The Rudiments of Behavior Change:
Using the Coach Approach to Mount
Lasting Change
AAPM&R Annual Meeting
October 2, 2015
Elizabeth Pegg Frates, MD
Assistant Professor, Part Time
Director of Medical Student Education
Institute of Lifestyle Medicine
Harvard 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
https://commons.wikimedia.org/wiki/File:Birds_eye_view_New_York_City.jpeg
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 of
American 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?
https://upload.wikimedia.org/wikipedia/commons/a/a3/PikiWiki_Israel_8122_decorated_garbage_can_in_eilat.jpg
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
• Treatment
• Cure
• Health
Coach/Guiding
• Self-efficacy
• Sustained Action
• Health
Patient Example
http://i.l.cnn.net/cnn/2008/HEALTH/01/15/ep.emergency.room/art.emergency.cnn.jpg
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…..
https://commons.wikimedia.org/wiki/File:Food_on_shelf.jpg
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?
https://commons.wikimedia.org/wiki/File:Doctor_talking_with_a_patient.jpg
How is your patient going to achieve
lasting change?
https://en.wikipedia.org/wiki/Wrestling
https://en.wikipedia.org/wiki/Waltz_(International_Standard)#/media/File:Бальный_танец.jpg
Literature Search
•
•
•
•
•
•
•
•
Randomized Controlled Studies
Non randomized study
Qualitative Reports
Case Study
Project Demonstration
Descriptive Articles
Commentaries
Medical Education
Study
Number of subjects
Primary Outcomes
Vale et al.
792 patients with cardiac
disease
Chol. drop 21 mg/dL vs.
7 mg mg/ dL (p <.0001)
Whittemore et al.
53 women with diabetes
Better diet selfmanagement, less diabetes
related distress, higher
satisfaction with care
Wolever et al.
56 patients with Type 2
diabetics
Significant reduction in
Hemoglobin A1C among
subjects with baseline > 7
Fischer et al.
191 children with asthma
(parents and children
coached)
Decreased rehospitalization rate
compared to controls
35.6% vs. 59.1% (p<.01)
Oliver et al.
67 cancer pain patients
Improved pain severity
compared to control
(p=.014)
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
https://commons.wikimedia.org/wiki/File:Doctor_and_couple_talking.jpg
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
https://pixabay.com/en/scale-machine-weight-weighing-37772/
Pollack et al. Am J Prev Med 2010;39(4):321-328
The Transtheoretical Model of Change
• James Prochaska,
PhD
– University of R.I.
• Stages
–
–
–
–
–
–
www.uri.edu/research/cprc/Pictures/Prochaska2.jpg
Pre-contemplative
Contemplative
Preparation
Action
Maintenance
Termination
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 precontemplator 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
Hojat et al. Acad Med. 2011;86:359-364
http://medicineworld.org/images/blogs/9-2008/Physician-07840235.jpg
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.
https://commons.wikimedia.org/wiki/File:PeanutButter.jpg
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)
https://en.wikipedia.org/wiki/Jogging
Key: Motivators, rewards, goals
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
https://en.wikipedia.org/wiki/Jeff_Hardy_(swimmer
Key: Motivators, rewards, goals +
variety and mentoring
)
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.
https://en.wikipedia.org/wiki/Mahatma_Gandhi
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.
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.
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•
•
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•
•
•
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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
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•
•
•
•
•
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•
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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. CommunityBased 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):321328
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