“I need to lose 20 pounds,” says Peter. “All of my doctors have told me this.”  His blood sugar, blood pressure, and cholesterol are all elevated again, this time while still on medication for the latter two.  Diabetes, hypertension, and stroke all run in Peter’s family, and at age 57, he wonders which will get him first.  He knows he’s overweight.  He feels fat, stiff, sluggish, and old—as if someone wound his body clock ahead twenty years without asking.  He really doesn’t want to add any more medication.  I know exactly what his doctors think:  ‘Then you have a lot of work to do!’  We know he did not get here overnight.  His weight is the cumulative result of years of dysfunctional patterns:  Indiscriminate eating, sleep deprivation, and disproportionately high work stress, among others.  Aberrations in glucose, blood pressure, and cholesterol all increased with weight, parallel outcomes of longstanding habits.  We doctors all know this, but it takes too long to talk to patients in detail about nutrition, sleep, stress, and physical activity (or so we think).  We assume they know what to do when we say, “Lose 20 pounds.”  But is this really helpful?  How else can we help our patients move toward their healthier selves?

We set weight loss goals all the time, all of us—physicians included. We choose a number on the scale—an outcome—that represents our better selves, however we see it.  I suggest today that behavior-oriented goals, rather than outcomes-oriented ones, lead to far greater and more meaningful success.  How much are we really in control of what we weigh, day to day?  Sleep deprivation and dehydration disrupt regulatory mechanisms of hunger and satiety. Stress alters metabolism in myriad ways, not to mention often causing more sleep deprivation—a dangerous downward spiral. Knowing this, and recognizing the pressures and stressors we all face every day, how could we physicians make our advice a little more relevant?  I present to you my Four A’s of Goal Setting:

1. Assess-ability

“I want to lose 20 pounds by April 15.”

A weight loss goal cannot be fully assessed until the designated endpoint—it is a lagging indicator.  I get no feedback on my progress until I arrive, and then it’s too late to do anything about the result.  Even if I weigh myself in the interim, how do I interpret the information?  A couple days of constipation and a few salty meals can spike my heft in alarming ways on any given morning.  I feel bad about myself when my weight goes up; I’m happy if it’s coming down.  But I’m not exactly sure what’s happening—I cannot accurately assess the situation.

Alternatively:  “I need to exercise 3 times a week, starting on Sundays.” And, I get to define what “exercise” means:  Walk an extra 1000 steps, do two circuits of the 7 Minute Workout, spend 20 minutes on the elliptical, or whatever!  This goal can be easily assessed instantly, anywhere, anytime.  It’s Thursday morning.  Have I worked out three times this week?  How many days of the week are left to achieve this goal?  Which days will I most likely be able to do this?  Now I can make a clear and concrete plan.

Mark, like Peter, is overweight, sedentary, and motivated to make some changes. He has recently started walking one mile, 3 days per week.  He also wants to change his eating, but doesn’t know where to start.  I suggest logging his food with an app such as My Fitness Pal (I have no financial or other interests in their business or in 7 Minute Workout).  He inputs his weight, height, and overall activity level, newly elevated to “lightly active.” He also enters his weight goal: lose 0.5 pound per week.  The program calculates his daily calorie goal, and each time he logs a meal, he can see exactly where he stands.  The app helps him keep track of progress, objectively, in both the short and long term.  Science tells us that feedback—the more frequent and specific, the better—boosts and maintains motivation.  The more easily Mark can assess his status toward achieving his goal (staying within his daily calorie limit), the more likely he will stay the course.

2. Actionability

Outcome goals do not elicit action.  “Lose weight.”  This statement is too vague—it cannot be acted upon. It doesn’t tell me what I need to do.  Furthermore, once I have ‘lost weight,’ what do I do then?  How did I get here, and how do I continue?  “Maintain the weight loss.”  How?  Focusing our gaze on the distant endpoint often leads to meandering, or worse, standing still.  I do not suggest ignoring the outcome or invalidating it, but rather paying attention to the practices that will get us there, rather than just talking about being there already.  Setting goals as actions or behaviors—doing specific things—lays out the steps to take toward a desire outcome.  Action leads to self-efficacy and empowerment.

Peter asks himself, ‘What needs to happen in order for me to lose 20 pounds?’ He makes this list:

• Limit fast food to once a week. Assess-ability check: It’s Friday morning. Have I already had McDonald’s this week? Yes? Salad bar it is. No? Ooo, opportunity: Maybe I can resist today and tomorrow and exceed my goal! Empowerment city, here I come!
• Move more. Assess-ability check: Have I moved more this week? Ummmm…How do I know? Revision: Get on the treadmill for 45 minutes, four times a week. Check.
• Get to bed by 10pm every night. Assess-ability checks out here, too.

3. Attainability

Are Peter’s goals realistic? How likely is he to accomplish these three behaviors?  He and his doctors all feel a sense of urgency to get control of his situation.  Society also has a way of pressuring us to go ‘all in.’  Like if we’re not all in the gym 5 times a week for an hour of intense cardio and free weights, we’re just not doing enough, so why bother?  All of these factors can push us to set lofty, unattainable goals, thereby setting ourselves up to fail.

Peter, an older single dad, works 12 hour days. He prioritizes his three daughters, who often need help with homework and want to talk at night.  Looking over his action-oriented goals list again, a few adjustments become necessary:  Change treadmill to twice a week, for 20 minutes.  When it comes to exercise, anything is better than nothing!  He had not noticed the anxiety lurking in his chest as soon as he had said “45 minutes, four times a week.”  Now he feels relief and enthusiasm, rather than dread.  He also realizes that as busy season at work approaches, late nights will be inevitable. Getting to bed by 11:00pm at least on weekends, and maybe one more night a week, is more realistic.

These revised targets are what Daniel Pink might call “Goldilocks” goals.  Not too easy, not too hard.  Peter will have to stretch some weeks to achieve them.  But they lie within reach, if just barely.  Regular successes will strengthen the new routines and keep him motivated.  Over time, as he feels more effective, he may set progressively demanding behaviors to aim for.  Iterative victories will move him ever closer to his desired outcome.

4. Accountability

This one makes sense, right? What good is having an assess-able goal if you don’t bother to assess it?  I think this has to do with maintaining our intrinsic motivation.  If I have successfully set up my goal with the three characteristics above—if it’s specific, within reach, and easily appraised —then of course I want to know how I’m doing!  This can be done as simply as marking an X on a calendar, as Jerry Seinfeld suggests.  In the photo on this post, you can see my officemates and me doing the same thing.  We can choose accountability only to self, such as on My Fitness Pal, and also to others.  This is why Weight Watchers helps a lot of people—knowing we have to show up and weigh in keeps us honest and on track.  I feel obligated here to point out that accountability does not include shame in any form.  Dictionary.com defines accountable as “subject to the obligation to report, explain, or justify something; responsible; answerable.” Whatever method we choose to report, if it undermines self-esteem or motivation, we need to replace it.

What’s it all for?

Finally, let me address the foundation of the Four A’s: Meaning.  Despite repeated messaging from his doctors, Peter still found it hard to make lasting changes in his habits.  Even the specter of impending disease and disability could not move him to act, despite the rationale that he fully understood in his mind.  But going through the 4 A’s exercise, he realizes that 20 pounds—weight itself—is not the goal.  It’s merely the most tangible representation of his healthier self.  The true “Why” for the weight loss lies far deeper:  To model healthy habits for his girls; to stay active and travel after retirement; to finally take better control of his life.  The closer we can link behavior change to something meaningful and intrinsically motivating, the higher our chances of persistence and success.  For much more riveting descriptions of this concept, I refer you to Start with Why Simon Sinek and Drive by Daniel Pink.

Physicians face multiple demands on our attention. In a fifteen minute clinic visit, how can we more effectively help patients achieve meaningful behavior change?  I am a huge fan of motivational interviewing, and I think the 4 A’s align with this method.  Once a patient reaches the goal-setting stage of change, we can ask the following questions to hone the process and hopefully increase their chances for success:

1. Can I easily and accurately assess my status in achieving this goal?
2. Is the goal stated as an action that will move me toward my desired outcome?
3. How likely will I actually attain the action goal—is it really within reach?
4. What is the most effective way to keep me accountable for my progress (or lack thereof)?

Thank you for reading to the end, friends, I know this was long. I’ve been thinking through and talking to patients about these ideas for a while now, and applying them to my own health behaviors.  We all struggle with the same challenges.  Our increasingly hectic lifestyles make self-care harder.  As a physician, I will take any opportunity to help refine my patients’ goals and smooth the way to healthier habits.  The ultimate goal is to help them live their best lives, on their own terms.