Lifestyle Modification
Catherine Takacs Witkop
At the heart of every clinical recommendation to a patient lies a fundamental obstacle. When an individual walks out of her provider’s office, she either consciously or unconsciously realizes that she will need to change some aspect of her life in order to comply with the recommended treatment. Whether it is as simple as remembering to take a pill once per day or as complicated as losing weight, exercising, or needing to measure blood sugar every day, some modification to her daily schedule and status quo will be required. Although lifestyle modification can be difficult, the evidence is clear in many areas that it works. What providers need to understand, however, is that their input and support is often more critical here than in the standard therapeutic relationship. In this chapter, we review the evidence supporting lifestyle modification as a legitimate approach for prevention and therapy, explore the theoretical basis for behavioral modification, and identify key areas in women’s health where lifestyle modification can and should be recommended.
WHY LIFESTYLE MODIFICATION?
One of the best-studied areas to support lifestyle modification in prevention of chronic disease is in patients at risk for diabetes. Three large randomized controlled clinical trials of primary prevention of type 2 diabetes in three different countries have all demonstrated that maintenance of 3 to 5 kg (7 to 10 lb) of weight loss through diet and physical activity reduced the incidence of type 2 diabetes in high-risk individuals by 40 to 60% over 3 to 4 years.1, 2, 3 The largest and most recent study, the U.S. Diabetes Prevention Program, performed at 27 clinical centers throughout the United States, randomized over 3000 patients to control, use of metformin, or lifestyle intervention (achieve and maintain 7% or greater weight loss through a low-calorie, low-fat diet and at least 150 minutes of moderate physical activity per week).3 Over 3 years, the lifestyle intervention group lost an average of 5.6 kg and the incidence of diabetes was reduced by 58%. The number needed to treat to prevent one case of diabetes was 7 in the lifestyle management group versus 14 in the metformin-treated group. Most importantly, this risk reduction was similar in all ethnic, age, and BMI (body mass index) groups.3 The two earlier studies also demonstrated success in the reduction of risk of type 2 diabetes.
Familiarity with these three studies is critical for health care providers because they provide evidence that lifestyle modification does work. The challenge is translating what was done in large randomized controlled trials with significant patient support into the reality of clinical care. Difficulties include (a) providing convincing education to the health care providers on the benefits of implementation of lifestyle modification in their practice, (b) identifying the patients who would most benefit from lifestyle modification, and (c) creating systemwide solutions for the implementation. This chapter will address these three issues, specifically as they relate to providers of women’s health care.
LIFESTYLE MODIFICATION AS GOOD MEDICINE
Many providers have not received formal training in lifestyle modification, and only with an understanding of behavior change can a provider adequately address many of the issues that affect women’s health. Lifestyle modification must begin during the initial visit of a patient. The studies on prevention of diabetes described earlier are proof that lifestyle modification works. Now, let’s get to the heart of the matter.
MODELS OF BEHAVIOR CHANGE
Social cognitive theory (SCT) has been employed as the theoretical basis for a multitude of behavioral interventions. Its premise is that three factors—environment, person, and behavior—interact and a change in one affects the other two.4 Interventions to change health behaviors have used this theory as a guide. Providers of women’s health care can apply SCT to behavioral change counseling. A provider is not typically able to alter the patient’s physical or social environment but may be able to make recommendations on how the patient can modify her surroundings or with whom she interacts. For example, encouraging an individual to spend her lunch break with a colleague who takes a walk rather than sits in the smoking area to have a cigarette can have a positive impact on smoking cessation. Another factor that can impact behavior is person. The variables within an individual that might impact behavior modification include behavioral capability (knowledge and skills to
engage in the behavior), outcomes expectancies, observational learning, and perceived self-efficacy. Perceived self-efficacy is often highest when fewer barriers are in place to prevent the behavior change. Providing a patient with the understanding to successfully deal with these factors is key to SCT.
engage in the behavior), outcomes expectancies, observational learning, and perceived self-efficacy. Perceived self-efficacy is often highest when fewer barriers are in place to prevent the behavior change. Providing a patient with the understanding to successfully deal with these factors is key to SCT.
BOX 19.1 Stages of Change Model
Precontemplation
Contemplation
Determination
Action
Maintenance
Termination
The transtheoretical model (TTM) was originally developed by James Prochaska and Caro DiClemente and is the foundation of many of the behavioral interventions used in clinical medicine.5 The theory assumes that all people go through six stages of change in the process of altering a behavior. The six stages of change and a short description of each are listed in Box 19.1. In the first stage, the precontemplation stage, the patient does not have plans to change her behavior in the near future and often does not even believe that she is at risk for any adverse outcomes related to her behavior. In this stage, motivational interviewing (discussed later) may be particularly useful. Asking a patient’s permission to discuss the given behavior is recommended when she is in this stage because she may become angry and less likely to consider change in the future.
The contemplation stage follows. In this stage, the patient may begin to understand the connections between her behavior and potential adverse outcomes on her health. The obstacles to consider in this stage are knowledge gaps on options to change behavior and any doubts in self-efficacy. If the patient remains interested in change, the determination stage comes next when the woman makes a commitment to change behavior and makes concrete, actionable plans. Recognizing obstacles that may arise is critical during this stage and reassuring patients that relapses occur frequently will minimize the impact a relapse or pitfall may have on success of the behavioral change. During the action stage, the patient actually will make the change in lifestyle, but this may be followed by relapse. A visit with a provider if relapse occurs can help the provider guide the patient through any changes that could be made to reduce the risk of future relapse. Finally, the maintenance stage marks the last stage of change but is by no means the easiest. This stage requires ongoing evaluation, encouragement, and empathy.
The TTM also has identified 10 processes of change shown in Box 19.2. Once a provider is familiar with the model, he or she can identify the patient’s stage of change and then identify what intervention might be most effective.
BOX 19.2 Process of Change
Consciousness raising—increasing awareness via information, education, and personal feedback about the healthy behavior
Dramatic relief—feeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when they hear about how people are able to change to healthy behaviors
Self-reevaluation—realizing that the healthy behavior is an important part of who they are and want to be
Environmental reevaluation—realizing how their unhealthy behavior affects others and how they could have more positive effects by changing
Social liberation—realizing that society is more supportive of the healthy behavior
Self-liberation—believing in one’s ability to change and making commitments and recommitments to act on that belief
Helping relationships—finding people who are supportive of their change
Counterconditioning—substituting healthy ways of acting and thinking for unhealthy ways
Reinforcement management—increasing the rewards that come from positive behavior and reducing those that come from negative behavior
Stimulus control—using reminders and cues that encourage healthy behavior as substitutes for those that encourage the unhealthy behavior
MOTIVATIONAL INTERVIEWING
Motivational interviewing (MI) was first described by William Miller in 1983 and later expanded by Miller and Stephen Rollnick in 1995. The definition of MI at that time was described as “a directive, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence.”6 The techniques have continued to undergo refinement, but the overall goal of MI is to use reflective listening and other tools allow the patient to move through stages of change as described in the TTM. The following are the key points that best describe the spirit of MI as described by Rollnick and Miller7:
Motivation to change is elicited from the client, and not imposed from without.
It is the client’s task to articulate and resolve his or her ambivalence about the behavior.
Direct persuasion is not an effective method for resolving the ambivalence.
The counseling style is quiet and eliciting. Avoid arguments and confrontation.
The provider is directive in helping the client examine and resolve ambivalence; further skills training to effect the behavior change may also be required, but those are not the goals of MI.
Readiness to change is not a client trait but a fluctuating product of interpersonal interaction.
The therapeutic relationship is more like a partnership than expert/recipient roles.
The key skills can be summarized by the OARS acronym:
Open-ended questions
Affirm
Reflect
Summarize
More details on how to receive training in MI can be found at www.motivationalinterviewing.com.8
In a meta-analysis of 72 randomized controlled trials on effectiveness of “motivational interviewing” in a variety of behavior changes, MI had a significant and clinically relevant effect in changing behavior in approximately 75% of the studies.9 In a recent Cochrane systematic review of 14 studies and over 10,000 patients, MI was found to be effective for smoking cessation when given by general practitioners or trained counselors, and longer sessions (greater than 20 minutes) tended to be more effective than shorter ones.10 MI has also been used effectively in changing behaviors related to alcohol and drug use and HIV risk behaviors. Based on the evidence, organizations have recommended that providers understand and utilize MI with their patients in the appropriate clinical settings.11 Training in MI is not common in standard medical training programs, but providers should become familiar with it in order to have another tool in their toolbox for behavioral modification among their patients.
MI should not be confused with the more general “brief intervention.” Miller and Sanchez developed the acronym FRAMES to help instruct providers in the brief intervention.12 This approach includes the following:
Feedback (Compare the patient’s behavior with nonrisk behavior patterns.)
Responsibility (It is her responsibility to make the change.)
Advice (Give direct advice to change the behavior.)
Menu (Identify “risk situations” and offer options for coping.)
Empathy (Use a style of interaction that is understanding.)
Self-efficacy (Help the patient develop strategies, implement them, and commit to change.)
Several of the components are similar to MI, but “give direct advice” is clearly what makes this intervention different. Although both have been demonstrated to be effective in studies on health behavior change, it is helpful to understand the difference when reading the literature. For example, in smoking cessation, the brief intervention has proved effective, but MI is recommended for smokers who are in precontemplation.
Whether MI or brief intervention is used, providers should know that Current Procedural Terminology (CPT) codes and Evaluation and Management (E/M) service codes have been developed for patient counseling. The provision of such codes allows for practices to prioritize the commitment to counseling that is necessary for successful behavioral modification.
TOBACCO USE
An estimated 21% of American adults (44.5 million people) smoke and more than 440,000 Americans die from tobacco-related causes each year; in other words, one in five deaths is related to tobacco use.13 The Centers for Disease Control and Prevention (CDC) estimates that 18.3% of American women used cigarettes in 2008.14 A recent report from the Global Youth Tobacco Survey (GYTS) indicates that although boys aged 13 to 15 years are currently more likely to use tobacco than girls of the same age, that gap is closing, and in many countries, there is no significant gender difference.15 Despite a common misperception, lung cancer is responsible for one out of four cancer deaths in females (27,000 more annual deaths than breast cancer).16 Smoking reduces a woman’s life expectancy by 7 years. Smoking also has significant and multiple implications in pregnancy. These data indicate that women’s health providers have an important role in reduction of chronic disease burden among women and that role does not necessarily involve performing a pelvic exam.
The first step is to identify women who are ready to quit. Pregnancy is often a time of increased motivation. Many studies have demonstrated that 20 to 30% of women attempt to stop smoking while pregnant, and up to 40% who actually quit do so before their first obstetric visit.17 Pregnancy also provides a good example of how contextual educational material can improve outcomes. Although office-based cessation counseling session of 5 to 15 minutes with a trained provider can result in smoking cessation rate of 5 to 10%, the rate was 20% when pregnancy-specific materials were provided.18
Clinical Practice Guideline
The most recent U.S. guideline for treating tobacco use and dependence outlines recommendations for clinicians.19 The compelling evidence is based on thousands of cessation studies and has shown that clinicians can make a difference, even with a minimal intervention. Evidence has shown, however, that effectiveness of person-to-person contact for counseling increases with treatment intensity. A quick reference guide for clinicians can be found at http://www.ahrq.gov/legacy/clinic/tobacco/tobaqrg.htm.20 The 5 As and 5 Rs have
been demonstrated to result in long-term cessation rates (over 5 months) of 15 to 20%, as compared to 5% for smokers who try to quit on their own.21 The 5 As are the five major components of the brief intervention (Box 19.3). This model is straightforward and can be used as a screening and intervention tool by providers without additional training.
been demonstrated to result in long-term cessation rates (over 5 months) of 15 to 20%, as compared to 5% for smokers who try to quit on their own.21 The 5 As are the five major components of the brief intervention (Box 19.3). This model is straightforward and can be used as a screening and intervention tool by providers without additional training.
For those who are unwilling to quit, MI has been shown to increase future quit attempts. By identifying a tobacco user’s feelings, beliefs, ideas, and values about tobacco use, the provider can use the patient’s own “change talk” (any ambivalence about using tobacco) and “commitment language” (certain intentions, even if not complete commitment to abstinence) to increase the patient’s resistance to change.
The 5 Rs should be addressed for those who are unwilling to quit (Box 19.4).
ALCOHOL AND DRUG USE
Alcohol and drug abuse are a significant problem among American women. According to a recent report, 24% of women aged 15 to 44 years are binge drinkers.22 These rates are lower among women greater than 26 years of age but continue to be a problem throughout a woman’s lifespan. Heavy drinking is defined as drinking five or more drinks on one occasion on five or more days in the last 30 days, and the rates of heavy drinking among American women ranges from 2.4 to 10%.23 Furthermore, 9.8% of nonpregnant women and 5.1% of pregnant women aged 15 to 44 years reported illicit drug use in the past month.
BOX 19.3 5 As
Ask about tobacco use. Effective treatments exist that can produce long-term or even permanent abstinence. All health care providers should address tobacco addiction at every clinic visit. Strategies to accomplish this include expanding vital signs to include tobacco use, using status stickers, or indicating tobacco use status via the electronic medical record.
Advise to quit. In a clear, strong, and personalized manner, every tobacco user should be urged to quit. Patients who smoke may receive daily messages from friends, society, and the media to quit, thereby priming them for the provider’s advice. The provider should clearly state that it is possibly the most important thing that the patient can do to improve her health. Furthermore, personalizing the message can include things like pregnancy, asthma, children’s health complications, or its economic implications.
Assess willingness to make a quit attempt. “Are you willing to give quitting a try?” If so, the provider should provide intensive treatmentor refer the patient to someone who does. Furthermore, educational information should be provided, particularly if the patient is pregnant, an adolescent, etc. If the patient is not willing at this time, see discussion on the 5 Rs.
Assist in quit attempt. Strategies for implementation include the following:
Help the patient with a quit plan (set a quit date; tell family, friends, and coworkers about quitting; anticipate barriers; remove tobacco products/remove herself from environments).
Recommend use of approved medications (Table 19.1).
Provide practical counseling (problem solving/skills training).
Provide intratreatment social support (provision of social support as part of treatment).
Help secure social support outside of treatment (extra-treatment social support).
Provide supplementary materials, quitline numbers, etc.
Arrange follow-up within the first week and then the first month. Congratulate smokers who are abstinent, and encourage those who have relapsed to try again; consider more intensive treatment if necessary.
As in the case of screening for tobacco use, screening for alcohol and drug use needs to be universal and can be accomplished by adding a few questions to an intake form or incorporating reminders into an electronic medical record. The U.S. Preventive Services Task Force (USPSTF) recommends the use of a self-report screening test for alcohol disorders in the primary care setting.24 Screening questions include the Cut down, Annoyed, Guilty, and Eye-opener (CAGE), the Tolerance-Annoyed, Cut down, Eye-opener (T-ACE), TWEAK (same as T-ACE questionnaire), Alcohol Use Disorders Identification Test (AUDIT), or the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Questionnaire. These are presented in Appendix 19.A. An effective mechanism for making referrals needs to be in place, even if it is only in the form of a handout.
Even more than with other chronic disease, such as diabetes, hypertension, or obesity, trust in the provider is necessary for any substance-use behavioral change to occur. Women are more likely to hide their substance abuse or alcohol problems than men and are more likely to see only a gynecologist for their routine medical care, making the job of their provider more difficult. Unfortunately, a provider’s uneasiness with substance use screening and treatment and the patient’s concern about legal ramifications, social stigma, etc, often make the relationship more challenging. Patients with substance abuse problems need to be treated with dignity and respect. Given the number of programs available to assist women (pregnant or not) struggling with substance use and abuse, providers need to become comfortable with what is an obligation as part of being a provider of women’s health care.23 Pregnant women with substance abuse problems present their own set of
challenges. The American College of Obstetricians and Gynecologists (ACOG) has addressed some of the ethical issues related to substance abuse in pregnant women.23
challenges. The American College of Obstetricians and Gynecologists (ACOG) has addressed some of the ethical issues related to substance abuse in pregnant women.23
TABLE 19.1 Drugs Used for Smoking Cessation | |||||||||||||||||||||||||||||||||||||||||||||
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BOX 19.4 5 Rs
Relevance—Similar to a personalized message to quit, motivational interviewing can be used to identify how smoking cessation can be relevant to the individual.
Risks—Risks to the patient should be clearly described in terms the patient understands.
Rewards—are critical to success
Roadblocks—need to be identified; patients need to be encouraged, not discouraged
Repetition—As long as the patient is unwilling to quit, these Rs should be repeated.
As in tobacco cessation, numerous studies have been performed on screening for and treating alcohol and substance abuse. MI based on the TTM model of behavior change has been found to be extremely effective in treating women with alcohol abuse and substance abuse.25 The Brief Negotiated Interview and Active Referral to Treatment (BNI-ART) Institute is a program that encompasses behavioral change theory in a practical series of steps to deal with a patient struggling with addiction. The intervention algorithm can be found at http://www.ed.bmc.org/sbirt/docs/aligo_adult.pdf.26 It is critical for providers to understand some of the differences in substance abuse among women as compared to men. For example, psychosocial antecedents in women which tend to
be more common than in male substance abusers include depression, anxiety, bipolar affective disorder, phobias, psychosexual disorders, eating disorders, and posttraumatic stress disorders (PTSD).27 Such coexisting disorders make success in behavior modification significantly more difficult. Female substance abusers have a higher rate of lifetime history of sexual or physical abuse or assault, physical illness, an accident, or disruption in family life.22 Family issues often present barriers to successful behavior change. For example, as opposed to men seeking treatment for a substance abuse problem who are often encouraged by their spouses, women often are in dependent relationships and their partners may threaten violence or leave the relationship if the woman seeks care.28 Because the environment and social norms are so critical to behavior change as outlined earlier in the section on behavioral theory, these factors are often overwhelming barriers for a woman to seek care. Because of these differences between women and men, female treatment programs may be more appropriate to deal with issues that seem to affect female substance abusers more frequently.
be more common than in male substance abusers include depression, anxiety, bipolar affective disorder, phobias, psychosexual disorders, eating disorders, and posttraumatic stress disorders (PTSD).27 Such coexisting disorders make success in behavior modification significantly more difficult. Female substance abusers have a higher rate of lifetime history of sexual or physical abuse or assault, physical illness, an accident, or disruption in family life.22 Family issues often present barriers to successful behavior change. For example, as opposed to men seeking treatment for a substance abuse problem who are often encouraged by their spouses, women often are in dependent relationships and their partners may threaten violence or leave the relationship if the woman seeks care.28 Because the environment and social norms are so critical to behavior change as outlined earlier in the section on behavioral theory, these factors are often overwhelming barriers for a woman to seek care. Because of these differences between women and men, female treatment programs may be more appropriate to deal with issues that seem to affect female substance abusers more frequently.
OBESITY
Overweight (BMI ≥25) or obesity (BMI ≥30) now affects a majority of Americans, with the age-adjusted prevalence of these combined disorders estimated at 68% of American men and women in 2007 to 2008.29 Women are slightly more at risk than men; the 2007 to 2008 National Health and Nutrition Examination Survey (NHANES) demonstrated that 35.5% of women are obese, with a greater risk in non-Hispanic black Americans and Mexican Americans.29 Because overweight and obesity are associated with multiple other chronic conditions, including diabetes, hypertension, dyslipidemia, among others, weight issues are considered first, followed by recommendations for behavior modification for the other individual disorders.
As in tobacco use, readiness to change is an important factor in the success of behavior change. Therefore, once a diagnosis of overweight or obesity is made, it is important to ask the patient about past weight loss attempts as well as desire to lose weight. A full history should include the patient’s current understanding of weight loss, dietary habits, exercise history, in addition to medical history (comorbid conditions), medications, surgeries, and family history. The diagnosis of obesity is most commonly defined by BMI. BMI = weight (kg) / (height [m])2 or BMI = (weight [lb] × 703) / (height [in])2. Appendix 19.B provides a BMI chart using US pounds and inches. A BMI between 19 and 25 kg/m2 is considered ideal. BMI is a clinically useful measure and is most commonly used by medical providers. However, it does tend to overdiagnose obesity in young athletic women (with higher bone density and muscle mass) and underdiagnose it in the elderly. Skin calipers to measure skinfold thickness or underwater weighing can measure body fat percentage, but these are less available in physician’s offices. People with body fat percentages greater than 20% in men and 30% in women are considered obese.
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