Compendium of Health and Wellness Coaching: 2019 Addendum

Supporting Sustainable Health Behavior Change: The Whole is Greater Than the Sum of Its Parts

Behavior change is the foundation for effective lifestyle prescriptions, yet such change is individualized, nonlinear and typically requires ongoing support. Health and wellness coaching (HWC) is a behavior change intervention with rapidly accruing evidence of positive impact on health behaviors such as exercise, nutrition and stress management. Furthermore, HWC enhances prevention and mitigates exacerbation of chronic lifestyle diseases, at least in the short-term (up to 6 months post intervention). Although the impact on long-term stability of behavior change remains unclear, it is evident that effective partnering with patients using key communication strategies, autonomy promotion, and flexible permissiveness can empower patients to develop healthy lifestyles. This partnership can be cultivated by clinicians as well as clinical team members including nationally board-certified coaches. Although much research is needed regarding the ongoing maintenance of lifestyle changes beyond 6 months, this article seeks to equip clinicians with current evidence, theoretical insights and practical strategies from a "coach approach" to foster more intrinsic forms of motivation which, in turn, empowers patients to adopt and maintain health-promoting behaviors.

Group Health & Wellness Coaching: development and validation of the required competencies

BACKGROUND

As the popularity and demonstrated effectiveness of Health and Wellness Coaching (HWC) continue to grow to address chronic disease prevalence worldwide, delivery of this approach in a group format is gaining traction, particularly in healthcare. Nonetheless, very little empirical work exists on group coaching and there are currently no published competencies for Group Health and Wellness Coaching (GHWC).

METHODS

We used a well-established two-phase (Development and Judgment) process to create and validate GHWC competencies with strong content validity.

RESULTS

Seven highly qualified Subject Matter Experts systematically identified and proposed the GHWC competencies, which were then validated by 78 National Board Certified Health and Wellness Coaches (NBC-HWCs) currently practicing GHWC who rated the importance and use frequency of each one. The validation study led to 72 competencies which are organized into the structure and process of GHWC.

CONCLUSIONS

GHWC requires not only coaching skills, but significant group facilitation skills to guide the group process to best support members in maximizing health and well-being through self-directed behavioral change. As the presence of HWC continues to grow, it is imperative that GHWC skill standards be accepted and implemented for the safety of the public, the effectiveness of the intervention, and the value analysis of the field. Such standards will guide curriculum development, allow for a more robust research agenda, and give practical guidance for health and wellness coaches to responsibly run groups. High quality standards for GHWC are particularly needed in health care, where a Level III Current Procedural Terminology (CPT®) code for GHWC has been approved in the United States since 2019 and reimbursement of such has been approved by the Centers for Medicare and Medicaid for 2024.

Health and Wellness Coaching and Sustained Gains: A Rapid Systematic Review

The Transtheoretical Model of Change identifies key stages in behavior change, including a maintenance stage occurring when a behavior has been upheld for at least 6 months. Health and wellness coaching has demonstrated support for health behavior change, but maintenance of gains has received little attention. Our rapid systematic literature review characterizes both the research exploring sustained gains with health and wellness coaching and what is known about sustained gains after the completion of a health and wellness coaching engagement. Guided by The Cochrane Rapid Reviews Methods Group "Interim Guidance," we drew 231 studies from the 2018 and 2020 Sforzo et al "Compendium of the health and wellness coaching literature," and "Addendum…" appendices. Initial screening and coding for inclusion and exclusion criteria yielded 28 studies for data extraction. We examined studies across outcome categories (physiological, behavioral, psychological, and health risk assessment) to determine whether outcome measures were: not sustained; partially sustained; fully sustained; or improved from immediate post-intervention to a later follow-up period. Twenty-five of the 28 studies reviewed demonstrated partially, or fully, sustained or improved outcomes in one or more variables studied, with sustained gains demonstrated across outcome categories, strengthening confidence in HWC as a facilitator of lasting change.

Planting the Seed for Blood Pressure Control: The Role of Plant-Based Nutrition in the Management of Hypertension

PURPOSE OF REVIEW

Hypertension results in significant morbidity, mortality, and healthcare expenditures. Fortunately, it is largely preventable and treatable by implementing dietary interventions, though these remain underutilized. Here, we aim to explore the role of healthy dietary patterns in hypertension management and describe approaches for busy clinicians to address nutrition effectively and efficiently with patients.

RECENT FINDINGS

DASH, Mediterranean, vegetarian, and vegan diets that include minimally processed, plant-based foods as core elements have consistently shown positive effects on hypertension. Recommendations that distill the most healthful components of these diets can significantly impact patient outcomes. Clinicians can harness evidence-based dietary assessment and counseling tools to implement and support behavioral changes, even during brief office visits. Healthful plant-based dietary patterns can often effectively prevent and treat hypertension. Clinicians may help improve patient outcomes by discussing evidence-based nutrition with their patients. Future work to promote infrastructural change that supports incorporating evidence-based nutrition into medical education, clinical care, and society at large can support these efforts.

The Health Narratives Research Group (HeNReG): A self-direction process offered to help decrease burnout in public health nurse practitioners

Founded in accordance with 19th century sex roles and public health concerns, nursing evolved as other-directed, dependent on physician-focused diagnosis, prescription decisions, and public health advancements. The result of this other direction is that public health nurse practitioners have endured significant workplace stress resulting in burnout, especially during COVID-19. To help decrease their burnout, nurses require development of self-direction. The Health Narratives Research Group (HeNReG) has the potential to reduce burnout in nurse practitioners by encouraging the development of self-direction. The HeNReG process is presented through historically analyzed documents regarding reducing burnout in health researchers by developing self-direction including: (1) three years of archived year-end feedback results provided by participants, (2) archived participant responses to specific HeNReG-related writing prompts, and (3) a comparison of HeNReG results with the outcomes of resilience programs. The conclusion-the HeNReG offers an effective option for reducing burnout in health researchers that has the potential to decrease nurse practitioner burnout in a way that resilience programs do not. Tailoring the HeNReG process to public health nurses is discussed, inviting future research for reducing burnout in public health nurses.

Using concepts from trauma-informed care: Potential to inform health and wellness coaching for college students

College students are struggling to maintain well-being, with mental health challenges becoming exceedingly disruptive. Health and wellness coaching can be utilized in the college setting in addition to counseling to connect college students with resources, provide support through accountability and unconditional positive regard, and promote personal growth. Trauma-informed care is an effective approach for supporting those who may be or are experiencing trauma and is shown to be relevant in the college setting. This paper describes a rationale for integrating trauma-informed care and health and wellness coaching to enhance overall college student well-being, foster academic achievement, and create a safe, inclusive environment for growth.

A Rubric to Assess the Design and Intervention Quality of Randomized Controlled Trials in Health and Wellness Coaching

Objective

To collect health and wellness coaching (HWC) literature related to treatment of obesity and Type 2 Diabetes (T2D) for systematic assessment using a novel rubric.

Data Source

Pubmed, CINAHL, and PsychInfo.

Study Inclusion and Exclusion

Given 282 articles retrieved, only randomized and controlled trials meeting a HWC criteria-based definition were included; studies with intervention <4 months or <4 sessions were excluded.

Data Extraction

Rubric assessment required details of two theoretical frameworks (i.e., study design and HWC intervention design) be extracted from each included paper.

Data Synthesis

Data were derived from a 28-item rubric querying items such as sampling characteristics, statistical methods, coach characteristics, HWC strategy, and intervention fidelity.

Results

29 articles were reviewed. Inter-rater rubric scoring yielded high intraclass correlation (r = .85). Rubric assessment of HWC literature resulted in moderate scores (56.7%), with study design scoring higher than intervention design; within intervention design, T2D studies scored higher than obesity.

Conclusions

A novel research design rubric is presented and successfully applied to assess HWC research related to treatment of obesity and T2D. Most studies reported beneficial clinical findings; however, rubric results revealed moderate scores for study and intervention design. Implications for future HWC research are discussed.

Nudging as a Support for Behavioral Change in Lifestyle Medicine

The practice of lifestyle medicine and its emphasis on behavioral change continues to grow around the world. Yet much of the burden of disease weighing on healthcare systems from chronic, modifiable conditions remains stubbornly present. From a behavior change perspective, efforts to date have primarily focused on public health messaging and public health campaigns (global approaches) to interventions such as health coaching (individual approaches). There exists an opportunity to consider contextual elements which support behavioral change. The practice of "nudging" behavior in primary care and allied health settings is proposed as a means of responding to these contextual opportunities. Nudging does not assure change; however, it can invite curiosity about change and small behavioral efforts in the direction of a desired change. Furthermore, its nature conserves autonomy and patient choice while inviting a health-creating behavior. As such, when considered and applied in the context of public health and individual treatment options, it creates a consistent milieu in which behavior change is facilitated.

Health Coaching for Weight Loss Among Overweight and Obese Individuals in Saudi Arabia: A Retrospective Analysis

Background Health coaching is an increasingly used strategy to help in adopting lifestyle changes for weight loss. While Saudi Arabia has one of the highest obesity prevalences worldwide, research on lifestyle interventions for weight loss is limited. Aim We aimed to investigate the effectiveness of health coaching for weight loss among the Saudi population in real-world primary healthcare settings. Methods This is a retrospective observational study. Secondary data from the health coach national program in the Eastern Health Cluster were retrieved. Obese and overweight individuals aged 15 years or older with weight-related goals who completed at least 12 weeks of coaching were included in the analysis. The primary outcomes are weight change (kg) and weight change percent (%) of the initial weight. We further compared the weight change% between different follow-up methods (i.e., physical, virtual, and hybrid) and studied the factors associated with -5% weight loss. Results In total, 465 participants were included in the analysis, with a female predominance (66.2%) and a median initial weight of 90 kg (interquartile range (IQR): 77, 101). The median follow-up duration was 127 days (IQR: 101, 157), and the median total number of coaching sessions was three (IQR: 2, 5). The mean weight change was -2.68 kg (95% confidence interval (CI): -3.12, -2.24), p<0.001. Comparing each follow-up group, no statistically significant difference was found when controlling for number of visits (p=0.059). The adjusted means for weight change% were -3.77%, -2.59%, and -2.54% for hybrid, physical, and virtual visits, respectively. Factors that were associated with achieving at least -5% weight loss were male sex (adjusted odds ratio (aOR)=1.87, 95% CI: 1.16, 3.02), five or more total coaching visits (aOR=5.23, 95% CI: 2.88, 9.50), longer follow-up duration (aOR=1.09, 95% CI: 1.03, 1.15), and having a weight management goal (aOR=4.5, 95% CI: 1.63, 12.45) as the reason for initial coaching visit. Conclusion We found statistically significant weight change among clients who completed 12 weeks of coaching in primary care settings. The findings in this paper contribute to the importance of lifestyle interventions for weight loss among the Saudi population. However, stronger controlled studies are needed to confirm this finding.

Dosing of Health and Wellness Coaching for Obesity and Type 2 Diabetes: Research Synthesis to Derive Recommendations

Health and wellness coaching (HWC) is an effective intervention for lifestyle disease such as obesity and type 2 diabetes. The evolving HWC profession needs recommendations to guide clinical practice, particularly the appropriate dose of coaching. The purpose of this paper was to systematically review and synthesize HWC literature to derive HWC programming recommendations. Of 102 papers retrieved, 88 were retained with data extracted determining HWC session number, frequency, duration, program length, and total coaching load. Differential analysis yielded no statistical difference in programming variables for randomized control trials and other designs, nor for studies with significant findings v. those not finding statistical significance, allowing these data to be pooled. The HWC intervention for obesity was slightly more intense (15 sessions over 7-8 mo) than the diabetes programming (12 sessions over 9-10 mo). On average, HWC programming applied in the peer-reviewed literature was 12-15 sessions of 35-40 min duration over 7-9 months. These recommendations for HWC programming variables are put forth as initial practice guidelines and should be examined with comparative effectiveness study for optimization. HWC best practice guidelines for other patient groups (e.g., heart disease, cancer, and chronic pain) should also be studied once an adequate literature data base is available.

Employee Group Coaching Program for University and Hospital Employees During COVID-19: A Feasibility Study

Background

Workplace wellbeing programs can be beneficial but range widely in approach. A group coaching model offers numerous benefits.

Objective

To evaluate feasibility of group coaching for employees during COVID-19.

Methods

Employees (n = 29) at a university and university hospital underwent a 12-week group coaching program. Measurements of feasibility -- including enrollment, attendance at sessions goal attainment and satisfaction -- and exploratory outcomes including perceived physical and mental health and stress were administered at beginning, middle, and end of the program, plus 2 follow-ups.

Results

Twenty-six of the 29 program enrollees (96% women; 65% university employees) opted to complete surveys at 1 or more time points, and 9 individuals completed surveys at all 5 time points. Median attendance was 9 sessions. Participants opted to focus on movement, nutrition and mind/body goals and all participants reported making progress toward their goal during the program. Exploratory wellness outcomes showed meaningful improvements in perceived physical and mental health and reduced stress during the program, with return to near baseline 12 weeks after program completion. Perceptions of workplace wellness culture varied by employer.

Conclusion

Despite pandemic-related disruptions to life, work, and health, online group coaching is feasible and acceptable to participants. The program should be replicated to evaluate whether the improvements in exploratory wellness outcomes observed during the program are statistically significant. The apparent return to baseline levels by 24 weeks suggests that post-program maintenance support may be helpful.

Calling on All Child and Family Practitioners to Help Mitigate the Impacts of the Poor Behavioural Health of Children with Psychiatric Illness

Adolescents and children (aged 6 to 17+ years) admitted to inpatient psychiatry or intensive out-of-home mental health programs (formerly called residential mental health treatment centres) are among those with the most severe psychiatric illnesses. Moreover, these children also have very poor behavioural and biopsychosocial health including sleep deprivation, difficult relationships, problematic use of electronic devices, academic difficulty, poor school engagement, insufficient exercise and poor diets; all of these were noted before the pandemic. The pandemic has only increased the social isolation, poor health behaviours and mental health challenges for many children and adolescents. The poor behavioural and psychosocial health of those in their youth with psychiatric illnesses can exacerbate symptoms and can interfere with academic performance, development and good decision making; these biopsychosocial health behaviours are modifiable. All child and family practitioners including pediatricians, family physicians, nurses, social workers, psychologists and psychotherapists have an important role in fostering the behavioural and biopsychosocial health (i.e., sleep, positive relationships, electronic device use, exercise and diet) of all family members and especially children with psychiatric illness. Enacting biopsychosocial lifestyle interventions before or during childhood and adolescence may reduce the burden of mental illness.

Nutrition and behavior change: a review of recent literature

PURPOSE OF REVIEW

The current article will highlight recent trends and novel approaches to behavior change strategies in nutrition. Physicians, nurses, and other healthcare professionals play key roles in counseling patients on lifestyle change, which is critical for patients with chronic conditions. Nutrition science continues to advance, and new approaches to behavior change are needed for successful implementation at the individual and population level.

RECENT FINDINGS

The solutions to obstacles around healthful eating patterns are varied, population-dependent, and require a multipronged approach. One area of focus is the language around behavior change, ensuring it is clear and emphasizes its multifactorial nature. For young adults, the careful use of video games and social media may be essential. For older adults, altering food consistency and ensuring proper nutrient intake are crucial factors. Vulnerable populations remain susceptible to malnutrition and need special attention. Despite significant advances in managing and treating diseases, there are still gaps in nutrition counseling and behavior change efforts.

SUMMARY

Every age and stage of life needs a focus on healthful foods, and nutrition counseling at each stage has its unique nuances. Careful attention to the language of change and the phrasing used in counseling is vital for educating, connecting with, and empowering patients to change. Changing healthcare operations and provider behavior around nutrition counseling is a part of the solution to the worldwide problem of unhealthy eating patterns and practices.

Hypertension Control and Medication Titration Associated With Lifestyle Medicine Virtual Group Visits and Home Blood Pressure Monitoring

Less than a quarter of the 116 million adults with hypertension in the United States have blood pressure (BP) lower than the guideline-recommended goal of 130/80 mmHg. There is a critical need for novel interventions that integrate evidence-based recommendations—such as lifestyle medicine and home BP monitoring (HBPM)—into clinical care. In this study, we tested the hypothesis that a four-part, primary care physician-led Virtual Group Visit (VGV) series combining lifestyle medicine, Health and Wellness Coaching (HWC), and HBPM could lead to a reduction in BP and antihypertensive medications. There was a decrease in systolic (β = −.108 mmHg per day; P = .046) and diastolic (β = −.058 mmHg per day; P = .026) BP. Thirteen of the 22 patients (59%) who started the VGV series on medications had at least one medication dosage reduced or discontinued during the VGV series, and 8 of the 18 patients (44%) who finished the VGV series on medications had at least one medication dosage reduced or discontinued in the 180 days after the VGV series. This pilot study demonstrates for the first time that lifestyle medicine VGVs, coupled with HWC and HBPM, are associated with improved BP control and medication deprescribing.

Digital Health Coaching for Type 2 Diabetes: Randomized Controlled Trial of Healthy at Home

Digital health coaching is an intervention for type 2 diabetes mellitus (T2DM) that has potential to improve the quality of care for patients. Previous research has established the efficacy of digital interventions for behavior change. This pilot study addresses a research gap in finding effective and accessible behavioral interventions for under-resourced individuals with T2DM. We examined the impact of Healthy at Home, a 12-week phone and SMS-based (short message service) digital health coaching program, on insulin resistance which is an upstream marker for T2DM progression. We compared this intervention to usual diabetic care in a family medicine residency clinic in a randomized controlled trial. Digital health coaching significantly improved participants' calculated Homeostatic Model Assessment for Insulin Resistance (HOMA2-IR) by −0.9 ± 0.4 compared with the control group (p = 0.029). This significance remained after controlling for years diagnosed with T2DM, enrollment in Medicaid, access to food, baseline stage of change, and race (p = 0.027). Increasing access to digital health coaching may lead to more effective control of diabetes for under-resourced patients. This study demonstrates the potential to implement a personalized, scalable, and effective digital health intervention to treat and manage T2DM through a lifestyle and behavioral approach to improve clinical outcomes (http://clinicaltrials.gov, NCT04872647).

Coaching: A Primer for the Radiologist

The practice of coaching using positive psychology is an emerging and promising approach to address the radiologist burnout epidemic, with the focus on wellness even more urgent given the coronavirus disease 2019 pandemic and other recent stressful events. Coaching uses a strengths-based approach to help radiologists identify and achieve positive emotions, create meaningful relationships, increase engagement and purpose, and develop coping skills for personal and professional stressors, including communication, improving resilience, team building, and mindfulness. Health and wellness coaching promotes healthy behavior change as a means of averting or mitigating chronic lifestyle-related diseases and is a potential treatment for burnout and stress management. Coaches help clients enhance self-motivation, identify strengths, and implement a framework for change by applying psychological resources, including mindfulness, positive mind-set, resilience, self-efficacy, and self-awareness. The framework of coaching is built upon psychological safety, mindfulness, accountability, and the coach-client relationship. Coaches use the three fundamental skills of mindful listening, open-ended inquiry, and perceptive reflections to empower clients on their journeys to achieve their best selves.

Development of an observational tool to assess health coaching fidelity

OBJECTIVE

This study describes the development of the Health Coaching Index (HCI), an observational tool for assessing fidelity to implementing health coaching practical skills.

METHODS

Initial HCI items were developed, adapted following cognitive interviews, and refined during coding training. Participants (n = 42) were trainees who completed a National Board for Health and Wellness Coaching (NBHWC)-approved training program and coached a standardized patient. Interrater reliability for the HCI was determined by calculating interclass correlations from ten videos coded by three raters. Construct validity was evaluated from 42 recordings using Spearman's Rho between HCI and Roter Interaction Analysis System (RIAS) codes.

RESULTS

The interclass correlation (ICC) for HCI total score was 0.81, considered an excellent level of inter-rater agreement. Some significant correlations between HCI and RIAS codes supported construct validity (e.g., patient activation: Rho = 0.32; empathy: Rho = 0.36).

CONCLUSION

The HCI total score can reliably be used to assess fidelity to health coaching skills, and the HCI has construct validity similar to the RIAS as a measure of patient activation.

PRACTICE IMPLICATIONS

Adoption and further study of the HCI tool will allow for a more consistent implementation of health coaching skills, and may facilitate more robust training of health coaches for clinical practice and research.

The functional medicine approach to atrial fibrillation: can a cure for atrial fibrillation be found in the gut?

PURPOSE OF REVIEW

The importance of addressing the proximal causes of atrial fibrillation is recognized, yet frustration with the currently applied preventive measures is high. This review describes the functional medicine model (FMM), which identifies the proximal causes of atrial fibrillation at the level of gene-environment interaction.

RECENT FINDINGS

The pathological processes leading to atrial fibrillation sustaining disorder have been elucidated in translational studies and are described as 'nodal points.' Examples are inflammation, oxidative stress, autoimmune mechanisms, and visceral adiposity. These same nodal points also cause disorder that results in atrial fibrillation-related complications and the development of atrial fibrillation-associated diseases. These nodal points vary from patient to patient and can be identified by careful evaluation of the patients clinical phenotype.

SUMMARY

The application of the FMM identifies the gene--environment interactions that facilitate the patients nodal points and corrects them with emphasis on personalized diet, nutrition, and lifestyle changes.

Coaching skills for medical education in a VUCA world

The world is in the midst of the COVID-19 pandemic. Healthcare professionals and students globally are experiencing an increasingly 'VUCA' (volatile, uncertain, complex and ambiguous) healthcare and educational climate. Our future medical workforce needs skillsets to manage the personal and emotional challenges of work, uncertainty and change. These include organization, time management, proactive and consistent clinical skill development, effective communication, person-centred approaches, self-reflection and self-care. This is critical for success during undergraduate medical education and ongoing clinical practice to build personal resilience, provide the best possible clinical care in a different healthcare ecosystem, innovate for better healthcare systems and advocate for more vulnerable communities. Our faculty and students have been eager to learn and apply solution-oriented coaching skills to help to mitigate against burnout, hold more rewarding, person-centred conversations in clinical practice and enable them personally to respond flexibly and adapt constructively to change. Coaching training should comprise an essential component of the undergraduate medical curriculum and continuing professional development, supporting our medical workforce to derive joy from the practice of humanistic healthcare and develop the leadership skills to help shape a way forward through the challenges we are experiencing in an increasingly VUCA healthcare climate.