Patient Engagement
Behavior Change Basics: Simplicity to Self-Compassion (11:15)

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.

More From Patient Engagement
Barriers to Providing an Oustanding Patient Experience

Buzz Survey Report: Patient Experience

An independent NEJM Catalyst report sponsored by University of Utah Health on barriers to achieving an excellent patient experience.

The Patient Engagement Capacity Framework

The Patient Engagement Capacity Model: What Factors Determine a Patient’s Ability to Engage?

Patient engagement assessments often don’t dig deep enough to identify why patients don’t participate in their own health care. We present a new model to help providers pinpoint the reasons for lack of engagement and address them more effectively.

Organizational Mindset Is the Biggest Barrier to Engaging Patients as Consumers

Survey Snapshot: The Patient-Physician Relationship Is Key

Both parties involved in a consumer-facing transaction have access to important information about the product or service — but this isn’t the case with health care.

What High-Need, High-Cost Patients Say About How to Reduce High Utilization of ED and Inpatient Services

High-Need, High-Cost Patients Offer Solutions for Improving Their Care and Reducing Costs

More home health care and after-hours clinics, telemedicine, and home delivery of medications are among top solutions.

Top Physician Pain Points Identified by Chronic Patients

Unmet Needs: Hearing the Challenges of Chronic Patients with Artificial Intelligence

With natural language processing and machine learning, researchers are identifying patient emotional and medical needs that are not being met by clinicians and patient advocacy groups.

Health Care Can Learn a Lot from Other Consumer-Facing Industries - Especially About Customer Service - Consumerization of Health Care

Patient Engagement Survey: Health Care Has a Lot to Learn from Consumer-Friendly Industries

The consumerization of health care continues to reshape the way that patients engage with providers and experience care. Most providers see this fundamental change in the health care model as a necessary response to changing patient demands, and have embraced the need to learn from other industries.

Bilazarian01_pullquote patient engagement both sides of the bed

Patient Engagement from Both Sides of the Bed

When patients and families are included in medical rounds as valued members of the team, the quality of care improves.

Ten Guiding Principles for Patient-Centered Care as Described by Mountain States Health Alliance to consider with patient-centered outcomes research (PCOR)

Complementary Approaches to Patient Engagement in Patient-Centered Outcomes Research

It’s important for providers to understand and apply the key principles foundational to patient-centered outcomes research efforts.

Selected Advantages of Improved Patient Electronic Access to Health Data

Patient-Led Data Sharing — A New Paradigm for Electronic Health Data

The pieces are in place for a truly disruptive shift in how patients can access and use their own clinical data to improve their health.

Collapse of Two Online Health Communities as Result of Removal of Users Starting from Superusers

Online “Superusers” as Allies of the Health Care Workforce

Three proposed steps for integrating peer-driven online health communities with traditional services to improve health outcomes for people with chronic conditions.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


Patient Incentives

70 Articles

Survey Snapshot: Is Transparency the Answer…

NEJM Catalyst Insights Council members say that while transparency might be necessary, we have to…

Primary Care

184 Articles

New Evidence on Stemming Low-Value Prescribing

New research suggests that deploying strong and surprising messages could help to address overprescribing of…

Digital Health Care in China: Benefits…

China’s experience offers insights for integrating digital and non-digital health care services.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now