Setting and Achieving Health Goals
Taking Steps To Get Better At Getting Better
Improving health is part of the prescription for anyone with cardiac issues. Achieving goals for better health leads to a longer, better quality of life. This is the case whether someone is trying to reduce high blood pressure, manage a potentially debilitating condition such as heart failure, peripheral artery disease, or a number of other chronic conditions.
It’s hard to imagine that there are many people who haven’t heard that a healthy diet, regular physical activity and not smoking are cornerstones for a healthier lifestyle. Yet, in a worldwide survey of 7,519 patients with known cardiovascular disease, less than 1 in 20 demonstrated all three healthy lifestyle habits. These findings are not new — this failure has been going on for decades. Breaking old habits is hard. Building new habits takes time. It takes conscious, persistent effort to achieve both.
To help sort out how we can get better at getting better, we got expert advice from cardiovascular physiologist Barry Franklin, Ph.D., director of the Preventive Cardiology/Cardiac Rehabilitation Program, William Beaumont Hospital, Royal Oak, Michigan, and professor of internal medicine, Oakland University William Beaumont School of Medicine.
In addition to his academic expertise and years of practice in this field, Franklin has a passion for this subject that was crystal clear in our interview.
Heart Insight (HI): If patients are so bad at meeting their goals, why set health goals at all?
Dr. Barry Franklin
Dr. Barry Franklin (BF): There are two reasons: First, there’s increasing evidence in the scientific literature, that you become what you think about. This is considered one of the single most important strategies for success. Second, successful people visualize their goals, write them down, and think about them regularly. I often tell patients, “The 10 most powerful two-letter words in the English language are ‘If it is to be, it is up to me.’” In other words: Take responsibility. You, the person you see in the mirror every day, have the single greatest influence on your destiny relative to health. It’s not your doctor who you see once or twice a year for 10 minutes. It’s the decisions you make on a day-to-day basis, predominantly your behavioral choices. So, for lifestyle modification to work, the patient needs to know where they’re at and what direction they need to go — that’s the point of setting goals.
HI: Why are ‘realistic goals’ important? Why not set big goals? What’s the benefit of realistic goals?
BF: In a word, motivation. Realistic goals are likely to produce action, and it’s well known in the field of personal achievement that the universe rewards action. It pays to act.
Here’s an example: I recently saw a patient who weighed 300 pounds, whose body mass index was 46. According to the tables, this individual would have to weigh about 160 pounds to achieve a “normal” BMI of approximately 25. It would be extremely discouraging to tell a 300-pounder he’s about double the weight he should be. Instead I asked him, “What do you think would be an achievable short-term weight goal for you?” Anything he tells me under 300, I agree with him. In other words, I want to get him moving in the right direction.
Another example, a patient says to me, “Doc, should I do 30, 60 or 90 minutes of exercise a day? I’ve read that all three amounts are appropriate.” “What are you doing now?” I ask. If they say, “Nothing, that’s why I’m asking you the question,” I’ll say, “Give me 10 minutes a day, three times a week over the next two or three months. Can you do that?” Invariably, they’ll say, “Yeah, I can do that, but it’s not what I should be doing.” But my goal is not for them to instantaneously meet the guidelines but to get them moving. Frequently, they’ll come back at the end of three months and say, “I started with 10, then I went to 12, then 14. Now, I’m doing 40 minutes, five days a week.”
Inertia is a major barrier to making permanent lifestyle changes. It’s also one of the easiest things to overcome. All that’s necessary is for the patient to act. And the easier it is for the patient to act, the easier it will be for him/her to overcome inertia. Overcoming inertia with downscaled, realistic goals is a key priority.
My feeling as a clinician is that attempting to initially achieve the guideline recommendations are often unrealistic and discouraging to patients.
HI: What are the steps to setting realistic goals?
BF: Number 1, do your homework: Surround yourself with highly skilled, caring and compassionate physicians or other allied health professionals.
Second, if you’ve had a cardiac event, bypass or valvular surgery or angioplasty, enroll in a cardiac rehab program.
Number three, develop a plan of your goals and a timeline for hitting them and constantly review the written plan.
Fourth, recruit friends and family to support you. When I consult with a cardiac patient, I encourage them to bring their spouse or a family member with them because I want that spouse or family member to realize that in order for the patient to succeed, they need their help and support.
Number five, where possible, find a role model, another person who has the same health challenge you have, who’s succeeded and who can share his or her strategies with you.
HI: How do you break goals into simple steps?
BF: Lifestyle modification is similar to the law of inertia — a body at rest tends to remain at rest, and a body in motion tends to remain in motion. That means that time is an ally to successful modification. In other words, it took you a long time to get to 300 pounds, so it’s going to take some time to get back to a healthier weight.
Your steps have to be steps that you think you can realistically accomplish. Ordinary effort on a day-to-day basis can yield extraordinary results. Remember, “Inch by inch, life’s a cinch; yard by yard, life is hard.”
HI: How does having a limitation like shortness of breath, leg pain or impaired stamina affect goal setting?
BF: Adapt your approach by capitalizing on your deficit. Let me give you an example: I see patients every day with heart failure. They’re short of breath after walking 50 feet and can’t possibly do 30 minutes of exercise all at one time. But they can do it in segments that add up to 30 minutes. A great analogy here is a piggy bank: You, as a heart failure patient, don’t have to put a dollar bill in the piggy bank all at one time. You can put in four quarters or 10 dimes or even 20 nickels; in other words, accumulate the dollar deposit by putting in smaller amounts over time. Five-minute bouts of exercise throughout the day will get you to 30 minutes. When it comes to exercise, the latest research says, “Every minute counts.” Regardless of the deficit, there is a way to modify your approach to make you successful.
HF: What common mistakes do people make related to setting or achieving goals?
BF: They set unrealistic goals. They try for a while, but results come too slowly. They quit and go looking for something easier or faster. They don’t persist; yet, persistence is the key to success. With health goals, many people think it’s all or nothing, but that is simply not true. Achieving health goals is like running a marathon, not a sprint. Don’t worry about any particular point in the race where you may not have performed so well — like when you went to a wedding and had some prime rib and a piece of cheesecake. Don’t give up the entire plan because you deviated for a day or two. Get back on track. Recognize you’re going to deviate periodically, and all is not lost when you do. Success is measured by what you do over the long term, not by what you do on any one day.
HI: How does social support affect motivation and outcomes?
BF: There’s a big national emphasis right now on reaching out to the family or spouse or partner, not just to the patient. You get better health outcomes when the patient’s spouse or family members are involved in activities or consultations. There was a classic study done years ago in which they asked cardiac patients how supportive their spouses were of the cardiac rehab program. Not surprisingly, those who said their spouse was very, very supportive had the best attendance, and those who said their spouse really felt the patient shouldn’t be involved or it took too much time, or whatever, had the worst attendance. There’s no question that spousal support affects motivation and outcomes, and the good clinicians and most effective programs try to target more than the isolated patient.
HI: What types of social support are most beneficial to help patients reach their goals?
BF: First, if at all possible, get involved with group treatment. Join a group where you are surrounded by other people who have similar challenges and who are successful.
Second, try to gain the support of the spouse or partner.
Third, find a role model to emulate.
Fourth, help others help themselves — we get what we give by serving others. I’m a student of the world’s longest living populations, the populations that live into their 90s and 100s. Researchers have identified five common characteristics: They don’t smoke. They eat lots of fruits, veggies and whole grains. They’re physically active. And the last two are very, very relevant to this question of support: They put family first, and they stay socially engaged. People who are surrounded by strong family support and who are socially engaged tend to be more likely to achieve their goals.
HI: People want to be perfect. Is that motivating or daunting?
BF: Many people give up the entire plan because they fail to follow it over a day or two, but people aren’t perfect. Like I said, achieving good health is a marathon, not a sprint, so don’t worry about any particular point in the race. Remember, the universe rewards action, so most of the time, be moving in the right direction. Don’t obsess about doing it perfectly.
HI: How does a person stay on track and stay motivated?
BF: First of all, I think keeping track and writing things down is a good thing. Keeping a log is highly effective in achieving one’s goals.
I also suggest our patients buy a big glass jar and display it prominently in their home. Then I tell them, “Put a penny in the jar every day that you follow your exercise, diet and medication plan, and don’t smoke. If you fall off the wagon for a day and don’t follow your plan, take a penny out. Or if you really want to penalize yourself, take two pennies out.” Then watch the pennies accumulate. When the jar is full or approaching full, you’ll know you’re well on your way to your health-fitness goals. It’s such a great visual that doing a little bit over time makes a big difference. I also think it is motivating to see the pennies getting higher and higher. And if somebody visits and says, “What is this jar with the pennies?” You get to tell them what you’re up to, and inevitably they will say, “Looks like you have a lot of successful days under your belt. Good for you.”
HI: What happens when you fill the jar and meet your goals? Talk about celebrating success.
BF: People can ‘cash in’ the saved pennies (it will be more than you think) and use it to help celebrate their success. As a clinician who’s been advising patients for 40 years, celebrating is not going back to the previous behaviors, no matter how briefly. Don’t go out after you lost 10 pounds and eat a large pepperoni-and-sausage pizza. Or don’t have just one cigarette after you’ve stopped smoking because the likelihood is, you’ll start smoking again. Choose something to reinforce the new lifestyle. For instance, buy yourself some new clothes that fit. Or take a trip with somebody who supported you to get you to this place.
HI: Anything else for our readers?
BF: In summary, a healthy lifestyle plays an important role in the primary prevention of heart disease and risk of cardiac death in middle-aged and older men and women, even among those taking medications for high blood pressure or elevated blood cholesterol. Moreover, systematic reviews now show that the mortality risk reductions associated with lifestyle changes in cardiac patients (may be) similar to or greater than those reported for medications that protect your heart after a heart attack. Collectively, these findings and other recent reports suggest that the effects of lifestyle modification and combination drug therapy on cardiovascular risk reduction appear to be independent and additive.
The last thing that I would leave you with is a story about the late General Norman Schwarzkopf. He was once asked how he’d respond to an enemy attack. “Counterattack,” he said. I would contend that when the enemy is heart disease, the strategy is no different. The best counterattack is aggressive, long-term lifestyle modification complemented by adherence to prescribed medications like aspirin, statins, and beta blockers.
How to Change Your Eating Habits
By Tammi Hancock, R.D., L.D., Consulting Dietitian
Establishing healthy eating habits is important for long-term success of your weight goals. Start by choosing small, reasonable goals you can achieve within a short amount of time. Celebrate each success, even if the celebration is just a small acknowledgement, like ‘I did it, good for me!’ Once a goal is achieved and becomes part of your normal routine, add a new goal. A series of successfully met goals can eventually lead to a healthy lifestyle.
- Make sure your immediate environment is set up to help you succeed. Most people are visually oriented, and just a glance at a certain food can lead to cravings.
- Remove the candy dish from your desk.
- Plan your route through the office to avoid walking past a table of treats.
- At home, keep healthy foods, such as fruits and vegetables on the counter and store high-calorie, high-fat foods out of sight in cupboards.
- If watching TV, do an activity during commercial breaks to avoid ads that promote food cravings (commercial breaks are the perfect time to do a few stretches, or get some steps in around the house.)
- Leave serving dishes in the kitchen and plate food before sitting down to eat a meal. Not having serving dishes at the table reduces temptation and requires extra effort to go to the kitchen for seconds.
- For large restaurant portions, pre-box some into a to-go container and set it aside before starting to eat. If your fellow diners are in agreement, ask that the server not bring a bread basket or bowl of chips.
By establishing small, reasonable goals that you can accomplish in a supportive environment, a healthy lifestyle is achievable and sustainable long term.