Diabetes Self-Management Blog

There’s a whole new trend in self-management programs — don’t change yourself or what you do. Instead, change your environment to make healthy behavior easier. Stop beating your head against a brick wall. Take down the wall, or at least pad it!

This environmental approach is being called SystemCHANGE (Change Habits by Applying New Goals and Experiences). At the American Association of Diabetes Educators conference in early August, I heard a lecture by Shirley Moore, RN, PhD, a professor at Case Western Reserve University, about her research in this area. She said most educators, therapists, physicians, and other professionals try to change people’s minds. Build their confidence, the theory goes, get them better information, help them find support, and they’ll stop smoking, eat smaller portions, exercise, or whatever you want them to do.

Dr. Moore said that by and large, these approaches haven’t worked. She says we need to take a more “ecological” approach, meaning “take into account the… accommodation between a person and the… setting in which the person lives.”

Ecological theory considers four main influences of environment on behavior. These are: the family environment, and the physical, social, and community environments. Any one can be a focus for change.

“The goal,” says Dr. Moore, “is to make your desired behavior the default behavior. Make the easy thing to do the right thing to do.” So if you want to exercise, her model would: “Focus on building habitual exercise into the immediate environment and day-to-day routines, so people succeed despite wavering motivation and effort.” In other words, if there’s no parking space near your door, you’ll park farther away and walk. If there’s no TV remote, you’ll have to get up to adjust the TV. If you like ping-pong and you’ve got a table in the house, you’re likely to play.

Professor Moore’s SystemCHANGE study recruited 380 people who had had heart attacks or heart surgeries. There were three groups — a cognitive-behavior–based change program (“Change+”), her environmental SystemCHANGE program, and regular care. I gather that “regular care” meant being told by their doctors to exercise more.

The SystemCHANGE program involved people making their own plans for an environmental change, usually a small one. Like “put the vegetables on the top shelf of the refrigerator instead of down below in the bins where no one ever looks,” or “leave my tennis shoes by the door so I’ll grab them on the way out in the morning and exercise during my lunch hour.” Then they had to keep careful records about whether their change was working.

Dr. Moore got this change model from a business idea called PDSA (Plan-Do-Study-Act). In PDSAs, you come up with a small plan and test it quickly. You see what’s wrong with it and what works, and refine the plan accordingly. In SystemCHANGE, the small plans are called “experiments.” Participants are encouraged to think of themselves as scientists, studying their own behavior.

The really cool thing about SystemCHANGE is that the whole family gets involved, making a group plan and recording the results. Many families made storyboards about their experiments and decorated them with pictures and graphs.

Average age of people in the study was around 67, mostly white, mostly male. The System CHANGE group exercised more than the behavior change group, but not dramatically so. Both groups did more than usual care (“doctor’s orders”) group.

To me, the most positive result of SystemCHANGE is that it appears to make people more empowered about their health. One year later, 86% of those in this group reported that they were identifying causes and effects in what interfered with exercise and what helped. Seventy five percent were still doing “small tests of change in their routines.” This is a much more positive approach than blaming or crediting everything to “willpower” or even “self-efficacy” or self-confidence

Notice that Dr. Moore’s team was not looking for clinical outcomes, only at behaviors. Changing behavior can be good, but no one particular behavior is likely to make much difference in people’s long-term health (except maybe quitting smoking.) But I’m guessing that the change in people’s confidence, the bringing families together to work on health, and teaching how to use the scientific method in their personal lives might have profound affects on health and happiness.

What do you think? Have you thought about changing your environment for health? Have you tried it? I would be interested in hearing your stories and will pass them on to Dr. Moore as she plans further studies.

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