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Self-Monitoring: Influencing Effective Behavior Change in Your Clients,’ article below Select a health behavior other than exercise.Write a 1,200 word paper including the following:Develop your own self-monitoring scale for this health behavior.Explain how you would use this scale as an assessment tool in a behavioral health intervention.Summarize three current behavioral assessment techniques. Include a minimum of three scholarly references. Use article below Format your paper consistent with APA guidelines.Self-Monitoring: Influencing Effective Behavior Change in Your Clients by Melissa Burgard, B.S., and Kara I. Gallagher, Ph.D., FACSMLearning ObjectiveTo understand how to effectively use self-monitoring to assist clients with behavior change and improve client outcomes. Key words: Behavior Change, Self-Monitoring, Weight Loss, Feedback, Clients. Behavior change is a difficult process. As a health/ fitness professional, assisting clients with behavior change can be particularly challenging because client interaction is often limited. Many times, these meetings are not sufficient to target both eating and exercise behaviors and address the many barriers clients face. Because many health behaviors need to be targeted outside of these meetings, finding ways to track progress also is necessary to successfully provide clients with appropriate feedback and direction. Thus, teaching clients to self-monitor is an effective strategy for targeting both eating and exercise behavior change. Self-monitoring allows you to review your clients’ current eating and exercise behaviors, identify what needs to be modified so clients can reach their personal health/fitness goals, and provide feedback. By definition, self-monitoring is ‘‘the systematic observation and recording of target behavior’’ (1) and has been described as the most effective technique and the ‘‘cornerstone’’ of behavioral treatments for weight loss (2). Self-monitoring increases a client’s self-awareness, and this has been shown to positively influence eating and exercise behaviors (3). Several weight loss studies have shown that the more consistent participants were at self-monitoring and the more self-monitoring diaries were completed, the greater was the weight loss (4–6). In a review of studies, D.S. Kirschenbaum, Ph.D., determined that consistency is best defined as recording at least 75% of eating and exercise behaviors (7). This relationship also has been found in high-risk situations. In a study examining weight change during the holiday season, only the most consistent self-monitors lost weight (8). Although self-monitoring is considered to be a valuable tool for behavior change, it does require the consideration of several factors to be applied and used appropriately with your clients. Teaching your client to effectively and consistently self-monitor is a process that is dependent upon the client’s personality, goals, and knowledge regarding his or her behavior. Taking individual differences into account, your goal as the health/fitness professional should be to ‘‘help clients be the best self-monitors they can be’’ (8). As a guide, you can use the following ‘‘Four Ps of Self-Monitoring’’ to determine the best self-monitoring fit for your clients. Purpose of Self-Monitoring It is helpful to explain the benefits of self-monitoring to your clients so they understand the value and importance it has in promoting behavior change. Self-monitoring can lead to self-awareness regarding behaviors and can help the client regulate behavior more effectively by avoiding and coping with situations that often lead to failure. Self-monitoring records can help identify the specific nature of these situations by answering questions of how, what, when, where, and why. For example, self-monitoring can provide information regarding specific details of client behavior such as: How many calories do they eat? How much activity do they perform? Photo courtesy of Christopher R. Mohr 14 ACSM’S HEALTH & FITNESS JOURNALA JANUARY/FEBRUARY 2006 VOL. 10, NO. 1 Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. What type of foods do they eat? What foods do they tend to overeat? What time of day are they most likely to exercise? What types of exercise do they enjoy? When do they eat the majority of their calories? When are they most likely to miss a planned exercise session? Where do they make poor food choices? Where do they have opportunities for exercise? Why do they miss exercise sessions? Why do they want to lose weight or begin an exercise program? By addressing the specific details of clients’ behaviors that occur outside of in-person sessions, you can better assist them with recognizing patterns of behavior that may impact progress. Personalized Approach What to Monitor Once you have explained to the client the underlying purpose and benefits of self-monitoring, the next step is to decide with the client what behaviors to monitor in order to best reach their health/fitness goals. It is essential to keep in mind that this should not be a one-size-fits-all approach. Take a personalized approach to tracking client behavior that is based upon personality, environment, and individual characteristics and goals. For example, for clients who wish to lose weight, monitoring both eating and exercise information is the best way to determine if they are on track. For other clients, eating behaviors may be related to stressful situations, and thus, feelings of stress may be an additional variable you may want to monitor to assist with weight loss. Collecting baseline data is an important component of self-monitoring because it provides you with an understanding of what your clients are currently doing, which behaviors require minor modification, and which behaviors you may need to target more heavily. More information is helpful, but it is not necessary to have clients heavily self-monitor at the beginning of a program. Rather, collecting a typical weekday and a typical weekend day of information may be sufficient to capture a snapshot of current behaviors. Once this information is collected, it is beneficial to discuss these initial self-monitoring records with your clients. This will allow you to identify what areas or behaviors they find to be most troublesome and to gain greater insight into how they believe these behaviors can be changed. Amount of Detail Some clients may prefer to keep highly detailed self-monitoring records that include, for example, date, time, place, mood, description of food, quantity of food, calories, grams of fat, and hunger level (Figure 1). Others will simply want to record whether they made healthy eating choices at each meal. In determining the amount of detail your clients should use, pay careful attention to clients’ attitudes regarding monitoring, personalities, and time constraints. For some, more will be better, and this will provide you with ample information to offer feedback and direction; others may become overwhelmed and disheartened by trying to attend to too many variables. There are pros and cons to having clients provide a large amount of detail regarding behaviors. For example, although measuring body weight can tell you whether a client is on track, it does not provide you with any information on eating and exercise behaviors. This type of self-monitoring may work for an individual who is successfully losing weight. On the other hand, for the individual who is struggling with changing his or her body weight, you have very little information to determine what is impacting weight loss and will be limited in the amount of feedback you can provide. Figure 1. Example of detailed self-monitoring. VOL. 10, NO. 1 JANUARY/FEBRUARY 2006 ACSM’S HEALTH & FITNESS JOURNAL1 15 INFLUENCING EFFECTIVE BEHAVIOR CHANGE Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Thus, you need to discuss the optimal approach that allows them to easily self-monitor, while still adequately describing the behaviors at hand. Regardless of the amount of detail provided, the variables being monitored should be closely tied to the target behavior of interest. For clients interested in weight loss, these variables would include total food intake (including type, calories, and quantity), fat intake, and amount of exercise performed (5). If a client is unable or unwilling to provide this amount of detail, monitoring fewer variables will still increase awareness and serve to direct his or her attention toward the targeted behavior. Abbreviated measures still allow the client to track the behaviors he or she is interested in changing. In addition, it also allows the client to modify the type of recording to suit his or her personality and lifestyle. Figure 2 provides examples of abbreviated types of selfmonitoring that are based upon individual likes and needs. Looking at the examples, ‘‘Sarah’’ prefers to keep track of total calories but does not want to do so in an obvious way; she simply tallies calories consumed throughout the day in the margin of her day planner. ‘‘Jim,’’ on the other hand, prefers to have an overall picture of how well he is doing; he keeps track of his behaviors on a monthly calendar he posts above his desk. Allowing your clients to determine the optimal way they would like to monitor their eating and exercise behaviors will improve compliance to the self-monitoring process. Frequency of Monitoring Another factor that requires a personalized approach when prescribing self-monitoring is how frequently clients should record behavior. Unfortunately, there is no clear formula for the optimal frequency of self-monitoring; this will depend upon the client’s schedule and ability to monitor, as well as the targeted behavior, how frequently it occurs, and the degree of difficulty the client has experienced while trying to change the behavior in the past. For example, eating behaviors are best monitored every time they occur. A client who chooses to self-monitor his or her eating behaviors only at night will likely underestimate this information because it is difficult to remember exactly what and how much was eaten throughout the day. In addition, the self-awareness that occurs at such a late hour will do little good because the client cannot modify the eating plan for that day if needed. In general, the more frequently your clients monitor behavior, the better. Frequency of monitoring, however, should also be determined by how frequently the behavior may change. For someone interested in weight loss, weighing more than once per week is not necessary. In fact, frequent weighing throughout the day or week may lead to unrealistic expectations about how quickly weight loss should occur and can ultimately lead to frustration and disappointment. By selecting an appropriate frequency of monitoring for the behavior at hand and discussing individual preferences with your clients, you can maximize the consistency and effectiveness of self-monitoring. Pinpoint Method of Monitoring Once you have discussed which behaviors to monitor, the degree of detail, and monitoring frequency, the final step is determining how the client should monitor his or her behavior. With the increasing availability of health/ fitness information to the consumer, there are a number of self-monitoring methods from which you can choose. These vary from basic pen and paper methods such as sticky notes, diaries, or calendars to more advanced technologies such as pedometers, personal desk assistants (PDAs), MP3 players, cell phones, and the Internet. The most important determinant in which self-monitoring method to recommend is that it is one the client is willing and able to use. The Internet is one avenue of self-monitoring that is becoming increasingly popular and may be a viable option for many clients. Many commercial Web sites offer some form of self-monitoring for eating and exercise behaviors, and many of these are free of charge. Using the Internet for self-monitoring will depend upon the Figure 2. Examples of abbreviated self-monitoring. 16 ACSM’S HEALTH & FITNESS JOURNALA JANUARY/FEBRUARY 2006 VOL. 10, NO. 1 INFLUENCING EFFECTIVE BEHAVIOR CHANGE Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. availability and technologic expertise of your clients, but it does allow for frequent and relatively easy monitoring of eating and exercise behaviors. You also can have clients send you electronic copies of these records and easily track individual progress over time. Not all clients will prefer to use technology. Some individuals prefer to use a small notebook specifically for their self-monitoring or will simply check off their behaviors as they have met their goals (Figure 2). Whichever method is decided upon should be matched to the client’s preference for recording to enhance self-monitoring consistency. To further determine which method is most appropriate for your client, consider the following questions: 1. Does monitoring the target behavior require subjective or objective information? If you would like your client to monitor moods, feelings, or ratings of hunger or fatigue, then having the ability to record more detailed information is important. Thus pen and paper, e-mail, or a PDA may be good choices. On the other hand, if you are only interested in objective measures such as steps taken each day, a pedometer can sufficiently provide the client with the information he or she needs. 2. How does your client prefer to keep track of tasks? Does your client prefer technology and the ease of modifying entries by cutting, copying, and pasting, or does he or she prefer writing things down using pen and paper? 3. What is the client’s technologic experience? Does your client own a PDA or cellular telephone or have Internet access? Do they have Internet access throughout the day or only at limited times? 4. How frequently is your client willing to monitor? If the behavior requires frequent monitoring, it is important to find a tool that is readily available. If your client does not have the self-monitoring tool available at all times to record behaviors, determine a method that is more appropriate. Provide Feedback Perhaps the biggest advantage of self-monitoring is that it serves as an avenue for providing feedback to clients on the behaviors they are attempting to change. Therefore, the type and style of feedback you provide to clients is critical for appropriately directing and supporting positive behavior change. The feedback you provide will depend upon the amount of detail the client has reported in his or her self-monitoring records. For example, it is easier to respond to clients if you have a clear and detailed picture of the behaviors and choices they have made. Nevertheless, even less detailed accounts can give you an adequate indication of whether the client is on track. When reviewing self-monitoring records, you should ask the following questions: What is the overall picture? If a goal was predetermined, did the client meet his or her goal for the week? What are some positive behaviors or changes the client has made? Are there any patterns of behavior? Do these patterns support or interfere with the behavior change the client would like to make? Are there any additional factors to consider such as vacation, family emergency, or odd work hours? Once you have assessed the self-monitoring records, you are then able to provide feedback to the client based upon the previously outlined questions. Table 1 provides step-by-step tips for providing feedback. In addition, you also should consider the following strategies: 1. Use positive reinforcement. Positive reinforcement refers to any factor that increases the probability that the behavior will be repeated and can include encouraging statements, recognition of progress, and celebration of small yet meaningful changes. For example, if a client has struggled with an afternoon snacking habit that has ASCM Photo/Lori Tish VOL. 10, NO. 1 JANUARY/FEBRUARY 2006 ACSM’S HEALTH & FITNESS JOURNAL1 17 INFLUENCING EFFECTIVE BEHAVIOR CHANGE Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. interfered with her weight loss, switching from cookies to fruit is a meaningful change that should be encouraged and rewarded. 2. Provide prompts for engaging in additional positive behaviors and modifying negative behaviors. It is important to try to determine challenging areas for clients. This information can be learned from studying patterns within self-monitoring records. Focus upon one or two areas that the client can modify each week. 3. Modify the type of self-monitoring. Periodically, you should modify self-monitoring assignments for your clients based upon their progress, life events, and personal health/fitness interests. As a client begins to lose weight, for example, you may consider asking him to record less information as he may already have a certain amount of self-awareness regarding portion sizes and calorie content. Other examples of situations that require altering the type of self-monitoring include a client who has decided to focus upon a different health/fitness goal, a client whose schedule will change drastically because of work schedule or travel, or a client who begins to keep inconsistent self-monitoring records. Providing feedback to your clients allows you to extend your personal interactions with them. As the client begins to make (or not make) the necessary changes and you begin to have a better understanding of the individual personality type, you should modify your approach to feedback so that it continues to remain interesting and meaningful. Some clients will be driven by your feedback to make the positive changes needed to be successful and will enjoy receiving your comments. Others may be more rebellious and will decide not to heed your recommendations. By making proper adjustments to monitoring assignments and the feedback you provide, you can make self-monitoring a positive, effective tool to promote the accomplishment of clients’ targeted goals. Limitations of Self-Monitoring As with any tool used to promote behavior change, self-monitoring is not without limitations. First of all, self-monitoring will not be an effective tool for your clients unless they record honestly, frequently, and with enough detail to become more self-aware to regulate the targeted behavior. In addition, the mere act of recording behaviors may not be enough to bring about behavior change. If a client records eating and exercise behaviors but does not understand the concept of energy balance and energy deficit, then self-monitoring alone will not be a sufficient stimulus to promote weight loss. Therefore, work with clients to discuss areas that can be modified or targeted and educate Table. Step-by-Step Tips for Providing Feedback 1. Start Positive. Regardless of how well your client managed the targeted behavior and/or kept self-monitoring records, your first comment should be a positive one. This statement could be very general, (i.e. ‘‘Great job recording this week! I can see you are trying to make changes in your diet.’’) or it may specifically refer to a behavior, such as ‘‘You did a fantastic job reaching 150 minutes of physical activity this week!’’ 2. Identify 1-2 Areas to Target. Next, provide 1 to 2 specific and meaningful recommendations or suggestions to help the client make the necessary behavior changes. For instance, based on the self-monitoring records, you might suggest the client reduce high fat/high calorie foods by substituting these foods with more fruits and vegetables. Or you may highlight situations during the week where poor choices could have been linked to other factors (i.e. Friday dinner with out-of-town guest, baseball game, etc.). Be sure to include at least one strategy for how the client can prepare for these situations in the future. 3. Offer Encouragement. Motivate your client by offering them words of encouragement. Although behavior change is highly dependent on individual personalities, goals, personal barriers, etc., in general, clients respond more favorably to positive comments than negative ones. Celebrate your clients’ small successes throughout the week by recognizing small changes in an encouraging way. Offering a simple, ‘‘I know you can do this,’’ or ‘‘you are worth it’’ shows the client you understand that behavior change requires effort. 4. Make it Meaningful. Try to avoid offering the same feedback to all clients or the similar feedback to the same client week after week. The feedback you offer should be relevant to the target behavior and should offer clear direction for change. If the client is unsuccessful, modify the feedback you provide as the client may simply have misunderstood the direction you provided. When possible, discuss your feedback with the client in addition to giving them a written copy. ACSM Photo/Don Distel 18 ACSM’S HEALTH & FITNESS JOURNALA JANUARY/FEBRUARY 2006 VOL. 10, NO. 1 INFLUENCING EFFECTIVE BEHAVIOR CHANGE Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. them as to why these behavior modifications are important. A common criticism of self-reporting is that clients often underreport calories and food intake and overreport behaviors such as physical activity or calories expended (10, 11). Nonetheless, self-monitoring can still be a valid tool for tracking behavior change as individuals most likely under- or overreport such information on a consistent basis. Self-monitoring is not for every client. Some clients will feel burdened by tracking behaviors, and this may lead to poor compliance to exercise and eating recommendations. Thus, you need to be willing to modify self-monitoring assignments or eliminate it altogether if it begins to decrease, rather than promote adherence. Summary While the verdict may still be out on the ‘‘optimal’’ procedure for self-monitoring, research does support consistency of monitoring as a critical component of weight control and the adoption and adherence of an exercise regimen. There are a number of self-monitoring options available to you and your client. Therefore, your goal should be to individualize the assigned self-monitoring tasks to determine what works best for the client to enhance consistency of self-monitoring and promote favorable changes. Melissa Burgard, B.S., is a Master’s candidate and graduate research assistant in exercise physiology at the University of Louisville where her research focuses upon the role of self-monitoring, feedback, and prompting upon exercise adherence and weight loss. Kara Gallagher, Ph.D., FACSM, is an assistant professor in Exercise Physiology at the University of Louisville where her research focuses upon the role of exercise and behavior change in weight control. She is a member of the editorial board for ACSM’s Health & Fitness Journal.1 She is ACSM Exercise Specialist 1certified, ACE Group Exercise Instructor-certified, and has worked in university and health/fitness settings for the last 15 years. References 1. Kanfer, F. H. Self-Monitoring: Methodological limitations and clinical applications. Journal of Consulting and Clinical Psychology 35:148–152, 1970. 2. Wadden, T. A. The treatment of obesity: An overview. In: Obesity: Theory and Therapy (2nd ed.), A. J. Stunkard and T. A. Wadden (Eds.). New York: Raven Press, 1993, pp. 197–218. 3. Heesch, K. C., L. C. Masse, A. L. Dunn, et al. Does adherence to a lifestyle physical activity intervention predict changes in physical activity? Journal of Behavioral Medicine 26(4):333–348, 2003. 4. Boutelle, K. N., and D. S. Kirschenbaum. Further support for consistent self-monitoring as a vital component of successful weight control. Obesity Research 6(3):219–224, 1998. 5. Boutelle, K. N., D. S. Kirschenbaum, R. C. Baker, et al. How can obese weight controllers minimize weight gain during the high risk holiday season? By self-monitoring very consistently. Obesity Research 6(3):219–224, 1998. 6. Tate, D. F., R. R. Wing, and R. A. Winett. Using internet technology to deliver a behavioral weight loss program. Journal of the American Medical Association 285(9):1172–1177, 2001. 7. Kirschenbaum, D. S. The Nine Truths about Weight Loss. New York: Henry & Holt, 2000. 8. Baker, R. C., and D. S. Kirschenbaum. Weight control during the holidays: The potentially critical role of self-monitoring. Presented at the Meeting of the Association for Advancement of Behavior Therapy, New York, November 1996. 9. Madden, M., America’s online pursuits: The changing picture of who’s online and what they do. December 22, 2003. Available at http:// www.pewinternet.org/pfds/PIP_Online_Pursuits_Final.PDF. Accessed Aug 8, 2005. 10. Horner, N. K., R. E. Patterson, M. L. Neuhouser, et. al. Participant characteristics associated with errors in self-reported energy intake from the Women’s Health Initiative food-frequency questionnaire. American Journal of Nutrition 76:766–773, 2002. 11. Johansson, L.,K. Solvoll, G. E. Bjorneboe, et al.Under- and over- reporting of energy intake related to weight status and lifestyle in a nationwide sample. American Journal of Clinical Nutrition 68:266–274, 1998. Condensed Version and Bottom Line Interactions between health/fitness professionals and clients are often limited to face-to-face meetings in the gym or health club. Many clients, however, struggle with maintaining consistent healthy eating and exercise behaviors outside of these interactions. Self-monitoring allows you to monitor client progress and identify areas that may hinder client success. Self-monitoring also increases self-awareness of behaviors and allows the client to become familiar with other factors that are linked to the behaviors he or she would like to change. By incorporating self-monitoring into your interactions with clients and by providing meaningful, directed feedback, you can increase the likelihood that clients will successfully change eating and exercise behaviors. VOL. 10, NO. 1 JANUARY/FEBRUARY 2006 ACSM’S HEALTH & FITNESS JOURNAL1 19 INFLUENCING EFFECTIVE BEHAVIOR CHANGE Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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