Engineering Virtuous health habits using Emotion and Neurocognition: Flexibility for Lifestyle Optimization and Weight management (EVEN FLOW).

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Interventions to preserve functional independence in older adults are critically needed to optimize 'successful aging' among the large and increasing population of older adults in the United States. For most aging adults, the management of chronic diseases is the most common and impactful risk factor for loss of functional independence. Chronic disease management inherently involves the learning and adaptation of new behaviors, such as adopting or modifying physical activity habits and managing weight. Despite the importance of chronic disease management in older adults, vanishingly few individuals optimally manage their health behavior in the service of chronic disease stabilization to preserve functional independence. Contemporary conceptual models of chronic disease management and health habit theory suggest that this lack of optimal management may result from an underappreciated distinction within the health behavior literature: the behavioral domains critical for initiation of new behaviors (Initiation Phase) are largely distinct from those that facilitate their maintenance (Maintenance Phase). Psychological factors, particularly experiential acceptance and trait levels of openness are critical to engagement with new health behaviors, willingness to make difficult lifestyle changes, and the ability to tolerate aversive affective responses in the process. Cognitive factors, particularly executive function, are critical to learning new skills, using them effectively across different areas of life and contextual demands, and updating of skills to facilitate behavioral maintenance. Emerging data therefore suggests that individuals with greater executive function are better able to sustain behavior changes, which in turn protects against cognitive decline. In addition, social and structural supports of behavior change serve a critical buffering role across phases of behavior change. The present review attempts to address these gaps by proposing a novel biobehavioral intervention framework that incorporates both individual-level and social support system-level variables for the purpose of treatment tailoring. Our intervention framework triangulates on the central importance of self-regulatory functioning, proposing that both cognitive and psychological mechanisms ultimately influence an individuals' ability to engage in different aspects of self-management (individual level) in the service of maintaining independence. Importantly, the proposed linkages of cognitive and affective functioning align with emerging individual difference frameworks, suggesting that lower levels of cognitive and/or psychological flexibility represent an intermediate phenotype of risk. Individuals exhibiting self-regulatory lapses either due to the inability to regulate their emotional responses or due to the presence of executive functioning impairments are therefore the most likely to require assistance to preserve functional independence. In addition, these vulnerabilities will be more easily observable for individuals requiring greater complexity of self-management behavioral demands (e.g. complexity of medication regimen) and/or with lesser social support. Our proposed framework also intuits several distinct intervention pathways based on the profile of self-regulatory behaviors: we propose that individuals with intact affect regulation and impaired executive function will preferentially respond to 'top-down' training approaches (e.g., strategy and process work). Individuals with intact executive function and impaired affect regulation will respond to 'bottom-up' approaches (e.g., graded exposure). And individuals with impairments in both may require treatments targeting caregiving or structural supports, particularly in the context of elevated behavioral demands.





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Smith, Patrick J, Heather E Whitson, Rhonda M Merwin, C Virginia O'Hayer and Timothy J Strauman (2023). Engineering Virtuous health habits using Emotion and Neurocognition: Flexibility for Lifestyle Optimization and Weight management (EVEN FLOW). Frontiers in aging neuroscience, 15. p. 1256430. 10.3389/fnagi.2023.1256430 Retrieved from

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Heather Elizabeth Whitson

Duke School of Medicine Distinguished Professor in Neuroscience

Dr. Whitson's research is focused on improving care options and resilience for people with multiple chronic conditions.  In particular, she has interest and expertise related to the link between age-related changes in the eye and brain (e.g., How does late-life vision loss impact the aging brain or cognitive outcomes?  Is Alzheimer's disease associated with distinctive changes in the retina, and could such changes help diagnose Alzheimer's disease early in its course?).  Dr. Whitson leads a collaborative Alzheimer's Disease initiative that brings together investigators from Duke University and the University of North Carolina (UNC) at Chapel Hill, with a bold vision to transform dementia research and care across Eastern North Carolina. Dr. Whitson is also interested in improving health services to better meet the needs of medically complex patients.  Within the Duke Aging Center, she leads research efforts aimed at promoting resilience to late-life stressors (e.g., surgery, sensory loss, infection).  She has developed a novel rehabilitation model for people with co-existing vision and cognitive deficits, and she is part of a inter-disciplinary team seeking to improve peri-operative outcomes for frail or at-risk seniors who must undergo surgery.  As a co-leader of a national resilience collaborative, she seeks to better understand the biological and psychological factors that determine how well we "bounce back" after health stressors.  


Rhonda M Merwin

Associate Professor in Psychiatry and Behavioral Sciences

Rhonda M. Merwin, PhD, is an Associate Professor in the Department of Psychiatry and Behavioral Sciences. Dr. Merwin completed her doctorate at the University of Mississippi and an NIH-sponsored postdoctoral fellowship in Behavioral Medicine at Duke University Medical Center before joining the Duke faculty in 2008. Dr. Merwin has expertise in eating disorders, Acceptance and Commitment Therapy (ACT), and psychological concerns in the management of Type 1 diabetes. She is 1 of 111 peer-reviewed ACT trainers worldwide and a Fellow and the President-Elect of the Association for Contextual Behavioral Science. Dr. Merwin is leading work to address eating disorders in type 1 diabetes, a dangerous comorbidity that disproportionately affects women. Her research is funded by the National Institutes of Health (e.g., NIDDK, NIMH) and the Juvenile Diabetes Research Foundation (JDRF), among others. She is the author of ACT for Anorexia: A Guide for Clinicians. Dr. Merwin directs the ACT in Context Laboratory, which focuses on the mechanisms and treatment of eating disorders, or more broadly, problems in living that arise from an adversarial relationship with the body or the body's cues, and/or difficulty reading and responding to internal cues to meet one's physical and emotional needs. Her treatment development work integrates digital and mobile technologies to increase treatment access, and for contextually sensitive assessment and intervention, with a focus on processes of change. Dr. Merwin directs the ACT at Duke program, a clinical, research and training program in ACT and process-based therapy, that includes a practicum for psychiatry residents, and psychology fellows and graduate students to receive in-depth training in ACT, as well as community consultation team for local providers and continuing education events. Dr. Merwin teaches a psychotherapy course for psychiatry residents in the School of Medicine. For more information about Dr. Merwin's research, educational and clinical activities, see


Timothy J. Strauman

Professor of Psychology and Neuroscience

FOR POTENTIAL STUDENTS (fall 2024 class): 

Dr. Timothy Strauman and Dr. Ann Brewster will be seeking to admit a student for Fall 2024 who will be an important member of their collaborative projects. Dr. Brewster is an intervention scientist and a faculty member in Duke’s Social Science Research Institute. The collaborative projects focus on creating, testing, and implementing school-based therapeutic and preventive interventions for adolescents at risk for negative academic and mental health outcomes. We are partnering with the Durham Public Schools as well as with other local school districts, and Dr. Brewster has extensive experience and expertise in developing the partnerships, working with community members, and the intervention process itself. We are especially interested in applicants with experience in community-based interventions, with interests in adolescence, and with knowledge and experience working with both behavioral and neuroimaging data.

Professor Strauman's research focuses on the psychological and neurobiological processes that enable self-regulation, conceptualized in terms of a cognitive/motivational perspective, as well as the relation between self-regulation and affect. Particular areas of emphasis include: (1) conceptualizing self-regulation in terms of brain/behavior motivational systems; (2) the role of self-regulatory cognitive processes in vulnerability to depression and other disorders; (3) the impact of treatments for depression, such as psychotherapy and medication, on self-regulatory function and dysfunction in depression; (4) how normative and non-normative socialization patterns influence the development of self-regulatory systems; (5) the contributory roles of self-regulation, affect, and psychopathology in determining immunologically-mediated susceptibility to illness; (6) development of novel multi-component treatments for depression targeting self-regulatory dysfunction; (7) utilization of brain imaging techniques to test hypotheses concerning self-regulation, including the nature and function of hypothetical regulatory systems and characterizing the breakdowns in self-regulation that lead to and accompany depression.

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