Gary Foster, Chief Scientific Officer for Weight Watchers International, reviews four basic principles and practices when trying to help patients change their health behaviors.
Clinicians are “at high risk of doing the antithesis of this because there’s a human bias,” says Foster. “The more I’m trained, the more I know, the more I should tell you because it makes me feel good, like all this training is worth it,” one might think. But, he says, “Nothing could be further from the truth.”
Most patients, especially when it comes to eating and exercise, know what to do. They struggle with how to do it.
Foster describes a patient-clinician interaction where the patient wants to lose weight and asks for advice. The clinician describes what calories are, says to count them, and decides on a daily max; points out that 30% of the patient’s diet should consist of fat; talks math to determine 30% of 1,200 calories; divides that percentage into monounsaturated, polyunsaturated, and saturated fats; explains converting those calories into grams and reading grams on food labels; describes the importance of different types of fiber; and so on.
“You can imagine how a patient feels with that information. It’s like, ‘Thanks, but no thanks,’” says Foster. “A behavioral truism is the more simple the advice, the more likely it will be followed.”
“Simplicity matters. I can’t say it enough. I can’t say it strongly enough. When you’re tempted to go into the weeds or into nutritional complexities or into behavioral nuances, simplicity matters a lot.”
Clinicians often don’t do well at specificity because it takes another minute of their very limited time, says Foster. “A behavioral truism here is the more specific the goal, the more likely it will be accomplished. The more specific the goal, the more likely it happens.”
“I’ll do better. I’ll eat healthier. I’ll be more active.” How many times have you heard this?
“Plans work better than platitudes,” says Foster. “This aspiration of doing better, working harder, it wouldn’t work in any environment of behavior change.”
“The beauty of being specific is that the specificity of the plan leads to answer the question of how it can happen,” he adds.
Saying, “eat healthier,” isn’t a concrete goal, so it’s hard to approximate the steps to get there. If a more specific goal is to eat more fruits and vegetables, how do you measure that? “Specific goals are really important because they give a benchmark for success,” says Foster. “If the goal is to eat apples at 3:00, it’s pretty clear whether that happened or not.”
“For patients to feel progress, to feel a sense of self-efficacy and a sense of empowerment, they’re going to need to see some progress,” he says.
A common exercise goal is to walk more. But “how do you know next week if you’ll walk more next month?” Combining what and how, the goal could be, “I’ll keep my sneakers in the car, and on Mondays, Wednesdays, and Thursdays I’ll go directly from picking the kids up at school to the track and walk around while they play for 30 minutes.”
“It’s very clear whether that happens or not,” says Foster. “It doesn’t mean that the world is over because I didn’t do it [e.g., on Monday], but at least there’s [asking] what got in the way, and how could that be different?”
Asking How, not Why
When it comes to food and activity, this not an easy game to manage or master for a lot of environmental reasons. If we consider this the baseline, how can we help patients think through when things don’t go as well as they planned?
A clinician might say, “Tell me why that happened. What do you think is really happening there?”
“That gets you nothing, in my opinion, except navel gazing and potentially character assassination,” says Foster. “If this is a willpower issue or a motivation issue, are we supposed to hire a motivational speaker or are we supposed to give you a pharmacologic agent for willpower? If you ask the question of how, it gives you some therapeutic leverage.”
If someone comes in and says they had a rough week and ate a lot of cookies, you could ask why and be told they lacked willpower. Or, you could ask how that happened. “Think about this as little links in a behavior chain, just a few well-placed questions from you,” says Foster. “Where are the cookies come from? Where were they? What time was it?”
You might find out that the patient bought cookies, left them on the counter, and was home on a Saturday afternoon. That person was bored and tired, ate half a sleeve of cookies while watching TV, realized their mistake, and decided to throw in the towel and eat the rest of the cookies.
“At any point in this chain those links can be interrupted,” says Foster, by asking how questions. “How did you get from here to there? How was it that when you’re tired and bored, you get the urge to eat, not the urge to sleep?”
A “Good Dose” of Self-Compassion
One myth about self-compassion is that it’s selfish. But if you cannot take care of yourself, you won’t be able to effectively care for others. We’ve all heard the safety message on airplanes that if the air pressure goes bad, you should put on your oxygen mask first so that you can then help others. “It’s a nice analogy for patients that you need to have a fair degree of self-compassion to take care of others,” says Foster.
Another myth about self-compassion is tough love — calling yourself weak willed, lazy, or undisciplined and saying you have to work harder. “It increases motivation for about 30 seconds and what it really leads to is undermining of confidence and self-efficacy and motivation. That tough love stuff is nonsense in this context; it just doesn’t work,” says Foster.
Self-compassion means being kind to yourself, recognizing that nobody is perfect. “It’s a really simple thing, but a thing that’s often fraught with mythology, especially in a field like weight management where there’s this moral connotation [of] good foods and bad foods, on a diet, off a diet,” he says. “This whole idea of being kind to yourself feels sort of counterintuitive.”
Yet data show that self-compassion improves your relationship with others, makes you less afraid of failure, gives you a more positive outlook, helps you better maintain weight loss, and you take better care of your health even when stressed — and these are not soft outcomes.
From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.