just do it

DEATHCHRONIC

DISEASEBEHAVIOR

Mokdad et al., US Burden of Disease Collaborators (2018). JAMA

Dietary risksTobacco use

Leading ‘Causes’ of Death in U.S.Cardiovascular DiseasesNeoplasms (Cancer)Respiratory DiseasesNeurological DisordersDiabetes, Endocrine Diseases

RISK FACTORS

Low Physical Activity

HEALTHY BODY WEIGHT

NOT SMOKING

Healthy Diet

PHYSICAL ACTIVITY80%

Ford et al., 2009; McGinnis & Foege, 1993

Rel

ati

ve

Ris

k o

f M

or

tali

ty

-50%

-40%

-30%

-20%

-10%

0%

7 Servings/Day10 Servings/Day

CHD Stroke CVD Cancer All-Cause

vs. 1 serving per day

choosemyplate.gov

Katz & meller, 2014

Can we say what diet is best for health?

Stampfer et al., 2000

CHD Risk Reduction

2 = 27%

3 = 57%

4 = 66%

5 = 83%

12

5.16.7

Placebo Lifestyle

Inc

iden

ce

of

Dia

bet

es

Ca

ses/

100

per

son

s

Metformin

Diabetes Prevention

Program

Ratner, 2006

CHD Reversal?

Esselstyn, 2001

Ornish et al., 2008

Cancer

Down regulation of 31 cancer-related genes.

“By 2 years of follow-up, 27 percent of control patients and 5 percent of experimental patients had undergone

conventional prostate cancer treatment .”

Ornish et al., 2008

THE NORTH KARELIA PROJECT

Vartiainen, 2018

LIFESTYLE MEDICINE

The evidence-based practice of helping individuals and families adopt and

sustain healthy behaviors that affect health and quality of life.

The use of evidence-based lifestyle therapeutic approaches to prevent

treat, and reverse lifestyle-related chronic disease.

Ford et al., 2005

HEALTHY BODY WEIGHT

NOT SMOKING

Healthy Diet

PHYSICAL ACTIVITY5%

Troost et al., 2012

The process of monitoring and changing our behavior when our normalcy is interrupted.

Self-Regulation

NORMALCY?

NORMALCY?

1. Give Insight-If you can just make people see, then they will change.

2. Give knowledge-If people just know enough, then they will change.

3. Give Skills -If you can just teach people how to change, they do it.

4. Give hard time-If we can make people feel badly or afraid enough.

Butterworth, 2008

don’tWhy We

just do it

?

DEATHCHRONIC

DISEASE

?

BEHAVIOR

?

?

FRAME

act

do

health

Focus

Latimer et al., 2008

Gain, Challenge, Approach Loss, Threat, Avoid

Regulatory Focus

Latimer et al., 2008

Prevention Behaviors Diet Obesity Oral Health Physical Activity Safe Sex Skin Cancer Smoking Virus/Vaccine Other

Detection Behaviors Breast Cancer

Heart Oral Health

Safe Sex Other

Gain, Challenge, Approach

Loss, Threat, Avoid

Gain, Challenge, Approach

Gallagher & Updegraff, 2011

Behavior cannot be

understood without

consideration to a standard

STANDARD?

What does patient Value?

Identity > Values > Standards > Goals

The “Meaning”

1. Self-Esteem

2. Sex

3. Survival

4. Status

5. Spirituality

6. function

7. Family

8. ...Faries et al., Unpublished Data

Health care climate questionnaire

2. I feel my HCP understands how I see things with respect to

my health.

5. I feel that my HCP accepts me whether I follow their

recommendations or not.

12. I feel that my HCP cares about me as a person.

14. My HCP tries to understand how I see my health before

suggesting any changes.

Williams et al., 1996

✓ Focus on Positively Framed Messages

✓ Focus on Action goals

✓Connect to patient’s Focus (values)

FRAMEFOCUS

Response

“Don’t step on it. It makes you cry.”

Successful Comparison

Positive Feelings

Motivation continues

UNSuccessful Comparison

Negative Feelings

Change, give up, try harder

EFFO

RT

LEV

EL

StandardBelow Above

Depressed Sad Frustrated Eager Happy Blissful

“It makes me angry.”“How does that [diagnosis]

make you feel?”

“Sad and very Disappointed.”

“Well, I am pretty frustrated Right now.”

Higher Effort

Lower Effort

Higher Effort

Health care climate questionnaire

7. My HCP encourages me to ask questions.

11. My HCP handles my emotions very well.

13. I feel very good about the way my HCP talks to me about

my health.

15. I feel able to share my feelings with my HCP.

Williams et al., 1996

★ The Behavior can lead to negative feelings

Emotional Response

Dear Diet, Things just aren’t going to work between us. It’s not me, it’s you. You’re tasteless, boring, and I can’t stop cheating on you.

★ How good does ‘healthy’ option taste?

★ Passing up fast food when it is wanted?

★ Bring a salad to work?

Can result

in reproach“I will never diet again!”

Emotional Response

★ The Behavior can lead to negative feelings

I’m fairly certain my efforts to get into better shape have been somewhat hindered by my deep seeded hatred of exercise.

Emotional Response

Heart Rate

Ventilation

Receptors Baro–

Chemo– Mechano–

Muscle Damage

Sweat

Fatigue

WELL-BEING FATIGUE DISTRESS

Strong Exhausted Crummy

Great Fatigued Awful

Positive Tired Miserable

Terrific Drained Discouraged

McAuley & Courneya, 1994

Subjective Exercise Experience Scale

Williams et al., 2008 Rhodes & Kates, 2015

Very Bad

Bad Fairly Bad

Neut Fairly Good

Good very good

–5 –4 –3 –2 –1 0 +1 +2 +3 +4 +5

12 months

+41min/wk

✓How does the patient respond?

✓What does their response tell you?

✓What is your Response?

FRAMEResponse

“Indicators such as blood glucose, weight, and lab values were not discussed as value-free facts, but instead carried strong

emotional and evaluative connotations. People recognized tracking as work, judged themselves as “good”

or “bad” for their data and their diligence in collecting it…

Ancker et al., 2015

Attitude

Attitude

Attitude Intention Behavior

Control

norms

Ancker et al., 2015

5-a-day

Intention to use supplements

Control

Attitudeof supps

Health Value

Supplement Users: Believed more strongly than

non-users that taking dietary supplements would stop them from getting ill and help

them to be healthy

Norms

Conner et al., 2001

Boring

Fun

Defeating

Exciting

Worthwhile

Worthless

Important

Painful

OkayPleasant

✓ Health

✓ Weight Loss

✓ Body Image

✓ Disease Prevention

✓ Mood

✓ Cognitive Function

✓ Better Fitness

✓ ...

✓ Time

✓ Cost

✓ Effort

✓ Family Conflict

✓ Risk of Injury

✓ Give Up Other Things

✓ Sweaty and Stinky

✓ ...

BENEFITS COSTSEXERCISE

Hall & Fong, 2007

Exerc

ise F

requen

cy

0

100

200

300

Perceived Temporal Proximity0 1 2 3 4 5 6 7 8 9

COSTS BENEFITS

Point of Decision

Repeated Performance

How do you shift the curve?

Hesselink et al., 2014

Att

itu

de

✓What does the patient think about the Rx?

✓Use the Rx & team resources to ‘shift the curve’

✓What do you think about the Rx?

FRAMEattitude

“It is our attitude at the beginning of a difficult task which, more than anything else, will affect its successful outcome.” – Dr. Williams James

Motivation

“What fits your busy schedule better, exercising one hour a day, or being dead 24 hours a day?”

General drive to change or act in a particular way.

Motivation

Different Types

Extrinsic Motivation

Intrinsic MotivationAmotivation

Other-Determined

Self-Determined

Deci & Ryan, 1985

Guilt Goal

“I have no desire to exercise.” “I will start exercising, only

because you are making me do it!”

“I Enjoy exercising!”

AM OD

IM

“I exercise, so I get healthier and maintain my

weight.”SD Goal

“I Exercise, so I do not feel guilty.” Guilt

Extrinsic Motivation

Intrinsic MotivationAmotivation

Other-Determined

Self-Determined

Deci & Ryan, 1985

Learning for its own sake

3 Sources of IM

To Accomplish:

To Experience

Stimulation:

Meeting optimal challenges

Fun and pleasure

Deci & Ryan, 1985

To Know:

Extrinsic Motivation

Intrinsic Motivation

Amotivation

Other-Determined

Self-Determined

Demonstrate and exert control over our environment

3 Innate Needs

Autonomy:

Competence:

To be the origin of our own actions Self-determined

Need to be in caring relationshipsPlace in social order

relatedness:

Health care climate questionnaire

1. I feel that my HCP has provided me choices and options about

my health.

3. I am able to be open with my HCP about my health.

10. My HCP listens to how I would like to do things

regarding my health.

Williams et al., 1996

Weight

year 3MVPA

Autonomy

Support

weight loss at 3 years

Silva et al., 2011YEAR 2YEAR 1

Autonomous

Exercise

Motivation

Autonomous

Exercise

Motivation

AdherenceAutonomous

MotivationAutonomy

Support

Medication Adherence

Williams et al., 1998

R2 = 0.68

“These results thus indicate that autonomous self-regulation is strongly related to self-reports of adherence and pill counts…interventions should focus on supporting

patients' autonomy to enhance autonomous regulation, which in turn would be expected to improve adherence.”

Hospital Readmissions

Ileostomy

Readmission

RateAutonomy

Support

Self-Care Checklist 1. A healthy stoma should look like: 2. If my stoma has too little output, I will need to do:

3. My stoma is not healthy if: 4. To prevent dehydration I will: 5. If skin around my stoma is irritated, I will:

YEAR 2YEAR 1

28%

20%

50

40

30

20

10

0

Hardiman et al., 2016 N = 430

✓What type of motivation does the patient have?

✓ Teach, Harness your inner educator

✓Support autonomy, choice & Enjoyment

FRAMEMotivation

sites.google.com/site/compendiumofphysicalactivities

3 METs Brisk Walk, 2.5 mph

6 METs Hiking, Cross Country

4 METs General Gardening

5 METs Very Brisk Walk, 4 mph

Vacuuming

mowing yard, walking

digging worms, shovel

play w/ child, vigorous

3 METs

6 METs

4 METs

5 METs

Sexual Activity, ActivE Vigorous Effort2.8 METs

6 METs

Efficacy

If I believe can, I might.

If I believe I can’t, I probably won’t.

Attitude Intention Behavior

Control

norms

Ancker et al., 2015

5-a-day

Confidence and belief in your abilities to

do a specific task or behavior

“Somewhat Confident” 2x the Odds of Meeting PA Recommendations “Very Confident” 3x the odds of meeting PA Recommendations

Eyler, 2003

Self–Efficacy

MASTERY EXPERIENCES

self-Efficacy

Challenging,

Yet Attainable

MASTERY EXPERIENCES

Vicarious EXPERIENCES

self-Efficacy

Kazory, 2008

Dress the part?

Live the part?

Healthy Eating… exercise…

Control

+Personal Habits…Disclosure

Frank et al., 2000

Healthy?

% R

an

kin

g 7

-10

(Ex

trem

ely

)Frank et al., 2000

Control

Physician Disclosure

100

90

80

70

60

50

40

30

Believe Diet?

Motivate Diet?

Believe Exercise?

Motivate Exercise?

“In conclusion, we have shown compelling evidence

indicating that physicians’ health matters, and

that physicians’ personal Physical activity

practices influence their clinical Physical activity

attitude and practices.”

Lobelo et al., 2008

MASTERY EXPERIENCES

self-Efficacy

Vicarious EXPERIENCES

Persuasion/ Feedback

Perfectionist

SKEPTIC

Partier

Critic

WorrierWarrior

CAREGIVER

REalist

Optimist

DreamerPessimist

THe Committee

1. Encouragement 2. In- depth, informative Feedback 3. Rationale why some strategies were

successful, and others were not

“You can Do it”

Health care climate questionnaire

4. My HCP conveys confidence in my ability to make changes

regarding my health.

6. My HCP has made sure I really understand my health risk

behaviors and the benefits of changing these behaviors

without pressuring me to do so.

8. I feel a lot of trust in my HCP.

Williams et al., 1996

✓Set ‘challenging, yet attainable’ tasks or goals

✓ Encouragement goes a long way (Grace + Truth)

✓Provide informative feedback to learn from

✓Practice what you preach

FRAMEEfficacy

Hospita

ThePATIENT

PATH

Provider PATH Program

Mark D. Faries, PhD Texas A&M AgriLife Extension

Texas A&M School of Public Health

Medication

LifestyleAdherence When

Is The Medicine

THANK YOU!