Earlier this week I wrote a post about raising heart healthy children. The data summarized in that post may be the most important data I discuss all year when you consider that heart disease kills more of us than anything else. Thing is, I’m not surprised many of you haven’t read it. I expected it.
It’s just so flipping hard to read, or have any interest, or take advice about health when the advice or data requires us to make big changes. Or when the advice (regardless if we trust it or not) seems intuitive and self-evident. Things like eating less, restricting salt, or exercising more don’t sound so new. Those are things we already know we should do, but we often just can’t find a way to implement change in our totally overwhelming and busy lives. Big changes regarding how much we exercise, what we eat, and how we model behavior for our children seem daunting, overwhelming, and somewhat paternalistic. I also think it’s uninspiring to read about preventing heart disease in our kids because it feels so far off (thinking of our child dying of a heart attack or stroke doesn’t really compute) and really, we often can’t see heart disease. Heart disease walks around us silently.
That’s where we physicians fail, I think. There is convincing data about preventative health care that urges us to help get our patients to change behaviors that cause them suffering and ultimately threaten their life. But we fail to convince our patients to make changes because we simply don’t make it relevant enough. Or easy enough. Or we’re not convincing because we don’t demonstrate that we follow our own advice. Many docs are constantly trying to figure out what works best. See this tweet from Dr Pourmassina, an internal medicine physician in Seattle.
I think about ways to improve our translation of research for our patients all the time. And I think telling stories really helps. But I didn’t begin that post about heart disease with a story. Although there are many.
Last weekend for example, I set out to exercise every single day (without fail) for 30 days. I haven’t had time to prioritize exercise (let’s be honest: since F was born) over the last 5 years. And in my quest for 1 month of change, already I’ve failed. I made it only 3 days. And not for a lack of motivation; I love to run.
But yesterday I was gone from home for over 15 hours and it simply left no time for self-care. When I got home around 10pm, I couldn’t muster up the energy to step out into the cold air for a run. My loss, really. Now I have to re-start my 30 day challenge feeling a bit defeated.
I think we’re all very similar as we raise our children; we want to do this right (eating right, exercising, parenting perfectly), and often we are highly motivated (we care more about our children than anything else). It’s just the time crunch. Or the cost of implementing change. So many demands, so many things to change.
Back in September, I had the fortune to hear BJ Fogg present at Stanford about his model for behavior change. As I understood him, activating a change of behavior demands a trigger and a balance between the ease or ability of a new behavior and the motivation we carry to implement the change. He plots ease of an activity against motivation. Habits, he described, are things that stick around in our life every day because either they are super easy (tying your shoes or brushing your teeth or feeding your dog) or the motivation is fairly easy to come by (hunger cues us to eat every day, for example). He urges us to make new, desired behaviors simply easier. If we do, they will be more likely to happen. And so while I think more about talking with families in my clinic about preventing heart disease, I wonder, what has worked in your life to change your bad habits? How do you find time to exercise, make healthy meals, prepare healthy snacks, and prioritize an hour a day of outdoor play for your kids? What have you done to make these things easier?
Please share. I have my ideas but we need your ideas more.
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Davis Liu, MD says
Found this book helpful in providing a framework to change behavior!
https://www.amazon.com/gp/aw/d/0979356407/ref=redir_mdp_mobile/192-6305229-0579157
Murfomurf says
As I keep saying [a lone unemployed public health researcher’s voice from downunder]: Doctors shouldn’t be surprised that patients don’t do what they’re told. Humans need more than a twice a year prompt from their doctor, a poster in the waiting room or a 30 second TV ad to change a lifetime of learning and habits! Even the invention of a subset of Public Health entitled “Health Promotion” hasn’t worked as it doesn’t instruct each individual in a group (eg. heart attack risks), how and when to do what! The whole mad merry-go-round depends on psychology- and that’s not JUST deciding at what Stage of Change you are!!
As we have escaped the constraints of our natural environmental and seasonal demands, there is no strong external force to mold our behaviour in a healthy direction. Modern healthcare has distorted our relationship with the powers of natural selection so we don’t notice things like my 52-year-old [wildly healthy] friend dying of bowel cancer after a lifetime of tangling with high-octane fuels while racing his motorcycle and other boys’ toys. We don’t notice grandma deteriorating rapidly after we buy her all the new-fangled things like a dishwasher, garbage disposer and a gardener to weed for her, a community helper to get the groceries.
The scourges of modern living affect the whole community from birth to death. We need a “whole of community” approach and to get the whole community involved- we might even have to bully some of them into it for the sake of their grandchildren! Whatever the approach, I think it needs community health & fitness “coaches” to rally people within a neighbourhood to get out there every day and MOVE! The reminders have to be often and constant [why not use modern technology, eg. SMS, Twitter etc] and a real human must develop some interpersonal contact with each individual. THEN many more people might join the crowd and we’ll be halfway to a fitter and healthier community. Also, if a few conspicuous people in each community fall ill due to the increased exercise, we have to push everyone out of their own comfort zones so they don’t get all superstitious and give up what they’ve started!
I really do believe each country should put most of their Public Health budgets into this type of community fitness program with gradual enrolment as research is happening on the early-adopters. We’ve had a million trials of various approaches and then the efforts have collapsed trying to get enough similar trials to do Cochrane reviews. When reviews hesitate or disagree, this gives people an excuse not to implement. Why not adopt the “Just do it” motto?- At least some people will have more fun in their lives, giving you a lower mental health burden!
It’s not what you say to the community but what you DO WITH the community that will help bring about behaviour change.
Katherine Leon says
“Responsibility.” It is a word that is missing from many conversations today, and I noticed it is missing from healthcare discussions as well. I’m a big fan of your message but would like to point out that not once do you mention the responsibility we each have to ourselves, our children, our families, and society in general for taking ownership of our health and purpose in life.
Parents shouldn’t be “convinced” by a doctor to do what is right. Part of the parental dialogue needs to include the concept of responsibility. It is missing! In our schools, government, healthcare system, media, entertainment industry, sports world — where is it? Who ever talks about responsibility any more? No one.
Getting a baseline blood draw for cholesterol when my sons are age 9-11 isn’t boring or complicated. It is my responsibility as a parent (now that I know)to help my children grow into heart healthy men.
Could we please add “responsibility” back into the equation?
Thank you for raising the awareness of cholesterol and heart disease as a lifelong concern.
Katherine Leon
Josie says
This is something that I constantly struggle with. In our family, we try to concentrate on one change at a time, and to make those changes part of our routine. Things are great for a while, but life situations change, and the routine is disrupted, and you have to start it back up again. It’s a constant work in progress.
Last year, we started biking to work. My husband and I would trade-off kid drop-off and pick up so that the other one could ride to and from work. Because we were both doing it, we kept eachother motivated. Exercise as part of our commute meant that it was built into our routine, and it worked really well.
This summer, we focused on our diet. I took a nutrition class on a whole-foods-based diet (wwww.tqidiet.com), and we implemented the changes. It was very difficult for the first three weeks while we completely changed how we do grocery shopping and food prep, but now it’s become habit. We’ve been eating this way for 5 months now. It’s great.
But… the exercise has fallen off. Starting in September, we have kids in two different schools, and my commute has changed. So our old bike commute doesn’t work anymore. We haven’t yet figured out a new routine, and so our exercise is much more sporadic.
I think that making it routine is important, but also realizing that routines have to change to adapt to our changing lives. So, you have to expect that every few months, you will have to put in the effort to re-vamp the old routines or kick-start a new one.
Wendy Sue Swanson, MD says
I liked this staged (and forgiving) approach. Makes so much sense. Have been thinking about it since you wrote this…am trying to focus on one major change we could make now to keep and work on for the next few months.
Steve Krizman says
Stories of what it takes to live with or survive an illness might prove motivating. How does an executive do dialysis? How old were the kids when she died of cervical cancer? What sports did he have to give up? How many months was shout of work and how did she survive financially?
These stories would help people viscerally feel consequences and see that illness is not just some unpleasant interlude between periods of feeling healthy.
Viki says
I have a very short list of priorities as a parent. I want to raise my children to love God, to live lives inspired by faith. I want them to feel connected to creation – be stewards of the earth, appreciate how interconnected we are with others and our environment. I want them to grow to be loving, kind, and compassionate. They will learn that first from how I treat them, and second from how they see me treat others. I need inspiration to find motivation! 😉
Eating whole foods, treating animals humanely, caring for the environment, supporting sustainable farming, recycling, donating, volunteering, hiking, carpooling, gardening, composting… it’s all part of being interconnected. Everything I just mentioned can seem like a chore, a guilt trip, or a burden unless it’s a value that you then endeavor to make part of your lifestyle.
Practically speaking:
I don’t buy white flour, or white rice, or boxed mixes. If you eat grains, making them whole is the easiest change to make as you won’t have to change your recipes much.
Make veggies at least 50% of the meal. I serve salads with most meals, upping it to closer to 75%.
3-4 days per week: treat meat – esp red meat – as a minor ingredient. E.g., substitute a veggie for a portion of the meat in your stew, a bit more peppers and a bit less steak in the fajitas. (I’ve inherited high cholesterol from my mom, so I have to eat less saturated fat than the average person.)
I never cook separate meals for the kids. I don’t order from kids menus in restaurants, so there’s no ubiquitous burger, corn dog, or mac n cheese.
I’ve been in exactly one situation where fast food was unavoidable in feeding the family. (We were driving through the Midwest at night and there was inclement weather.)
We go on rainy day walks. We end up meeting other families that like having the part to themselves on rainy days. If it’s coming down hard, we go swimming after dinner, walk around the mall, or see what’s happening at the community center or Y. Aside for major holidays, there’s always a place to walk or run around. Most museums have a free day or night each month. That’s another fun way to get out of the house and move around.
Jill says
I live your lifestyle Seattle mama doc. On those long clinical days, I look for 10 minute pockets of time and use them to climb a tower of stairs. Voila, the “hurry-up & wait” time becomes active meditation time. If I do it even once I log a success and spend my evening just being a mama to my 2 little ones with no guilt.
Wendy Sue Swanson, MD says
Jill, I wouldn’t say that this is “guilt” per se (not getting to run as much this week as I would have liked) but rather it’s disappointment and exhaustion. I don’t have guilt about exercise, although I do have guilt about missing my kids. More, the nights that I don’t get to eat as well as I’d like or exercise like I would like, I feel anguish over not being able to find a way to truly prioritize personal health preservation over work. The kids get my time, personal health/wellness often don’t. That’s where I struggle…
Emily Gibson says
I’m a physician who also works long days and does not do the self care that my age and genetics demand. I do stay active though, not because it is easy but because of necessity. My husband and I live on a farm with livestock and part of daily chores is at least an hour of barnwork that necessitates lots of manual labor: lifting, pushing, shoveling and plenty of walking. It isn’t exciting but it can be meditative.
True, few people live on a farm but lots of people have dogs that need walking, or children who need an outing. It needs to happen because it must happen–it isn’t discretionary. My animals can’t live without my physical care for them. Neither can our children.
Yolanda @ One Family Table says
I struggle a lot with the conversations I have with my patients about this. I work with families that are also just trying to get food on the table. I get how empty my words are to them. Because when I go home to my life, I feel so overwhelmed myself by parenting too, and yet I don’t battle poverty, illiteracy, single parenthood, and chronic illness like my patients. I’m always asking how to make it more real and do-able for my families. I mainly work with them on thinking up three clear and specific steps they can take. Rather than talk about exercising every day, we figure out times they can go out for a walk as a family. Rather than say they need to eat healthier, I show them where to look on the nutrition label and we decide on a food they will no longer buy at the supermarket because he kids are snacking constantly on it when they’re home. Baby steps, but if a step can be taken at all, it really is a small victory. The same goes for myself.
tlp says
A long time ago I decided to add things to my life that were better for me, rather than try to kick the things that were bad. I focus on one thing at a time that makes for a “good life” lived. Instead of a gym (which would never work), we pay for a post office box so I’m forced to walk uphill to get the bills. Once out of the office, I breathe easier, and go for a 20 minute up and downhill vigorous walk. It should be 5-6 days a week, but more often its 3-4.
We struggle to find time to cook together as a family, but we do it two evenings a week, and every Saturday morning. My boys (4 and 1) love the kitchen because we eat there together (its a rule to only eat in the kitchen), and they have their own drawers of tools.
Every Sunday my husband takes one boy grocery shopping so they can find their way around a store, and he gets to help pick out the fruit and veggies for the week. My husband didn’t learn how to make his way around a grocery store until he was 30 (“girls shop” – but not this one!).
That’s all we can handle. Working to pay the bills takes all the rest of the time (and energy) we have. But for us, so far, its enough.
Wendy Sue Swanson, MD says
LIke the concept of “good life lived” and the concept of not only seeking it out but putting in place practices that demand it. Such an optimistic and hardy way to live up to your own expectations.
Dr_som says
Society can and should be part of the solution. School breakfast and lunch still lack the recommended fresh fruit and vegetables and whole grains. I pack my kids lunch for that reason. Physical activity is not incorporated in novel ways during school hours. Children need to learn what vigorous physical activity feels like and healthy stretching not the basic rules of various sports which can be pursued outside of school hours. Fast food is cheap and easy and probably will need to be more expensive before it is less attractive to consumers. Food stamps and WIC do not encourage the purchase of healthy fresh food. comprehensive family nutrition guidance and supervised exercise programs are not paid for by most insurance companies. The patients I’ve seen who have lost weight have done it without my help, motivated by reasons other than their BMI. I would LOVE to help outside the examining room. Anyone know how to change the school menu or PE class?
Wendy Sue Swanson, MD says
Dr_Som, did you see this? This is where it is hard to trust that society will help us prepare and provide safety measures. We have to be stronger than what surrounds us as parents and protectorates when it comes to health:
https://www.nytimes.com/2011/11/16/us/politics/congress-blocks-new-rules-on-school-lunches.html?_r=3
Steve Levinson, Ph.D. says
I couldn’t agree more with Murfomurf. Doctors shouldn’t be surprised that patients often don’t do what they’re told.
A clinical psychologist, I’ve spent the past 20+ years trying to make sense of why even the smartest and most motivated people often fail to follow through on their own good intentions. I’m convinced that the very design of the normal human mind is itself the major culprit. Amazingly, there’s really no dependable mechanism to ensure that good intentions will actually influence behavior. In fact, there’s not even a mechanism to ensure that people will actually remain actively aware of their own good intentions – and without enough attention, those intentions will surely fail.
It’s foolish to ignore the implications of this fundamental disconnect between intentions and behavior. Yet foolish is mostly what we’ve been. We expect effectively-presented health information and inspiring stories to be enough to persuade patients to change their ways, but they are only enough to persuade patients to DECIDE to change their ways. They’re rarely enough to get patients to actually follow through on those intentions.
I believe that the healthcare field won’t make much headway in helping patients follow through until we accept that the normal human mind has these very real deficiencies and we start looking seriously for ways to work around them.
Technology can certainly help. For example, I developed a simple personal electronic device (MotivAider) that improves follow through by automatically keeping its user’s attention focused on any chosen behavioral objective. With the right use of “reminder technology,” we can at least prevent worthy health-related intentions from getting lost in the shuffle.
I agree, too, that society can help by making it easier or making it feel more necessary for people to act in accord with their healthy intentions, as well as by making it more difficult for people to violate their own intentions.
For anyone who may be interested in taking a closer look at the problem of poor follow through, there’s a 17 minute presentation I prepared on the subject at https://tinyurl.com/24vmf6g.