HEALTH BEHAVIOR CHANGE: CASE DISCUSSIONS IN NUTRITION A M Y L O C K E, M D, F A A F P, A B I H M

HEALTH BEHAVIOR CHANGE: CASE DISCUSSIONS IN NUTRITION A M Y L O C K E, M D, F A A F P, A B I H M

RECOMMENDED PRACTICE CHANGES 1. Adequately assess patients current dietary habits 2. Assess patient specific barriers to optimal nutrition 3. Use motivational interviewing to move patients towards healthier options Use SMART goals 4. Work as a part of a team to provide practice-based counseling and community-based resources to help patients achieve and maintain a healthy lifestyle

BARRIERS TO PROVIDING ADVICE Time Priorities for the visit Expertise/Feelings of inadequacy Perception of efficacy Lack of referral options Stigma/negative physician attitudes

DEVELOPING A CUSTOMIZED PLAN Detailed History Review the options Realistic shortand longterm goals Engage team Reassess

What motivates? FINDING MOTIVATION What are goals? Lose weight? Lower blood pressure? Cholesterol? Sugar? Fall less? Be stronger? Feel better? Live longer?

MOTIVATION: WHAT DOESN T WORK Brief one-time educational intervention Unrealistic goals Guilt Recommend against exercise due to chronic disease Focus on dramatic weight loss

WHERE TO BEGIN? Change takes time Think of a goal you accomplished Set small concrete goals Write them down and commit to someone else Get someone to check in on progress Can be office, friend, family, etc. Track success

SOLUTIONS Meet patients where they are Simple messages Focus on positives (what to do more of) Lead by example SMART Goals

MOTIVATING INDIVIDUALS WITH CLEAR GOALS Health and wellness over weight loss Feel better, have more energy Short term Positive Tailored: start with one step Play: What is fun? Self Monitoring: tracking Each day is a new day Close follow-up

SMART GOALS Specific Measurable Achievable Realistic Time-bound Make a list of meals for the week with a shopping list each Sunday so that I have food in the house to make dinner each night without going to the store

CASE: CHIEF COMPLAINT Wants to loose weight

HISTORY OF PRESENT ILLNESS 45 yo woman with with a recent diagnosis of prediabetes presents with BMI of 30 and a desire to loose weight. She is here today to discuss. She has tried dieting in the past and after initial weight loss, she regains more.

HISTORY PMH: Seasonal allergies Meds/OTC: Flonase, Vitamin D Allergies: Penicillin Family History: Father: HTN Mother: breast cancer at 70 Sister: depression

SOCIAL HISTORY Lives with her husband and three kids ages 7, 10 and 15. Minimal alcohol No tobacco or other drugs College degree, works as a middle school teacher

REVIEW OF SYSTEMS Some fatigue, tired when wakes up Occasional headaches Congested in Spring

PHYSICAL EXAMINATION Obese woman in no apparent distress Exam is otherwise unremarkable BP 125/79 BMI 32 A1C 5.8 Lipids: Total Cholesterol 195, TG 160, HDL 45, LDL 98

LIFESTYLE HISTORY Nutrition: eats some fruits and veggies; cooks at home 3 nights a week Physical Activity: on feet at work; plays with kids on weekends; walks dog Sleep: 6 hrs per night Stress: work balance; child care Social Connection: well connected with family and friends

ASSESSMENT Obese woman with pre-diabetes interested in weight loss. Some fatigue and headaches. Diet quality is unclear. Minimal physical activity and insufficient sleep. Significant stressors. Good social support.

PLAN What would you like to do? Who do you want on your team?

ASSESSING DIETARY HABITS WHAT I S THE P ATIENT E ATING?

LIFESTYLE HISTORY Nutrition: Physical Activity: Sleep: Stress: Social Connection: Screen time:

ASSESSING DIETARY HABITS Free form discussion 24 hour recall 24-72 hr diet diary Specific questions: Frequency cooking, eating out, assess barriers

QUICK NUTRITION HISTORY Fruits and veggies Eating out Beverages Snacks 24 hr food recall Happy with food eaten? Cooking skills Time and money constraints

TAILORING THE MESSAGE Fruits and veggies Healthy fats Cut back on fast food Limit sweet beverages

FOOD RECALL EXERCISE In the next few minutes: pair up take a 24 hour food recall with your partner Don t forget snacks and beverages switch

DEBRIEF Issues that came up? How do you interpret the results? What do you do next?

ASSESSING BARRIERS WHAT ARE THE ROADBLOCKS?

BARRIERS: INDIVIDUAL Food knowledge Cooking skill Food prep interest Taste preference Family expectations Recognition of satiety Mindless eating Ability to read food labels Financial/food availability Time management Hours worked Child care Other activities (i.e. TV) Emotional eating

BARRIERS: SOCIETAL Industry/lobby Advertising Subsidies Normalcy Bad food everywhere Obesity commonplace Food availability Food deserts

ASSESSING BARRIERS ROLE PLAY In pairs, one person is the patient and the other the physician Stay in your role as you discuss roadblocks Have the patient rate their likelihood of being able to make the change (1-10) Ask what makes them choose the number they chose rather than a lower number

DEBRIEF ROLE PLAY EXERCISE Share what worked and what didn t work As the patient, how did you feel? As the physician, what could you have done differently?

MOTIVATING CHANGE HOW DO WE DO SOMETHING DIFFERENT?

MOTIVATING CHANGE EXERCISE In pairs, one person is the patient and the other the physician (switch from last exercise) Stay in your role as you discuss setting a SMART goal

SMART GOALS Specific Measurable Achievable Realistic Time-bound Bike 30 minutes three times a week at the park near my house with my neighbor after dinner

DEBRIEF ROLE PLAY EXERCISE Share what worked and what didn t work As the patient, how did you feel? As the physician, what could you have done differently?

USING RESOURCES WHO C AN HELP?

BUILDING THE TEAM The office The health system The community The country

THE OFFICE TEAM Physician APRN/PA Nurse Medical Assistants Pharmacist Dietician Social Work Psychology Health Coach

NEW PROGRAMS Shared medical visits Nurse/dietician visits with T/G codes Comprehensive Lifestyle Programs

HEALTH SYSTEM PARTNERS Specialties: cards, endocrine, ortho, etc. Disciplines: PT, health coaching, dieticians, public health, pharmacy, psychology Human Resources

COMMUNITY PARTNERS Community foundations Grocery stores Culinary schools Recreation centers (i.e. YMCA) Community gardens City urban planners

APPS My Fitness Pal Spark People Fitbit MyNetDiary My Plate Sage Project ShopWell Nutrients (Foodle) HealthyOut Lose It

RESOURCES FOR PATIENTS Harvard School of Public Health www.nutritionsource.org Ending the Food Fight, David Ludwig www.endingthefoodfight.com Mindless Eating: Why We Eat More Than We Think, Brian Wansink www.mindlesseating.org Many apps and websites ABE s for Everyone My Fitness Pal, Sparkpeople, etc. The Hunger Within, Marilyn Migliore

WHAT CAN YOU DO? Feed yourself and those you love with healthy food Focus on food over nutrients Learn to cook Move for fun Lobby for change Nationally Locally Patients Meet people where they are Talk about lifestyle with patients Set large and small goals