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!
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