When it comes to this AADE annual meeting recap, I’m going to work backwards chronologically because the most important session I attended actually came at the very end of the conference.
On Saturday morning, I attended the final keynote of the AADE. The guest speaker was BJ Fogg, an author and psychologist who founded the Persuasive Technology Lab at Stanford University. Dr. Fogg’s presentation was enlightening and presented methods for behavioral change in a way that I had never really considered before, and he has also created several online resources for designing behavior change that I have found very valuable.
I will not be able to do Dr. Fogg’s presentation justice if I tried to recap it, so instead I’m going to highlight a couple of aspects that I found most relevant for myself. Hopefully you’ll get something out of it too!
Dr. Fogg opened his talk by sharing that new research has concluded that it’s incredibly difficult to externally motivate people to do what they don’t want to do. I’d wager to say that it’s also extremely difficult to internally motivate yourself to do what you don’t want to do. This can be seen time and time again in the “scare tactics” that doctors and diabetes educators like to share with their patients (us!).
“If you don’t take care of yourself, do you know what will happen? You’ll go blind / lose a kidney / have a heart attack / lose a foot / get eaten by locusts.”
Okay, so I made up that last one, but you get the idea.
Dr. Fogg’s advice: Help people do what they want to do. It’s really such a simple concept when you think about it, and yet so many of us fail at this. Even with ourselves! I have lost track of the times I’ve thought to myself “I need to do more strength training” or “I need to get up earlier” or “I need to eat less carbs.” All of these are good, healthy habits, but they aren’t necessarily things that I want to do. And when you don’t want to do something, it’s virtually impossible to get someone to do it! Most of the time, in fact, people will rebel against whatever it is that you’re telling them to do.
Behavior change (or what Dr. Fogg calls “behavior design”) comes down to this simple equation:
Behavior = Motivation + Ability + Triggers
Essentially anything that we want to do (behavior) is a combination of our desire to do said behavior, our ability to do it (that is, skill or know-how) and a trigger (a reminder or prompt). Now, Dr. Fogg’s website Behavior Model has a lot of the background information available, written and in video, so I encourage you to check it out because I’m not going to go into super depth about the equation other than to say: it’s freaking brilliant!
Dr. Fogg explains that when you are trying to accomplish a particular behavior, it’s necessary to have these three things. If you’re having difficulty adopting a behavior into your everyday life, Dr. Fogg says it’s best to work backwards in the equation.
First, you’ll want to look at your triggers. How easy is it to remember that you want to do something? Do you have an alarm clock? Do you have an accountability partner or a friend that you do things with? Dr. Fogg shared a helpful fill-in-the-blank sentence for triggers: “After I ________, I will __________.” By using your established routine to create new habits, you’re more likely to stick with it because you’re building upon something you’re already doing. For example, Dr. Fogg said that he wanted to build the habit of doing push-ups. With a touch of embarrassment, he shared that his phrase was “After I pee, I will do two push-ups.” Isn’t that funny?! Yet so simple!
He also said that it’s important for the development of habits to have a little reward or acknowledgement of success, so he likes to say “Awesome!” It doesn’t have to be anything crazy, just a little “Good job” or “Way to go.” Another example he used was flossing. He said that even though a goal might be to floss your whole mouth, even doing one tooth is good. He acknowledgement of success was “Way to keep up the habit.” Even if it wasn’t the entire goal, at least there was an attempt and effort to keeping up a habit.
If adding a trigger or two into your life isn’t working, then Dr. Fogg suggests making sure that the habit wasn’t too difficult. Many people try to incorporate new habits and they go way overboard by saying they are going to do an hour of exercise every day or they’ll run a mile, etc. But if these activities are beyond your current physical ability, then it might not be something to do right now. If you’re highly motivated, as shown in the graph, then the activity can be a bit harder than if you were only moderately motivated. And if you’re hardly motivated at all, then the activity has to be as easy as pie because otherwise you just won’t do it.
Dr. Fogg did not spend much time discussing motivation, because motivation is not something that is easily altered. I think this is something that is important to recognize. While things can motivate you or inspire you, they are not necessarily things that you can necessarily create yourself. They tend to be things that are just naturally there for you, although sometimes circumstances can change and you’ll suddenly be motivated. But motivation is essentially your desire to do something, and so if you don’t have a desire to do something, then it might be worthwhile to reconsider the behavior that you’re doing.
The Behavior Wizard is a nifty website that asks you a few questions about the behavior you’re hoping to accomplish, and the results guide you in figuring out how to use triggers, abilities and motivation to your advantage. The quiz is based on a chart that Dr. Fogg created that outlines the different types of behaviors (new behavior, familiar, foreign) and lengths of time (one time, forever). Depending on where you fall in the chart, there will be different tactics for you to follow.
After listening to Dr. Fogg’s inspiring and intriguing speech, I started to think about the different behaviors that I wanted to adopt or strengthen. There was one that I immediately started dwelling on: testing my blood sugar. When I got my A1C back from the Novo Nordisk booth and saw that it had jumped significantly, back to 8.2%, I knew I had to get my ass in gear before my next endo appointment. Testing my blood sugar seemed like a logical behavior to focus on because it was something that I know I don’t do enough of.
The first area that we should look at are triggers, but I felt like my triggers were pretty obvious: at a meal. Like a phone ringing, the sight of food should trigger me to test my blood sugar. My phrase could be, “After I test my blood sugar, I will eat.” (So a bit of a twist on Dr. Fogg’s original suggestion.) But even then I will still ignore the trigger, so I knew I had to think a little deeper.
I moved on to Ability, but my ability to test my blood sugar didn’t seem reasonable. Testing your blood sugar is one of the easiest things you can do in managing your diabetes. Using a glucose meter is not that hard. Five year olds can test their blood sugar. I know how to test my blood sugar, and yet I still won’t do it.
Then I moved on to Motivation and that’s where I got stuck, because how do you motivate yourself to do something that you don’t want to do?
I chatted with another CDE about my conundrum, and she said that it had nothing to do with Triggers or Ability and everything to do with Motivation. And she said that if I’m not motivated to do something — if I don’t want to do something — then it’s going to be very difficult to do something unless it’s the easiest thing on the planet. She suggested wearing a continuous glucose monitor.
As some of you may recall, I lost part of my CGM and so I haven’t been wearing it, but I realized that was probably the solution. My blood sugars were significantly better while I was wearing a CGM because it was a very passive way of monitoring my BGs. Since I didn’t want to monitor my BGs all the time, the CGM was a way of making it as easy as possible.
When it Triggered me that I really needed to do something for my blood sugars, I was more Motivated to use my Ability to test using a meter and take insulin.
See what I did there?
Another thing I realized through Dr. Fogg’s talk was that being on shots and strength training for exercise were no longer working for me. Managing my diabetes on shots has increased the difficulty to the point where I need a significant trigger, like a high blood sugar, to do what I need to do. Seeing a BG of 152 mg/dl isn’t enough for me to want to whip out a correction injection of one unit, so consequently I don’t have as tight of control as I could.
Strength training is another “should” that I really don’t want to do. I’ve never really liked strength training and yet I keep prodding myself to do it, hoping that it’ll catch on. But like Dr. Fogg said at the beginning, we should be focusing on doing what we want to do. What do I want to do? Running! Even though it’s still hard for me to do, my motivation to do it is very high because I want to get better at it. I don’t want to get better at strength training. But with running, I want to get faster and I want to go farther. Even though it’s hard, it’s also kind of fun!
Last night, I was talking to my husband about what I had learned and I told him that I wanted to scale back on my strength training and focus on running more often. Even though it might not be as “effective” in losing weight, it was physical activity that I enjoyed doing. And maybe occasionally I would feel “in the mood” to do a 30 Day Shred video, but I wouldn’t expect it of myself and consequently, I won’t feel bad when I don’t do it.
My insulin pump is also forthcoming (although I still don’t have a confirmed date, arg!) and my CGM? Well, I’ll just have to suffer a little bit longer since we really can’t afford the $200 replacement fee. But having the awareness that I need to first identify what I want to do, rather than what I should or ought to do, has really been life-changing. I have heard it mentioned so many times in terms of other people with diabetes who are really struggling with diabetes that it never occurred to me that it might apply to my own life with diabetes. And I think that’s something that more of us need to realize. Just because we aren’t the worst of the worse and just because we are educated and experienced doesn’t mean that we are the exceptions to these behavioral concepts.
Human minds work in remarkably similar ways. It’s time to design our behavior accordingly.