Promoting healthy lifestyles is a challenge for many primary care practices. Although most patients understand the importance of physical activity and healthy eating, many seem unable to change their unhealthy behaviors to reduce weight and improve chronic conditions. Medications often take a predominant role in the treatment of these patients, even though medications alone are rarely completely effective for chronic conditions, and lifestyle changes have been shown to significantly reduce morbidity and mortality rates for most chronic diseases.1 In addition, patients can feel embarrassed and ashamed of their situations, and physicians can feel pressed for time, causing them to avoid the very dialogue they need to embrace in order to facilitate a breakthrough in improved health.
There is a better way.
Overview of the AIM-HI program
The Americans in Motion-Healthy Interventions (AIM-HI) research study,2 conducted by the American Academy of Family Physicians (AAFP) National Research Network and the AAFP Americans In Motion program, involved 21 practices whose clinicians and office staff were encouraged to use AIM-HI strategies and educational tools, discussed below, to improve their personal fitness levels and to promote fitness as the “treatment of choice” for all patients. Fitness was defined using three domains – physical activity, healthy eating and emotional well-being. The research found improvements in three areas:
Self-reported eating behaviors
41.8 percent of patients reported an increase of at least one-half serving of healthy foods per week at 10 months.
44.8 percent of patients reported a decrease of at least one-half serving of unhealthy foods per week at 10 months.
Self-reported physical activity
The number of patients who reported physical activity of at least 20 minutes per day, three days per week increased by 10 percent from baseline to four months.
The number of patients who reported physical activity of at least 20 minutes per day three days per week increased by 10.1 percent from baseline to 10 months. (While this is only a slight increase over the previous measure, it shows that the improvements in physical activity seen at four months were maintained at 10 months.)
Total body weight
All data are from patients who completed 10-month research visits. Of the 610 patients enrolled in the study, 62 percent remained in the study from baseline to 10 months.
The four strategies
The AIM-HI approach to fitness promotion involves the following strategies.
1. Create a healthy office. The first step in fostering a healthy office culture is encouraging family physicians to be fitness role models. Most patients already view their personal physician as a role model, and they perceive physicians who practice healthy personal behaviors as more credible and better able to motivate them to make healthy lifestyle choices.3 These physicians are also more likely to provide fitness counseling to their patients.4
Getting physicians involved raises personal awareness of fitness issues among office staff as well and encourages all members of the practice to “walk the talk,” make simple changes in their own lives and share their personal journeys with patients. As physicians and staff members meet personal fitness goals and incorporate the AIM-HI concepts and tools, changes become evident to patients.
It can be helpful to identify a champion to lead these efforts in your practice. That person can facilitate an initial staff meeting to express the importance of personal fitness and the desire to improve fitness among physicians, staff and patients. Since all members of the practice will need to buy into the program, use a collaborative process. Your practice may want to form a committee to assist the champion in launching and establishing this change.
Several practices in the research group issued staff challenges and created support teams to kick off the program. They also created fitness success posters highlighting staff members who had achieved significant milestones in reaching fitness goals, such as getting off medications, reducing blood pressure and glucose levels, losing weight and improving emotional well-being. Posters were placed strategically throughout the clinic to stimulate healthy internal competition and alert patients to the new fitness culture.
2. Make needed process changes. Conduct a brief, informal assessment of your practice by asking yourself the following questions:
How does your practice environment currently promote fitness (physical activity, healthy eating and emotional well-being)? Identify challenges you face, and imagine what it might look like if your clinic were successfully doing everything it could do to promote fitness.
What roles and responsibilities do staff members have in promoting fitness? This must be a team effort, not merely a physician responsibility. For example, front-desk staff can ask patients to complete a fitness inventory. The nurse or medical assistant can calculate BMI, measure waist circumference, review the fitness inventory and reinforce fitness concepts before the physician enters the exam room. After the exam, a staff member might return to the room to answer questions, help with goal setting or provide patient education. (For patient handouts on a variety of health-related issues, visit https://familydoctor.org/online/famdocen/home/healthy.html.)
What tools or systems do you need to implement to support your efforts? Your practice will likely need to make process changes such as adding BMI and waist circumference to routine vital sign measurements, incorporating a fitness inventory into periodic screenings, displaying fitness-related patient education materials in your reception area and exam rooms, and adding prompts or reminders for addressing fitness with patients.
3. Get patients involved. To initiate fit-ness conversations with patients, family physicians in the research study found it helpful to capitalize on teachable moments, such as poor laboratory results, a recent diagnosis of chronic illness, new patient visits, annual visits and well-child exams. They also found that switching from an advice-giving communication style to a more patient-centered, conversational style elicited a more receptive response from patients. Physicians in the study also used motivational interviewing techniques such as the following:
Open-ended questions – e.g., “How are you feeling about your health these days?”
Affirmation – e.g., “You may not be at your goal yet, but look at how far you’ve come.”
Reflective listening – e.g., “It sounds as though you don’t feel confident about making this change but you do want to change.”
Summaries – e.g., “Let me summarize what we’ve just talked about.”
These techniques have proven effective to motivate healthy behavior change in patients.5,6 (Editor’s note: Look for an article on motivational interviewing in the May/June issue of FPM, and find more information at http://motivationalinterview.net.)
When initiating fitness conversations with patients, the first objective is to assess their current levels of activity, healthy eating and emotional well-being and their readiness to change. Study results indicated that addressing each domain separately is more manageable and less overwhelming to patients. An assessment like the one shown below can be helpful.
The next step is to help patients set small, reasonable goals. To address the first domain of fitness, physical activity, goals do not need to involve joining a rigorous exercise program at an expensive gym or developing an athletic, muscle-bulging body or a model’s figure. Dispel these concepts, and emphasize the term “physical activity” versus “exercise,” as the latter often is attached to ideas of unattainable body physiques and unachievable goals.
Rarely does lecturing patients on the importance of engaging in 30 to 60 minutes of uninterrupted physical activity every day result in long-term health behavior change.7 Instead, ask patients what they think they could do for just five to 10 minutes per day to improve their physical activity. If the patient is leading a sedentary lifestyle, taking one flight of stairs instead of the elevator, parking the car at the far end of the lot to increase steps, or walking the dog briskly can all be part of increasing physical activity. The idea is to build confidence and capacity, while avoiding injury or a sense of failure. Patients should feel positive about the goals they have selected. Ask them how confident they are in their ability to complete each goal. If their confidence is high, write the goal on a fitness prescription for the patient to take home, and note it in the patient’s record so you can ask about it at future visits. If their confidence is low, work with them to select a more doable goal.
The second fitness domain is healthy eating, which involves more than just “good” dietary nutrition. Patients also need to understand the thought processes associated with their eating habits, and many will need to restore their physiological identification of hunger and learn to respond appropriately to it. In the AIM-HI program, patients were encouraged to think about why they were eating and to eat only when they were hungry. This non-diet approach allows patients to let go of rigid diet rules or strict weight-reduction diets that seldom work in the long run.8
Emotional well-being is the third fitness domain. Because physical activity and healthy eating are often tied to patients’ emotional health, addressing this domain can often jump-start their motivation to tackle the others. Some family physicians may feel uncomfortable questioning patients about their emotional well-being. However, failure to do so could be a missed opportunity to inspire healthy behavior changes. Ask patients if they are feeling sadness, stress or anxiety, and help them understand possible causes, such as a broken relationship, too many activities or even a lack of sleep. Share strategies for coping, such as learning to express feelings in appropriate ways, talking to a close friend, counselor or religious adviser, using relaxation methods and taking time for self-care.
Another way to address emotional well-being is through a food and activity journal in which patients record what they eat each day and how they feel. This can help patients understand how their emotions play a part in what they eat, and it can teach them not to reach for food in order to deal with stress or other emotions. Patients should also be encouraged to set small, achievable goals related to their emotional well-being, such as spending five minutes each morning in prayer or meditation or having lunch with a friend once a week.
The AIM-HI program utilizes three tools:
A fitness inventory. This brief survey asks questions such as “How many hours each day do you spend watching TV or videos or on the computer?” and “How often does stress or depression affect your ability to pursue healthy lifestyle changes?” These questions are designed to assess the patient’s level of physical activity, nutrition and emotional well-being, as well as his or her readiness to make changes in each of these areas.
A fitness prescription. This form is used to record one or more simple, measurable fitness goals that the patient and physician have agreed upon. The patient then takes this form home as a reminder of what was discussed. The form also lists follow-up dates.
A food and activity journal. Patients can use this template to record what they ate, how they felt and what they did to be active for one week.
4. Follow up. Most people change their behavior gradually. They may move forward and backward through the four stages of change – pre-contemplation, contemplation, preparation and action – before moving on to the maintenance stage, where the goal is to minimize relapse.9 Relapses of some sort are almost inevitable, but a mutually developed, individualized plan for support and follow-up can help patients sustain a healthier lifestyle. The plan should address how and when you will evaluate the patient’s progress or renegotiate goals. In some cases, a face-to-face visit will be required. In other cases, follow-up can occur by phone or e-mail with a nurse, dietitian or health educator. Follow-up should occur within three weeks in most cases. The plan should also list resources in your community that can assist your patient, such as physical activity centers, walking groups, psychologists and health educators.