Raynard S. Kington, M.D., Ph.D.

Former Associate Director, Office of Behavioral and Social Sciences Research Now Deputy Director, National Institutes of Health

The second day of the conference began with a keynote address by Dr. Kington, who heads up an office at NIH that is charged with developing and expanding the knowledge base in social and behavioral science research. The office was created by Congress eight years ago in response to the perceived need to understand how behavior and social issues relate to health. Behavioral and social sciences’ research is relevant to addressing osteoporosis because such research can have an influence on interventions that are designed to elicit behavior changes that will have an impact on osteoporosis, including physical activity, smoking, and diet. Dr. Kington focused most of his remarks on the lessons to be learned from campaigns to increase physical activity and to reduce smoking rates.

With respect to physical activity, the problem facing the country is straightforward–Americans do not exercise enough. Just over 35% of men and 41% of women are physically inactive during leisure time. Only 25% of American adults engage in recommended levels of physical activity (30 minutes of moderately intense activity on five or more days a week or 20 minutes of vigorously intense activity three or more days a week). Physical activity can reduce the risk of osteoporotic fractures by increasing bone strength and by improving muscle strength and balance, which reduces the likelihood of falls. Conversely, a lack of physical activity can lead to greater prevalence of osteoporosis and increased incidence of hip fractures, as demonstrated in Table 4, which shows a clear correlation between levels of physical activity and the incidence of hip fractures.

Table 4

Hip Fracture Incidence and Hours Per Week of Physical Activity.

The successful campaign to change smoking habits (which has helped to cut the rate of smoking in half since 1964) offers some interesting lessons that can be applied to physical activity and other behaviors that have a direct impact on osteoporosis. These lessons include the following:

• Information about risk is not enough in and of itself to change behavior.

• Interventions need to be targeted at both prevention and treatment.

• It is important to intervene at multiple levels, including society at large, local communities, and individual patients.

As an example of these three lessons, Dr. Kington noted that effective smoking interventions have included efforts targeted at current users (e.g., counseling, pharmacologic therapies) as well as prevention campaigns (e.g., education, clinical information, restricting access, price increases via taxes, restrictions on smoking in public places, counter-advertising, and a stigmatization of the behavior).

But even with smoking, huge challenges remain. First and foremost, more than 20% of the population still smokes. One of the big problems in influencing smoking rates and other behaviors is how to maintain the behavior change over long periods of time. While there are many successful programs for short-term behavioral change for smoking, physical activity, and diet, relapses are very common. Only about one in four smokers who quit on their own is still not smoking after three months. One in five people who exercise regularly reports lapses of three or more months on at least three separate occasions. The average dieter loses 8% to 12% of their baseline weight within six months of beginning their diet. But by four years, the average weight loss is only 4% off the baseline. This failure to maintain behavior change raises two important research questions:

• Are the neurobiological, social/psychological, and other processes involved in adopting a new, short-term behavior change different from those for sustaining a behavior change over time?

• How should the knowledge of factors involved in initiation versus maintenance phases of behavioral change efforts determine the structure of interventions designed to maintain behaviors?

With respect to behavior change related to physical activity, several challenges remain. One relates to the physical environment, including the perceived safety of neighborhoods. Simply stated, individuals are more likely to exercise if they believe they live in a safe community. The reluctance to exercise in communities that are perceived to be unsafe is especially pronounced among older individuals. Other aspects of the physical environment must also support physical activity, including access sidewalks, walking trails, bike paths, malls, school gyms, parks, recreational facilities, and brightly lit stairwells. The U.S. Task Force on Community Preventive Services (USTFCPS) has addressed these issues through a variety of recommendations that combine information (e.g., community-wide campaigns, point-of-decision prompts for stair use), behavioral and social approaches (e.g., school-based physical education, social support interventions in community settings, individually adapted health behavior change), and environmental and policy approaches (e.g., creation of access to places for physical activity combined with informational outreach).

A second challenge involves creating a social environment that promotes physical activity. Dr. Kington noted that the social environment surrounding smoking has changed dramatically over the last 40 years. In the 1950s, smokers happily asked for a cigarette from a fellow smoker (who happily obliged). By the 1970s, smokers began asking nonsmokers for permission to smoke in their presence, and today smokers automatically excuse themselves to go outside to smoke. Attitudes about physical activity today are largely where attitudes about smoking were in the 1950s. Americans still have not made exercise a priority over other leisure-time activities, such as watching television. A social environment that promotes physical activity must address the time constraints that people face as well as provide the family, cultural, and worksite support that individuals need.

Other research challenges related to community interventions for increasing physical activity include the following:

• New technologies to measure physical activity levels in real-world settings.

• Strategies to increase participation rates.

• Strategies to increase the long-term effectiveness of interventions.

• Better understanding of the differences between interventions for initial behavior change and behavior change maintenance.

• New approaches to increase the effectiveness of self-help interventions.

• Better understanding of how to tailor and deliver exercise programs to children and adolescents.

• Strategies for assisting racial, ethnic, and cultural diversity in populations.

An additional challenge exists for providers in clinical settings. Since the vast majority of individuals have been to a health care provider within the past year, clinical settings offer an excellent opportunity for intervention. Unfortunately, however, the USTFCPS has not found sufficient evidence demonstrating the effectiveness of behavioral counseling on physical activity by physicians (and thus has not included such counseling in its recommendations). The challenge for the research community is to determine which interventions (if any) work in clinical settings, and to create interventions that can be implemented in these settings. Finally, additional challenges facing behavioral and social science researchers in the area of osteoporosis include understanding how genes interact with social and physical environments to influence behaviors and health outcomes, and determining how to promote long-term adherence to treatment regimens. With increased life expectancies, some patients may be treated for 20, 30, even 40 years. Little is known about how to maintain compliance over this long a period of time.

Unfortunately, however, as several audience members pointed out, very few behavioral and social scientists currently work on issues related to osteoporosis. The scientists have difficulty finding funding, while agencies get few applications for funding from behavior and social scientists. To address this issue, Dr. Kington called for “two-way pressure,” with both sides making a concerted effort to find each other. He also called on various government agencies, foundations, and other organizations to form “cross-agency” relationships that focus on identifying needed positions and attracting and retaining behavioral and social scientists to fill them.