I bloody love pancakes.
This was a typical breakfast for me when vacationing through California a few years ago. Pancakes, maple syrup, bacon, eggs….copy and paste every day. I loved it.
But I KNEW I was taking the piss a bit. As a type 1 diabetic, my risk of cardiovascular disease and heart attack is already elevated at 3 times the general population. I know this. But so often, my predilection for greasy syrupy goodness gets the better of me.
“I do not understand what I do; for I don’t do what I would like to do, but instead I do what I hate”. Paul the Apostle
What we do for ourselves is usually more powerful than what can be done to us.
This article is for those wishing to understand how to change behaviour toward better outcomes. Suitable for individuals, as well as clinicians and trainers working with patients and clients.
Behaviour is bizarre.
We often know what to do, but somehow or other don’t execute on it.
Research about the mechanisms, pathophysiology, interactions and other minutiae of exercise, for example, snowballs year on year. Ad campaigns show us ravaged lungs from smoking. Doctors show us liver test results that should shock us into binning all our stella there and then.
But we often don’t.
We know we shouldn’t smoke or drink to excess. We know that exercise is one of the best things we can do. It’s rarely further detail or knowledge that we’re lacking. But we’re all familiar with the disconnect that can occur between our intentions and actions.
Yet, all around us, there are daily victories and transformations that bypass social media and attention.
The ex-convict I met who, one particular day, quit all drugs, alcohol and violence to become a strength coach and pillar to many in his local community. The patient I was expecting to commence anti-depressants for who, instead, returned uplifted by her daily discoveries of her own unappreciated capability, challenging and rightly congratulating herself, one step at a time. The type 2 diabetic who resolves and successfully manages, off his own back, to lose 10kg, reverse his disease and drop his medications.
How do these people pull the trigger and make such incredible changes?
Before we begin this journey, I want to touch on just one global example that our behaviour directly impacts upon; our mortality.
James Clear, author of Atomic Habits, asserts that our current state is “a lagging measure of our habits”. What we do, what we think, what we know, what we own…almost any outcome is a result of our habits and behaviours multiplied by time. Your ability to drive your car is a lagging measure of your repeated practice. Your knowledge of your field is a lagging measure of the time invested learning it. Our physical health is, to a large extent, a lagging measure of the lifestyle we have lead.
We know that 71% of deaths, worldwide, are caused by chronic disease .
80% of these deaths are caused by the big four:
- Cardiovascular disease
- Chronic lung disease
Dr Nugent, Vice-President of the CNCD Global Initiative, places non-communicable disease next to the pandemic of climate change, highlighting common traits as ‘preventable, human-caused, multi sectorial, catastrophic [and] impoverishing’ crises. The drivers of these risk factors can be manifold, including socioeconomic, education, genetic, and other influences. However, it is abundantly clear that a small handful of individual behaviour traits can disproportionately steer us off the cliff toward these chronic disease states; namely physical inactivity, poor diet, smoking and alcohol.
No medical intervention can adequately undo the damage that results from prolonged exposure to these health behaviours.
Of the global population:
1.13 billion people have high blood pressure (hypertension) 
40% of the global population are obese or overweight 
Almost 10% suffer from diabetes 
Around 25% have metabolic syndrome 
A pattern emerges.
- Chronic diseases are the leading cause of death ➡️
- The majority of chronic disease is caused by 4 factors: high blood pressure (hypertension), high blood sugar (hyperglycaemia), overweight/obesity, and dyslipidaemia. ➡️
- These 4 factors are disproportionately influenced by 4 behaviours: physical inactivity, poor diet, smoking and alcohol 
Behaviour drives pathological processes that disproportionately affect health and mortality [7, 8].
Clearly, you may be a shining beacon of health and still die from a heart attack at the age of 85, which would be ‘natural’. I’m afraid that’s not what this is about though. The majority of premature deaths are still caused by the ‘big four’ as outlined above.
The biomedical argument for paying attention to behaviour is clear. Like compounding interest, favourable behaviours repeated now will result in a more favourable future. Likewise, repeated omission of health-promoting behaviours, coupled with seemingly insignificant sub-optimal lifestyle choices, stretched out over the lifespan, can accelerate our decline and eventual death.
If it mainly boils down to just doing the right thing, why do these diseases still cause the lion’s share of deaths worldwide?
Enter the smoke and mirrors world of human behaviour. There have been countless iterations of behavioural models articulated over the past century. We are likely all familiar with the concept of ‘homeostasis’ that we were taught in biology 101 at school.
Let’s first treat humans as if they are basically just a brainstem on legs.
At the very bottom of the hierarchy, biological needs do shape behavioural choices. On a most basic level, the hypothalamus and hormonal state will amplify the volume dial of, for instance, ‘hunger’ or ‘thirst’, which will very tangibly alter our behaviour to seek satiety or hydration. In this context, we are reactive to internal states of cold, hunger, thirst, pain, and fatigue and so on. Historically, observations of rats and animals in labs were used to apply this ‘reward learning’ theory to human behaviour. But you’d be forgiven for feeling offended by this attempt to explain your complex life decisions, and even animal studies debunk this simplicity when a mouse hedonistically pursues cocaine in a spiralling state of addiction, against all homeostatic sense.
“the emphasis on homeostatic deficit detection may also have had a cost in decades past, by diverting attention from other equally pressing questions about motivation in the brain 
The reductionist model of homeostasis as an explanation for behaviour conceptually stripped us down to zombies, where a deficit of human brains to eat would drive one to pursue and consume more hapless victims. Hoping that we had some distinguishing features that set us apart from the undead, observations have been made that innumerable behaviours seem to be pursued without any apparent utility or purpose; a kitten playing with a ball of string, climbing a mountain, participating in a singing competition.
All this is just to illustrate the point that motivations for behaviour can be clear-cut (such as food-seeking to satiate hunger) or much less apparent (sky-diving or writing, even when painful to do, for example).
We can look at two primary domains of consciousness from which behaviour seem to emanate from.
The conscious and the subconscious
Modern dual process theory (as popularised in Daniel Kahneman’s ‘Thinking Fast and Slow) categorises our thought across two ‘systems’:
- System 1: implicit/automatic/subconsicous
- System 2: explicit/controlled/conscious
Whilst more elaborated on today, this schema is not a new idea.
Plato conceived of human behaviour as a chariot rider and horse; the former representing the deliberate, self aware ego, whilst the horse embodied the characteristics of the id, being automatic and reflexive.
Dealing first with our subconscious landscape, there appears to be an element of arbitrariness about behaviour: addiction, self-deception, opaque thought processes and so on muddy the waters. Something that makes the study of behaviour and motivation so difficult is the black box of our own minds. There are blind spots, biases, and corners that we cannot see around which nevertheless influence much of our actions and thoughts. A very easy way to illustrate this is to ask yourself to sit somewhere, eyes closed, and think of nothing for just two minutes.
The assault of bizarre and random thoughts that immediately crash in don’t seem to ‘come from’ us. ‘Thought insertion’ is a diagnostic criterion used in assessing psychotic symptoms , but that’s precisely what seems to happen when we try to think of nothing.
Traumatic experiences can retreat from conscious awareness and may continue to influence us, in the way we feel or respond to certain things. Habits or addictions can also commandeer the autopilot function of our lives and de-rail us before we even realise. Trauma, addiction, pathological thought processes and mental illness are at the extreme end of this spectrum, and require professional intervention and/or a significant individual effort. These are out-with the scope of this article.
The point is that at least some subsection of ourselves seems to be less transparent or accessible than we may (or may not) wish.
This does makes sense.
If we had to bring all of our lucid consciousness to bear on every waking moment, and to process every decision we faced, we would be paralysed. We need heuristics, biases, rules-of-thumb and other auto-pilot functions just to get out of the house. Although these cognitive shortcuts can sabotage us in some situations, they also allow us to exist in an infinitely complex reality.
Throughout this series on behaviour, we will nonetheless mostly focus on the conscious Rider, who is the actor that we can most immediately influence, with downstream effects on the more subconscious elements of our behaviour.
Where the horse and rider live
Fancy diagrams of brains and MRI cross-sections are always a great way to seem clever in these sorts of articles, but I’ve found researching this part to be a real challenge*. It’s very easy to get caught in the weeds of neuroscience, but a basic overview of anatomical areas may nonetheless be useful.
‘linking fuzzy concepts to specific brain regions is…necessarily problematic’ 
The first thing to say is that although we often want to find discrete areas and say ‘that’s the part that my coffee addiction lives in’, the truth is that the brain is a continuous, parallel processing system that we cannot neatly carve up like a geographical map.
The horse (system 1, implicit/automatic/subconsicous) is strongly associated with the mesocorticolimbic dopamine pathway, commonly known as the ‘reward system’, which is an umbrella term that covers a few specific areas of the brain. Much of the dopamine signalling implicated in behaviour and motivation originates from the ventral tegmental area (VTA).
There are two broad pathways that span out from the Ventral tegmental area:
1. (mesolimbic pathway) ➡️ nucleus accumbens, hippocampus and amygdala. This pathway primarily influences incentives, motivation, reinforcement and fear.
2. (mesocortical pathway ) ➡️ prefrontal cortex. This pathway primarily influences cognition, executive function and emotion.
In response to certain stimuli (obvious ones are sex, food, drugs etc), dopamine produced in the ventral tegmentum is then couriered out to different neighbourhoods of the brain responsible for emotion, memory, attention and action, reinforcing the experience in all these areas in a positive feedback loop.
Place your palm on your forehead.
The rider (system 2, explicit/controlled/conscious) primarily resides in the prefrontal cortex, right behind your forehead, which is split up into a number of subdomains whose specific roles are ongoing topic of discussion. Importantly, the prefrontal cortex is the throne of executive functions; planning, attention, inhibition, cognitive flexibility (thinking outside the box) – all traits a good chariot rider would require.
The role of the prefrontal cortex is to coordinate behaviour to achieve novel goals, as well as automating these novel behaviours to free up previous resources for ongoing tasks. This is HABIT FORMATION, and results in outsourcing once difficult, new tasks to the horse, who can more automatically carry out such behaviours .
As for self control and inhibition, imaging has shown that higher levels of prefrontal cortex activity predicts a higher percentage of choices made for delayed rewards, when under conditions of increasing temptation for immediate reward.
A subsection of this brain region, the ventromedial prefrontal cortex, seems to be a convergence point for weighing up values and choices and, as we will explore later, central to self-identity and core values . This latter part is particularly crucial in behaviour.
The horse and rider exert bi-directional influences on one another. The horse can influence behaviour of the rider by altering cortical activity, and vice versa when engaged by higher-order cortical regions (where the rider ‘lives’).
That’s it for an introduction to pulling the trigger on behaviour change, pending part II.
Some of the key things we have covered so far:
- Although behaviour change is often viewed challenging, there are innumerable examples of people across all walks of life who enact incredible changes for themselves and others.
- Behaviours disproportionately influence a huge number of health outcomes, including mortality.
- There are many schema and theories of behaviour, one of which is system 1 and system 2, or the rider and the horse
- The horse is an embodiment of the subconscious, implicit and automatic behaviours that characterise our habits, biases, heuristics, assumptions and other cognitive shortcuts that can serve or sabotage us, depending on the context.
- Neuro-anatomically, the horse is found in the mesocorticolimbic system, which influences memory, emotion, motivation, incentive, fear and behaviour.
- The rider represents the conscious, explicit and deliberate behaviours that allow us to rationalise, plan, resist, goal-set, and map a course of behaviour.
- The rider is found in the prefrontal cortex, which is the seat of executive function and where identity and core values seem to be located.
*I am aware how out of my depth I may be getting here so reader-submitted corrections readily welcomed
- World Health Organisation, Non-communicable diseases, 2018, available at https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
- Mensa G.A, Epidemiology and global burden of hypertension, Oxford Medicine Online, 2018, available at https://oxfordmedicine.com/view/10.1093/med/9780198784906.001.0001/med-9780198784906-chapter-61
- World Health Organisation, Obesity and Overweight, 2018, available at https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
- World Health Organisation, Diabetes, 2018, available at https://www.who.int/news-room/fact-sheets/detail/diabetes
- Saklayen MG. The Global Epidemic of the Metabolic Syndrome. Current Hypertension Reports. 2018.
- World Health Organisation, Global Status Report on NCDs, Chapter 1 Burden: mortality, morbidity and risk factors, 2010, available at https://www.who.int/nmh/publications/ncd_report_chapter1.pdf
- Ritchie H., Roser M., Our World in Data, Causes of Death, 2018, available at https://ourworldindata.org/causes-of-death
- Buck D., Tackling multiple unhealthy risk factors: emerging lessons from practice, Kings Health Fund, 2018, available at https://www.kingsfund.org.uk/publications/tackling-multiple-unhealthy-risk-factors
- Berridge KC. Motivation concepts in behavioral neuroscience. Physiol Behav. 2004;
- ICD-10 Criteria for Schizophrenia, available at https://www.icd10data.com/ICD10CM/Codes/F01-F99/F20-F29/F20-
- Mcclure SM, Bickel WK. A dual-systems perspective on addiction: Contributions from neuroimaging and cognitive training. Ann N Y Acad Sci. 2014;
- Diamond A. Executive functions. Annu Rev Psychol. 2013;64:135–168. doi:10.1146/annurev-psych-113011-143750
- Berkman ET. The neuroscience of goals and behavior change. Consult Psychol J. 2018;