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

1. OWCHOnline Weightmanagement Counselingprogram for Healthcare providers Module 3: Models of Behavior Modification Yale-Griffin Prevention Research Center www.yalegriffinprc.org

2. Modules for Lifestyle Counseling • Module 1 provided an overview of the obesity epidemic and explained the importance of lifestyle counseling. • Module 2 demonstrated how to write an exercise prescription and give basic nutritional advice. • Module 3 provides an overview of behavior modification constructs that inform lifestyle counseling efforts.

3. Behavior Modification • Integrating behavioral modification models into the primary care setting has the potential to facilitate patients’ behavior change. • Improved health behavior may be achieved by: • Individualizing intervention to patient characteristics & needs • Setting goals & problem solving with patients • Multiple follow-up contacts • Support of patient’s social and physical environment; integration with community opportunities • Whitlock EP, et al. Multiple behavioral risk factor interventions in primary care. Summary of research evidence. American journal of preventive medicine 2004;27:2:61 -79 • Estabrooks PA, et al. Physical activity promotion through primary care. JAMA 2003;289;22:2913-16.

4. The Five As

5. The 5 As Lifestyle change can be facilitated by: • Listening to patients • Considering patient priorities • Developing collaboration with patient • Incorporating patient values, preferences and social environment • The 5 As mnemonic helps to promote patient lifestyle change: Assess, Advise, Agree, Assist and Arrange

6. The 5 As: Assess • Assess patient’s current health status. • Assess patient’s physical abilities and current level of physical activity. • Assess patient’s current dietary habits. • Assess patient’s readiness for change Assessments can be done using a brief questionnaire; office staff can assist.

7. The 5 As: Advise • Advise patient regarding health risks; relate risks to patient’s recent lab results and/or current symptoms. • Advise patient on the potential benefits of behavior change. • Provide guidance for dietary change • Provide exercise prescription using FITT (Frequency, Intensity, Type & Time)

8. The 5 As: Agree • Agree with the patient if he/she is planning a lifestyle improvement. • Collaboratively develop a personalized action plan. • Set specific goals for physical activity and nutrition based on patient interest and confidence in the behavior (time, duration, frequency).

9. The 5 As: Assist • Assist patient to identify personal barriers to adopting lifestyle changes. • Assist in developing strategies to overcome barriers. • Assist to locate community opportunities for weight loss and physical activity and social support. Provide written copy of plan to patient and maintain in office medical record.

10. The 5 As: Arrange • Arrange a plan for follow-up support and problem solving. • Telephone calls and mailed reminders • Ex: “Our office nurse would like to contact you next week to see how things are going.” Estabrooks PA, et al. Physical activity promotion through primary care. JAMA 2003;289;22:2913-16.

11. Algorithm for the Treatment of Obesity Serdula, M. K. et al. JAMA 2003;289:1747-1750.

12. Behavioral Models

13. Theory-Based Behavioral Models Integrating behavioral modification models into the primary care setting has the potential to facilitate patients’ behavior change. • Health Locus of Control • Health Belief Model • Social Cognitive Theory • Transtheoretical Model (Stages of Change) • Pressure System Model Institute of Medicine. Health and Behavior: the Interplay of Biological, Behavioral, and Societal Influences. National Academy Press. Washington, D.C. 2001

14. Locus of Control A behavior is dependent on the individual’s beliefs regarding the value of the outcome (reinforcement) and the perceived probability of that reinforcement occurring (expectancy). • Reinforcement can be: • Internal Locus • Belief in level control and/or responsibility for own health status; events result from one’s own behavior & actions. • External Locus • Belief that events are determined by the actions of others, fate or chance (self-efficacy is likely to be low). Identification of the locus of control (internal/external) will help the clinician choose the most effective lifestyle counseling approach. Gilbert, G.G., Sawyer, R.G., 2000, Health Education, Creating Strategies for School and CommunityHealth.Sudbury, Massachusetts. Jones and Bartlett.

15. Health Belief Model (HBM) • Focused on attitudes & beliefs of the individual • An individual will take health-related action if he/she: • Believes a negative health condition can be avoided • Expects the health condition can be avoided by taking a recommended action • Believes in ability to succeed with the recommended health action Glanz, K., Rimer, B.K., Lewis, F.M., 2002. Health Behavior and Health Education: Theory, Research and Practice. 3rd Ed, San Francisco, Jossey Bass.

16. HBM: Key Concepts

17. HBM: Key Concepts, cont’d Glanz, K., Rimer, B.K., Lewis, F.M., 2002. Health Behavior and Health Education: Theory, Research and Practice. 3rd Ed, San Francisco, Jossey Bass Publishers.

18. Social Cognitive Theory • Based on interactions between behavior, environment, and person forming the basis for action. • Self-efficacy beliefs influence goals, outcome expectations and perceived environmental impediments. • Interventions focus on individual’s control of behavior and their environment. • Goals must be realistic and attainable. • Bandura A. Health promotion by social cognitive means. Health Educ Behav.2004 Apr;31:2:143-64 • Glanz, K., Rimer, B.K., Lewis, F.M., 2002. Health Behavior and Health Education: Theory, Research and Practice. 3rd Ed, San Francisco, Jossey Bass.

19. Transtheoretical Model (TTM) • Model was developed for smoking cessation. • Health behavior changes occur in 5 stages (Stages of Change) reflecting patient motivation. • Individualized intervention is based on readiness to make lifestyle change. Affected by: • Decisional Balance: reflects the pros and cons of the behavior • Self-Efficacy: situational confidence with ability to perform task. • Di Clemente C, Prochaska J. Self-change and therapy change of smoking behavior: a comparison of processes of change in cessation and maintenance. Addict Behav 1982; 7: 133-142. • Glanz, K., Rimer, B.K., Lewis, F.M., 2002. Health Behavior and Health Education: Theory, Research and Practice. 3rd Ed, San Francisco, Jossey Bass. • Hall K, Rossi J. Meta-analytic examination of the strong and weak principles across 48 health behaviors. Preventive Medicine 2008; 46:3:266-27

20. TTM: Stages of Change • Searight R. Realistic Approaches to Counseling in the Office Setting. American Family Physician; 2009;79:4:277-84 • 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.

21. TTM: Self-Efficacy • Situation-specific confidence; coping with frustration. • Important predictor of weight outcomes. • Enables the individual to perform a behavior change successfully and deal with times of temptation. • Assists with pursuit of goals despite difficulties & lapses. • Self-efficacy may improve as goals are met as well as with verbal support from others. • 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. • Palmeira A et al. Predicting short-term weight loss using four leading health behavior change theories. International Journal of Behavioral Nutrition and Physical Activity 2007, 4:4-14

22. TTM: Processes of Change Ten actions individuals utilize to proceed through the stages of change; serve as guides for designing interventions.

23. TTM: Processes of Change • Consciousness raising: Increasing awareness and acquiring new knowledge that support behavior change. • Dramatic relief: Feeling the unpleasant emotions that accompany ‘unhealthful behavioral risks’. • Environmental reevaluation: Seeing the negative or positive affects of one’s healthful or unhealthful behaviors on their social and physical environment. • Self-reevaluation: Understanding behavior change is a component of one’s identity. • Self-liberation: Diligence in one’s commitment to change behavior.

24. TTM: Processes of Change 6. Helping relationships: Finding and utilizing a social environment supporting behavior change. 7. Counter-conditioning: Replace unhealthy behaviors with healthier alternatives. • Reinforcement management: Provide more rewards for healthy behavior change and reduce rewards for unhealthy behavior change. 9. Stimulus control: Eliminate cues to negative behaviors and add new cues to encourage positive behaviors. • Social Liberation: Recognizing that opportunities supporting positive behavior change are improving.

25. Pressure System ModelPSM

26. Pressure System Model (PSM) • Applies stages of change to counseling interventions in primary care environments: • 2-question algorithm identifies patient's counseling focus • Separates the two elemental goals of behavioral counseling: • Raising motivation • Overcoming resistance • PSM derives its name from meteorology – differences in barometric pressure determine wind direction. • Movement will go from high to low pressure. As motivation increases, resistance will be overcome- or vice versa. • Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72

27. Pressure System Model (PSM) • Behavior change requires the right “MO”: • M = Maximizing Motivation • O = Overcoming Obstacles • Raising motivation is a standard approach for behavioral counseling in a primary care setting using motivational interviewing Motivationmust exceed resistance for behavior change. Change will not occur if perception of difficulty is greater than the rewards. • Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72

28. Motivational Interviewing • Style of patient-practitioner communication, specifically designed to resolve ambivalence and build intrinsic motivation for patients’ behavior change. • Focuses on creating a comfortable atmosphere without pressure, coercion or confrontation. • Patients are better able to: • Share their concerns about changing • Understand their reasons for or against making changes • Make informed decisions • Feel invested in their choices • Encourages self-efficacy. Adapted from Borrelli B.(2006). Using Motivational Interviewing to Promote Patient Behavior Change and Enhance Health. Medscape Family Medicine.

29. Motivational Interviewing Miller W, Rollnick S. Motivational Interviewing. The Guilford Press; Second Edition edition (April 12, 2002)

30. Motivational Interviewing OARS Approach: - Open-ended questions - Affirmations - Reflective listening - Summaries Empathy by clinicians using the OARS approach in motivational interviewing promotes an attitude of acceptance, supports collaboration, and builds a solid foundation of practitioner-patient communication.

31. OARS Approach • Open-ended questions: • Help elicit less “biased” information in comparison to close-ended questions which put the patient in a passive role. • Usually begin with “Tell me about…” • “Tell me about how your activity plan is going?” • Affirmations: • Statements of appreciation and understanding are important for building and maintaining rapport. • Offer positive affirmations to patients by acknowledging their efforts to make changes (small and large). • “You took a big step by coming here today.” • “That is great that you were able to be active every day this week.”

32. OARS Approach • Reflective listening: • Involves trying to better understand what the patient means by reflecting it back in a short statement. • Helps keep the patient thinking and talking about change. • Patient: “It is difficult for me to move around.” • Physician: “Sounds like you are finding it difficult to be physically active.” • Summaries: • Used to transition to another topic (usually mid-consultation). • Involves highlighting both sides of a patients ambivalence. • “You have several reasons for wanting to be physically active. You say you would like to get more exercise. On the other hand, you say that finding time is a hassle. Is that how you are feeling?”

33. PSM: Five Counseling Scenarios

34. PSM: Five Counseling Scenarios • Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72

35. Summary of Module 3 • There is strong evidence associating the risks of sedentary lifestyle and weight gain to increased morbidity and mortality. • Lifestyle counseling for weight maintenance or loss may have significant benefits. • Behavioral change models with Motivational Interviewing (MI) techniques may help facilitate patients’ behavioral changes. • Module 4 provides a specific strategy for incorporating lifestyle counseling in a primary care setting. • Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72 • Katz DL, et al. Impact of an educational intervention on internal medicine residents’ physical activity counseling: The Pressure System Model. J Eval Clin Pract. 2008; 14: 294-299.