OWCH O nline W eight management C ounseling program for H ealthcare providers

1. OWCHOnline Weight management Counseling program for Healthcare providers Module 4: The Pressure System Model of Lifestyle Counseling in Primary Care Yale-Griffin Prevention Research Center www.yalegriffinprc.org

2. Module 4 • Module 1 described the obesity epidemic and stressed the importance of lifestyle counseling. • Module 2 provided a basic understanding of health-promoting diet and physical activity recommendations in clinical practice. • Module 3 introduced key behavioral theories and motivational techniques to support patient change. • This module provides simple and practical steps to integrate lifestyle counseling into the primary care setting using the Pressure System Model (PSM). • Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001 Jan;32(1):66-72

3. WHY? Primary Care Lifestyle Intervention • National advisory groups and major medical organizations consistently recommend therapeutic lifestyle changes as the initial and preferred means of modifying chronic disease risk factors such as hypertension, hyperlipidemia, low HDL and obesity. • Reduction of risk factors through lifestyle intervention may reduce the incidence of premature mortality and of the leading chronic diseases. • Aronne L, Havas S, et al. The Obesity Epidemic: Strategies in Reducing Cardiometabolic Risk. Am J Med. 2009:122:4A • www.nhlbi.nih.gov/guidelines • ADA 67th Scientific Sessions, June 2007 • Alberti et al. Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the Association for the Study of Obesity Heart Federation; International Atherosclerosis Society; and International National Heart, Lung, and Blood Institute; American Heart Association; World International Diabetes Federation Task Force on Epidemiology and Prevention;. Circulation. 2009:120 (16): 1640. • NCEP - http://www.nhlbi.nih.gov/about/ncep/index.htm • JNC 7 Guidelines - http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm

4. AAFP Recommendation Family physicians should counsel all patients on nutrition, physical activity, and behavioral strategies to prevent inappropriate weight gain and obesity. Family physicians should screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. (Intense counseling involves more than one session per month for at least 3 months). Am Fam Physician. Metabolic Syndrome: Time for Action; 2005 www.aafp.org/online/en/home/policy/policies/o/obesityandoverweight.html

5. Purpose of PSM The Pressure System Model (PSM) was developed to distill leading behavioral theories and make them work in the primary care setting for lifestyle counseling. The 3 objectives of this program are to: • Make lifestyle counseling fit comfortably into the context of primary care. • Make lifestyle counseling and behavior change incremental, and thus manageable for patient and provider alike. • Direct counseling toward the domain where it is most likely to make a positive difference. Each of these will now be addressed in greater detail. • Katz DL, Shuval K, Comerford BP, Faridi Z, Njike VY. Impact of an educational intervention on internal medicine residents' physical activity counselling: the Pressure System Model. J Eval Clin Pract. 2008 Apr;14(2):294-9 • Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001 Jan;32(1):66-72.

6. Making Lifestyle Counseling Fit Comfortably into Primary Care The PSM offers a counseling system that respects the time constraints of the primary care setting. A simple two-question algorithm identifies the focus for a brief, targeted counseling session which may be conducted in less than two minutes per encounter.

7. Making Lifestyle Counseling and Behavior Change Incremental Behavior change is approached incrementally. An ongoing dialogue between you and your patient during brief multi-contact counseling interventions allows for adjustments with modifications over time. Acceptance of the incremental nature of change by you and your patient is essential to avoid frustration and resultant failure.

8. Directing Counseling Where It Will Make a Positive Difference Nutrition and exercise counseling is performed with consideration for the motivational and/or resistance forces that govern behavioral patterns. Your approach to counseling is individualized based on your patient’s stage or readiness for change. The two-question algorithm determines your patient’s current lifestyle practice and their willingness to change. It places your patient in one of five categories which identify the counseling focus: raising motivation, lowering resistance, or some of both.

9. PSM Validation Research The PSM research model was tested in a randomized controlled trial to evaluate the promotion of physical activity. Seven Yale University-affiliated internal medicine programs were randomly assigned to a PSM-based behavioral counseling program (intervention) or standard curriculum (control). PSM training consisted of skill building in behavioral counseling, didactic sessions augmented by role-play, use of the algorithm to identify counseling needs of patients and a list of commonly encountered barriers to physical activities with strategies to address them. Katz DL, et al. Impact of an educational intervention on internal medicine residents' physical activity counseling: the Pressure System Model. J Eval Clin Prac. 2008 Apr;14(2):294-9.

10. PSM Research Results demonstrated efficacy in the primary care setting • 65 internal medicine residents trained in PSM; 35 controls received standard residency training. • 195 patients were in the PSM group; 121 in control group • Results: Patients improved physical activity (PA) from baseline after 6 and 12 months of intervention (p = 0.0376 and p = 0.046). No improvement was observed in the control group (p = 0.7224 and p = 0.5160). • Medical residents in the intervention group increased PA counseling 1.5 times more than at baseline. Katz DL, et al. Impact of an educational intervention on internal medicine residents' physical activity counseling: the Pressure System Model. J Eval Clin Prac. 2008 Apr;14(2):294-9.

11. Origins of the PSM The Pressure System Model derives its name from meteorology, where differences in barometric pressure determine the direction in which the wind blows. Just as wind blows from a high pressure area to a low pressure area, so does behavior move in accord with the greater force: motivation vs. resistance. This is displayed schematically in the next slide.

12. Motivation vs. Resistance Change is attempted when motivation exceeds perceived resistance. Maintenance of status quo Change Obstacles/ Resistance Motivation

13. Here are the steps to implement the PSM with your patients: Your patient’s weight, waist circumference, waist-hip ratio and BMI, as well as lab results, will provide the introduction and rationale for addressing lifestyle change. You then Apply the Algorithm: 2 questions are posed to place your patient into one of the five categories, each of which determines the appropriate emphasis of counseling: raising motivation or overcoming resistance or some of both. The next 3 slides will review the 2 questions and the algorithm to identify the category.

14. 1st Step: Two Questions • Question 1: Are you currently (eating a healthful diet / getting regular physical activity, etc.)? If no: • Question 2: Are you ready and willing to begin (eating a healthful diet / getting regular physical activity)?

15. ALGORITHM to determine PSM CATEGORY QUESTION 1: Are you currently (eating a healthful diet / getting regular physical activity, etc.)? YES NO QUESTION 2: Are you ready and willing to begin (eating a healthful diet / getting regular physical activity)? CATEGORY 1 CONDITIONAL YES YES NO Recent Attempt / Relapse Prior Attempts / Given Up CATEGORY 4 CATEGORY 5 CATEGORY 2 CATEGORY 3

16. PSM Algorithm- Patient Questions • Question 1: Are you currently (eating a healthful diet / getting regular physical activity, etc.)? • YES: Category 1: Maintenance • NO: Go to Question 2 • Question 2: Are you ready and willing to begin (eating a healthful diet / getting regular physical activity)? • MAYBE: Category 2/3:Tried: relapsed or burned-out • YES: Category 4: Ready to change • NO: Category 5: Unprepared for change

17. Category Counseling Focus: the ‘M/O’ • Category 1 = Maintenance • Category 2/3 = Relapse / Burn-out • Category 4 = Motivated, but anticipates barriers • Category 5 = Low Motivation Focus on “M” motivation Focus on “O” obstacles

18. Counseling FocusMotivation vs. Resistance • The conventional approach to behavior change counseling has focused primarily on raising motivation, i.e., pointing out risks of a behavior and stressing benefits of changing the behavior. • This ‘advice-giving’ is a relatively ineffective means of raising motivation. And, even if the desire for change, or motivation, is high, change cannot occur if resistance or obstacles are higher still. • Failure to change diet or improve physical activity is often a consequence of excessive resistance rather than inadequate motivation. Thus, impediments to sustainable lifestyle change must be identified and strategies to overcome them must be explored and implemented.

19. Counseling FocusMotivation vs. Resistance • The PSM separates two fundamental goals of behavioral counseling: raising motivation and overcoming resistance. Each of the 5 categories determined by the PSM algorithm has specific implications for counseling. • Patients for whom motivation is relevant should receive motivational interviewing. The objective here is to assist your patient to work through ambivalence about changing behavior. A simple tool to expedite a patient’s progress through his/her ambivalence is a decision balance. • When resistance is greater than motivation, it is necessary to work collaboratively with your patient to identify the impediments to change and identify solutions. • The following slides address counseling approaches to raise motivation and overcome resistance.

20. Motivation • Motivation is fundamental to change. • Motivationmust exceed resistancefor behavior change to occur. • Eliciting patient’s own positive reasons and arguments for change will maximize motivation. • Belief in the importance of the condition to be avoided, in personal risk, and in the utility of change, are components of motivation. • An accepting, empowering climate helps to increase motivation. • Motivational Interviewing is a patient-practitioner communication that is designed to resolve ambivalence and promote motivation for behavior change.

21. Principles of Motivational Interviewing (MI) • Express empathy: Respectful listening; attitude of acceptance; non-judgmental: acknowledging patient’s ambivalence as a normal part of change; legitimizes patient’s feelings. • Develop discrepancy: Highlighting discrepancy between behavior and their important goals. The patient should state the arguments for making a change. Decisional Balance can help. • Avoid Argumentation: Conveys that the patient is in charge and builds the therapeutic alliance. Argumentation leads to defensiveness. • Roll with resistance: Resistance is a signal to respond differently. Acknowledge that change may take time. • Support self-efficacy: Offer encouragement and support in the patient’s belief to be able to change. Build on past success. The patient is responsible for choosing and making the changes. Miller W, Rollnick S. Motivational Interviewing: Preparing people for change. New York: Guilford. Press, 2002

22. MI uses the OARS method of communication. Here are some examples: • Open-ended questions: • How do you see exercise fitting into your daily schedule? • Why is a change important to you? • Tell me about the physical activity you enjoy. • Affirmations: • Beginning something new is difficult. • That is great that you were able to exercise most days. • Reflective listening: • Making this change sounds important to you. • You are worried about your weight. • Summaries: • You expressed several activities you would like to do more but have difficulty fitting them into your schedule. Is this how you feel?

23. Decision Balance • This is a simple tool to help your patient assess his/her sources of ambivalence. These may change over time, so it is helpful to use this tool intermittently, especially when progress has slowed. • The decision balance table may be completed during an office visit or between visits. • The apparent gaps in the balance provide opportunities for you to give advice or information that may swing the balance in favor of making positive behavior changes. • This tool also helps you to identify when change efforts are likely to be premature and potentially unsuccessful.

24. Decision Balance Weighing the pros and cons (costs & benefits) of change • Patients “talk” themselves into making changes. Helps identify true issues and find motivation. • Clinicians can explore and support in a collaborative effort. • Pros: Benefits of changing • Cons : Costs of changing Costs of change Benefits of change • Miller W, Rollnick S. Motivational Interviewing: Preparing people for change. New York: Guilford. Press, 2002 • Glanz, K., Lewis, F.M., & Rimer, B.K. , 2000. (3rd Eds.) Health Behavior and Health Education:Theory Research and Practice. San Francisco, CA: Jossey-Bass Publishers.

25. Decision Balance Table

26. An Example of a Physical Activity Decision Balance

27. Resistance • Obstacles or resistance must be acknowledged in order to change a behavior. • You can assist patients to convert obstacles into challenges or opportunities by • Identifying universal barriers • Identifying patient-specific barriers • Collaboratively addressing solutions/alternatives • Impediment Profiling: Research with smokers to identify patient specific barriers and solutions concluded that individualizing interventions based on personal barriers can enhance success with behavior change. O'Connell M, Yanchou-Njike Vkatz D, et al. Far Impediment profiling for smoking cessation: application in the worksite. Am J Health Promot. 2006 Nov-Dec;21(2):97

28. Impediment Profiling Identifying the impediments to changing a diet or implementing a physical activity program can help to shift the balance between motivation and difficulty. Once you and your patient recognize the obstacles to the behavior change, you can collaborate to find strategies to overcome them. Examples of impediments to behavior change: a schedule that does not accommodate exercise, lack of cooking or food shopping knowledge, household smoker, etc. • O'Connell M, Comerford BP, Wall HK, Yanchou-Njike V, Faridi Z, Katz DL. Impediment profiling for smoking cessation: application in the worksite. Am J Health Promot. 2006 Nov-Dec;21(2):97-100. • Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC. Impediment profiling for smoking cessation. Preliminary experience. Behav Modif. 2003 Sep;27(4):524-37. • O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan W, Katz DL. Impediment profiling for smoking cessation: results of a pilot study. Am J Health Promot. 2003 May-Jun;17(5):300-3. • Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001 Jan;32(1):66-72.

29. Category-Specific Counseling You have identified the need for lifestyle counseling and you have asked the 2 questions to determine your patient’s category which directs your counseling focus: maximizing motivation or overcoming obstacles, or some of both. The following slides provide category specific information and examples of counseling.

30. Patient Category 1 Patients in this category are currently in the action phase. Behavior change is in the process of being modified or maintained. Motivation may wane as new and unexpected obstacles are encountered. The patient needs encouragement to sustain motivation. Identified difficulties should be discussed to develop tailored strategies. Counseling is focused on how and why to maintain positive changes.

31. Patient Category 1 Goal: Maintain Motivation Anticipate potential obstacles Counseling Emphasis: Motivation Emphasize success; praise, encouragement Anticipate real or potential obstacles Reinforce self-efficacy Offer opportunity for follow-up Key Questions: • List reasons for your success • Which strategies were successful for you? • Do you anticipate difficulties in maintaining these behaviors? • Do you wish to change any part of your action plan?

32. Patient Category 2 • Patients in this category were motivated in the past to attempt change but had a relapse and are not currently practicing the healthy lifestyle change. • A relapse generally suggests that an obstacle was encountered. The obstacle (s) resulted in a temporary lapse as the difficulty in sustaining change exceeded motivation. • Troubleshooting the obstacle of the previous effort, as well as identifying and planning for other potential obstacles, should be a focus of the counseling effort. Counseling must also re-establish self-esteem and motivation.

33. Patient Category 2 Goals:Overcome Resistance / Obstacles • Re-establish self-efficacy (belief in one’s ability to achieve a particular goal) and re-establish and motivation. Counseling Emphasis: Resistance • Foster forgiveness; Alleviate feelings of failure • Lapses and fall-backs must be accepted as a normal element of behavior change. • Identify Obstacles & strategies to overcome them • Restore confidence and encourage a new attempt. Key Questions: • Tell me about what helped to motivate you when you tried previously? • How might we revise your action plan to help move forward again? • What difficulties occurred when you previously tried? • Do you anticipate the same obstacles now?

34. Patient Category 3 Patients in this category often have a history of repeated, unsuccessful efforts. Multiple failed attempts at behavior change may result in a feeling of ‘burn-out’ producing feelings of remorse and low self-esteem. This patient needs help to overcome the sequelae of prior failed attempts. Counseling efforts should help patients in this group to understand that failure is not their fault, but a result of encountering barriers. Assistance to identify the barriers and collaborate on solutions should be a focus. Assisting to regain self-esteem and motivation are also important to this patient category.

35. Patient Category 3 Goals:Overcome Resistance / Obstacles • Re-establish self-efficacy (belief in one’s ability to achieve a particular goal) and re-establish motivation Counseling Emphasis: Resistance/Obstacle • Foster forgiveness; Alleviate feelings of failure. • Lapses and fall-backs must be accepted as a normal element of behavior change. • Identify Obstacles & strategies to overcome them. • Help to establish a new set of goals. • Restore confidence and encourage a new attempt. Key Questions: • Tell me about what helped to motivate you when you tried previously? • How might we revise your action plan to help move forward again? • What difficulties occurred when you previously tried? • Do you anticipate the same obstacles now?

36. Patient Category 4 Patients in this category are considering or contemplating behavior change. They are not currently practicing the beneficial behavior, but are interested in making the change. Motivation & opposing resistance are of similar strength. This balance can be tipped by raising motivation and/or addressing perceived impediments with strategies to reduce the difficulties. Thus, counseling efforts should focus on increasing motivation to induce change, with attention to potential barriers and their solutions. Emphasis is both on why change should occur and how change can be achieved.

37. Patient Category 4 Goals:Overcome Resistance / Obstacles: • Increase self-efficacy & motivation • Establish action plan collaboratively Counseling Emphasis: Motivation and Resistance: ∙Decision Balance to clarify rationale for change ∙Emphasize personal benefits of healthy behaviors ∙Identify potential obstacles & strategies to overcome ∙Increase motivation/self-efficacy Key Questions: • What are your biggest obstacles for change? • How do you see exercise / improved nutrition fitting into your daily schedule? • Why is a change important to you?

38. Patient Category 5 Patients in this category are pre-contemplative and have not yet thought about making the behavior change. Initial counseling goals are directed at raising awareness, interest, and motivation. The counseling effort should attempt to encourage contemplation for change and preparation for action. The focus of counseling is on what behavior changes are indicated and why. Difficulties in achieving behavior changes should be discussed in anticipation of potential obstacles. Keep in mind that behavior change is incremental and done over time. Small steps should be recognized and counseling focus may be adjusted according to need at each visit.

39. Patient Category 5 • Work with patient to complete a decision balance; revise it over time as indicated. • Motivation must increase for change to occur. Goal: Establish motivation Counseling: Motivational Interviewing. Assist to develop decision balance chart. Explore ambivalence. Relate to patient’s personal health status. Key Questions: • What does having elevated cholesterol / high B/P mean to you? • What would help you to make a change? • What are the pros / cons of making a change?

40. Revisiting the algorithm and category specific counseling focus: • Category 1 = Maintenance • Category 2/3 = Relapse / Burn-out • Category 4 = Motivated, but anticipates barriers • Category 5 = Low Motivation Focus on “M” motivation Focus on “O” obstacles

41. QUESTION ALGORITHM to determine PSM CATEGORY QUESTION 1: Is patient engaged in a healthful lifestyle practice (regular physical activity / healthy diet)? YES NO QUESTION 2: Is patient willing to adopt a healthful lifestyle practice? CATEGORY 1 CONDITIONAL YES YES NO Recent Attempt / Relapse Prior Attempts / Given Up CATEGORY 4 CATEGORY 5 CATEGORY 2 CATEGORY 3

42. Summary of PSM Steps • Identify Category: Ask the two questions to identify patient category. • Identify counseling priority based on category: should counseling be focused primarily on raising motivation, lowering resistance, or both? • Provide relevant homework: dietary advice & instructions; physical activity prescription; decision balance. • Schedule follow-up visit as with other clinical interventions: track behavior; assess response; tailor counseling to help your patient move forward at each visit. Remember that behavior modification is a process and change is incremental.

43. In summary… • Healthcare providers have an important role in motivating and assisting patients’ healthy behavior changes; patients expect advice and assistance from providers. • Interventions must evaluate readiness, motivation and potential obstacles to increase the likelihood of maintaining a plan of action. • Adopting a healthy, balanced diet and a physically active lifestyle requires a series of behavioral changes. • Reinforcement and continuity of care in the primary care setting can help with long-term adherence to a healthy lifestyle.

44. Summary, cont. • Nutrition and physical activity should be addressed as a routine part of primary care. • Incorporating lifestyle counseling into primary care practice can be done in brief exchanges of approximately 2 minutes. • The PSM model provides a 2-question algorithm to determine patient’s readiness to change. • Counseling is category specific, directedto either maintain/maximize motivation or identify/problem-solve obstacles toward the goal of healthy behavior change. • Behavior changes are facilitated by empowering patients to gain increasing control. • A therapeutic alliance between clinician & patient is essential.

45. Patient Vignette Assess: 56 y/o male presents for annual PE; BMI(32); waist circumference 108 cm (42.5 inches); taking no medications; diet high in refined carbs and low in fruit/vegs; “weekend warrior”; history of joining gym for regular exercise but dropped out. Question 1: For the past 6 months (or more) have you performed moderate physical activity for 30 minutes or more on most days of the week? Answer: NO Question 2: Are you ready to begin a regular program of physical activity? Answer: YES You identify this patient as a Category 3.

46. Patient Vignette Visit 1: • You have already related the need for a lifestyle change to physical findings (labs, waist circ, weight). • Your counseling focus is to work with the patient to identify the obstacles from previous attempts that resulted in dropping out. • Strategize to find solutions that may bypass the obstacles and enhance success; collaborate to create a new action plan: • What other physical activity options are available? (30-45 minutes walking/biking/hiking 5 times weekly; resistance training 2 times weekly). Write FITT exercise prescription. • If timing is an issue, would several shorter physical activity sessions per day be an option? • Foster forgiveness for previous failed attempts; do not allow blame; help your patient re-establish the belief that success is possible. • Schedule follow-up visit.

47. Patient Vignette Visit 2 • Assess response; track progress • How is exercise fitting within your life now? Tell me about it (when, where, type, intensity). • Check weight, waist circumference. • Record current physical activity type, duration, intensity. • Counseling focus: • Continue to support motivation and self-efficacy. • Acknowledge all success. • Explore new or potential obstacles. • Collaborate to find solutions (alternative physical activities; several shorter physical activity intervals, etc). 3. Arrange follow-up visits; telephone call and mail/internet support; consider community opportunities.

48. Patient Vignette – ongoing visits • Continue to assess physical activity lifestyle change. • Track progress • Measurements (weight, waist circ, BMI). • Physical Activity type, duration, frequency. • Add resistance exercise or increase duration if indicated. • Counseling focus: • Continue to explore new/potential obstacles and solutions. • Continue to acknowledge & support successes. • Use decision balance as appropriate. • Revise counseling focus as indicated - Address nutrition as physical activity becomes integrated.

49. Patient Vignette Agree: collaboratively develop action plan: example: 30-45 minutes walking/biking/hiking 5 times weekly; resistance training 2 times weekly. Assist: decisional balance chart: benefits and obstacles of increasing physical activity; strategies to overcome barriers; exercise Rx using ‘FITT’, community opportunities for support. Arrange: follow-up visits, telephone calls, mail/internet support.

50. -Resource Materials-