Health Coaching As a Lifestyle Medicine Process in Primary Care

FOCUS | PROFESSIONAL

Health coaching as a lifestyle medicine process in primary care

Shivaun Conn, Sharon Curtain ONE IN TWO AUSTRALIANS has at least one What is health coaching? chronic disease,1 with preventable lifestyle factors (eg poor diet and Health coaching is the practice of health Background Lifestyle medicine is a relatively new nutrition, physical inactivity, smoking education and health promotion within a approach to managing lifestyle-related and alcohol overconsumption) known coaching context to enhance the well-being disease. Health coaching is an integral to account for at least 70% of the of individuals and to facilitate the part of lifestyle medicine that can be total healthcare burden.2 General achievement of their health-related goals.4 used to facilitate behaviour change in practitioners (GPs), as the first and key lifestyle areas. most consistent point of contact with Health coaching incorporates evidence- Objective patients, play a vital part in prevention, based health behaviour change The aim of this article is to familiarise early intervention and management of interventions and techniques from general practitioners with the emerging lifestyle-related disease. Traditionally, behavioural medicine research literature, discipline of health coaching and show the health professional’s role in assisting positive psychology, health and coaching its effectiveness in primary care. patients to change their unhealthy habits psychology, and athletic and performance Discussion and adopt healthier lifelong behaviours coaching. It can be used in health The recognition that the traditional has been to educate, persuade and promotion, prevention, early intervention, healthcare approach is not fully effective prescribe actions to reduce ill health. treatment and management of chronic at supporting health behaviour change The World Health Organization conditions such as in lifestyle medicine. in an era of chronic diseases has led to states that ‘simply giving information Using the Transtheoretical Model,5 the emergence and growth of a new to patients is unlikely to change approach to the prevention and health coaching identifies the patient’s treatment of lifestyle-related diseases – behaviour; health care providers must stage of change, guiding clients to take the practice of health coaching. understand the psychological principles stage-appropriate actions to increase that underlie self-management confidence or importance and therefore training and comprehend that moving clients towards readiness. motivating patients requires more Health coaching supports patients to than imparting brief information build self-determination – the process to the patient’.3 Long-term health by which a person controls their own life behaviour change requires a different – and self-efficacy – the belief that one approach to acute disease management. has the capability to initiate and sustain a To achieve sustainable health desired behaviour. Motivation is generated behaviours and outcomes, patients by supporting patients to evoke their need to be supported in behaviour own compelling reasons for change and change techniques that promote articulate a clear vision of their health goals. self-efficacy, self-determination and Deci and Ryan’s self-determination theory self-responsibility. of motivation6 is applied through fostering

autonomy, competence and relatedness, the chance of patients implementing and confident they feel about changing their and linking clients to intrinsic motivators. maintaining health behaviour change. behaviour. Using rating questions is an Once the patient is ready to change, The benefits of health coaching are not effective way to gauge confidence and they are encouraged to have a curious and only limited to patient outcomes, but also importance. flexible mindset of trial and correction, result in: Ask your patient, ‘Given everything learning, growth and compassion as • enhanced practitioner job satisfaction going on in your life, how important is they are guided towards their goals • enhanced patient satisfaction with it to you to lose weight?’ The patient is while connecting to their values and services and outcomes asked to respond on a scale of 0–10, vision. The health coaching process • improved consultation efficiency and with 0 meaning ‘not important’ and 10 encourages self-reflection, self-awareness, effectiveness meaning ‘very important’. If your patient self-regulation and positivity. Patients are • decreased reliance on the medical gives you a low score, such as 4, they supported to build confidence, focusing on system by patients who learn are not ready to change. Attempting to strengths as they learn from past failures self-management skills educate or persuade them, such as by and successes to overcome barriers and • enhanced multidisciplinary professional providing advice about how to lose weight increase facilitators for change. Behaviour collaboration. or information about consequences, is an change is more likely to be maintained ineffective strategy. when goals are self-determined, as patients are both motivated to take Integrating health coaching Find out the reasons they want action and are invested in the result. into practice to change Integrating health coaching into practice Ask, ‘Why did you choose 4 and not 2?’ requires an understanding of a patient’s (ie why not a lower number?). The patient Evidence to support health coaching readiness to change and of the support will describe why change is important Systematic reviews of health coaching in patients need to change (Figure 1). This to them, and you can reflect these comparison to traditional care (Table 1) can be achieved by asking patient-centred motivational hooks back to the patient have found health coaching to: questions. to strengthen their decision to change. • significantly improve patients’ Patient-centred questions can help For example, they might say, ‘I chose a physiological, behavioural, ascertain the importance of change to 4 because I know that losing weight can psychological and social outcomes7 a patient, build confidence, generate help my diabetes’. That allows you to ask • significantly improve one or more of insights and momentum, and ensure goals them to tell you more about how it would the behaviours of nutrition, physical are determined by the patient. benefit them, and they will begin to talk activity, weight management or Consider an overweight patient with themselves into change. medication adherence8 pre-diabetes. Weight loss has been identified • improve glycaemic control and reduce as an important goal for this patient. Find out about the barriers glycated haemoglobin for patients with Asking, ‘Why did you choose a 4 and type 2 diabetes9,10 First, assess readiness to change not an 8?’ can reveal the barriers and • improve medication adherence11 Readiness is influenced by how important reasons why change is not a priority. The • assist with weight loss and increase the behaviour is to the patient and how patient may have low confidence due to the levels of motivation and personal satisfaction12 • be an effective strategy to promote Table 1. Comparisons between a traditional clinical approach and coaching reductions in energy intake, body approach in primary care weight and body mass index13,14 Traditional approach Coaching approach • improve physical activity.15 These findings are in addition to a Practitioner is the health expert Patient is respected as the expert in their number of studies that show the efficacy own life of motivational interviewing in smoking Practitioner provides advice and solutions Practitioner offers information on the basis of cessation, alcohol reduction and other what the patient identifies as needed 16 behaviour change. Practitioner decides the health priority Patient chooses the health goals, strategies and targets

Can primary care benefit from Practitioner focus is on why the patient has Practitioner looks for positives and not made the required changes affirms client the practice of health coaching? Incorporation of the health coaching Practitioner assumes client is ready Practitioner identifies client readiness and framework into primary care can improve to change offers strategies to increase confidence and importance. patient outcomes. Health coaching increases

678 | AJGP VOL. 48, NO. 10, OCTOBER 2019 © The Royal Australian College of General Practitioners 2019 HEALTH COACHING AS A LIFESTYLE MEDICINE PROCESS IN PRIMARY CARE FOCUS | PROFESSIONAL

failed attempts to lose weight in the past, effectiveness and efficiency of an Australian diploma due to launch at knowledge gaps or competing priorities. consultations. the beginning of 2020. The practitioner can ask: Incorporating health coaching into primary The level of health coaching training • ‘What information would you like care can be done in a number of ways: needed by an individual will depend on to know?’ • GPs can incorporate health coaching pre-existing training, skills, knowledge • ‘What skills and support do you need?’ into their consultations and experience. Practising health • ‘If you were going to change, how would • GPs can refer patients to practice nurses coaching skills on an ongoing basis and you do it?’ and/or allied health professionals who participating in continuing professional • ‘What is already working and/or what are trained as health coaches development is also essential. have you considered changing?’ • GPs may refer to a qualified/accredited The practitioner can then provide missing health coach who may consult within information, challenge beliefs or explore or outside a practice via face-to-face Summary what is possible. delivery, telephone or Zoom/Skype. Prevention and management of chronic health conditions is an area of growing Patient-centred goal setting Health coaching training demand. Integrating health coaching into Behaviour change is more likely The increasing popularity of health primary care can significantly improve to be maintained when goals are coaching has resulted in the emergence patients’ physiological, behavioural, self-determined. The practitioner can ask: of various training options. Choices psychological and social outcomes, as well • ‘What are you willing to try?’ range from training in individual as lead to higher rates of satisfaction for • ‘What feels achievable?’ behaviour change disciplines – such as both patient and clinician. • ‘What do you want to achieve?’ cognitive behavioural therapy, positivity While these strategies are just the tip psychology and motivational interviewing of the behaviour-change iceberg, they – to short courses in health coaching, Key points can begin to help patients build the a number of online-based courses and • Chronic diseases call for different self-determination and self-efficacy that postgraduate qualifications in coaching approaches to management at the leads to sustainable behaviour change. psychology. The need for credible clinical level. training qualifications that focus on • Health coaching is a relatively new Modes of delivery Australian guidelines and standards has approach to modifying behaviours Health coaching may be integrated resulted in the options for health coach associated with the development of into primary care practice to improve training expanding from short courses to ill health.

• Behaviour change theories • Positive psychology • Appreciative inquiry • Stages of change theory Health psychology and behaviour change • Cognitive behaviour therapy principles, models and • Motivational interviewing techniques • Mindful awareness

• Goal setting • Health knowledge • Communication • Relationship-building skills Skills and techniques Experience, • Effective questioning • Empathy from performance knowledge and skills • Overcoming setbacks • Listening skills of health practitioner and development • Awareness and • Problem-solving skills coaching self-responsibility • Coaching models

Figure 1. A number of skills and models can be integrated into general practice to adopt a health coaching approach.

Health coaching uses health behaviour Sharon Curtain BSc, MDiet, Dietitian, Nutritionist, 9. Wayne N, Perez DF, Kaplan DM, Ritvo P. Health • Health Coach, Director, Campaign Healthy, Vic; author coaching reduces HbA1c in type 2 diabetic change theories to build motivation and co-creator, Diploma of Health Coaching, Vic patients from a lower-socioeconomic status and promote self-determination and Competing interests: S Conn is a Board Member community: A randomized trial. J Med Internet Res 2015;17(10):e244. doi: 10.2196/jmir.4871. self-efficacy. of the Australasian Society of Lifestyle Medicine (voluntary unpaid position). S Curtain is the co-author 10. Thom DH, Ghorob A, Hessler D, De Vore D, • Health coaching acknowledges the and co-creator of the Victoria University Polytechnic’s Chen E, Bodenheimer TA. Impact of peer Health Coaching Diploma course. health coaching on glycemic control in low- patient’s stage of change, and increases income patients with diabetes: A randomized Funding: None. importance and confidence to increase controlled trial. Ann Fam Med 2013;11(12):137–44. Provenance and peer review: Commissioned, readiness to change. doi: 10.1370/afm.1443. externally peer reviewed. 11. Thom DH, Willard-Grace R, Hessler D, et al. The impact of health coaching on medication References adherence in patients with poorly controlled diabetes, hypertension, and/or hyperlipidemia: 1. Australian Institute of Health and Welfare. Recommended resources A randomized control trial. J Am Board Australia’s health 2018. Cat. no. AUS 221. Fam Med 2015;28(1):38–45. doi: 10.3122/ • Miller WR, Rollnick S. Applications Canberra: AIHW, 2018. jabfm.2015.01.140317. of motivational interviewing. 2. Australian Institute of Health and Welfare. 12. Muñoz Obino KF, Aguiar Pereira C, Australia’s health 2016. Cat. no. AUS 199. Motivational interviewing: Helping Caron-Lienert RS. Coaching and barriers to Canberra: AIHW, 2016. people change 3rd edn. New York, NY: weight loss: An integrative review. Diabetes 3. World Health Organization. Adherence to Metab Syndr Obes 201710:1–11. doi: 10.2147/ Guilford Press, 2013. long-term therapies: Evidence for action. DMSO.S113874. • AMA STEPS forward – Health coaching: Geneva: WHO, 2003. 13. Tucker LA, Cook AJ, Nokes NR, Adams TB. 4. Palmer S, Tubbs I, Whybrow W. Health coaching Telephone-based diet and exercise coaching and Help patients take charge of their health* to facilitate the promotion of healthy behaviour a weight-loss supplement result in weight and fat • BMJ Learning – Motivational and achievement of health-related goals. loss in 120 men and women. Am J Health Promot interviewing in brief consultations* Int J Health Promot Educ 2003;41(3):91–93. 2008;23(2):121–29. doi: 10.4278/ajhp.07051646. doi: 10.1080/14635240.2003.10806231. 14. Shahnazari M, Ceresa C, Foley S, Fong A, Zidaru E, • The ineffective physician: 5. Prochaska JO, DiClemente CC. The Moody S. Nutrition-focused wellness coaching Non-motivational approach* transtheoretical approach: Towards a systematic promotes a reduction in body weight in overweight eclectic framework. Homewood, IL: Dow Jones US veterans. J Acad Nutr Diet 2013;113(7):928–35. • The effective physician: Motivational Irwin, 1984. doi: 10.1016/j.jand.2013.04.001. interviewing demonstration* 6. Deci EL, Ryan RM. Intrinsic motivation and self- 15. Barrett S, Begg S, O’Halloran P, Kingsley M. determination in human behavior. New York, NY: Integrated motivational interviewing and cognitive Plenum, 1985. behaviour therapy for lifestyle mediators of *Links to these resources are available online. 7. Kivelä K, Elo S, Kyngäs H, Kääriäinen M. The overweight and obesity in community-dwelling adults: A systematic review and meta-analyses. effects of health coaching on adult patients with BMC Public Health 2018;18(1):1160. doi: 10.1186/ chronic diseases: A systematic review. Patient s12889-018-6062-9. Authors Educ Couns 2014;97(2):147–57. doi: 10.1016/j. pec.2014.07.026. 16. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Shivaun Conn BSc (Nutrition) (Hons), Accredited Motivational interviewing: a systematic 8. Olsen JM, Nesbitt BJ. Health coaching to Practising Dietitian (APD), Accredited Nutritionist review and meta-analysis. Br J Gen Pract improve healthy lifestyle behaviors: An (AN), Health Coach, Director, Discovery Health 2005;55(513):305–12. Coaching, NSW; Vice President, Australasian integrative review. Am J Health Promot Society of Lifestyle Medicine, Vic. 2010;25(1):e1–e12. doi: 10.4278/ajhp.090313- [email protected] LIT-101. correspondence [email protected]