Episode 9: Coping with Diabetes Part 2: Goal Setting

EPISODE 9: COPING WITH DIABETES PART 2: GOAL SETTING

Dr. Rita Kalyani:  Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes.  I’m your host, Dr. Rita Kalyani at Johns Hopkins.  We developed this podcast as a companion to a Patient Guide to Diabetes website.  If you want a trusted and easy to understand resource for diabetes, or to listen to previous podcasts, please visit Hopkinsdiabetesinfo.org.  Today, we are pleased to welcome back Dr. Marissa Alert, a clinical psychologist, who will share with us her vast expertise in how to manage psychosocial factors and therapies and strategies used to address these factors such as, cognitive behavioral therapy and goal setting.  Welcome, Dr. Alert.

Dr. Marissa Alert: Hi Rita.  It’s really great to be back.  I know our last discussion was pretty lively, and some really great questions and information was covered.  And I look forward to talking more about diabetes management and mental health.

RK:                  Could you share with us what is the role of goal setting and cognitive behavioral therapy?

MA:                  Yeah, that’s a great question.  We know that goal setting is and being able to set proper goals is really important part of not just diabetes self-management, but also plays a role in terms of therapy as well.  And depending on what the patient is pursuing, or what outcome they’re looking for, goal-setting can certainly be a part of that toolkit that I mentioned that allows patients to leave with skills that will help them to thrive and function better.  And so, in the process of therapy, a therapist may focus on helping a patient to set realistic goals, especially if that’s the source of their stress.  So, if someone in managing their diabetes tends to set a lot of unrealistic goals, or goals that are too vague, or goals that are just not in line with things that they are able to do or things that they want to do, then helping the patient recognize that and helping them to set better goals or SMART goals could certainly be a focus of therapy.

RK:                  Dr. Alert, I wonder if you could talk about setting goals.  We all know what goals are.  But some goals, depending on how you frame them, can be harder to achieve than others.  When you talk to people about setting goals, what are some examples of practical goals that someone with diabetes could set?  How many goals are too much?  Can someone have too many goals?

MA:                  To answer the first part of your question, in terms of helping people to set goals, one of the approaches that is often used is the SMART Goal formula: so helping people set goals that are Specific, Measurable, Attainable, Relevant, and Time-bound.  This formula ensures that people aren’t setting goals like, ‘I want to manage my diabetes’.  We know that that’s way too vague.  It’s not specific.  We don’t know the time limit.  We don’t know what that looks like.  And a goal as vague as that, makes it really difficult for someone to track and measure how well they’re managing their diabetes.  And so, what really helps them to hone in on, ‘What am I doing?’, ‘Where am I doing it?’, ‘When am I doing it?’, and ‘How am I doing it?’, and ‘For how long am I going to be doing this?’

And so for instance, when I have people start out, if let’s say that they’ve not been active, they’ve held a pretty sedentary lifestyle, either because of their job requirements or any physical disabilities, and they’re trying to get active.  I help them start out by setting small goals and keeping things small for a number of reasons.  One, it when we set goals that are too big, sometimes that sets us up you know for failure.  And when we fail, we feel like ‘ugh, here we go again, like I’m not going to be able to conquer this,’ when in reality, it’s not that.  There’s a problem with the goal you’re trying to achieve, it’s just your approach.  Instead of saying, you know, ‘I’m going to lose 50 pounds, you know, by next month,’ there’s nothing wrong with wanting to manage your weight, but having that unrealistic goal of 50 pounds by next month is where the problem lies.  When we’re thinking about goal-setting, is ensuring that people are setting small, realistic goals.

And also when it comes to goal setting, it’s important for people to think about their resources and their capabilities.  As I am right now, ‘do I have what I need?’, ‘ Am I ready to actually take on pursuing this goal?’  And so if it is that I’m trying to be more active, and based on my home environment, it’s impossible for me to do any at home exercises, and I want to go to the gym, but I don’t have a car and I don’t know how to drive.  But my goal is ‘I will go to the gym three times per week.  I don’t know how I’m getting there.  I don’t have a car.  And this isn’t a pretty walkable neighborhood.  So I have to drive about 30 minutes.’ All these things that people said with all the right intentions, it’s helping them to take a step back and really assess their goal, if it’s smart, and also take into consideration how realistic it is, which is part of that formula.

And one of the things that I encourage people to think about as well, is their “why”.  Why are we working on this goal?  And really helping them to figure out what that reason is because we know that it’s quite normal when people are pursuing their goals that there will be setbacks.  They’re going to be days where they’re not feeling motivated.  They don’t want to do anything.  And so, on those days, tapping into the ‘okay, but I don’t want to do this, but I really want to be around for my grandkids,’ or ‘I really don’t want to have diabetes complications, that’s going to lead to my leg getting amputated.’ Helping people to come back to why it is they’re working on something is really helpful when we couple that with the SMART Goal Setting approach.

RK:                  So weight loss is a very common goal that many patients have and a goal that many patients struggle with.  You gave an example of a kind of a very general goal of losing 50 pounds in a month that might already set someone up to be not as successful.  What would be an example of a goal that might be more achievable, more practical, for someone to achieve if they’re trying to lose weight?

MA:                  Losing weight is pretty broad, right?  And so if someone wants to lose 50 pounds, we know that there are things that need to happen for them to do so, right?  It’s not simply ‘every day, I’m going to lose 50 pounds, I’m gonna lose 50 pounds.’ But what are the behaviors that are going to lead to them losing 50 pounds?  And so, starting there is where I would begin.  So, would that mean, ‘how we’re eating?’, ‘how active we are?’ And so those are the behaviors that will be focused on because losing weight, just that term, is not a behavior.  And with goals, we need to be able to identify ‘what are what actions will I be taking to get to that goal?’.

And so with that behavior, it’s the goal of exercising or being physically active four times a week, you know, for 10 minutes could be a realistic goal for starting off.  And in addition to it being realistic, I may hone down on ‘okay, but where am I being physically active for for 10 minutes?’ And ‘what exactly am I doing?’ And I’m starting there because we want to start off small – make sure that it’s something that’s manageable, it’s reasonable.  And especially if someone has not been active before, then keeping that to something that’s doable and realistic.  So, 10 minutes might be enough for now because that’s, you know, my day is filled with meetings.  And that’s all the time I have in between.  We’ll move from 10, as things change, people feel a lot more confident in achieving that goal. What we find is that people naturally increase, and so it moves from 10 to 15 to 20.  And so, having that one goal of being active and increasing physical activity, we know is going to help.

And then the other part, it’s huge part of weight loss is someone’s diet; what they’re eating.  And so the next goal will focus on ‘How is that person eating?’ ‘What are they eating?,’ and coming up with a specific goal for that.  And we know that those goals together can help them with achieving their weight loss.  And for the eating example, it could be that, you know, ‘I will eat fast food, you know, once a week instead of four times a week, and I will eat it on Sundays for the next four months.’  And so we recognize that, you know, with those two approaches, eventually that person will lose weight.  And I’m just keeping it very simple.  But those numbers can change depending on the individual, what they have access to, what they’re capable of doing, and what they’re willing to do.

The question about ‘If there’s too many goals?’ to come back around to that, the answer is yes.  Especially around New Year’s, or when people are setting goals, there’s could be about 10 to 15 things that they’re trying to do all at once.  And in the past, I’ve done the same thing as well, like, ‘it’s New Year, and I should do this, this, this, this, this and this’, and I’m trying to do everything all at the same time.  And I, you know, have amnesia because I didn’t tend to remember that last year, that’s what I did, and it didn’t work, but I’m starting off the year doing the same thing.  And it’s recommended that people pursue maybe, you know, one, two or three goals at most.  And it depends on what’s manageable and what those goals are.  Because what we find is that if people start off with too many goals, it gets really overwhelming.  And it makes it a lot likely for them to not be able to be consistent with some of their other goals.  So something eventually falls off-track.  And that may derail someone from, you know, working on those other goals.  And so it’s not just the one goal that they’re not working on anymore.  It’s that that one goal affects how they’re able to pursue the other goals.  And so because of the overwhelm, and additional stress and sense of failure that comes with people not being able to achieve all six, seven goals that they set out to work on at the same time, we recommend that they start off again, small.

You know, so thinking about the New Year, people, one thing I want to note is that people often think that they have to wait until a whole year to go by.  So it’s February, almost March.  Things have not been going that well.  I need to wait until next January.  And the reason people do that is because of something known as the “Fresh Start Effect”, where they tend to tie changes with or setting goal with things that are changing.  And the New Year’s is one that we’re pretty familiar with.  But the start of a week can be one.  And so let’s forget about last week.  This week, I’m going to work on this specific goal again and not having to wait you know, months or years for something to start over.  We can set those fresh starts for ourselves. 

RK:                  I wonder if you could talk about what if someone’s doing well?  What if someone is making steps to lose weight, let’s say and they’re trying to lose 20 pounds, maybe they’ve lost five pounds.  They’re on their way there.  Do you recommend any kind of positive reinforcement or rewarding?  Or how should individuals continue to motivate themselves or keep themselves on track?

MA:                A lot of people can identify with making progress.  And one of the things that often gets in the ways of people waiting for the other shoe to drop.  Knowing that ‘you know, what I’m doing really well, maybe something’s gonna get in the way’.  And then they get caught up in that.  To your point about rewards, I think there are a number of ways that we can reward ourselves.  And when it comes to that, I think it’s critical to not use reward that’s going to be counterproductive.  So with every pound, I lose, I’m going to binge eat, or I’m going to go and celebrate at the buffet.  So really thinking about, you know, as we do things that help us to get closer to our goal, it’s okay for us to pat ourselves on the back to recognize the progress that we’ve made, even if it’s not that big.  Because as long as you’re heading in the right direction, I like to think about it as ‘progress is progress’.

And so there are a number of ways that people can reward themselves, you know, that can be thinking about, you know, ‘the next pound, I lose, I’m going to take a road trip,’ or ‘I’m going to check out this museum feature that I’ve been wanting to take a look at,’ or ‘I’m going to make sure that I do something fun with my family,’ or you know, there’s so many things that we can do. But the important thing is that we know that by rewarding ourselves, we’re reinforcing that behavior.  We know that reinforcement and that reward helps with habit-building, as well.  And so, if those two things are in place, we know people are a lot more likely to repeat those behaviors.  And then it gives them something to look forward to, as well.

RK:                  Well, I think that this discussion on how to facilitate someone who’s not at the previous functional level to get back to where they were before, or someone who’s trying to set goals to continue on that path to progress is important, because there are so many goals that a patient could have both those that they discussed with their healthcare provider for improving their glucose control, or their blood pressure or weight management versus individual goals that they might just have for themselves, ‘checking my glucose more often,’ or ‘making sure that I take my insulin as prescribed.’  I think that these kinds of techniques are so critical to ensure that you’re successful in your diabetes management.

Well, I think that’s a great place to end for today.  Starting small, simple, specific goals and having a fresh start each time can really, it sounds like, pave the way for future success in coping with diabetes, and really having positive, cognitive approaches to thinking through challenges that might arise.  So, thanks so much, Dr. Alert.  It was great to have you back again to talk about cognitive behavioral therapy and the role of goal-setting, and how people can have SMART goals at home to attain their goals.  We really, really appreciate the practical advice you shared today.  And thank you so much for coming back again to talk to our audience. 

MA:                  Yeah, I was really excited to be back again.  These are some of my favorite topics and things to discuss.  I hope that from this discussion, patients are able to see that they are able to set goals, they shouldn’t give up on goal setting, they shouldn’t completely throw therapy out the window; that these are things that have been proven to work and again, the idea is to help them to get back to a level of functioning where they can live their best life.

RK:                  I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed, we develop this podcast as a companion to our Patient Guide to Diabetes website.  Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.  For more information, visit Hopkinsdiabetesinfo.org.

We’d love to hear from our listeners.  The email address is HopkinsDiabetesInfo@jhmi.edu.  Thanks for listening.  Be well and see you next time.