Q&A: How small steps can help GLP-1 users build healthier habits

A Stanford study shows simple digital prompts can motivate people taking GLP-1 medications to make lifestyle changes. It’s a simple premise: What if something as small as a digital nudge could put someone on the path to healthier habits while taking GLP-1 medications?

“Achieving your best health involves a lot more than pharmacotherapy alone,” said Maya Adam, MD, Ph.D., the director of health media innovation and a clinical associate professor of pediatrics at Stanford Medicine. “And we found that giving people these little nudges may be very effective.”

Adam and a team of Stanford Medicine researchers set out to test that premise via a quantitative study that measured how digitally delivered microsteps focused on healthy habits—along with the type of animated storytelling videos Adam specializes in—influenced GLP-1 users’ expectation to make lifestyle improvements. Some habits reinforced by the material include: scheduling movement time, including protein at each meal, swapping sugary drinks for water, going outside for five minutes without devices.

The multicountry, randomized, controlled trial showed a level of receptiveness that now has researchers committed to honing digital tools that provide microstep prescriptions—a concept borrowed from Arianna Huffington’s Thrive Global, Adam said—for nutrition, physical activity, sleep hygiene, and stress management. The findings are published in the journal JAMA Network Open.

The next step, Adam said, is longer-term behavior change studies as well as qualitative work—some of which is already being conducted by collaborator Fatima Rodriguez, MD, MPH, associate professor of cardiovascular medicine and associate director of the Stanford Center for Digital Health. Rodriguez recently conducted interviews with patients from 15 states about their experiences using GLP1s.

We asked Adam, who is also the faculty lead for the Global Health Media Innovation Lab and an associate director for the Center for Digital Health at Stanford, about the genesis of her research and how it could help GLP-1 users.

What inspired this work?

One of the biggest challenges historically has been for health care professionals to sustainably support patients in changing behaviors. Things like eating, exercise, mindfulness, stress reduction, sleep—all of those things that we know are so important for our health. It’s just really challenging for physicians to know how to message that effectively and to have the time. Microsteps could be a low-cost, highly scalable solution.

Why microsteps and digital delivery?

We’re always looking for innovative ways to scale health messages, and increasingly, we’re turning to digital pathways to encourage people to embrace healthier behaviors. But, for them to be adopted, the evidence suggests that they need to be little tweaks rather than sweeping changes. Microsteps are changes that the developers at Thrive Global are calling “too small to fail.” They’re tiny little behaviors that, if we integrate them, add up to health benefits and give us confidence in our ability to change.

How did GLP-1 patients become the target audience?

We’ve seen a rapid increase in GLP-1 use, not just in the United States, but globally. The evidence for their effectiveness is growing, yet as powerful as these medications are, they aren’t a complete solution. Medication and behavior change work best together.

In many cases, GLP-1s may also create the right conditions to reframe how people view their health—especially if they have been struggling for a long time. There is perhaps greater potential for a reset when suddenly someone feels like they’re winning. There’s maybe a moment when people think: “Yeah, bring it on. Watch me win the behavior game, too.”

Do the results support the premise you set out to test, and what were you looking for exactly?

Yes, so this study measured what we call proximal indicators. In simple terms, these are early signals that suggest a long-term outcome may happen. Researchers use these indicators because they give you a sense early on whether an approach might be worth studying over time.

Those indicators include things like behavioral intention or behavioral expectation. The two are similar in some ways, but researchers have studied the subtle differences between them. The consensus is that behavioral expectation may be a better predictor—or a better proximal indicator—of long-term behavior change because it takes into account real-world barriers to that change.

Behavioral intention means you intend to adopt a certain behavior, whereas behavioral expectation factors in the likelihood of adoption with all things considered. While our study showed that microsteps increased behavioral expectations, it is still not the end goal—it’s an indicator that we may be on the right track. Behavioral expectation is necessary for behavior change, but it’s not sufficient by itself.

What’s next for prescribing microsteps?

After we identify the barriers, we ask, “How can we support behavior change?” From there, we explore questions about dosing over time: how many microsteps, how much variety in the microsteps, and how frequently do people need to receive these health nudges. We then extend the exposure over time and measure behavior change at three months, six months, and perhaps a year. That’s how we slowly start to learn about how these small interventions can be most effectively integrated into the care pathways of GLP-1 users. It’s an exciting time to be doing this work.