My Presentation to The Royal Society of Medicine in London

Speaker 1: Hi everybody. How are you doing? Can you take a second just to all sit up straight, sit up straight in your chair, get back? You just got back from a break, I missed the lunch so I’m really hungry now and the good thing is that you all just burned about 2 calories, so that’s nice. You only have to walk another 9,998 steps and you will hit your 10,000 step goal.

Maneesh: Hi everybody. How are you doing? Can you take a second just to all sit up straight, sit up straight in your chair, get back? You just got back from a break, I missed the lunch so I’m really hungry now and the good thing is that you all just burned about 2 calories, so that’s nice. You only have to walk another 9,998 steps and you will hit your 10,000 step goal.

Our population today is living longer than any generation in the past and we’ve cured millions of patients in infectious diseases and it’s been an amazing century for vaccination and cures but in the 21st century we’re facing a new challenge, and that challenge is lifestyle diseases. Cardiovascular disease, some types of diabetes and obesity are often caused by our own lifestyles, by ourselves and the only cure is not a vaccination but it’s going to be a habit of exercise over time.

My name is Maneesh Sethi and I’m the founder of behavioral technology group and Pavlok, as was mentioned. I focus on building on wearable devices that help form good habits and break bad habits. Ever since I started studying persuasive technology at Stanford I was really interested in how wearables can form good exercise habits. If you haven’t heard of wearables, you’re not alone. This year over 100 million devices were shipped. Next year 150 million will be shipped but still fewer than 50% of our population is familiar that wearables even exist or what they are but wearables at their core are simple microcomputers that are built and attached to human beings. You might wear them as accessories or you might wear them on clothing and these wearable devices have the ability to sense and track data with little sensors inside of them and they actually communicate with your Smartphone typically, so they don’t actually do any processing on their own. They have really good battery usage and your phone can connect with them and assemble that data and share it how it should be shared.

Here you can see a little infographic with the well connected man. This is from a few years ago and it’s interesting there’s a lot of devices that existed a few years ago that are being used. The Google Glass is common now. The Nike FuelBand Fitbit are great at tracking steps and tracking your sleep. The jaw bone era, if you guys remember those little jaw bone devices that people still sometimes walk around in, I got a present. It’s actually this thing. It’s like a wearable device. I didn’t think it was a wearable device until I looked at this slide yesterday and I was like “wow, I have one on me right now” and this enables me to communicate and speak on the phone and make recordings and talk without having to actually look at my phone. I can also communicate with Siri when it’s cold in Boston. It’s really useful for like sending reminders to myself. I would press the button, Siri would pop up on my phone and I’d be like “remind me to do my homework before I get to school.” Lastly, you can even see some wearable devices for pets. The whistle is used to track your dog’s daily activity.

Wearables are becoming a really big industry. By 2018 we’ll probably see about $22 billion spent in the consumer space and $8 billion spent for the non-consumer space. These wearables are getting really, really large and they’re getting very useful and they’re becoming deeply integrated in our daily activities without us even knowing it.

Right now I want to talk a little bit about some sorts of devices, what they can track, what they do, why it’s interesting. Starting off we can look at activity trackers or fitness trackers. You’re probably familiar with the Fitbit or the FuelBand. Who in the audience owns a fitness tracker of some variety? Wow, many of you do. Fitness trackers are really interesting system because they use an accelerometer. It’s a little chip that’s been in existence for a long time; it just became really cheap. It measures acceleration as it moves up and down but with that small accelerometer it’s able to calculate how many steps somebody walks. You can even use it to track sleep data, how people sleep or their moving patterns throughout the day. Here you can see for example a week of my life that was spent apparently in moderate exercise and you can see that on each day it’s able to identify how many steps I walk and how much of that time was spent in super active mode or in light exercise mode and then on each day you can actually break it down to step by step, hour by hour elevation changes as well and I found it’s really interesting like here you can see where it’s highlighted, 3:00 PM, it says 1693 steps. I had no idea that I was walking that many steps. I just didn’t want to pay a taxicab in New York City but I ended up getting to 20% of my 10,000 step goal.

Next, a lot of wearables can measure vitals as well. The one on the right, the Withings blood pressure monitor is pretty cool from a healthcare perspective. It’s a really automated system where it’s like a little blood pressure device that you put on your arm and you just press the button and it automatically inflates and finds your blood pressure and reports that data back to be saved and shared.

There are some other interesting devices too such as the Basis. I’m wearing the Basis right now. It measures my heart rate and my steps. It measures a lot of information at once. I can tell right now that my heart rate is 120. Apparently I’m nervous. It can also measure your perspiration, skin temperature, which has really interesting use cases for things like stopping gamblers from spending too much money at specific times or stock traders as well. This is what the Basis looks like and it can measure your sleep data which I, was preparing for this presentation, you can see I didn’t sleep too much but it lets me know when I was in light sleep, when I was in deep sleep, at exactly what time I fall asleep and also when I sleep was spent in the REM sleep. This information is really useful at a larger perspective, like how much activity I have the day after I slept well or how sleep affects my scores or grades or reports.

Another one that’s in the same column and the same row is the LUMOback which I have right here. Remember when I mentioned, I asked everybody to sit up straight. This device actually knows when you’re in good posture and when you’re in bad posture and then it will start to vibrate in order to give you feedback to remind you to sit up straight.

The last one is environmental factors; this scale is called the Withing scale. You can replace your bathroom scale with it and you can track your weight over time as well as your heart rate but it also measures the surrounding air quality and the temperature of the room so you’ll know if your room is battered, good I guess. Here you can see my weight over time. It turns out I get fatter in the holidays.

Right now I want to talk to you about the power of wearable devices, what they mean for the future, especially for healthcare. I think that today’s wearable devices are our best bet at saving lives and curing the most common killers of our generation and I think future medicine lies in wearables. I want to talk a little bit about how they’re going to change the way that we do research in healthcare. They’re going to help stem our current lifestyle disease epidemic through behavior change and they might even create a sort of paradigm shift for the healthcare industry and I’ll delve into.

Starting off, medical research in wearables can lead to more accurate significant results. Today medical research often uses experimental test groups that are pretty small and we use them to test cause and effect but the results can be inaccurate and it’s very tough to get groups of people who are willing to check in and do the experiments and do the data, but we can improve that information on wearables. As I showed you earlier we can get accurate, instantaneous results and activity details just by having people wear a simple band and if you look on the slide, which is the evolution of medical sensors, you can see that at the beginning, we began with manual data collection, manual data transmission, so you think of writing down how active you were and passing it to your doctor when you see him next time. We’re probably between the first and second generations right now, where we start to automate that data collection and that data transmission. We have the technology already to move towards the third generation of both automating collection and transmission. I think the next generation will be analyzing that data to find massive traits and trends within the large scale data we’ll be able to identify. The hard part of course is getting people to wear these things and I think that we’re getting better and better at that day by day. We started off in 2003, a little accelerometer you put in your waist that measure how many steps participants walked but the problem is that as few as 40% of participants would keep that on for 6 days. You leave it by your side table and you just never put it on the next day. On the other hand when they turn it into a wrist band, the percentage of people that stuck through with it was 70%-80%. In fact with some of them, the average was 22 hours of wearing it per day. I myself did not mean to wear this jaw bone, the whole G thing in my head when I came here but it became such a natural part of my day that I forgot to take it off before I started the presentation and I think the next step and we’re seeing this already happen, is integration of these wearables and the information that they provide into things that we already do. The iPhone 5s if you have one has an accelerometer built into it and the makers of Run Keeper just recently released an app called Breeze and this app is automatic. It just sits on your phone and all it does is it just tells you the amount of steps that you’re walking throughout the day and every time I just get up to go get some coffee and I sit down, it says “congratulations, you just walked 100 steps” and trophies fly down and glitters fly from the sky and I’m like “yeah I do walked 100 steps. That was great!” The interesting thing about it was how it scales. It scales, starting off with just 1000 steps. It doesn’t make it difficult. You’re naturally going to hit this 1000 steps just by existing but each day that you get these trophies and these positive rewards and it starts to reward you more and more and the steps become harder and harder until you just want to keep that trend up.

This brings us to an interesting point, which is about knowing what we should do versus knowing what we already do. A lot of people don’t know how many steps they walk. In fact, most people don’t know how many steps they walk. I think that Dr. William Bird this morning was speaking of Bob, this hypothetical Englishman who would walk 6 miles a week to watch a football game but it turned out that he had no idea he was walking that 6 miles. It’s just a natural part of his routine. A recent study that was done at Harvard, maids were measured and what happened was the doctor, Dr. Ellen Langer, she realized that maids tend to exercise all day. They do heavy physical labor. They’re essentially surpassing by law the physical guidelines recommended and what happened was she went in and asked these maids how many steps they were walking, how active they were, what their physical activity levels were and she found that more than 2/3 of them said that they weren’t active at all or they have very little exercise throughout their day. Then she started to measure their vitals, their waist to hip ratio, and she measured their weight and their blood pressure and she found that they actually match the perception of what they did but not the actual amount of exercise that they did. She started to look in to this data and she took a group of 84 nurses and she broke them into 2 test cases. To the first she gave me them education. She said “the act of making a bed requires this many calories. The act of scrubbing requires this many calories. You’re probably burning this many calories this week” and to the second group she said nothing and they came back a month later and looked at the results and found that the group that had been told what the amount of calories they’re burning, actually lowered their blood pressure levels by 10%, they dropped their weight, and their waist to hip ratio improved and the other group remained exactly the same but the interesting thing about this is when they looked at the actual actions of the people, they hadn’t changed their motions at all. It was simply a placebo information effect that caused them to lose weight. There’s an interaction here between the mind and the body that wearables can help communicate and then you look at this data right here and you’re able to see that hour by hour I was walking steps without realizing I was walking these steps. These data can be incredibly powerful for people who have no idea how much exercise they’re already doing.

The next step after identifying exactly how many steps the people are walking, is to help change behavior and help shift the way that people start to do things and so this has been my experience. I focus on behavior change. I was studying persuasive tech and behavior change in Stanford University and I was lucky enough to study under Professor B.J Fogg, who taught me the Fogg behavior model and he broke down the factors that induce behavior change and he found that there was 2 core actions – there was motivation and the ability. Behavior change happens when someone is motivated to make that change and when that action is easy to do. Motivation is not a simple problem solved. Saying something to a patient like “you should exercise and walk more because in 30 years you might get a disease that might hurt you” is not very motivational. It has no real value to him directly. As well it’s really difficult to just walk for 30 minutes or to do physical activity for 30 minutes. What does that really mean? It doesn’t mean anything when they don’t realize that they already are doing physical exercise for part at a time.

I focus, with my company Pavlok, on breaking down these factors and inducing behavior change through the smallest core concepts. To increase motivation we say don’t worry about the disease in the future. That’s never motivated anybody ever. Let’s look at what specifically can we start to do to motivate an individual to change their behavior, starting off with adding a little bit accountability. We give an accountability partner, someone who’s going through the same challenges as you and you guys work together and a coach who’s able to remind you and ask you “what did you do each day? What are you going to do tomorrow?” We also add some incentives and reinforcements. We’ll do something like pledge that if you walk for 50 steps today for 5 days in a row, you’ll get to buy yourself a massage on Friday; some little changes that lead to changing your behavior. The next step was to make it easy to do. Exercising for 30 minutes, it’s hard. If anybody here has ever seen the Focus T-25 beach body class taught by Shaun T., the difference between 25 minutes and 30 minutes is astronomical, perceptually but the difference in reality is very little.

How do we make an action easier to do? I use a process I call micro-habits, which is taking a grand audacious goal and breaking it into its core components, so you say something like “you don’t have to go to the gym and exercise for 30 minutes. All you have to do is go outside your door in your gym clothes and lock it right after breakfast. If you want to come back in, you’re good to go but if you go outside and lock it after breakfast on Monday, Tuesday, Wednesday, Thursday and Friday, you’re going to get a massage on Friday.” That small ability of changing the action from something hard to do to something so easy to do where you can’t fail and then adding a tiny bit of motivation, a little bit of reinforcer makes the behavior far more likely to change. As we’ll talk about tomorrow, as small behaviors change, habits start to form or it becomes more automatic and it actually requires willpower to not do something than to do something. My professor himself, after he flushes his toilet he does 10 pushups before he washes his hands and he tells me that it’s impossible for him to not do pushups, it becomes so obvious.

There’s one example about behavior change that I think is really interesting, which is one of our students he started to do the act of watching an exercise workout video every morning, so he have to watch it. He didn’t have to actually exercise but his goal was he had to sit down and watch an exercise video and what he found, he started reporting his results, was that this small shift lead to humungous shifts over time – the act of watching the video lead to him exercising; the act of watching the video make him start to wake up earlier so he’ll have time to watch that video. The act of waking up earlier meant he started to sleep earlier, which meant he stopped going out as much, which meant he stopped drinking alcohol and now it’s been 90 days in a row and he’s worked out 90 days in a row. He also wakes up at the same time everyday, which is pretty cool.

We’ve been able to identify these specific core concepts that radically shift behavior in individuals and the next step is to radically shift that behavior in population and I’m just briefly going to say my vision for the future, what I think we can do and why wearables are relevant in this process. The fact is that today we’re still using very difficult means to motivate people to make behavior change, telling people what they should do but they only come in and check in once every 6 months. How will they really know what they do in those 6 months? How many times have you lied to your doctor about how many drinks you have last week for example. With wearables however, we get accurate data, start to understand exactly what patients are doing and over time start to add proper incentives that can really lead to massive shifts. If you imagine, for example this magical world in my head that I see and I envision in the near future, which is entering into a grocery store and as you’re entering into this grocery store immediately your wrist starts to vibrate, there’s a screen and you look at it and it says “just for you! The NHS is offering a 50% off special on kale.” You need [17:46] and you’re less likely to get a disease if you eat that kale. And the beauty of this is that the money, where does the money come from? I don’t know how it works in the UK but in America I can it coming from insurance companies because insurance companies will save money when someone doesn’t have to use the resources that would be necessary when they go to the hospital. There’s a grand vision, a grand scheme with even like Google Glass, putting green arrows down. You can see how this world might…through wearables we’ll be able to lead to a more positive reinforcers and less of sort of a grand audacious strategy of being physically active that no one really does.

That’s basically it. My name is Maneesh Sethi and I think that wearables might be leading to a giant shift in healthcare. Thank you.

[00:00:00] Mike: Maneesh studied in Stanford and has setup various technological companies worldwide. And he’s the CEO of behavioral technologies, which is about behavioral change.

[00:00:24] Maneesh Sethi: Thank you very much Mike. Well I don’t know what’ happening here, but in the mean time I wanted to ask everybody about what activity would they like to do every day – daily –kind of habit you would form that you think overtime might make a difference in your life. Just take a second and think about it – it’s an interesting question to have. Okay.

[00:01:29]: So anybody has any ideas? What will you do? What habits will you do every day? Someone speak up come on. There’s a lot of different habits that can be achieved overtime and day by day they become more automatic. Here’s a quote that is a good reflection of what that means. This is by Peter Drucker. He is one of my heroes. He is a management expert and he talks about how the small changes that executives can make that leads to humongous returns. One of them is a simple habit if pushing yourself. If you start to do a little more and more each day, you’ll start to realize that it becomes easier and easier to do more and you’ll put more strain on yourself, but you’ll never actually feel like you’re doing more work. You just find yourself doing more. That’s why today I want to talk a little bit about how to form good exercise habits in training. I’m talking about habits in general and they’re focused on exercise habits. There’s a lot of interesting distinctions between forming good habits and breaking bad habits and we’ll go a little bit into that as well.

[00:02:28] I’m going to start off with a story about a taxi driver I recently had named Abas. I was using Lyft. I don’t know if Lyft exist here. It’s like a cool little iPhone app like Uber – it will pick you up pink mustaches that come off at the front of the car – it’s the cutest thing. And Abas picks me up, and I sit down and I told him that I’m building a device that lets you form good habits and break bad habits and he’s like “(Abas) oh that’s interesting, I’ve just lost 80 lbs” and I look at him and I’m like “are you sure?” And he’s like “(Abas) yeah but I’ve just gained it back too”.

[00:02:58] Okay. That is interesting. Tell me the story. And he’s like “(Abas) actually we’re almost here” and I said “Nah no dude let’s just ride again, tell me the story”. And he starts telling me the story about how he made a decision one new year that he was going to start exercising. And so he realized that his work was about 45 minutes away from his house. And he would wake up early and his friend with him to wake up early and drive to the gym. And from there they would go workout and exercise. And from the gym they would go to work. And because they woke up early they skipped traffic and they got the positive reward of driving fast and skipping traffic. And he started to lose a lot of weight.

[00:03:36] Now after 3 months his friend stopped going to the gym but he kept on going. Abas pushed through. He was eating salads, he was tracking the calories that he ate and he lost 80 lbs in about 9 months and then something happened. What was that something – it was a context shift. Abas’s job changed. And he suddenly didn’t have a set schedule – he would wake up and go to the gym on time. One of his friends said a small little remark saying “hey I think you’re getting a little too thin.” So he started thinking to himself, “maybe I should eat a little more, maybe it’s okay.” And what happened is he started to realize that his new work had a gym just across the street like a block away and it totally changed the conversation on Abas’s mind from home-to-gym-to-work, he changed that conversation to home-if I take a left I go to the gym-if I take a right I go to work. And so what he found is he would find himself driving to work. He’d be in traffic, he’d be pissed off, using up his willpower reserves and he would arrive at this choice – this junction, and you know what he would say? He would say, “I’ll just go to work for a minute, drop my bag off and I’ll go to the gym right after. And he never did again.

[00:04:41] Now literally the minute I got out of his car I canceled my Boston Sports Club Gymnasium and I signed up for Sport Club LA, which costs (not in LA, it’s in Boston and it’s on the way to work) 3 times the price, but it was ON The Way to Work instead of 1 block past my work. And I found that my gym ratio tendency increased. From 2 times a week, to 5 times a week; every single day. Why?

[00:05:10] Because I would pass by my gym lookup, see it, trigger the fact that I should be at the gym then well I’m running a habit company so I know a little bit about habits and I realize that my requirements for focus is simply on “all I have to do is enter the gym”. I don’t even have to work out. But if I enter the gym every day for 5 days on Friday I get to give myself a massage. It’s great. I’ll just go in and swipe my card. And one day in particular, I went to the gym in a suit, in exactly this suit, and I went to the gym and I have a meeting and I was like I got to go, I got to run to the gym and really quickly I got to swipe my card otherwise I get charge this $50 penalty and if I do go I get this massage on Friday. And I go to the gym and I literally walk up and I suddenly started to feel this little stretch and like “uhh maybe I should just do one quick stretch?” And I go do this one stretch and my personal trainer sees me and says “Maneesh, what are you doing? Why are you in a suit?” And I’m like “I didn’t even know.”

[00:06:07] 5 minutes later I’m doing an ab workout, a pushup set, I did an entire work out, missed my meeting, and I had a suit all drenched (I should have probably dried cleaned it). But at the end of the day, what was weird about this moment was that I wasn’t trying to go to the gym, I just found myself at the gym. And that’s really what a habit is. A habit is when it takes more effort to not do something, than to do something. Now if you think about habits that we commonly have, things like brushing your teeth every morning. I’m assuming most of you here brush your teeth every morning and if I ask you to raise your hand if you don’t you probably won’t.

[00:06:50] I sometime give this talk and talk about your brushing your teeth story and every once in a while someone comes up to me and says “can you get my boyfriend to start brushing his teeth every morning? It would really improve our relationship.”

[00:07:03] The thing about brushing our teeth is that we did not brush our teeth for hundreds of thousands of years. Right? And today we do. And you wake up in the morning and if you don’t brush your teeth you get that little weird feeling in your mouth. You just feel icky and dirty. Granted some of it probably dry mouth, some of it because of that feeling of dryness in your mouth. But that didn’t stop hundreds of thousands of years of humans from not brushing their teeth. What that feeling is, is it serves as a trigger that puts your brain into automatic mode. That trigger makes your brain start remembering the last time that it brushed its teeth – and that it’s easier to actually brush your teeth to remove that feeling than to live with that feeling. And you start thinking about it – how come we don’t floss? It’s exactly the same way. We’re just not used to the flossing activity. That said, if you start to floss every day – for about, between 30 and 66 days, you will find it more difficult to not floss than to floss. By the way, flossing adds between 5 to 7 years to your life, maybe you guys should look into that (I should too probably).

[00:08:02] This brings up an interesting conversation, which is about habit versus willpower. So I want to ask everyone in the audience a question. Which would you rather have, would you rather have a $100 today or would you rather have a $150 in a month? Who would choose, in this experiment I’d be giving you a check – so you would be given a check that is dated for today or a check that’s dated a month from today. Who would choose a hundred dollars today? Raise your hands if you would. About 10% 20% and the rest, who would choose a $150? That’s great. And there’s a reason why you made a decision. Because, well economically the correct decision and also because you just had a little bit of coffee. You just had a bit of food outside. This is a really interesting experiment. It’s been done multiple times. Where they will offer this decision. Do you want to want a $100 today or do you want it in a month – a $150 in a month. And they find that typically, most people – about 80% will choose the $150 in a month. Unless they’re subjected to decision fatigue. And decision fatigue is that experience of making a lot of decisions, asking yourself a lot of questions, having debates about should I do X or should I do Y. So you can imagine the best wedding planners in the world use this powerfully. Well they start of by bringing you in and say, “Would you like red or green balloons, would you like carnations or roses?” And they start off with these irrelevant questions that each of them begins to use your decision making or willpower reserves. Then they say, “Would you like that really expensive add-on photo service that we can provide?” then you say “Yes! Just fine, give it to me”. And that’s what they did in this experiment. They said, “Would you like $100 today or a $150 in a month?” Then they ask one test group, “Would you like X or Y? Would you like green or blue balloons?” They make them go suffer these decision fatigues and then they ask them these questions and then their answers changed. They changed from, most people flipped. Most people say and choose $100 today rather than $150 in a month. Now there’s a 3rd test group. This is really interesting. The 3rd test group which was suffering the same decision fatigue and was asked the questions, but right before they received the question, they were given a glass of Coca-Cola, and glucose replenishes your willpower reserves. It can be used in experiments to increase your willpower. And so right after they were asked that question, the number reverted back to the old numbers saying 80% like getting $150 in a month. And the rest saying they would take the smaller amount.

[00:10:44] Even on the paper itself it says, “We used soda only because it spikes your glucose” this is not an effective way to train your willpower so do not use this of feel some consequences.

[00:10:58] This next slide is due to a gentleman who was discussing his favorite slide from my presentation yesterday, which had a pretty maid in the background. And it’s related to whether willpower question where they asked exactly the same questions. And then they took women and men and put them in 4 test groups and they asked one test group – they showed attractive women to men they showed non-attractive women to the men then they showed attractive men to the women and non-attractive men to the women and they asked exactly the same question and they found that only one of the groups – the one that is the men viewing the attractive women – as soon as they saw the attractive women – they would ask for a $100 right now.

[00:11:54] That’s more likely evolutionary than willpower but it is an interesting situation. Very interesting about willpower is that willpower as I’ve mentioned can be replenished with glucose. Willpower can also be replenished by sleep. Sleep is the most effective way to improve willpower. And I’m sure you remember my slides yesterday where I showed my sleeping habits and I slept very few hours preparing the presentation and the thing about sleep is that the more you sleep the better your willpower is. That means that better decisions, the better executive functioning you will have the next day. The more you sleep, the more productivity you will be meaning you’ll get more hours out of the day. But realistically, what would you do with an extra hour a day? And who could you become with an extra hour a day?

[00:12:40] Now I’m going to show a few pictures of articles online and a few old guys telling us that we should do some waking up early. Apparently successful entrepreneurs wake up early. Apparently power women wake up early. Even Aristotle told us to wake up early and so did Benjamin Franklin who’s in the $100 you just took. The thing about waking up early is that it is a keystone habit. A keystone habit is a single habit, a solitary act that once implemented it starts a chain reaction that begins other habits naturally. So I started doing a test on what would happen if I woke up early. And I did with a – I made a wristband that electrocutes me whenever I feel like it. And so I set it to shock me every morning at 6 am just to see what would happen. See if I would wake up a little bit earlier or if I would try to snooze it (it wakes you up). What I noticed is that as I woke up earlier, suddenly I had more time in a day. My willpower reserves were high so I would start to meditate. In fact I had enough time that I could go to the gym. In fact I had enough time that I could take a meandering walk to the park and not focus on sprinting out of the door with my briefcase in my hand and not going to the gym and getting to work and being in this ape mode – chimp mode where nothing matters except what I’m doing and I can’t think like a human and I eat every single skittle in front of me. And it’s like, god I like skittles. And I realize that this one extra hour would lead to humongous massive effects. Now there are other keystone habits. There is a few that I’ve identified and other scientists have identified. I found that morning rituals are very effective. So you probably do something every morning already. You probably brush your teeth. You probably take a shower. You probably notice that when you take a shower you have this ability to think about other things and brainstorm and ideas come to you in the shower. And the reasoning for that is that it is a habit. And your brain stops using its cognitive load. And starts using – freeze up its ability to think. When you enter the shower, when water hits you, it’s like a trigger that activates your brain to become in automatic mode.

[00:14:41] Other keystone habits that we’ve identified are meditation, that’s been really effective in helping people improve their entire life. Exercise is one of the most common keystone habits. Once you start to exercise you typically start to sleep better; you’ll start to wake up earlier; you’ll start to dink less; you often add more greens to your diets – naturally – just by adding the habit of exercising. How many people here noticed that you can eat well and like if you eat well you exercise and if you exercise you eat well but if one of those things messes up either one of those things falls away I’ve noticed that it’s a huge situation? But when you start to start to fix individual habits like waking up on time your body starts to regulate and it becomes automatic.

[00:15:26] Now I want to talk a little bit about this automaticity – how these triggers change habits. This is actually really cool because it came from the University College of London. I found it really interesting because this slide changed my life. This little graph, probably doesn’t mean much to you, but the study was done nearby and the way it was is at the University College of London they asked people to choose a habit they want to change add – something they wanted to do and they started to measure how much time it would take before that habit became automatic – before the brain reach the maximum level of automaticity – when did it require more willpower to not do the action than to do the action. And they found that for simple actions, like drinking a glass of water after breakfast it would take about 20 days before the habit is formed in the brain, before it felt uncomfortable to not drink a glass of water after breakfast. For difficult habits like doing 50 sit-ups the max was 84 days. It took 84 days before it became ingrained so deeply that after breakfast I would do 50 sit-ups or else something is weird. But the average was about 66 days for most habits. You can get that down to 20 days if you make the habit simpler. And that was really interesting because I found that consistency is key. And when you start to do something consistently your brain starts to work on a different way. That trigger starts to set off the base or where your habits are typically stored and it doesn’t use executive function; it doesn’t use your willpower reserve it doesn’t force you to think about actions and make decisions instead it allows you to do it automatically – you don’t require any willpower whatsoever. Even more beautifully that one study showed to me that in 30 to 66 days you can completely become a different person.

[00:17:13] If you choose one small action in particular the keystones habits, after 30 days, you won’t be able to not do it. And that’s pretty powerful. Aristotle said it best, he woke up on times, and he knew what he was talking about “We are what we repeatedly do – Excellence then is not an act, but it’s a habit”. So I just mentioned a moment ago the when a trigger is encountered a habit causes the brain to go into automatic mode. Now there are ways to form habits, and this is a common method I’m sure people in the audience have seen. This is based on a book called “The Power of Habit” by Charles Duhigg. It’s a very good book. He talks about how can you ingrain a habit into your brain. And a way to do so is to identify cue a trigger of something you already do like “after breakfast I will” or “after I’ve arrived at work I will”. You would choose a routine, the action that you want to do and then you give yourself a reward. He showed some pretty paradoxical examples where he would give, the routine was to exercise, the reward was to eat a cookie and it clearly outbalanced the amount of exercise that was done. But the power of this is that after a while you can remove the reward because you can begin to fuse the feeling of the action as the reward. So if anybody say I wanted to choose a habit that they wanted to form, for example, going to the gym, exercising. You might choose a cue, something that you already do typically best to start in the morning because of your willpower reserves then you’ll identify after that “I will do this and if I do this I will receive a reward.” And if you start to implement that put it into function for 30 days and you stick to the program that habit will become ingrained in your brain.

[00:19:07] But how do you get people to stick with the program, that’s the hard part. Yesterday I briefly discussed the fog behavioral model where we looked at behavioral modification – how we can get people more motivated and able to do actions. And as I mentioned people’s behaviors are unlikely to succeed unless motivation is high and the ability to action is easy to do. At that point there’s this little blue action line that you see a trigger is required some sort of trigger in the last slide it would be considered a cue here it’s a trigger a reminder is another good word. When that trigger hits at the moment of high motivation and a moment of easy ability that trigger succeed. What if it’s hard to do for example what if you walk to the gym and you’re really ready to go but you’re in a suit, unless your motivation is extremely high in my case I don’t want to lose $50 then your ability will be really difficult. You just don’t have your little gym shoes as a good excuse for your brain to go into. So I looked deeply into how I could build motivation. We started off by looking at what factors were very powerful for motivation. So we looked into reinforcement and we looked into accountability. And we started to build this into what we were doing. I started to understand there is a lot of power in reinforcement. Myself, I am about a year ago weight about 2 stone – 2 and half stone more than I do now – that’s like 14 lbs. right? Yeah.

[00:20:37] I weight 2 and half stone more than I do now and I made a bet to a friend of mine. A bet that I was going to the gym every day or I pay $50 if I didn’t go to the gym. Now I’ll tell you what happened in my brain when I remember that I had that bet. I wake up in the morning and I say to myself “I don’t want to go to the gym, but there’s no way I’m paying James $50 I’ll just go I’ll get it out of the way.” It’s changed the decision it was completely automatic and what I found was that by pre committing by using my willpower on that one day that one conversation that we had that I promised to pay him $50 if I didn’t go to the gym for the next 14 days, that was my one moment of willpower that I used. But when it came down to the actual action because I had this fear of loss I was able to go to the gym without having to force myself to go to the gym. I just knew I would be there. There was no decision to make. I had to go. I’m going to come out of this slide in a moment but I wanted to show the power of negative reinforcement, which is something I don’t think is talked about enough. Positive reinforcement is used a lot. Positive is a great way to cement habits, to make them maintained, to keep them focused. But there is a lot of power in negative reinforcement the fear of loss can be an incredible motivator. There’s a website called Stick, that was formed based on these 2 I believe it was Yale professors who decided to have a bet with each other that they would lose weight and if they didn’t they would have to pay a penalty. And it was like several thousand dollars.

[00:22:13] What they started to do was, they realized how powerful it was. When they added this accountability and they added this negative reinforcement bet, they built a website around it. And it became very popular. It allows you to choose where your money will go so you can choose your friend to take your money if you fail or you can even choose a charity or an anti-charity. So the biggest funding source of the George W. Bush public library right now is Stick.com. I was just remarking before the presentation that I had to squat 350 times or else I would have to pay that same amount of money to the George W. Bush library and it is like really really just chilling my brain.

[00:23:00] Recently they did a study near times analysis of a 125 thousand people who were on stick.com and they looked at the success rate of people who made these bets and used referees. And they found that when somebody did not have a bet and no referee there’s a 29% chance of succeeding on their commitment. When they added a referee and a bet that skyrocketed to 80%. 80% is really really hard to get to, if you imagine trying to get yourself to do something you say you’ll do, you’ll probably fail more than 80% of the time. This is an amazing understanding of how powerful a small fear of loss can be. And that fear of loss is really powerful for getting habit started. I don’t want to say that negative reinforcement is the end of the all. Negative reinforcement is a great way to get started positive reinforcement is a great way to make it stick. Okay?

[00:23:53] The second column here you can see the referee and that brings up the accountability aspect of the motivation. Accountability is a situation of having somebody you report to somebody who knows what’s going to happen, somebody who knows you’re not cheating, somebody who’s going to be your monitor and ideally your friend. And as you start to add accountability into the action of having a reinforcement bet, you can find yourself actually, let me rephrase the. If you have a bet going on, and you don’t have an accountability partner, you might cheat. But if you have an accountability partner it will motivate positively and it will keep you honest. We are starting to use technology to be our accountability partner as well. GPS is a lot better than your wife or girlfriend who’ll be nice. And let’s you off a couple of times. These are great ways – positive and negative reinforcement are effective mechanisms to increase motivation on the behavior spectrum. The second part is to increase the ability, and this is something that I am very interested in when I talk to people of what habits they would form. I used to run a platform called getitdonein30. Where we would allow people to commit to doing an action for 30 days and they would use the betting system in order to identify what they would do.

[00:25:07] I would have phone calls with all of our clients and all of them would say “you know I want to go to the gym 6 days a week and I’m going to exercise 45 minutes. I’m going to do it every day.” And I’m like “no you’re not. There’s no chance you’re going to do it. You’re going to work out in like 5 years. Why don’t we start small or let’s make it as simple as possible. You can commit simply to going outside in your gym clothes 6 days in a row. You don’t have to go all the way to the gym. Just go outside in your gym clothes. You don’t have to go the gym and workout you simply have to get here and swipe your card, that’s enough.” And as we start to build this out we realize the power of micro habits. The ability to take a gigantic action and break it down to core small functions and then make it so easy to succeed that you cannot fail then add in the bet that if you do fail you get like a fear of loss losing money penalty and you add those two together and it multiplies into something much bigger than itself.

[00:26:02] I wanted to focus on how we can use, or what are some great ways to improve ability? You start with micro habits, I’ve mentioned just for people in the audience interested in trainability as well to make good decision and to stick through what you say. Other great ways to improve your executive function. Best way to do this is through meditation. I highly recommend an app called “get headspace”. It helps you meditate. There’s also a couple of systems that exists wearable devices could give you feedback to let you know when you’re training your executive function properly. You can do “eeg”, there’s a device called “the muse”, which you can buy down the street, from the “EE store” it’s a telecom store. It’s a little Bluetooth powered eeg device that can measure your beta, alpha, gamma waves. And they use like a stress relaxation app to know when you’re successfully and unsuccessfully doing an action that stimulates the executive function of your mind. There’s also a device that I use called “The upgraded brain focus trainer”, that’s an executive function HED-HEG measurement that you put on the front of your forehead. It measure that flow of oxygen to your prefrontal cortex. And you can use that to train it. But realistically, I’m making more hard, it should be easy, download “get headspace”.

[00:27:20] The third thing is to add effective triggers, thus making sure that the triggers are cemented deeply within your life. It’s really important. The example I gave earlier about moving the one block before me was incredibly powerful in my regime. So we took all this information together and we decided to build out what I call the Pavlok habit model. It was a system that we integrated all of our information and we put it together in order to create a system that would work to motivate people to get to their goal. We started off with a giant goal of exercising 30 minutes per day. And we said let’s break that down into the smallest possible action we possibly could do. For example the micro habit of “after I drink my morning coffee, I will step outside in my gym clothes”, that’s it. I would step outside all I have to do. You do that for enough time and you’ll find that it becomes natural for you to have your gym clothes on and step outside after breakfast. But once you’re already outside, no one is stopping you from going into the gym, you can go if you want. If you don’t want to you don’t have to. The next step was to increase that micro habits step by step. You’re simply going to go to the gym and swipe your card and you’re going to go ahead and do an activity for 5 minutes. And over time it becomes easier and easier to get to the next step. The powerful part here is the motivator, so you reward when you succeed but you for the beginning stage you’re often punished if you fail. And we made sure to have an accountability mechanism. I’d like to use GPS in an app phase, but we’re finding out that Facebook chat is incredibly powerful for motivational tools, let me show you in a moment.

[00:28:56] We’ve been testing accountability groups in order to make sure that people stick to what they’re going to say. Using this model, and we’ve found that triangular groups are really powerful 3-4 people in a Facebook chat and always one woman at least is really important, I don’t know why, but it’s super important. Every single one of our all male test groups just disappeared. But as long as there’s this one woman it always keeps the conversation going. My thinking is the reason why is because it’s just like – I have no idea. I don’t understand – what am I supposed to say?

[00:29:35] But we started to use these models and training on some individual test cases and we found that some of our results. So we had one person who started to wake up early and then she started doing some mindfulness meditation. And now she now she reads and now she writes and that was all she started sleeping earlier with that habit model. Daniel right here began writing a thousand words now he writes most of the words are on my website. She started brushing her teeth before as a habit trigger and then started to go to sleep. Going to sleep is really important. Going to sleep early is really important. Turn off your electronic before you go to sleep best it’s really important. We did a measure of Facebook group questionnaire to ask a few people the same question “how are your habits going?” “Who’s sticking with it?” and you can see the results here. David on the right saying I’ve managed to do my micro habit every day and increasing the actions that micro habit created a chain reaction. He was the guy I mentioned yesterday who’s required to simply sit down and watch a workout video. It’s very interesting.

[00:30:44] The results always had this skyrocketing effects and this next slide I’m going to introduce one case – one of my favorites. This is a man names David and he had cancer when he was 25. I mean he got over it and at 28 he had heart attack. And he’s now 32 and it’s like and he knows that out of anybody who should be going to the gym or should be exercising – it’s David. And so I’m just going to show a video this is I think day 7 of the program.

(Playing video…)

[00:32:01] One small change, and his small change, “I will leave my house right after finish my breakfast dishes and lock my door”. That was the change, and it became this. He’s now on day 28, he’s missed one day out of 28 days. And he doesn’t have any penalties involved what so every. He only received rewards. In general, I wanted to just give you guys a little discussion of how habit change works and how it can work and I think that there’s a really potential for all of us to be able to instill the ability to form habits in individuals. The trick is to break it down, make it simple, and help add positive motivational tools as well as increasing the ability for users to do so. Thank you.