What if there was a pill you could take to prolong your life by more than ten years? Research shows that adopting healthy lifestyle habits can do exactly this and without bad side effects.
Harvard researchers wanted to know what impact these diet and lifestyle habits had on life expectancy:
1. Eating a healthy diet (eating more fruits, vegetables, nuts, whole grains, and healthy fats; and eating less red and processed meats, sugary beverages, and high-salt and fatty foods)
2. Being regularly physically active (at least 30 minutes a day of moderate to vigorous activity)
3. Maintaining a healthy body weight (a normal body mass index [BMI])
4. Not ever smoking
5. Having moderate alcohol intake (no more than one drink daily, meaning 12 ounces of beer, 5 ounces of wine, or 11/2 ounces of distilled spirits)
They looked at data from more than one hundred and twenty thousand people who had been studied for three to four decades, including self-reported habits, body measurements, and health outcomes. What they found was pretty remarkable: those who had all five diet and lifestyle habits lived significantly longer, on the order of fourteen years for women and twelve years for men! That’s more than a decade of extra life without any pills or supplements. The more of these habits that people had, the longer they lived; having even just one habit prolonged life expectancy by two years. Adults who had none of these habits were far more likely to die young, mostly from cardiovascular disease or cancer.
As amazing as the findings of this study were, they basically confirmed the findings from other similar large observational studies: a few healthy habits can extend our lives significantly.
Asking people what they eat, drink, and do and then relating it back to their health outcomes is one way to study the impact of diet and lifestyle. Another more scientifically rigorous approach is to take a bunch of people with risk factors for certain diseases, give some of them a diet and lifestyle change intervention, and see what happens. This is the strongest type of research study. One study like this was the Diabetes Prevention Program, which took people at risk for type 2 diabetes and gave them either a twenty-four-week diet and lifestyle intervention, a medication (metformin), or a placebo (a fake pill), to see if anything could lower their risk for developing diabetes.
The very comprehensive diet and lifestyle intervention had the goal of changing participants’ daily habits and included: sixteen classes teaching basic nutrition and behavioral strategies for weight loss and physical activity, lifestyle coaches with frequent contact with participants, supervised physical activity sessions, and good clinical support for reinforcing an individualized plan. The reasoning behind this intervention was: we know that an unhealthy diet and lifestyle can cause type 2 diabetes, but can a healthy diet and lifestyle prevent it? Since type 2 diabetes is a huge risk factor for heart and related diseases, it’s important to know if it can be avoided.
Perhaps not surprisingly the diet and lifestyle intervention was incredibly effective. After three years, the diet and lifestyle group had a 58 percent lower risk of developing diabetes than the placebo group. Participants aged sixty and older had an even better response, with a whopping 71 percent lower risk of developing diabetes. The diet and lifestyle effect lasted: even after ten years, those folks had a 34 percent lower risk of developing diabetes compared to the placebo group. Men, women, and all racial and ethnic groups had similar results (and almost half of participants represented racial and ethnic minorities). These results are not surprising to me nor to other doctors because we have all seen patients with prediabetes get their sugars down with diet, exercise, and weight loss alone.
Meanwhile, the medication group had a 31 percent lower risk of diabetes after three years and an 18 percent lower risk after ten years, which is also significant. It’s perfectly all right to use medications along with diet and lifestyle changes, because each boosts the effect of the other. Studies looking at the combination of medication (metformin) with diet and lifestyle changes have shown powerful results.
Diet and lifestyle changes are so effective for diabetes prevention that as of April 2018, insurance companies are covering these programs for people at risk. The Centers for Disease Control and Prevention (CDC) has published the entire twenty-four-week curriculum on its website, and clinics around the country are establishing programs (check out www.cdc.gov/diabetes/prevention/index.html). Here is a summary:
During the first half of the program, you will learn to:
• Eat healthy without giving up all the foods you love
• Add physical activity to your life, even if you don’t think you have time
• Deal with stress
• Cope with challenges that can derail your hard work—like how to choose healthy food when eating out
• Get back on track if you stray from your plan—because everyone slips now and then
In the second half of the program, you will enhance the skills you’ve learned so you can maintain the changes you’ve made. These sessions will review key ideas such as:
• Tracking your food and physical activity
• Setting goals
• Staying motivated
• Overcoming barriers
Take special note of the behavioral components. These aspects are critical to any successful diet and lifestyle change program, including one you create for yourself.
People can even reverse diabetes by changing their diet and lifestyle habits. In a study of more than three hundred participants who had already been diagnosed with type 2 diabetes, 46 percent of those who completed a twelve-month intensive diet and weight loss intervention—no medications, only nutrition and behavioral support—successfully reversed their diabetes, compared to 4 percent of those in the control group. As amazing as those results are, I have seen even more dramatic results in practice.
When my patient Preeti was diagnosed with type 2 diabetes, it was very advanced, with a hemoglobin A1c (HbA1c, the most common screening test for diabetes) of 11. That corresponds to an average blood sugar of 275. (For context, a normal average blood sugar should be under 126.) We were shocked: she had some risk factors for diabetes (ethnicity, overweight, and some family history) but no symptoms. Tests confirmed the diagnosis, and we had no choice but to start insulin injections along with metformin. I had little hope we would be able to discontinue either of these.
But Preeti was determined to make lifestyle changes. As she explained to me, “Prevention is more important than being treated with medicine, so there is a natural motivation not to be on medication if I can possibly avoid it.” She followed a nutritionist’s advice to avoid sugar and white flour, and eat more fruits and vegetables, lean proteins, beans, legumes, and whole grains. She also cut down on portion sizes, exercised every day for at least 30 minutes, and lost weight (20 pounds, from a BMI of 28 down to a BMI of 25).
All of that effort paid off: at a six-month follow-up appointment, her HbA1c was 5.8 (which corresponds to an average blood sugar of 120), and we were able to discontinue insulin altogether.
Preeti successfully treated her diabetes, but it didn’t happen overnight. In her own words, “It takes time to make adjustments, and it’s so important to have patience and be kind to yourself when you slip up.” Like other patients who have made big lifestyle changes, it was not with diet and exercise alone, but also with trial and error, persistence, and trust in the process.
Metabolic syndrome is a cluster of problems (abdominal obesity, high blood pressure, abnormal cholesterol, and high blood sugars) very strongly associated with heart and related diseases. Cardiologist, researcher, and author Malissa Wood, MD, developed and studied a two-year comprehensive lifestyle change program for high-risk women in a socioeconomically disadvantaged city near Boston. The women had significant risk factors for heart disease—not only traditional risk factors like metabolic syndrome, but also high rates of stress, anxiety, and depression. The Health Awareness and Primary Prevention in Your Neighborhood (HAPPY) Heart Program incorporated nutrition; exercise; stress reduction classes (tai chi, yoga, and meditation); health coaching; and smoking cessation counseling. She found that among participants, the rate of metabolic syndrome fell from 65 percent to 35 percent at year one, and then to 28 percent at year two. Not only that, but their reported levels of stress, anxiety, and depression also significantly decreased.
The program was small (sixty-four women) but powerful. Many of the participants were financially challenged single mothers or grandmothers caring for kids, and they had a lot of stressors. In her published research, Wood cites the community support the program provided as perhaps one of its most important features: “In addition to becoming a place where the women came for education and exercise, the HAPPY Heart events and classes provided a psychologically therapeutic experience.” In an interview, Wood emphasized the importance of good stress management as a foundation for successful behavioral change: “A lot of cardiologists go right to the LDL, the labs, the meds. Me? I ask, ‘What’s going on in your life right now?’ Because no one is going to hear anything you have to say about nutrition and activity if you don’t manage their stress first.” Dr. Wood emphasizes that effective comprehensive lifestyle change programs should feature a strong behavioral component that helps participants to better manage stress. You’re going to learn why this is so important in Chapter 3. If you’re curious about the HAPPY Heart Program curriculum, much of it was published in Dr. Wood’s book Smart at Heart: A Holistic 10-Step Approach to Preventing and Healing Heart Disease for Women.
Lifestyle change programs can even be effective for people who already have heart disease. It was many decades ago that physician pioneer Dean Ornish, MD, first published research showing the positive impact a comprehensive lifestyle change program could have for patients with coronary heart disease. The initial amazing finding was that participants were able to make changes and sustain those changes over time. One of his early studies showed that after a year, program participants had a 37 percent lower LDL (the “bad” cholesterol) without taking cholesterol medications, far fewer episodes of chest pain (91 percent fewer), and measurable decreases in the blockages of their coronary heart disease, as compared to patients not in the program who had far more episodes of chest pain (165 percent more) and worsening of their coronary heart disease. The trial was so successful that it was extended another four years, and participants had even more improvements. The program has been replicated at other sites and has shown to be associated with many significant positive health outcomes, including improvements in BMI, cholesterol, blood pressure, HbA1c, exercise, and functional capacity, as well as less depression and hostility.
Dr. Ornish describes the program in his own words: “This lifestyle medicine program includes a whole-foods, plant-based diet (naturally low in fat and refined carbohydrates); stress management techniques (including yoga and meditation); moderate exercise (such as walking); and social support and community (love and intimacy). In short, eat well, move more, stress less, love more . . . Although the program is only nine weeks long, 85–90 percent of people are still following it after a year.”
The irony that it is a natural, holistic, commonsense approach that works best now in this modern age is not lost on Ornish. “During the past forty years, we’ve used high-tech, state-of-the-art scientific measures to prove the power of these low-tech and low-cost interventions.” Again, it’s important to note that this successful program is about far more than diet and physical activity. The stress management and social support components are just as important. (Dr. Ornish has written extensively on this topic, and I highly recommend The Spectrum.)
Similar programs have been initiated by other groups, which also found positive health outcomes. Program costs can be high (between $3,800 and $4,441 by one 2012 study), but cost-benefit analyses show that participants have significantly fewer hospitalizations and lower overall healthcare costs.
While formal, comprehensive lifestyle change programs work well, they can be hard to find, require multiple in-person visits over a prolonged period (two months to two years), and are very expensive if insurance doesn’t cover the costs. What is it about these programs that makes them work, and can we create our own program?
Lasting lifestyle change really means changing our everyday habits, well, for life. That’s all it is. Sounds so simple, right? Let’s try to better understand how habit change works.
We are only recently seeing high-quality health research studies targeting habits, but what we are seeing is safe, cheap, and effective. One recent study compared two weight loss programs: a psychological program that emphasized body image acceptance and a healthy relationship with food versus a habit-based program that helped participants break unhealthy habits while developing and maintaining healthy habits. Forty-three overweight or obese participants completed the twelve weeks of classes and group meetings. Surprisingly, both groups lost the same amount of weight—15 pounds. But the kicker was at follow-up. After six months, the psychological program participants gained 7 pounds (for a net loss of 8 pounds), while the habit-based participants lost 4 pounds (for a net loss of 19 pounds).
Another study of five hundred and twenty obese adults looked at a simple habit-based weight loss tool: a leaflet describing ten evidence-based health habits (called the “Ten Top Tips”), handed to patients and reviewed with a nurse at a single regular appointment. Half of the participants got the leaflet and a little logbook for self-monitoring, and the other half had a variety of other usual options, including referrals to weight loss centers and subscriptions to meal plans. The “Ten Top Tips” group lost an average of 5 pounds, and the weight loss was maintained after two years, without any further intervention.
Using a habit-based intervention for health is extremely promising, not only because such an approach has been shown to result in weight loss that was maintained over time, but also because it’s inexpensive and doesn’t involve medications or surgeries (so virtually no side effects or risks).
Experts in economics and business already understand how important habits are and how powerful they can be—for profits. Marketers design their advertisements with the goal of making your choice of their product automatic. That’s what brand loyalty is, after all: habit.
Business consultant Stephen Covey’s classic book, The 7 Habits of Highly Successful People: Powerful Lessons in Personal Change, is largely based on his observations of and experience from working with organizations. Investigative reporter Charles Duhigg’s book The Power of Habit: Why We Do What We Do in Life and Business earned rave reviews from The Wall Street Journal and the Financial Times, and then enjoyed more than sixty weeks on The New York Times bestseller list. It was intended for business executives, but interestingly, the author also presents examples of how health habits can be changed for the better. In a follow-up interview, he described how researching and writing the book led him to change his own eating and exercising habits, and he lost 35 pounds.
Economists Christopher Payne and Rob Barnett applied the economic principles of “meta-rules and micro-habits” for their own lasting weight loss—more than 100 pounds combined. Their book, The Economists’ Diet: The Surprising Formula for Losing Weight and Keeping It Off, has been hailed as a sensible, real-life plan. We in medicine, on the other hand, have been a little slow to recognize the power and potential of habits.
The overarching goal of a successful lifestyle change program is to change the participant’s daily habits, for good. We’ve seen that effective programs feature a strong behavioral component, which can include classes, health coaches, therapists, and group meetings; nutrition education with guidance from a dietitian; and a physical activity piece that often includes supervised exercise sessions or other activity monitoring. Here is a detailed overview of each of these components:
Changing habits isn’t easy. This is why behavioral strategies are so critical. Successful lifestyle change programs emphasize the following behavioral areas:
Many stress-reducing techniques are associated with reductions in heart disease risk, especially exercise, mindfulness, meditation, and yoga. People who more effectively manage stress tend to have lower blood pressure, as well as lower rates of depression and anxiety. Most importantly, effective stress management is a key foundational skill for making healthy lifestyle changes stick. We’re going to go into this in depth in Chapters 3 and 4.
Sleep problems, especially sleep apnea, are associated with a higher risk of heart disease, while treating sleep apnea lowers risk. Chronic sleep deprivation makes everything worse and causes weight gain. Getting enough sleep helps us better manage stress, as well as lose weight.
People who have a solid support system have fewer health problems, perhaps because healthy relationships help us manage stress and avoid depression. This, in turn, can be protective against heart disease. There are other ways that family and friends can help us stay healthy. Studies show that eating meals with others helps us eat healthier and more slowly. Cultures that emphasize a leisurely sit-down family meal tend to have fewer chronic diseases overall. In addition, embarking on a lifestyle change plan with someone else helps us stick to the plan. Successful lifestyle change programs require classes and group meetings; some also feature family-style meals. The social support provided through these programs has been cited as one of the main reasons for their success.
Successful lifestyle change programs promote a healthy eating pattern, encouraging wholesome, natural, unprocessed foods, especially plants, and discouraging sugary, refined, or processed foods.
Hundreds of studies over decades prove that a plant-based diet is the healthiest diet. This means mostly fruits and vegetables; whole grains; legumes (beans, lentils, peas); and nuts and seeds. Studies show that eating ten servings of fruits and vegetables daily is associated with a 24 percent reduced risk of heart disease and 33 percent reduced risk of stroke. Even eating just two and a half servings daily can reduce the risk of developing heart disease by 16 percent, and of stroke specifically by 18 percent. That’s half a grapefruit, an apple, and 3 tablespoons of peas. The fiber in fruits and vegetables binds cholesterol and fills us up, helping us eat fewer calories. Plus, fruits and veggies contain plant nutrients called antioxidants, which prevent and heal damage to blood vessels.
Most traditional diets (such as the Mediterranean diet) are associated with extremely low rates of heart and related diseases. The reason? Almost across the board, traditional diets are made up of mostly plants. They do not feature added sugar, refined flour, processed factory-made foods, cured/smoked or red meats, or fried foods. Though books and articles often refer to the Mediterranean diet, you can call it anything you like, as long as it’s mostly vegetables, fruits, legumes, whole grains, nuts, and seeds. Seafood can also be a big component, and we’ll go more into this in Chapter 5. Meanwhile, I recommend Dr. T. Colin Campbell and Dr. Thomas Campbell’s The China Study and Dr. Michael Greger’s How Not to Die as excellent plant-based diet informational resources.
It’s true that drinking a little bit every day significantly lowers the risk of heart disease. But there are a few potential problems: one, not everyone can safely drink alcohol. Two, drinking even a bit more than is recommended is bad for you and can cause a number of other health problems. Three, alcohol has calories and can make it harder for people to lose weight. Four, alcohol lowers inhibitions, which can lead to eating more. We’re going to cover the pros and cons of alcohol more extensively in Chapter 5.
Having a healthy weight (BMI of 18–24) is associated with lower blood pressure, blood sugars, and cholesterol, as well as lower risks for heart disease. Weight loss through diet and lifestyle change is infinitely preferred over medications or surgeries, given their risks and costs. Most people who change their daily habits will lose weight. We’ll cover this in Chapter 6.
Exercise of the body is exercise of the heart and blood vessels, too, making them flexible and stretchy, which keeps blood pressure down. Good blood flow brings in oxygen and healing molecules like antioxidants as it flushes out toxins. Exercise directly burns calories as well as builds muscle tone, which also boosts metabolism, helping us lose weight, prevent weight regain, and maintain a healthy weight. Even if there is no weight loss, exercise lowers blood sugars. The recommended goal is about 150 minutes of moderate physical activity per week, and we’ll learn how to reach this goal in Chapter 7.
This one goes without saying, but it really is important. Quitting smoking—at any age—decreases the risk of heart disease and increases life span. We’ll cover how to quit smoking in Chapter 8.
Comprehensive lifestyle change programs involve a team of professionals. Even if you’re not in a program, you may have access to many of these experts, depending on your medical history, insurance, and location. They may be able to provide resources and support for you.
Many people can call themselves nutritionists, so it’s important to understand that this can refer to a wide range of education, training, and clinical experience. For example, a nutritional consultant may have a high school degree and have passed an open-book certification exam, while a registered dietitian nutritionist (RDN) has a bachelor’s degree, 1,000 or more hours of clinical training, and passed a national certification exam.
I spoke with Linda Delahanty, chief dietitian at the Massachusetts General Hospital Diabetes Center, who clarified the role of the nutrition expert: “It’s the combination of knowledge of the evidence base—nutrition science, food composition—and counseling skills that make the best dietitian. In other words, someone who can skillfully combine the science and the art.” She explains that “a registered dietitian provides an individual assessment of medical profile, lifestyle, current eating habits, and learning style, in order to create a personalized plan that focuses on the patient’s nutrition priorities” and that developing the right plan is “a process that takes time . . . . Dietitians typically spend an hour for the first session to do a thorough assessment, then schedule follow-up visits to educate, advise, and use behavioral counseling strategies to help people integrate these lifestyle changes into daily routines.”
Successful lifestyle change programs feature a strong behavioral component, usually involving mental health providers. There are many types, with widely varying education and training. Here are some common titles and what they mean:
• Health coach certification is available to almost anyone who takes a course, either in person or online.
• Licensed mental health counselor (LMHC) is a certification available to individuals with a master’s degree in counseling, psychology, addictions, or therapy who have had clinical training and who have passed an exam.
• Licensed clinical social workers (LICSW) must have a master’s degree in social work, do clinical training, and pass an exam; they are licensed in each state and entitled to work independently.
• Psychologists have an advanced degree such as PhD, PsyD, or EdD, have completed an internship and post-doctoral training, and have passed a national exam.
• Psychiatrists are physicians who have completed medical school and a psychiatry residency, passed a national certification exam, and obtained a state license. Psychiatrists work with people using a variety of counseling approaches and can also prescribe medications or other therapies.
If you are looking for a mental health provider to work with you, Massachusetts General Hospital psychologist Kathleen Ulman, who has more than four decades of clinical experience in individual and group psychotherapy, offered this advice: “There are many providers who are excellent therapists . . . . It all depends on how much postgraduate study, supervision, and experience they have had. The important thing to know is that you should choose someone who is licensed and with whom you feel comfortable. Research shows that the most important factor in the success of psychotherapy or counseling is the relationship between the therapist and the patient.”
Many people can carry the title of “Doctor.” It’s important to find someone whose education and training meets your expectations and whose philosophy fits with yours.
These doctors have similar training. Both complete four years of college, plus four years of medical school, a clinical internship and residency program, and then pass a national certification exam and obtain a state license, as well as ongoing maintenance of certification requirements. Traditional MDs practice evidence-based medicine, following clinical guidelines and standards based on published research. DOs also practice musculoskeletal manipulation and tend to have a more holistic, individualized approach.
An MD or a DO can pursue additional training in these specialties:
• Obesity medicine specialists treat obesity using behavior modification, diet and lifestyle education, medications, and surgery.
• Lifestyle medicine specialists treat diseases using behavior modification, diet and lifestyle education, and health coaching.
• Functional medicine specialists identify and treat the root causes of disease using practices generally not based on scientific evidence but very individualized to the patient’s symptoms.
Naturopaths and chiropractors are also doctors, with different education, training, and experience.
• Naturopathic physicians may use nutritional and botanical medicine, naturopathic manipulative therapy, and homeopathy to encourage the patient’s own self-healing process.
• Chiropractors focus on the diagnosis and treatment of neuromuscular disorders, using manual adjustment and/or manipulation of the spine to reduce pain and improve the functionality of patients.
It can be helpful to work with an expert in physical health, but some titles that sound similar are actually very different:
• Physiatrists are MDs or DOs who have completed a residency training program in physical medicine and rehabilitation, which emphasizes restoring function and quality of life to patients with musculoskeletal or neurological problems. They may subspecialize in sports, brain or spinal cord injury, neuromuscular, or pain medicine.
• Physical therapists have completed a bachelor’s degree and a three-year accredited doctoral program, and have passed a licensing exam. Physical therapists evaluate patients and develop treatment plans using techniques to promote the ability to move, reduce pain, and restore function.
• Personal trainers have a high school degree and have completed a personal trainer certification program. They can oversee an individual’s fitness program in a fitness facility or private setting.
This book is not the first to combine evidence-based lifestyle recommendations along with behavioral change advice. Earlier in this chapter I presented the successful lifestyle change programs of Dean Ornish, MD, and recommended his book The Spectrum, as well of cardiologist Malissa Wood, MD, and her book Smart at Heart. I’d also like to highlight the work of other well-established, respected experts.
Walter Willett, MD, DrPH, is a physician, professor, researcher, and author who has been described as “the world’s most influential nutritionist.” While he has written loads of excellent articles and books, the most relevant one is Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating, now in its second edition. In it he explains nutrition research and recommendations in a straightforward manner, also presenting some basic behavioral tips for healthy eating.
David Katz, MD, MPH, is a world-renowned expert in nutrition, obesity, and disease prevention. His book Disease Proof: Slash Your Risk of Heart Disease, Cancer, Diabetes, and More—by 80 Percent includes solid research explained clearly, as well as “skillpower,” a number of practical behavioral tips and tools for everything from buying and preparing food, to navigating restaurants and socializing, to fitting in fitness.
These books emphasize that decades of science support the same, relatively simple diet: well-balanced and rich in fruits and vegetables, beans and legumes, whole grains, nuts and seeds, and maybe seafood, dark chocolate, and a little alcohol. They include healthy recipes and a lot of sound advice. I do not receive any benefits from providing these recommendations; rather, I know that we’re all on the same passion-driven mission, and if my book doesn’t work for you, then maybe theirs will. Heart disease is a huge problem, and it can only help to spread the word on how to prevent and treat it.
In this chapter you saw the research supporting healthy lifestyle changes to prevent heart disease. Formal, comprehensive, intensive lifestyle change programs work very well, in large part because of the built-in behavioral component.
I have several patients who have created their own successful lifestyle change programs. In one case, a middle-aged patient had fallen into an unhealthy pattern, with steadily increasing weight, blood pressure, cholesterol, and sugars. “I wanted to get healthy, but I couldn’t seem to get anywhere with it,” remembered Vivienne. Her diet was poor, and she didn’t exercise. “On weekday mornings I’d head down to the coffee shop for a slice of breakfast pizza or an egg sandwich.” Her husband was a good cook who made big Italian dinners featuring garlic bread and lasagna. “We would eat the leftovers all week long,” she recalled. “It was just what we did, and it was all bad habits . . . . But that all changed when we found out about my heart.”
An X-ray done for totally different reasons uncovered a surprise finding of coronary artery atherosclerosis, i.e., heart disease. Tests showed a blockage in one of the coronary arteries. It was caught early enough that she could still do something about it without needing any procedures or surgeries. The cardiologist prescribed some medications but also strongly advised a healthier diet and more exercise, which have been shown to reverse heart disease.
Vivienne began making changes. “I started with little things, and I kept going,” starting with her weekday breakfast habit: “Now, I have a nice big fruit bowl and yogurt for breakfast or fruit and cottage cheese.” Her husband got on board, as well: “He still cooks Italian meals, but we’ll have chicken marsala or turkey tips. He steams veggies, and we pick on those all week.” No more cheesy pasta leftovers.
She figured out how to add activity to her day, considering that she doesn’t go to a gym. “When I’m cleaning my house, I’ll put disco music on and dance around. I love disco!” she said with a laugh.
It’s been a year and a half, and Vivienne has maintained a weight loss of more than 20 pounds. She’s only on any medications because we know she has heart disease: a low-dose statin and a baby aspirin are all she takes. But even better? “I feel great, and I like the way I look too!”
I asked her if she had any advice for readers. She thought for a moment and then offered: “You have to have a good enough reason to begin with. Then it’s just all these little things every day, and they add up.” She mused, “Now, I don’t even think about it.”
It’s become habit.
In the next chapter we’ll learn more about science of habit and review some basic psychology and stress management skills so that you can change your habits and make the changes stick.