we’re too smart for that sort of thing. Then, seizing on Skinner’s loudly proclaimed conviction that communities should actively shape human behavior to promote social justice and harmony, they argued that if behavior modification were to work on humans, it would be a morally repugnant and even fascist method of forcing people to toe an official line.
In 1971, Stanley Kubrick’s seminal film A Clockwork Orange echoed this fear by centering on a government’s attempt to reduce criminal behavior via methods amounting to a brutal caricature of behavior modification: the “debilitating and will-sapping techniques of conditioning” that presaged “the full apparatus of totalitarianism,” as one character puts it. (The movie actually depicts Pavlovian, not Skinnerian, conditioning—a distinction lost on the public.) That same year, Time put Skinner on its cover, headlining its profile “Skinner’s Utopia: Panacea, or Path to Hell?” The overheated charges stuck. By the mid-1970s, the behavior-analysis field had essentially gone underground, its remaining practitioners having moved from prominent universities to relatively obscure ones.
Vargas took me to Harvard to see one of the few signs that her father was once the luminary of its psychology department, or indeed that he was ever there: an odd, cluttered display of circuit boards, random machinery, and a photo of Skinner, placed next to a self-service café in the basement of the psychology building, a curiosity to be contemplated over a cappuccino.
Skinner remains a staple of Psych 101 at most colleges, but typically only for a brief, often sneering mention, as if behaviorism was a strange, ugly fad. “He became a whipping boy for cognitive scientists,” says Dean Keith Simonton, a psychologist at the University of California at Davis, who has studied how his field views Skinner. “Psychology students were taught that his techniques didn’t work, that it was a bad direction for psychology to go in, and that he was a bad person, though he wasn’t. He just got kind of a bad rap.” It was a rap that the public bought wholesale, notes Christopher Bryan, a psychologist at UC San Diego. “There was a notion that there’s something icky about psychological techniques intended to manipulate people,” he says.
It made little difference that holdout behaviorists continued to accumulate evidence that Skinner’s techniques helped tame all sorts of otherwise confounding behavioral problems, including nail-biting, narcotics addiction, child abuse, and, yes, criminal recidivism (no Clockwork Orange–style punishment involved). But the most stunning example was autism: studies in the late 1980s and early ’90s established that behavior analysis, unlike any other treatment, was effective in helping children with autism communicate, learn, and refrain from violent behavior, to the extent that some patients shed their diagnosis. The success with autism pumped money into the field of behavior analysis, leading many of its researchers to look for other big challenges. And by the beginning of the 21st century, there was widespread concern about an obesity epidemic.
That Skinner’s theory could be successfully applied to obesity was no surprise. Decades earlier, when no one spoke of an obesity problem, Skinner had been writing about diet and exercise as an example of how behavior could be modified. In a 1957 paper in American Scientist, he cited a Harvard University study in which rats were conditioned to eat when they weren’t hungry, causing what Skinner called “behavioral obesity.” His followers did not have to reach far for the converse, speculating that an organism might be induced to willingly reduce food intake, were it rewarded for doing so.
They were eventually proved right by Weight Watchers, which launched its “behavior modification plan” in the mid-1970s. The program’s close adherence to Skinner’s basic principles has consistently garnered some of the best long-term weight-loss results of any mass-market program. The key characteristic of Weight Watchers and other Skinnerian weight-loss programs is the support and encouragement they provide to help participants stick with them. (Much the same is true of AA, which is strikingly similar to a behavior-modification program.) Weight Watchers and the other programs do not claim to magically burn fat, or make appetite disappear, or blast abs. They aim to gradually establish healthful eating and moderate exercise as comfortable, rewarding routines of daily life rather than punishing battles of willpower and deprivation.
The specifics may sound familiar: set modest goals (to encourage sustainable progress and frequent reinforcement); rigorously track food intake and weight (precise measurement is key to changing behavior, especially when it comes to eating, since a few bites a day can make the difference between weight loss and weight gain); obtain counseling or coaching (to diagnose what environmental factors are prompting or rewarding certain behaviors); turn to fellow participants for support (little is more reinforcing than encouragement from peers, who can also help with problem-solving); transition to less-calorie-dense foods (to avoid the powerful, immediate reinforcement provided by rich foods); and move your body more often, any way you like (to burn calories in a nonpunishing way).
Study after study proves the effectiveness of this rough Skinnerian formula, which is the basis of the great majority of well-regarded weight-loss programs. “Willpower doesn’t work,” says Jean Harvey-Berino, a University of Vermont behavioral scientist who researches weight-loss methods. “What works heavily relies on Skinner—shaping behavior over time by giving feedback, and setting up environments where people aren’t stimulated to eat the wrong foods.” As the evidence continues to pile up, it’s getting harder to find weight-loss researchers who disagree, says Jennifer Shapiro, a psychologist specializing in weight loss and the scientific director at Santech, a San Diego health-technology firm. “More and more studies demonstrate the effectiveness of behavioral approaches based on Skinnerian reinforcement.”
Not that Skinner ever gets much credit. The experts who run successful behavioral weight-loss programs, including Weight Watchers, seem at best vaguely aware of these techniques’ Skinnerian roots, or choose to downplay them. Instead, they frame their programs in the more fashionable terms of behavioral economics or social-cognitive theory, or offer the nontheoretical argument that they just plain work. But this would have been fine with Skinner, says Vargas. “He used to say that the ultimate worth of a science is in how much good it can do in the world.”
So widely accepted is the long-term effectiveness of Skinnerian weight-loss programs that most well-regarded bariatric-surgery clinics require patients to follow such a program before surgery, in order to prove their ability to avoid regaining much or even most of the weight after—as more than one-fourth of bariatric patients eventually do, according to some studies. Even clinical programs for rapid weight loss rely on Skinner’s tenets. The 25-year-old Weight Management Program at the Miriam Hospital—one of Brown University’s teaching hospitals in Providence, Rhode Island, and the home of the National Weight-Control Registry—is a highly regarded program in which many of the patients are more than 200 pounds overweight. Typically, patients are started out on an Optifast diet, a physician-mediated program that replaces some or all meals with liquids and food bars in order to “give patients some distance from food,” as one psychologist there puts it. But the Miriam program’s goal is for its patients to gradually build healthy eating habits with ordinary food, and to add in daily walks. The program reports that about one-third of its patients keep all the weight off for two or more years. And that figure, which is some 16 times the success rate implied by the “98 percent gain it all back” statistic we keep hearing, turns out to be fairly typical of leading clinical weight-loss programs.
But despite their relative success, Skinnerian weight-loss programs have not become the default treatment for obesity the way AA has for alcoholism. One reason, of course, is that most would-be weight-losers can’t afford these programs (insurance usually won’t cover them) or don’t have the time, patience, or motivation to commit to one. At up to $3,500, the six-month Miriam outpatient program is a relatively good deal, especially compared with Canyon Ranch, which offers a well-regarded residential program for about $1,200 a day.
“We know how to get people to eat healthier and exercise,” says Steven Blair, an exercise and epidemiology researcher at the University of South Carolina. “The question is how to roll out the needed behavioral strategies to 50 million unfit adults in the U.S. Even if there were enough trained counselors to work with that many people, which there aren’t, the cost issues would be overwhelming.”
And there’s another limitation. These programs work by sticking participants in a “Skinner box”—which was, literally, a closed glass box in which Skinner trained his animals; figuratively, it’s an environment that can be tightly controlled and in which behavior can be rigorously tracked, so as to ensure the dominance of the prompts and reinforcements that lead to a desired change. When a patient is “in the box”—that is, actively participating in a formal program—results are reliably good. The bigger challenge comes when people leave the program to plunge back into an environment rife with caloric temptation.
Most programs try to provide remote monitoring and support, but inevitably, many patients let these looser ties dissolve, and then they gain back weight. That’s why these programs tend to report long-term success rates of only about 30 percent. This is a much bigger problem for mass-market programs like Weight Watchers, which don’t charge enough to offer individual coaching or frequent, intimate group meetings. Effective as it is for a highly affordable program, Weight Watchers places its clients in a Skinner box of gossamer walls.
Twelve years ago, Michael Cameron was on his hands and knees in his doctor’s office. He had once been able to do dozens of push-ups, but because he had put on 105 pounds in the five years since college, his arms now shook with the effort of not collapsing to the floor. “What’s wrong with me?” he moaned. His doctor suggested antidepressants. Cameron walked out of the office and had an epiphany. “I thought to myself, I know how to solve this problem,” he says.
Actually, solving behavior problems was what he did for a living. Cameron was an experimental psychologist specializing in behavior analysis at McLean Hospital, Harvard’s teaching hospital for psychiatric disorders, and was the founding chairman of the behavioral-analysis department at Simmons College, in Boston. Amid all the various weight-loss solutions he’d considered, he’d never thought to try his own field’s techniques. Now he asked himself: What would Skinner do?
Cameron looked for aspects of his environment that were abetting his overeating. He worked nonstop at the office, eating very little there, so he was famished when his commute home took him past a long line of fast-food restaurants. After scarfing a meal from one of those, he would come home to a paperwork session conducive to the mindless munching of calorie-bomb snacks—he was particularly partial to peanut butter. He would vow to exercise the next morning but find himself running out the door to work instead. Little by little, he started making changes. He prioritized eating a decent breakfast and lunch, and found a new route home that bypassed the junky restaurants. He came home and immediately prepared healthy snacks, including a low-calorie peanut-based food, so they’d be in front of him while he worked. To kick-start his workouts, he got his gym bag ready at night and left it in front of the door. He religiously tracked his food intake, exercise, and weight, graphing the results to see how his efforts were paying off. He enlisted his colleagues, friends, and family to support him.
Cameron eventually lost more than 100 pounds, and has kept every one of them off in the years since, losing a few more besides. Though he focuses on children with special needs—he’s now the clinical director of Pacific Child and Family Associates, a national chain of clinics headquartered in Santa Paula, California—he also works independently with a small number of clients who want to lose weight. Five years ago, recognizing that he didn’t have time to personally help as many people as he’d like, he started wondering how he could extend his reach. Could weight-loss programs be administered remotely, or even in a semi-automated fashion?
The tools seemed to exist. Plenty of Web-based programs tracked food intake and exercise, and smartphone apps were starting to offer similar options. Videoconferencing allowed not only for remote one-on-one coaching, but also for group meetings. And Twitter made impromptu check-ins, questions, and encouragement easy. “I realized there wasn’t any part of it that couldn’t be done on a screen,” Cameron says. “And that meant it would be easy to scale up.” He started some pilot projects, enlisting graduate students to help coach and lead groups.
It was Cameron’s name I gave to my brother that night—I had heard about his program from scientists in the behavior-modification field. Starting a few weeks later, the first thing Dan did every morning was step on a scale that wirelessly transmitted his weight to his computer, which automatically Tweeted any loss or gain to the other participants in Cameron’s program. Every time I saw him, he’d pull out his phone to read an encouraging tweet from one of them, or fire off one of his own, or plug in the components of the meal he was eating, or check how many minutes of walking he’d logged that day. Sometimes he’d excuse himself for 10 minutes to take part in a group meeting on his laptop.
Over the course of a few months, I watched him gradually transform from the guy who had always piled his plate high with fried chicken and french fries to the guy who seemed genuinely thrilled to cap off a brisk walk with a piece of grilled fish, some beans, and a salad. As the habits set and his weight stabilized near his goal, the formal prompts and supports of the program were slowly “faded.” But the new routines seem to have stuck. (I just called him to check—he weighed 168 this morning.) Cameron has followed up with many of his past clients, and reports that all of them have kept the weight off.
Cameron was ahead of the game, but the world has been catching up to him quickly. Jeff Hyman, a successful serial Internet entrepreneur, spent one week and about $14,000 for himself and his wife at Canyon Ranch three years ago, and was struck both by the effectiveness of its behavior-modification approach and by the realization that the same techniques could be applied online at a much lower cost. He recruited two highly regarded behavior change–focused obesity researchers to design a one-year, Web-based program called Retrofit, which launched late last year.
Retrofit users track their eating and exercise online and have weekly Skype sessions with a registered dietician, a psychologist, and a “mind-set coach.” (If a client loses 10 percent of his or her weight by the end of the year, Hyman doubles these three employees’ compensation for that particular client.) After the year is up, clients can still arrange occasional consultations, and Retrofit continues to monitor their weight via wireless scale, so that a coach can reach out if the number starts to rise. “We have no interest in helping you lose weight” temporarily, says Hyman. “We want you to keep weight off.”
Though Cameron’s and Hyman’s programs create relatively effective virtual Skinner boxes, they don’t solve the cost problem. Retrofit charges about $3,000, and while Cameron hasn’t charged for his services, he calculates that were he doing this for a living, his fees would have to be in that ballpark as well. That’s a bargain for intensive programs of this sort, but still out of range for much of the public. The reason, of course, is that both programs remain dependent on relatively highly paid professionals to deliver the sort of one-on-one behavioral coaching and problem-solving that has always been key to Skinnerian behavior change.
But technology is radically lowering that cost barrier. Today, for absolutely nothing, would-be weight-losers can download many of the key elements of a Skinnerian behavior-modification program directly to their phones and computers. One of the most popular options is Lose It, an app and Web site that allows users to pick a goal weight and a time line for reaching it, and then formulates a daily calorie count accordingly. Lose It then lets users track their eating and physical activity, which they can do by holding their phones up to a food package’s barcode, or by tapping the screen a few times at the start and end of a walk (the app offers a range of activity categories, including guitar strumming, household walking, and sex). Lose It uses this data to provide clear, graphic feedback on users’ daily progress—you might see at a glance that having dessert will send your numbers into the red, but that if you walk for 20 minutes after dessert, you’ll go back into the green.
My wife, who has been struggling with her weight since the birth of our third child nearly two decades ago, started using Lose It late last year. Within three months, she was down to her college weight. Now several of her friends, family members, and colleagues have downloaded the app and are using it to lose weight steadily and comfortably. Lose It’s Boston-based parent company claims 10 million users so far and an average per-user weight loss of 12 pounds—an amount most doctors consider enough to dramatically improve health. Weight Watchers has since released a roughly similar app of its own.
Like most other Skinnerian weight-loss apps, Lose It lets you share your data with others for that all-important social support. But some tools take this sharing much further. Rajiv Kumar and Brad Weinberg, while on rounds as medical students at Brown University six years ago, were struck by the observation that the patients who lost weight or made other difficult changes in their behavior seemed to be the ones who set clear goals and then got lots of encouragement to meet them from friends, family, and co-workers, and especially from fellow weight-losers. Kumar and Weinberg took two years off from medical school to found Shape Up RI, a nonprofit with a Web site that allowed users to compete against one another on weight-loss and fitness teams. Shape Up RI tracked steps walked, miles run, vegetables eaten, and pounds lost, sharing that information among teammates, competitors, and supporters. Today, a for-profit offshoot, ShapeUp, caters mostly to large companies that run team competitions among employees; reinforcement may take the form of prizes, perks, and even money. Kumar, who is now ShapeUp’s chief medical officer, says that the 14,000 employees at one large client have logged nearly 5 billion steps and lost some 41,000 pounds—a shrewd investment for the employer and insurer paying their health-care costs.
Other apps make use of punishment, a technique that Skinner did not approve of but that can be smartly incorporated into an otherwise Skinnerian program. GymPact, an iPhone app, asks users to commit to visiting a gym a certain number of times each week and agree to forfeit at least $5 each time they skip. The app confirms users’ presence at their gym via GPS and charges their credit card if they don’t show up as planned. The company then divvies up the skip fees among those who honor their weekly commitments—so you get reinforced for going, and punished for not going.
So far, the scientific literature is proving these programs effective. When the University of Vermont’s Harvey-Berino studied the effectiveness of online Skinnerian weight-loss support groups, for example, she found that the results in pounds lost were comparable to results achieved by in-person groups. She’s now conducting a larger study with $3.5 million in funding from the National Institutes of Health, which, along with the Centers for Disease Control and Prevention, has increasingly thrown its support behind behavioral approaches to obesity. (Michelle Obama’s “Let’s Move” campaign is essentially Skinnerian, seeking to change children’s environments in ways that encourage them to make small changes in what they eat and how much they exercise; the program is even sponsoring the development of diet-and-exercise apps.)
Abby King, a leading health-related behavior-change researcher at Stanford University, has studied smartphone apps that aim to get older, non-technology-savvy people to move more throughout the day. The study subjects, most of whom had never used a smartphone before, significantly increased their activity. “If it works on them, it will work on anyone,” says King. “Skinner was right-on, in terms of any sentient being from pigeons to humans responding to setting goals, tracking progress, and getting feedback. These tools can provide all that, and can reach into any population to do it.”
Looking forward, improvements in the technology powering these apps should sharpen their impact. “This line of research is beginning to blossom,” says the University of South Carolina’s Blair, who recently helped the school land $6 million in funding for a new center studying technology-driven weight loss and related behavioral changes. “Right now we can get 30 percent of people to change their behavior, which is huge, but we’ll learn to get 40 percent, and then maybe 50 percent.”
One turning point will come when smartphone apps can automatically tailor their recommendations and feedback to an individual user’s behavior, just as a real-life behavior analyst would. In a review study for the International Journal of Obesity, Hirohito Sone, a researcher at the University of Tsukuba, in Japan, concluded that while weight-loss programs that include online tools are already more effective than conventional programs, individualization of these tools will take them much further. Details that these programs may eventually take into account, he says, include “lifestyle and environmental factors like types of job, whom you live with, how busy you are, what ethnic group you belong to, and what kind of activity or type of food and drinks you like.”
That may sound like a tall order for a smartphone app, but software and hardware improve substantially almost month to month. Michael Cameron is investigating developing “smart algorithms” that would take care of much of what he now does in the process of helping people lose weight. “The software will pick up the behavior patterns,” he says. “You might still need someone to have an occasional conversation with the client about the patterns, but as soon as you start automating and guiding decision-making, the need for a person like me becomes much more manageable.”
Cameron helped my brother Dan notice, for example, that he tended to take the longest walks when he set out after dinner, with a family member, and recommended making that a daily routine. A smartphone, by using GPS to track when Dan walked and a family-and-friend-tracking app to note whom he was with, could easily have done the same. Eventually, Cameron says, phones will be able to track swallowing and stomach distension to provide even better analysis of eating habits, without requiring the user to so much as tap the screen.
Dozens of research centers and hundreds of millions of dollars in investment in mobile-health technology have made such capabilities imminent possibilities. “It’s all about finding ways to automate Skinnerian conditioned reinforcement,” says Stephen Intille, a researcher at Northeastern University’s new doctoral program in “personal health informatics.” “You put sensors in phones and throughout the home, you develop algorithms that can infer what people are doing, and then you provide tailored automatic feedback that reinforces the right behaviors.”
The mobile-health field—“mHealth” to those in the know—is a rapidly growing subset of the tech-heavy, preventive approach to health care that was a foundation of the Obama administration’s reform bill. Health-insurance companies and government officials alike are drawn to the ability of smartphone apps to reach tough-to-access patients, to effect long-term lifestyle changes, and to do it all at a very low cost. Weight loss is just one example. Today, an iPhone owner can also download Skinnerian apps to help her stick to her birth-control schedule, monitor her blood sugar, quit smoking, or get more sleep. Mobile health’s potential savings to the health-care system are enormous. A 2010 study by one research firm reckoned that the savings in the United States and Canada from mobile monitoring of patient health could climb to as much as $6 billion a year by 2014. If mobile apps could reduce obesity and its associated costs by just 5 percent, the savings would amount to about $15 billion a year in the U.S. alone. The effect on eldercare would be even larger; a Boston Consulting Group report from earlier this year projects a possible cost reduction of 25 percent, which by one study’s figures would amount to about $30 billion.
This potential has made investment in this technology a no-brainer for health insurers and corporations. Blue Cross and Blue Shield of North Carolina, like many large insurers, offers its members Web-based weight-management and exercise-promoting tools, and is looking into providing mobile apps. “We’re very excited about the potential of these tools,” says Dr. Don Bradley, the company’s chief medical officer. “Up to 70 percent of health-care costs are related to lifestyle. If we can’t control those costs, we can’t keep our products affordable.”
And the outsized effect of simple Skinnerian tools has not been limited to health. Any number of apps allow users to kick other bad habits or cement good ones. Urge, a two-year-old “mobile behavior change company” based in Nashville, offers an app that prompts users to hold off on impulse purchases so they can hit budgeting goals, and reinforces their frugal decisions by tracking money saved for the purchase of a coveted item. Apps such as Habit Maker, Habit Breaker let users choose the behavior they’d like to target, whether it’s saying “thank you” more or going shopping less.
In Silicon Valley and the Bay Area, start-ups hawking these apps are becoming so common that you can’t avoid bumping into their founders. At Palo Alto’s storied University Coffee Cafe, I recently found myself sitting next to a young fellow named Yoav Lurie, who turned out to be running a Boulder-based company called Simple Energy, which uses Facebook as a social-reinforcement tool for conserving energy by tracking, sharing, and reinforcing certain behaviors. The product, like many of its competitors in the booming field of energy-related apps, is sponsored by large utility companies incentivized to reduce their reliance on conventional power sources.
Government agencies are in a similar position to benefit. I was speaking with a manager at the U.S. Department of Transportation about public transit when he mentioned that the agency is testing an app that provides local travelers with various transportation options for specific trips and that could gently reinforce decisions to use public transit by pointing out the extra calories commuters would burn by walking to the station and the carbon they’d avoid emitting by leaving their cars at home.
Of course, none of these tools would have much of a future if the public continued to harbor the kind of Big Brother paranoia that smeared Skinner’s reputation. Should we be wary of utilities that try to shift our energy use or health insurers that try to change our diets? Skinner would have celebrated these efforts, for their capacity to change society on a grand scale. But at what point does the interest of the individual diverge from the interest of corporations or the government—and will we even notice, if we’ve already surrendered all our choices to our iPhones?
The central irony of Skinner’s theory is that to control our behavior, we must accept a fundamental lack of control, acknowledging that our environment ultimately holds the reins. But an individual choosing to alter his environment to affect his behavior is one thing; a corporation or a government altering an individual’s environment to affect his behavior is another. The line between the two scenarios can blur. Nowadays most of us aren’t likely to wonder about the DOT’s motives when it urges us to take the light-rail instead of a cab. If it benefits the commuter, the government, and the environment, then what’s the problem? But the very definition of the Skinner box is that the inhabitant is not in control. In fact, he may not even know he’s in the box.
Julie Vargas, who lives with her husband in the house she grew up in, a few miles from Harvard, showed me her father’s study, which she has left untouched. It turned out to be the crowded basement sanctum of an inveterate tinkerer and gadget guy. Lacking WiFi and Bluetooth in his office, Skinner had jury-rigged strings and all sorts of wooden and cardboard doodads that enabled him to tweak his environment from his desk chair: by hiding the face of a clock he found himself watching, or by turning on a tape recorder that inspired him to organize his thoughts.
Though more advanced in execution, today’s electronic nudges and tweaks are identical in purpose: use what you can control to affect what you can’t. The simple elegance of this concept flips on its head Chomsky’s suggestion that behavior modification treats people as if they were no more intelligent than animals. What distinguishes our intellect from animals’ is not that we can go against our environment—most of us can’t, not in the long run—but rather that we can purposefully alter our environment to shape our behavior in ways we choose.
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bump, to read later0
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very interesting, thanks for posting0
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Fascinating. Thanks so much!0
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