Josh Klapow, PhD
January starts as a fresh page, when people are full of the resolve to finally make the positive changes they’ve been meaning to get around to—go to the gym, eat healthy, stop smoking, get control of their time and stress.
By midmonth, many of these resolutions begin to derail, and as the first buds of spring begin to appear, most are only fading memories of good intentions gone awry. People tend to gradually slip back into the routine of the familiar.
Health behaviors are the Achilles heel contributing to modern plagues like diabetes, cancer, heart disease and hypertension. However, a recent study indicated that primary care physicians spend very little time discussing this topic with patients.
One factor, of course, is that there simply isn’t time to go into such complex issues after dealing with the primary reason for the visit. Another is that some patients are so sensitive about feeling they’ve failed to meet their doctor’s expectations that they might avoid necessary care. And most insurers don’t reimburse time spent on issues like weight loss, though this could change as the focus shifts toward prevention.
The question is, what are the most effective ways for physicians to support their patients in making lasting changes and help them improve the odds for success?
Wanting To Change Vs. Knowing How
“Most people don’t fail for lack of motivation. They fail for lack of the skill set they need to make changes,” Josh Klapow, PhD said. An associate professor at UAB’s School of Public Health, psychologist Klapow is known for his expertise in health behaviors and outcomes assessment.
“There’s a science to making changes, with plenty of research behind it,” he said. “However, it also isn’t a big part of medical education, so many physicians may not have the training to pass along those skills. And it takes more time than is likely to be available in an office visit.
“One possibility would be to train a nurse practitioner to coach patients in changing health behaviors. Alternatively, a member of the office staff could compile lists of local resources on handout sheets for various changes patients want to make.”
By approaching patients in a spirit of encouragement rather than judgment, the healthcare team can offer information to help sustain their efforts to make lasting changes.
Some behavior changes are about starting and building habits, such as exercise, taking medications on time, and following up on regular checkups. Others require stopping a behavior, such as smoking or drugs. There are also behaviors that must continue as part of life, but need to change, such as healthy eating and learning to live with stress without being overwhelmed by it.
Although there are differences in the nature of these changes, Klapow says the skill set people need to succeed is essentially the same. He outlined these skills in a book he recently wrote with psychologist Sheri Pruitt, PhD, Living SMART: Five Skills To Change Your Health Habits Forever.
“SMART is a mnemonic for five basic skills people can use to be more successful in making changes,” Klapow said. “S is for set achievable goals. Goals should be specific—not ‘I’m going to walk more,’ but ‘I’m going to walk on the YMCA track Monday, Wednesday and Friday, and build up to 30 minutes a day.’ The goal should also be achievable. Don’t say ‘I’m going to lose 50 pounds next year.’ First, that’s a lot to lose. More importantly, that’s a wish for an end result, not a behavior that will help you achieve that result. Achievable goals would be adding three more servings of fruits and vegetables and avoiding simple sugars and starches.
“The M is for monitor. You’re more likely to stick to a behavior if you track it. Write down what you eat, or the days you exercise.”
“A is about arranging for success,” Klapow said. “Set up your world to have what you need in place. Get rid of the cigarettes and junk food. Stock up on fruits and vegetables.
“R is for recruiting support. Research shows that a strong support network improves the odds for success. You need encouragement, so go ask for it. “
Klapow suggests being specific about the kind of support you need. Food police are rarely helpful, but friends who keep junk food out of sight or congratulate you when you’ve made it through coffee without a cigarette can be helpful allies. There are also online support groups who can help.
“T is one of the most important parts of change,” Klapow said. “T is treat yourself. Behavior that is reinforced is more likely to be repeated. Rewards should be frequent and not too far in the future. Plan what the treat will be so you can look forward to it.
Progress Vs. Perfection
“If you don’t achieve your goal every day, don’t dwell on it,” Klapow said. “Instead, try to identify how things got off track and consider what you can do differently to make reaching your goal easier next time. Life being what it is, drifting motivation happens to almost everyone.”
One of most valuable bits of advice Klapow offers is a suggestion for how to avoid letting a slip become a fall. “It’s the three-day rule. Most people will screw up along the way. What’s important is to recognize what’s happening and have a plan to get back where you want to be. If you go three days in a row without meeting your goal, take five minutes to sit down and write out why. Now, pick an exact date when you will get back to working toward your goal. Post it where you can see it and plan for it. Then, when that day comes, start working again.”
I Want To Change, But I’m Too Stressed Out
If managing stress is a habit you need to change, how do you approach that?
“With stress, you have three options,” Klapow said. “You can change the situation causing the stress. You can change how you interpret the situation. Or you can change how your body reacts to it.”
If you can’t change the situation, look at what you’re telling yourself about it. Are your expectations realistic? Is your interpretation accurate?
If you can’t change the situation or what it means to you, can you diminish its effect on your body by using meditation or perhaps a key word to signal that relaxation response when you recognize that you are getting stressed?
Where Do I Start?
As resources for information on the practical aspects of building healthy behaviors, Klapow suggests that physicians look into programs offered by local hospitals and the websites of associations that focus on diabetes, heart disease, and cancer, as well as professional associations related to nutrition and wellness.
Through the UAB School of Public Health, Klapow has his own website that offers tips of the week, healthy action minute videos, and a collection of free downloadable tools to assist in goal setting and monitoring at DrJoshK.com.
Wellness As A Lifestyle
Lauren Whitt, PhD, is the coordinator for UAB’s employee wellness program and an adjunct professor in the Department of Human Studies.
Her advice on helping patients make healthy changes echoes that of Klapow.
“One of the best things doctors can do for their patients is to be aware of the programs around them and have someone in their office pull together handout pages listing resources that can help patients get started,” Whitt said. “Where are the local gyms, parks and community programs or recreational activities that are either free or available at low charge? Where are the farm stands with fresh produce? Who offers smoking cessation programs?
“Exercise is like a magic pill that can help us live longer, feel better, be more relaxed and healthier, but when people think of it as hard, they don’t want to do it. We need to rethink how we look at exercise and look for activities we enjoy.”
Jogging may be one person’s definition of torture, but they may find they actually like aquatics or dancing. Even people who don’t like walking on a track may find that strolling through a garden or aerobic shopping behind a cart in a big box store has its rewards.
“A lot of people say they don’t have time,” Whitt said. “The problem is they are trying to make time and fit it in on top of everything else in their schedule. We need to rethink how we frame our lives. It’s like putting rocks in a jar. You put the big rocks in first, and fit the little rocks between them. The big rocks are our job and our family. Our health should also be a big rock. It’s what allows us to do everything else. Then we fit in the small rocks.”
Whitt also suggests looking for opportunities to work more activity into our day. “When you’re on the phone, walk on the treadmill, or use your cell phone and go out to walk.”
First And Goal
Breaking free of tobacco is rarely easy, but it can make a life and death difference in health.
“To quit, it helps to have a plan and a support base,” Whitt said. “Most people try multiple times before they succeed. I tell them to look at it like a ballgame. You’ll probably be tackled more than once before you make it to the end zone. A good resource is 1-800-QuitNow. They offer a four-week free nicotine replacement program.”
Don’t Keep The Monkey
Stress is something you can’t eliminate from life. It’s important to build resiliency skills. Learn to anticipate situations that are likely to involve stress and plan how you are going to handle them. Understand that this, too, will pass and next year you may not even remember it,” Whitt said.
“It helps to keep the stress of work independent from other parts of your life. Leave it behind when you go home. And when someone brings you a problem, it’s fine to be supportive, but don’t let them make their problem your problem. Don’t keep the monkey when it doesn’t belong to you.”
Your Mileage May Vary
Now that research is showing that 60% of obesity is influenced by genetics and many of the behaviors we once thought were learned seemed to be hard wired, an important part of making healthy changes is understanding that the results one person can expect may not be the same as that another person experiences when putting in the same effort. Calories in and calories out may conform to the laws of thermodynamics, but just as the miles you’d get from a gallon of gas in a Lincoln would differ from the miles you’d get in a Miata, the results two different bodies and brains get from the same effort tend to differ. Patients need to understand this so they can celebrate their own successes instead of comparing themselves to someone else.
“The genes we get are the hand we are dealt,” Klapow said. “Until we have gene therapies that can change that, we have to play the hand we are dealt and focus on what we can do.”
Whitt added, “Every time we decide whether to take a bite or light a cigarette, we need to remind ourselves—we have a choice.”