Michael T. Smith, Ph.D. Michael T. Smith, Ph.D. JHU CENTER for BEHAVIOR JHU CENTER for BEHAVIOR

msmith62@jhmi.edu5510 Nathan Shock Dr., STE 1005510 Nathan Shock Dr., STE 100

Baltimore, MD 21224Baltimore, MD 21224410-550-7000 Phone410-550-7000 Phone

Behavior Change Self-Study: Self monitoring and Goal Setting

AimsAims

1) Brief review of take home messages from first lecture on principle of behavior change

2) Reinforce the Utility of Health Belief for the BMW Rotation

3) Introduce the Experiential learning component of the rotation

• Goal setting / Self Monitoring with FitBit tracker

• Physical activity or Sleep Duration

• Social Learning Dimension

• Activity Group Discussions (creating a community focused on facilitating behavior change)

• Incentives plan for posting

Take Home MessagesTake Home Messages

1) Myth: Behavior change is hard

2) Start with targets where patient is ready , confident & able

3) Make it personal (appeal to the beast)

4) Set small realistic SMART goals (75% confident)

5) Use Prompts, triggers, & clear environmental path /barriers

6) Use social learning principles Make public a personal commitment

Modeling

Norms

7) Self monitoring: must be easy and informative

General Principles of Behavior General Principles of Behavior Change: Change: Health Belief ModelHealth Belief Model

Seriousness of the risk / disease

Odds it will happen to me ?

Ability to change ?

Reminders / Triggers

Self -Efficacy is King

To help patients make a health behavior change: 1) Teach patients how serious their related medical condition is and how behavior influences it. Convince patients that a bad disease outcomes are likely to

happen / are happening to them personally. Bolster their perceived ability (confidence) to make the behavior changes. Teach them to use prompts in their environment to remind them to change.

Experiential Learning Component:Experiential Learning Component:ObjectivesObjectives

Overall Objectives:

1)Increase empathy for the challenges of asking patients to change

2)Gain in insight into use of goal setting, self-monitoring, social determinants, and incentives as behavior change tools

1)Increase self-efficacy for helping patients make sustainable changes

1) Create a supportive culture of healthy behavior change We serve as models for ourselves and our patients

2)Establish enduring resources for the JHMI community for patients and healthcare professionals

3)Improve your own health / wellbeing and have fun

Experiential Learning Module: Experiential Learning Module: OverviewOverview

Two Components Managed Online Via Fitbit Website:

1)Rotation-related Small Groups•Goal Setting / Self-Monitoring•Opt to view and discuss each others progress towards personal goals on line (sharing is optional)•Aggregrate the data by cohort for comparison by other cohorts

2) General Discussion Groups (not personal goals)

Physical ActivityEating Behavior / ObesitySubstance Abuse / AlcoholSmoking / TobaccoSleepGeneral Health Behavior Change

Ground Rules: small group & general Ground Rules: small group & general discussion groupsdiscussion groups

• Posting personal goals / sharing progress / data is optional

• Only open to Hopkins residents and CBH faculty / staff

• Absolutely No PHI

• Be Kind & Respectful of yourself, peers and patients

• No profanity

• No question is stupid

• Push yourself a little

Rotation-Related Small Groups Rotation-Related Small Groups

Self-Monitoring•If you can not measure it, you can not improve it. - Lord Kelvin

•Establishing a baseline to measure progress is critical

•Must be quick and easy: objective data is especially helpful

•Immediate real-time digestible feedback on behavior

• Can act as a prompt / reminder

• Easier to make small course corrections than deal with large setbacks

Strategies and tools : Strategies and tools : PreparationPreparation

Goal Setting:Poorly crafted goal: “I want to lose weight.”

Smart goal

Specific:

Measurable:

Action - Oriented

Reasonable:

Time Delineated

Long-term Goal

“I want to lose 1 pound / week for 3 months by:”

Short-term Goals / Steps

1) Decrease alcohol to 2 servings / week

2) Cut meal portion sizes by about 20% and limit red meat to 2X week

3) Limiting snacks to 100 calories of fruits & veggies between meals

4) Walking 10,000 steps, 4 days a week

Physical Activity GoalPhysical Activity Goal

Setting a Long-term (3 – 6 month) PA Goal: where to start

DHHS Guidelines Adults (18-64 years olds):

•150 minutes / week of moderate-vigorous aerobic physical activity• 30 Minute brisk walk, 5 days a week or more.• Accumulate in intervals at least 10 minutes at a time

• shorter intervals do not have the same health benefits.

•Strengthening activities, like push-ups, sit-ups and lifting weights,• at least two days a week.

Physical Activity Goal:Physical Activity Goal:Setting a Long-term PA Goal: a place to start

Pedometer Programs Are Effective (several meta-analyses)

• Richardson et al. Annals of Family Medicine, 6(1), 69-77 & Bravata et al., JAMA, 298(19), 2296-304

10,000 Steps-a-day as a long-term target – Why?

•Individuals meeting 10,000 steps / day; likely to meet DHHS PA guidelines

• (LeMasurier et al., Res Q Exerc Sport , 74, 389-94)

•Lowers blood pressure in mild essential hypertension

• Iwane et. al., Hypertension Research, 23, 573-580

• Produces weight loss over 36 weeks in sedentary overweight / obese adults

• Schneider et al., American Journal of Health Promotion, 21, 85-89 (2006)

Normative Data, Steps / Day:Normative Data, Steps / Day:Bohannon, Physical Therapy, 87(12), 1642-1650 (2007)

• Canadian Amish Steps/Day: Males (aged 34 = 18,425/day & Females Aged 32 = 14,196/day

Special Population Targets to Consider (Engel & Lidner, Diabetes Education, 32(1), 2006)

Healthy older adults:

6000-8500 step / day

Older Adults with disabilities and chronic illnesses:

3500-5500 steps / day

Physical Activity Goals: Approaches Physical Activity Goals: Approaches

a) Percentage increase from baseline: e.g., 25%

b) Graded approach

If baseline:

< 8000 step / day: increase by 10% every 2 weeks until 10K and hold

8000 - 10,000 / day: increase by 5% every 2 weeks until >10,000

If > 10,000 / day: Consider specific goals for exercise, e.g. 30 min/day of moderate to vigorous activity to include jogging 4 days/week for 30 mins.

C) Increase by a constant from baseline: + 2000 steps- increasing 400 steps a week

If Sleep has no purpose, then it would be the biggest

mistake evolution has ever made...

Allan Rechtschaffen

Sleep DurationGoal

38% of Adults Report Insufficient sleep

(CDC)

Mor

talit

y R

isk

Per

cent

age

Self-Reported Total Sleep Time

Kripke et al. 2001, Arch Gen Psych

Sleep Duration Increases Diabetes Sleep Duration Increases Diabetes RiskRisk

• Experimental sleep restriction to 4 hrs/night for 6 days causes insulin resistance (Spiegel et al. (Lancet, 1999)

• Sleep duration impacts prevalence of diabetes

Adjusted for age, sex, race, waist girth, caffeine, alcohol, smoking, and apnea-hypopnea index Gottlieb et al. (2005)

Arch Intern Med

J of Sleep Research

2, 1-12 (2003)

Sleep Extension Goal Setting: Sleep Extension Goal Setting: Strategies/Approach Strategies/Approach

Normal adult sleep ranges between 7- 8.5 hours / night• This may be insufficient for some.

• Historically before advent of electric light, average sleep time was 8.5+/night

• Considerable individual variability in sleep need

•Make small weekly increments (5 or 15 minutes)

•Consider Chronotype (lark or owl)• Generally easier to get up later than to go bed earlier

• Intrinsic clock is 24 hour +20 mins• Getting up later is going with the grain

• unless phase advanced and / or older adult

•Stopping rule for sleep window extension• Average weekly Sleep Efficiency (total sleep time / Time in BED * 100) drops

below 85-90%

Sleep Extension Goal Setting: Sleep Extension Goal Setting: CAVEATSCAVEATS

1) Appropriate for insufficient sleep syndrome:

• Normal sleep that is curtailed due to choice, habits or environmental circumstances

2) Do not select this goal if you likely have a sleep disorder.• Insomnia - trouble initiating or maintaining sleep with daytime

consequences: • Despite adequate sleep opportunity• Sleep Extension will make Insomnia worse

• Sleep apnea• Circadian Rhythm Disorders• Periodic limb movement disorder • Restless legs syndrome• Narcolepsy/hypersomnia

General Discussion GroupsGeneral Discussion Groups

• 6 Content Areas: Moderated by CBH “champions” Physical Activity Eating Behavior / Obesity Substance Abuse / Alcohol Smoking / Tobacco Sleep General Health Behavior Change

• Open to all residents and CBH Faculty as soon as they they signup for their fitbit account.

• During Rotation must post at least 1 new question or comment a week in different categories that arise related to patient care • General questions (no PHI)• Seeking resources• Issues / Concerns

CBH General Discussion GroupsCBH General Discussion Groups

•Discussion threads intended to be an educational resource only

•Not to be construed as psychological or medical advice/consultation

•Champions will log in at least once / week

•Gems and teaching points that are particularly useful will be edited into enduring materials to compliment the existing materials on the CBH website.

•Champions and CBH faculty will be encouraged to share their fitbit data with the general community

• Norms• Role model

Incentivizing Discussion BehaviorsIncentivizing Discussion Behaviors

•Monthly $100 Prizes (must be health-related items)• E.g. Exercise clothes, fruit, session with a personal trainer, etc

•To be eligible for a monthly prize (winner determined by lottery)

• Must make at least one substantive post during the month• Earn up to one new entry in the monthly drawing per week

• Post can’t simply be a brief reply of encouragement (though this is encouraged)

• Must be a new thread / topic / query / issue / resource / thoughtful comment

•Grand Prize at end of the program = $1,000 value of a Health-related item or service

• year long membership at Maryland Athletic Club • A bike• Treadmill, etc.

To be eligible for grand prize – must have at least 1 substantive post every month for 8 monthsEarn up to one new entry in grand prize drawing for every month in which all weeks had a least one post

Date of download: 1/16/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Financial Incentive–Based Approaches for Weight Loss:  A Randomized Trial

JAMA. 2008;300(22):2631-2637. doi:10.1001/jama.2008.804

Effect of incentives may attenuate over timeBest where short-term behaviors can have a major impact

• Incentivizing perinatal care, Physical Rehab, etc• Extrinsic motivation might compromise intrinsic motivation in some personality

types