Using the SMART-EST Goals in Lifestyle Medicine Prescription

Abstract

Lifestyle modifications can effectively decrease chronic disease risk but studies show little to no time during patient encounters is spent on lifestyle medicine counseling. The SMART-EST goal framework facilitates both a rich discussion of lifestyle medicine and a comprehensive patient-centered action plan for health behavior change. The tenets of the SMART-EST goal-setting process are discussed.

‘While lifestyle medicine counseling is underutilized, it has been shown that this advice is more effective in changing behavior when complemented by a written prescription for lifestyle change.’

The evidence is clear that lifestyle modifications, including whole-food plant-based nutrition, regular exercise, and avoidance of risky substance use can reduce chronic disease risk by as much as 90%.^1,2 But evoking positive behavior change in a time where environmental barriers and social norms that encourage unhealthy habits prevail presents a significant challenge. In fact, it is estimated that only 37.9% of the population is consuming a healthy diet, 46.5% obtaining the recommended amount of physical activity, and 71.5% avoiding tobacco. ³

As a health care professional, one approach to promoting behavior change lies in providing counseling or advice about healthy lifestyles. Unfortunately, very little time is spent providing lifestyle medicine information, if it is discussed at all. Studies have shown only about 32% of patients receive physical activity counseling from their physician, 28% of smokers reported their provider offered assistance in cessation, and, on average, less than 1 minute of a patient encounter is spent talking about diet, exercise, or smoking.^4-6 While lifestyle medicine counseling is underutilized, it has been shown that this advice is more effective in changing behavior when complemented by a written prescription for lifestyle change. ⁷

There is limited published guidance in writing effective lifestyle medicine prescriptions. That which does exist, often focuses on a single aspect of lifestyle medicine and does not always take into account patient motivation or environmental barriers. These influences can easily shroud provider advice when not considered. The following describes a goal-setting framework that can be used to generate a patient-centered lifestyle prescription that incorporates evidence-based lifestyle medicine recommendations and health behavior change theories.

SMART-EST Goal Setting

The concept of SMART goals is not new. As it relates to health behavior change, goals should be specific, measurable, achievable, relevant, and time-bound. ⁸ The SMART-EST goals are also evidence-based, strategic, and tailored to the patient. The SMART-EST goal characteristics can be applied to a lifestyle medicine prescription. Once a patient demonstrates interest in engaging in a lifestyle modification to improve their health, providers can use the SMART-EST goal-setting process to assist the patient in generating a written action plan.

The prescription should be specific. It is easy to advise patients to “work on their diet and exercise.” But this counseling lacks important information like how much and what types of activity the patient should engage in, what constitutes a healthy diet, and which changes are most pertinent to the patient and their objectives. To create specific goals, action words or phrases should be used to describe what the patient will do and additional clarification about type and amount should be included. For instance, walk 30 minutes daily, meditate 10 minutes each morning, sleep 7 hours per night, or consume 5 servings of fruits and vegetables daily.

The prescription should be measurable. It is hard to assess for progress if a goal is not easily measured. The measure should be a number, percent, or some standard unit used to illustrate success over time. For example, how many minutes per day will the patient walk or what percent of their meals each week will be plant based.

The prescription should be attainable. While the physical activity guidelines for Americans recommend 150 minutes of activity per week, this may be an unreasonable goal for a sedentary, deconditioned patient. Setting an initial goal that is more realistic for the patient would be more appropriate. Goals should also consider the patient’s resources and stated barriers. A patient living paycheck to paycheck is not likely to engage a personal trainer, just as a patient with significant osteoarthritis of the knee is not likely to run stadium stairs for exercise.

The prescription should be relevant to the patient. Is the targeted behavior likely to evoke the change the patient wishes to achieve? For example, if the patient is concerned with decreasing their cholesterol levels, it may be better to focus on a reduction in consumption of animal products rather than an increase in mindful meditation. When creating an action plan, it is important that the provider is explicit in helping the patient understand the relationship between the targeted behavior and the desired outcome.

The prescription should be time-bound. Each goal should provide a clear target date for initiation/completion. If the behavior is not initiated or the goal is not achieved within the designated timeframe, it should be reviewed and reassessed. In essence, this component of the SMART-EST goal is the expected start-date or the timeline for follow-up.

The prescription should be evidence-based. A lifestyle medicine prescription should be held to the same standard as a prescription for pharmacotherapy. Has the intervention been shown to be effective? The goal should include an action that is supported by evidence from a well-designed study, clinical practice guideline, or expert opinion. The evidence-based aspects of the prescription are expressed in the goal’s specificity, measurability, and relevance.

The prescription should be strategic. Health behavior change theories and techniques including the health belief model, theory of planned behavior, social cognitive theory, transtheoretical model of behavior change, motivational interviewing, cognitive-behavioral therapy, and positive psychology, among others, should be incorporated into the goal-setting process.^9-12 These fundamental health behavior change concepts address patient beliefs about risks and benefits, motivation, self-efficacy, and environmental influences that can easily undermine advice from health care providers. An example of application here is the concept of stage-matched goals, using the transtheoretical model of behavior change. If a patient is contemplating the idea of smoking cessation, it would be more appropriate to set a goal that helps the patient analyze the risks and rewards of cessation than set a quit date and provide a prescription for nicotine-replacement therapy. A goal to set a quit date would be more appropriate for a patient in the preparation or action stage of change. A patient in the contemplation stage is not yet convinced changing is the best course of action.

The prescription should be tailored to the patient. Lifestyle medicine is not one-size-fits-all. The grounding evidence upon which lifestyle medicine prescriptions are made is universal; however, the way in which that evidence is applied to the patient is unique and should align with the patient’s physical, social, cultural, spiritual, and economic needs and preferences.

Discussion and Conclusions

Unlike traditional prescriptions where the provider instructs the patient to engage in a specific behavior, lifestyle medicine prescriptions should be patient-centered and provider guided. The SMART-EST goal-setting framework facilitates a rich discussion between the patient and provider and ensures patient-centeredness. The framework can be used as a checklist where each letter in the acronym serves as a discussion prompt or point of consideration for the provider. When collaborating with patients to create SMART goals the specific, measurable, and time-bound components are clearly visible in the written goal, while the attainable and relevant components are abstract concepts that must be verbally discussed with the patient. The “-EST” components may not be explicitly written out within the SMART goal statement, but it is important for the health care professional to ensure they are incorporated into the goal-setting process. Lack of knowledge and clinical skill are commonly cited barriers to providing lifestyle medicine education and intervention. ¹³ Thus, continuing education in evidence-based lifestyle medicine recommendations and health behavior change theory may be necessary to implement the SMART-EST goal setting into practice. Another commonly cited barrier to lifestyle medicine counseling and intervention is time. ¹³ While the SMART-EST goal setting can be completed during a brief intervention, many patients benefit from intensive monitoring and follow-up. Board-certified health and wellness coaches (NBC-HWCs) are specially trained in health behavior change and can serve as a resource for busy providers who would like to incorporate intensive lifestyle medicine interventions in their practice. Further study is needed to determine the effectiveness of lifestyle medicine prescription using the SMART-EST goals framework but the process lays the foundation for comprehensive lifestyle medicine discussion and action planning in the primary care setting.