The Rudiments of Behavior Change: Using the Coach Approach to Mount

Lasting ChangeAAPM&R Annual Meeting

October 2, 2015Elizabeth Pegg Frates, MD

Assistant Professor, Part Time Director of Medical Student Education

Institute of Lifestyle MedicineHarvard Medical School

Disclosures

• I have my own private practice for lifestyle medicine/ wellness coaching and consulting, called Wellness Synergy.

• I am on the Scientific Advisory Board for Curves.

There are three main goals for this presentation.

• Emphasize the importance of behavior change in medicine

• Discuss the value of the coach approach for motivating behavior change

• Demonstrate the use of the transtheoretical model to help mount lasting change

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http://www.torange.us/Fashion-and-beauty/Clothes/Smelly-sneakers-15437.html

Vitamin C for Therapeutic Lifestyle Counseling (TLC)

• C – Collaboration• C—Connection• C--Compassion

Prevalence for CV Risk Factors in US Adults

NHANES 2005-2006

Healthy lifestyles revolve around the use of our feet and fingers.

• Regular physical activity

• Nutrient dense diet• Smoking cessation• Limiting alcohol • Weight management

http://farm4.static.flickr.com/3187/2673543494_d2aea6f32c.jpg

Dr. David Katz, Director of the Yale University Prevention Research Center

• President Elect ofAmerican College of

Lifestyle Medicine-Empowering people to

take control of their habits

-Yale Preventive Medicine Residents at ILM

-Author of Disease Proof

http://www.nuval.com/images/upload/image/General/katz.JPG

Actual Causes of Death in the US

“Knowledge is Power.”

Sir Francis Bacon

https://en.wikipedia.org/wiki/Francis_Bacon

The mount lasting change pyramid is key.

Adapted from Moore M. and Tschannen-Moran B. Coaching Psychology Manual. Lippincott Williams & Wilkins (2010) p. 43.

Evidence Based Theories Behind Behavior Change Methods

• Motivational Interviewing (Rollnick and Miller)– Following, guiding, directing with the use of

listening, asking, informing to evoke change talk

• Appreciative Inquiry (AI) (David Cooperrider)– Discover, Dream, Design, Deliver, Destiny– Working with strengths, finding the positive

• Transtheoretical Model of Change (Prochaska)– 6 Stages

Evidence Based Theories Behind Behavior Change Methods

• Self-Determination Theory (Ryan and Deci)– Autonomy, connection, competence

• Social Ecological Model– Individual, relationship, community, societal

What will happen to your prescription and words of advice?

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Should you spend your time advising or negotiating?

• Brief negotiation vs. direct advice vs. control– Brief negotiation

significantly better than control

• Increasing minutes of physical activity per week

• Hollisdon, M, Thorogood M, White I, Foster C. Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care. International Journal of Epidemiology, 2002, 31. 808-815

https://commons.wikimedia.org/wiki/File:A_doctor_advising_a_poor_and_wretched_looking_man,

The 4 A’s of Behavior Change Become 5.

• Assess• Advise• Agree• Assist• Arrange

http://my.americanheart.org/professional/ScienceNews/Foundational-Factors-for-Cardiovascular-Diseas

How do you switch from advising to negotiating?

• Expert Approach • Coach Approach

There are important differences in 5 main areas.

• Sharing knowledge• Listening• Asking questions• Approaching

problems• Taking responsibility

Sharing Knowledge

Listening

Asking Questions

Approaching Problems

Taking Responsibility

The End Goal

Expert/Directing Coach/Guiding• Treatment

• Cure

• Health

• Self-efficacy

• Sustained Action

• Health

Patient Example

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Expert Approach

• ER• CHF exacerbation can

not breath• Acute medical

intervention• Stabilization• Prescription• Education

http://www.aginghomehealthcare.com/images/oxygen_user.gif

The soup was a big part of the problem.

https://commons.wikimedia.org/wiki/File:Bowl_of_chicken_soup.jpg

Back again….

http://www.aginghomehealthcare.com/images/oxygen_user.gif

Little did I know…..

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Coach approach

• Would you like to hear about CHF and what causes exacerbations?

• What do you eat that is loaded with salt?

• What does your cupboard look like?

• How do you think you can reduce your intake of salt?

• What do you plan on doing with the soups and canned foods in your cupboard?

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How is your patient going to achieve lasting change?

https://en.wikipedia.org/wiki/Wrestling

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Literature Search

• Randomized Controlled Studies

• Non randomized study

• Qualitative Reports

• Case Study

• Project Demonstration

• Descriptive Articles

• Commentaries

• Medical Education

Conclusions

• Health coaching led to improved health outcomes in:– Cardiovascular disease– Diabetes– Physical activity– Cancer pain– Asthma

Lessons learned from these seedling studies

Limitations• Small sample sizes• Lack of consistency with

coaching specifics• Lack of long term follow up(3 years, 5 years)

Common Threads• 1:1 relationship• Collaboration/negotiation• Goal Setting• Accountability

Motivational Interviewing and Stroke Patients

• Stroke 2011• 411 patients from

stroke unit• Usual care vs

Intervention• 4 weekly sessions of

MI• MI improves patients’

mood and reduces mortality at 12 months

Watkins et al. Stroke. 2011;42:1956-1961

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Motivational Interviewing and Weight Loss

• 40 Primary care MDs• 461 over-weight or obese

patients• Measure MI consistent

behavior (collaborating, reflective listening) vs MI inconsistent behavior

• Patients of MI consistent MDs had weight loss vs patients of MI inconsistent MDs who had weight gain or maintenance

Pollack et al. Am J Prev Med 2010;39(4):321-328

https://pixabay.com/en/scale-machine-weight-weighing-37772/

The Transtheoretical Model of Change

• James Prochaska, PhD– University of R.I.

• Stages– Pre-contemplative– Contemplative– Preparation– Action– Maintenance– Termination

www.uri.edu/research/cprc/Pictures/Prochaska2.jpg

Transtheoretical Model of Change

Wellcoaches® training manual, 2008

The Pre-contemplators

• Ask if the patient would like to hear about or read about the benefits of exercise

• I understand that you are not ready to change, but please know that when you are ready, I will be here to help.

• May I tell you something? I think that it is important for your health….

Key: Empathy

What do you do with the pre-contemplator who smokes?

http://news.bbc.co.uk/media/images/38209000/jpg/_38209970_smoking300.jpg

Physicians’ Empathy Influences Clinical Outcomes

• 891 Diabetic patients• 29 Family physicians• Hgb-A1c, LDL-C• Jefferson Scale of

Empathy• High empathy scores for

MD correlated with good control of Hgb A1c and LDL-C in patients

http://medicineworld.org/images/blogs/9-2008/Physician-07840235.jpgHojat et al. Acad Med. 2011;86:359-364

Contemplators

• Ask the patient to consider what things would be like if they did not begin an exercise program

• Ask the patient to consider what things would be like if they did begin an exercise program

• Ask the patient how important exercise is to them

• Work with the patient to identify a powerful, intrinsic motivator

Key: Vision and Motivators

The People in Preparation

• Ask the patient how confident she is in her ability to perform exercise

• Ask how the patient can increase her confidence in her ability to perform exercise

• Develop a SMART exercise goal for the patient

• Identify possible obstacles and brainstorm strategies around them

Key: A solid plan with SMART goals and identify potential problems

Identifying potential problems is helpful.

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The People in Action

• Review physical activity guidelines

• Write an exercise prescription

• Follow up on the patient’s progress

• Congratulate patients on their exercise

• Encourage patients to meet the guidelines

• Ask about walks or runs for non-profits (AHA)

Key: Motivators, rewards, goals

https://en.wikipedia.org/wiki/Jogging

The People in Maintenance• Discuss the patients

exercise routine• Consider

recommending cross training

• Review health benefits with patient

• Congratulate patient• Write an exercise

prescription • Recommend becoming

a mentor to family or friends

Key: Motivators, rewards, goals +variety and mentoring

https://en.wikipedia.org/wiki/Jeff_Hardy_(swimmer)

What stage of change are you in?

Disclosure

Can physicians who disclose their healthy personal behaviors to patients improve their credibility and their ability to motivate?– Videos of physicians

counseling patients– ½ minute of self disclosure

re: dietary and exercise practices

– Bike helmet and apple on desk

Frank E, Breyan J, Elon L. Physician Disclosure of Healthy Personal Behaviors Improves Credibility and Ability to Motivate. Archives of Family Medicine. 2000;9:287-290.

Disclosure Study Continued

Subjects-– Patients in the waiting

room at an internal medicine clinic at Emory

Results-– Viewers of the physician

disclosure video rated the physician as more believable and motivating regarding exercise and diet.

Frank E, Breyan J, Elon L. Physician Disclosure of Healthy Personal Behaviors Improves Credibility and Ability to Motivate. Archives of Family Medicine. 2000;9:287-290.

https://en.wikipedia.org/wiki/Mahatma_Gandhi

Exercise counseling and physician’s exercise habits

• Is there a relationship between the personal exercise habits of physicians and their practices in counseling on exercise?

• YES• Physicians who exercise

counsel on exercise.Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and counseling practices of primary care physicians: a national survey. Clinical Journal of Sports Medicine. 2000;10(1):40-8.

How worn out are your sneakers?

Lifestyle and Death

“Be the change you want to see in the world.”

Mahatma Gandhi

https://en.wikipedia.org/wiki/Mahatma_Gandhi

Summary

• Counseling on lifestyle is critical for our population’s health and wellness.

• Using the Coach approach for behavior modification will help health care providers empower patients to mount lasting change.

• Recognizing what stage of change a patient is in for a given behavior will help identify the most appropriate intervention for that patient at that time.

Finally--Here’s to more dancing!

References• Conn VS, Hafdahl AR, Mehr DR. Interventions to Increase Physical Activity Among Healthy Adults:

Meta Analysis of Outcomes. American Journal of Public Health 2011; 101(4): 751-758.

• Debar LL, Ritenbaugh C, Aickin M, Orwoll E, Elliot D, Dickerson J, Vuckovic N, Stevens VJ, Moe E, Irving LM. A Health Plan-Based Lifestyle Intervention Increases Bone Mineral Density in Adolescent Girls. Archives of Pediatric Adolescent Medicine. 2006;160:1269-1276.

• • Dowd T, Kolcaba K, Steiner R. The Addition of Coaching to Cognitive Strategies: Interventions for

Persons With Compromised Urinary Bladder Syndrome. Journal of Wound Ostomy Continence Nursing 2003;30:90-99.

• • Edelman D, Oddone EZ, Liebowitz RS, Yancy WS, Olsen MK, Jeffreys AS, Moon SD, Harris AC, Smith

LL, Quillian-Wolever RE, Gaudet TW. A Multidimensional Integrative Medicine Intervention to Improve Cardiovascular Risk. Journal of General Internal Medicine 2006; 21: 728-734.

• • Holland SK, Greenberg J, Tidwell L, Malone J, Mullan J, Newcomer R. Community-Based Health

Coaching, Exercise, and Health Service Utilization. Journal of Aging and Health 2005; 17: 697-716.• • Oliver JW, Kravitz RL, Kaplan SH, Meyers FJ. Individualized Patient Education and Coaching to

Improve Pain Control Among Cancer Outpatients. Journal of Clinical Oncology 2001;19:2206-2212.

References• Sacco W, Morrison AD, Malone JI. A Brief, Regular, Proactive Telephone

“Coaching” Intervention for Diabetes. Rationale, Description, and Preliminary Results. Journal of Diabetes and Its Complications 2002; 18: 113-118.

• • Tidwell L, Holland SK, Greenberg J, Malone J, Mullan J, Newcomer R. Community-

Based Nurse Health Coaching and its Effect on Fitness Participation. Lippincott’s Case Management 2004;9(6):267-279.

• • Tucker LA, Cook AJ, Nokes NR, Adams TB. Telephone-Based Diet and Exercise

Coaching and a Weight-loss Supplement Result in Weight and Fat Loss in 120 Men and Women. The Science of Health Promotion 2008;23(2):121-129.

• • Vale MJ, Jelinek MV, Best JD, Dart AM, Grigg LE, Hare DL, Ho BP, Newman RW,

McNeil JJ. Coaching Patients On Achieving Cardiovascular Health (COACH). Archives of Internal Medicine 2003;163:2775-2783.

• • Whittemore R, Melkus GD, Sullivan A, Grey M. A Nurse-Coaching Intervention for

Women with Type 2 Diabetes. The Diabetes Educator 2004; 30 (5): 795-804.

References

• Hojat et al. Acad Med. 2011;86:359-364• Watkins et al. Stroke. 2011;42:1956-1961• Pollack et al. Am J Prev Med 2010;39(4):321-

328

Books

• Co-Active Coaching, by Laura Whitworth, Karen Kimsley-House, Henry Kimsley-House, and Phillip Sandahl

• Wellness Coaching for Lasting Lifestyle Change, by Michael Arloski, PhD

• Motivational Interviewing in Health Care, by Stephen Rollnick and William Miller.

• Changing For Good by James Prochaska et al.• Coaching Psychology Manual by Margaret Moore and

Bob Tschannen-Moran