Self-Efficacy, Strength Training, and Disease

By: Nick Soleyn, Editor in Chief

I am counting—one, two, three, four, five, six—thumb pressing on my wrist where the radial artery passes just beneath the skin, the passing marks time with me as I watch the seconds on my watch fall farther behind. My pulse is too fast, about ninety beats-per-minute, borderline between normal and racing. Then, I feel it again—twenty-eight, twenty-nine, thirty, thirty-one, pause. I breathe as the hiccup in the too-fast rhythm seems to stretch, too long this time. Thud. Thirty-two, thirty-three, thirty-four. I let out my breath, willing my muscles to relax and my heart to slow down, wondering if it was just my imagination. Then, I start counting again.

An irregular heartbeat gets your attention like a skipping record, but there is nothing you can do about the distorted music except wait for the next beat. With mine, sometimes enough time would pass for me to wonder what would happen if the next beat never came. But I didn’t feel faint or out of sorts otherwise. I exercised regularly, and I am young. These episodes had been happening off and on for a few months. They always went away. I didn’t bother to mention them to my wife or my doctor. Actually, I didn’t even have a primary care physician. I didn’t know who I would talk to, even if I wanted to. I rationalized away anything serious, but looking back—if I am honest with myself—I was scared. I didn’t want to know if anything was wrong. I was young, and I exercised. The episodes always went away. And they did this time as well, and they didn’t return. The last one happened about a year before I had a heart attack.

The Fable of the Dragon Tyrant

“Once upon a time, the planet was tyrannized by a giant dragon. The dragon stood taller than the largest cathedral, and it was covered with thick black scales. Its red eyes glowed with hate, and from its terrible jaws flowed an incessant stream of evil-smelling yellowish-green slime. It demanded from humankind a blood-curdling tribute: to satisfy its enormous appetite, ten thousand men and women had to be delivered every evening at the onset of dark to the foot of the mountain where the dragon-tyrant lived. Sometimes the dragon would devour these unfortunate souls upon arrival; sometimes again it would lock them up in the mountain where they would wither away for months or years before eventually being consumed.” —N. Bostrom, “The Fable of the Dragon Tyrant,” J. of Med. Ethics, Vol. 31, No. 5 (May 2005)

This is the beginning of a story by Professor Nick Bostrom. The Dragon Tyrant represents aging, demanding, as its seemingly inevitable tribute, death. In the story, the kingdom of civilization builds up around that inevitability. As the kingdom grows, so too does the dragon’s appetite.

The kingdom’s industries come to depend on the dragon. It is an organizing force, not just inevitable but beneficent, and from its existence, economic and philosophical justifications sprout: people have purpose due to their shortened lives. Eventually, the structures and rationalizations for the dragon are complex and interwoven into the kingdom’s society. Technology advances and presents the people of the kingdom with a possibility: they could challenge the dragon, even kill it, but the cost would be great, it would take a long time, and there would be no guarantee of success. Just the possibility of change, however, created a simple challenge to the complex justifications for the dragon: “the dragon is bad; it destroys people.” Belief, technology, and self-efficacy allow the kingdom to challenge the Dragon Tyrant.[1]

Lesser Dragons

The moral of the Dragon Tyrant story is that passive acceptance and ignorance of what may seem impossible or inevitable may be “fatal barriers to urgently needed action.” In the case of aging, this may cause us to miss opportunities to pursue research and technologies that will slow or stop the aging process someday.

But, while aging is perhaps the great and terrible Dragon Tyrant, we might take professor Bostrom’s allegorical connections further to include some lesser dragons. There is a great deal of passive acceptance that also contributes to major killers in the world—conditions of human health that are driven more by our behavior than by the inevitability of sickness and death: cardiovascular disease, diabetes, and other chronic and preventable illnesses. And, it is within our current power to shrink these lesser dragons down in size. It comes down to individual actions, taken en masse, for our own health and the health of those around us.

When I could have curbed my own dragon, the one signaled by my heart fluttering in my chest, I didn’t. It is an odd thought now, and I have spent a great deal of time reflecting on my unwillingness to face something so life-threatening. It was, in part, because the dragon was not yet at my doorstep. Admittedly, not very heroic.

Heroes, according to Joseph Campbell and his writings on hero myths, answer the “Call to Adventure.” The call is the beginning of the hero’s journey, when the hero must decide to upset the status quo. Taking up the Call to Adventure is a high ideal in our stories, possibly because it is something we resist in our daily lives. Change is not easy. The bigger and more potentially dangerous the change, the more difficult the call is to answer. When the “zone unknown” involves confronting your own mortality, it is even more so.^[2] Most of us are a bit hobbit-ish in our resistance to such adventure. Not everyone chooses to step off their porch and chase down the unknown dragon, even when you know that you should. That was my reaction, at least. But individual decisions like mine get repeated the world over, creating global burdens and concerns, revolving around personal choice, belief, and self-efficacy.

Health Belief Models and Self-Efficacy

In the 1950s, the United States Public Health Service wanted to know why so many people choose not to patriciate in programs to detect and prevent disease. In answer, social psychologists created the Health Belief Model in an attempt to identify and explain how people make personal health-related decisions. The Health Belief Model describes two spinning wheels that pull a person closer to or farther away from a particular action. The first wheel is the perceived threat of an illness or disease. A person will likely ask themselves, “how susceptible am I?” and “how severe is the threat to my well-being?” The Health Belief Model says that if you are scared and the object of your fear is severe, then you are more likely to take action to prevent or detect a disease or to improve your general well-being. A far-off mythological dragon is less likely to spur someone to go out looking to kill it.

The other wheel of the Health Belief Model is perceived efficacy: “how effective do I think the disease countermeasures will be?” This, according to the Dragon Tyrant Fable, is the argument against certain actions because there may be no guarantee of success. People may choose to avoid basic preventative actions against a very real threat if they do not believe the actions are safe or effective. For example, in 2003, eroding public trust in the “Kick Polio Out of Africa” campaign lead to boycotts of the polio vaccine.^[3] In the US, we see resistance to annual flu vaccinations due to its perceived ineffectiveness, and vaccine hesitancy—due to lack of a belief in the importance, safety, or effectiveness of vaccines—is one of the World Health Organization’s (WHO) top ten threats to global health. Belief in effectiveness combines with associated costs and other barriers to reduce the likelihood that a person will take recommended health actions. So, some dragons thrive by making you believe they are no threat to you, others thrive on the strength of their reputations for invulnerability, and all benefit from impediments, whether self-inflicted or out of one’s control, to positive health actions.

The Health Belief Model and related models depend on a few key assumptions: “[1] that a substantial proportion of the mortality from the leading causes of death is attributable to the behavior of individuals, and [2] that behavior is modifiable” (Norman, 2017). Statistics on the global burden of disease suggest that the first assumption is accurate. Studies have confirmed the effects of behavior on chronic and preventable diseases. Active and passive behaviors such as diet, not smoking, sleeping, and regular exercise repeatedly have shown to improve morbidity and long-term survival. Healthy behaviors produce biological changes in the individual; or they act as buffers and raise awareness, allowing a person to combat the health risks; or they lead to early detection and treatment (Norman, 2017).

The second assumption—that behavior can be modified—is less straight forward. In 2012, the WHO set a target to decrease the number of deaths from non-communicable diseases for people under the age of seventy by 25%. These “premature deaths,” accounting for 33% of all deaths under the age of seventy in the US, are most closely related to behavioral risks. Achieving large changes in early deaths from these lesser dragons—diabetes, cardiovascular disease, lung disease, and cancer—will require large, population-level changes in individual behaviors, in particular diet, tobacco and alcohol consumption, and increased physical activity (Marteau et al., 2012). But, if information alone dictated human behaviors, change would be relatively easy.

Information is part of the issue, for sure, but plenty of people understand risks and want to improve their health, yet they still have problems with change. “Human behavior is not actually driven by deliberation upon the consequences of actions, but is automatic, cued by stimuli in the environment, resulting in actions unaccompanied by conscious reflection” (Marteau, 2012). If everyone’s decision-making brain was a balance between pros and cons, the war on behaviors would be a war of information. Instead, it is a war of self-efficacy.

Self-efficacy combines belief, as outlined in the Health Belief Model, and practice. Because believing that you can make a change is something you learn. Above, I mentioned the first effect of behavior on health: creating a biological change in the individual. The learned behavior that leads to meaningful change is incredibly similar to what we do with barbells on our backs. We affect biological change through habitual practice. This goes both ways:

“The person who has gone through a very severe accident may conclude that he is not the master of his own fate and that death is ever at his door. In the face of such an overwhelmingly stronger and more threatening world some men seem to lose confidence in their own abilities, even the simplest ones.

…

When we can no longer handle the situation, when the world is too much for us, when we are not masters of our own fate, when we no longer have control over the world or over ourselves, certainly we may speak of feelings of threat. Other situations in which ‘there is nothing we can do about it’ are also sometimes felt to be threatening.” (A. H. Maslow, Motivation and Personality, p. 136.)

I experienced this after a heart attack that seemed to have no other cause than the roulette wheel of fate landing on my number. Training helped me reassert control. I started by walking, eventually making it back to lifting weights. But renewed control came with renewed interest in the things I wasn’t doing before. I improved diet, increased my activity levels (started “doing cardio”), and started seeing my doctors regularly. I also began to understand training for strength in a different way: strength as part of the bigger picture of health.

Training helps teach us self-efficacy, and self-efficacy is anathema to the lesser dragons that prey on individual behaviors and passivity. It fills our quiver with arrows, because we understand that change through action is not only possible but also something that we can direct, aiming for the outcomes we want and those that we need. My own lessons came later than I would have liked, but I have learned that strength, health, sports, and fitness—the many targets we set up and aim our biological arrows of change at—are not mutually exclusive or incompatible with each other. No armor is impenetrable, but if there is an armor against the dragons of disease, it is built on the truth that change is possible. When you train for strength, you are not just making your body stronger; you are practicing self-efficacy—confidence in bringing about meaningful change—through training. And each individual act of defiance adds up to big changes to complex social problems, through simple, effective means.

References

Alexandre de Figueiredo, Clarissa Simas, Emilie Karafillakis, Pauline Paterson, Heidi J Larson, “Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modeling study,” Lancet, 396: 898–908 (2020).

Ayodele Samuel Jegede, “What Led to the Nigerian Boycott of the Polio Vaccination Campaign?,” PLoS Med., 4(3): e73 (2007)

Nick Bostrom, “The Fable of the Dragon-Tyrant,” J. Med. Ethics, Vol 31, No. 5, pp. 273-77 (2005) (available at: https://www.nickbostrom.com/fable/dragon.pdf).

Norman, M. Conner, “Health Behavior,” Ref. Module in Neuroscience and Biobehavioral Psych. (2016) (http://dx.doi.org/10.1016/B978-0-12-809324-5.05143-9)

Theresa M. Marteau, Gareth J. Hollands, Paul C. Fletcher, “Changing Human Behavior to Prevent Disease: The Importance of Targeting Automatic Processes,” Science, Vol. 337 (2012).

Notes

[1] Read the fable here: https://www.nickbostrom.com/fable/dragon.html). Or, watch an animated version from CGP Grey on YouTube (https://youtu.be/cZYNADOHhVY).

[2] “The call to adventure signifies that destiny has summoned the hero and transferred his spiritual center of gravity from within the pale of this society to a zone unknown. This fateful region of both treasure and danger may be variously represented: as a distant land, a forest, a kingdom underground, beneath the waves or above the sky, a secret island, lofty mountaintop, or profound dream state; but it is always a place of strangely fluid and polymorphous beings, unimaginable torments, superhuman deeds, and impossible delights.” Joseph Campbell, The Hero with a Thousand Faces.

[3] “In northern Nigeria in 2003, the political and religious leaders of Kano, Zamfara, and Kaduna states brought the immunization campaign to a halt by calling on parents not to allow their children to be immunized. These leaders argued that the vaccine could be contaminated with anti-fertility agents (estradiol hormone), HIV, and cancerous agents.” Ayodele Samuel Jegede, “What Led to the Nigerian Boycott of the Polio Vaccination Campaign?” PLoS Med 4(3), e73 (2007)