Rules of Engagement (ROE) for Reversing Lifestyle Disease

Stephanie Habif
May 23, 2017 · 6 min read

In 2009, I worked with one person. Her name was B. She was my client and I was her health coach. B was a 63-year old sedetary, obese woman with pre diabetes and hypertension. She survived divorce and breast cancer. B’s doctors told her she had a small window of opportunity to change her ways otherwise she’d likely end up with Type 2 diabetes and/or another cancer.

Worried about her health and longevity, B’s family approached me: “Steph, she’s going to die soon if she doesn’t change — do you think you can help her?” They connected me with B and when I first spoke with her, she said she didn’t exercise because of a pinched nerve in her cervical spine. She also said she was overwhelmed about where to begin.

B hired me directly to be her full-time coach. We worked together for 7 months. I lived in a guest room in her house during the weekdays. She was my N = 1 to test all I knew about health behavior change.

I combined health behavior science with peak performance strategy to teach B how to best practice her daily health. She used me to coach her through an exercise and nutrition plan that also taught her how to sleep better, manage pain, and find new health services (like a physical therapy and psychotherapy). In 7 months, she lost almost 50 lbs, reversed her diabetes trajectory, and crossed the finish line of the NYC Marathon.

Here’s what happened to her body:

Pre and post data

Before you question whether I was qualified to take on such a job, find comfort in the list of other health professionals who were available and/or involved B’s change journey:

B’s clinical providers
My notebooks from working with B

I received regular supervision from my mentors. I documented B’s progress with photos, audio, and quantitative data. I kept detailed, daily notes about our work, both in digital and hard copy. It is, to date, the most comprehensive ethnography of my career.

I presented B’s story at the and continue to draw inspiration from the volumes of our collective work. She was proof that small, daily changes — diligently practiced —lead to big successes. At the end of our time together, the question left for me was “how do we take what we know works in behavioral science and scale it to lots of people in an effective and affordable way?”

I didn’t know the answer, so I moved to Silicon Valley with no job, no friends, and a desire to find out. This question is what fuels me and the entire digital health industry still to this day. Over the last eight years, I’ve been involved as a digital health behavior designer and strategist in many capacities. Here’s what I’ve learned are the psychosocial rules of engagement (ROE):

1. The effort must be collective.

Relationships are the #1 predictor of any health behavior change outcome. With B, my top priority at all times was maintaining trust not just with her but her social support system. When her support system was positively, actively reinforcing her, she succeeded. When not, she slipped. Health does not happen in a siloh, and behavior change requires active social support above and beyond anything else.

2. Do not threaten autonomy.

The person trying to change must be the primary decision maker at all times. B never wanted to be told what to do. She needed to have the choice at all times, and she needed to feel empowered by her choice.

3. Build on detailed & descriptive feelings.

During week 3, B said “I’m going to say something weird, but my insides feel different.” I replied, “Describe different.” She said, “My stomach on the inside feels looser…it doesn’t feel stuffed.” She soon also said that her outsides felt different: “I noticed today that my ring was loose around my finger. It’s usually pretty tight.” So we regularly used “loose” and “tight” to learn about things like hunger/satiety signals, muscle building, and stress levels.

4. Normalize failure.

Not every day is going to be a good day. Pain, plateaus, fatigue, frustration, fear, and anxiety are all a normal part of change. Keep calm and carry on. No matter what the scale says or how your clothes fit, keep the faith. Make room for bad decisions. Use joy and humor to cope with failure.

B’s bathroom mirror inspiration

5. Honor fear and bring it to the center of the change.

B was terrified of failure. She said she used to accuse her children over the years of not trying hard enough.

“I used to be in the shower and think about losing weight, and I thought if I tried I wouldn’t be able to…that I’d fail, and that threw me into a state of panic! It was awful. So I did over the years what I accused my kids of: I didn’t try to lose weight because I was afraid to fail.”

Once she trusted me that I would be there with her, for her, when she felt afraid, she chose to feel fear and talk about it. I said several times, “I won’t let you fail.” B needed to feel safe.

6. Use love to provide feedback.

Some people may respond well to numbers, but B did not give a shit about quantitative data. She did, however, care deeply about her children and grandchildren. So we used one of her grand daughter’s hair ribbons to document her waist circumference. Each time we measured her waist, we made a black mark on the ribbon to document her progress. She kept that ribbon hanging in her room as a daily reminder.

7. Focus on process and performance, not outcome.

Today (October 26th) she weighs 169 lbs. Her blood sugar is stabilized, she has weaned off half of her meds; she has not complained of pain in months, and her last cortizone injection was the first week of May 2009. She reports good energy, good mood, and regular physical activity.

She wants to walk the NYC marathon this Sunday. She has never attempted an athletic endeavor like this before; she has followed (and complied to) a 4-month marathon training program. She is proud to walk as a breast cancer survivor (she will NOT wear her prosthetic breast [she had a mastectomy in 1997]) and hopes to cross the finish line in 8 hours.

About 10 days ago, while B was out for her 22-mile training walk, she experienced acute pain in her shins: shin splints. This is a new symptom for her. She pursued a course of ice, elevation, anti-inflamatories, physical therapy, stretching, and rest. However, her shins still hurt. Over the past 3–4 days she has done several ice soaks, and each night she elevates her legs. She and I have decided to take it hour to hour. And we’ll see how she feels.

The marathon is in 6 days.

-from my journal October 26, 2009.

When we first started working together, B never imagined she’d cross the finish line of the NYC marathon. But she did. On November 1, 2009 she finished in 7 hours 22 minutes.

Me and B at mile 19 of the NYC marathon
Stephanie Habif

Written by

Behavioral Scientist doing ux research + behavior design strategy for consumer engagement @Tandem Diabetes Care and @DesignLabUCSD.