A recent article in The Journal of the American Medical Association (JAMA) discussed why health-tech’s focus on tracking and traditional health coaching isn’t working for most patients.
The JAMA article states, “Many approaches to patient engagement highlight the benefits of feedback and self-monitoring as if most individuals naturally increase resolve when they encounter failure. These programs are premised on the view that patients are eager to meet challenges with renewed effort. These programs largely ignore individuals who, when they experience the same signal, become demoralized and avoidant. In actively avoiding worrisome feedback—whether real or anticipated—these individuals disengage from otherwise beneficial programs or clinical care when monitoring is emphasized, and as a result, they do not benefit from monitoring and might be harmed.”
We are living in an increasingly connected world where startups praise data for data’s sake, but we may be mistaken in thinking that tracking and monitoring more biometric data is the solution. Does it really matter whether we take 10,000 steps daily versus 9,000? Tracking and traditional health coaching are only effective if we first, measure what matters, and second, give support and modulate that support based on a patient’s personal barriers to success.
I spoke with Rebecca Adams, Ph.D, the newest member of Virta’s research team, who recently completed her psychology fellowship at the Stanford University School of Medicine. Dr. Adams both conducts research on behavior change in diabetes and works with patients as a practicing psychologist.
Dr. Adams emphasized the importance of providing individualized support and of encouraging patients to take the emotion out of numbers—viewing numbers as information, not as a referendum on one’s success or personal worth.
Jim: Hi Rebecca. Welcome to the Virta team - great to have you here! This recent JAMA article states that monitoring and tracking can actually backfire, making some patients discouraged and causing them to avoid the tracking. Why does this happen?
Rebecca: If, through monitoring and tracking, a person notices that things aren’t going as well as they wanted—like a high blood glucose reading—then the tracking can become a distressing reminder of that. When researchers have interviewed patients about their experiences with blood glucose monitoring, they say their readings can either intensify their feelings of failure or success, depending on how closely the numbers match their goals and expectations (Peel, 2004).
Jim: Right, so if someone gets off to a good start the monitoring can help reinforce behavior change. But other patients might get off to a poor start and be discouraged. Are certain people more prone to be discouraged as a result of increased monitoring?
Rebecca: How much control people feel they have over the outcome is one factor that may affect how they respond to monitoring. If they feel like they should be able to control their numbers, they might experience a high or low number as a personal failure and feel guilty. For blood sugar, a person has some control, but they’ll never have full control. There are so many things outside of someone’s control that affect blood sugar, like stress and hormones (Barata, 2013). Having more realistic expectations for how much control they have can take some of the pressure off and make monitoring less distressing. On the other hand, if someone feels no control over their numbers, they might stop monitoring because they find it distressing or they feel their actions have no impact. As a clinician, it’s important to find that balance and convey to patients that while they have control over some of the factors that influence the biomarkers we are monitoring, they don’t have full control due to other factors. It’s our job to help our patients use the biomarker value as information, and not view it as indicative of one’s worth.
Jim: Yes, and I think that was the experience of type 2 diabetes patients tracking blood glucose that was described in the JAMA article.
Rebecca: In the study of 450 people, half the patients stopped monitoring before the end of the year and those receiving enhanced monitoring had greater attrition suggesting a negative effect of more focus on metrics. Neither of the groups that self-monitored had better glycemic control than the group that did not monitor (Barata, 2013).
Jim: In the Virta trial, which also included daily glucose monitoring, 1 year results showed retention was 83% among our intervention patients with type 2 diabetes. 70% achieved glycemic control below the diabetes range, 60% without use of diabetes specific medication. Why do you think our outcomes were so radically different from standard self-monitoring?
Rebecca: I’d point out two important differences. First, Virta suggests specific changes the patient can make in their behavior to achieve nutritional ketosis and superior blood sugar outcomes. Second, patients have the guidance of an expert health coach who is there daily to help in interpretation and emotional support. This helps patients gain a sense of control. So while the self-monitoring of biometrics is important for Virta’s success, it is really just one part of the overall treatment, and the support the health coach provides is personalized and goes beyond just biometric values.
Jim: So, they were measuring something that mattered and they had explicit direction as to what to do with the information. Instead of biometric-based alerts, Virta gives full behavior change support that takes biometric values into account.
The other thing I’ve observed in our patients is this feedback loop that happens as people succeed. There is true joy in achieving positive results - not only getting blood sugar under control and getting off of medication - but just feeling better. People achieve that relatively quickly. The first thing that happens as levels of ketones start to rise, way before weight loss or a better A1c reading, is that people just start to feel better and they start to have improved mood and energy and decreased hunger and cravings. It's that kind of positive impact on your health that leads people to say, "I'm going to keep doing this."
Rebecca: That’s a lot more enjoyable than just tracking and not seeing much change, or seeing metrics go in the opposite direction.
Jim: How about individualization and keeping tracking going? What can treatments that provide monitoring or coaching do to help patients keep their motivation up? How can we tailor a treatment to the patient?
Rebecca: There are lots of reasons someone might not be monitoring, so the first step is for the health coach to assess those reasons. It might be that they have some educational needs—maybe they don’t know how to implement changes to improve blood sugar, and so they’re not monitoring. Often there are also emotional or practical barriers—maybe checking their blood sugar makes them feel guilty or embarrassed or generates another negative emotion. A study of over 44,000 people with diabetes showed that the people who had to pay more out-of-pocket for test strips checked their blood sugar less often, suggesting cost can be a practical barrier to checking (Karter, 2000).
The solution is understanding an individual’s specific barrier and modulating support based on that.
My experience has been that people who view their numbers simply as information get the best results from monitoring. Numbers are never good or bad, but just information to use to make future decisions. Clinicians can teach people early on to view their numbers this way.
Jim: How is this related to shame—shame about being sick, shame about needing help, shame about failure to report positive results when tracking/monitoring?
Rebecca: For someone who feels ashamed of having diabetes, any monitoring can serve as a stressful reminder that this is part of their life. For many people with diabetes, checking blood glucose evokes negative feelings because they’re used to using the value to determine how much medicine they need to take. On Virta, many patients are able to reduce or eliminate medications, so that can relieve some of the stress of checking their biomarkers.
Jim: Is it helpful to focus on effort versus results—i.e. praising the effort of tracking and reporting accurately versus the results of a lower blood glucose? Should we, as a profession, be praising effort over results when the results are positive as well as when they are negative?
Rebecca: It’s important to praise and reward based on the behavior rather than results. We know from decades of behavioral psychology research that rewarding a behavior (such as through praise) increases its frequency. Behavior is under our full control, but the day-to-day numbers aren’t. Someone can follow their treatment plan perfectly but still have a number outside of their ideal range, so to keep them motivated, you need to take the emotion out of numbers and praise the effort. When you praise a specific number, you’re attaching emotion to that number.
Jim: How should we change the language we use to help patients be more comfortable with monitoring?
Rebecca: The language we use makes a huge difference.
Here’s an example: the phrase “test your blood sugar” implies a right and wrong result. “Checking” instead of testing is a much more neutral term.
Jim: Is measuring forever a good thing? Should all people with type 2 diabetes be measuring their blood sugar every day forever?
Rebecca: No, self-monitoring is a tool to reach the destination, not the destination itself. Measurements are meant to be actionable, so if the data is no longer needed, the frequency of self-monitoring can decline. On Virta, a patient on insulin might start Virta measuring glucose three times a day. After a few months, after glycemic control has been achieved and insulin has been discontinued, checking might drop to once a day. A few months later if things are stable, glucose checks might be just a few times a week to make sure things are remaining on course.
Jim: That’s the best outcome of tracking I can think of. Thanks!